bluuebunny/crossref_metadata_2025 huggingface dataset:
Prostacyclin Usage for Spinal Cord Protection During Experimental Thoracic Aortic Cross-Clamping
Authors: Katircioğlu Salih Fehmi , Gökce Perran , Özgencil Eser , Saritas Zuilfikar , Sener Erol , Yilmazkaya Bayram , Koc Bahattin , Tasdemir Oğuz , Bayazit Kemal
Published: June 2007

The risk of paraplegia associated with thoracic aortic cross-clamping is high even when various methods of spinal cord protection are used. In this study prostacyclin 12 (PGI2) was selected as an agent to reduce the spinal cord injury because of its vasodilator, antiaggregant, and cytoprotective properties.

Twelve dogs underwent sixty-minute aortic occlusion. Six dogs received PGI2 whereas the other 6 did not (controls). PG12 administration was started at a rate of 5 ng/kg/minute five minutes before aortic occlusion. This dosage was increased to 25 ng/kg/minute during aortic occlusion. PGI2 at a dosage of 5 ng/kg/minute was maintained for a period of five minutes after the aortic occlusion was released.

Three dogs in the control group were paraplegic. There were no paraplegic dogs in the PGI2 group. Distal aortic perfusion pressure was 31 ± mmHg in the PGI2 group and 22 ±3 in the control group (P <0.008).

As a result of this study the authors conclude that PGI2 is a valuable agent for decreasing the risk of spinal cord injury during thoracic aortic cross-clamping lasting sixty minutes.
Transcranial Doppler in the Acute Phase and Follow-up of Internal Carotid Artery Dissection
Authors: Viola Stefano , Uncini Antonino , Matta Edgar , Aquilone Lucio , Gambi Domenico
Published: June 2007

Internal carotid artery dissection (ICD) causes transient ischemic attack (TIA) or stroke by hemodynamic or thromboembolic mechanisms. Diagnosis of ICD is made by angiography. The aim of this study was to evaluate the role of three-dimensional transcranial Doppler (TCD-3D) in ICD.

The authors report a fifty-seven-year-old man presenting sudden aphasia, left neck pain, and homolateral headache and a sixty-year-old man presenting sudden right neck pain, homolateral headache, and Horner's syndrome. Selective digital subtraction angiography showed the typical elongated regular stenosis (string sign) of ICD. At onset TCD-3D revealed in both patients: (1) decreased blood flow velocity over the internal carotid dissected segment and inverted flow velocity over the homolateral anterior cerebral and ophthalmic artery; (2) reduced pulsatility index with normal blood flow velocity over the homolateral middle cerebral artery suggestive of valid autoregulation of cerebral blood flow (CBF). TCD-3D at days 15 and 40 and at months 2 and 6 after stroke showed progressive recanalization beginning from the day 40 in the first patient and from the day 15 in the second patient with successive complete normalization of Doppler parameters.

Although angiography remains the most reliable diagnostic study, TCD-3D results are useful for evaluating, in the acute phase, the efficacy of collateral blood supply and autoregulation of CBF, which are important as prognostic indexes and as indications for therapeutic strategy, and, afterward, for the timing of recanalization indicative of a good long-term prognosis.
The Age of a Venous Thrombosis: Experimental and Clinical Experience with Duplex Color-Coded Ultrasound
Authors: Eisele Ralf , Orend Karl-Heinz , Mohr Michael , Schulte Michael
Published: June 2007

The crucial point for all therapeutic considerations is the exact estimation of the age of the thrombus. Until the present, phlebography, an invasive technique, has been the gold standard in venous diagnostics. The intention of this study was to investigate the efficiency of duplex color-coded ultrasound (DCCU). The authors evaluated ultrasonic criteria for an acute thrombus by using experimental thrombi in rats. They screened for venous thrombosis in 20 acutely amputated lower extremities from vascular patients. Findings of ultrasound were controlled by histopathologic thrombus examination. Finally 40 traumatologic patients were examined for deep vein thrombosis with DCCU after an immobilization of one leg. Comparison of ultrasound and histopathology revealed that three phenomena can be safely discriminated: type I (acute thrombus one to ten days), type II (three to five days), and type III (> six days). After immobilization of lower extremities they found 3 type I (acute) thrombi in 40 patients. Age estimation of venous thrombi by duplex color-coded ultrasound is possible. DCCU is a rapid and noninvasive technique; instead or in addition to phlebography, it may be extremely helpful in decision making for therapeutic strategy.
Intraoperative Stent Implantation for Venous Anastomotic Stenoses of Hemodialysis Grafts
Authors: Mickley V. , Rilinger N. , Friedrich J. M. , Storck M. , Abendroth D. , Sunder-Plassmann L.
Published: June 2007

Ten filiform stenoses and 1 complete occlusion of the venous anastomoses of 11 hemodialysis grafts were diagnosed during operative revision for shunt thrombosis. After Fogarty balloon thrombectomy, the lesions were treated by intraoperative balloon angioplasty and stent implantation (IAS). All grafts could be used for hemodialysis immediately after IAS. The patients could be followed up for six to twelve months. Within 2 stents, restenoses causing rethromboses of the shunts occurred after three and seven months, respectively. In 1 case another intraoperative dilation was successful, and the other was treated by graft prolongation. All other stents were widely patent at the last examination as demonstrated by color duplex sonography. IAS proved an effective alternative to surgical revision of the stenosed anastomosis. It may be applied without difficulty to patients with multiple preceding revisions and provides excellent success rates.
Percutaneous Transluminal Angioplasty in the Treatment of Vein Graft Stenosis
Authors: Gahtan Vivian , Weiss Jeffrey P. , Kerstein Morris D. , Harpavat Mona , Roberts Andrew B.
Published: June 2007

Vein graft stenosis is a precursor to graft failure and its management is controversial. The authors reviewed their experience with percutaneous transluminal angioplasty (PTA) for these lesions.

