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Biomedical subjects

J V Robbs

Publications and source records attributed to J V Robbs.

At least 37 records · Page 2Linked to original sources
PubMed2000

Management of proximal axillary and subclavian artery injuries.

BACKGROUND: The aim of this study was to review the management and outcome of proximal axillary and subclavian artery injuries, and to estimate the prehospital mortality rate for subclavian injury through forensic pathology autopsy data. METHODS: Data were collected prospectively for 260 patients who presented between 1977 and 1996 with trauma to the proximal axillary and subclavian arteries. RESULTS: The majority of victims (214, 82 per cent) were admitted following stab injury. Some 154 patients (59 per cent) presented within 24 h of sustaining an injury and, of these, 59 (38 per cent) required immediate surgery. An additional 67 patients (26 per cent) attended 2 days or more after injury. Comparison of these data with those from forensic autopsy reports suggests that the prehospital mortality rate for penetrating subclavian trauma was approximately 75 per cent. CONCLUSION: Approximately 25 per cent of subclavian artery injuries caused minimal initial symptoms but delayed complications prompted attendance for medical attention. The majority of patients who survived subclavian artery injury and attended for medical attention were haemodynamically stable on admission; selective arteriography provided valuable information in these patients. Supraclavicular and infraclavicular incisions avoided clavicular division and reduced the postoperative morbidity associated with distal subclavian artery injuries.

Adult↗
PubMed2000

Spontaneous carotid artery aneurysms.

BACKGROUND: Spontaneous carotid artery aneurysms are infrequently reported, and are almost always non-atherosclerotic. METHODS: The records of 29 patients with a spontaneous carotid aneurysm treated in an academic vascular unit between 1990 and 1998 were reviewed. RESULTS: All 29 patients were black South Africans; three had bilateral aneurysms. There were 24 men and five women, of mean age 35 (range 13-62) years. Some 25 aneurysms involved the common carotid artery, 12 of which affected the bifurcation, and seven were located in the internal carotid artery. Twenty-five aneurysms were managed surgically, four of which were ligated owing to sepsis. Histo- logical evaluation showed human immunodeficiency virus-related arteritis in four, tuberculous aneurysms in ten, Takayasu's arteritis in two, atherosclerosis in three and non-specific chronic inflammation in four patients. Microbiological examination was negative in all but one patient who had Salmonella sp. cultured. Outcome was generally favourable, but one patient died from massive hemispheric infarction. There were no other new neurological deficits. CONCLUSION: Carotid aneurysms pose a considerable surgical challenge but are amenable to operative intervention with good result. Ligation appears to be well tolerated in this group of predominantly non-atherosclerotic aneurysms.

Adolescent↗
PubMed2000

Gunshot injuries of the popliteal artery.

BACKGROUND: Guidelines for the management of popliteal artery trauma emanate mainly from military experience. This study was undertaken to describe the management of popliteal injuries in a civilian vascular surgical unit with a large trauma workload. METHODS: A retrospective review of records of patients treated between 1983 and 1997 was undertaken. RESULTS: Some 117 popliteal artery gunshot injuries were treated (83 low velocity, 16 high velocity, 18 shotgun). Associated fractures occurred in 44 patients and 40 had popliteal vein injuries. Treatment of the arterial injury included vein graft interposition in 71, primary reanastomosis in 19, prosthetic graft interposition in four, lateral suture in one, vein patch in one and ligation in one patient; 84 fasciotomies were performed. No perioperative deaths occurred. There were 20 primary and 14 secondary amputations. Factors associated with amputation were high-velocity injuries, delay in revascularization in excess of 7 h, arterial transection, associated fracture, and compartment syndrome or muscle infarction. CONCLUSION: Civilian popliteal gunshot injuries are attended by a high amputation rate. Prompt resuscitation and revascularization appear to be the only correctable factors that may improve limb salvage rates.

Adolescent↗
PubMed2000

Management of penetrating cervicomediastinal venous trauma.

