Low-energy arterial injury at the shoulder with progressive or delayed nerve palsy.
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We describe 20 patients, aged between 43 and 88 years, with delayed nerve palsy or deepening of an initial palsy caused by arterial injury from low-energy injuries to the shoulder. The onset of palsy ranged from immediately after the injury to four months later. There was progression in all the patients with an initial partial nerve palsy. Pain was severe in 18 patients, in 16 of whom it presented as neurostenalgia and in two as causalgia. Dislocation of the shoulder or fracture of the proximal humerus occurred in 16 patients. There was soft-tissue crushing in two and prolonged unconsciousness from alcoholic intoxication in another two. Decompression of the plexus and repair of the arterial injury brought swift relief from pain in all the patients. Nerve recovery was generally good, but less so in neglected cases. The interval from injury to the repair of the vessels ranged from immediately afterwards to 120 days. Delayed onset of nerve palsy or deepening of a nerve lesion is caused by bleeding and/or impending critical ischaemia and is an overwhelming indication for urgent surgery. There is almost always severe neuropathic pain. (+info)
Axillary-axillary interarterial chest loop conduit as an alternative for chronic hemodialysis access.
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OBJECTIVE: After exhaustion of all conventional arteriovenous (AV) access options, an alternative approach is an arterioarterial conduit. The purpose of this study was to examine the utility of an axillary-axillary (AA) interarterial (IA) access in this subset of patients. METHODS: A retrospective review was performed of all patients who underwent placement of an AA IA access. Patients were observed for functional aspects and complications. Outcomes were determined according to the Society for Vascular Surgery/American Association for Vascular Surgery standards for reports for dealing with AV accesses. RESULTS: Twenty patients (median age, 59 years; range, 41-82 years) underwent AA IA access placement under general anesthesia between May 2001 and December 2004. Exhausted upper extremity AV access options were found in 14 patients (70%), with central vein occlusion in 5 patients (25%), and 12 patients (60%) had ischemia from steal syndrome. High-output cardiac failure was present in one patient. Median follow-up was 7.4 months (range, 0.5-45.3 months). The 30-day perioperative mortality rate was 5%. There was one (5%) early access thrombosis that resulted in moderate ischemia. Late access thrombosis occurred in three patients (15%), and all cases were asymptomatic. Early postoperative bleeding necessitated surgical intervention in four patients (20%). Late graft infection (n = 1; 5%) occurred after repeated thrombectomy. The primary and secondary patency rate was 90% and 93%, respectively, at 6 months. CONCLUSIONS: This short-term initial study showed that the AA IA loop access could be implanted with acceptable perioperative morbidity and with an excellent secondary patency rate. Further follow-up is necessary to determine the long-term complication rate and to allow more reasonable comparison with other methods of access. (+info)
Surgical treatment of axillary artery aneurysm.
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Aneurysms of the axillary artery are rare and dangerous lesions that threaten the upper extremities with vascular and neurologic compromise. Most can be treated effectively with surgical excision and vascular grafting. We retrospectively assessed 4 axillary artery aneurysms upon which we operated from February 1998 through March 2004. Three patients were admitted to our clinic for symptomatic axillary masses. The remaining patient was transported to our clinic emergently due to massive hemorrhage of an enlarging axillary mass that occurred during biopsy of the mass at another hospital. In this patient, the ruptured axillary artery aneurysm was diagnosed by means of emergent upper-extremity selective angiography. All patients were treated surgically by means of aneurysmectomy and graft interpositioning--with polytetrafluoroethylene grafts in 2 patients and saphenous vein grafts in the other 2. Surgical treatment of axillary artery aneurysms is of importance in avoiding thromboembolism and ischemia, which in turn can lead to gangrene and amputation of the affected extremity. For this reason, operative management of such cases should not be delayed. (+info)
Right axillary artery cannulation for surgical management of the hostile ascending aorta.
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Extensive aortic disease, such as atherosclerosis with aneurysms or dissections that involve the ascending aorta, can complicate the choice of a cannulation site for cardiopulmonary bypass. To date, the standard peripheral arterial cannulation site has been the common femoral artery; however, this approach carries the risk of atheroembolism due to retrograde aortic perfusion, or it is undesirable because of severe iliofemoral disease. Arterial perfusion through the axillary artery provides sufficient antegrade aortic flow, is more likely to perfuse the true lumen in the event of dissection, and is associated with fewer atheroembolic complications. From September 2000 through March 2004, 27 patients underwent right axillary artery cannulation for acute ascending aortic dissection (n = 16), ascending aortic aneurysm (n = 9), or coronary artery bypass grafting (n = 2). Direct artery cannulation was performed in the first 4 patients, and the last 23 patients were cannulated through a longitudinal arteriotomy via an 8-mm woven Dacron graft. Seventeen patients underwent hypothermic circulatory arrest and antegrade cerebral perfusion. Two patients died intraoperatively: one due to low cardiac output and one due to diffuse bleeding. One patient suffered mild right-arm paresthesia postoperatively, but recovered completely. Axillary artery cannulation was successful in all patients; it provided sufficient arterial flow, and there were no intraoperative problems with perfusion. In the presence of extensive aortic or iliofemoral disease, arterial perfusion through the axillary artery is a safe and effective means of providing sufficient arterial inflow during cardiopulmonary bypass. In this regard, it is an excellent alternative to standard femoral artery cannulation. (+info)
Recannulation of the right axillary artery for complex aortic surgeries.
