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Iatrogenic and Noniatrogenic Arterial Trauma: A Comparative Study – Commentary

28 Σεπτεμβρίου, 2012

Δεν επιτρέπεται σχολιασμός στο Iatrogenic and Noniatrogenic Arterial Trauma: A Comparative Study – Commentary

Συντάχθηκε από:

Αναστάσιος Λιάτας, MD, F.I.C.A. – Διευθυντής Χειρουργός

A C Liatas, MD, F.I.C.A. – Consultant Surgeon

Athens  General  Hospital  » EVAGELISMOS «

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Iatrogenic and Noniatrogenic Arterial Trauma

Purpose of study

This study compared patients with iatrogenic and noniatrogenic arterial injuries.

Conclusion

Retrospective assessment of the appropriateness of technique, made separately by two vascular surgeons, revealed instances of potentially avoidable iatrogenic arterial injury. The increasing incidence of iatrogenic arterial trauma may therefore be considered reducible.

Commentary

The paper states the expected conclusions: that iatrogenic injuries increase with the incidence of invasive procedures, that such injuries are nearly always related to the catheterization site and that in them thrombosis is a more frequent complication than hemorrhage. The noniatrogenic injuries (blunt trauma, motor vehicle accident and knife and gun injuries) had a predictably higher rate of associated and postoperative complications. The 14% mortality rate reported in the iatrogenic group is nearly 4-10 fold that reported in larger reviews. These results may be biased by the relatively few cases included in this report. – Ramon Berguer; Detroit

Δημοσίευση Άρθρου

Το πλήρες άρθρο έχει δημοσιευτεί στο:  [International Vascular Surgery 1991; 1:92-93]

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Για το πλήρες άρθρο «Iatrogenic and Noniatrogenic Arterial Trauma…» πατήστε:  Εδώ (.pdf αρχείο).

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Iatrogenic and noniatrogenic arterial trauma – a comparative study

15 Σεπτεμβρίου, 2012

Δεν επιτρέπεται σχολιασμός στο Iatrogenic and noniatrogenic arterial trauma – a comparative study

Συντάχθηκε από:

Αναστάσιος Λιάτας, MD, F.I.C.A. – Διευθυντής Χειρουργός

A C Liatas, MD, F.I.C.A. – Consultant Surgeon

Athens  General  Hospital  » EVAGELISMOS «

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Iatrogenic and Noniatrogenic Arterial Trauma

Introduction

Iatrogenic arterial trauma may arise in diagnostic or therapeutic  procedures   (Gr.   ἰατρός  =  physician, γεννώ = give birth to). The incidence of reported iatrogenic  arterial  trauma  has  clearly risen in recent years, as a result of the dramatically increased performance  of  cardiac  catheterization  and angiography, or of the increasingly  radical  operations now performed for a variety of lesions in all surgical fields.

Purpose of study

This study compared patients with iatrogenic and noniatrogenic arterial injuries.

Discussion

Although iatrogenic arterial trauma is a well defined clinical entity, its reported incidence in relation to total numbers of arterial injuries varies from 1.4% to 76% . In our study, 34% of the arterial injuries were iatrogenic. As some cases of iatrogenic arterial injury are not reported for fear of legal consequences, no clear picture of the problem’s size is obtainable.
The arteries of the extremities most often affected were brachial and femoral, the commonest sites of arterial puncture in the iatrogenic group, and leg arteries were mostly injured in noniatrogenic group. Orthopaedic and general surgery were responsible for most iatrogenic injuries. Haemorrhage, presenting either as an arterial bleed or as an expanding haematoma, occurred in 28 of our 43 non iatrogenic arterial injuries, but in only four of the 22 in the iatrogenic group (p < 0.001). The patients in that group presented mainly with severe or mild ischaemia.
The postoperative mortality rate did not differ significantly between iatrogenic and noniatrogenic group, which accords with previously reported corresponding rates of 10% and 15 % . Other authors found 4 %  or 1.7%  mortality in their series of iatrogenic vascular injury, compared with 14 % in our series.
Factors of two types have been implicated in iatrogenic vascular injury, viz. doctor-related (inadequate knowledge, inefficient anatomic dissection or traumatic or faulty technique) and patient-related (inflammation, tumour, irradiation, reoperation, anatomic variations). Most of them are related to arterial catheterization performed mainly by nonsurgeons.

