RESUMEN
Ligation of perforator veins in the lower extremity for the treatment of venous ulceration can be performed using a minimally invasive technique with endoscopic instruments. Several studies have documented that the endoscopic technique has a lower wound-related complication rate compared to open perforator vein ligation. We report the complication of postoperative subfascial hemorrhage requiring reexploration after subfascial endoscopic perforator vein ligation and describe a minimally invasive method for its control using balloon tamponade.
Asunto(s)
Oclusión con Balón , Cateterismo , Endoscopía , Fascia , Hemorragia/etiología , Hemorragia/terapia , Complicaciones Posoperatorias , Úlcera Varicosa/cirugía , Adulto , Humanos , Pierna/irrigación sanguínea , Ligadura , Masculino , Reoperación , Venas/cirugíaRESUMEN
A beneficial effect in blood pressure control is presumed for patients on an intensive preoperative antihypertensive regimen who undergo empiric renal revascularization. Nonetheless, a noticeable decline in surgical cure rates for hypertension has been recently observed in patients with generalized atherosclerosis. The outcome of patients on multiple preoperative antihypertensive agents who underwent combined aortic and renal artery reconstruction was reviewed. The study population comprised 43 patients who underwent concomitant renal artery and aortic reconstruction for atherosclerotic disease between 1983 and 1995 and who were taking two or more antihypertensive medications and had a serum creatinine of less than or equal to 1.7 mg/dL. Operative management included an aortic reconstruction with either unilateral (n = 22) or bilateral (n = 19) aortorenal bypass or renal endarterectomy (n = 2). Operative mortality was 4.7% (2 of 43). The estimated 5-yr probability of survival was 83% (95% C.I. 0.70, 0.99). Late follow-up data on blood pressure control were available for review in 32 patients at a median follow-up of 37 months. Hypertension was cured in 1 (3%) and improved in an additional 15 (47%) patients. The numbers of antihypertensive medications taken preoperatively (mean = 2.7) declined at late follow-up (mean = 1.6). Notably, the largest reduction was observed with beta blockers (p = 0.006), central sympatholytics (p = 0.041), and angiotensin converting enzyme (ACE) inhibitors (p = 0.052). The number of preoperative antihypertensive medications was not significantly related to survival or to blood pressure improvement. However, uncontrolled preoperative hypertension despite antihypertensive therapy was associated with a favorable blood pressure response to operation (p < 0.001). Patients on an intensive antihypertensive regimen can safely undergo concomitant renal artery and aortic reconstruction for the empiric management of hypertension. Poorly controlled preoperative hypertension in the presence of multiple antihypertensive agents is a favorable marker for improved postoperative blood pressure control.
Asunto(s)
Antihipertensivos/administración & dosificación , Aorta Abdominal/cirugía , Arteriosclerosis/cirugía , Implantación de Prótesis Vascular , Endarterectomía , Hipertensión Renovascular/cirugía , Premedicación , Obstrucción de la Arteria Renal/cirugía , Arteria Renal/cirugía , Anciano , Aneurisma de la Aorta Abdominal/mortalidad , Aneurisma de la Aorta Abdominal/cirugía , Arteriosclerosis/mortalidad , Presión Sanguínea/fisiología , Quimioterapia Combinada , Femenino , Estudios de Seguimiento , Mortalidad Hospitalaria , Humanos , Hipertensión Renovascular/mortalidad , Pruebas de Función Renal , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/cirugía , Obstrucción de la Arteria Renal/mortalidad , Reoperación , Estudios Retrospectivos , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
The purpose of this study was to determine the clinical characteristics of chronic renal failure patients who developed hand ischemia in the limb carrying the dialysis angioaccess. A retrospective review of the charts of 352 patients who underwent 409 upper extremity arteriovenous access, and who were subsequently diagnosed as steal syndrome, was performed at the Emory University Hospital between February 1992 and January 1997. Hand ischemia occurred after 13 of 299 arteriovenous grafts (4.3%) and after 2 of 110 direct forearm arteriovenous fistulas (1.8%). Six patients developed ischemic manifestations immediately postoperatively, 2 in the first week, 4 after 1 month, and 1 after 1 year. Thirteen occurred in association with the primary access procedure. Two cases occurred following graft thrombectomy and outflow dilatation. Seven patients were mildly symptomatic with dialysis-induced pain, coldness, or numbness; 8 patients developed severe ischemic manifestations in the form of sensory loss in 3, severe intolerable pain with impalpable pulse in 3, and digital gangrene and amputation in 2, one of whom developed an unhealed amputation stump and required a higher amputation level with satisfactory healing of the revised stump. Three patients were treated conservatively, 6 by banding, 4 by ligation, 1 by embolization, and 1 by distal ligation and bypass operation. Clinical characteristics of patients with hand ischemia included long-standing insulin-dependent diabetes (10), chronic hypertension (12), peripheral arterial disease (14; 93.3%), coronary artery disease (8), and systemic lupus erythematosis (1). Severe peripheral arterial diseases are commonly found and may be markers for risk of hand ischemia after access surgery.
