Videothoracoscopic-guided management of a central vein perforation during hemodialysis catheter placement

We present a case of the successful repair of an iatrogenic central vein lesion using a videothoracoscopic approach. The confluence of the right innominate vein and the superior vena cava was perforated during the placement of a right internal jugular vein long-term dialysis catheter. The misplacement of the tips of the catheter in the right pleural space was promptly observed. The catheter was removed under pleural videothoracoscopic vision while a tamponade was directly applied to the mediastinal perforation. Massive bleeding was prevented and the central vein perforation was treated successfully using a minimally invasive technique

Trauma to arteries of the forearm

Trauma to arteries of the forearm corresponds to 20% of total arterial trauma. The authors analyzed 24 patients with non iatrogenic trauma of the forearm arteries, cared for from January 1987 to December 1990. All patients were male, trauma by penetrating instrument was the most frequent, with 21 cases (87.5%), absence of pulses was the most frequent clinical manifestation (62.5%), fifteen patients did not present ischemic manifestations (54.2%) and half of the patients did not exhibit neurological symptoms. Injury to only one artery was found in 11 cases, five of them in the radial artery (20.8%), five in the ulnar artery (20.8%) and one in the interosseous artery (4.2%). Concurrent injury to the radial and ulnar arteries was found in 13 cases (54.1%). Regarding nervous impairment, injury to the radial nerve was found in four cases (16.6%) and of the median and ulnar nerves, one case in each (4.1%). All patients with concurrent injury to the ulnar and radial arteries (13) were submitted to arterial restoration. The 11 patients with injury to a sole artery of the forearm were managed as follows: ligature of the interosseous artery in one case, ligature of the radial artery in four cases, raphe of the radial artery in one case, ligature of the ulnar artery in three cases, restoration of the ulnar artery using a segment of the v. saphena in the two cases in which the Allen test had been positive. One patient died in the immediate postoperative period as a result of multiple organ failure due to polytraumatism. Preservation of the member was attained in 23 patients (95.8%) and the sole amputation, was due to extensive traumatism of the soft tissues with severe infection and systemic impairment

Arterial embolectomy in lower limbs

Arterial embolisms in the lower limbs occur frequently, and are of great interest to the vascular surgeon. The authors studied 159 cases of arterial embolisms in lower limbs from January 1991 to July 1993. Ages varied from 12 to 98, with a mean of 58. Eighty patients were male and 78 were female. In most cases, etiology of the embolus was well-established, and mainly caused (78 percent) by atrial fibrillation. Occlusion was most frequent in the femoral artery (53.4 percent). All patients presented severe lower limb ischemia, but not gangrene, on admission. The duration of ischemia, between the onset of symptoms and the liberation of arterial flow, was in most patients (67.9 percent) less than 24 hours. All patients were submitted to lower limb embolectomy with the Fogarty catheter, of which 70.9 percent were done through the femoral artery. Fasciotomy was performed on 48 patients due to a compartimental syndrome. Nineteen patients died immediately after operation; 68.4 percent due to heart failure. Twenty-three (16.4 percent) of the 140 surviving patients (150 operated limbs) were submitted to amputations after the occlusion of artery branches, which had undergone embolectomies. One hundred and twenty-seven limbs (84.6 percent) were preserved in 117 patients (83.5 percent). Eleven cases (7.3 percent) required repeated surgery with the Fogarty catheter. The patients with muscle tenderness, paralysis, or ischemia lasting longer than 24 hours had worse results in relation to the preservation of the limb (p<0.05). We conclude that patients who present lower limb embolisms, are in good clinical condition, and who do not have any necrosis in the limbs, have good outcomes as to limb preservation, along with low complication rates, after embolectomy with the Fogarty catheter. Limb preservation was significantly higher in patients who did not present muscle tenderness, and who had normal motor activity and a ischemia duration of less than 24 hours

Surgical treatment of noniatrogenic trauma of the femoral arteries

Trauma to the femoral arteries corresponds to 30 percent of all arterial traumas. The authors reviewed 74 patients with noniatrogenic trauma of the femoral arteries treated from January 1991 to December 1993. Ages ranged from 11 to 50 years, with a mean of 24. Seventy-one patients were male and three female. Fifty-two patients (70.2 percent) were white, 20 (27 percent) were black and two (2.8 percent) were Asian. Trauma due to firearms had the highest incidence, with 61 cases (82.4 percent). Absence of pulse was the most frequent clinical symptom (62.5 percent). Severe ischemia, with risk of loss of limb, was found in 66.2 percent of the cases. The superficial femoral artery was impaired in 77 percent of the cases. A preoperative arteriography was performed on only five patients, victims of multiple penetrating trauma or an asymptomatic penetrating wound along a vessel passage. In six cases, arterial and venous ligature was the chosen procedure. In three cases, a primary arterial anantomosis was performed. Simple arterriorraphy was feasible in one patient. In 64 of the patients, a venous graft was undertaken using a segment of the inverted great saphenous vein withdrawn from the other lower limb. Fasciotomoy was used in 32 patients (43.2 percent), all of whom exhibited pasting of the lower limb muscles at admission. One patient died during the immediate postoperative period as the result of multiple organ failure caused by polytraumatism. Preservation of the limb was attained in 72 patients (97.3 percent) Severe, previously-incurred ischemia was responsible for the only two amputations, aggravated by an exceedingly long delay between the time of injury and surgery. One of these patients, in addition to severe ischemia, had extensive injuries to the soft tissues. We conclude that trauma of the femoral arteries, attended while the limb still maintains its vitality, has a positive clinical outcome with a high rate of limb preservation. Mortality usually results from injury to other organs