Conclusion

As iatrogenic arterial injuries may occur even in the most capable hands, they must be recognized and adequately corrected so as to reduce the risk of incapacitating sequelae.

Δημοσίευση του Άρθρου

Το πλήρες άρθρο έχει δημοσιευτεί στο: [ Eur J Surg 1991; 157:17-20 ]

Αρχείου του Άρθρου

Για το πλήρες άρθρο «Iatrogenic and Noniatrogenic Arterial Trauma: a comparative study» πατήστε: Εδώ  (.pdf αρχείο).
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Η χειρουργική θεραπεία των ανευρυσμάτων της κοιλιακής αορτής σε υπερήλικες

14 Ιουνίου, 2012

Δεν επιτρέπεται σχολιασμός στο Η χειρουργική θεραπεία των ανευρυσμάτων της κοιλιακής αορτής σε υπερήλικες

Συντάχθηκε από:

Αναστάσιος Λιάτας, MD, F.I.C.A. – Διευθυντής Χειρουργός

A C Liatas, MD, F.I.C.A. – Consultant Surgeon

Athens  General  Hospital  » EVAGELISMOS «

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Σύνοψη Άρθρου

Σκοπός αυτής της μελέτης είναι η ανάλυση όλων των περιπτώσεων Ανευρυσμάτων Κοιλιακής Αορτής (Α.Κ.Α) που χειρουργήθηκαν εκλεκτικά ή επειγόντως στο Αγγειοχειρουργικό Τμήμα του Νοσοκομείου μας κατά την τελευταία 10ετία με ιδιαίτερη έμφαση στους ασθενείς ηλικίας >75 ετών που χειρουργήθηκαν για Α.Κ.Α οξέως ή εκλεκτικά. Διαπιστούται στατιστικά σημαντική διαφορά στη θνητότητα μετά από εγχείρηση για ρήξη Α.Κ.Α μεταξύ υπερηλίκων (>75 ετών) και ασθενών ηλικίας (<75 ετών) που έχουν καλό προσδόκιμο επιβίωσης.

Abstract

«Surgical Treatment of Abdominal Aortic Aneurysms in the Elderly»

An increasingly growing incidence of abdominal aortic aneurysms has been observed in recent years resulting from the increase of life expectancy. Therefore aneurysmatectomy has become one of the most frequently performed operations in vascular surgery. From 1985 to 1989 seventy nine cases of abdominal aortic aneurysms were operated upon in the Department of Vascular Surgery of Athens General Hospital. 41 were elective whereas 38 were due to a ruptured abdominal aortic aneurysm. Group A (28 cases) included patients > 75 years of age (mean age = 79 years) and Group B (51 cases) comprised of patients <75 years of age (mean age = 67.3 years). There was a statistically significant difference in the mortality rate in the operated patients of groups A and B following rupture of their aneurysm whereas there was not such a difference among the patients of both groups when they had operated their aneurysm electively. Therefore elective surgery of abdominal aortic aneurysm should be undertaken in the elderly when life expectancy is anticipated to warrant the risks of the almost inevitable rupture of such an aneurysm.

Δημοσίευση Άρθρου

Το πλήρες άρθρο έχει δημοσιευτεί στο: [ Ιατρικά Χρονικά, Τόμος ΙΓ, Τεύχος 4, Σελ. 357-360 ]

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Για το πλήρες άρθρο «Η Χειρουργική Θεραπεία των Ανευρυσμάτων…» πατήστε:  Εδώ (.pdf αρχείο).

