Volume 16 Number 4 October 1992
media and adventitia. As shown by this study and others the cellular infiltrate is immunologicaUy active; immunoglobin and cytokines are identifiable within the vessel wall. 4's Macrophages are also found in aneurysms both alone and in association with lymphoid follicles and atherosclerotic plaques. These macrophages contribute to the immune response by presenting antigen to the CD-positive lymphocytes, thereby perpetuating the process, and by releasing inflammatory mediator cytokines. Many cytokines have been identified within the aortic wall and by tissue explant cultures (interleukin-1, interleukin-8, tumor necrosis factor, and interferon-~). The macrophage may further contribute to the pathogenesis of aneurysmal disease by secreting collagenases and elastases, which may promote degradation of the extracellular matrix. In addition, many smooth muscle cells express human leucocyte antigen (locus) DR, signifying activation by one of the immune mediators. From atherosclerotic plaques to AAA and IAAA there is a spectrum of inflammation that varies only in degree and not cell type. Many interesting questions are raised by this article. What has initiated the immune mechanism and perpetuated it? Is the antigen an elastin fragment or low-density lipoprotein? Is the immune response in IAAA and AAA a variant of that associated with atherosclerotic plaques? And has the inflammatory response lost regulatory control, leading to autodigestion of the aorta? Aneurysmal disease represents a complicated interrelationship between the immune response, the synthetic function of the vascular smooth muscle cell, and a yet undescribed genetic abnormality. Continued studies of the immune mechanism as performed in this report offer new venues of research in aneurysmal disease.
Letters to the Editors
663
Delayed postoperative bleeding from polytetraItuoroethylene carotid artery patches To the Editors:
A recent article (J VAsc SURG 1992;15:661-3) reported three cases of delayed postoperative bleeding after a polytetrafluoroethylene (PTFE) patch was used for closure of the arteriotomy after carotid endarterectomy. The first case involved 6-0 Prolene suture (McGaw Laboratories, Inc., Irvine, Calif.), and the second and third cases used "7-0" PTFE suture. W. L. Gore & Associates, (Newark, DeL) specifically developed PTFE sutures for use in situations in which the suture and the needle have the same diameter. The sutures used in the report do not fit this description but have needles larger than the suture. The thinner patch in particttlar tends to bleed from the needle holes when large needles are used to pull small sutures through. In our practice we prefer the CV-6 Gore-Tex suture (W. L. Gore & Associates) on a PT-9 needle for patching carotid arteries with PTFE. The CV-5 Gore-Tex suture (with any of the following needles: TT-13, TH-13, PT-13, and PH-13) works equally well but seems a little large for a small carotid artery. Bleeding has not been a problem. John W. Smith, MD
8300 Dodge St. Omaha, NE 68114
REFERENCE 1. McCready RA, Siderys H, Pittman JN, et al. Delayed postoperative bleeding from polytetrafluoroethylene carotid artery patches. J VASCSURG 1992;15:661-3. 24/41/39753
William H. Pearce,MD
Associate Professor of Surgery Division of Vascular Surgery Department of Surgery Northwestern University Medical School 251 E. Chicago Ave. Chicago, IL 60611-2614
REFERENCES 1. Koch AE, Haines KG, Rizzo RJ, et al. Human abdominal aortic aneurysms: immunophenotypic analysis suggesting an immune-mediated response. Am J Patho11990;137:1199-213. 2. Leu HJ. Inflammatory abdominal aortic aneurysms: a disease • entity? Histological analysis of 60 cases of inflammatory aortic aneurysms of unknown etiology. Virchows Arch [A] 1990; 417:427-33. 3. McMahon JN, Davies JD, Scott DJA, et al. The microscopic features of inflammatory abdominal aortic aneurysms: discriminant analysis. Histopathology 1990;16:557-64. 4. Stella A, Gargiulo M, Pasquinelli G, et al. The cellular component in the parietal infiltrate of inflammatory abdominal aortic aneurysms (IAAA). Eur J Vasc Surg 1991;5:65-70. 5. Brophy CM, Reilly JM, Walker Smith GJ, et al. The role of inflammation in nonspecitic abdominal aortic aneurysm disease. Ann Vasc Surg 1991;5:229-33. 24/41/39151
A case of nutcracker syndrome: Treatment by mesoaortic transposition To the Editors:
Mesoaortic compression of the left renal vein (LRV) producing renal venous hypertension, pelviureteral varices, hematuria, or left flank pain has become known as the nutcracker syndrome (NCS). 1 We recently treated this rare condition in a young man by a new m e t h o d - transposition of the superior mesenteric artery (SMA).
