bluuebunny/crossref_metadata_2025 huggingface dataset:
81-Fluorodeoxyglucose Positron Emission Tomography as a Novel Imaging Tool for the Diagnosis of Aortoenteric Fistula and Aortic Graft Infection
Authors: Krupnick Alexander S. , Lombardi Joseph V. , Engels Friederike H. , Kreisel Daniel , Zhuang Hongming , Alavi Abass , Carpenter Jeffrey P.
Published: March 2006

The diagnosis of aortic graft infection and aortoenteric fistula can be difficult to establish using conventional radiographic imaging modalities. Positron emission tomography (PET) imaging with 18-fluorodeoxyglucose (FDG) can rapidly provide anatomically clear images and define areas of inflammation with increased glucose metabolism. In this report the authors present a case of aortoenteric fistula diagnosed by FDG-PET. Early diagnosis led to rapid surgical intervention with graft removal and extraanatomic bypass. These encouraging results warrant larger controlled studies to evaluate the utility of FDG-PET in the diagnosis of prosthetic aortic graft infection.
Treatment of a Celiac Artery Aneurysm with Endovascular Stent Grafting
Authors: Atkins B. Zane , Ryan J. Mark , Gray John L.
Published: March 2006

As a result of more sophisticated and more commonly performed investigative procedures, aneurysms of the visceral abdominal vasculature, including celiac artery aneurysms, are increasingly recognized. Traditional therapy for visceral artery aneurysms has been limited to open aneurysmectomy or aneurysmorrhaphy to prevent catastrophic aneurysmal rupture. However, these procedures are associated with significant postoperative morbidity and mortality despite technical successes. High complication rates are likely related to poor preoperative conditions among the patient population typically presenting with these visceral artery aneurysms. This report introduces an alternative therapy for visceral artery aneurysms and highlights the potential for catheter-based interventions. This case report depicts a 61-yearold morbidly obese woman diagnosed with a 10-centimeter celiac artery aneurysm during investigation of upper abdominal pain. Given the patient's poor medical condition, punctuated by hemodynamic instability, open operation was avoided, and percutaneous embolization was not feasible owing to a large aneurysm neck. Therefore, inflow to the celiac artery aneurysm was excluded by placing a modular stent graft component within the abdominal aorta at the celiac artery orifice. During the intervening 12 months since stent graft deployment, the aneurysm sac diameter has steadily decreased, as determined by serial computed tomography scans. This report underscores the potential for catheter-based techniques to offer new therapeutic options for patients with visceral artery aneurysms. Careful individualization is required given the highly variable size, location, and character of such lesions.
Cerebral Oximetry Monitoring During Carotid Endarterectomy: Effect of Carotid Clamping and Shunting
Authors: Cuadra Salvador A. , Zwerling Jonathan S. , Feuerman Martin , Gasparis Antonios P. , Hines George L.
Published: March 2006

Cerebral oximetry is a simple method of measuring regional cerebral oxygen saturation (rSO2). One promising application is its use during carotid endarterectomy (CEA) to help minimize the risk of perioperative stroke. The authors used the INVOS-4100 cerebral oximeter at several steps during CEA to measure the effect of carotid clamping and shunting on rSO2. The authors prospectively evaluated 42 consecutive CEAs in 40 patients. All had CEA under general anesthesia with the routine use of a Javid shunt. The INVOS-4100 oximeter was used to measure rSO2 before clamping (t1), after clamping but before shunting (t2), 5 minutes after shunt insertion (t3), and after patch closure with reestablished flow (t4). The Wilcoxon signed-rank and rank-sum tests were used for analysis. Clamping of the internal carotid artery (t1 vs t2) resulted in a drop of ipsilateral rSO2 by –12.3% (p<0.001). Shunt insertion (t2 vs t3) increased rSO2 by 10.9% (p< 0.001). Contralateral rSO2 for the same time periods was insignificant. Patients with preoperative neurologic symptoms had a greater decrease in rSO2 after clamping (–18.4%) compared with a decrease of –10.4% in asymptomatic patients (p=0.037). Cerebral oximetry monitoring is simple and inexpensive. The study showed statistically significant changes in rSO2 as a result of clamping and shunting of the carotid artery. Symptomatic patients had a greater drop in rSO2.
Lesser Saphenous Vein Thrombophlebitis: Its Natural History and Implications for Management
Authors: Ascher Enrico , Hanson Judith N. , Salles-Cunha Sergio , Hingorani Anil
Published: March 2006

