Stenting of a renal artery bifurcation stenosis

Gene therapy, in particular the transfer of genes encoding immunostimulatory molecules (cytokines and costimulatory molecules) as well as selectively cytotoxic enzymes and DNA vaccination, has the potential of enhancing cell mediated immune responses against tumours including those of colorectal origin. Genes can be transferred using viral vectors either to cultured tumour cells in vitro that can be returned to the patient as a "cancer vaccine", or directly to tumour cells in vivo. Vaccination with DNA constructs expressing specific tumour antigens characteristic of colorectal neoplasia can trigger immune recognition and destruction of tumour cells. The aim is to tip the balance from protumour to antitumour mechanisms by generating a local immune response and systemic antitumour immune memory to destroy metastases. Studies in murine models, combined with human studies, show that such approaches could become an adjunct to current treatments for human colorectal cancer in the near future.     

Focal occlusive disease of the common femoral artery: a report of 20 cases

Occlusive disease localized to the common femoral artery without contiguous involvement of the external iliac and superficial femoral arteries is distinctly uncommon in vascular surgical practice. Twenty patients with focal occlusive disease in 21 common femoral arteries are featured in this report. All except one had severe disabling symptoms: Fontaine classification was stage I in one patient, stage IIb in 13, and stage III in six patients. The probable aetiology, based on clinical features and angiographic observations, was identified as atherosclerosis (nine cases), thromboangiitis obliterans (three) and Takayasu's arteritis (two). Histological features of mucoid vasculopathy, a novel disorder, was seen in one patient while no specific aetiology was evident in five patients. Associated lesions were seen in fourteen patients: aortoiliac in one, femoropopliteal in seven (without any continuity to the common femoral lesion), internal iliac in three and tibial in three. Balloon angioplasty of the common femoral artery lesions was attempted in 14 patients with successful outcome in nine. Three patients (including two with failed balloon angioplasty), underwent thromboendarterectomy and two bypass procedures (iliofemoral, one; femoropopliteal, one). Late reocclusion occurred in one patient each in the angioplasty and surgical groups. There were no procedure-related complications in either group.     

Iatrogenic vertebrobasilar insufficiency after surgery of the subclavian or brachial artery: review of three cases

OBJECTIVE AND IMPORTANCE: Vertebrobasilar insufficiency resulting from disease of the subclavian artery is well recognized. Usually, this occurs as the "subclavian steal" syndrome in the context of chronic subclavian stenosis and is consequently well tolerated because of collateralization. Acute disruption of the hemodynamics of the aortic arch vessels, however, can produce disastrous sequelae. CLINICAL PRESENTATION: We present three cases of iatrogenic vertebrobasilar insufficiency sustained as complications of surgery of the left subclavian artery or its distal continuation. The cases were chosen from a review of approximately 400 emergency neurosurgery consultations requested at the Los Angeles County Hospital between November 1995 and February 1996. INTERVENTION: The first patient underwent repair of a traumatic brachial artery occlusion and awoke postoperatively with bilateral cortical blindness, right hemiparesis, and multiple cranial nerve deficits that were most likely caused by acute subclavian steal. The second underwent removal of a subclavian embolus and developed bilateral cerebellar infarction leading to persistent coma, possibly from inadvertent embolization of the vertebral artery during surgery. The third underwent resection and bypass grafting of a subclavian aneurysm. Good backflow was reported when the vertebral artery was disarticulated from the subclavian artery, and this vessel was not reimplanted into the graft. The patient suffered massive cerebellar infarction leading rapidly to brain death. CONCLUSION: There are myriad ways in which the inherent redundancy of the vertebrobasilar system may be jeopardized, and when this protective mechanism fails, the results can be disastrous. Flow through the vertebral arteries may be compromised by thrombosis, embolization, dissection, inappropriate ligation, excessive head rotation, hypotension, vasospasm, or acute subclavian steal. These examples illustrate the importance of understanding the complex physiology of posterior fossa circulation as the basis of pre-, intra-, and postoperative management of patients undergoing surgery of the subclavian artery.     