Thirty-one infrainguinal vein grafts (30 patients) underwent 59 PTAs at 44 different sites. Mean patient age was 66.7 years, and 17 (57%) were men. Hemodynamically significant lesions (>50% diameter reduction) were established by duplex scan or angiography. All patients had follow-up duplex graft surveillance. Determination of recurrence was based on duplex criteria (peak systolic velocity >200 cm/sec, velocity ratio >2). PTA outcomes at 3 months were divided into successful and unsuccessful categories. Eight stenoses were excluded from this assessment secondary to follow-up < 3 months. All bypass grafts were patent through their last evaluation. Ninety percent of lesions (46/51) received adequate initial dilations. The successful group (41/51 lesions, 80%) had a mean follow-up of 10.8 months (range 3.0-26.3). In this group, 12 lesions recurred with a mean time from PTA of 5.3 months (range 3.0-13.6). Of the 10 unsuccessfully treated lesions, five were angioplasty failures and five recurred within 3 months. The distal anastomosis was the most unsuccessful location to be treated (P=0.01). The length of the lesions and the age of the graft did not influence outcome (P>0.05). There were two complications from PTA: an occlusion effectively treated with thrombolytic therapy and one distal embolization.

In conclusion, 80% (41/51) of stenoses treated with PTA were successful for at least 3 months. Two thirds of first-time lesions were stenosis-free at 1 year. PTA is a safe, reasonable method for the management of vein graft stenosis. The distal anastomosis is the most difficult site to manage.
Quality of the Long Saphenous Vein Conduits Used for Coronary Artery Bypass Grafting Operations
Authors: Giannoukas Athanasios D. , Stavridis George T. , Labropoulos Nicos , Bailey David , Glenville Brian , Nicolaides Andrew N.
Published: June 2007

The aim of this study was first to select preoperatively suitable long saphenous vein (LSV) segments by using color flow duplex imaging (CFDI) and second to evaluate the quality of the harvested LSVs histologically. Forty LSVs in 38 consecutive patients (mean age 63 years) were examined by CFDI for patency and luminal diameter. None of the patients had documented previous deep venous thrombosis or superficial thrombophlebitis. Perioperatively, 79 LSV specimens were harvested from the ankle, knee, and midthigh regions and examined histologically for wall calcification and fibrosis. According to the amount of fibrosis present the specimens were classified as being normal or mildly, moderately, or severely affected.

All LSVs were found patent and nonvaricose, and their diameter ranged from 0.18 to 0.54 cm at the ankle, 0.29 to 0.69 cm at the knee, and 0.25 to 0.77 cm at the midthigh level. On histology 11% of the specimens were found to be normal, and 43% were mildly, 38% moderately, and 8% severely fibrotic. Also, various grades of fibrosis were found in different sites of the same vein. None of the specimens had calcification.

It is concluded that the majority of the LSVs used for coronary artery bypass grafting have some degree of fibrosis. The histologic appearance of the LSV wall in a particular site cannot predict the condition of vein throughout its length. CFDI can be useful in the perioperative conduit selection.
The Use of Preoperative Noninvasive Vascular Studies for the Evaluation of Radial Artery Conduits for Coronary Artery Bypass Grafting
Authors: Wolk Seth W. , Moores Harold K. , Lampman Richard M. , Misare Bruce D. , Erlandson Errol E. , Kong Bobby K. , Fowler Jennifer J. , Page Jeanne M. , Babcock Shelly L. , Whitehouse Walter M.
Published: June 2007

Background: The increased use of the radial artery for coronary artery bypass conduits has heightened the awareness of potential resultant hand ischemia. The Allen test and subsequent modifications have been used to evaluate the patency of the superficial palmar arch (SPA). The purpose of this study was to determine if changes in blood flow patterns of the SPA assessed by the modified Allen test parallel changes in blood pressures of the first and second digits following radial artery occlusion.

Methods: Continuous-wave Doppler ultrasound and photoplethysmography (PPG) were used to evaluate blood flow in the SPA and first and second digits, respectively, before and after manual occlusion of the radial artery in 60 extremities. A second continuouswave Doppler probe was used to ensure complete occlusion of the radial artery. Digit skin temperature was controlled between 36° and 37.5°0. A reduction of >20 mmHg in blood pressure was arbitrarily chosen to reflect a clinically significant change in digit arterial pressure.

Results: Six of the 60 extremities (10%) studied showed a decrease in the audible Doppler signal over the SPA following radial artery occlusion. Reduction in digit arterial pressure following radial artery occlusion occurred in 13 of 60 extremities (21.7%). Digit arterial pressure reductions ranged from 20 to 58 mmHg (mean ±SD, 35.2 ±12.8 mmHg), demonstrating a 40% decrease in digital pressure. Changes in SPA flow did not parallel digital pressure changes following occlusion of the radial artery.

