South African Journal of Surgery - Volume 53, Issue 1, 2015
Volume 53, Issue 1, 2015
Source: South African Journal of Surgery 53 (2015) http://dx.doi.org/10.7196/SAJS.2650More Less
The development of vascular surgery in the 1970s as a distinct subspecialty of general surgery was based on the fact that this discipline required a subtle but real difference in approach and surgical skills, with specific requirements for training. The subsequent development of a plethora of endovascular therapies during the last two decades has also mandated that surgeons practising in this field acquire skills that are not part of general surgical training. As a consequence for those interested in this emerging specialty, the formation of professional societies that promote excellence in the development, teaching and practice of vascular surgery became progressively more attractive.
Stent graft repair of subclavian and axillary vascular injuries : the Groote Schuur experience : vascular surgerySource: South African Journal of Surgery 53, pp 5 –9 (2015) http://dx.doi.org/10.7196/SAJS.2368More Less
Background. Trauma-related subclavian and axillary vascular injuries (SAVIs) are generally associated with high morbidity and mortality rates in the surgical literature. There is an emerging trend towards increasing use of stent grafts (covered stents) for repair, with evidence limited to small case series and case reports.
Objectives. To report on the clinical and device-related outcomes of stent graft repair of trauma-related SAVIs at a single institution.
Methods. A retrospective chart review of all patients with trauma-related SAVIs requiring stent graft repair was performed. Outcome measures included technical success, mortality, amputation rate, device-related complications (early and late), and reintervention rates (early and late).
Results. A total of 31 patients was identified between June 2008 and October 2013 (30 males, 1 female). Mean age was 27.9 years (range 19 - 51). All 31 patients sustained a penetrating injury (93.5% stab, 6.5% gunshot injuries). There were 21 subclavian and 10 axillary artery injuries. Five patients (16%) were HIV-positive. Nine patients (29%) were shocked on presentation. Early results (30 days): There were no periprocedural deaths. Primary technical success was 83.9% (26/31). Five patients required adjunctive interventional or operative procedures. There were no early procedure-related complications, reinterventions or open conversions in this study. Overall, suboptimal results were seen in five patients (one type I endoleak and four type II endoleaks). Follow-up results (>30 days): Nineteen patients (61.3%) were available for follow-up. Mean duration of follow-up was 55.7 weeks (range 4 - 240). Overall stent graft patency was 89.5% (17/19). Four patients (21.1%) had an occluded stent graft. Stent graft salvage was possible in two patients. Three type II endoleaks were seen on follow-up. Late reinterventions were performed in five patients (26.3%). Conversion to an open procedure was not required in any patient. There was one late death and one major amputation of a stented limb in a patient who had sustained severe soft-tissue injuries during the follow-up period.
Conclusion. Perioperative, early and intermediate results suggest that stent graft repair of select trauma-related SAVIs is relatively safe and effective. Axillary arteriovenous fistulas remain a particular challenge using this treatment modality. Larger prospective studies are required to define the utility of stent grafts for select trauma-related SAVIs better.
The influence of diabetes mellitus on early outcome following carotid endarterectomy : vascular surgerySource: South African Journal of Surgery 53, pp 9 –12 (2015) http://dx.doi.org/10.7196/SAJS.2394More Less
Background. There are few studies that look at the influence of diabetes mellitus on early outcome following carotid endarterectomy (CEA). Those available have reported conflicting results, with some showing poor outcome and others similar outcome to those without diabetes mellitus.
Objective. To assess the influence of diabetes mellitus on early outcome following CEA.
Methods. Clinical data on patients who had CEA over a 5-year period were acquired from a prospectively maintained computerised database. They were divided into two groups, namely diabetics and non-diabetics.
Results. Two hundred and sixty-four charts were analysed. There were no significant differences in patient demographics and risk factors for atherosclerosis between the two groups. The majority (71%) of patients had CEA for symptomatic carotid disease. Carotid shunting was performed selectively, and significantly more diabetic patients had CEA under the protection of a carotid shunt (p=0.0469). Postoperative strokes, transient ischaemic attacks and deaths were not significantly different between the two groups.
Conclusions. Diabetes mellitus had no influence on the early surgical outcome following carotid endarterectomy.
Time since injury is the major factor in preventing tranexamic acid use in the trauma setting : an observational cohort study from a major trauma centre in a middle-income countrySource: South African Journal of Surgery 53, pp 13 –18 (2015) http://dx.doi.org/10.7196/SAJS.2250More Less
Background. Haemorrhage is responsible for about a third of in-hospital trauma deaths. The CRASH-2 trial demonstrated that early administration of tranexamic acid, ideally within 3 hours, can reduce mortality from trauma-associated bleeding by up to 32%.
Objective. To explore whether, in our trauma network in a middle-income country, patients arrived at hospital soon enough after injury for tranexamic acid administration to be effective and safe.