OBJECTIVES: to evaluate the results of management of penetrating cervicomediastinal venous trauma. DESIGN: retrospective study. Materials forty-nine consecutive patients with cervical and thoracic venous injuries treated at a tertiary hospital between 1991 and 1997. Method patients identified from a computerised database and data extracted from case records. RESULTS: forty-five patients were male and the mean age was 25.3 years. Forty injuries were due to stabs and 9 to gunshots. 22 patients were shocked, 25 actively bleeding and 31 were anaemic. Veins injured were internal jugular in 25, subclavian in 15, brachiocephalic in 6, and superior vena cava in 3. Injured veins were ligated in 25 cases and repaired by lateral suture in 22. No complex repairs were performed. There were 8 perioperative deaths and 5 cases of transient postoperative oedema. Venous ligation was not associated with increased risk of postoperative oedema. CONCLUSIONS: ligation is an acceptable form of treatment of cervicomediastinal venous injuries in the presence of haemodynamic instability, or where complex methods of repair would otherwise be necessary.

Adult↗
PubMed2000

Angiographic embolisation in arterial trauma.

OBJECTIVES: to evaluate the use of endovascular occlusion in the treatment of arterial trauma. METHODS: records of patients with penetrating arterial injuries treated by endovascular occlusive techniques were culled from the computerised database of the vascular service. RESULTS: the study period spanned 7 years. Forty-two patients were studied with injuries to the cervicofacial vessels (24), lower limb (16) and upper limb (1). 13 had an arteriovenous fistula. There were 4 failures. In 2 cannulation was not achieved and in 2 with A-VF distal vessel occlusion was impossible. Two patients developed complications. In the remainder, treatment was effective and durable. CONCLUSION: this treatment modality is effective and safe in the treatment of penetrating trauma in selected patients.

Angiography↗
PubMed2000

Clinical profile of HIV-related aneurysms.

OBJECTIVES: to describe the clinical features, management, outcome and laboratory features of human immunodeficiency virus (HIV)-related aneurysms. MATERIALS: twenty-eight HIV positive patients with arterial aneurysms treated at a single university teaching hospital in a 6-year period. METHODS: case review of clinical records and laboratory findings. Specimens from patients surgically treated submitted for microbiological and histological examination. RESULTS: ninety-two aneurysms were seen (range 1-10 per patient) in a young patient population (median age 30 years). Nineteen patients had evidence of advanced HIV infection. Aneurysms were atypically located and most frequently involved the carotid (24), superficial femoral (21) and popliteal (nine) arteries. Twenty-five of the 31 symptomatic aneurysms were treated surgically. Surgical intervention comprised arterial reconstruction for 19 and aneurysm resection and ligation for the remainder. Histological examination revealed distinctive arteritic features. There were two treatment-related deaths, with short-term post-operative outcome being otherwise favourable. CONCLUSIONS: HIV related aneurysms are characterised by their predilection for young patients, multiplicity, atypical location and their distinct histological features. Their increasing frequency reflects the unchecked advance of the HIV epidemic.

Adolescent↗
PubMed2000

Occlusive arterial disease in HIV-infected patients: a preliminary report.

OBJECTIVES: to preliminarily describe the clinical features and management of arterial occlusive disease in human immunodeficiency virus (HIV) infected patients. MATERIALS: twenty HIV positive patients with symptomatic large-vessel arterial occlusion treated by a tertiary vascular unit in a 3-year period. METHODS: retrospective review of clinical case records. RESULTS: patients were noted to be young (median age 37 years), with preponderance of males. Twelve patients had evidence of advanced HIV infection. All patients had critical ischaemia, involving the upper limbs in four and the lower limbs in 16. Coagulation abnormalities were noted in two cases. Operative intervention in 18 patients included revascularisation in seven. Thrombotic occlusion of normal-looking arteries was noted. Arterial biopsy revealed leucoIcytoclastic vasculitis indicative of HIV arteritis in three of five cases examined. CONCLUSIONS: initial experience with large-vessel occlusive disease in HIV positive patients suggests an underlying arteritic aetiology, with clinical and pathological features distinct from atherosclerosis. Further in-depth study is necessary to clarify the pathophysiological basis thereof.

Adolescent↗
PubMed1999

Left renal vein variations.

