Program and Abstracts
For
The 7th International Symposium on Vascular Surgery Update
in Conjunction with
The 2nd Scientific Meeting of the Saudi Society for Vascular Surgery
Date:
Sunday and Monday, January 20-21, 2008 (Muharram 11-12, 1429)
Venue:
College of Medicine, King Saud University
Riyadh- Saudi Arabia
Fee:
Free for members
300SR for non-members
Speakers:
National and International Speakers
CME Credit:
12 CME hours from the Saudi Council for Health Specialties
ORGANIZING COMMITTEE:
Chair:
Dr. Mussaad M Al-Salman
Professor of Surgery and Consultant Vascular Surgeon
Dean, College of Medicine
King Saud University
Riyadh, Saudi Arabia
Vice President of the Saudi Society for Vascular Surgery
Co-Chair:
Dr. Mohammed Al-Omran
Assistant Professor of Surgery and Consultant Vascular Surgeon
Division of Vascular Surgery
College of Medicine & King Khalid University Hospital
King Saud University
Riyadh, Saudi Arabia
Treasurer and Research Committee Chair
The Saudi Society for Vascular Surgery
Dr. Badr Aljabri
Assistant Professor of Surgery and Consultant Vascular Surgeon
Head, Division of Vascular Surgery
College of Medicine & King Khalid University Hospital
King Saud University
Riyadh, Saudi Arabia
Members:
Dr. Hassan Al-Zahrani
Professor of Surgery and Consultant Vascular Surgeon
Chairman, Department of Surgery
College of Medicine
King Abdulaziz University
Jeddah, Saudi Arabia
President of the Saudi Society for Vascular Surgery
Dr. Abdullah Alwahbi
Assistant Professor of Surgery and Consultant Vascular Surgeon
Head, Division of Vascular Surgery
King Abdulaziz Medical City
Riyadh, Saudi Arabia
Secretary General of the Saudi Society for Vascular Surgery
Dr. Kaissor Iqbal
Consultant Vascular Surgeon
Division of Vascular Surgery
College of Medicine & King Khalid University Hospital
King Saud University
Riyadh, Saudi Arabia
INVITED SPEAKER FACULTY:
Dr. Thomas F. Lindsay
Professor of Surgery and Staff Vascular Surgeon
Chairman, Department of Vascular Surgery
University of Toronto
Toronto, Ontario
Canada
Dr. Heitham T. Hassoun
Assistant Professor of Surgery and Staff Vascular Surgeon
Department of Vascular Surgery
Johns Hopkins University
Baltimore, MD
USA
Director of Vascular Interventional Therapy
Tawam Hospital-Johns Hopkins International
Al Ain, Abu Dhabi
UAE
Dr. Mohammed S. Sobeh
Consultant General, Vascular and Transplant Surgeon
Department of Vascular Surgery
Barts and The London NHS Trust
London, United Kingdom
Dr. Mohammed I. Al-Majed
Assistant Professor of Anasthesia and Staff Anasthesiologist
Departement of Anasthesia
College of Medicine & King Khalid University Hospital
King Saud University
Riyadh, Saudi Arabia
Outlines for the Scientific Program:
- Day 1: Sunday, January 20, 2008 (Muharram 11, 1429)
|
|
Activity |
Speaker |
|
7:30-8:15 |
Registration |
|
|
8:15-8:30 |
Opening Remarks |
Prof. M Al-Salman |
|
8:30-9:20 |
New Trends in Vascular Surgery |
Prof. TF Lindsay, Canada |
|
9:20-9:45 |
Endovascular Management of Traumatic Thoracic Injury |
Dr. M Sobeh, UK |
|
9:45-10:15 |
Percutanous Abdominal Aortic Aneurysm Repair |
Dr. H Hassoun, USA |
|
10:15-10:45 |
Coffee Break |
|
10:45-11:30 |
Recent Advances on the Perioperative Anesthetic management of the Vascular Patient. |
Dr. M Al-Majed, KSA |
|
11:30-12:00 |
Risk Reduction in Patients with Peripheral Arterial Disease: Where Do We Stand in Saudi Arabia? |
Dr. M Al-Omran, KSA |
|
12:00-13:00 |
Prayer & Lunch Break |
|
13:00-14:00 |
Scientific Papers Session -I : Aortic Interventions |
|
14:00-15:00 |
Scientific Papers Session -II: Hemodialysis Access and Venous Disorders |
|
15:00-15:30 |
Prayer & Coffee Break |
|
15:30-17:00 |
SSVS General Assembly Meeting |
The member of the SSVS |
|
20:00- 22:30 |
SSVS Dinner |
The member of the SSVS |
- Day 2: Monday, January 21, 2008 (Muharram 12, 1429)
|
|
Activity |
Speaker |
|
8:00-8:30 |
Training in Vascular Surgery: The Saudi Experience |
Prof. M Al-Salman, KSA |
|
8:30-9:00 |
Current Standards for Training in Vascular Surgery
|
Prof. TF Lindsay, Canada |
|
9:00-9:30 |
Recent advances in protecting kidneys and gut from ischemia/reperfusion injury post aortic surgery.
|
Dr. H Hassoun, USA |
|
9:30-10:00 |
Coffee Break |
|
10:00-11:30 |
Scientific Papers Session-III: Vascular Trauma |
|
11:30-12:30 |
Prayer & Lunch Break |
|
12:30- 13:50 |
Scientific Papers Session-IV: Peripheral Arterial Disease |
|
13:50-14:10 |
Coffee Break |
|
14:10-15:00 |
Scientific Papers Session-V: Vascular Diagnostic Modalities and Miscellaneous Topics |
|
15:00-15:15 |
Closing Remarks |
Prof. M Al-Salman |
Detailed Scientific Program:
Day 1: Sunday, January 20, 2008 (Muharram 11, 1429)
08:15 Opening Address
Dr. Mussaad Al-Salman
Session 1:
Moderators: Dr. Hassan Al-Zahrani and Dr. Mussaad Al-Salman
08:30 New Trends in Vascular Surgery
Dr. Thomas F Lindsay
University of Toronto, Toronto, Canada
09:20 Endovascular Management of Traumatic Thoracic Injury
Dr. Mohammed Sobeh
Barts and The London NHS Trust, London, United Kingdom
09:45 Percutanous Abdominal Aortic Aneurysm Repair
Dr. Heitham Hassoun
Johns Hopkins University, Baltimore, MD, USA
10:15 Coffee Break
Session 2:
Moderators: Dr. Saad Al-Garni and Dr. Abdullah Alwahbi
10:45 Recent Advances on the Perioperative Anesthetic management of the
Vascular Patient
Dr. Mohammed Al-Majed
King Saud University, Riyadh, Saudi Arabia
11:30 Risk Reduction in Patients with Peripheral Arterial Disease:
Where Do We Stand in Saudi Arabia?
Dr. Dr. Mohamed Al-Omran
King Saud University, Riyadh, Saudi Arabia
12:00 Prayer and Lunch Break
Session 3: Scientific Papers Session-I: Aortic Interventions
Moderators: Dr. Thomas Lindsay and Dr. Mohammed Sobeh
13:00 Endovascular Exclusion of Aneurysms of the Aortic Arch, Thoraco-Abdominal
Aorta and Juxta-Renal Aorta
Mr. Kossa, S. Haulon, A. AlKreedees, R. Azzaoui, T Modine, L Destriux-Gannier,
C Decoene, G Fayad, H. Warembourg
CHRU of Lille, France
13:10 Endovascular Repair of Blunt Traumatic Thoracic Aortic Injuries:
Retrospective Analysis From Two Teaching Centers in Saudi Arabia
Shaltot M, Al Garni S, El kayali A, Al Kohlani H , Al Turki S , Al Moaqel M. Al Wahbi AM.
Riyadh, Saudi Arabia
13:20 Endovascular Treatment of Acute Aortic Emergencies: Early Results
Badr Aljabri, MD; Tawfiq Abu-AlNasr MD; Abdulmajeed Al-Tuwaijri, MD; Musaad
Al-Salman, MD; Mohammed Al-Omran, MD
Riyadh, Saudi Arabia
13:30 Fate of Left Kidney after Left Renal Vein Division during management of Aortic
Occlusive Disease.
Mohamed A Elsharawy*, MS MD FRCS and Khaled M Moghazy **, MS MD
Al-Khober,Saudi Arabia.
13:40 Mycotic Infrarenal Abdominal Aortic Aneurysm: Case Series & review of the
literature
Samer Ali; Mohammed Bafaraj
Makkah, Saudi Arabia
13:50 Unfavourable Aortic Aneurysms Anatomy: Challenging Scenarios for Vascular
Surgeons
Hamid Al-Ghamdi, MBBS; Badr Al-Jabri, MD; Musaad M Al-Salman, MD;
Kaissor Iqbal, MBBS; Mohammed Al-Omran, MD, MSc.
Riyadh, Saudi Arabia.
Session 4: Scientific Papers Session -II: Hemodialysis Access and Venous Disorders
Moderators: Dr. Heitham Hassoun and Dr. Saud Al-Turki
14:00 The effect of venous outflow diameter on the patency rate of arteriovenous fistulae
Alaa Amin, FRCSI, ABS,KSUF
Taif, Saudi Arabia.
14:10 Does regional anesthesia influence early failure of elbow arteriovenous fistulae?
Mohamed A Elsharawy*, MS MD FRCS and Roshdy Elmotwely**.
Al-Khober, Saudi Arabia.
14:20 Managing the life line: The Dialysis Vascular Coordinator, the way to improve
Hemodialysis Access outcomes
Showmer A, Bakarman K, AlKohlani H, Ayad E, Enezy K, Mahmoud I, ELKayali A,
AlTurki S, AlWahbi AM
Riyadh, Saudi Arabia.