Conclusion: Continuous-wave Doppler ultrasound of the SPA following radial artery compression alone does not accurately predict digit ischemia. Digit arterial pressure measurement of the first and second digits of upper extremities offers a relatively simple and objective method for evaluation of potential ischemic complications following radial artery harvest. This finding is important because many physicians only use a modified Allen test with radial artery compression to assess potential digit ischemia.
Comparison of Transcutaneous Oxygen-Tension Measurements and Ankle/Arm Indices in the Perioperative Period
Authors: Sano Chiaki , Ugaeri Hidehiro , Samuels Louis , Matsumoto Teruo , Kerstein Morris D.
Published: June 2007

Transcutaneous oxygen tensions (TcPo2) were compared with ankle blood pressures in 160 lower extremities of 36 diabetic and 48 nondiabetic patients in the perioperative period. TcPo2 measurements were related to regional perfusion indices (RPI) (RPI = TcPO2 foot/TcPO2 chest), and ankle pressures were used to calculate ankle/arm systolic pressure indices (AAI). Severity of disease: Group I: claudication, 57/160 (36%); Group II: rest pain, 66/160 (41%); Group III: tissue loss, 37/160 (23%).

In Groups I, II, and III, preoperative mean AAI and RPI were 0.46, 0.23, 0.32 and 0.41, 0.21, 0.16, respectively. The net mean increases in AAI and RPI with revascularization for Groups I, II, and III were 0.42, 0.51, 0.41 and 0.46, 0.49, 0.62, respectively. Groups I, II, and III extremities exhibited drops in RPI with limb elevation both preoperatively and postoperatively, which averaged 0.06, 0.05, 0.14 and 0.16, 0.11, 0.14, respectively. The diabetic extremities, postoperatively, exhibited significantly greater drops in RPI (p < 0.05). RPI measurements correlated more precisely than AAI with preoperatively and postoperative perfusion.
Ruptured Internal Iliac Artery Aneurysm
Authors: Isiklar H. , Jenkins M. , Sarin S. , Adiseshiah M.
Published: June 2007

A patient with a ruptured internal iliac artery aneurysm who presented with acute urinary retention and tenesmus is described. Obliterative aneurysmorrhaphy was performed, and thrombus in the sac was removed and an in-situ drain was placed in the sac. The patient's urinary symptoms resolved postoperatively.
Patient Outcomes Following Placement of a Second Inferior Vena Cava Filter
Authors: Haase Steven C. , Wolk Seth W. , Lampman Richard M. , Sarosi Michael G. , Misare Bruce D. , Erlandson Errol E. , Whitehouse Walter M.
Published: June 2007

Inferior vena cava (IVC) interruption is being performed with increasing frequency. Indications for this procedure have expanded since the introduction of percutaneous placement techniques. Indications for placement of a second IVC filter are less well defined. It has been reported that a second filter can be placed safely. The purpose of this study was to investigate the intermediate and long-term follow-up of these patients.

Five patients underwent placement of a second IVC filter at one institution from 1992 to 1996. During the same period a total of 439 patients underwent IVC filter placement. The five patients, ranging in age from 46 to 67 years, included three men and two women. The indication for the second filter placement was a confirmed or strongly suspected recurrent pulmonary embolus (PE), with thrombus in and above the previously placed IVC interruption device in all patients. Three of the five patients suffered from poorly controlled malignancies. One patient had an ependymoma of the spinal cord that was completely excised. The fifth patient had a documented hypercoagulable state: factor V resistance to activated protein C. The mean time between placement of the first and second filters was 31 weeks (range: 1-65 weeks). Mean follow-up was 94 weeks (range: 0-252 weeks). One patient died within 24 hours of filter placement from profound hypoxemia from a preexistent PE. No fatal PE occurred in any of the four remaining patients. Two patients in this study, following placement of a second IVC filter, had documented pulmonary emboli that were nonfatal. Two patients died as a result of their underlying malignancies.

While placement of a second IVC interruption device is an infrequently performed procedure, it appears to be efficacious in preventing death from pulmonary emboli in this extremely high-risk group of patients.
A New Approach to the Treatment of Penetrating Injuries to the Vertebral Artery
Authors: Mclaughlin Daniel J. , Modic Michael , Masaryk Thomas , Pratt Debra , Huang David
Published: June 2007

Penetrating injuries to the vertebral artery remain an unusual, yet challenging, problem in trauma patients. Once thought to be rare, the awareness of this type of injury is increasing, in part because of arteriography for patients with penetrating cervical trauma. Mortality rates have been reported from 5-50% in various reviews. Early and late complications are common and often life-threatening. These include bleeding, pseudoaneurysm, arteriovenous fistula, thrombosis, and stroke. In addition, distal vertebral artery trauma represents a distinctly more complex and technically challenging problem. Standard surgical practice has been operative ligation (proximal and distal) and/or direct repair of the injured vessel. However, surgical exposure and repair of the injured vessel is often technically difficult, especially when the upper cervical portion of the artery is involved. Interventional radiologic techniques are now being used to diagnose and treat many complex vascular injuries. A new treatment for a Zone III vertebral artery gunshot wound is presented here. Using endovascular techniques the authors were able to successfully occlude the proximal vertebral artery via an ipsilateral approach, and the distal vertebral artery via a contralateral approach. This unique application of nonoperative interventional technique has significant implications for vascular surgery. This report represents the first successful treatment of a Zone III vertebral artery occlusion treated by endovascular methods.
Atherosclerotic Aneurysms Following Carotid Endarterectomy with Dacron Patch Angioplasty: An Unreported Complication
Authors: Byer A. , Quirke T. E. , Ritota P. C. , Keys R. C. , Marcus B.
Published: June 2007

