Visceral Infarction Research Articles

Cocaine-Associated Ischemic Colitis

Cocaine use can result in various gastrointestinal complications, including gastric ulcerations, retroperitoneal fibrosis, visceral infarction, intestinal ischemia, and gastrointestinal tract perforation. We report cocaine-associated colonic ischemia in three patients and review the literature. Including ours, 28 cases have been reported, with a mean patient age of 32.6 years (range, 23 to 47 years); 53.5% were men and 46.5% were women. The interval between drug ingestion and onset of symptoms varied from 1 hour to 2 days. Cocaine is a potentially life-threatening cause of ischemic colitis and should be included in the differential diagnosis of any young adult or middle-aged patient with abdominal pain and bloody diarrhea, especially in the absence of estrogen use or systemic disorders that can cause thromboembolic events, such as atrial fibrillation.

Pararenal aortic aneurysms: The future of open aortic aneurysm repair

Purpose: As endovascular stent graft repair of infrarenal abdominal aortic aneurysms (AAAs) becomes more common, an increasing proportion of patients who undergo open operation will have juxtarenal aneurysms (JR-AAAs), which necessitate suprarenal crossclamping, suprarenal aneurysms (SR-AAAs), which necessitate renal artery reconstruction, or aneurysms with associated renal artery occlusive disease (RAOD), which necessitate repair. To determine the current results of the standard operative treatment of these patterns of pararenal aortic aneurysms, we reviewed the outcome of 257 consecutive patients who underwent operation for JR-AAAs (n = 122), SR-AAAs (n = 58), or RAOD (n = 77). Methods: The patients with SR-AAAs and RAOD were younger (67.5 ± 8.8 years) than were the patients with JR-AAAs (70.5 ± 8.3 years), and more patients with RAOD were women (43% vs 21% for JR-AAAs and SR-AAAs). The patient groups were similar in the frequency of coronary artery and pulmonary disease and in most risk factors for atherosclerosis, except hypertension, which was more common in the RAOD group. Significantly more patients with RAOD had reduced renal function before surgery (51% vs 23%). Supravisceral aortic crossclamping (above the superior mesenteric artery or the celiac artery) was needed more often in patients with SR-AAAs (52% vs 39% for RAOD and 17% for JR-AAAs). Seventeen patients (7%) had undergone a prior aortic reconstruction. The most common renal reconstruction for SR-AAA was reimplantation (n = 37; 64%) or bypass grafting (n = 12; 21%) and for RAOD was transaortic renal endarterectomy (n = 71; 92%). Mean AAA diameter was 6.7 ± 2.1 cm and was larger in the JR-AAA (7.1 ± 2.1 cm) and SR-AAA (6.9 ± 2.1 cm) groups as compared with the RAOD group (5.9 ± 1.7 cm). Results: The overall mortality rate was 5.8% (n = 15) and was the same for all the groups. The mortality rate correlated ( P < .05) with hematologic complications (bleeding) and postoperative visceral ischemia or infarction but not with aneurysm group or cardiac, pulmonary, or renal complications. Renal ischemia duration averaged 31.6 ± 21.6 minutes and was longer in the SR-AAA group (43.6 ± 38.9 minutes). Some postoperative renal function loss occurred in 104 patients (40.5%), of whom 18 (7.0%) required dialysis. At discharge or death, 24 patients (9.3%) still had no improvement in renal function and 11 of those patients (4.3%) remained on dialysis. Postoperative loss of renal function correlated ( P < .05) with preoperative abnormal renal function and duration of renal ischemia but not with aneurysm type, crossclamp level, or type of renal reconstruction. Conclusion: These results showed that pararenal AAA repair can be performed safely and effectively. The outcomes for all three aneurysm types were similar, but there was an increased risk of loss of renal function when preoperative renal function was abnormal. These data provide a benchmark for expected treatment outcomes in patients with these patterns of pararenal aortic aneurysmal disease that currently can only be managed with open repair. (J Vasc Surg 1999;29:902-12.)

Antiphospholipid syndrome: patterns of life-threatening and severe recurrent vascular complications.