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The Atherosclerotic Popliteal Artery Aneurysm

28 Μαΐου, 2012

Δεν επιτρέπεται σχολιασμός στο The Atherosclerotic Popliteal Artery Aneurysm

Συντάχθηκε από:

Αναστάσιος Λιάτας, MD, F.I.C.A. – Διευθυντής Χειρουργός

A C Liatas, MD, F.I.C.A. – Consultant Surgeon

Athens  General  Hospital  » EVAGELISMOS «

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Introduction

Aneurysms of the peripheral vessels are located in most cases in the popliteal arteries and are mainly atherosclerotic in nature. Popliteal artery aneurysms cause serious complications and they are the 2nd most common ones after abdominal aortic aneurysms.

In contrast to the aneurysm of the abdominal aorta, with rupture being its main complication, the popliteal artery aneurysm causes primarily an acute or chronic ischemic syndrome. The morbidity of the popliteal artery aneurysm is high because it is mostly diagnosed and treated when complications have been established. Hence, during the first examination, Wychulis and Evans have identified evidence of a previous arterio-arterial embolism in 38% and 51% of their cases respectively and in 12% of the patients’ toes necrosis existed already.

In an effort to minimize morbidity, every attending doctor has to be proficient in both the natural course of the disease and the therapeutic alternatives in both the acute and chronic stage.

In this study, we present an analysis of our own patients with regard to the diagnosis, surgical treatment and interventional results of the acute and chronic course of atherosclerotic popliteal artery aneurysms.

Patients and methods

28 patients with 48 popliteal artery aneurysms were treated as in-patients between 1982 and 1990. We found bilateral popliteal artery aneurysms in 19 (68%) patients whereas in 10 (36%) ones popliteal artery aneurysm coexisted with aneurysm elsewhere in the body. 36 (75%) of the popliteal artery aneurysms developed complications, specifically 15 (31%) developed peripheral arterio-arterial embolism, 16 (33%) had acute arterial thrombosis, 4 (8%) presented with non treatable ischemic damage of the affected extremity, 1 (2%) had ruptured and 2 (4%) had concomitant compression-caused venous thromboses. The severe complication of acute arterial occlusion resulted in amputation in 20% of the cases. Peripheral embolisms had caused obstruction of the outflow tract with persistence of incapacitating intermittent claudication even postoperatively. Severe ischemic complications occurred in cases of small aneurysms as well. In conclusion, all popliteal artery aneurysms regardless of their size must be treated promptly in order to avoid serious complications.

Clinical picture

The characteristic clinical and the diagnostic findings were as follows:

  1. In all cases of non-thrombosed aneurysms, there was a striking palpable pulsating mass in the popliteal fossa, whereas in the thrombosed aneurysms there was a palpable non-pulsating mass in the area.
  2. In cases of acute ischemia of a lower extremity along with a coexisting aneurysm in the ipsilateral popliteal fossa, the cause of the ischemia was also a popliteal artery aneurysm.
  3. Aneurysms on both popliteal fossae were found in 19 (68%) patients. Like Brunner, we do observed significant differences between sides.

Diagnosis

The diagnosis was completed with the x-ray examinations. The simple radiogram showed in some cases the calcified aneurysmal border. Ultrasonography and computer tomography helped in establishing the diagnosis and determine the size of the popliteal aneurysm, in addition to investigate and localize further coexistent aneurysms elsewhere in the body. Furthermore, these examinations were helpful in the differential diagnosis regarding cystic formations or tumors. Unfortunately, these diagnostic modalities do not give sufficient information about the condition of the peripheral vessels distal to the aneurysm, which are however important for the surgical planning. The arteriography was almost in every case typical for the aneurysm, except for the cases with partial or total occlusion.

Surgical Method

In 34 surgeries a medial femoropopliteal access was chosen, while a dorsal one was chosen only in one surgery. The aneurysm (if small) was eliminated through proximal and distal ligation. Collaterals, if present, were ligated as well. Big aneurysms were clamped off at the proximal and distal end, were opened lengthwise and were evacuated from the thrombotic material. In order to avoid popliteal venous injuries, only a partly resection was performed, preserving the wall section adjacent to the vein. The re-establishment of the vascular continuity was effected in 21 cases with an autologous venous transplant of the contralateral great saphenous vein. In the remaining 14 cases, we used synthetic grafts, mostly PTFE. If the trifurcation was involved in the underlying disease or in the case of occlusion of the same, the distal anastomosis was usually performed without any difficulties, due to the general vascular dilation, in the central or distal part of the arteries of the lower leg.