The highly complex embryological development of the left renal vein compared to its right counterpart results in greater variations which are clinically significant. The study aimed to identify these variations and to document its incidence. Cadaveric study: 153 kidney pairs were harvested en bloc, dissected, 100 resin casts prepared and 53 plastinated; renal venography performed on further 58 adults and 20 foetal cadavers. Clinical study: (retrospective analysis): a) radiological study, 104 renal venograms; b) live related renal transplantation, 148 donor left kidneys; c) abdominal aortic aneurysm surgery, 525 patients. Total sample size: 1008. Renal collars observed in 0.3%; retro-aortic vein 0.5%; additional veins 0.4%; posterior primary tributary 23.2%, (16.7% Type IB; 6.5% Type IIB, cadaveric series, only). Our results differ significantly in incidence to that reported in the literature: renal collar 0.2-30%; retro-aortic vein 0.8-7.1%; additional renal vein 0.8-6%. Variations are clinically silent and remain unnoticed until discovered during venography, operation or autopsy. To a transplant surgeon, morphology acquires special significance, since variations influence technical feasibility of operation. Prior knowledge of circum-aortic vein is important when blood samples from suprarenal or renal veins are collected. Collar may provide developed collateral pathway immediately after surgery if renal interruption planned without awareness of its presence. Variations restrict availability of vein for mobilisation procedures. In aortic aneurysm repair, retro-aortic vein is important. During retroperitoneal surgery, the surgeon may visualise a pre-aortic vein but be unaware of an additional retroaortic component or a posterior primary tributary, and may avulse it while mobilising the kidney or clamping the aorta.

Adult↗
PubMed1999

Aneurysms of the persistent sciatic artery.

The persistent sciatic artery is a rare anatomical anomaly of the lower limb vasculature. It may be noted incidentally, or it may present with limb ischaemia or aneurysmal degeneration. Management entails exclusion of the aneurysm and vascular reconstruction. A case of bilateral persistent sciatic artery aneurysms and a review of the embryological development, clinical features, and management are reported. The persistent sciatic artery (PSA) may result from an aberration in the development of the arterial supply to the lower limb. It is a rare anomaly, with sporadic cases reported in the literature, few of which have been angiographically documented. A report of a patient treated at King Edward VIII Hospital, Durban, is presented here.

Adult↗
PubMed1999

Aorto-iliac occlusive disease in the different population groups--clinical pattern, risk profile and results of reconstruction.

BACKGROUND: It has previously been accepted that atherosclerotic disease is uncommon among blacks worldwide; however, recent studies have increasingly reported atherosclerotic disease in this group. STUDY DESIGN: Prospective study of hospital patients with aorto-iliac occlusive disease presenting to the vascular service of the Durban metropolitan hospitals. The study was designed to assess clinical pattern, risk profile and results of reconstruction in these patients. METHODS: This is a study of 688 patients with aorto-iliac occlusive disease managed over 9 years in Durban, with clinical pattern and risk factors compared in the different population groups. A subgroup of 492 patients underwent aortobifemoral bypass, providing material for comparison of the results of reconstruction in the different population groups. RESULTS: More black patients presented with gangrene and threatened limb, whereas whites tended to present early with claudication. All groups had hypertension and diabetes as risk factors. In addition, whites and Indians had ischaemic heart disease, which was not found among blacks. Mortality was 5% (blacks 1.8%, whites 8.5%, Indians 5%). Medium-term occlusion rates were 19% in blacks, 13% in Indians and 5% among whites. Five-year cumulative patency rates were 92% for whites, 77% for Indians and 74% for blacks. CONCLUSION: Whites do significantly better than blacks, who tend to present at an advanced stage of the disease. The presence of ischaemic heart disease among whites and Indians contributes to the higher mortality in these groups.

Adult↗
PubMed1998

A comparison of laser Doppler fluxmetry and transcutaneous oxygen pressure measurement in the dysvascular patient requiring amputation.

