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Nonspecific arteritis: A special clinicopathological entity
22rid World Congress of the International Society for Cardiovascular Surgery 8.6 SE) years. Three suture aneurysms were detected at the same time in one patient. Surgical treatments were performed on 15 aneurysms in 10 patients except for two; a patient with severe inflammation, and a patient who died of suture aneurysm rupture before reoperation. Repeated operations had to be performed for the recurrence of suture aneurysms in two cases. There were two operative deaths. Nine patients, including a non-operated case, were followed-up from 1 to 29 years (mean 6.8 years) after the final operation. Three deaths occurred during the follow-up periods. The cause of late death consisted of rupture of a true aneurysm in one patient at 3 years, heart failure in one at 5 years, and anaphylactic shock due to a blood transfusion reaction in one at 5 years. The remaining six patients are in good condition. In conclusion, the most serious late complication of surgery for Takayasu's arteritis is suture aneurysm formation. Longterm regular follow-up of the patients is necessary for the early detection of suture aneurysms. Surgery should be performed without delay.
20.5
Nonspecific Arteritis: A Special Clinicopathological Entity M.H. EL-BATANOUNY, Cairo, Egypt This clinicopathological study included a series of 120 patients, 85 males and 36 females. The mean age was 33 years, and there were 105 patients with occlusive arteries and 15 with aneurysmal (visceral and peripheral) arteries. In suspected cases with atherosclerosis, Buerger's and Behcet's disease were excluded. Occlusive disease included 90 patients with proximal and 15 patients with distal arterial involvement, the latter with digital gangrene and palpable peripheral pulses. Eight patients with proximal involvement presented with acute limb ischemia. In cases with occlusive proximal involvement, there was a special predilection for the iliac and popliteal arteries. The distribution of occlusive lesions was quite different from that of atherosclerotic lesions. Occlusion and dilatation may occur in the same patient. Arteriography showed the non-affected arteries to be smooth and relatively narrow. The lesions were segmental and sometimes multicentric. Histopathology showed thickening of the arterial wall, fragmentation of the media, marked fibrosis and narrowing of the lumen. The veins were affected with inflammatory reactions, but the nerves were spared. Subacute cases and distal involvement responded to conservative treatment including corticosteroids, anticoagulants and prostaglandins. Thrombectomy for cases with acute proximal occlusion had a poor prognosis. Although there is no plane cleavage as for thrombendarterectomy in atherosclerosis, endarterectomy is, however, occassionally possible, but bypass surgery is the principal reconstructive procedure when indicated. No significant relation was found to hepatitis, typhoid, cryoglobulinaemia, LE or a rheumatoid background. Fibrogenesis was significantly higher than is normal as shown by measuring procoilagen Ill and fibronectin.
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20.6
Treatment of Rheumatoid Vasculitic Cutaneous Ulcers Using H y p e r b a r i c O x y g e n Therapy A. G UPTA, M. ]AMSHIDI and ].R. R UBIN, Youngstown, Ohio, USA Rheumatoid vasculitic cutaneous ulcerations are generally refractory to conventional therapeutic modalities including debridement, topical wound care and skin grafting. Consequently, patients are at an increased risk of infection, wound extension, health care exhaustion, and subsequent limb loss. Hyperbaric oxygen therapy (HBO) has effectively been used to promote healing of cutaneous ulcers due to diabetes, thalassemia, ultraviolet radiation injuries and pyoderma gangrenosum. Tissue studies reveal enhanced capillary ingrowth, reduced tissue edema and lipid peroxidation and increased tissue oxygenation, wound tensile strength and collagen formation after HBO. Furthermore, HBO has been shown to increase the killing ability of leukocytes, inhibit endotoxin release and is lethal to certain anaerobic bacteria. To evaluate the effect of hyperbaric oxygen therapy on rheumatoid skin ulcers, eight patients referred for vascular surgery with nonhealing ulcers were prospectively placed on a hyperbaric oxygen regimen which consisted of 100% Fio2, given locally at 2 ATM for 60 to 90 rain, 3 times daily. Average patient age was 63 years (range 56-71 years) and 75% were female. Wounds were examined daily by the same physicians for signs of healing. Complete wound healing occurred in 87.5%. One patient expired 8 weeks after treatment secondary to a myocardial infarction suffered following total knee replacement. Of those responding to treatment, the mean time to healing was 5.6 weeks (range 4-12). Two patients had recurrent ulcerations 3 and 4 weeks following discharge. We conclude that hyperbaric oxygen therapy for rheumatoid vasculitic ulcers is a safe and expedient modality for the treatment of this disease. Uniform wound healing was observed in 87.5% of patients who had previously failed on other treatment regimens. We believe that the great benefit of this therapy, in addition to achieving uncomplicated wound healing, is the ability to treat these chronically hospitalized patients as outpatients, thus reducing medical costs and patient's noncompliance.