To demonstrate the variety and recurrence patterns of severe arterial and venous thromboembolic events that occur in patients with the antiphospholipid syndrome. Radiology records were reviewed in 800 of 1,633 patients with positive test results of antiphospholipid syndrome. Patients with radiologic evidence of antiphospholipid syndrome and no other hypercoagulable state were included if the observed thromboembolic event met one or more of four criteria for severity: extreme complications or mortality, three or more recurrent events, unusually young age, and/or unusual sites affected. In the 24 patients who met the selection criteria, 72 thromboembolic episodes and 56 (78%) recurrences were found. Arterial complications included aortic occlusions, visceral infarctions, upper- and lower-extremity arterial thrombosis, strokes, and repeated graft occlusions. Venous complications included portal vein thrombosis, transverse and sagittal sinus thrombosis, upper- and lower-extremity thrombosis, and recurrent pulmonary emboli. Vascular complications of antiphospholipid syndrome include serious and life-threatening events. Primary thromboembolic episodes often recur at the same site or within the same system (arterial vs venous system). These events can also trigger a rapid succession of critical thrombotic episodes at multiple sites.

Systemic, cerebral, and pulmonary segmental mediolytc arteriopathy: Villainous masqueraders of vasculitis

Segmental mediolytic arteriopathy (SMA) is a newly described and uncommon variant of arterial fibromuscular dysplasia that affects principally visceral small and medium sized arteries. SMA is characterized by myolytic dysplasia of the arterial media, intramural dissection, and thrombosis or ruptured aneurysms resulting in visceral hemorrhage and infarction as the dire consequences. Because of its relative obscurity and frequent angiographic manifestation of microaneurysms, clinically SMA mimics polyarteritis nodosa, and the patient so diagnosed had been treated with immunosuppressive therapy with a catastrophic outcome. Five new cases of unsuspected SMA are described herein, three involving visceral arteries and, for the first time, one case each affecting the cerebral and pulmonary parenchymal arteries. Three of the five patients did not survive because SMA remained unrecognized until after death and a subsequent review of the biopsy and autopsy specimens. Death in each of the three patients was directly attributable to complications of SMA or indirectly to septic complications of the immunosuppressive therapy for the misdiagnosed vasculitis. Clinicians and pathologists alike should become better acquainted with this unusual form of noninflammatory arteriopathy, so as not to misdiagnose it as vasculitis.

Laparoscopic Upper Abdominal Operations and Mesenteric Infarction

Mesenteric visceral infarction occurring after laparoscopic procedures in the upper abdomen may be a direct result of physiologic changes induced by carbon dioxide pneumoperitoneum and other technical elements with these procedures. The reported case is characteristic of a seemingly successful operative result interrupted by this devastating complication.

Optimal exposure of the proximal abdominal aorta: A critical appraisal of transabdominal medial visceral rotation

Adequate exposure of the upper abdominal aorta and its branches is a necessary prelude to safe and durable reconstruction of this aortic segment. Although a variety of approaches to this exposure have been described, few outcome data are available to assess the benefits and limitations of the different exposure options. In this series we report the results of the transabdominal medial visceral rotation (MVR) approach to exposure of the paramesenteric and pararenal aorta. One hundred eight operations were performed in 104 patients, representing 19.5% of all aortic reconstructions during a 5.5 year interval. Most patients had hypertension (n = 77, 71.3%) or a history of smoking (n = 83, 76.9%). Heart disease was present in one third of patients (n = 33) and a similar proportion had abnormal renal function (elevated creatinine level) before operation (n = 40, 37.0%). One third of patients (n = 34) had undergone previous aortic or aortic branch reconstruction. Eighty percent of procedures were elective (n = 87). Seventy-one patients (65.7%) required renal revascularization, usually for hypertension or elevated creatinine levels, whereas 37 patients (34.3%) underwent visceral reconstruction, most often for symptoms of chronic mesenteric ischemia. Only 22 patients required isolated infrarenal aortic repair. Most of the aortic lesions were aneurysmal (n = 42). Eighty percent of procedures (n = 88) required suprarenal or more proximal aortic clamping. The most frequently used reconstruction techniques were bypass (n = 39, 36.1%), endarterectomy (n = 18, 16.7%), or both (n = 23, 21.3%). There were four intraoperative deaths (3.7%) and 15 postoperative deaths (13.9%). All intraoperative deaths and four postoperative deaths were related to hemorrhage and its complications. Visceral infarction was the most frequent cause of postoperative death. The intraoperative complications that were determined to be related to the medial visceral rotation approach included splenic injury (n = 23, 21.3%), one aortic injury, and one adrenal injury. The aortic injury was associated with substantial intraoperative bleeding and subsequent death. The postoperative complications resulting from MVR included pancreatitis (n = 5), which contributed to death in two patients, and possibly some of the cases of visceral infarction not associated with visceral reconstruction. The other common postoperative complications, cardiac (n = 25, 24.0%), pulmonary (n = 32, 30.8%), renal (n = 20, 19.2%), and infectious (n = 17, 16.3%), were attributed to the procedures performed. Transabdominal MVR exposure of the upper abdominal aorta provides unrestricted access to the visceral branch-bearing segment of the aorta and places no limitations on the choice of arterial reconstruction technique. The associated morbidity and mortality rates are typical of patients undergoing these complex vascular repairs, but the frequency of splenic injury and postoperative pancreatitis is increased.