OBJECTIVE: To determine the predictive power of laser Doppler fluxmetry (LDF), both heated and unheated, as a preoperative investigation of wound healing potential in dysvascular patients requiring amputation, by comparison with transcutaneous oxygen pressure measurement (TcpO2) and the limb to chest TcpO2 index. METHODS: Thirty-five non-diabetic patients with peripheral vascular disease were investigated before amputation. Heated and unheated LDF and heated TcpO2 measurements were taken on the chest wall and at the routine above-knee, below-knee and mid-foot amputation levels. Wound healing potential was evaluated against a TcpO2 index value of 0.55 and on clinical outcome. RESULTS: A heated LDF value of 4.9 arbitrary units (au) was shown by receiver-operator characteristic curve to have the best predictive power, with an overall accuracy for preoperative prediction of wound healing of 91.4%, and a predictive value for wound failure of 89%. Based on the heated LDF of 4.9 au, review of 26 amputations performed shows the overall accuracy for preoperative prediction of wound healing of 92.3%, a predictive value for wound healing of 100%, and a predictive value for wound failure of 62.5%. CONCLUSION: A heated LDF value of 4.9 au appears to be a useful predictor of the potential of an amputation site to heal.

Amputation, Surgical↗
PubMed1998

Resympathectomy for sympathetic regeneration.

Explanations for recurrent sympathetic activity after an apparently successful sympathectomy are varied and often tenuous. Among the theories given for recurrent sympathetic activity are the development of alternate neuroanatomic pathways, the possibility of an incomplete operation (failure to appreciate an alternative anatomic pathway at the time of surgery, i.e., nerve of Kuntz), and sympathetic regeneration. The latter, although long suspected, has never been conclusively demonstrated in humans. In this report, a case of recurrent sympathetic activity with conclusive evidence of sympathetic regeneration is described.

Adult↗
PubMed1998

Carotid endarterectomy after recent stroke--how soon? An interim analysis.

AIM: To determine whether timing of carotid endarterectomy (CEA) was significant in terms of morbidity and mortality for significant carotid stenosis in a prospectively evaluated cohort of patients with recent stroke. METHODS: A tailored protocol using contemporary neuro-imaging modalities including transcranial Doppler and non-invasive angiography. Standardised clinical scores, neurological deficit scores, an aetiopathogenic scale and disability stroke scales were used in the two group. Statistical analysis was done to compare differences in two groups: CEA done less than 6 weeks after stroke (group 1) and CEA done more than 6 weeks after stroke (group 2). RESULTS: Patients formed part of the Durban Stroke Data Bank (N = 655), with 26 patients in group 1 (CEA a mean of 16 days after stroke) and 34 in group 2. There were no statistically significantly differences between the two groups with regard to demographic factors, clinical scales, neurological deficit scores and investigate findings. There was 1 post-CEA stroke and 1 death in each group (P = 0.781), which was not significantly different. CONCLUSION: Timing of CEA after stroke may be unimportant with regard to mortality and morbidity in patients with relatively small stable neurological deficits. Other causative factors, as yet unclear, remain to be identified.

Algorithms↗
PubMed1998

Aortobifemoral bypass in the presence of superficial femoral artery occlusion: does the profunda femoris artery provide adequate runoff?

Of a total of 492 patients (984 limbs) undergoing aortobifemoral bypass for aorto-iliac disease, 123 limbs with occlusion of the superficial femoral artery (SFA) were compared with 861 limbs with a patent SFA, and were prospectively monitored to assess the efficacy of the profunda femoris artery (PFA) as sole 'runoff' of this operation. There were more late occlusions in the limbs with occluded SFA (15%) compared to those with a patent SFA to begin with (7%). The five-year patency rate was 87% for limbs with patent SFA and 80% for limbs with occluded SFA. Claudicants had a higher 5-year patency rate compared to threatened limbs irrespective of runoff. We conclude that profunda femoris can be used as sole runoff although the rate of occlusion tends to be higher in this group compared with counterparts with patent SFA.

Adult↗
PubMed1997

Aortic arch angiography prior to carotid endarterectomy. Is its continued use justified?