CASE REPORT An 18-year-old man was admitted with a history of intermittent hematuria and chronic left flank and abdominal pain. The patient had been in good health until 1'/2 years before this examination, when he experienced gross hematuria after a 12-foot fall on his buttocks. At that time a physical examination revealed only left flank and abdominal tenderness. No varicoceles were present. Results of laboratory analyses were normal except for macroscopic hematuria on urinalysis. Urine culture results were negative. An excretory urogram showed
media and adventitia. As shown by this study and others the cellular infiltrate is immunologicaUy active; immunoglobin and cytokines are identifiable within the vessel wall. 4's Macrophages are also found in aneurysms both alone and in association with lymphoid follicles and atherosclerotic plaques. These macrophages contribute to the immune response by presenting antigen to the CD-positive lymphocytes, thereby perpetuating the process, and by releasing inflammatory mediator cytokines. Many cytokines have been identified within the aortic wall and by tissue explant cultures (interleukin-1, interleukin-8, tumor necrosis factor, and interferon-~). The macrophage may further contribute to the pathogenesis of aneurysmal disease by secreting collagenases and elastases, which may promote degradation of the extracellular matrix. In addition, many smooth muscle cells express human leucocyte antigen (locus) DR, signifying activation by one of the immune mediators. From atherosclerotic plaques to AAA and IAAA there is a spectrum of inflammation that varies only in degree and not cell type. Many interesting questions are raised by this article. What has initiated the immune mechanism and perpetuated it? Is the antigen an elastin fragment or low-density lipoprotein? Is the immune response in IAAA and AAA a variant of that associated with atherosclerotic plaques? And has the inflammatory response lost regulatory control, leading to autodigestion of the aorta? Aneurysmal disease represents a complicated interrelationship between the immune response, the synthetic function of the vascular smooth muscle cell, and a yet undescribed genetic abnormality. Continued studies of the immune mechanism as performed in this report offer new venues of research in aneurysmal disease.
Letters to the Editors
663
Delayed postoperative bleeding from polytetraItuoroethylene carotid artery patches To the Editors:
A recent article (J VAsc SURG 1992;15:661-3) reported three cases of delayed postoperative bleeding after a polytetrafluoroethylene (PTFE) patch was used for closure of the arteriotomy after carotid endarterectomy. The first case involved 6-0 Prolene suture (McGaw Laboratories, Inc., Irvine, Calif.), and the second and third cases used "7-0" PTFE suture. W. L. Gore & Associates, (Newark, DeL) specifically developed PTFE sutures for use in situations in which the suture and the needle have the same diameter. The sutures used in the report do not fit this description but have needles larger than the suture. The thinner patch in particttlar tends to bleed from the needle holes when large needles are used to pull small sutures through. In our practice we prefer the CV-6 Gore-Tex suture (W. L. Gore & Associates) on a PT-9 needle for patching carotid arteries with PTFE. The CV-5 Gore-Tex suture (with any of the following needles: TT-13, TH-13, PT-13, and PH-13) works equally well but seems a little large for a small carotid artery. Bleeding has not been a problem. John W. Smith, MD
8300 Dodge St. Omaha, NE 68114
REFERENCE 1. McCready RA, Siderys H, Pittman JN, et al. Delayed postoperative bleeding from polytetrafluoroethylene carotid artery patches. J VASCSURG 1992;15:661-3. 24/41/39753
William H. Pearce,MD
Associate Professor of Surgery Division of Vascular Surgery Department of Surgery Northwestern University Medical School 251 E. Chicago Ave. Chicago, IL 60611-2614
REFERENCES 1. Koch AE, Haines KG, Rizzo RJ, et al. Human abdominal aortic aneurysms: immunophenotypic analysis suggesting an immune-mediated response. Am J Patho11990;137:1199-213. 2. Leu HJ. Inflammatory abdominal aortic aneurysms: a disease • entity? Histological analysis of 60 cases of inflammatory aortic aneurysms of unknown etiology. Virchows Arch [A] 1990; 417:427-33. 3. McMahon JN, Davies JD, Scott DJA, et al. The microscopic features of inflammatory abdominal aortic aneurysms: discriminant analysis. Histopathology 1990;16:557-64. 4. Stella A, Gargiulo M, Pasquinelli G, et al. The cellular component in the parietal infiltrate of inflammatory abdominal aortic aneurysms (IAAA). Eur J Vasc Surg 1991;5:65-70. 5. Brophy CM, Reilly JM, Walker Smith GJ, et al. The role of inflammation in nonspecitic abdominal aortic aneurysm disease. Ann Vasc Surg 1991;5:229-33. 24/41/39151
A case of nutcracker syndrome: Treatment by mesoaortic transposition To the Editors:
Mesoaortic compression of the left renal vein (LRV) producing renal venous hypertension, pelviureteral varices, hematuria, or left flank pain has become known as the nutcracker syndrome (NCS). 1 We recently treated this rare condition in a young man by a new m e t h o d - transposition of the superior mesenteric artery (SMA).
CASE REPORT An 18-year-old man was admitted with a history of intermittent hematuria and chronic left flank and abdominal pain. The patient had been in good health until 1'/2 years before this examination, when he experienced gross hematuria after a 12-foot fall on his buttocks. At that time a physical examination revealed only left flank and abdominal tenderness. No varicoceles were present. Results of laboratory analyses were normal except for macroscopic hematuria on urinalysis. Urine culture results were negative. An excretory urogram showed