War injuries of the femoral artery and vein: a report on 67 cases

During the war in Croatia (from May 1991 to December 1995), 67 patients with war injuries of the femoral vein and/or artery were treated at the Surgical Clinic of Split Clinical Hospital. All the wounded were admitted directly from the battlefield or from front-line hospitals. There were five women and 62 men with a median age of 29 (range 15-54) years. There were 70 arterial (28 isolated) and 49 venous injuries (six isolated). Forty-six arterial injuries were repaired by reverse vein graft. Four proximal profound femoral arteries were reconstructed. Major venous injuries were repaired, 11 by compilation autogenous vein graft. No synthetic grafts were used. Repair of veins with large defects using compilation saphenous vein grafts gave good results. Six profound femoral veins and two superficial femoral veins were ligated. Vein ligation should be avoided unless another life-threatening injury demands priority. Twenty-one patients required open prophylactic fasciotomy. Two patients died (3%) and three ultimately underwent amputation (5%). Intermittent hyperbaric oxygen therapy was given to 18 heavily wounded patients with beneficial effect. The results support an immediate and coordinated approach to femoral vascular trauma with repair of arterial and venous injuries.     

Posterior urethral valves in adults: a report of 2 cases

Herein we review 2 cases of posterior urethral valves in adults. Significant secondary bladder neck obstruction occurred in both cases and required transurethral incision before the bladder outlet obstruction was relieved. The management is described of the secondary upper tract changes that occurred.     

Extratesticular lipoma: report of 2 cases and a new classification

We report 2 cases of intrascrotal extratesticular lipoma and propose a new classification. If the possible anatomic sites of origin and the histology of this neoplasm are considered during dissection the tumor can be excised without unnecessary orchiectomy when the blood supply of the testicle can be preserved.     

Odontogenic fibroma in Sprague-Dawley rats: a report of 2 cases

Two cases of odontogenic fibroma occurring in aged Sprague-Dawley rats are described. Both neoplasms were associated with a maxillary incisor and had identical histomorphological features. They were composed of solid proliferations of primitive, dental pulp-like mesenchyme separated by areas of collagenization. Small strands and islands of mainly undifferentiated odontogenic epithelium immunostaining for keratins were scattered throughout both tumours. As a further characteristic, the lesions contained small foci of mineralization which were either cementum-like or resembled dysplastic dentin. The odontogenic fibroma represents a further type of odontogenic tumour in rats, which due to its typical histomorphology, can easily be differentiated from other odontogenic tumours such as ameloblastic odontoma or ameloblastoma.     

Vertebral artery injury following mild neck trauma: report of two cases

Two cases of vertebral artery injury following mild neck trauma are reported. A 52-year-old man was hospitalized with gait disturbance 7 days after mild traffic accident. Right vertebral angiogram revealed complete occlusion of the rt. vertebral artery (VA) and MR images revealed infarction in the rt. cerebellar hemisphere and rt. dorsolateral part of the medulla oblongata and revealed the thrombus in the rt. VA. He underwent anticoagulation and became asymptomatic. Angiogram 6 months later revealed the vessel to be normal. A 23-year-old man who has a habit of self-manipulation of his neck was hospitalized on the day when he experienced dysesthesia in the left part of his face and left upper and lower extremities and unsteady gait. MR images revealed multiple infarction in bilateral cerebellar hemispheres and thrombus in bilateral VAs. Bilateral vertebral angiogram revealed severe stenoses of bilateral VAs. He underwent anticoagulation and wore soft collar. Angiogram 20 days after onset revealed improvement of bilateral VA stenoses. He was discharged with no neurological deficit. It is said that vertebral artery injuries in association with head and neck trauma are relatively rare, but this condition is possible to be more common than realized, considering that the case of unilateral VA occlusion or the case with well developed collateral circulation is sometimes well tolerated for ischemia and that this condition can occur even after mild head and neck injury. The diagnosis must be established by vertebral angiogram, but MRI and MRA are very useful as ancillary methods. The therapeutic point is to prevent propagation of the thrombus and distal embolism, accordingly wearing a collar and anticoagulation are important.     

