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Treatment of iatrogenic false aneurysms
856
Letters to the Editor
Reply Eric D Strauch, MD Baltimore, MD We appreciate the comments of Drs Riegler and Cosentini. In fact, we concur with their premise that bile salts should and will have different effects in the small intestine versus the colon. We hypothesize that bile salts have beneficial effects on the small intestinal mucosa and have shown that bile salts stimulate small intestinal mucosal restitution, increase small intestinal mucosal proliferation through c-myc expression (Surgery, in press), and protect the intestinal mucosa against TNF-␣–induced apoptosis (submitted). We appreciate the discrepancies between our studies and the studies cited and agree that these discrepancies are likely the result of differences between small intestinal mucosa and colonic mucosa. The small intestine and colon have different functions, susceptibility to injury, and malignant potential. It is not unexpected that the effects of bile salts on the small and large intestinal mucosa should be different. We believe that further study of the effects of bile salts on intestinal mucosa is warranted.
J Am Coll Surg
dovascular management of catheter-induced subclavian arterial injury was described by Becker and colleagues in 19912 and by May and colleagues in 1993.3 As the frequency of endovascular interventions increases, we can expect an increase in its use for both iatrogenic and noniatrogenic arterial injuries. In short, endovascular stenting or stent-grafting should also be considered as a potential treatment for arterial injuries, although it should be used only in conjunction with appropriate surgical consultation.
REFERENCES 1. Franklin JA, Brigham D, Bogey WM, Powell CS. Treatment of iatrogenic false aneurysms. J Am Coll Surg 2003;197:293– 301. 2. Becker GJ, Benenati JF, Zemel G, et al. Percutaneous placement of a balloon-expandable intraluminal graft for life-threatening subclavian arterial hemorrhage. J Vasc Intervent Radiol 1991;2: 25–229. 3. May J, White G, Waugh R, et al. Transluminal placement of a prosthetic graft-stent device for treatment of subclavian artery aneurysm. J Vasc Surg 1993;18:1056–1059.
Reply Treatment of Iatrogenic False Aneurysms Zsolt T Stockinger, MD, FACS New Orleans, LA I read with interest the article by Franklin and colleagues1 in the August 2003 issue of JACS, which reviewed the treatment of iatrogenic false aneurysms. The article provided an excellent review of the management options for iatrogenic pseudoaneurysms, with one notable exception: no mention in the text (and only one reference in Table 1) of endovascular stenting or stentgrafting as an option. Stenting for both iatrogenic (eg, catheter-related) and noniatrogenic (eg, traumatic) pseudoaneurysms has been reported in the literature for more than a decade. It has potential as an option for management of injuries not amenable to noninvasive techniques (eg, compression, injection) because of location, particularly for injuries with difficult surgical exposures. For example, en-
Joseph A Franklin, MD, Denise Brigham, RN, William M Bogey, MD, RVT, FACS, C Steven Powell, MD, FACS Greenville, NC Dr Stockinger raises an excellent point regarding endovascular stent grafting of iatrogenic or traumatic pseudoaneurysms. We have used endovascular stent grafts in situations where open surgical exposure is difficult, such as subclavian artery aneurysms and pseudoaneurysms referenced in the letter by Dr Stockinger. This treatment is a major advance in difficult to get at anatomic locations. Our article was meant to highlight the treatment of iatrogenic femoral pseudoaneurysms especially in regard to our favorable experience with ultrasound-guided thrombin injection. This could have been elucidated better if the title had included the word femoral. Nonetheless, we do not consider the femoral artery a good location to use endovascular stent grafts because it isan easily accessible artery, the grafts may have a tendency to kink and thrombose, and there is the possibil-
Letters to the Editor
Reply Eric D Strauch, MD Baltimore, MD We appreciate the comments of Drs Riegler and Cosentini. In fact, we concur with their premise that bile salts should and will have different effects in the small intestine versus the colon. We hypothesize that bile salts have beneficial effects on the small intestinal mucosa and have shown that bile salts stimulate small intestinal mucosal restitution, increase small intestinal mucosal proliferation through c-myc expression (Surgery, in press), and protect the intestinal mucosa against TNF-␣–induced apoptosis (submitted). We appreciate the discrepancies between our studies and the studies cited and agree that these discrepancies are likely the result of differences between small intestinal mucosa and colonic mucosa. The small intestine and colon have different functions, susceptibility to injury, and malignant potential. It is not unexpected that the effects of bile salts on the small and large intestinal mucosa should be different. We believe that further study of the effects of bile salts on intestinal mucosa is warranted.
J Am Coll Surg
dovascular management of catheter-induced subclavian arterial injury was described by Becker and colleagues in 19912 and by May and colleagues in 1993.3 As the frequency of endovascular interventions increases, we can expect an increase in its use for both iatrogenic and noniatrogenic arterial injuries. In short, endovascular stenting or stent-grafting should also be considered as a potential treatment for arterial injuries, although it should be used only in conjunction with appropriate surgical consultation.
REFERENCES 1. Franklin JA, Brigham D, Bogey WM, Powell CS. Treatment of iatrogenic false aneurysms. J Am Coll Surg 2003;197:293– 301. 2. Becker GJ, Benenati JF, Zemel G, et al. Percutaneous placement of a balloon-expandable intraluminal graft for life-threatening subclavian arterial hemorrhage. J Vasc Intervent Radiol 1991;2: 25–229. 3. May J, White G, Waugh R, et al. Transluminal placement of a prosthetic graft-stent device for treatment of subclavian artery aneurysm. J Vasc Surg 1993;18:1056–1059.
Reply Treatment of Iatrogenic False Aneurysms Zsolt T Stockinger, MD, FACS New Orleans, LA I read with interest the article by Franklin and colleagues1 in the August 2003 issue of JACS, which reviewed the treatment of iatrogenic false aneurysms. The article provided an excellent review of the management options for iatrogenic pseudoaneurysms, with one notable exception: no mention in the text (and only one reference in Table 1) of endovascular stenting or stentgrafting as an option. Stenting for both iatrogenic (eg, catheter-related) and noniatrogenic (eg, traumatic) pseudoaneurysms has been reported in the literature for more than a decade. It has potential as an option for management of injuries not amenable to noninvasive techniques (eg, compression, injection) because of location, particularly for injuries with difficult surgical exposures. For example, en-
Joseph A Franklin, MD, Denise Brigham, RN, William M Bogey, MD, RVT, FACS, C Steven Powell, MD, FACS Greenville, NC Dr Stockinger raises an excellent point regarding endovascular stent grafting of iatrogenic or traumatic pseudoaneurysms. We have used endovascular stent grafts in situations where open surgical exposure is difficult, such as subclavian artery aneurysms and pseudoaneurysms referenced in the letter by Dr Stockinger. This treatment is a major advance in difficult to get at anatomic locations. Our article was meant to highlight the treatment of iatrogenic femoral pseudoaneurysms especially in regard to our favorable experience with ultrasound-guided thrombin injection. This could have been elucidated better if the title had included the word femoral. Nonetheless, we do not consider the femoral artery a good location to use endovascular stent grafts because it isan easily accessible artery, the grafts may have a tendency to kink and thrombose, and there is the possibil-