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Owing to the increased use of the axillary artery for arterial inflow during cardiopulmonary bypass, patients with previous cannulation at this site who require reoperation will be encountered more and more frequently. We describe the cases of 2 patients who required recannulation of the axillary artery for complex reoperations of the thoracic aorta. The technique and pitfalls are described. The decision was made to reuse the previous cannulation site at the right axillary artery due to the presence of large pseudoaneurysms in proximity to the sternum. The old 8-mm Dacron stump was found and excised, and a new 8-mm Dacron graft was sutured to the right axillary artery for arterial inflow. In the 1st patient, the Dacron side-graft enabled insertion and subsequent inflation of an EndoClamp within the Dacron graft of the ascending aorta, which obviated profound hypothermia. In the 2nd patient, recannulation of the right axillary artery enabled us to open the sternum at low flow using moderate hypothermia, given that antegrade cerebral perfusion was easily accessible in the event of a more prolonged arrest time. Both patients recovered fully, without neurovascular complications secondary to the recannulation of the right axillary. Recannulation of the right axillary artery is safe during complex reoperation of the thoracic aorta. It avoids retrograde perfusion in the often-diseased descending thoracic aorta. Furthermore, sternal reentry may be performed under moderate hypothermia, because antegrade cerebral perfusion can be initiated with ease. (+info)
Recurrent lower limb embolism from thoracic aortic mural thrombus: a rare presentation of occult malignancy.
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Initial presentation of a malignant disease as recurrent attacks of lower limb ischaemia due to emboli from a mural thrombus in the descending thoracic aorta is extremely rare. A diagnosis of malignancy may thus easily be overlooked. Recent advances in imaging technology have made the diagnosis of thoracic aortic mural thrombi much easier. Occult malignancy should always be suspected in the absence of biochemical evidence of hypercoagulability. We report on a patient with underlying malignant disease who presented with lower limb ischaemia that was relieved by axillobifemoral bypass. (+info)
Aortic reoperations: experience with 23 patients using axillary artery cannulation.
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The increase in the number of cardiac operations has brought about an increase in aortic pathology that requires reoperation. The aim of the present study was to evaluate axillary artery cannulation in aortic reoperations. We operated on 23 patients diagnosed with acute type A aortic dissection (13 patients), chronic type A aortic dissection (7 patients), aortic pseudoaneursym (2 patients), and arcus aorta aneurysm (1 patient). The right axillary artery was cannulated directly or through a side graft which was anastomosed to the artery. Antegrade cerebral perfusion with moderate degree hypothermia was used for cerebral protection. Four patients were lost after the operation (17.4%) and no cerebral complications were encountered. Axillary artery cannulation provides safe reentry to the chest and provides good cerebral protection in aortic reoperations. (+info)
Axillo-iliac conduit for haemodialysis vascular access.
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OBJECTIVES: To describe a series of venous surgical procedures performed to maintain vascular access. METHODS: We report eight patients with end-stage renal failure (ESRF) who had complex renal access problems. Three patients had central venous occlusion and underwent veno-venous axillo-iliac bypass. In five further patients with a symptomatic central venous obstruction we performed axillo-iliac arterio-venous grafting (AVGs) in order to achieve haemodialysis access. All patients were assessed pre-operatively with duplex ultrasound and venogram of upper and lower limbs. The axillary artery or vein, and iliac vein were approached via infraclavicular and extra-peritoneal groin incisions, respectively. Non-externally-supported polytetrafluoroethylene (PTFE) was used as a conduit in all patients and anti-coagulation regimen were commenced post-operatively. RESULTS: Following venous diversion surgery, there was a dramatic improvement in the facial and limb swelling experienced by the patients. There was no significant peri-operative morbidity. The veno-venous graft is still patent at 14 months in patient one, at 10 months in patient two, and 5 months in patient three. In the second group, who had arterio-venous grafts, the mean follow-up was 13.2 (7-20) months with a secondary patency rate of 80% at 6 months. Four patients had patent, usable grafts at 12 months. In two cases, graft occlusion was treated with successful thrombectomy. CONCLUSION: Axillary-iliac veno-venous diversion can overcome the symptoms and complications of superior vena cava and innominate vein obstruction. Although, axillo-iliac arterio-venous graft fistulae formation was previously described it has not been widely used. We have found the procedure to have low morbidity and advocate its use in these complex cases. (+info)