1/9. Total excision of the sternum and thoracic pedicle transposition of the greater omentum; useful strategems in managing severe mediastinal infection following open heart surgery.Mediastinal sepsis following open heart surgery is a significant cause of death. Open drainage of the mediastinumalone was employed originally in management of this problem. More recently, debridement, drainage, and reclosure have been used. Various irrigation solutions, such as antibiotics and Betadine, have been advocated to control severe mediastinal sepsis. Three principles of management in patients unresponsiveness to the above techniques have proved successful in two patients with life-threatening mediastinal sepsis: (1) radical, complete excision of the sternum and adjacent costal cartilages; (2) transposition of the greater omentum on a vascular pedicle to the mediastinum; and (3) primary closure with full-thickness rotational skin flaps. The radical excision of the sternum removes residual foci of sepsis in cartilage and sternal bone marrow. The transposition of the omentum provides a highly vascular, rapidly granulating covering for the contaminated great vessels and hase been successfully to prevent recurrence of suture line bleeding of an exposed ascending aortic anastomosis site. Primary closure of the wound with full-thickness skin flaps provides a suprisingly satisfactory covering for the heart. Preoperative and postoperative measurements of ventilatory mechanics have shown relatively small ventilatory impairment after the alteration of the thoracic cage imposed by excision of the sternum. Two patients have returned to active lives. A treatment failure probably due to incomplete adherence to these guidelines also is presented.- - - - - - - - - - ranking = 1keywords = vessel (Clic here for more details about this article) |
2/9. False aneurysm of the peroneal artery: an unusual complication of femoro-peroneal bypass grafting.Non-traumatic false aneurysm formation involving the native crural vessels is rare. We present the case of a false aneurysm of the native peroneal artery, which complicated femoro-peroneal bypass grafting. It seemed most likely to be of an infective aetiology, arising as a consequence of contiguous methicillin resistant staphylococcus aureus wound infection. This was previously unreported in the literature. Successful management was achieved by primary suture, local wound debridement, excision of the distal graft and replacement with an interposition vein graft through uninfected tissue planes.- - - - - - - - - - ranking = 1keywords = vessel (Clic here for more details about this article) |
3/9. Use of a local fasciocutaneous flap for treatment of exposed vascular grafts to the dorsalis pedis artery.Exposed or infected peripheral vascular grafts pose a significant challenge to the vascular surgeon. Although graft removal and extraanatomic bypass is feasible in selected circumstances, this procedure is generally not applicable for bypass to the pedal vessels. Preservation of patent grafts is almost always required for limb salvage. We present a case report of an exposed vein graft to the dorsalis pedis artery. We conclude that a local fasciocutaneous flap is an excellent treatment option, and describe the procedure in detail.- - - - - - - - - - ranking = 1keywords = vessel (Clic here for more details about this article) |
4/9. Utility of the inferior gluteal vessels in free flap coverage of sacral wounds.An improved technique for gaining access to the inferior gluteal vessels is presented. This method allows rapid isolation of these vessels, preservation of greater pedicle length, and improved access for the performance of microsurgery. The innervation and function of the gluteus maximus is also preserved. We believe the use of this technique makes the inferior gluteal vessels the receptor vessels of choice for microsurgical procedures in the sacral area. An illustrative patient is presented in whom these vessels were used for a combined serratus anterior-latissimus dorsi free muscle flap for sacral wound coverage.- - - - - - - - - - ranking = 9keywords = vessel (Clic here for more details about this article) |
5/9. Functional total and subtotal heel reconstruction with free composite osteofasciocutaneous groin flaps of the deep circumflex iliac vessels.Functional and esthetic reconstruction of the bony and tendinous structures with a stable, sensate soft tissue integument after complex posttraumatic defects of the heel is demanding. Cases are rare in the literature and hardly comparable due to their heterogeneity. The reconstructive approach has to consider both patient profile and the reconstructive tree, with free microvascular flaps playing a primary role. The goals are the reconstruction of both osteotendinous structures and slender soft tissue lining for proper shoe fitting for ambulation and mechanical and thermal protection. The flap should be sensate in weightbearing areas to optimize gait and to prevent long-term complications by ulcers. The osteofasciocutaneous deep inferior circumflex artery (DCIA) flap is especially suitable for complex heel defects with subtotal or total loss of the calcaneal bone as all components (iliac bone, groin skin, and fascia lata) can have a wide range of size and shape. We operated on 2 cases with this variable composite flap. One patient had a complete heel defect by war shrapnel. The complete calcaneus, soft heel, and achilles tendon were reconstructed. The second patient had an empty os calcis after a comminuted fracture and a lateral crush-induced soft tissue defect. In both patients, a stable wound closure, osseous integration, and weightbearing ambulation could be achieved.- - - - - - - - - - ranking = 4keywords = vessel (Clic here for more details about this article) |