14:30 Endovenous Laser Therapy of the Great Saphenous Vein: Early and Intermediate
Results
Riyadh, Saudi Arabia.
14:40 Do Management Strategies Reduce Vascular Access Complications?
M Mazen Hachem, M Bosaeed, M Wakka, A Hamdan
Jeddah, Saudi Arabia
14:50 Pulmonary embolism – Surgical aspects: Review of the Literature
Mohamed M Ramzy, MD, FACS
Qassim, Saudi Arabia.
15:00 Coffee Break
15:30 SSVS General Assembly Meeting
Day 2: Monday, January 21, 2008 (Muharram 12, 1429)
Session 5:
Moderators: Dr. Hassan Al-Zahrani and Dr. Badr Aljabri
08:00 Training in Vascular Surgery: The Saudi Experience
Dr. Mussaad Al-Salman
King Saud University, Riyadh, Saudi Arabia
08:30 Current Standards for Training in Vascular Surgery
Dr. Thomas F Lindsay
University of Toronto, Toronto, Canada
09:00 Recent advances in protecting kidneys and gut from ischemia/reperfusion injury
post aortic surgery
Dr. Heitham Hassoun
Johns Hopkins University, Baltimore, MD, USA
09:30 Coffee Break
Session 6: Scientific Papers Session-III: Vascular Trauma
Moderators: Dr. Hussein Al Kohlani and Dr. Yahiya Ashgan
10:00 THE MANGLED LOWER EXTREMITY: Limb Salvage or Amputation?
Sameh Barayan, MD, FRCSEd, FRCSC, FACS; Ashraf Noureldin, MD
AL KHOBAR , Saudi Arabia
10:10 Management of Mangled Extremity
El Sayed A. El Zayat
Riyadh, Saudi Arabia
10:20 Management Algorithm for Blunt Renal Artery Occlusion in Multiple Trauma
Patients
Ali Jawas, MD, FRCSC; Fikri Abu-Zidan, MD, FRCS, PhD, DipApplStats
Al-Ain, United Arab Emirates
10:30 155 vascular injuries: a retrospective study in Kuwait, 1992-2000
Asfar S, Al-Ali J, Safar H, Al-Bader M, Farid E, Ali A, Kansou J
Kuwait
10:40 Vascular Trauma: A Local Center Experience
Elham Khouja, MD
Maddinah, Saudi Arabia
10:50 Vascular Trauma: A Single Center Experience
Omar Balubaid
Jeddah, Saudi Arabia
11:00 Management of a Large Common Femoral Artery Traumatic Psudoaneurysm in 5-
Months Old Girl: A Case Report
Nabeel Batheeb, MBBS; Badr Al-Jabri, MD; Mohammed Al-Omran, MD, MSc;
Mussaad M Al-Salman, MD.
Riyadh, Saudi Arabia
11:10 Neglected Traumatic Arterio-Venous Fistula
Abdulmoula Tahani
Dammam, Saudi Arabia
11:20 Stent-grafts in the management of hemorrhagic complications related to femoral catheter insertion: report of two cases
Abu-AlNasr T, AlKohlani H, Al Moaqel M, Al Turki S, AlWahbi AM
Riyadh, KSA
11:30 Prayer and Lunch Break
Session 7: Scientific Papers Session-IV: Peripheral Arterial Disease
Moderators: Dr. Gaith Khougair and Dr. Mohammed Al-Omran
12:30 Does Visfatin Correlates with the Severity of Peripheral Arterial Disease in Diabetic
Patients?
Sultan Al-Sheaik, MD; Eman El-Eter, MD, PhD; Talal Al-Tuwaijri, MD; Badr
Al-Jabri, MD; Musaad M Al-Salman, MD; Mohammed Al-Omran, MD, MSc.
Riyadh, Saudi arabia
12:40 Intermediate results of percutanous endovascular therapy and bypass surgery of
femoropopliteal occlusive disease: non-randomized prospective study
A.Marakbi, A. Hassan, and A.Bdwey
Jeddah, Saudi Arabia
12:50 Endovascular Treatment for Acute Limb Ischemia
M Mazen Hachem, MD, FACS., Gh. Atasi, A. Qanawi, M Brembali, M Bosaeed, A.
Al-Hamdan and M Wakka
Jeddah, Saudi Arabia
13:00 Short Segment Distal Leg Bypass: A valuable but often neglected surgical option
Ala' Groof, FRCSC; Haitham Al-Khayat, FRCSC; Adnan Sadeq, FRCSC.
Kuwait City, KUWAIT
13:10 Peripheral Arterial Disease Evaluation in the Saudi Project for Assessment of
Coronary Events Registry reveals a Missed Opportunity in Preventing the adverse
Cardiovascular Outcomes: A Pilot Study (SPACE-PAD-I)
Badr Aljabri, MD; Ayman Al-Saleeh, MD; Sultan Al Sheikh, MD; Talal Al-Tuwaijri, MD;
Khalid Al-Habib, MD; Mohammed Al-Omran, MD, MSc
Riyadh, Saudi Arabia
13:20 Upper Limb Ischemia in a 15 months old girl: A case report
Elham Khouja, MD
Maddinah, Saudi Arabia.
13:30 Carotid-subclavian bypass: an off-pump myocardial revascularization
Case Report & Literature review
Ghatfan SHAABAN, MD
ARAR, Saudi Arabia
13:40 Primary systemic amyloidosis with extensive vascular involvement: Case report
and review of literature
Tahira Aslam, MBBS, FCPS, MRCS and Ahmed Maged Farghaly, MD, MRCS
Riyadh, Saudi Arabia
13:50 Coffee Break
Session 8: Scientific Papers Session-V: Vascular Diagnostic Modalities and Miscellaneous
Topics
Moderators: Dr. Sameh Barayan and Dr. Elham Khouja
14:10 Outcome of Surgical Treatment for Carotid Body Tumors:
King Khalid University Hospital Experience
Tawfiq Abu-AlNasr MD; Musaad Al-Salman, MD; Badr Aljabri, MD; Kaissor Iqbal,
Abdulmajeed Al-Tuwaijri, MD; Mohammed Al-Omran, MD, MSc.
Riyadh, Saudi Arabia.
14:20 Assessment of Peripheral Arterial Occlusive Disease; Comparison of 64 Single
Source Multidetector CT Angiography and Intraarterial Digital Subtraction
Angiography
Bakarman K, Showmer A, AlKohlani H, Al Moaqel M, Ayad E, Enezy K, El Kayali A,
Al-Turki S, Alwahbi A
Riyadh, Saudi Arabia.
14:30 Evolution of Vascular Laboratory: The Saudi Arabian Experience
Kaisor Iqbal, MD; Mohammed Noor, BSc, Linda Al-Wabeel, BSc; Badr Aljabri, MD;
Mohammed Al-Omran, MD, MSc; Mussaad Al-Salman, MD
Riyadh, Saudi Arabia.
14:40 The applicability of Pre Test Probability model for Deep Vein Thrombosis in
combination with D- Dimer testing
Mirza Baig; Khalid Al-Brekeit.
Riyadh, Saudi Arabia.
14:50 Supraclavicular Approach for the Treatment of Arterial Thoracic Outlet Syndrome:
King Khalid University Hospital Experience
Tawfiq Abu-AlNasr MD; Musaad Al-Salman, MD; Badr Aljabri, MD; Kaissor Iqbal,
Abdulmajeed Al-Tuwaijri, MD; Mohammed Al-Omran, MD, MSc.
Riyadh, Saudi Arabia.
15:00 Adjourn
ABSTRACTS
Endovascular Exclusion of Aneurysms of the Aortic Arch, Thoraco-Abdominal Aorta and Juxta-Renal Aorta
Mr. KOUSSA, S. HAULON, A. ALKREEDEES, R. AZZAOUI, T MODINE, L DESTRIEUX-GANNIER, C DECOENE, G FAYAD, H. WAREMBOURG
Department of Cardiovascular Surgery, Cardiologic Hospital, CHRU of Lille, France
Corresponding Author
Dr. Ali Al-Kreedees
Cardiologic Hospital
CHRU of Lille, France
Tel.: 0033 6 33 81 3525
Email: kreedees@yahoo.com
Objectives: Description and evaluation of new endovascular techniques and hybrids for the treatment of the complex aortic lesions.
Methods: Retrospective study among patients contra-indicated for a conventional surgery and presenting with an aneurysm of the aortic arch (group 1), thoraco-abdominal (group 2), or juxta-renal (group 3). The treatment was carried out by transposition of the supra-aortic trunks associated the establishment of covered endoprostheses(s) for the group 1, retrograde mesenteric and renal bridging associated the establishment of covered endoprosthese(s) for the group 2, of endoprotheses fenestrated for the group 3. An evaluation of the patients and an angioscanning of the operated site were programmed 1, 6; 12, and 24 months after the intervention.
Results: From March 2002 to January 2005, 13 patients (average age 71 years) were operated for aneurysm of the arch (n=4), thoraco-abdominal (n=3), and juxta-renal (n=6). A coronary revascularisation without CEC was carried out in a concomitant way among 2 patients of the group 1. Un banding of the aorta was carried out among 2 patients of the group 2. A patient of the group 1 died brutally in the 7th post-operative day. A patient of group 3 presented with an aggravation of his preoperative renal insufficiency. The average follow-up was 9 months. No secondary gesture was carried out. The maximum diameter of the aneurism decreased among 5 patients and remained stable at the 8 others.
Conclusion: The treatment of complex aortic lesions among patients presenting with contra-indications to a conventional surgery can be carried out with the assistance of endovascular techniques. The continuation of the follow-up is necessary before recommending these techniques as the first option.
