RESUMEN
The surgical repair of 16 aorto-caval (A-C) fistulas (15 male and one female patient; average age of 61.3 years) is reviewed. Fourteen fistulas were caused by aneurysm's erosion, one by iatrogenic injury, while one followed abdominal blunt trauma. The interval from presumed occurrence to diagnosis ranged from 6 h to 2 years. The presence of an abdominal bruit (87.5%) was the most reliable physical finding. Congestive heart failure was prominent in three (18.7%) cases, while severe lower extremity edema in five (31.2%). Two patients (12.5%) had hematuria, two (12.5%) renal insufficiency, while four (25%) scrotal edema. The diagnosis was not recognized before the surgery in five (31.2%) cases. In all 16 cases after transaortic suture of the fistula, aortic reconstructions were performed. Four operative deaths (25%) occurred, in patients who were not correctly diagnosed before surgery. In one case the cause of death was massive bleeding, and in three MOFS. All other patients were followed from 1 to 17 years (mean 4 years and 2 months). All grafts are patent, and there is no lower extremity venous insufficiency or pelvic venous hypertension. Surgical repair of A-C fistulas is mandatory to prevent serious complications.
Asunto(s)
Enfermedades de la Aorta/cirugía , Fístula Arteriovenosa/cirugía , Vena Ilíaca/cirugía , Vena Cava Inferior/cirugía , Adulto , Anciano , Aorta Abdominal/cirugía , Enfermedades de la Aorta/diagnóstico , Fístula Arteriovenosa/diagnóstico , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
INTRODUCTION: Most of the patients with aortoiliac occlusive diseases have a multilevel localization of atherosclerotic diseases. In patients with aortoiliac occlusive diseases, the femoro-popliteal segment is involved in 28 to 66% of cases. These patients are usually old persons with many risk factors. Therefore, simultaneous proximal and distal reconstruction is often associated with a higher morbidity and mortality rates. In contrast, can proximal reconstruction help only patients with multilevel occlusive diseases? The aim of this paper is: definition of factors determining late patency rate of aortobifemoral bypass graft in patients with multilevel occlusive diseases; definition of factors determining clinical effects after aortobifemoral bypass procedures. MATERIAL AND METHODS: This prospective study included 283 aortobifemoral reconstructions due to aortoiliac occlusive diseases operated between January 1st, 1984 and December 31st, 1992 at the Institute of Cardiovascular Diseases of the Serbian Clinical Centre in Belgrade. Bifurcated polytetrafluorethylene (PTFE) grafts were used in 136 patients, and standard nonimpregnated knitted Dacron grafts in 147 paetients. There were 25 (8.8%) female and 258 (91.2%) male patients, average age 56.88 years. Ninety one (32.2%) patients had claudication discomfort (Fonten stadium II), 91 (32.2%) disabling claudication discomfort (Fonten stadium IIb), 45 (15.9%) rest pain (Fonten stadium III), and 56 (19.8%) gangrene (Fonten stadium IV). In 45 (15.9%) patients previous vascular procedures were performed. Prior to operation Doppler ultrasonography and translumbar aortography were done. Isolated aortoiliac occlusive diseases with intact femoro-popliteal segment (Type I) were found in 83 (29.3%) patients; combined aorto-iliac and diseases of superficial femoral artery (Type II) in 170 (60%) patients; and combined aorto-iliac and femoro-popliteal diseases (Type III) in 30 (10.7%) individuals. Transperitoneal approach to abdominal aorta and standard inguinal approach to femoral arteries, were used. In 154 (54.4%) patients proximal anastomosis had an end to side (TL), while in 129 (45.6%) end to end (TT) form. In 152 (26.88%) patients distal anastomosis was found on the common femoral artery (AFC), while in 414 (73.2%) on the deep femoral artery (APF). In 7 patients the aorto-femoro-popliteal "jumping" bypass was performed, and in 29 subjects the simultaneous sequential femoro-popliteal bypass graft (Figures 1, 2, 3, 4a and 4b). The patients were followed-up over a period from one, six and twelve months after reconstruction, and later once a year, using physical examination and Doppler ultrasonography. In patients with suspected graft occlusion, anastomotic