The authors report 4 atherosclerotic extracranial carotid aneurysms (AECA) in 3 patients who had carotid endarterectomies with Dacron patch angioplasty (CEADP). This complication has not previously been reported with this patch material in this location. These AECAs were found in a group of 204 patients. Two hundred thirty-two arteries (1.7%) who had CEADP and who returned for regular follow-up from 3 months to 15 years postoperatively. Three aneurysms were excised after angiographic confirmation and replaced with autologous saphenous vein interposition grafts uneventfully. One of the three patients who had bilateral CEADP has since developed a contralateral aneurysm presumed to be an AECA but has refused angiography and surgery. This aneurysm remained essentially unchanged for two years after detection. The patient was then lost to follow-up. The diagnosis of AECA in the patients who were operated on was confirmed by histology. Dacron patch angioplasty as an adjunct to carotid endarterectomy is an accepted technique which yields satisfactory results. This report however, cautions about a significant complication which occurs late in the postoperative course of patients who have had this procedure.
Retroaortic Left Renal Vein Disclosed by Digital Subtraction Angiography
Authors: Martínez-León J. Ignacio , Domínguez-Viguera Luis , García-Medina José , Casal-Rivas Moisés , Bohórquez-Sierra J. Carlos
Published: June 2007

Retroaortic left renal vein is a relatively uncommon venous anomaly. Its clinical importance is unclear, but diagnostic and surgically hazardous implications make it a condition that must be kept in mind. Computed tomography (CT) scanning has been largely advocated as the most accurate imaging method in assessing this anomaly. Digital subtraction angiography (DSA) is not usually reported as detecting retroaortic left renal veins. The authors report a case in which a retroaortic left renal vein could be detected both by CT scan and by DSA, a finding that could be confirmed intraoperatively during aortic aneurysm surgery. Most of the relevant literature is briefly commented on and reviewed.
Steps to Minimize Ischemic Colitis Following Abdominal Aortic Surgery
Authors: Sanfelippo Peter M.
Published: June 2007

The development of ischemic colitis following abdominal aortic surgery is associated with substantial morbidity and mortality. Attention to preoperative, intraoperative, and postoperative aspects can reduce the incidence and severity of ischemic colitis and significantly reduce morbidity and mortality.
Renal Artery Aneurysm During the Postpartum Period
Authors: Bengisun Uğur , Ersoz Sadik , Bilgin Omer F. , Sanlidilek Umman , Ceylan Ibrahim
Published: June 2007

Ruptured renal artery aneurysm, especially during pregnancy, is an infrequent but a catastrophic disorder. Rupture of renal artery aneurysm during pregnancy is associated with high maternal and fetal mortality of about 80%. The incidence of renal artery aneursyms in the postpartum period is unknown. We report a case of intact saccular renal artery aneurysm diagnosed and treated successfully by excision of the aneurysm and primary repair in the postpartum period.
Greater Saphenous Vein Aneurysms
Authors: Alonso-Pέrez Manuel , Caeiro Santiago , Guitian Maria D. , Sάnchez Mercedes , Segura Ramόn J.
Published: June 2007

Unlike arterial aneurysms, the venous aneurysms are a much less frequent pathology and clinical experiences are limited to isolated cases. Those involving veins of the neck and extremities are the most frequent. The authors report one case of two greater saphenous vein aneurysms and comment on the literature.

The patient was a 43-year-old man with an antecedent right inguinal hernia repair, who had been presenting for the last 4 years because he had a growing mass in the right groin, currently measuring 6 cm in diameter, causing local discomfort; this mass was reduced in a recumbent position or with manipulation; and 7 cm lower there was another similar painless mass measuring 5 cm in diameter. Duplex scanning showed two aneurysms in the greater saphenous vein, which did not contain thrombus. Phlebography was not carried out. The surgical approach was a complete extraction of the greater saphenous vein.

From the review of the literature it is concluded that uncomplicated greater saphenous vein aneurysms are not associated with pulmonary embolism (unlike popliteal vein aneurysms) the surgical treatment is indicated when they cause discomfort or for aesthetic reasons.
The Popliteal Artery Entrapment Syndrome
Authors: Andrikopoulos Vassilios , Papacharalambous Gerasimos , Antoniou Ioannis , Panoussis Panagiotis
Published: June 2007

The purpose of this retrospective study was to evaluate the early and long-term results of vascular reconstruction for popliteal artery entrapment syndrome (PAES). Fourteen patients (18 legs) who underwent surgical treatment for PAES over a 10-year period were included. Seven patients underwent simple myotomy and remained symptom-free for a 5- to 96-month follow-up period. Seven patients underwent myotomy and vein graft: the graft remained patent in four cases, in one case the graft thrombosed and was successfully reoperated on, and two patients remain asymptomatic without palpable pulses. Of the three patients with a polytetrafluoroethylene (PTFE) graft, one is symptom-free with a patent graft, one continues to present with intermittent claudication (IC), whereas the third subsequently underwent above-knee amputation. PAES, a congenital abnormality, requires surgical treatment and any conservative management may be deleterious. Early diagnosis is of utmost importance because in the early stage, simple surgical procedure offers a permanent therapeutic result. Thus, every young sportsperson, with even minor lower extremity problems, should be examined by a vascular surgeon.
Treatment of Rheumatoid Vasculitic Cutaneous Ulcers with Regional Hyperbaric Oxygen
Authors: Hirko Mark K. , Jamshidi Mohammad , Gupta Ashish , Rubin Jeffrey R.
Published: June 2007