ENDOVASCULAR REPAIR OF BLUNT TRAUMATIC THORACIC AORTIC INJURIES: RETROSPECTIVE ANALYSIS FROM TWO TEACHING CENTERS IN SAUDI ARABIA
Shaltot M, Al Garni S, El kayali A, Al Kohlani H , Al Turki S , Al Moaqel M. Al Wahbi AM.
Division of Vascular Surgery & Division of Interventional Radiology, KAMC, Riyadh, KSA and Division of Vascular Surgery, KFSH, Riyadh, KSA
Corresponding Author:
Dr. Abdullah Alwahbi
PO BOX: 22490 RIYADH 11426
TEL: +9661-2520088 #14119 #14118 #14137
FAX: + 9661-2520051
Email: alwahbi1@hotmail.com
Background: Endovascular therapy has recently extended to the treatment of blunt traumatic thoracic aorta and has been approved to be safe in emergency. The aim of this study is to evaluate the results of endovascular stent graft placement (from two tertiary care teaching hospitals in Riyadh) for treatment of traumatic thoracic aorta injuries.
Methods and Results: Sixteen consecutive patients out of seventeen (18 to 74 years old male; mean 37 years) underwent stent grafting of the aortic isthmus in aortic traumatic rupture after motor vehicle accident. The implantation procedure was technically successfully in all cases. There was no death, surgical conversion or paraplegia. One patient showed minor degree of endoleak at discharge, resolved spontaneously after one month. Acute lower limb ischemia occurred in one patient secondary to thrombosis at femoral arteriotomy site, treated successfully by patch angioplasty. Two patients who had associated pelvic fractures, developed pulmonary embolism and required IVC filter insertion. Stent graft covered the orifice of left subclavian artery in two patients, which tolerated well without revascularization. Mean follow up was 16 months (Range 3-45 months). Thrombosis of peudoaneurysmal sac was found in all patients.
Conclusion: Although long-term results from our centers are unknown, we conclude that endovascular repair of thoracic aortic injuries after blunt trauma can be performed safely and is the treatment of choice in emergency.
Endovascular Treatment of Acute Aortic Emergencies: Early Results
From the Division of Vascular Surgery, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia.
Fax: +9661 467-9493
Background: Acute aortic diseases are challenging to treat. If not treated, they carry high mortality rate. Endovascular stent grafting has emerged as an option to treat these emergencies with reported significant lower mortality and morbidity. The aim of this study was to evaluate the early results of endovascular stenting in treating a variety of acute aortic emergencies.
Methods: We prospectively collected data from consecutive patients who presented to King Khalid University Hospital with acute aortic diseases between April 1, 2007 and November 30, 2007 and were treated with endovascular stent grafts. Presentations of patients were; blunt traumatic thoracic aorta ruptures (n= 4), ruptured true thoracic aortic aneurysms (n = 4), and ruptured proximal anastomotic aortic psudoaneurysm (n = 1). Diagnosis was confirmed by multi-planer enhanced computed tomography with 2.5 mm cuts for accurate stent grafts sizing. Stent grafts were introduced through a common femoral artery cut down.
Results: A total of 12 stent grafts (Gore Excluder, California USA) implanted in 9 patients (8 males and 1 female) with a mean age of 45 years (16 – 73 years). Technical success rate defined by complete exclusion of the pathology was 100%. 30-days mortality rate was 22%. Both patients who died were from the ruptured true thoracic aortic aneurysm group and no patients died from the traumatic thoracic aorta ruptures. One patient died from acute renal failure that also required an axillary bi-femoral bypass at the original procedure for lower limb revascularization due to distal aortic occlusion and another died from hemoptysis from bronchoscopic confirmed bronchogenic carcinoma. In addition, one patient suffered from myocardial infarction from the ruptured true thoracic aortic aneurysm group treated medically. Non of the patient in the traumatic rupture group suffered from major complications.
Conclusion: Endovascular stent graft is an effective treatment option for an acute aortic emergencies particularly those who present with traumatic ruptures. Long-term follow-up is required to confirm its durability.
Fate of Left Kidney after Left Renal Vein Division during management of Aortic Occlusive Disease
Mohamed A Elsharawy*, MS MD FRCS and Khaled M Moghazy **, MS MD.
Department of Surgery* and Department of Radiology**King Faisel University, Al-Khober, Kingdom of Saudi Arabia.
Corresponding Author:
Dr Mohamed A Elsharawy
P O Box 40081, Al-Khobar 31952
Kingdom of Saudi Arabia.
Fax: 0096638966728
Email: elsharawya@yahoo.co.uk
Tel; 00966501852057
Background: Left renal vein division (LRVD) has been used as a technical aid to gain exposure to the peri-renal aorta and to control bleeding in abdominal aortic operations. A few retrospective series studied the effect of such division on the overall renal function with contradicting results. The aim of this study is to assess the effect of such division on the left kidney during management of aortic occlusive disease.
Patients and methods: A prospective study was undertaken on all patients that had abdominal aortic bypass surgery for occlusive disease scheduled between October 2003 and September 2007. Some of the patients had disease, which extended to juxta-renal aorta and LRVD was necessary. We examined the effect of this division on the renal function of the left kidney. Renal function was assessed by measuring serum creatinine and creatinine clearance preoperatively and postoperatively up to 14 days. Left kidney was assessed by performing computed tomography (CT) with contrast preoperatively and 3rd day post-operatively. If the CT showed any abnormality, the left kidney was followed up by ultrasonography and CT.
Results: Thirty-two patients were included in this study. Four patients had LRVD. The preoperative mean serum creatinine (LRVD 0.95±0.12 vs. 0.98±0.08, p=0.65) and mean creatinine clearance (LRVD 99±12 vs. 94±11, p=0.36) did not show statistically significant difference between the LRVD group and the rest. At 3rd day postoperatively, there was insignificant rise of mean creatinine (LRVD 1.2±0.15 vs. 1.0±0.1, p=0.18) and insignificant drop of mean creatinine clearance (LRVD 57±8 vs. 85±9 p=0.06) in the LRVD group. At 14th day post-operatively, the mean creatinine (LRVD 1.0±0.11 vs. 0.99±0.1, p=0.39) and the mean creatinine clearance (LRVD 95±9 vs. 98±6 p=0.84) returned back to normal. CT abdomen showed diffuse swelling and congestion of the left kidney in all cases that had LRVD, which reverted normal at 14 days (7-14 day).
Conclusion: Selective LRVD during aortic occlusive surgery does not compromise the left kidney
Mycotic Infrarenal Abdominal Aortic Aneurysm: Case Series & review of the literature
Samer Ali; Mohammed Bafaraj
Al-Noor specialist Hospital, Makkah, Saudi Arabia
Corresponding Author:
Dr Samer Ali
Al-Noor specialist Hospital
Makkah, KSA
E-mail: samerali10@yahoo.com
Background: Mycotic abdominal aortic aneurysm is a rare and life threatening event. It can be subtle and easily missed till the time of its fatal complications. Furthermore, surgical management is challenging.
Methods & Results: Retrospective review for Al-Noor specialist Hospital experience with mycotic abdominal aortic aneurysm. Three cases were identified. The clinical presentation, management and outcomes were described.
Conclusion: In-situ graft reconstruction seems to be an attractive effective treatment in comparison with other modalities
Unfavourable Aortic Aneurysms Anatomy: Challenging Scenarios for Vascular Surgeons
From the Division of Vascular Surgery, King Saud University, Riyadh, Saudi Arabia.
Badr Al-Jabri, MD
King Khalid University Hospital
Department of Surgery,P.O. Box 7805(37)
Riyadh 11472, Saudi Arabia
Email: aljabribadr@hotmail.com
Management of Aortic aneurysms is advancing day by day, and after the introduction of endovascular intervention, the morbidity and mortality improved significantly and the numbers of patients who are legible for intervention are increasing , but still there are many situation where vascular surgeons are still faced with difficulties because of unfavourable anatomy. In this case series we are presenting three challenging cases of aortic aneurysms along with their management plan.
The effect of venous outflow diameter
on the patency rateof arteriovenous fistulae
Alaa Amin, FRCSI, ABS,KSUF
Department of Surgery, Alhada Military Hospital,Taif, Saudi Arabia.
Corresponding Author:
Alaa Amin, FRCSI, ABS,KSUF
Consultant Vascular Surgeon
Alhada Military Hospital,Taif
Email:dralaaamin@yahoo.com
BACKGROUND: Many surgeons refuse to do distal ArterioVenous accesses (AV accesses) claiming high percentage of failure due to small diameter of veins. We review in this study the best diameter of venous out flow of the AV accesses to increase the patency rate.
METHOD: A prospective cohort study including all consecutive patients needed AV access creation in the form of AV fistula or AV graft from February 2005 until May 2007. The patients were divided into two groups according to the diameter of the vein which was used as an outflow for the AV access. Those patients who have AVF with out flow veins less than 2.5-mm caliber were used group A and those patients who have a vein more than 2.5-mm caliber were used group B. Also, patients with an AV graft access formation were divided into two groups. Group C where a small-caliber vein was used for outflow and group D where there is a larger-caliber vein used for outflow. The diameter of the vein was calculated according to the preoperative Duplex ultrasound and intraoperative direct measuring tape. All AV fistulas created by the same surgeon. No intraoperative heparin was given and end-to-side anastomosis was done using CV7. All small veins less than 2.5 mm were dilated using a Hegar dilator up to 2.5 calibers. All grafts that were used were 6-mm graft. All arteriotomies were done were more than 12 mm. The patients were followed up for two years. Patency rates were calculated over six months for each vascular access. Access considered failed if AV accesses were thrombosed and the patient is not a candidate for thrombectomy.