6/9. rectus abdominis myocutaneous flap used to close a median sternotomy chest defect. A case report.A 55-year-old white man presented with an infected median sternotomy wound after coronary artery bypass grafting, with subsequent dehiscence and exposure of the heart and great vessels. A left-sided rectus abdominis myocutaneous transposition flap was used for closure.- - - - - - - - - - ranking = 1keywords = vessel (Clic here for more details about this article) |
7/9. hepatic artery aneurysm. Report of an unusual case and review of the literature.hepatic artery aneurysms are relatively infrequent lesions and may represent significant problems in both diagnosis and management. Indeed, as many as 30 to 50 per cent of cases are completely unsuspected and are discovered only at autopsy. A case of a very large hepatic artery aneurysm (greatest dimension of approximately 35 centimeters) presenting as an asymptomatic epigastric mass is reviewed, with emphasis on preoperative evaluation and operative technique. Selective arteriography was the cornerstone of diagnosis with other investigative modes proving not to be effective. Surgical therapy included obtaining proximal and distal control, meticulous ligation of the numerous feeding vessels, and finally evacuation and partial excision of the aneurysm sac with careful suture ligation obliteration of the orifice of each feeding vessel. Restoration of hepatic artery flow was not attempted and no compromise in liver function was seen in the postoperative period. The literature on hepatic artery aneurysms is reviewed to include typical presentation, diagnostic methods, surgical approach, and common complications. Only through a high index of suspicion and early angiography can this frequently fatal lesion be detected early in its course and subsequently be subjected to successful surgical management.- - - - - - - - - - ranking = 2keywords = vessel (Clic here for more details about this article) |
8/9. Use of the omental free flap for soft-tissue reconstruction.omentum can be useful as a free flap for soft-tissue reconstruction in a variety of difficult wounds. omentum was successfully used as a free flap in 11 of 15 patients. Of the 15 defects, 2 were located on the scalp, 2 on the face, 2 on the thigh, and 9 on the lower leg. The failure rate of 27% (4 out of 15) was higher than the 10 to 15% failure rate that we have experienced with skin and muscle flaps. The most frequent cause of failure was the use of diseased recipient vessels for the microvascular anastomoses, that is, vessels with scar tissue, inflammation, or arteriosclerotic changes. Poor blood flow in the recipient vessel also was a harbinger of trouble. This low-flow phenomenon was more prevalent when the anterior tibial vessels of the lower leg were used. In spite of these problems, omentum is useful as a free flap for selected difficult soft-tissue defects.- - - - - - - - - - ranking = 4keywords = vessel (Clic here for more details about this article) |
9/9. Free flap failure in a patient with a long standing, infected, squamous cell carcinoma.A 40-year-old patient presented with a long history of a pilonidal sinus, which had been operated on several times during the last 20 years. On clinical examination the patient had a large tumour in the sacral and perineal region, with involvement of the rectal wall. General surgeons first attempted to excise the tumour with wide healthy margins, and close the wound by local flaps. After partial flap necrosis and wound dehiscence, the patient underwent a reconstruction with a free latissimus dorsi myocutaneous flap. During the anastomosis it was noted that the recipient vessel walls were brittle, mainly at the arterial site, so the arterial anastomosis had to be done three times. Despite this the artery thrombosed again 12 hours later. biopsy specimens were taken from the anastomotic sites and studied under light microscopy. There were signs of acute intramural inflammation, with many polymorphonuclear leukocytes present in microabscesses, and spots of necrosis in the elastic layer at the site of the recipient artery. In conclusion, the long lasting infection was considered to be the main factor that caused the anastomosis to fail, leading to thrombosis, through alteration of the vessel walls. The anomalies in the vessel walls were found at some distance from the clinically diseased area, further than is usually found in acute infection. The use of primary arteriovenous vein graft anastomosis can be made on undamaged vessels, and possibly a less traumatic anastomosis such as the "sleeve" type, should be considered for similar cases.- - - - - - - - - - ranking = 4keywords = vessel (Clic here for more details about this article) |