Methods. A prospective cohort study of 50 consecutive patients admitted to our trauma unit was undertaken. Inclusion criteria were as for the CRASH-2 study: systolic blood pressure < 90 mmHg and/or heart rate >110 beats per minute, with injuries suggestive of a risk of haemorrhage. Patients with isolated head injuries were excluded. The mechanisms of injury, time since injury and any reasons for delay were recorded.
Results. Thirteen (26%) patients presented early enough for tranexamic acid administration. Of these, only three patients presented within the 1st hour. Eleven patients had a documented time of injury >3 hours prior to presentation. We were unsure of the time of injury for 26 patients, although for most of these it was likely to be >3 hours before presentation.
Conclusions. The majority (74%) of bleeding trauma patients did not present within the timeframe allowed for safe administration of tranexamic therapy. Of those who did, most would have benefited from even earlier commencement of therapy. This raises the possibility that tranexamic acid may be more effective on a population basis if incorporated into prehospital rather than in-hospital protocols; future studies should explore the benefits and risks of this approach.
Lessons learned from the endovascular management of blunt thoracic aortic injuries : a single-centre experienceSource: South African Journal of Surgery 53, pp 19 –21 (2015) http://dx.doi.org/10.7196/SAJS.2407More Less
Background. Blunt thoracic aortic injuries (BTAIs) remain a leading cause of death after blunt trauma. In severe injuries, thoracic endovascular aortic repair (TEVAR) has provided a less invasive alternative to conventional open repair.
Objective. To report the TEVAR-related complications and uncertainties in patients who presented with traumatic pseudoaneurysms (grade III BTAI).
Methods. From April 2004 to February 2012, 55 patients (42 male, mean age 34.7 years) with severe BTAI were treated with stent grafts. Computed tomography (CT) was used to diagnose the injuries, and follow-up scans were planned at 6 and 12 months. We report the complications and the technical uncertainties related to the procedure.
Results. Successful sealing of the injury sites was achieved in all patients, either with a thoracic stent graft (53/55) or infrarenal aortic aneurysm extender cuffs (2/55). During hospitalisation, 13 patients died after TEVAR (mean 14 days). Procedure-related complications included left common carotid artery coverage (1/55), ischaemic left leg (1/55) and graft collapse (1/55). The procedure-related uncertainties included excessive graft oversizing (15/55), poor graft apposition to the inner curve of the aorta (19/55) and left subclavian artery coverage (24/55).
Conclusion. Stent grafts appear safe and effective in treating pseudoaneurysms caused by BTAI. However, they are likely to be associated with long-term complications and monitoring strategies of >30 years may be necessary.
Source: South African Journal of Surgery 53, pp 22 –25 (2015) http://dx.doi.org/10.7196/SAJS.2444More Less
Background. Thoracic outlet syndrome (TOS) is one of the most poorly understood syndromes. Neurogenic TOS is found in 95% of cases. The described anatomical spaces transform and evolve into 'entrapment spaces'. The aetiology is unclear. This study was based on the observation by a single surgeon that there appeared to be a high incidence of anatomical abnormalities in patients with neurogenic TOS.
Objective. To attempt to clearly define anatomical anomalies causing TOS.
Methods. The records from a prospectively maintained computer database of 219 patients submitted for surgery over a 10-year period (1999 - 2009) were reviewed. A substudy was done on the patients operated on over the last 4 years (n=63) in whom details of the intraoperative anatomical findings were meticulously recorded.
Results. Over the last 4 years, the surgical findings in the last 63 patients (67 operations) revealed a significant number of anatomical abnormalities believed to be responsible for the nerve compression. Brachial plexus anomalies were found in 99% of the patients - the majority comprised the postfixed configuration. In addition, 58% had a soft-tissue anomaly, 27% had a bony anomaly and 3% had other abnormalities. The majority had combinations of these abnormal findings.
Conclusion. These findings strongly suggest that there is usually an identifiable anatomical cause, typically the brachial plexus, for the symptoms of TOS. We strongly recommend that the supraclavicular approach be used in order to define anatomical aberrations. Brachial plexus configuration anomalies causing TOS have not been emphasised previously. Further detailed recordings of these findings may help us better understand the aetiology of this poorly defined syndrome.
Source: South African Journal of Surgery 53, pp 26 –27 (2015) http://dx.doi.org/10.7196/SAJS.2458More Less
The internal iliac artery and cruciate anastomosis are important collateral vessels in severe aortoiliac occlusive disease. This report describes a patient with left leg rest pain due to occlusion of the left common and external iliac arteries. In addition, there was a high-grade stenosis of the right common iliac artery. Direct catheter canulation of the left internal iliac artery revealed that it was patent. Endovascular stent placement was successful in re-establishing blood flow into the left internal iliac artery. Ischaemic rest pain was relieved and the ankle brachial index was maintained at 0.85 at 6 months follow-up.
Source: South African Journal of Surgery 53, pp 28 –29 (2015) http://dx.doi.org/10.7196/SAJS.1888More Less
A case of endovascular treatment of blunt aortic bifurcation transection using a peripheral stent graft : case reportSource: South African Journal of Surgery 53, pp 30 –31 (2015) http://dx.doi.org/10.7196/SAJS.2218More Less