In all cases with acute ischemia, a generous fasciotomy was performed following the completion of vascular continuity.

Discussion

Aneurysms of the popliteal artery are the most frequent ones among all peripheral aneurysms. They are mainly of atherosclerotic in origin and only 4% of the cases have different origin, such as: Marfan syndrome, syphilis, bacterial infection, Behçet-syndrome, trauma or entrapment syndrome of the popliteal artery. The medical condition usually becomes apparent in the 5th-7th decade of age and afflicts mainly men in a gender ratio of 30:1.

The most frequent severe complication of popliteal aneurysms is the acute thrombotic occlusion, which often has a dramatic course.

The timely diagnosis and treatment of the acute cases is decisive for the final result. Apart from the acute arterial occlusion, the popliteal aneurysm leads also to peripheral arterioerterial embolisms which can be asymptomatic.

We did not experience any amputation in the “a froid” operated cases, but we observed a persistence of the pre-existing intermittent claudication with invalidating consequences. The frequent permanent invalidity of patients operated upon in the complication stage, calls for timely surgery of all popliteal aneurysms, regardless of their size.

 

This paper was presented in «Aneurysma, Forum Angiochirurgicum», Innsbruck 4 – 6 October 1990

and has been published in: [ angio archv Bd. 20 (1991); 278-281 ]

The full article is free (.pdf) : Atherosclerotic aneurysm of the popliteal artery

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Οι μηροϊγνυακές παρακάμψεις στους υπερηλίκους

15 Απρίλιος, 2012

Δεν επιτρέπεται σχολιασμός στο Οι μηροϊγνυακές παρακάμψεις στους υπερηλίκους

Συντάχθηκε από:

Αναστάσιος Λιάτας, MD, F.I.C.A. – Διευθυντής Χειρουργός

A C Liatas, MD, F.I.C.A. – Consultant Surgeon

Athens  General  Hospital  » EVAGELISMOS «

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Femoropopliteal Bypasses in the Elderly

Σύνοψη Άρθρου

Σκοπός αυτής της μελέτης είναι η ανάλυση όλων των περιπτώσεων μηροϊγνυακών (Μ-Ι) παρακάμψεων που εκτελέστηκαν κατά την τελευταία 4ετία στο Αγγειοχειρουργικό Τμήμα του Γενικού Κρατικού Νοσοκομείου Αθηνών σε ασθενείς με αποφρακτική αρτηριοπάθεια σταδίων III και IV κατά Fontaine με ιδιαίτερα έμφαση σε εκείνους > 75 ετών. Εκτελέστηκαν 57 Μ-Ι παρακάμψεις από το 1985-1989. Διεπιστώθη: 1) ότι οι Μ-Ι αποφράξεις στους υπερήλικους πρέπει να χειρουργούνται με τοποθέτηση παρακάμψεως, ιδίως αυτολόγου φλεβικού μοσχεύματος όπου αυτό είναι δυνατόν, και 2) ότι η ηλικία και οι περιφερικές ισχαιμικές βλάβες δεν πρέπει να είναι ανασταλτικοί παράγοντες της χειρουργικής θεραπείας δεδομένης της υψηλής θνητότητας του μείζονος ακρωτηριασμού καθώς και των κοινωνικών προβλημάτων που απορρέουν από αυτόν.

