A 55-year-old man presented to the emergency department with a 5-day history of lower back pain and fevers. On admission, the white cell count was 24.7 x IOY'L, erythrocyte sedimentation rate (ESR) was 116mmh and a computed tomography (CT) scan revealed a right lower pole renal mass and a 4-cm infrarenal abdominal aortic aneurysm (AAA). Blood cultures were taken and the patient started on gentamicin and ceftriaxone.Two days after admission a right nephrectomy was performed. Frozen-section study could not distinguish between a neoplastic or infective mass. The renal mass was contiguous with the aneurysm which was not resected due to the high degree of technical difficulty and the possibility that the invasive mass was neoplastic.One day later the aortic aneurysm ruptured and the patient returned to the operating theatre after massive transfusion and cardiopulmonary resuscitation. Antibiotics were changed to ticarcillin clavulanate and gentamicin. Postoperatively the patient was haemodynamically stable for several days but died as a result of haemorrhage. Yersinia enterocolitica serogroup 3 biotype 4 was isolated from the original blood cultures and also from intra-operative aortic and renal specimens. The final kidney histology was consistent with tubulo-papillary renal cell carcinoma and the aortic wall showed severe atheroma and calcification but no carcinoma.
The clinical presentation and management of 102 vascular injuries associated with bone and joint trauma, in 100 patients over a 6-year period, is reviewed. Eighty-three injuries involved the lower limbs. Amputation became necessary in 16 patients. In 12 this was directly attributable to delay in revascularization or the extent of the soft tissue injury with consequent sepsis. Early graft occlusion in an otherwise salvageable limb occurred in four patients (3.9 per cent). Successful therapy involves close co-operation between vascular and orthopaedic surgeons with the vascular injury taking priority. The orthopaedic injury should be treated on its merits. In contaminated or comminuted fractures skeletal traction (or in suitable cases exoskeletal fixation) can be employed without adversely affecting the vascular repair. A plea is made for early diagnosis of concomitant vascular injury in patients with bone and joint injuries; this depends on clinical awareness and careful and repeated examination.
Acute thrombus deposition after carotid endarterectomy was considerably less for vein patch closure than for synthetic patches. A 6-mm patch width caused less thrombus deposition both on the patch itself and on the artery wall compared with a 12-mm patch, but the difference was proportional to the patch width.
Platelet inhibitory therapy improves patency in arterial grafts but when aspirin is given over 20% of patients discontinue therapy. We evaluated a specific Thromboxane A2 antagonist (GR32191 - Glaxo Group Research) on graft platelet uptake and pseudo-intimal hyperplasia in a canine model.Thirty greyhounds were randomised to orally administered placebo, GR32191 25mg, or aspirin150mg (ASA) plus dipyridamole 50mg (DPM) 12 hourly, commencing 48 hours prior to implantation of a 6cm length of 6mm-PTFE in the femoral artery. Autologous 111In-platelete were infused on the fifth postoperative day and platelet uptake measured by probe and ratemeter with the daily rise in graft radioactivity over reference expressed as Thrombogenicity Index (TI). Drugs were continued to 8 weeks when 111In-platelets were again infused and graft uptake measured on the excised graft and expressed as a ratio to blood. Percentage luminal stenosis was measured by grid microscopy.GR32191 significantly reduced luminal stenosis and graft platelet uptake compared to placebo and although TI appeared lower with both platelet inhibitory regimens this did not achieve statistical significance (p<0.1>0.05). Thromboxane A2 antagonists reducethrombus formation on artificial surfaces andbeing specific may have less undesirable effects.
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