Little attention has been given to superficial thrombophlebitis and particularly to lesser saphenous vein thrombophlebitis (LSVT) by vascular surgeons. A prospective nonrandomized study was conducted to assess LSVT's potential association with deep venous thrombosis (DVT) as well as its natural history. Between January 1994 and December 1995, the authors reviewed 33 cases of LSVT detected by duplex scanning in 32 patients at their institution's vascular laboratory. Combined LSVT/DVT was treated with heparin and warfarin. LSVT alone or LSVT plus greater saphenous vein thrombophlebitis (GSVT) were treated with local warm compresses and nonsteroidal antiinflammatory drugs. Follow-up scans were obtained in 23 of the 32 patients and ranged from 2 weeks to 18 months after diagnosis of LSVT. Thirty-one patients had unilateral LSVT and 1 patient had bilateral LSVT. Isolated LSVT was found in 9 patients (28%), LSVT combined with DVT occurred in 21 patients (65.6%), and 2 patients had LSVT/GSVT. LSVT was contiguous with DVT in 15 patients, and in 5 patients it was noncontiguous. Within 3 months, 9 of 16 patients (56%) with LSVT/DVT had complete or partial resolution of their LSVT, and 1 (14%) of the 7 patients with LSVT and LSVT/GSVT had improved. Within 18 months, 13 of 16 patients (81%) with LSVT/DVT had complete resolution of their thrombus while only 3 of 7 patients (43%) with LSVT and LSVT/GSVT had resolved. These data show that LSVT is more often associated with DVT (65.6%) than previously believed. While most LSVT will improve in 18 months, those associated with DVT will resolve sooner. Whether anticoagulation accounted for this difference remains to be proven.
Surgical Correction of Pseudoaneurysm of the Extracranial Carotid Artery: The Usefulness of Retrograde Cerebral Perfusion
Authors: Yamashita T. , Higami T. , Shida T.
Published: March 2006

Although a pseudoaneurysm of the common carotid artery is not encountered frequently, its surgical treatment is technically challenging. A case is reported of a large pseudoaneurysm of the right common carotid artery in a 45-year-old woman, presenting with respiratory distress, following a wound infection 3 months after tracheoplasty. Instead of a vascular shunt, deep hypothermic circulatory arrest with retrograde cerebral perfusion was used for protection of the brain against hypoxia during the arterial reconstruction. The pseudoaneurysm was easily corrected with an autologous saphenous vein, without any hazardous dissection through the dense fibrosis around the fragile pseudoaneurysm, under circulatory arrest.
Vascular Smooth Muscle Cell Migration: Current Research and Clinical Implications
Authors: Willis A. I. , Pierre-Paul D. , Sumpio B. E. , Gahtan V.
Published: March 2006

Atherosclerosis and intimal hyperplasia are major causes of morbidity and mortality. These processes develop secondary to endothelial injury due to multiple stimuli, including smoking, diabetes mellitus, hypertension, and hyperlipidemia. Once this injury occurs, an essential element in the development of both these processes is vascular smooth muscle cell (VSMC) migration. Understanding the mechanisms involved in VSMC migration and ultimately the development of strategies by which this process can be inhibited, has been a major focus of research. The authors present a review of the extracellular proteins (growth factors, extracellular matrix components, and cell surface receptors) and intracellular signaling pathways involved in VSMC migration, as well as potential therapeutic approaches to inhibit this process.
Associations Between Renovascular Disease and Prevalent Cardiovascular Disease in the Elderly: A Population-Based Study
Authors: Edwards Matthew S. , Hansen Kimberley J. , Craven Timothy E. , Bleyer Anthony J. , Burke Gregory L. , Levy Pavel J. , Dean Richard H.
Published: March 2006