Cholesterol Embolism in Intensive Care Patients

Four case reports are presented, followed by a discussion of the acute, potentially life-threatening manifestations of the cholesterol embolism syndromes. Every major organ system except the lungs may be directly affected by cholesterol emboli; devastating consequences encompass cerebral, myocardial, spinal cord, intestinal, renal, and other visceral organ infarction, as well as peripheral and perineal gangrene. Additional complications include severe hypertension, gastrointestinal bleeding, and hemodynamic instability. Anticoagulants and thrombolytic therapy may exacerbate atheromatous embolism and are relatively contraindicated. Aggressive supportive therapy may improve chances of survival, but long-term prognosis is poor. Prevention remains the most important aspect in this devastating disorder.

Hyperpotassemia during major vascular surgery: a possible indicator of visceral infarction.

Hyperpotassemia during major vascular surgery: a possible indicator of visceral infarction.

“Shaggy” Aorta Syndrome with Atheromatous Embolization to Visceral Vessels

Spontaneous atheromatous visceral embolization from diffuse aortic atherosclerotic disease is an unusual and poorly understood entity. We have reviewed our experience with 88 patients who suffered atheromatous embolization from a "shaggy" aorta. Visceral embolization was evident in 36 patients (40.9%). Nine were treated nonoperatively with three patients dying within a week of presentation and an additional five patients dying within five years due to continuing renal and intestinal embolization. Surgical correction was undertaken 28 times in 27 patients. Endarterectomy or graft replacement of the aorta did not necessarily prevent visceral infarction or renal failure. Extra-anatomic bypass with ligation of the distal external iliac arteries appears to be associated with the lowest morbidity and mortality. Anticoagulation of these patients does not prevent embolization and may be contraindicated for long-term management.

Treatment of Patients with Aortic Dissection Presenting with Peripheral Vascular Complications

The incidence of peripheral vascular complications in 272 patients with aortic dissection during a 25-year span was determined, as was outcome after a uniform, aggressive surgical approach directed at repair of the thoracic aorta. One hundred twenty-eight patients (47%) presented with acute type A dissection, 70 (26%) with chronic type A, 40 (15%) with acute type B, and 34 (12%) with chronic type B dissections. Eighty-five patients (31%) sustained one or more peripheral vascular complications: Seven (3%) had a stroke, nine (3%) had paraplegia, 66 (24%) sustained loss of a peripheral pulse, 22 (8%) had impaired renal perfusion, and 14 patients (5%) had compromised visceral perfusion. Following repair of the thoracic aorta, local peripheral vascular procedures were unnecessary in 92% of patients who presented with absence of a peripheral pulse. The operative mortality rate for all patients was 25% +/- 3% (68 of 272 patients). For the subsets of individuals with paraplegia, loss of renal perfusion, and compromised visceral perfusion, the operative mortality rates (+/- 70% confidence limits) were high: 44% +/- 17% (4 of 9 patients), 50% +/- 11% (11 of 22 patients), and 43% +/- 14% (6 of 14 patients), respectively. The mortality rates were lower for patients presenting with stroke (14% +/- 14% [1 of 7 patients]) or loss of peripheral pulse (27% +/- 6% [18 of 66 patients]). Multivariate analysis revealed that impaired renal perfusion was the only peripheral vascular complication that was a significant independent predictor of increased operative mortality risk (p = 0.024); earlier surgical referral (replacement of the appropriate section of the thoracic aorta) or more expeditious diagnosis followed by surgical renal artery revascularization after a thoracic procedure may represent the only way to improve outcome in this high-risk patient subset. Early, aggressive thoracic aortic repair (followed by aortic fenestration and/or abdominal exploration with or without direct visceral or renal vascular reconstruction when necessary) can save some patients with compromised visceral perfusion; however, once visceral infarction develops the prognosis is also poor. Increased awareness of these devastating complications of aortic dissection and the availability of better diagnostic tools today may improve the survival rate for these patients in the future. The initial surgical procedure should include repair of the thoracic aorta in most patients.