Hyperbaric oxygen therapy (HBO) has been used to promote healing of cutaneous ulcers secondary to diabetes mellitus, ionized radiation exposure injuries, gas gangrene, crush injuries, and necrotizing fasciitis. Despite the beneficial effects of HBO, there have been conflicting clinical experiences reported regarding its efficacy. To evaluate the effects of localized HBO, eight patients who were referred to a vascular surgery service with nonhealing rheumatoid vasculitic cutaneous ulcers were placed on a regional HBO regimen consisting of 100% fraction of inspired oxygen at 2 x atmospheric pressure for 60-90 minutes three times daily. Wound healing occurred in 87.5% of patients with a mean healing time of 4.7 weeks (range 2-10 weeks). The authors conclude that localized HBO for the treatment of refractory rheumatoid vasculitic ulcers is a safe and expedient modality to be considered and that these chronically hospitalized patients, exhausting other treatment regimens, may benefit from HBO therapy.
Simplified Cardiopulmonary Bypass Technique for the Surgical Treatment of Renal Tumors with Intracaval and Intracardiac Extensions
Authors: Oba Jun'ichi , Yasuda Keishu , Shiiya Norihiko , Matsui Yoshiro , Goda Toshihiro , Sakuma Makoto , Kato Hiroyuki , Tanda Katsutoshi , Koyanagi Tomohiko
Published: June 2007

The authors report four cases of renal tumors with intracaval and intracardiac extensions that can be removed successfully during cardiopulmonary bypass surgery. The management was relatively simple: mild hypothermia, empty heartbeat, monocaval cannulation, and no circulatory arrest. Bleeding from the hepatic or renal veins was controlled by temporary occlusion of the hepatic artery, the portal vein, and the renal artery for a short duration. The authors also advocate thrombectomy of the hepatic vein using direct observation to relieve hepatic congestion. No complications were experienced postoperatively. One patient died of systemic metastasis 9 months after the operation. Another died of cytomegalovirus infection 3 months postoperatively. The remaining 2 are leading normal lives. Although the surgical indication for these advanced tumors is controversial, the patients' quality of life may be improved by this aggressive yet simple and safe approach.
Utility of Laparoscopy for Identification of Hepatic Disease Before Aortic Surgery
Authors: Huber Thomas S. , Ozaki C. Keith , Flynn Timothy C. , Seeger James M.
Published: June 2007

Postoperative hepatic failure is a significant yet unpredictable cause of death after elective aortic surgery. Routine preoperative evaluation is frequently insufficient to identify patients at risk. This study was designed to prospectively evaluate the utility of laparoscopy before aortic surgery in patients at a high risk for postoperative hepatic dysfunction. Patients at high risk for postoperative hepatic insufficiency were identified by history, physical examination, and routine blood work. Diagnostic laparoscopy was performed immediately before the planned aortic surgery through a single umbilical incision using standard technique. Liver biopsies were obtained in patients with equivocal findings. The planned operative procedure was undertaken based on the laparoscopic findings. The laparoscopic findings were correlated with those at laparotomy and the postoperative course. Eleven patients scheduled for aortic surgery (indication: aortoiliac occlusive disease [AIOD], five; abdominal aortic aneurysm [AAA], four; renal artery stenosis [RAS], two) were deemed high risk for postoperative hepatic dysfunction owing to alcohol abuse (11 patients), hepatomegaly (1 patient), or laboratory abnormalities (4 patients). Laparoscopy was performed in all patients without complication and required 24 ± 13 minutes (± sd). Laparoscopy revealed a normal liver in three patients, mild liver disease in five, severe cirrhosis in two, and equivocal findings in one patient (frozen section biopsy showed normal liver). The planned aortic procedure (AIOD, aortobiiliac bypass [ABF]; AAA, aortoaorto/aortobiiliac [ABI], RAS, bilateral aortorenal bypass) was performed in nine patients and aborted in the two patients with cirrhosis. The laparoscopic findings correlated reasonably well with those at laparotomy (identical, six patients, lapscope overestimate, two patients, lapscope underestimate, one patient). Postoperative hepatic failure and death occurred after aortic surgery (lapscope, normal liver) in one patient, and transient laboratory abnormalities were seen in two patients (lapscope, mild liver disease). The direct variable and total hospital costs for the laparoscopic study performed as an adjunct to the aortic surgery were $123 and $472 respectively.

Diagnostic laparoscopy before aortic surgery is a safe, simple, inexpensive adjunct that may help further identify patients at high risk for postoperative hepatic dysfunction.
Explantation of Infected Hemostatic Puncture Closure Devices
Authors: Tan Swee Lian
Published: June 2007

Hemostatic puncture closure devices for the femoral artery are currently marketed as a means of shortening hemostasis, ambulation, and observation times after cardiac catheterization procedures. Some of these devices are deployed external to the artery, but at least one device, Angio-SealA (Sherwood, Davis & Geck), includes a polymer anchor that is deployed inside the artery. Major complications may arise from the use of this device, including thrombosis, embolization of the anchor, and infection. The manufacturer does not claim that the device reduces the incidence of local complications as compared to the traditional technique of manual compression. The author presents a case of infection of the groin involving the Angio-Seal device in which the patient presented with septic shock and renal failure after cardiac catheterization. A large abscess was present, and removal of the device required arterial surgery in an infected field. The author reports on the technique and precautions used to surgically remove the device and to prevent further complications.
Coarctation of the Lower Thoracic Aorta
Authors: Kerby Jeffrey D. , Smith J. Kevin , Chapman Gregory D. , Jordan William D.
Published: June 2007