Atherosclerotic renovascular disease (RVD) is a suspected contributor to the morbidity and mortality of cardiovascular disease (CVD) through its potential effects on blood pressure and excretory renal function as well as through its associations with other forms of CVD. However, population-based data regarding the associations between the presence of RVD and prevalent CVD are lacking. The Cardiovascular Health Study (CHS) is a prospective, multicenter cohort study of CVD among elderly Americans. As part of an ancillary study, participants in the Forsyth County, North Carolina, cohort of the CHS were invited to undergo renal duplex sonography (RDS) to establish the presence or absence of RVD (defined as any focal peak systolic velocity =1.8 m/second or the absence of a Doppler-shifted signal from an imaged artery). Demographic, risk factor, and prevalent CVD data were obtained from the CHS coordinating center and matched with ancillary study participants. Eight hundred thirty-four CHS participants (including 525 women [63%], 309 men [37%], 194 African-Americans [23%], and 635 Caucasians [76%]) with a mean age of 77.2 ±4.9 years underwent RDS examination. RVD was present in 57 participants (6.8%). Overall, clinical and/or subclinical manifestations of CVD were present in 603 participants (72.3%) at the time of RDS. Participants with RVD demonstrated a significantly greater prevalence of angina (p=0.002), previous myocardial infarction (p< 0.001), = 25% diameter-reducing internal carotid artery stenosis (p= 0.010), increased carotid intimal medial thickness (p= 0.003), and major electrocardiographic abnormalities (p= 0.013). Following adjustment for demographics and cardiovascular risk factors, the presence of RVD demonstrated a significant and independent association with prevalent coronary artery disease but not with prevalent cerebrovascular or lower extremity vascular disease. These results suggest important population-based associations between RVD and both clinical and subclinical manifestations of CVD, especially coronary artery disease.
A Comparison of AneuRx Aortic Cuff and Zenith Distal Flare Exclusion of Common Iliac Artery Ectasia for Endovascular Aneurysm Repair
Authors: Hakaim Albert G. , Lau L. Louis , Neuhauser Beate , Klocker Josef , Oldenburg W. Andrew , McKinney J. Mark , Paz-Fumigalli Ricardo , Stockland Andrew
Published: March 2006

Stent-grafts are ideally terminated within the common iliac artery (CIA). However, CIA ectasia may require hypogastric artery occlusion, with stent-graft extension to the external iliac artery. Alternatively, the diameter of the distal stent-graft may be increased, or flared, to allow exclusion of the abdominal aortic aneurysm. This report details the authors’ experience with this technique. Forty-one patients received bifurcated stent-grafts (BSG): 20 received an AneuRx device, and 21 received a Zenith device. CIA ectasia (diameter 15–25 mm) was treated with a distal flare of 2–4 mm greater than the CIA diameter. Patients were followed up with computed tomography scan at 1, 6, and 12 months. Statistical analysis was performed using ANOVA within groups and unpaired two-tailed t test between groups. A p value of <0.05 was considered significant. Eight of 20 patients (40%) (11 CIA) received an AneuRx device and 13/21 (62%) (17 CIA) received a Zenith device, with a distal flare. Values are (n) mean (mm) ± SE. There were no deaths, endoleaks, migrations, or conversions to open repair. Follow-up mean was 24.7 and 20.6 (range 15–28) months for AneuRx and Zenith groups, respectively. In comparing initial and 12-month CIA diameters, AneuRx grafts 20 ±0.8 vs 21.5 ±1.0 were not significantly different, p= 0.2, nor was the same comparison for Zenith, 17 ±0.5 vs 19.1 ±0.4, significant, p= 0.57. At a mean follow-up of 12 months, distal flare of iliac limbs with either AneuRx or Zenith devices affords a seal for CIA ectasia and/or aneurysms complicating EVAR.
Endovascular Rescue of a Maldeployed Aortic Stent-Graft Causing Renal Artery Occlusion: Technical Considerations
Authors: Lin Peter H. , Bush Ruth L. , Lumsden Alan B.
Published: March 2006