Results: A total of 100 arterio venous accesses were created in 86 patients from February, 2005 till May, 2007. Their age ranged between 8 years and 96 years with a mean of 43.8±22.6. Males to females ratio was 1.26. Out of them, 67 were hypertensive (67% %) and 43 patients were diabetic (43%). All diabetic patients with renal failure were also hypertensive. The accesses include 85 fistulae and 15 grafts. The Fistula was divided into two groups. The first group (A), 43 fistula created using less than 2.5 mm vein as a venous out flow. While in the second group (B), 42 fistulas created using more than 2.5 mm vein as a venous out flow. A failure rate of 16.2% was reported in the first group, while it was 2.4% in the second group. This difference was statistically not significant .The grafts were also divided into two groups. In the first group(C), 8 grafts created using less than 2.5 mm vein as a venous out flow and in the second group (D), 7 grafts created using more than 2.5 mm vein as a venous out flow. The patency rate in the first group was 37.5% while in the second group, it was 71.4%. This difference was statistically not significant. However the overall patency rate of all AVaccesses created using an out flow vein more than 2.5mm diameter (93.9%) was obviously better than the patency rate of AV accesses using a small caliber out flow vein (76.5%), P<0.05.
CONCLUSION: Using a large (>2.5mm) diameter vein as a venous out flow will maximize the chance of patency of AV access.
Does regional anesthesia influence early failure of elbow arteriovenous fistulae?
Mohamed A Elsharawy*, MS MD FRCS and Roshdy Elmotwely**.
Department of Surgery* and Department of Anesthesia** , King Faisel University, Al-Khober, Saudi Arabia.
Corresponding Author:
Dr Mohamed A Elsharawy
P O Box 40081, Al-Khobar 31952
Saudi Arabia.
Fax: 0096638966728
Email: elsharawya@yahoo.co.uk
Tel: 00966501852057
Background: Some recent studies have shown that the use of regional anesthesia in elbow arteriovenous fistulae (AVF) causes significant vasodilatation and improvement of their blood flow. However, none had shown that these effects can improve outcome of the vascular access. The aim of this study was to assess if regional anesthesia can affect early failure of elbow AVF.
Patients and methods: A prospective study was performed on all patients with end-stage renal disease referred to the Vascular Unit of King Fahd University Hospital between September 2004 and September 2007 for permanent vascular access and had elbow AVF constructed. Patients were divided into 2 groups: Group 1; patients who underwent the operation under regional anesthesia and Group 2; patients operated under general anesthesia, indicated by patients’ refusal or failure of regional anesthesia. Data including patient characteristics and the type of AVF were recorded. The internal diameter of the vein and artery and intra-operative blood flow were measured. Complications of both types of anesthesia were recorded. Patients were followed up for 3 months.
Results: During the above period, 84 cases were included in this study. Complete brachial plexus block was achieved in 57 patients (68%). Seven patients were converted to general anesthesia and 20 patients had AVF under general from the start. There were no significant differences between the 2 groups as regard basic characteristics or operative data. Early failure was in 11 fistulae (13%). There were no instances of systemic toxicity, hematomas, or nerve injury from the block. No major complications were reported from the general anesthesia. There was no significant difference between 2 groups as regard early failure of AVF (Group 1, 14% vs. Group 2 11%. P=0.80)
Conclusion: Our data failed to show advantage of regional over general anesthesia in terms of early outcome of AVF.
Managing the lifeline: The Dialysis Vascular Coordinator, the way to improve Hemodialysis Access outcome
Showmer A, Bakarman K, AlKohlani H, Ayad E, Enezy K, Mahmoud I, ELKayali A, Al Turki S, AlWahbi AM
Division of Vascular Surgery, KAMC, Riyadh, Saudi Arabia
Corresponding Author:
Dr Abdullah Alwahbi
PO BOX: 22490 RIYADH 11426
TEL: +9661-2520088 #14119 #14118 #14137
FAX: + 9661-2520051
Email: alwahbi1@hotmail.com
It is well established that the leading cause of morbidity in end stage renal disease patients is related to access placements and its complications. Hemodialysis vascular access- related hospitalization accounts for more than 20% of ESRD hospitalization. The impact of dysfunctional vascular access on physician time, health care resources and patient's quality of life is profound. With the beginning of the year 2001 a multidisciplinary team was formed consisting of a vascular surgeon, nephrologist, radiologist, and a vascular access coordinator. Practice guidelines where constructed according to Dialysis Outcomes Quality Initiatives (DOQI) recommendations tailored to our resources. The most important member of the vascular access team was the coordinator, with the following duties: Liaison among nephrologist, vascular surgeons, radiologists and dialysis nurses, scheduling of all dialysis access procedures, maintain computerized records of all access procedures (Vascular access registry), identify access problems and issues, education of patients, dialysis and ward nurses,regular follow-up of patients, and coordinate admissions, procedures, and dialysis of patients from outside Riyadh. Our objectives where as follows; shifting access surgery to day surgery which will significantly reduce the hospitalization, early referral of patients with Pre renal failure to avoid insertion of central catheters, increase fistula placement, establish a quality assurance program for access monitoring, prompt intervention on failing fistulas, strict infection control measures, and early referral of access complication for surgical assessment. We are presenting our experience, where most of these objectives where achieved. We recommend the a vascular coordinator is a must in every tertiary dialysis
Endovenous Laser Therapy of the Great Saphenous Vein: Early and Intermediate Results
From the Division of Vascular Surgery, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia.
Mohammed Al-Omran, MD, MSc
King Khalid University Hospital
Department of Surgery,P.O. Box 7805(37)
Riyadh 11472, Saudi Arabia
Email: m_alomran@hotmail.com
Fax: +9661 467-9493
Background: Endovenous laser therapy (EVLT) is a new, minimally invasive percutanous endovenous technique for ablation of the incompetent great saphenous vein (GSV). The aim of this study was to evaluate the early and intermediate results of occlusion and recanalization rates and complications after EVLT of the GSV.
Methods: Between March 1, 2006, and November 30, 2007, we conducted a prospective clinical trial to treat patients with incompetent GSV using a 980-nm multidiode laser (inter-medic) with intermittent fiber pullback and tumescent local anesthesia. Patients were followed up prospectively with duplex ultrasonography at day 1 and at 1, 3, 6 and 12 months.
Results: Endovenous GSV ablation was performed on 150 limbs in 122 patients. General anesthesia was used in 4% of the patients. The mean age was 35 years and 66% were females. According to the CEAP classification, majority were C2 (80%). The average voltage use was 14 W (range from 10 to 15 W). The pulse time was 5 seconds with 1 second pause. GSV occlusion rates were 99 % at day 1, 98.7 % at 1 week, 97.6 % at 1 month, 96.3 % at 3 months, 95.4 % at 6 months, and 94.2 % at 12 months after EVLT. Subanalysis of the patients who received a voltage of 15W showed a GSV occlusion rate of 100% at 1 week, 99.2 % at 3 months, 97.5% at 6 months, and 96.6% at 12 months. Concomitant avulsion phlebectomy was performed in 80 limbs. Significant bruising was seen in 17 limbs (11.3%) and superficial thrombophlebitis was seen in 2 limbs (1.3%) however, edema, excessive pain, hematoma, or cellulitis were not seen. Thrombus protruded into the lumen of the common femoral vein (CFV) was seen in two limbs (1.3%) after EVLT. Both patients were treated with anticoagulation. Duplex follow-up scans of these two patients performed at 12 weeks, showed that the thrombus previously identified at duplex scan was no longer protruding into the CFV.
Conclusion: Short term and intermediate results of EVLT are excellent. Greater doses of energy delivered are associated with better results. Long-term follow-up and comparison with standard GSV stripping are required to confirm the durability of EVLT.
Do Management Strategies Reduce Vascular Access Complications?
M Mazen Hachem, MD, FACS., M. Bosaeed, M. Wakka and A. Hamdan
Vascular Surgey Division, King Khalid National Guard Hospital, Jeddah, KSA
Corresponding Author:
M Mazen Hachem, MD, FACS.
Consultant & Head; Division of Vascular Surgery
King Khalid National Guard Hospital
Jeddah/ KSA
Tel: + 966-2-624 0000/ 22071
Email: mmhachem@hotmail.com
Vascular access related complications, are one of the most important reasons for patient hospitalization, morbidity and even mortality. It is more higher in patients with AVG compared with patients with a functioning AVF. NFK-DOQI committee currently recommends that in any dialysis center the majority of new dialysis patients should have a primary AVF constructed in an attempt to improve overall patency rates and reduce access related morbidity and mortality. Unfortunately, creation of an AVF is not always possible as a consequence of prior vascular access surgery, insufficient caliber of forearm vessels or sclerosis caused by prior venipunctures. Although less thrombotic and infectious complications occur in AVF, the AVF is not ideal since adequate maturation of AVF, sufficient dilatation and arterialization, fails in up to 30% of all newly created fistulae, resulting in delayed initiation of dialysis treatment or placement of temporary central venous dialysis catheters, and related morbidity. Considering the increasing age of hemodialysis patients, prolongation of the dialysis therapy, and the increase of the number of patients requiring hemodialysis, the number of AV grafts and permenet catheters will probably increase rather than decrease. As a consequence, vascular access complications will continue to challenge vascular access teams. Adherence to the management strategies since 2003 in our institute resulted in significant improvement in AVF patency rates and reduction in VA complications and related morbidity.
Pulmonary embolism – Surgical aspects: Review of the Literature
Mohamed M Ramzy, MD, FACS
Qassim, Saudi Arabia
Corresponding Author:
Dr Mohamed M Ramzy
E-mail: mramzy40@hotmail.com
Phone: 0507970608
Background: Pulmonary embolism is a life threatening conditions that occurs when a clot of blood or other material blocks an artery in the lung. This is an extremely
common & highly lethal condition & is one of the most prevalent disease processes responsible for inpatient mortality (30%). Its diagnosis is overlooked in most cases (70%).