Giant aneurysms of the proximal anterior cerebral artery: report of three cases

Aneurysms of any size involving the A1 segment of the anterior cerebral artery are unusual, but giant aneurysms in this location are exceedingly rare, with only five cases previously reported in the literature. We report three cases of A1 segment giant aneurysms presenting with mass effect that were successfully treated. A discussion of the salient features of diagnosis and treatment are presented, along with a brief review of the literature describing these aneurysms. The role of newer imaging modalities, including magnetic resonance imaging, magnetic resonance angiography, and intraoperative angiography, is discussed. The three patients were treated by direct exploration, trapping, and endaneurysmal decompression. Giant A1 segment aneurysms present a unique opportunity to safely trap and decompress the aneurysm with definitive cure.     

Constrictive pericarditis after coronary artery bypass surgery as a cause of unexplained dyspnea: a report of five cases

Constrictive pericarditis after coronary artery bypass grafting (CABG) is rare and can present as unexplained dyspnea. We report five consecutive cases of post-CABG constrictive pericarditis seen within a period of 17 months at our institution. All patients presented with heart failure of unknown etiology within a period of 8-84 months after surgery. During the initial post-CABG period, two patients had developed postcardiotomy syndrome that was successfully treated with steroids. They were all assessed noninvasively and invasively. In all patients, the diagnosis of constriction was initially suspected clinically (symptoms, high jugular venous pressure with deep "X" and "Y" descents, pericardial knock). Echocardiography showed transmitral flow typical of constriction in all patients and hepatic venous flow in two. Two patients showed rapid left ventricular relaxation. In all patients, hemodynamic assessment showed diastolic equalization of pressures in all chambers, "W" shape waveform in right atrial pressure, and "dip and plateau" configuration in right and left ventricular pressure waveforms. Diagnosis was confirmed surgically in four patients who were subjected to pericardiectomy-pericardial stripping (three survived, one died). One patient refused surgery. We conclude that constrictive pericarditis, although rare, should be suspected in every case of unexplained dyspnea post CABG. It can appear early or late after surgery, and clinical examination plays an important role in its early recognition. It requires a full noninvasive and invasive assessment in case of clinical suspicion.     

Venous graft repair following brachial artery thrombosis in a neonate

A case of venous graft repair to recover blood flow of a newborn's upper extremity, is described. Even though this complication remains uncommon, we emphasize on to avoid brachial artery for vascular monitorization and to perform microsurgical revision as elective procedure if conservative therapy is unsuccessful.     

Intestinal changes after jejuno-ileal shunt in obesity: a report of 2 cases

Two cases of end-to-end and end-to-side jejuno-ileal bypass for the treatment of obesity are reported in which both patients underwent reoperation 17 and 23 months later respectively. Macroscopic examination and measurements of length of the various segments of the small intestine have been performed twice in each patient: at the time of the bypass and at the second surgical procedure. In one patient a histological study of both the excluded and functioning small intestine was carried out at the time of each surgical procedure. The functioning intestine had increased in size while the excluded segment had become narrowed. The height of the villi had increased slightly in the functioning ileum and more so in the functioning jejunum compared with the preoperative measurements. In contrast, the height of the villi was moderately reduced in both the bypassed jejunal and ileal segments. These findings confirm the results of experimental studies in animals.     

Hepatitis C virus infection presenting as a polyarthritis: report of 2 cases

Several disease have been associated with hepatitis C virus infections, including rheumatologic, hematologic and neoplastic disorders. We report two women, aged 57 and 39 years old whom the initial presentation of hepatitis C virus infection was an arthritis resembling rheumatoid arthritis. Laboratory work up revealed abnormal liver function tests, stimulating the search for hepatitis C virus infection, having both patients positive ELISA tests. Detection of this agent is extremely important when selecting a therapy for the articular disease, since several drugs used in the treatment of rheumatic disorders are potentially hepatotoxic and immunosuppression is risky in the setting of a viral hepatitis.     