The technical success of an endovascular abdominal aortic aneurysm repair depends on the endograft exclusion of the aneurysm along with preservation of flow to major aortic branches, such as the renal or hypogastric artery. A proximally malpositioned aortic endograft may result in inadvertent renal artery occlusion, which may lead to renal infarction with irreversible loss of the renal function. In this report, the authors describe an endovascular rescue technique to salvage a proximally maldeployed aortic endograft that inadvertently covered the renal artery orifice. Physicians performing endovascular aneurysm procedures should be aware of such a salvage maneuver in the event an aortic endograft is proximally maldeployed and occludes the renal artery orifice.
Management of Infected Aortic Prosthetic Grafts
Authors: Swain Timothy W. , Calligaro Keith D. , Dougherty Matthew D.
Published: March 2006

The management of infected prosthetic grafts is one of the most challenging problems facing vascular surgeons. High mortality and morbidity rates with traditional treatment have led many surgeons to consider different and novel strategies. Diagnosis is usually straightforward, but occasionally is unclear even after extensive clinical and radiologic investigations. Although routine total graft excision for all infected aortic grafts is still favored by some vascular surgeons, most favor only partial graft excision if only the distal limb of the graft is involved. Placement of in situ autologous vein or cryopreserved grafts have gained popularity, and investigations are continuing regarding the use of in situ antibiotic and silver-coated prosthetic grafts. In this article the authors review the incidence and etiology of aortic graft infections, methods to prevent these complications, the diagnosis of infected aortic grafts, and lastly the management of these complicated cases, including total graft excision and partial and complete graft preservation.
Robot-Assisted Laparoscopic Aortic Reconstruction for Occlusive Disease
Authors: Killewich Lois A. , Cindrick-Pounds Lori L. , Gomez Guillermo
Published: March 2006

Aortobifemoral bypass is the standard method for revascularization of aortoiliac occlusive disease but is associated with significant morbidity and mortality. Laparoscopic aortic reconstruction eliminates the large incision but is limited by the cumbersome nature of laparoscopic instrumentation. A robotic system (da Vinci Computer-Enhanced Robotic Surgical System, Intuitive Surgical, Mountain View, CA) has been developed that allows the surgeon to suture in the same manner as in open procedures. The authors report the first case of an aortic reconstruction for occlusive disease performed using the da Vinci system. A 53-year-old woman presented with gangrene of the left great toe. Angiography revealed distal aortic occlusive disease and occlusion of the common iliac arteries bilaterally. Dissection of the aorta was performed by a transabdominal-retroperitoneal approach modified from Dion (J Vasc Surg 26:128–132, 1997). With use of laparoscopic techniques, the abdominal contents were retracted to the patient's right side while the kidney and ureter remained in the retroperitoneum. The aorta was isolated from the bifurcation proximally to the left renal vein. The patient was anticoagulated, and the aorta was clamped below the left renal artery and proximal to the bifurcation. The da Vinci robotic system was placed on the patient's right side, and an extruded polytetrafluoroethylene (ePTFE) graft was passed into the retroperitoneum. While seated at a computer console viewing the operative field on a screen, the surgeon used robotic instruments to fashion an arteriotomy and complete an end-to-side aortic anastomosis using ePTFE suture. The left groin was opened and the aortic graft passed down to the groin. The reconstruction was completed by performing a left-to-right femoro-femoral bypass in standard, open fashion. The procedure was completed in 8 hours with an aortic clamp time of 65 minutes and a 500 cc blood loss. The patient was extubated in the operating room, ate a regular diet on postoperative day 2, and was discharged on postoperative day 4 without complications. Return to normal activities occurred 2.5 weeks postoperatively. The da Vinci robotic system facilitated creation of the aortic anastomosis and shortened aortic clamp time over that achieved with laparoscopic techniques. Robot-assisted laparoscopic aortofemoral bypass should decrease the morbidity and mortality of aortic reconstruction, while providing a durable solution to aortoiliac occlusive disease.
Superior Mesenteric Artery Angioplasty and Stenting via a Retrograde Approach in a Patient with Bowel Ischemia
Authors: Milner Ross , Woo Edward Y. , Carpenter Jeffrey P.
Published: March 2006