Methods & Results: A review of this lethal condition is presented with regards to its pathogenesis, diagnosis, treatment & the surgical interventions adopted with the more recent endovascular applications.
Conclusions:
1) A thorough diagnostic protocol should be followed to exclude other causes that may simulate PTE.
2) Definitive diagnosis is attained by selective pulmonary angiography.
3) Primary therapy in the form of clot dissolution with thrombolysins or embolectomy is reserved for patients with high risk of adverse clinical outcome.
4) Secondary therapy in the form of anticoagulation or placement of inferior vena cava filter is reserved for patients with almost normal right ventricular function.
5) Surgical management is applied if there is a peripheral source for PTE.
6) Endovascular interventional management is available to treat the most severe cases of massive PTE.
THE MANGLED LOWER EXTREMITY:
Limb Salvage or Amputation?
Sameh Barayan, MD, FRCSEd, FRCSC, FACS; Ashraf Noureldin, MD
Saad Specialist Hospital, Department of Surgery, AL KHOBAR , Kingdom of Saudi Arabia
Corresponding Author:
Dr Sameh Baryan
Saad Specialist Hospital
Department of Surgery
PO Box 30353, AL KHOBAR 31952
Saudi Arabia
Email: sbarayan@saad.com.sa or ssbarayan@yahoo.com
Background: In severe traumatic injuries to the lower extremity, it is often a difficult decision to attempt heroic efforts aimed at limb salvage or to amputate primarily. Amputation has been, and still is, considered by some to mean failure of treatment and a disaster to the patient. Others argue that amputation may not be so and may even be a more sensible decision than a futile attempt of repair that may bring more misery to the patient and may even cost him his life.
Methods & Results: A prospective study was conducted in which 46 cases with serious limb injuries due to various types of trauma were studied. Twenty three cases had a primary amputation while in the remaining twenty three heroic efforts were made in an attempt to repair the injuries. Both groups of cases were reviewed and followed up with the short term and long term results of both modalities of treatment recorded. It was found that prolonged unsuccessful attempts at salvage are costly, highly morbid and sometimes lethal. Primary amputation is recommended in some patients according to certain criteria and scoring systems.
Conclusion: Despite advances in reconstructive surgery, there is still a distinct place for primary amputation in selected cases, and it should not be considered a failure of treatment but a sound decision based on experience and solid criteria that may save the patient the misery of brief hope followed by misery and sometimes ultimate death.
Management of Mangled Extremity
El Sayed A. El Zayat
Clinical Sciences Department, King Fahad Medical City, Riyadh, Saudi Arabia.
Corresponding Author:
Dr. El Sayed A. El Zayat
Head of Clinical Sciences Department
FOM – KFMC – MOH – KSA
Email: elsayedelzayat@yahoo.com
Background: The management of extremity arterial injury in cevelians is a challenging task. We usually follow the western world protocols of management which in this case is usually based on the experience of others because of relatively small number.
Method & Result: Senior Surgeon, Orthopedist, Vascular Surgeon and Neurosurgeon. Orthopedic repair always before vascular injury repair. 62 limbs with sever injuries, there was;
· 19 Popliteal Artery injuries
(Were treated by saphenous vein graft)
· 16 Radial +/- Ulnar Arterial injuries
(Were treated by end to end or cephalic vein graft)
· 12 Brachial Artery injuries
(Were treated by cephalic or saphenous vein graft)
· 7 Femoral Artery injuries
(Were treated by PTFE or vein patch graft)
· 6 Tibial Arteries injuries
(Were treated by either end to end or saphenous vein graft)
· 2 Axillary Artery injuries
(Were treated by saphenous vein graft)
We had no death: 81% 1ry patency, 53% 2ry patency and 94% limb salvage
Conclusion: We concluded that upper limb injury has better prognosis. The scoring system was able to identify the patients at risk of amputation but prediction in individual patient was difficult. We recommend that all injuries whatever its score should be cared fully and explored.
Management Algorithm for Blunt Renal Artery Occlusion in Multiple Trauma Patients
Ali Jawas, MD, FRCSC; Fikri Abu-Zidan, MD, FRCS, PhD, DipApplStats
Department of Surgery, Tawam and Al-Ain hospital, Al-Ain, United Arab Emirates
Corresponding Author:
Dr Ali Jawas
Department of Surgery,
Faculty of Medicine and Health Sciences,
P O Box 17666, Al-Ain, United Arab Emirates
E-mail: amjawas@yahoo.com
Background: Management of renal artery thrombosis in multiple trauma patients has been a controversial issue. We have reviewed our recent experience in this area so as to develop a management algorithm.
Methods: A Retrospective study was performed to evaluate treatment outcomes and complications of all patients who presented to two trauma centers (at Tawam and Al-Ain hospital) with blunt traumatic renal artery occlusions during the last 3 Years.
Results: A total of five patients have been identified during the period between January 2005 and September 2007. All five patients have severe associated injuries. Three patients were treated conservatively. Two patients had laprotomy to treat other associated injuries; the kidney was left in situ in one patient who underwent damage control laprotomy with packing of the liver. The other patient had an attempted renal artery repair which was aborted due to continued haemo-dynamical instability. At one year follow up the serum creatinine were within normal range in all patients. Hypertension has developed in one patient who was recommended to have a nephrectomy.
Conclusions: Conservative management is advised in the treatment of unilateral blunt renal artery thrombosis, these patients needs a close follow-up to identify the subgroup that may develop hypertension. Blunt renal artery thrombosis in multiple trauma patients indicates severe injury; surgeons should critically assess the overall clinical status of these patients with the added risk of mortality against chances of recovering the renal function.
155 vascular injuries: a retrospective study in Kuwait, 1992-2000
Asfar S, Al-Ali J, Safar H, Al-Bader M, Farid E, Ali A, Kansou J.
Vascular Surgery Unit, Department of Surgery, Mubarak Al-Kabeer Hospital, Safat, Kuwait
Corresponding Author:
Dr Hussein Safar
Email: AAASAFAR@hotmail.com
OBJECTIVES: To audit the management of vascular trauma in Kuwait, 1992-2000.
DESIGN: Retrospective open study.
SETTING: Vascular surgery unit, teaching hospital, Kuwait.
SUBJECTS: 155 patients with vascular injuries, most of which (n = 118) involved the extremities. 21 had neck injuries, 10 abdominal, and 6 chest.
INTERVENTION: Revascularisation usually using the long saphenous vein in addition to direct repair or end-to-end anastomosis.
MAIN OUTCOME: Morbidity (amputation) and mortality.
RESULTS: Four lower limb grafts failed, two of which (2/69, 3%) required amputation. Overall, four patients died (3%), one of pulmonary embolism and 3 of severe injuries to major abdominal vessels. 3/10 patients with abdominal vascular trauma died. Mean (SD) follow up period was 4.4 (2) years.
CONCLUSIONS: Civilian violence has increased in Kuwait. Vascular trauma to abdominal vessels is associated with high mortality. Autogenous saphenous vein forms an excellent conduit for revascularisation.
VASCULAR TRAUMA: A LOCAL CENTER EXPERIENCE
Elham Khoujah, MD
Division of Vascular Surgery, King Fahd General Hospital, Al Madinah, Saudi Arabia
Corresponding Author:
Dr Elham Khouja
King Faha General Hospital
Department of Surgery
Al Madinah, Saudi Arabia
Email: ekhoujah@hotmail.com
Background: Road traffic accidents considered to be the first cause of mortality and disability among young age group in Saudi Arabia, retrospectively we are discussing our experience in Al Madinah region, as being the only referral centre covering all vascular surgery cases
Methods & Results: From Jan.2004 – Dec.2007, 70 cases and 70 limbs of vascular trauma were managed in our unit, with predominance of males, age range (4y – 56y), penetrating injuries were the direct cause of vascular injuries in 95%, while blunt trauma was the cause of vascular injuries in 5% of cases, and viability of the extremity was the master key during evaluation. Of the 70 cases, one case ( 1.42%) underwent primary amputation, tow cases ( 2.85%) ended by a secondary amputation, the remaining 67 limbs( 95.7%), were saved with fairly acceptable function in 90% , & limited disability in 10% of cases mainly lower limbs.
Conclusion: viability of extremity is a very sensitive indicator for salvage, but such a decision needs the outermost cooperation of orthopedic & plastic surgeons.
Vascular Injuries: A Single Center Experience
Omar Balubaid
Vascular Surgery Unit, Department of Surgery, KFGH, Jeddah, Saudi Arabia
Corresponding Author:
Dr Omar Balubaid
Email: dr_balubaid@yahoo.com
Vascular injuries of extremities and management Vascular injuries of extremities (upper and lower limb in adults and children) in our experience we see the most common following RTA which are in form of crush injury or blunt trauma with subsequent vascular insufficiency, arterial injuries could accompanied with venous injury ,arterial injury could be life threatening because of perfuse bleeding and this necessitate immediate management to save patient life and his limb and decision making in vascular surgery is critical ,there is different types of injuries which we can see frequently in the last 10 years between lab ours due to sharp instrumentation which in severe cases may lead to arm amputation , most injuries are crush injuries which are accompanied with muscle ,bones, tendons, and nerves which need teem work to manage such cases include vascular, plastic, and orthopedic surgeon ,in children we noticed that most vascular emergency is supracondylar fracture of the elbows other cause of vascular injuries penetrating whether opened or closed either by penetrating bullet or knife or other sharp object ,in our experience we think careful examination of the patient and injured limb is crucial and to asses carefully the circulation of the limb ,we found emergency angiography is helpful in most case especially in closed injuries ,different vessels can be effected in upper limb most frequently are axillary, brachial arteries in cases of RTA ,radial and ulnar artery injuries due to sharp instruments .In the lower limbs ,fracture pelvis can be accompanied with injuries of major vessels in the pelvis like common iliac arteries and it is braches and accompanied veins, we notice that all vessels of the lower extremity more frequently than vessels of the upper limb especially in RTA. Managements need explorations of the injured limb and reconstruction of the injured vessels whether by primary repair or if there is lose segment which need grafting and is always advisable to autogenous graft ,synthetic graft like PTFA is limited for major vessels in the pelvic trauma.
