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PURPOSE: The purpose of this study was to review the various extrathoracic reconstruction options in patients with occlusive disease of the supraaortic trunks and to define the efficacy of these procedures in maintaining graft patency and relieving symptoms. METHODS: Forty-four consecutive patients underwent 47 extrathoracic bypass procedures of the supraaortic trunks for correction of symptomatic subclavian (SCA), common carotid (CCA) or innominate (INA) artery occlusive disease between July 1975 and May 1994. SCA stenosis (n = 27) was associated with upper extremity claudication (55%), vertebrobasilar insufficiency (15%), or both (30%). CCA stenosis (n = 14) was accompanied by hemispheric symptoms in 86% and global ischemia in 14%, whereas INA stenosis (n = 3) was associated with transient ischemic attacks (67%) and right arm ischemia (33%). RESULTS: SCA revascularization included carotid-subclavian or carotid-axillary bypass (n = 19), axilloaxillary bypass (n = 8), and subclavian-carotid transposition (n = 3). CCA reconstructions included subclavian-carotid (SC) bypass (n = 13) and carotid-carotid bypass (n = 1). INA procedures included three axilloaxillary bypasses. Six patients had an associated carotid endarterectomy, and three underwent concomitant vertebral artery transpositions. Intraluminal shunts were not routinely used. Vein was used as a conduit in five procedures, and a prosthetic graft (23 Dacron, 16 polytetrafluoroethlyene) was used in the remainder. The average postoperative intensive care unit and hospital and hospital stay were 1 and 5 days, respectively. Follow-up was available in 43 of 44 patients (mean = 26.2 months). The perioperative mortality rate was 2.2% (one axilloaxillary). There were five graft occlusions in procedures involving the axillary artery (3 of 11 axilloaxillary, 2 of 7 carotid-axillary) as compared with one of 29 thromboses when the operation was confined to the supraclavicular fossa (p < 0.05) Relief of symptoms was achieved in all patients with patent grafts. There were no perioperative strokes in the series. Other complications included one brachial plexus neuropraxia (axilloaxillary) and four patients with phrenic nerve neuropraxia. CONCLUSION: Extrathoracic revascularization of the supraaortic trunks is well tolerated and durable when operations are confined to the supraclavicular fossa and do not involve the axillary artery.

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PURPOSE: To evaluate the results of femorofemoral bypass graft (FFBPG), we analyzed 110 consecutive FFBPGs performed at our institution during an 11-year period. METHODS: In 62 (56%) patients the indication for surgery was claudication and in 48 (44%) patients rest pain or tissue loss. In 42 patients the superficial femoral artery (SFA) was occluded. A preoperative percutaneous transluminal balloon angioplasty (PTA) was performed in 24 (22%) patients to correct a significant donor iliac artery stenosis. In 48 (44%) patients a total of 54 arterial procedures were performed simultaneously with FFBPG. RESULTS: After surgery 75 (68%) patients were moderately or markedly improved, whereas 20 (18%) were minimally improved, unchanged, or worse, including 7 (6%) with hemodynamic failures. The in-hospital mortality rate was 4.5%. Actuarial patient survival rate was 70% +/- 8.6% at 6 years. The actuarial primary graft patency rate was 83% +/- 4.2% at 1 year, 71% +/- 6.9% at 3 years, 60% +/- 8.3% at 5 years, and 51% +/- 9.6% at 6 years. Age, sex, and race of the patient did not influence graft patency. Grafts placed for limb-threatening ischemia or in patients with SFA occlusion had a similar patency rate compared with those placed for claudication or in patients with patient SFA. The overall limb preservation rate was 83% +/- 7.3% at 5 years but was only 64% for patients who underwent operation for limb-threatening ischemia. CONCLUSIONS: In conclusion, FFBPG offers moderately low long-term patency in a population with limited survival. Outflow procedures performed concomitantly with FFBPG seemed to compensate for the negative impact on graft patency rate of ipsilateral SFA occlusion and limb-threatening ischemia. Limb-threatening ischemia, however, carried a significantly higher (p < 0.05) amputation rate. The influence of preoperative donor iliac artery percutaneous transluminal balloon angioplasty on FFBPG patency remains unclear.

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A 51-year-old woman with known dextrocardia presented with left-sided abdominal pain and symptoms consistent with biliary colic and cholelithiasis. Abdominal ultrasound confirmed the diagnosis of gallstones, as well as situs inversus with the liver and gallbladder on the left side and the spleen on the right. Laparoscopic cholecystectomy was performed without incident. The procedure was uncomplicated except for being the mirror image of that done with the gallbladder in the normal location. Cholelithiasis occurring with situs inversus is rare and may present a diagnostic problem. The extrahepatic anatomy of the biliary and venous system is the mirror image of the right sided liver. Historic and genetic aspects of situs inversus, as well as current theories regarding its etiology are presented. Situs inversus totalis does not appear to be a contraindication to laparoscopic treatment of cholelithiasis.

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Organ preservation for transplantation is associated with endothelial cell damage. This vascular injury results in increased capillary permeability, graft edema, and early graft dysfunction. This damage may be the limiting factor in preservation of these organs. This study uses flow cytometric assessment of membrane integrity to examine the effects of various organ preservation solutions on human umbilical vein endothelial cell cultures. Confluent plates of human umbilical vein endothelial cells were incubated at 4 degrees C for 24, 48, and 72 hours in commonly used preservation solutions. After cold incubation, the cells were harvested and stained with propridium iodide and fluorescein diacetate. Cells were examined using a flow cytometer for membrane integrity and cytosolic activity. When examined after 24, 48, and 72 hours, cells stored at 4 degrees C in a 5% polyethylene glycol salt solution were significantly less damaged than those stored in any other solution (p less than 0.05). After 48 and 72 hours at 4 degrees C, cells stored in ViaSpan were significantly more intact than cells stored in EuroCollins and 0.9% saline solution (p less than 0.05). This study demonstrates that endothelial cell damage occurs during cold storage and that a polyethylene glycol-based solution showed superior cellular preservation.

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Inflammation of the appendix is a common cause of acute abdominal pain. The etiology and pathophysiology of appendicitis have been well described. The initiating factor often is obstruction of the appendiceal lumen by inspissated stool, barium, food, parasites, or hyperplastic lymphoid tissue. Two patients have been identified who developed appendicitis temporally related to blunt abdominal trauma, without other clear etiology. Although absolute documentation of trauma as an etiologic factor in these cases is difficult, theoretical mechanisms for the occurrence are discussed. In the setting of right lower quadrant pain following mild to moderate blunt abdominal trauma, acute appendicitis should be considered as a possibility.

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