Incarcerated paraesophageal hernia

The case of an 80-year-old woman with an incarcerated paraesophageal hernia is presented. Among diaphragmatic hernias, the paraesophageal or type II hernia occurs with an incidence of 5%, sliding or type I hernia occurs with an incidence of 95%. Incarcerated paraesophageal hernia is a surgical emergency requiring rapid decompression and reduction to minimize catastropic consequences of hemorrhage, perforation, and visceral infarction. The clinical presentation and diagnostic workup of the patient with incarcerated type II diaphragmatic hernia are discussed.

Abdominal trauma: pre-operative assessment and postoperative problems in intensive care.

Although penetrating abdominal trauma is on the increase in Australia, blunt trauma continues to account for the majority of cases and usually presents a more challenging problem than the former. Diagnosis has been greatly facilitated by the widespread use of peritoneal lavage and computerised tomography. Conservative management of solid organ ruptures, especially of the spleen, is being increasingly utilised in selected cases. If haemorrhage continues following initial resuscitation, urgent laparotomy is required. Heroic attempts at achieving normo-volaemia in the presence of major haemorrhage must not be allowed to delay laparotomy. Postoperative problems such as intra-abdominal sepsis or visceral infarction usually have few if any localising features; more typically multiple organ failure insidiously develops. When no clear extra-abdominal cause exists, laparotomy must not be delayed.

Lymphocytes and necrosis of the cutaneous microvasculature in malignant atrophic papulosis: A refined light microscope study

Malignant atrophic papulosis is a disease characterized by multiple distinctive cutaneous and often lethal visceral infarctions. In some individuals, the diagnosis is not made until the skin manifestations are noted in a seriously ill patient with gastrointestinal and/or central nervous system disease. In other individuals, the disorder may pursue a benign course with only skin manifestations for many years. Using refined light microscopy to examine the skin lesions, the extensive nature of the necrotic microvascular alterations, a predominant lymphocytic infiltrate, and neural changes are documented. These findings suggest that the cutaneous lesions of malignant atrophic papulosis may result from a lymphocyte-mediated necrotizing vasculitis that affects the entire cutaneous microvasculature.

HEMORRHAGIC INFARCTION OF THE GREATER OMENTUM

In recent years interest in abdominal visceral infarction has been reawakened. 1 Much of the literature, however, has been concerned with mesenteric vascular occlusion and its effect on the gastro-intestinal tract. 2 The purpose of the present communication is to record a case of thrombosis of the omental venous system not associated with venous thrombosis elsewhere in the abdomen or with torsion of the omentum. REPORT OF A CASE History. —C. F., a 53 year old white man, entered the Bellevue Hospital on June 3, 1936, because of dyspnea, orthopnea and swelling of the ankles. Since 1929, when a 4 plus Wassermann reaction of the blood was discovered, he had received intensive antisyphilitic therapy. A diagnosis of arteriosclerotic, hypertensive syphilitic cardiac disease was made in 1934, when the patient was first seen, suffering from cardiac failure. Except for moderate diminution of cardiac reserve and occasional attacks of severe precordial pain,

Estudos sobre thrombose cardiaca e endocardite parietal de origem não valvular

Estudos sobre thrombose cardiaca e endocardite parietal de origem não valvular