20.7
Reduction of Hospital Stay with Expeditious Management of Ischemic lnvasive Foot Infections B.B. CHANG, R.P. LEATHER, W.E. LLOYD, D.M. SHAH, R. C. DARLING, III, P.S.K. PATY and W.E. LLOYD, Albany, New York, USA Management of infected ischemic diabetic limbs requires antibiotic therapy, abscess drainage, and revascularization. However, revascularization is often delayed for several days or weeks as the infection is controlled. In an effort to decrease hospital stay and costs, and to increase limb salvage, a series of 382 extremities with distal occlusive disease were managed with autogenous distal bypass. Sixty-two of these limbs (55 diabetic) had severe invasive infections. These patients all received intravenous antibiotics and abscess drainage if necessary. Vascular reconstruction was carried out as soon as possible, within 48 b of admission. An in situ bypass was used preferentially (52 cases). Patients were maintained on intravenous antibiotics in the perioperative period. Partial foot
CARDIOVASCULAR SURGERY SEPTEMBER 1995
20.5
Nonspecific Arteritis: A Special Clinicopathological Entity M.H. EL-BATANOUNY, Cairo, Egypt This clinicopathological study included a series of 120 patients, 85 males and 36 females. The mean age was 33 years, and there were 105 patients with occlusive arteries and 15 with aneurysmal (visceral and peripheral) arteries. In suspected cases with atherosclerosis, Buerger's and Behcet's disease were excluded. Occlusive disease included 90 patients with proximal and 15 patients with distal arterial involvement, the latter with digital gangrene and palpable peripheral pulses. Eight patients with proximal involvement presented with acute limb ischemia. In cases with occlusive proximal involvement, there was a special predilection for the iliac and popliteal arteries. The distribution of occlusive lesions was quite different from that of atherosclerotic lesions. Occlusion and dilatation may occur in the same patient. Arteriography showed the non-affected arteries to be smooth and relatively narrow. The lesions were segmental and sometimes multicentric. Histopathology showed thickening of the arterial wall, fragmentation of the media, marked fibrosis and narrowing of the lumen. The veins were affected with inflammatory reactions, but the nerves were spared. Subacute cases and distal involvement responded to conservative treatment including corticosteroids, anticoagulants and prostaglandins. Thrombectomy for cases with acute proximal occlusion had a poor prognosis. Although there is no plane cleavage as for thrombendarterectomy in atherosclerosis, endarterectomy is, however, occassionally possible, but bypass surgery is the principal reconstructive procedure when indicated. No significant relation was found to hepatitis, typhoid, cryoglobulinaemia, LE or a rheumatoid background. Fibrogenesis was significantly higher than is normal as shown by measuring procoilagen Ill and fibronectin.
104
20.6
Treatment of Rheumatoid Vasculitic Cutaneous Ulcers Using H y p e r b a r i c O x y g e n Therapy A. G UPTA, M. ]AMSHIDI and ].R. R UBIN, Youngstown, Ohio, USA Rheumatoid vasculitic cutaneous ulcerations are generally refractory to conventional therapeutic modalities including debridement, topical wound care and skin grafting. Consequently, patients are at an increased risk of infection, wound extension, health care exhaustion, and subsequent limb loss. Hyperbaric oxygen therapy (HBO) has effectively been used to promote healing of cutaneous ulcers due to diabetes, thalassemia, ultraviolet radiation injuries and pyoderma gangrenosum. Tissue studies reveal enhanced capillary ingrowth, reduced tissue edema and lipid peroxidation and increased tissue oxygenation, wound tensile strength and collagen formation after HBO. Furthermore, HBO has been shown to increase the killing ability of leukocytes, inhibit endotoxin release and is lethal to certain anaerobic bacteria. To evaluate the effect of hyperbaric oxygen therapy on rheumatoid skin ulcers, eight patients referred for vascular surgery with nonhealing ulcers were prospectively placed on a hyperbaric oxygen regimen which consisted of 100% Fio2, given locally at 2 ATM for 60 to 90 rain, 3 times daily. Average patient age was 63 years (range 56-71 years) and 75% were female. Wounds were examined daily by the same physicians for signs of healing. Complete wound healing occurred in 87.5%. One patient expired 8 weeks after treatment secondary to a myocardial infarction suffered following total knee replacement. Of those responding to treatment, the mean time to healing was 5.6 weeks (range 4-12). Two patients had recurrent ulcerations 3 and 4 weeks following discharge. We conclude that hyperbaric oxygen therapy for rheumatoid vasculitic ulcers is a safe and expedient modality for the treatment of this disease. Uniform wound healing was observed in 87.5% of patients who had previously failed on other treatment regimens. We believe that the great benefit of this therapy, in addition to achieving uncomplicated wound healing, is the ability to treat these chronically hospitalized patients as outpatients, thus reducing medical costs and patient's noncompliance.
20.7
Reduction of Hospital Stay with Expeditious Management of Ischemic lnvasive Foot Infections B.B. CHANG, R.P. LEATHER, W.E. LLOYD, D.M. SHAH, R. C. DARLING, III, P.S.K. PATY and W.E. LLOYD, Albany, New York, USA Management of infected ischemic diabetic limbs requires antibiotic therapy, abscess drainage, and revascularization. However, revascularization is often delayed for several days or weeks as the infection is controlled. In an effort to decrease hospital stay and costs, and to increase limb salvage, a series of 382 extremities with distal occlusive disease were managed with autogenous distal bypass. Sixty-two of these limbs (55 diabetic) had severe invasive infections. These patients all received intravenous antibiotics and abscess drainage if necessary. Vascular reconstruction was carried out as soon as possible, within 48 b of admission. An in situ bypass was used preferentially (52 cases). Patients were maintained on intravenous antibiotics in the perioperative period. Partial foot
CARDIOVASCULAR SURGERY SEPTEMBER 1995