Management of a Large Common Femoral Artery Traumatic Psudoaneurysm in 5-Months Old Girl: A Case Report
From the Division of Vascular Surgery, King Saud University, Riyadh, Saudi Arabia.
Musaad M Al-Salman, MD, FRCS, FACS
King Khalid University Hospital
Department of Surgery,P.O. Box 7805(37)
Riyadh 11472, Saudi Arabia
Email: mussaad@ksu.edu.sa
Five months old baby girl with a congenital hip dislocation (CDH), presented by her mother in hip spica 1month post- adductor tenotomy with pulsatile mass and bleeding in the right groin at the site of surgery.
Duplex scan showed multiloculated, 5cm size psudoaneurysm in the right groin, arisisng from the right common femoral artery.
Trial of thrombin injection was done under ultrasound (U/S) guidance which obliterated the flow primarily, but it recurs after 2 days due to its multiloculated nature.Another trial of thrombin injection was done, but was not successful.
The right groin was explored surgically under general anesthesia and a primary repair of the psudoaneursym was performed. The post operative course was uneventful.
Neglected Traumatic Areterio-Venous Fistula
Abdulmoula Tahan
Division of Vascular Surgery, Dammam Central Hospital, Dammam, Saudi Arabia
Corresponding Author:
Dr Abdulmoula Tahani
Background: Long lasting neglected arterio-venous fistula might result in progressing degenerative changes of the involved vessels which cannot be controlled and stopped even many years after repair of fistula.
Methods & Results: A 54 years male was a victim of bullet injury to left thigh 23 years ago, ten years after the injury a neglected femoral-femoral arterio-venous fistula was diagnosed and repaired. Twelve years after the repair patient developed a huge aneurysm in the previously diffusely dilated afferent femoral artery, which was recently resected by synthetic bypass graft.
Conclusion: Long lasting traumatic arterio-venous fistula of medium and large arteries is a serious injury of progressing nature. The deeply degenerative irreversible changes with weakening of the arterial wall continue to cause new complications even years after successful repair of the fistula.
Stent-grafts in the management of hemorrhagic complications related to femoral catheter insertion: report of two cases
Abu-AlNasr T, AlKohlani H, Al Moaqel M, Al Turki S, AlWahbi AM.
Division of Vascular Surgery & Division of Interventional Radiology, KAMC, Riyadh, KSA
Corresponding Author:
Dr Abdullah Alwahbi
PO BOX: 22490 RIYADH 11426
TEL: +9661-2520088 #14119 #14118 #14137
FAX: + 9661-2520051
Email: alwahbi1@hotmail.com
Background: Femoral artery bleeding related to femoral catheter insertion is an infrequent but morbid complication.
PURPOSE: Evaluation of percutaneously implanted covered stents in acute vascular bleeding as therapeutic alternative to conventional surgical treatment.
METHODS & RESULTS: We report 2 cases of hemorrhagic complications related to use of femoral catheter insertion that were successfully managed with stent-grafts. Due to severe medical comorbidities they were considered unsuitable for conventional surgical management and underwent an emergency endovascular repair with a balloon-expandable covered stent. Both patients presented with clinical signs of hypovolemic shock. The diagnosis of active bleeding through the puncture site was made by clinical suspension and emergency digital subtraction angiography.
Conclusion: These cases illustrate that endovascular therapy may be a safe and efficient alternative in the emergent management of active femoral artery bleeding when traditional open surgery is contraindicated. The use of stent-grafts proved to be efficient in the management of these life-threatening hemorrhagic complications.
Does Visfatin Correlates with the Severity of Peripheral Arterial Disease in Diabetic Patients?
From the Department of Physiology (EE); and the Division of Vascular Surgery (TA, BA,SA, MMA, MA), King Saud University, Riyadh, Saudi Arabia.
Mohammed Al-Omran, MD, MSc
King Khalid University Hospital
Department of Surgery,P.O. Box 7805(37)
Riyadh 11472, Saudi Arabia
Email: m_alomran@hotmail.com
Background: Visfatin is a peptide that is highly expressed in visceral fat and was isolated as a secreted factor that promotes the growth of B cell precursors and more recently was reported to act as an insulin mimetic factor. This study was undertaken to investigate the role of visfatin in the development of PAD in diabetic patients.
Methods: We prospectively collected data from 100 consecutive diabetic patients who were referred to the Vascular Surgery outpatient clinic at a Tertiary Care Hospital for assessment for their PAD between January 2006 and December 2006. According to the patients’ ankle brachial index (ABI), they were divided into two groups; group I where their ABI <0.5, and group II where their ABI between 0.5 and 0.9. Fasting blood samples were collected for blood sugar (FBS), triglycerides (TG), total cholesterol, HbAc1, and plasma visfatin. Measurements of systolic & diastolic blood pressure and body mass index (BMI) were done.
Results: The mean age for these patients was 57 years and 24% were women. No differences were detected between the two groups regarding, TG, FBS, total cholesterol, HbAc1, BMI and blood pressure. The plasma visfatin level in group I was 87.1 ng/ml compared to 63.1 ng/ml in group II (p=0.034). The glucose/visfatin ratio was markedly lower in group I compared to group II (13.1 vs. 17.9; p=0.04). Furthermore, plasma visfatin level was negatively correlated with ABI (P<0.005), suggesting its association with the severity of PAD.
Conclusions: Visfatin plays a role in the pathophysiology of PAD regardless of the diabetic status and it can be used as a marker for the severity of atherosclerosis. Whether the elevated plasma levels of visfatin in patients with PAD is a compensatory mechanism or initiative of the disease process needs further investigation.
Intermediate results of percutanous endovascular therapy and bypass surgery of femoropopliteal occlusive disease: non-randomized prospective study
A.Marakbi, A. Hassan, and A.Bdwey
Jeddah Heart Institute (Department of Vascular Surgery), Dr Erfan Hospital, Jeddah, Saudi Arabia.
Corresponding Author:
Dr. Ahmed Marakbi
Email: ahmedmarakbi@hotmail.com
Background: Endovascular has dramatically alerted the treatment of peripheral vascular disease. Lesions that were previously thought amenable only to surgical treatment now can be successfully managed percutaneous. Although most consider vein bypass to be the gold standard in surgical treatment of severe atherosclerotic disease. Synthetic graft is used currently in practice for femoro above knee popliteal bypass. The purpose of this study to detect the efficacy of femoro-popliteal bypass and PTA +/- stenting for superficial arterial occlusive disease. This non randomized prospective study was designed to evaluate the effectiveness of treating of superficial artery occlusive disease percutaneous with balloon dilatation with and without stents and also surgical femoral to above knee popliteal bypass with synthetic materials.
Methods & Results: Femoropopliteal PTA and femoro-popliteal bypass (graft) was performed on 118 consecutive limbs (109 patients) from March 2003 to march 2007. Patients had symptoms ranging from claudication to rest pain with or without tissue loss and non - randomized prospectively to one of two groups. The limbs that were treated with angioplasty with and without self expandable stents (n=56). The limbs were treated surgically with PTFE or Dacron grafts (n=62). The length of occlusion or stenosis ranging from 2cm to 34 cm. follow up evaluation with ankle brachial index and color duplex were performed at 1, 3, 6, 12, and 18 months. Patients were monitored for a median of 18 months. No statically difference was found between the two groups in primary patency (p=.895) or secondary patency rate (p=.861). In surgical group Technical success was achieved in 94% of patients, with no deaths and a major morbidity rate of 7%. In PTA group 91% with 2% major morbidity. The 18-month patency, in surgical group primary patency was 73%, and secondary patency was 84% (9 peripheral reintervention), resulting in a limb preservation rate of 92% in all patients regardless of clinical presentation. In PTA group primary patency was 77%, and secondary patency was 89%.Interval conversion to bypass surgery occurred in 6 patients (9%).
Conclusion: The choice of open surgical bypass vs. percutaneous angioplasty and stenting for femoro-popliteal segment is still of controversial. Nevertheless, in our study shows no significant difference in synthetic bypass vs. endovascular fashion, provided you apply the TASC recommendations for the SFA treatment. However still we need follow up and do randomized trial between endovascular & bypass surgery.
Endovascular Treatment for Acute Limb Ischemia
M Mazen Hachem*, MD, FACS., Gh. Atasi**, A. Qanawi**, M Brembali**, M Bosaeed*, A. Al-Hamdan* and M Wakka*
*Division of Vascular Surgery, **Division of Interventional Radiology
King Khalid National Guard Hospital, Jeddah, Saudi Arabia
Corresponding Author:
M Mazen Hachem, MD, FACS.
Consultant & Head; Division of Vascular Surgery
King Khalid National Guard Hospital
Jeddah/ KSA
Tel: + 966-2-624 0000/ 22071
Email: mmhachem@hotmail.com
Background: Acute limb ischemia (ALI) is both limb and life threatening. Treatment options include surgical intervention and thrombolysis. Many still consider surgery to be the best treatment option, despite reports of high mortality (20% to 30%) and morbidity. Limb salvage rates are as low as 60%. Others including us favor the alternative approach of intra-arterial catheter directed thrombolysis (CDT).