Acute mesenteric ischemia continues to be a highly morbid diagnosis with a high mortality rate. Percutaneous management of mesenteric ischemia is being more widely applied. Its utility is limited, though, for patients who present with an acute abdomen from ischemic bowel. The authors report a novel combination of open and endovascular techniques via a retrograde superior mesenteric artery (SMA) approach to treat acute mesenteric ischemia in the setting of an acute abdomen.
Tuberculous Aneurysm of the Supraceliac Aorta
Authors: Forbes Thomas L. , Harris Jeremy R. , Nie Robert G. , Lawlor D. Kirk
Published: March 2006

Significant vascular complications are rare following systemic infections with Mycobacterium tuberculosis (TB). This report describes a 33-year-old man who presented with a short history of abdominal discomfort and febrile episodes with no prior history of infection with TB. Ultrasound, CT scan, and aortography confirmed the presence of a pseudoaneurysm originating from the posterior aspect of the supraceliac aorta at the level of the diaphragm. Via a full thoracoabdominal approach, periaortic inflammatory tissue and the aortic wall itself were debrided, and repair of the pseudoaneurysm was achieved with a synthetic patch. Mycobacterium tuberculosis was isolated from the aortic wall, and anti-TB medications were instituted. Postoperatively the patient did well and was discharged after 14 days. As illustrated by this case, tuberculous mycotic aneurysms of the aorta are optimally treated with a combination of medical and surgical therapy, and early diagnosis is essential to ensure survival.
Hypertension and the Vascular Patient
Authors: Samson Russell H.
Published: March 2006

Hypertension is intricately entwined in vascular pathology and morbidity and uncontrolled blood pressure is a leading cause of cardiovascular mortality. Unfortunately, many patients will present to the vascular surgeon with uncontrolled blood pressure elevation and yet, although vascular surgeons have been involved in treating the renovascular etiology, they seldom become actively involved in the medical management of hypertension. However, positive reinforcement by the vascular surgeon about the benefits of blood pressure control may significantly impact the patient's willingness to comply with medications. Some of these medications may also have secondary benefits such as reducing the incidence of diabetes. Accordingly modern vascular surgeons, who want to do more for their patients, need to have a basic understanding of hypertension and its treatment. This manuscript provides an overview of the modern definitions and treatment methods for primary hypertension that should provide the vascular surgeon with sufficient information to play an active role in the management of this co-morbid condition.
Gastrointestinal Complications Following Infrarenal Endovascular Aneurysm Repair
Authors: Malinzak Lauren E. , Long Graham W. , Bove Paul G. , Brown O. William , Romano William , Shanley Charles J. , Zelenock Gerald B. , Bendick Phillip J.
Published: March 2006