UNLABELLED: Patients with significant stenosis at the carotid bifurcation are traditionally subjected to four vessel aortic arch angiography prior to consideration for carotid endarterectomy. The advent of the non-invasive vascular laboratory has necessitated a reappraisal of this approach. AIMS: 1. Determine the yield from aortic arch angiography and its influence on surgical management. 2. Evaluate the accuracy of clinical examination and the non-invasive vascular laboratory in the detection of aortic arch branch lesions. METHODS: One hundred and twenty-nine consecutive patients undergoing evaluation for carotid endarterectomy were prospectively enrolled into the study. The protocol entailed: 1. Clinical recording of upper limb pulses, blood pressure and supraclavicular bruits. 2. Duplex scan examination to evaluate proximal inflow into the carotid arteries. 3. Four vessel aortic arch angiography to detect aortic branch lesions. Data from the non-invasive tests were compared to angiography. Patients with aortic arch branch lesions were further evaluated to determine the proportion requiring additional surgery. RESULTS: Nineteen patients had angiographic evidence of aortic branch disease (14.7%); six involved the common carotid artery, three the innominate artery and 10 the subclavian artery. All of these lesions were detected by the combination of unequal blood pressure, pulse deficit, bruit or duplex scan. Seven patients underwent additional surgery (5.4%) which included carotid-subclavian bypass (five), aortoinnominate bypass (one) and innominate endarterectomy (one). CONCLUSION: In patients with significant stenosis at the carotid bifurcation undergoing evaluation for carotid endarterectomy, aortic arch angiography is unnecessary except in a small percentage of patients with abnormal clinical and non-invasive findings.

Aorta, Thoracic↗
PubMed1997

Choosing the proximal anastomosis in aortobifemoral bypass.

BACKGROUND: The preferred method of proximal aortic anastomosis (end to end or end to side) in aortobifemoral bypass remains controversial. METHODS: This is a study of 492 patients who had an aortobifemoral bypass for aortoiliac disease over 9 years in which end-to-end (166 patients) and end-to-side (326 patients) proximal aortic anastomoses were compared. The decision as to the type of anastomosis was made at operation, depending on the severity of aortic disease. Outcome was related to the site of the proximal anastomosis and the state of the distal run-off. RESULTS: The overall perioperative mortality rate was 5 per cent. Early graft occlusion occurred in six patients in the end-to-side group and none in the end-to-end group. During follow-up nine patients (5 per cent) had graft occlusion following end-to-end anastomosis and 56 (17 per cent) following end-to-side anastomosis (cumulative patency 87 and 75 per cent respectively). Patency was not affected by the distal run-off. DISCUSSION: End-to-end anastomosis yields significantly better results than end-to-side anastomosis irrespective of distal run-off.

Adult↗
PubMed1996

Aneurysms due to intimomedial mucoid degeneration.

OBJECTIVE: Review management of patients presenting with aneurysms due to intimomedial mucoid degeneration (IMMD). DESIGN: Retrospective analysis. SETTING: Metropolitan Vascular Service, Departments of Haematology and Pathology, University of Natal. MATERIALS AND METHODS: Case records reviewed over an 11 year period. Twenty-two patients were submitted for surgery. All had histological confirmation of disease. All patients were black African (Negro) descent and nineteen were female. Average age was 52 years. RESULTS: Fifteen patients had involvement of descending aorta and seven patients had extra-aortic involvement. Hypertension was noted in half of the patients. Seven patients presented acutely with rupture (4) and ischaemic lower limbs due to dissection (3). Total absence of clot within aneurysm lumen was a distinctive finding on ultrasound, CT-scan and angiography. Treatment followed standard vascular surgical principles. Three patients died following emergency aortic replacement. Three patients developed severe intraoperative bleeding problems following elective aortic aneurysm resection due to primary fibrinolysis. All had normal preoperative coagulation profiles. CONCLUSION: IMMD is a rare disease affecting the intima and media of vessel wall involving aortic and extra aortic vessels, predominantly in younger African females with hypertension. Lack of clot within aneurysm lumen should alert surgeon to predisposition toward bleeding diathesis. Meticulous suture technique is essential as aortic wall is friable. Medium to long term results are satisfactory.

Adult↗