METHODS: We analyzed the treatment outcomes of 33 limb in 32 patient (7 upper limbs, 26 lower limb) with ALI underwent CDT at our institution from December 2003 to December 2007. Age, median: 64, male/female was 1.7. 78% were diabetics. The underlying causes of ALI included 11 limbs with arterial embolism, 16 limbs with arterial thrombosis, 6 limbs with graft occlusion in 5 patients. The time from the onset of ischemic symptoms ranged from 1 to 70 days (mean = 11). The arterial sectors involved were femoral in 12 cases, popliteal in 4 cases, aortoiliac in 1 case, distal in three cases, subclavian in 5 cases and brachial in tow. CDT consisted of placing a catheter in the clot and the infusion of rtPA according to précised protocol. Clinical, homodynamic, coagulation and angiographical changes were assessed periodically. Infusion time ranged from 24 to 60 hours (mean = 24 hours).
RESULTS: The underlying causes of ALI were arterial embolism in 33.5%, arterial thrombosis in 48.5% and bypass graft occlusion 18%. Severities of ischemia according to the SVS/ISCVS classification, 30 limbs (91%) were classified as category II and 3 limbs (9%) were in category III. For the limbs with embolisms, 7 embolectomies (including 4 cases treated with adjuvant CDT) and 4 CDT as only procedure were performed. For the limbs with thromboses, all had CDT followed by PTA. For the patients with acute graft occlusion, 2 redo bypasses, 4 CDT followed by PTA were performed. We experienced major limb amputations in 6%, hospital mortality in 3% and recurrence of ischemic symptoms in 9% during the follow-up period. Of the patients with category III ischemia, major limb amputation and hospital mortality rates were 6% and 3%, respectively. Minor bleeding around the catheter occurred in 12.5% of patients.
CONCLUSION: CDT has been shown to be useful for rapid clot dissolution, unmasking underlying stenoses, and helping to determine the best treatment strategy (either surgery or PTA) and resulted in better outcome.
Short Segment Distal Leg Bypass:
A valuable but often neglected surgical option
Ala' Groof, FRCSC; Haitham Al-Khayat, FRCSC; Adnan Sadeq, FRCSC.
Kuwait City, KUWAIT
Corresponding Author:
Dr. Ala' Groof, MD, FRCSC
New Dar Al-Shifa Hospital
SAFAT
P.O. Box: 3390, code 13034
KUWAIT
E-mail: ala@alagroof.com
Objective: To reintroduce and emphasize the importance of short segment (Popliteal-distal) leg bypass as a valuable option to help heal ulcers, limit the extent, or even prevent amputation in critical leg ischemia (CLI).
Methods and Results: Four cases of CLI presented to our vascular service over a 12 month period, with non healing ulcers/gangrenous toes as well as rest/night pain. All were diabetic with a mean age of 59. Patients were worked up in the usual fashion, with duplex ultrasonography and lower limb angiography. ABI were less than 0.4 in all 4 cases. Duplex ultrasonography showed dampened signal, monophasic at the level of the ankle. Angiography showed good blood flow through distal Aorta, Femoral, and Popliteal arteries bilaterally. Trifurcation of Popliteal artery consistently showed a single diseased vessel run off, with multiple segments of stenosis. Cardiac workup revealed no evidence of reversible ischemia and all patients were medically optimized before surgery. Classical Popliteal to distal leg bypass was performed in all cases using reversed vein harvested from the same leg. Three of the 4 cases ended up with minor (toe) amputation, one had non healing ulcer that was debrided, all in the same surgical time of performing the bypass. Mean length of stay in hospital was 7 days. All were discharged after adequate pain control and on an antiplatelets agent (Plavix 75 mg PO OD). Patients were followed up for a mean period of 8 months, in which all had healed wounds/ulcers and mean ABI of more than 0.8 and all grafts were patent.
Conclusion: Short segment (Popliteal-distal) leg bypass is an important surgical option, often neglected due to the misconception of small vessel disease in diabetic vasculopthy. We consider this as a valuable tool that can help diabetic patients with healing chronic ulcers and minimizing or limiting the extent of lower limb amputations.
Peripheral Arterial Disease Evaluation in the Saudi Project for Assessment of Coronary Events Registry reveals a Missed Opportunity in Preventing the adverse Cardiovascular Outcomes: A Pilot Study (SPACE-PAD-I)
From the Division of Vascular Surgery (BA, SA, TA, MA); and from the Division of Cardiology (AA, KA), King Saud University, Riyadh, Saudi Arabia.
Riyadh, Saudi Arabia.
Mohammed Al-Omran, MD, MSc
King Khalid University Hospital
Department of Surgery,P.O. Box 7805(37)
Riyadh 11472, Saudi Arabia
Email: m_alomran@hotmail.com
Fax: +9661 467-9493
Background: Peripheral Arterial Disease (PAD) is a marker of systemic atherosclerosis with an elevated risk of cardiovascular mortality and morbidity. This study was undertaken to identify the prevalence of PAD in patients presenting with acute coronary syndrome and do not have previous history of coronary artery disease in order to identify the missed opportunity in treating these patients and potentially avoiding such cardiovascular events.
Methods: We prospectively collected data from consecutive patients who presented with acute coronary events over 4 months. PAD was diagnosed if the Ankle-Brachial index was less than 0.90 and/or if the patient had signs or symptoms suggestive for PAD. Risk factors and risk reduction therapy were compared between patients with and without PAD.
Results: A total of 51 patients were recruited. The mean age for these patients was 62 years and 27% were women. Prevalence of PAD was 45 %, of these, 61% were asymptomatic. Prevalence of PAD in patients with no previous history of CAD was 48%, of these, 64% were asymptomatic. There was no difference in atherosclerotic risk factors between patients with PAD compared to patients without PAD. Utilization of risk reduction was suboptimal in patients with PAD; only 61% were on aspirin, 48% were on statin therapy, 43% were on beta-blockers and 30% were on angiotensin converting enzymes inhibitors.
Conclusion: There is a great opportunity in preventing acute coronary events that we are missing. This is can be achieved by recognizing patients with PAD (symptomatic or asymptomatic) and aggressively control their risk factors.
Upper limb ischemia in a 15 months old girl: A case report
Elham Khoujah, MD
Division of Vascular Surgery, King Fahd General Hospital, Al Madinah, Saudi Arabia
Corresponding Author:
Dr Elham Khouja
King Fahad General Hospital
Department of Surgery
Al Madinah, Saudi Arabia
Email: ekhoujah@hotmail.com
A 15 month baby girl was admitted to pediatric ICU as a case of diabetic ketoacidotic coma, the patient is also known to have liver fibrosis and bilateral polycystic kidneys, attempt to do arterial blood gases was done from right brachial artery after which patient developed cyanosis of Rt. Hand extended to the forearm, vascular surgeon was consulted about 15 hours post the incidence, full heparinization after giving a loading dose was started by the vascular surgeon in attempt to avoid surgery in such case, 7 hours later there was no improvement, so , patient was taken to O-R for exploration of the Rt. Brachial artery. Intra operatively needle puncture site was identified just above the bifurcation of the brachial artery through which arteriotomy was done, small intimal flap was found at the edge of the puncture site, flushing of the radial artery was smooth while flushing of the ulnar artery retrieved resistance, direct intra arterial injection of reteplase ( 3 Units ) was pushed slowly , after 5 minutes of observation, the hypotheaner imminence started to flush, one hour later patient started to show excellent improvement of circulation of the whole hand and forearm with complete return of radial pulse and triphasic signals over the ulnar artery after about 2 hours.
Carotid-subclavian bypass: an off-pump myocardial revascularization:
Case Report & Literature review
Ghatfan SHAABAN, MD
Prince Abdul Aziz Ben Musaad Hospital, ARAR, Saudi Arabia
Corresponding Author:
Ghatfan SHAABAN, MD
Consultant Cardio-Vascular Surgeon
Prince Abdul Aziz Ben Musaad Hospital, 91441
ARAR, KSA
Tel/Fax: 046613321
E-mail: g.shaaban@yahoo.com
Background: Occlusion of the subclavian artery proximal to a patent internal thoracic artery-coronary bypass is well recognized to produce recurrent myocardial ischemia. We report a case of this clinical entity with literature review.
Methods & Results: A 48 year-old man who had undergone left internal thoracic artery to left anterior descending coronary artery bypass grafting 5 years earlier presented with complaints of increasing angina pectoris and dyspnea. At examination, his left arm systolic blood pressure was lower by more than 20 mmHg than that of right arm. A transfemoral coronary angiography showed an occlusion in the proximal left subclavian artery, and a proximal occlusion of the left descending artery with no opacification of its distal segment; a true coronary-subclavian steal mechanism was not demonstrated. A left transradial angiography showed a patent internal mammary artery bypass to an excellent distal left anterior descending artery. A left carotid – subclavian bypass resulted in the immediate disappearance of angina and improvement of left ventricular function, and continuous benefit at a follow-up of 3 years.
Conclusion: Carotid-subclavian bypass grafting remains the procedure of choice for management of subclavian artery occlusion proximal to a patent internal thoracic artery-coronary bypass, even in case of failure to demonstrate a coronary-subclavian steal syndrome.