Aortic coarctation is an uncommon etiology for adult-onset hypertension. Few cases in the modern literature have been reported with lower thoracic aortic coarctation as a cause for hypertension. A 36-year-old woman who had been treated for 12 years with progressive hypertension presented to her local emergency room with worsening dyspnea on exertion and acute onset of left-sided chest and upper limb pain. Evaluation for myocardial infarction was negative; however an echocardiogram revealed concentric left ventricular hypertrophy with severe global dyskinesia and an ejection fraction of 35%. Cardiac catheterization and aortography identified a lower thoracic aortic coarctation with a 90 mm Hg gradient and mild abnormalities of the coronary arteries. There was no evidence of involvement of the visceral or renal arteries. After stabilization of her blood pressure with nipride, nitroglycerin, and esmolol, she underwent a left posterolateral thoracotomy for aortic repair using an interposition Dacron graft. Operative findings showed no evidence of arteritis. Pathologic examination of a removed portion of the aorta revealed severe calcific atherosclerotic vascular disease and fibrosis in the adventitia with no evidence of active inflammation. The patient was quickly weaned from intravenous antihypertensive medication postoperatively and eventually discharged after a normal convalescence with diminished hypertension.
Single Celiac-Superior Mesenteric Artery Bypass: An Alternative in Mesenteric Ischemia
Authors: Santoro Timothy D. , Cambria Robert A. , Seabrook Gary R. , Towne Jonathan B.
Published: June 2007

Operative reconstruction of the visceral vessels continues to have a high mortality rate. In this report, the authors describe a series of patients in whom a unique method of visceral reconstruction was employed. The single celiac-superior mesenteric artery (SMA) bypass, originating from and patching the celiac origin, and coursing to the SMA, is an effective way to revascularize both of these vessels. Fourteen mesenteric reconstructions performed in 12 patients (eight men and four women, mean age: 66 years) between 1989 and 1996 were reviewed. Eight patients had chronic intestinal ischemia (postprandial pain, mean weight loss 44 lb) for a mean duration of 11 months, and four patients had acute intestinal ischemia with peritonitis. Reconstructive procedures included seven single celiac-SMA bypasses; four bypasses from the aorta to the SMA, celiac artery, or both; one iliosuperior mesenteric bypass; and two visceral patch angioplasties. All single celiac-SMA bypasses remained patent; however, two of four antegrade aortomesenteric reconstructions failed within 24 hours. Operative time was shorter for single celiac-SMA bypasses than for other reconstructions (168 vs 231 min). Mortality rate was 25% (two of eight) in the patients with chronic ischemia, and 100% in those with acute ischemia. Long-term follow-up (15.5 months) in the six survivors operated on for chronic ischemia demonstrated resolution of symptoms in all. The single celiac-SMA bypass is an effective and expeditious method of visceral revascularization, with a short, straight graft. This technique requires two anastomoses instead of three, minimizes intraoperative intestinal ischemia, and is easily performed with prosthetic or autologous material.
Treatment of Upper-Extremity Phlegmasia Cerulea Dolens with Intra-arterial Thrombolysis
Authors: Gagne Paul J. , Martinez Jeffrey M.
Published: June 2007

Upper-extremity deep vein thrombosis is a common iatrogenic complication in patients who have had central venous catheters, and is usually associated with mild symptoms. This report is of a 57-year-old craftsman who developed phlegmasia cerulea dolens of his left upper extremity 16 hours after removal of an ipsilateral subclavian vein catheter. The extremity was tensely edematous, hand was mottled, and tips of the digits were cyanotic. Arterial Doppler signals were normal. Fourteen hours of extremity elevation and heparin anticoagulation resulted in no clinical improvement. Duplex ultrasonography and venography showed diffuse thrombosis of the veins of the arm and forearm, but patent axillary and subclavian veins. Due to the severity of the edema and evidence of vascular compromise, an infusion catheter, introduced through the right common femoral artery, was positioned in the left brachial artery and an intra-arterial urokinase infusion of the left upper extremity initiated. Within 12 hours, the patient's left upper extremity improved notably. Ninety-three hours later, the urokinase infusion was stopped and the left upper extremity appeared normal. Follow-up duplex ultrasonography documented no residual thrombus in the deep veins of the left arm and forearm. Six months later, the patient has no residual disability, extremity edema, or limitations in function. An extensive review of the English literature identified no previous reports of intraarterial thrombolysis for upper-extremity phlegmasia cerulea dolens. This case is discussed and pertinent literature reviewed.
Impact of an Adherence Program on the Health and Outlook of HIV-Infected Patients Failing Antiretroviral Therapy
Authors: Parry Michael F. , Wright Pamela , Stewart Julie , McLeod Gavin X. , Tucker James , Weinberg Amy R.
Published: June 2007

Background:We prospectively studied the impact of an adherence counselor on the outcome of patients failing antiretroviral therapy because of nonadherence. Methods:Forty-six patients, identified as chronically nonadherent were enrolled. Individual attention was provided using the information, motivation and behavioral methodology. HIV RNA (viral load, in copies/mL), CD4 count (in cells/mm3), and body weight before and after the adherence counselor were measured. Qualitative outcome and patient satisfaction were assessed by deidentified third-party interviews. Results:Over half completed at least 1 year; only 8 patients were lost to follow-up. Mean CD4 counts increased significantly ( P< .05) for completers at 6 and 12 months. Viral loads decreased between baseline and 6 months. Most clients reported subjective benefit from working with the adherence counselor. Conclusion:Although few clients showed complete virologic suppression, the value of an adherence counselor was validated. Longer term adherence programs should be evaluated.
The Evolution of Endoscopy: Wireless Capsule Cameras for the Diagnosis of Occult Gastrointestinal Bleeding and Inflammatory Bowel Disease
Authors: Davis Brian R. , Harris Hobart , Vitale Gary C.
Published: June 2007