stenosis, pseudoaneurysms, progression of distal diseases, Duplex ultrasonography and angiography were also used, and leukoscintigraphy in patients with suspected graft infection. Statistical analysis was performed by Long Rank and Student's t-test. RESULTS: Inhospital mortality rate was 11 (7%). Simultaneous distal reconstructions significantly increased the mortality rate (p< 0.01). The follow-up period was from 2 months to 9.5 years (mean 3.6 years). Configuration of proximal anastomosis showed no significant influence on graft patency (p>0.05) (Graphs 1, 2, 3). Location of distal anastomosis at the deep femoral artery contributed to statistically significant increase in graft patency (p < 0.01) (Graphs 4, 5, 6). Simultaneous distal bypass showed statistically significant increase in graft patency (p < 0.01), but also significant increase in inhopsital mortality rate (p < 0.01) (Graphs 7, 8, 9). The type of occlusive diseases had no statistically significant influence on graft patency (p > 0.05) (Graphs 10, 11, 12). Six (2.1%) early unilateral limb occlusions were observed. The reasons for early graft occlusions were: stenosis of distal anastomosis in 3 patients and pure run off in 3 subjects. In 5 patients urgent reoperations (limb thrombectomy and profundoplasty or femoro-popliteal bypass graft above the knee) were performed with complete recovery of patients. However, in one patient an above the knee amputation had to be done. During the follow-up period 14 (5.2%) late graft occlusions were recorded: 11 unilateral limb and 3 bilateral graft occlusions. The reasons for late graft occlusion were: distal progression of atherosclerotic diseases, distal anastomotic stenosis, proximal progression of atherosclerotic diseases and anastomotic neointimal hyperplasy. All patients with late graft occlusion underwent successful redo-operations. Next late redo-procedures had to be done: three new aorto-bifemoral bypass grafts (patients with bilateral occlusion), two limb thrombectomies, 6 limb thrombectomies with profundoplasty and 3 femoro-femoral "cross-over" bypass grafts. Configuration of proximal anastomosis and type of occlusive disease showed no statistically significant influence on the number of early and late graft occlusions (p > 0.05). Location of distal anastomosis at the deep femoral artery and simultaneous distal bypass, statistically significantly decreased the number of early and late graft occlusions (p < 0.05). "Small aorta syndrome" statistically significantly increased the number of late graft occlusions. Eleven distal anastomotic pseudoaneurysms were noted. In 8 patients pseudoaneurysms were infected and in 3 noninfected. In all patients new redo-operations were carried out. Graft infection was recorded in 5 (1.7%) patients. One (0.3%) secondary aortoduodenal fistula was found. During the follow-up period new disabling claudication discomforts were found in 46 patients. The causes were distal anastomotic stenosis in 30 patients and progression of distal arterial diseases in 16 subjects. Of the total number of 30 patients with distal anastomotic stenosis 14 were reoperated (profundoplasty) and 16 patients refused a new operation. Also, 16 patients with progression of distal atherosclerotic diseases were reoperated. The operation was a kind of femoropopliteal or crural bypass grafts. During the follow-up period 97 patients were asymptomatic, 128 showed significant improvement, 29 had disabling claudications, and 111 had amputations. Distal anastomosis at the deep femoral artery and patent superficial femoral artery, statistically significantly influenced the clinical course after operation (p 0.01), while configuration of proximal anastomosis and simultaneous distal bypass had no significant effects (p < 0.05). CONCLUSIONS: (1) Only location of distal anastomosis has a statistically significant influence on the patency of aorto-bifemoral bypass graft. (2) The location of distal anastomosis and type of occlusive disease have a statistically significant influence on the clinical effect of the operation. (3) The simultaneous distal bypass had no influence on the late patency of aortobifemoral bypass graft and on the number of asymptomatic patients. Also, it increased inhospital mortality rate.