Gastrointestinal complications are known to occur after open elective aortic aneurysm repair. This leads to increased morbidity, mortality, length of stay, and hospital costs. The authors hypothesize a change in the character and/or frequency of early postoperative gastrointestinal complications after endovascular aneurysm repair as compared to open abdominal aortic repair. This is a retrospective cohort study in which the medical records of 153 consecutive patients who underwent endovascular infrarenal aneurysm repair from November 1998 to August 2001 were reviewed for gastrointestinal complications. Of these 153 patients, 9 (5.9%) had postoperative gastrointestinal complications. Three patients (1.9%) underwent exploratory laparotomy for small bowel obstruction. One patient had had a right hemicolectomy for cancer 2 years before stent graft placement. This patient needed a partial small bowel resection. One patient had had a right hemicolectomy 4 months before stent graft placement; he had lysis of adhesions with no bowel resection. A third patient underwent operative repair of an incarcerated inguinal hernia. Six patients (3.9%) had paralytic ileus that was treated by nasogastric tube or observation resulting in an extended hospital length of stay. All cases of ileus resolved without any operative intervention. No patients in this series developed any intestinal ischemia, pancreatitis, cholecystitis, or gastrointestinal bleeding. After endovascular aneurysm repair, gastrointestinal complications such as ileus and postoperative small bowel obstruction are seen with a similar frequency as after open aortic repair. This occurs despite the absence of a laparotomy with mesenteric dissection and evisceration. In this series, these complications are associated with longer hospital length of stay but no increased mortality rate. No instances of colonic ischemia, pancreatitis, cholecystitis, or gastrointestinal bleeding were seen in this series.
Morbidity and Mortality Associated with Renal Insufficiency and Endovascular Repair of Abdominal Aortic Aneurysms: A 5-Year Experience
Authors: Vasquez Jay , Rahmani Ohmid , Lorenzo A. Cecilia , Wolpert Lorraine , Podolski Joseph , Gruenbaum Shaun , Gallagher James J. , Allmendinger Phillip , Hallisey Michael J. , Lowe Robert , Windels Mary , Drezner A. David
Published: March 2006

To evaluate the outcome of patients with renal insufficiency undergoing endovascular repair of abdominal aortic aneurysm (AAA), data were prospectively collected between 1998 and 2003 on patients undergoing elective repair of their AAA with a stent graft. The patients were divided into 2 groups: those with serum creatinine (Crs) concentrations <1.2 (Group A) and those with Crs = 1.2 mg/dL not requiring hemodialysis (Group B). The outcomes of the procedure for these 2 groups were compared. Different variables that existed between the 2 groups and contributed to mortality included estimated blood loss (EBL), volume of contrast used in the operating room, incidence of diabetes (DM), tobacco use, and history of myocardial infarction (MI). In total, 213 patients underwent elective repair of their AAA with use of a stent graft: 61% who had a Crs <1.2 mg/dL (Group A) and 39% who had a Crs =1.2 mg/dL not requiring dialysis (Group B). Among 129 patients with normal renal function there was an 18.6% complication rate and 1.6% mortality rate. Of 83 patients with renal insufficiency not on hemodialysis 30.1% (Fisher's Exact Test = 0.076) had 1 or more complications and there was a 6% (Fisher's Exact Test = 0.166) mortality rate. One patient in Group A (0.8%) progressed to hemodialysis and 5 (6%) patients in Group B progressed to end-stage renal disease requiring hemodialysis (p=0.068). A statistically significant higher proportion of the patients in Group B had a history of MI (p<0.001). There was no difference in the amount of EBL between the 2 groups, but a significantly lower amount of contrast (p<0.05) was used in patients with renal insufficiency.
Abdominal Aortic Aneurysms Following Orthotopic Heart Transplantation
Authors: Fazel Shafie , Lawlor D. Kirk , Forbes Thomas L.
Published: March 2006