Occult gastrointestinal bleeding and lesions associated with inflammatory bowel disease represent a diagnostic dilemma because they often lie in areas of the small bowel that are difficult to access with flexible fiberoptic endoscopy. Capsule endoscopy has been developed to access these areas in a way that avoids the pain and anesthesia risks of push endoscopy. The diagnostic yield of capsule endoscopy has proven to be superior to both flexible small-bowel endoscopy and radiologic studies in several prospective trials. Capsule endoscopy transmits a large number of images that do not correlate well with the standard endoscopic view, creating a diagnostic challenge for the endoscopist. Complications of this procedure include capsule retention in diverticulae or at stricture sites. The technology of this procedure continues to evolve through improving image resolution and diagnostic accuracy. Capsule endoscopy also represents an overall economic saving despite a high unit price compared with the expense of repeat diagnostic testing. Because the diagnostic yield of capsule endoscopy is nearly twofold greater than conventional endoscopy, it has become the procedure of choice for the dilemma of assessing small-bowel pathology for many clinicians. Further studies are needed to determine whether the capsule endoscope can replace conventional endoscopy in the firstline diagnosis of pathology in other parts of the alimentary tract.
Evaluation of the Efficacy of the Electrosurgical Bipolar Vessel Sealer (LigaSure) Devices in Sealing Lymphatic Vessels
Authors: Novitsky Yuri W. , Rosen Michael J. , Harrell Andrew G. , Sing Ronald F. , Kercher Kent W. , Heniford B. Todd
Published: June 2007

Various sources of ultrasonic and thermal energy have been developed to facilitate blood vessel ligation. However, their efficacy in sealing lymphatics has not been clearly established to date. We hypothesized that the electrosurgical bipolar vessel sealer (EBVS) produces reliable and durable sealing of large lymphatic vessels in a porcine model. Thoracic ducts from 4 adult pigs were explanted and sealed at multiple levels by using 3 different EBVS devices: LigaSure Atlas, XTD, and V. Fifteen seals (5 per group) were analyzed for sealing time and visual quality. Seal burst strength was measured by using a graduated pressure saline injection system. Twelve intact seals also underwent a histologic analysis. The mean overall burst strength of the seals was 271 78 mm Hg (127 to 360 mm Hg). The burst pressures in the 3 groups were not statistically different. The overall mean time to achieve a seal was 5.12.2 seconds (3 to 10 seconds). Seals were achieved significantly faster in the V group (4.10.6 seconds) compared with the Atlas (6.32.3 seconds) and XTD (6.4 2.6 seconds) groups. Qualitative seal assessment revealed minimal sticking and charring, a favorable degree of seal tissue clarity, and desiccation in the 3 groups. Histologic analysis demonstrated a fusion of lymphovascular channels with a complete obliteration of the lumens. We demonstrated that the use of EBVS results in a fast and effective sealing of large porcine lymphatic vessels. The seals created by all 3 devices burst at markedly supraphysiologic intraluminal pressures. Ongoing randomized human trials may prove the clinical benefits of the routine use of EBVS devices for various tissue dissections.
Minimally Invasive Management of Colon Cancer
Authors: Zerey Marc , Burns Justin M. , Kercher Kent W. , Kuwada Timothy S. , Heniford B. Todd
Published: June 2007

One of the most controversial issues in minimally invasive surgery has been the implementation of laparoscopic techniques for the curative resection of colorectal malignancies. Initial concerns included the potential violation of oncologic principles, the effects of carbon dioxide, and the phenomenon of port site tumor recurrence. Basic science research and large randomized controlled trials are now demonstrating that these fears were unjustified. Long-term outcomes of laparoscopic colon resection compared with open colon resection for malignancy are comparable, and there may even be a survival benefit for a subset of patients who undergo laparoscopic resection.
A Primer on Natural Orifice Transluminal Endoscopic Surgery: Building a New Paradigm
Authors: McGee Michael F. , Rosen Michael J. , Marks Jeffrey , Onders Raymond P. , Chak Amitabh , Faulx Ashley , Chen Victor K. , Ponsky Jeffrey
Published: June 2007

Access to the abdominal cavity is required for diagnostic and therapeutic endeavors for a variety of medical and surgical diseases. Historically, abdominal access has required a formal laparotomy to provide adequate exposure. Natural orifice transluminal endoscopic surgery (NOTES) is an emerging experimental alternative to conventional surgery that eliminates abdominal incisions and incision-related complications by combining endoscopic and laparoscopic techniques to diagnose and treat abdominal pathology. During NOTES, commercially available flexible video endoscopes are used to create a controlled transvisceral incision via natural orifice access to enter the peritoneal cavity. Common incision-related complications such as wound infections, incisional hernias, postoperative pain, aesthetic disdain, and adhesions could be minimized or eliminated by NOTES. NOTES has evolved from more than 2 centuries of technological innovations and continued growth in the field of surgical endoscopy. Innovative surgical endoscopists have slowly developed means to surpass the constraints of the gastrointestinal lumen by using a flexible endoscope. The future of surgical endoscopy may be the shared entity of NOTES, which further integrates endoscopy, gastroenterology, and minimally invasive and general surgery. Although the promise of NOTES is electrifying to surgeons and endoscopists, several key issues need to be characterized prior to the incorporation of NOTES into routine practice. This article reviews the status, contemporary body of literature, limitations, and potential future implications accompanying the development of NOTES.
Fundamentals of Service Lines and the Necessity of Physician Leaders
Authors: Jain Anshu K. , Thompson Jon M. , Kelley Scott M. , Schwartz Richard W.
Published: June 2007