Abstract

«Femoropopliteal Bypasses in the Elderly»

57 femoropopliteal bypasses were performed from 1985 to 1989 in the department of Vascular Surgery of Athens General Hospital. The patients in this study were divided into two groups: A and B. Group A included patients > 75 years of age and group 8 included patients < 75 years of age. Both groups were studied according to the type of graft (autologous of PTFE) which was used, whether the distal end of the graft was above or below the knee, the patency rate and the limb salvage rate. Femoropopliteal atherosclerotic occlusions in the elderly should be corrected surgically using autologous or PTFE grafts. Surgery of this type in the elderly is a well tolerated surgical procedure with minimal mortality and high limb salvage rate. Autologous vein grafts give better results compared to PTFE ones regarding the patency rate although the later is a good alternative when the saphenous vein is not available.

Δημοσίευση Άρθρου

Το πλήρες άρθρο έχει δημοσιευτεί στο: [ Ιατρικά Χρονικά, Τόμος ΙΓ, Τεύχος 5, Σελ. 415-418 ]

Αρχείο Άρθρου

Για το πλήρες άρθρο «Οι Μηροϊγνυακές Παρακάμψεις στους Υπερηλίκους» πατήστε: Εδώ (.pdf αρχείο).

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Το αρτηριοσκληρωτικό ανεύρυσμα της ιγνυακής αρτηρίας

3 Μαρτίου, 2012

Δεν επιτρέπεται σχολιασμός στο Το αρτηριοσκληρωτικό ανεύρυσμα της ιγνυακής αρτηρίας

Συντάχθηκε από:

Αναστάσιος Λιάτας, MD, F.I.C.A. – Διευθυντής Χειρουργός

A C Liatas, MD, F.I.C.A. – Consultant Surgeon

Athens  General  Hospital  » EVAGELISMOS «

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Εισαγωγή

Τα ανευρύσματα των περιφερικών αρτηριών εντοπίζονται, ως επί τω πλείστον, στις ιγνυακές αρτηρίες και είναι, κυρίως, αρτηριοσκληρωτικής αιτιολογίας. Τα ανευρύσματα της ιγνυακής αρτηρίας (ΑΙΑ) προκαλούν σοβαρές επιπλοκές και είναι η 2η συνηθέστερη εντόπιση μετά τα ανευρύσματα της κοιλιακής αορτής.

Σε αντίθεση με το ανεύρυσμα της κοιλιακής αορτής, η κύρια επιπλοκή του οποίου είναι η ρήξη του, το ΑΙΑ προκαλεί είτε οξύ είτε χρόνιο σύνδρομο. Η νοσηρότητα του ΑΙΑ είναι υψηλή λόγω, συνήθως, της διάγνωσης και θεραπείας του σε φάση ήδη εγκαταστηθεισών επιπλοκών.

Στην παρούσα μελέτη παρουσιάζουμε ανάλυση των δικών μας περιστατικών ως προς τα αποτελέσματα των διαγνωστικών μεθόδων, τη χειρουργική θεραπεία και τις θεραπευτικές παρεμβάσεις τόσο στο οξύ όσο και στο χρόνιο στάδιο των ΑΙΑ.

Δημοσίευση του Άρθρου

This paper was presented in “Aneurysma, Forum Angiochirurgicum”, Innsbruck 4 – 6 October 1990

and has been published in: [ angio archv Bd. 20 (1991); 278-281 ]

Αρχείο Άρθρου

Για το πλήρες άρθρο “ Το αρτηριοσκληρωτικό ανεύρυσμα της ιγνυακής αρτηρίας ” πατήστε: Εδώ  (.pdf αρχείο)

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Das arteriosklerotische Aneurysma der Arteria Poplitea

2 Φεβρουαρίου, 2012

Δεν επιτρέπεται σχολιασμός στο Das arteriosklerotische Aneurysma der Arteria Poplitea

Συντάχθηκε από:

Αναστάσιος Λιάτας, MD, F.I.C.A. – Διευθυντής Χειρουργός

A C Liatas, MD, F.I.C.A. – Consultant Surgeon

Athens  General  Hospital  » EVAGELISMOS «

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Einleitung

Aneurysmen an peripheren Gefäßen sind am häufigsten an der arteria poplitea lokalisiert und sind hauptsächlich arteriosklerotischer Natur. Sie führen nach dem Bauchaorten- aneurysma am zweithäufigsten zu ernsthaften Komplikationen.