Primary systemic amyloidosis with extensive vascular involvement: Case report and review of literature
Tahira Aslam, MBBS, FCPS, MRCS and Ahmed Maged Farghaly, MD, MRCS
Division of Vascular Surgery, King Fahad Medical City, Riyadh, Saudi Arabia
Corresponding Author:
Dr. Tahira Aslam
Assistant Consultant
Division of vascular surgery
King Fahad Medical City
Riyadh, Saudi Arabia
E-mail: tahira_khans@yahoo.com
Amyloidosis is a disease in which there is extra cellular deposition of insoluble protein matrix in different organs and tissues of the body and is usually associated with the bleeding tendency due to consumption of the coagulation factors. Angiopathy of small and medium sized arteries is reported with different forms of amyloidosis. In this case report, we are reporting a very rare presentation of primary systemic amyloidosis with extensive major blood vessels involvement resulting in Ischemic pain in the legs. The presentation with involvement of the large arteries in the absence of vasculitis leading to ischemic legs is very rare and is reported for the first time in literature.
Outcome of Surgical Treatment for Carotid Body Tumors: King Khalid University Hospital Experience
From the Division of Vascular Surgery, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia.
Mohammed Al-Omran, MD, MSc
King Khalid University Hospital
Department of Surgery,P.O. Box 7805(37)
Riyadh 11472, Saudi Arabia
Email: m_alomran@hotmail.com
Fax: +9661 467-9493
Background: Carotid body tumors (CBT) are a rare condition but are the most common form of head and neck paraganglioma. The aim of this study was to evaluate the outcome for surgical excision of CBT.
Method: We conducted a retrospective cohort study between 1994 and 2007, using the medical records database from King Khalid University Hospital, Riyadh, Saudi Arabia.
Results During the study period, 19 patients with CBT were identified. Of these, 3 patients had bilateral CBT. About 66% were female and mean age was 40.5 years. CBT was more common in the left side (58%). Neck lump and pain were the main presenting symptoms. Preoperative information derived from duplex scanning, magnetic resonance angiography, computed tomography, and in some patients the standard four-vessel Arteriography. All patients underwent surgical excision with no mortality. Two patients had hoarseness of voice postoperatively, 1 was due to permanent vagus nerve palsy in a patient who had excision for recurrent CBT and the other to transient vagus nerve palsy. One patient had a minor stroke postoperatively.
Conclusion: Careful surgical planning and prediction of perioperative complications using advanced radiological imaging coupled with the performance of CBT excision in high volume centers result in good outcomes.
Assessment of Peripheral Arterial Occlusive Disease; Comparison of 64 Single Source Multidetector CT Angiography and Intraarterial Digital Subtraction Angiography
Bakarman K, Showmer A, AlKohlani H, Al Moaqel M, Ayad E, Enezy K,
El Kayali A, Al Turki S, AlWahbi AM.
Division of Vascular Surgery & Division of Interventional Radiology, KAMC, Riyadh, KSA
Corresponding Author:
Dr Abdullah Alwahbi
PO BOX: 22490 RIYADH 11426
TEL: +9661-2520088 #14119 #14118 #14137
FAX: + 9661-2520051
Email: alwahbi1@hotmail.com
Imaging evaluation of Peripheral Arterial Disease requires the visualization of the detailed structural changes between the abdomino-pelvis and lower calf in order to decide on therapeutic management. Conventional angiography remains the technique of choice for further examination of Peripheral Arterial Disease; however low-invasive methods provide an excellent alternative. In this presentation, we describe our experience in new modality of vascular imaging techniques, Computed Tomography (CT) that provides useful information. Because of the improved spatial resolution of multi detector-row CT, CT Angiography is helpful in assessing structural changes and measuring the diameter of the vascular lumen for the planning of endovascular intervention. In the present study, we report our results in using 64 Single Source Multidetector CT Angiography in pre intervention evaluation for patients who presented with lower limb ischemia. Treatment decisions (surgical versus transluminal revascularization, or conservative treatment), and percutaneous treatment planning (access site, antegrade versus retrograde puncture) was made in the majority of patients based on lower extremity CT angiograms.
Evolution of Vascular Laboratory: The Saudi Arabian Experience
From the Division of Vascular Surgery, King Saud University, Riyadh, Saudi Arabia.
Musaad M Al-Salman, MD, FRCS, FACS
King Khalid University Hospital
Department of Surgery,P.O. Box 7805(37)
Riyadh 11472, Saudi Arabia
Email: mussaad@ksu.edu.sa
Tel.: +9661 467-1575
Fax: +9661 467-9493
Background: Accompanying the rapid growth of utilizing the non-invasive tests in the diagnostic work up in various fields of medicine, the utilization of non-invasive vascular ultrasound technology has increased dramatically in managing broad spectrum of vascular disorders and became an essential component of modern vascular surgery. In this study we sought to examine the trends of utilizing the various non-invasive vascular tests (NIVTs) in the management of wide spectrum of vascular disorders over the last 13 years in the first and largest Vascular Laboratory in Saudi Arabia.
Methods: A prospective cohort study was conducted utilizing the records from a prospectively collected database that maintained all the information for the various non-invasive vascular tests (NIVTs) that were performed at the Vascular Laboratory, King Khalid University Hospital in Riyadh, Saudi Arabia from 1995 to 2007. NIVTs were grouped as indirect tests (CW Doppler & Others) and direct tests (Color Duplex Imaging [CDI]). Direct tests (CDI) were further grouped into Carotid, Lower & Upper Limb arterial, by pass Graft Surveillance, Aorto-Renal-Visceral, Venous & Vascular Access Color Duplex Imaging.
Results: A total number of 40,820 NIVTs were identified over the study period. Of these, 29,478 (72%) were direct tests. The number of NIVTs has increased significantly, from 498 cases/year to 4881 cases/year representing a 10-fold increase over the study period with an increase of 75% per year (R2 =0.91; p < 0.01, linear regression analysis). The trend for utilizing the direct tests was more pronounced than that for indirect tests; the number of direct tests has increased significantly, from 179 cases/year to 3812 cases/year representing a 21-fold increase over the study period with an increase of 1.6 fold per year (R2 =0.92; p < 0.01), whereas the number of indirect tests has increased significantly, from 319 cases/year to 1069 cases/year representing a 3.4-fold increase over the study period with an increase of 26% per year (R2 =0.85; p < 0.05).
Conclusion: The use of various non-invasive vascular tests in the management of vascular disorders has increased substantially over the past decade. In response to these trends, more trained personnel & vascular laboratory facilities are needed in different vascular surgery centers in Saudi Arabia.
The applicability of Pre Test Probability model for Deep Vein Thrombosis in combination with D- Dimer testing
Mirza Baig; Khalid Al-Brekeit.
Department of Surgery, Vascular Surgery Division, Riyadh Military Hospital, Kingdom of Saudi Arabia.
Corresponding Author:
Dr Khalid Al-Brekeit
Email: brekeit@gmail.com
Background: Prospective Randomized controlled Trial to detect the applicability of Pre Test Probability model in combination with D-Dimer testing in the final diagnosis of Deep Vein Thrombosis in clinically suspected patients. Assessment of pre-test probability was the initial step in investigation of patients with Deep Vein Thrombosis (DVT). Our objective to evaluate the accuracy of Well’s pre-test probability model in combination with D- Dimer test and to assess the safety of a diagnostic strategy developed on these basis.
Methods & Results: we include 291 outpatients as well as inpatients with clinical suspicion of DVT were categorized as having a low, moderate or high pre-test probability using Well’s Criteria by the resident physicians who seeked the advise from senior Supervising physicians' when deemed necessary. Then, all the three cohorts went through D-dimer testing and leg compression ultrasonography. We found 40 patients (20%) had DVT. Prevalence of DVT in the low, moderate and high pre-test probability groups categorized by physicians in training alone was 4% (95% confidence interval (CI): 2% to 9%), 41% (95% CI: 22% to 47%) and 100% (95% CI: 61% to 100%) respectively.
Conclusion: Wells clinical model to determine pretest probability of DVT when combined with D-Dimer testing appears to be a safe strategy in assessment and management of patients with suspected of DVT.
Supraclavicular Approach for the Treatment of Arterial Thoracic Outlet Syndrome: King Khalid University Hospital Experience
From the Division of Vascular Surgery, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia.
Mohammed Al-Omran, MD, MSc
King Khalid University Hospital
Department of Surgery,P.O. Box 7805(37)
Riyadh 11472, Saudi Arabia
Email: m_alomran@hotmail.com
Fax: +9661 467-9493
Background: Thoracic outlet syndrome (TOS) refers to a group of complex symptoms in the upper extremity caused by compression of the brachial plexus, subclavian artery and vein. The goal of surgical therapy involves relieving compression of the neurovascular structures at the superior thoracic aperture. Different surgical approaches were described for the management of TOS. However, there is no "gold standard" procedure. Supraclavicular incision is becoming a popular approach used in the treatment of TOS. The aim of this study was to evaluate the outcome for supraclavicular approach for the treatment of arterial TOS.
Method: We conducted a retrospective cohort study between 1995 and 2007, using the medical records database from King Khalid University Hospital, Riyadh, Saudi Arabia.
Results: During the study period, 22 patients with arterial TOS were identified. Of these, 5 patients had bilateral arterial TOS. About 50% were female and mean age was 26 years. Hand ischemia in form of claudication or rest pain was the main presenting symptom. Preoperative information derived from duplex scanning and upper limbs Arteriography, and in some patients’ magnetic resonance angiography and computed tomography. All patients underwent supraclavicular approach with a single incision with no mortality. In all cases, a complete scalenoectomy was performed. Whenever present the cervical rib was resected and in some cases the first rib was also taken out. Associated vascular procedures included resection and replacement of 3 subclavian artery aneurysms, one axillary-brachial bypass, as well as four brachial embolectomies. The surgical procedures did not cause relevant complications. During follow-up; all patients were in complete resolution of symptoms and all reconstructed arteries were patent.
Conclusions: The supraclavicular approach is a safe and effective technique in managing arterial thoracic outlet compression.