Asunto(s)
Derivación Arteriovenosa Quirúrgica/efectos adversos , Mano/irrigación sanguínea , Isquemia/etiología , Diálisis Renal/efectos adversos , Amputación Quirúrgica , Catéteres de Permanencia/efectos adversos , Humanos , Isquemia/diagnóstico por imagen , Isquemia/cirugía , Enfermedades Vasculares Periféricas/complicaciones , Pronóstico , Radiografía , Factores de TiempoRESUMEN
BACKGROUND: Division of incompetent perforating veins has long been regarded as an appropriate approach for treatment of venous stasis ulcers. The development of endoscopic techniques using standard laparoscopic instrumentation has permitted the application of this therapy without the need for long open incisions, fraught with complications. METHODS: We report our experience with 20 cases of subfascial endoscopic perforator surgery (SEPS) in 19 patients. Seventeen limbs had active ulceration at the time of operation. A gas insufflation technique with two 10 mm ports was used in most cases. RESULTS: An average of four perforating veins were divided in each case. Mean operating time was 1.5 hours. At a mean follow-up of eight months, initial complete healing occurred in 14 of 17 ulcers, three ulcers improved, and three healed ulcers at the time of SEPS have remained healed. One patient developed a small area of recurrent ulceration after initial healing. There were no thromboembolic complications. One procedure was technically unsuccessful because of morbid obesity. One patient developed a wound infection, and one patient required re-exploration for a subfascial hematoma. CONCLUSION: SEPS is a safe, minimally invasive procedure which should become an important part of the surgical armamentarium in treating patients with venous ulcers.
Asunto(s)
Endoscopía/métodos , Úlcera Varicosa/cirugía , Adulto , Anciano , Endoscopios , Fasciotomía , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Flebografía , Resultado del Tratamiento , Úlcera Varicosa/diagnóstico por imagen , Úlcera Varicosa/fisiopatología , Cicatrización de Heridas/fisiologíaRESUMEN
Management of the patient with end stage renal disease and peripheral vascular disease represents a major challenge to the vascular surgeon. In this review, we developed guidelines for intervention based on our own institutional experience as well as literature review. There have been more than 290 patients reported to have 369 ischemic legs with threatened limb loss. There was an overall graft patency rate of 71% (range, 64% to 77%) and 60% (range, 48% to 90%) for 1 and 2 years, respectively. The mean limb salvage rate was 72% (range, 52% to 94%) at 2 years in these groups of patients. In the presence of rest pain and/or tissue loss, with favorable inflow and outflow (at least one vessel with direct flow into the foot), we strongly advised surgical bypass. In those patients who presented with rest pain and/or tissue loss, infragenicular surgical reconstruction led to a higher quality of life in comparison to patients with primary amputations. An indication for a primary amputation would be gangrene extending proximal to the mid foot. We have therefore outlined our findings and thoughts in the following article.