Patienten und Methode

28 Patienten mit 48 Poplitealaneurysmen wurden zwischen 1982-1990 stationär behandeIt. Wir fanden ein bilaterales Vorkommen bei 19 (68%) und eine extrapopliteale Koexistenz bei 10 (36%) der Patienten. 36 (75%) Aneurysmen waren durch folgende SymptomatoIogie kompliziert: 15 (31%) periphere arterioarterielle Embolie, 16 (33%) akute arterielle Thrombose, 4 (80%) nicht zu therapierender ischämischer Schaden, 1 (2%) Ruptur und 2 (4%) konkommitierende kompressionsbedingte Venenthrombosen. Die ernsthafte Komplikation des akuten Verschlußes führte in 20% der Fälle zur Amputation. Die periphere Embolien führten zur Beeinträchtigung der Ausflußbahn mit Persistenz einer invalidisierender claudicatio intermittens auch postoperativ. Die ischämische Komplikationen traten auch bei kleinen Aneurysmen auf. Zur Vermeidung der invalidisierenden Folgen, müssen die Poplitealaneurysmen rechtzeitig behandelt werden.

Therapie

Von den 28 Patienten wurden 19 (68%) mit 35 Aneurysmen (73%), operiert. Bei 4 (14%) anderen Patienten mit 4 (8%) Aneurysmen führte die langbestehende Ischämie zur primären Amputation. 5 (18%) Patienten mit 9 (19%) Aneurysmen wurden nicht operiert, (2 stimmten der Operation nicht zu, 1 Patient war nicht operabel und 2 Patienten kamen mit einer Ruptur der Aorta adominalis und starben im Anschluß an dieser Operation).

Ergebnisse

Von den 35 Eingriften an den Aneurysmen, endeten 6 (17%) mit der Amputation, im unmittelbaren postoperativen Verlauf. Alle 6 Fälle waren solche mit schwerer akuter Ischämie und verspäteter Diagnosestellung bzw. Revaskularisation. Die einzige Ruptur wurde mit Erfolg operiert. Erfolgreich waren ebenfalls die 18 Elektivoperationen. Bei allen Patienten mit präoperativer claudicatio inmittens, persistierte die Symptomatologie ebenfalls postoperativ. Während der Beobachtungszeit stellten wir 6 (21%) Bypassverschlüsse, bei Patienten mit primär erfolgreicher Revaskularisation. Die Folge war eine Verminderung der freien Gehstrecke. Eine Amputation war nicht notwendig.

Diskussion

Aneurysmen der Α. poplitea sind die häufigste aller peripheren Aneurysmen. Sie sind vorwiegend arteriosklerotischer Genese und nur in 4% Fälle anderer Ursache, wie: Marfan, Lues, bakterielle Infektion, Behcet-Syndrom, Trauma oder Entrapment-Syndrom der Α. poplitea.
Die häufigste schwerwiegende Komplikation von Poplitealaneurysmen ist der akute arterielle thrombotische Verschluß, welcher sehr oft einen dramatischen Verlauf hat.
Rechtzeitige Diagnose und Therapie in den akuten Fällen, ist für das endgülte Ergebnis maßgebend. Außer dem akυten arteriellen Verschluß, führt das Poplitealaneurysma zυ peripheren arterioarteriellen Embolien, welche, asymptomatisch sein können.
Die Häufigkeit der bleibenden Invalidität bei den Patienten die im Stadium der Komplikation operiert wurden, zwingen zur rechtzeitigen Operation aller Poplitealaneurysmen unabhängig von ihrer Größe.

This paper was presented in «Aneurysma, Forum Angiochirurgicum», Innsbruck 4 – 6 October 1990 and has been published in:

[ angio archv Bd. 20 (1991); 278-281 ]

The full article is free (.pdf) :  Das arteriosklerotische Aneurysma der Arteria Poplitea GE

Continue reading...