Aneurysm in a persistent sciatic artery. Apropos of 2 cases

Persistent sciatic is a vascular malformation resulting in the embryo from the preferential growth of the ischiatic posterior axis remaining atrophic. We report here two cases of unilateral, complete and incompleted, persistent sciatic arteries, complicated by buttock aneurysm.     

Uretero-external iliac artery fistula: a case report

We report a case of uretero-external iliac artery fistula. A 60-year-old female was referred to our hospital complaining of intermittent gross macrohematuria. She had undergone radical hysterectomy, radiation therapy and chemotherapy for advanced cervical cancer 2 years ago. The patient had a 7 Fr ureteral double-J stent for left hydronephrosis. Retrograde urography showed a filling defect (8 mm in diameter) of the left ureter. A contrast-enhanced computed tomographic scan showed left hydronephrosis and hydroureter but no evidence of fistula formation or extravasation. A pelvic arteriography revealed a pseudoaneurysm of the left external iliac artery at the crosspoint between the left ureter and the iliac artery. Surgical repair of the left uretero-external arterial fistula was successfully performed as well as left nephroureterectomy. The possibility of fistula formation between ureter and artery should be kept in mind in patients with long-term indwelling ureteral stents and history of radiation therapy.     

Joubert syndrome: a report of 5 cases

OBJECTIVE: To review clinical features, radiological findings and prognosis in Joubert syndrome. MATERIAL AND METHODS: We report 5 children (3 male and 2 female) with the diagnosis of Joubert syndrome by clinical and radiological findings. They were diagnosed in the first year of life, in the Hospital Infantil La Paz (Madrid, Spain), from 1971 to 1996. Three patients have already been published, and here, we report two new cases. RESULTS: Partial absence of the cerebellar vermis, hypotonia and developmental delay were seen in all patients. Other cardinal findings were episodic hyperpnoea (5/5) with periods of apnoea (2/5), abnormal eye movements (2/5) and strabismus (3/5), tongue protrusion (2/5), seizures (1/5), hemifacial spasms (1/5) and occipital meningocele (2/5). Clinical manifestations were first noticed soon after birth. Two patients died in the first 5 years of life, and the rest of the cases actually show severe mental retardation. CONCLUSIONS: Joubert syndrome is a rare and probably underdiagnosed syndrome with bad prognosis. This inherited condition is characterized by agenesis of the cerebellar vermis, mental retardation, hypotonia, episodic hyperpnoea and abnormal eye movements. Additional manifestations have been reported since the original cases were described.     

Transarterial brachial plexus anesthesia for hand surgery: a retrospective analysis of 346 cases

STUDY OBJECTIVES: To study the safety and efficacy of the transarterial approach to brachial plexus block with 60 to 70 ml of local anesthetic solution, and to compare the success and complication rates of this block performed by experienced or inexperienced anesthesiologists. DESIGN: Retrospective analysis of 346 records of ASA physical status I-IV patients who underwent elective unilateral orthopedic upper limb surgery with transarterial plexus anesthesia. SETTING: University teaching hospital. MEASUREMENTS AND MAIN RESULTS: Blood pressure (BP) and heart rate were measured at 5-minute intervals. Analgesia was registered as successful, incomplete, or failed. Any patient complaints or adverse reactions were recorded. The first 60 ml of local anesthetic provided surgical analgesia to 64% of patients. With a supplemental 10 ml of anesthetic, the overall success rate was 94%, with only 19 of 346 patients requiring general anesthesia. Experience in performing the block increased the success rate from 90% to 98% (p < 0.001). Six patients experienced either nausea or a transient BP decrease that did not require medication. There was no record of toxic or other serious adverse reaction. CONCLUSIONS: Transarterial brachial plexus block administered with a 60 to 70 ml dose of local anesthetic provides surgical analgesia for hand surgery with an excellent success rate and without serious adverse effects.