Asunto(s)
Aorta Abdominal/cirugía , Arteriopatías Oclusivas/cirugía , Arteria Femoral/cirugía , Oclusión de Injerto Vascular/etiología , Enfermedades de la Aorta/cirugía , Femenino , Humanos , Arteria Ilíaca , Masculino , Persona de Mediana Edad , Grado de Desobstrucción Vascular , Procedimientos Quirúrgicos VascularesRESUMEN
The effect of right ventricular pacing on left ventricular relaxation was studied in 13 patients (age 62 +/- 3 years), with the atrial sensing ventricular pacing mode (VDD). A control group of similar age (64 +/- 4 years) consisted of 11 patients with atrial pacing (AAI). The timing of events was determined in both groups at similar R-R intervals (921 +/- 77 ms vs 967 +/- 37 ms). The loading conditions as estimated by peak systolic wall stress (afterload) and end-diastolic left ventricular dimensions (preload) were approximately the same in both groups. The ratio of late to early filling velocities were similar in both groups. Dominant changes were: increased preejection period (142 +/- 13 ms vs 95 +/- 15 ms); and higher velocities of isovolumic relaxation flow (60 +/- 34 cm/s vs 25 +/- 4 cm/s) in patients with ventricular pacing. The isovolumic relaxation time was longer in patients with VDD pacing (127 +/- 14 ms vs 108 +/- 12 ms). Anterior systolic interventricular septal motion (paradoxal motion) was recorded in nine patients with VDD pacing and in none of the patients with AAI pacing. Isovolumic relaxation flow was detected during atrial pacing in five (45%) patients and in 13 (100%) patients during atrial sensing ventricular pacing, indicating asynchronous left ventricular relaxation. This data shows that VDD pacing compared to atrial pacing resulted in an altered activation pattern of the left ventricle, associated with delayed onset, asynchronous contraction with interventricular septal motion abnormalities and prolonged asynchronous left ventricular relaxation with abnormal motion manifested by the presence of isovolumic relaxation flow.
Asunto(s)
Estimulación Cardíaca Artificial/métodos , Ecocardiografía Doppler , Función Ventricular Izquierda , Arritmias Cardíacas/fisiopatología , Arritmias Cardíacas/terapia , Electrocardiografía , Humanos , Persona de Mediana Edad , Contracción Miocárdica , Marcapaso ArtificialRESUMEN
Eighty two aortic replacements of ruptured abdominal aortic aneurysms have been performed during the last 6 years. There were 72 male and 10 female patients, and the average age was 71.33 years. Hemorrhagic shock on the admission was observed in 45 patients, and 13 have been operated urgently without any diagnostic procedures. The transperitoneal approach have been used for the operation. Two aorto duodenal and one aorto caval fistulas, have been found. Only exploration (three patients died immediately after laparotomy and 6 after cross clamping) has been done in 9 cases, and the aortic replacement in 70 cases (27 with tubular, and 43 with bifurcated graft). In 3 cases and axillobifemoral bypass had to be done. During the operation eleven patients died, and 30 in postoperative period, during the period between one and 40 days. Total intrahospital mortality rate was 50%, compared with 3.5% for 250 electively operated patients with abdominal aortic aneurysms in same period. In postoperative period the most important cause of death was multiple organs failures. Statistically significant greater mortality rate (p > 0.01%) was found in cases of late operative treatment, hemorrhagic shock, intra-operational bleeding, ruptured front wall, suprarenal cross clamping and in patients older than 75 year. In complicated cases such as juxtarenal aneurysm, 3 sutures parachute technique for proximal anastomosis, a temporary transection of the left renal vein, and intraaortal balloon occlusive catheter for proximal bleeding control are recommended.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Rotura de la Aorta/cirugía , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/mortalidad , Rotura de la Aorta/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Tasa de SupervivenciaRESUMEN
Out of 100 patients treated by intraarterial perfusion of prostaglandin E1 we selected 36 cases who have been treated after a lumbar sympathectomy or reconstruction on the femoro-popliteal segment. The patients were in the III and IV stage of occlusive diseases by Fontain. All patients were divided into four groups: (a) prostaglandin E1 after a lumbar sympathectomy (20); (b) prostaglandin E1 after failed femoro-popliteal bypass (8); (c) prostaglandin E1 with patent femoro-popliteal bypass and distal progression of the occlusive disease (3); (d) prostaglandin E1 with previously femoro-popliteal reconstruction and poor run off (5). After intraoperative introduction of a catheter into the superficial femoral artery, profunda femoral artery (a, b), a patent graft (c) or just implanted graft (d), a continuous intraarterial perfusion of prostaglandin E1 was applied, in doses 10 nanograms/kg body weight/minute, in total doses 3000 nanograms. The perfusion time was 48-72 h. The patients were controlled immediately after treatment as well as 1, 3, 6 and 12 months after. Our early and late results of the intraarterial perfusion of prostaglandin E1 proved as a very successful limb salvage procedure.