In the demanding and unpredictable environment of the health care industry, hospitals and health systems continue to search for ways to improve the efficiency and quality of care provision and, thus, thrive. Service line organization in health care, a concept that was popularized in the past, has recently experienced a resurgence, spanning the gamut from small community hospitals to large academic medical centers. The modern service line has transformed into an organizational tool that provides hospitals and health systems with a novel approach to achieve the goals of efficient and effective care. Physician leaders can play an integral role in the management of service lines, using a combination of management skills and clinical expertise to provide the oversight and direction necessary for assuring excellence in clinical care and value in its delivery. This article presents an overview of service line structure, implementation, implications, and the role of the physician-leader.
The Effect of Octreotide on Pancreatic Damage in TNBS-Induced Colitis
Authors: Akgül Siraç , Erbil Yeşim , Giriş Murat , Aliş Halil , Yanik Burcu Tulumoğlu , Olgaç Vakur , Toker Gülçin Aykaç
Published: June 2007

Inflammatory bowel disease, a chronic condition of the intestine, is associated with numerous extraintestinal manifestations, including pancreatitis. This study investigated the effect of octreotide administration on oxidative damage in a rat model of colitis induced by 2,4,6-trini-trobenzene sulfonic (TNBS) acid. Colonic and pancreatic malondialdehyde and glutathione levels are indicators of oxidative damage, and TNBS-induced colitis significantly increased the colonic and pancreatic malondialdehyde levels and decreased glutathione levels. Octreotide treatment was associated with decreased malondialdehyde levels and increased glutathione levels in the colonic and pancreatic tissue. The colonic mucosal structure was preserved and pancreatic inflammation decreased in rats treated with octreotide. Octreotide also significantly decreased nuclear factor-kB expression by immunohisto-chemistry in the colonic and pancreatic tissue compared with TNBS-induced colitis group. Octreotide appears to have protective effects against TNBS-induced colonic and pancreatic damage. These results imply the reduction in mucosal damage owing to the anti-inflammatory and antioxidant effects of octreotide.
The Role of Laparoscopic Surgery in the Management of Tubal Prolapse
Authors: Lo Keith W. K. , Law L.W. , Yip S.K.
Published: June 2007

Fallopian tube prolapse is an unusual complication after hysterectomy. Different surgical options have been proposed, including abdominal, vaginal, and combined laparoscopic approaches, with partial or complete salpingectomy. This article presents experience in the management of 7 cases of fallopian tube prolapse with different surgical approaches according to the characteristics of the case. Additionally, 6 cases were reported in the English literature between 1960 and 2006 that required a second procedure after vaginal partial salpingectomy, and the causes of failure were reviewed. It is suggested that the choice between abdominal, vaginal, and combined laparoscopic approach with partial or complete salpingectomy in the management of prolapsed tubes must be decided individually, according to the patient's characteristics and the presenting symptoms. Laparoscopic surgery has a role in cases with dense intraperitoneal adhesions. It safely enables the mobilization of the prolapsed tube, allowing complete removal of the structure and resolution of symptoms.
Auto Identification Technology and Its Impact on Patient Safety in the Operating Room of the Future
Authors: Egan Marie T. , Sandberg Warren S.
Published: June 2007

Automatic identification technologies, such as bar coding and radio frequency identification, are ubiquitous in everyday life but virtually nonexistent in the operating room. User expectations, based on everyday experience with automatic identification technologies, have generated much anticipation that these systems will improve readiness, workflow, and safety in the operating room, with minimal training requirements. We report, in narrative form, a multi-year experience with various automatic identification technologies in the Operating Room of the Future Project at Massachusetts General Hospital. In each case, the additional human labor required to make these `labor-saving' technologies function in the medical environment has proved to be their undoing. We conclude that while automatic identification technologies show promise, significant barriers to realizing their potential still exist. Nevertheless, overcoming these obstacles is necessary if the vision of an operating room of the future in which all processes are monitored, controlled, and optimized is to be achieved.
Anatomy of a Malpractice Lawsuit
Authors: Prevatt Haley A. , Sturgill T. Cornelius , Austin J. Brent , Seif Elizabeth R. , Schwartz Richard W.
Published: June 2007

Given the prevalence of medical malpractice lawsuits, physicians are often thrust into the legal world without the education of a juris doctor. The risk of facing suit varies among specialties, but there is no guarantee any physician will proceed through his or her career without being a defendant in a lawsuit. Every physician stands a significant chance of being sued. Although a lawsuit is an exhausting and intimidating situation in and of itself, the ramifications of a plaintiff's verdict could have chilling effects on the physician's life, both professionally and personally. Therefore, it is imperative that every physician have an understanding of the legal process of which he or she may become involved. This article provides a practical guide for the physician, including the fundamental procedures of a medical malpractice lawsuit, the behavior that will be expected or required of the defendant physician, and the effect of disobeying the required procedures.