The purpose of these authors' study was to analyze their center's experience with orthotopic heart transplantation (OHT) and abdominal aortic aneurysms (AAA) with particular attention to corticosteroid dosing, hemodynamic parameters, and aneurysm growth rate. A retrospective review of all patients (453) who underwent OHT at their university-affiliated medical center over an 18-year period (1981–1999) was undertaken. Nine (2%) patients who developed AAAs were identified and aneurysm growth was correlated with corticosteroid immunosuppression and hemodynamic parameters. The mean age of OHT patients was 44.5 ±15 years and the majority were males (371 males, 82%). Median follow-up was 5.7 years. Ischemic cardiomyopathy (IC) was the most common indication for transplantation (45.5% of patients). All AAA patients were male (p= 0.157), with a mean age of 58.4 ±4.8 years (p= 0.001), and had undergone OHT for IC (p= 0.001). Mean arterial blood pressure and ejection fraction in the AAA patients had increased from pretransplant values of 107 mm Hg and 14.3 ±5.7% to 142 mm Hg (p=0.017) and 54.1 ±14.1% (p<0.001), respectively, before aneurysm repair. Mean aneurysm diameter at the time of repair was 6.0 ±0.8 cm, and the average growth rate was 1.2 ±0.4 cm/year in the 4 patients in whom it could be measured. Aneurysm repair was performed urgently in 2 patients and electively in 7 patients with 1 early postoperative death (11%). The extent of corticosteroid immunosuppression, corticosteroid pulses, and total corticosteroid dosing did not correlate with the rate of aneurysm growth. Improved hemodynamics and progressive posttransplant hypertension may contribute to aneurysm formation and growth in this group of patients.
Axillary Artery Injury from Humeral Neck Fracture: A Rare But Disabling Traumatic Event
Authors: Yagubyan Marineh , Panneton Jean M.
Published: March 2006

Axillary artery injury from blunt trauma to the shoulder is uncommon. Fracture of the neck of the humerus is a rare cause of injury to the axillary artery. Four cases of axillary artery thrombosis from humeral neck fracture are reported. Each of the first 2 patients presented with a pulseless and acutely ischemic limb after a trivial fall. A repair of the axillary artery with saphenous vein interposition graft was performed in the first patient. The extremity was salvaged, but a residual radial and ulnar neurologic deficit persisted. The second patient presented with a pulseless insensate upper extremity accompanied by motor loss. He underwent primary axillary artery repair. Still early in his postoperative course, he has had global brachial plexopathy and is undergoing intensive physical therapy. The third patient had a delayed presentation of brachial plexopathy and sympathetic reflex dystrophy. Arterial reconstruction was not required owing to excellent collateralization. The fourth patient presented with a cool pulseless extremity. His recovery is nearly complete after bypass of the axillary artery with a reversed saphenous vein graft. In addition, a review of the literature revealed 24 cases of axillary artery injury associated with humeral neck fracture. The mean age was 66.6 years. The most common mechanism of injury was a fall (79%). Thirteen patients (46%) presented with a neurologic deficit. Acute ischemia was present in 68%. Physical examination predicted the arterial injury in all but 1 patient. The injured axillary artery was repaired in 26 cases. Revascularization by an interposition graft was the most common procedure. All grafts and reanastomoses were patent and led to limb salvage. Of 9 primary repairs, 3 amputations were performed. Although limb salvage rate was 89%, a good functional outcome was obtained in only half of the patients. A high index of suspicion is required for early diagnosis of axillary artery injury. Despite excellent results of vascular reconstruction, the outcome remains determined by the excessive neurologic morbidity. Recognition of the associated brachial plexus injury is essential to improve the functional outcome of this unusual arterial injury.
Carotid Body Tumor A Case Report
Authors: Ling Felix J. , Weinrach David M. , Eskandari Mark K.
Published: March 2006

Carotid body tumors are rare neoplasms, which typically present as a slow growing, painless neck mass found along the anterior border of the sternocleidomastoid muscle. These tumors are generally benign but possess aggressive local growth potential. Therefore, definitive treatment requires surgical resection. The authors describe a case of a patient with a carotid body tumor and review the most recent literature on this unusual topic.
Simultaneous Bilateral Iliac Artery-to-Ureter Fistulae
Authors: Uzieblo Matthew R. , Rubin Brian G.
Published: March 2006

Formation of an artery-to-ureter fistula (AUF) is a rare event caused by pelvic surgery or ureteral instrumentation. This presentation details the unique occurrence and treatment of simultaneous bilateral iliac artery-to-ureter fistulae. A 55-year-old man developed significant arterial hemorrhage during ureteral stent removal initially from the right and, subsequently, from the left side. Following expedient ureteral balloon tamponade, endovascular management via femoral approach with vein-covered stents was successful for each fistula without adverse long-term effects. Endoluminal therapy using autologous tissue-covered stents represents a simple, yet durable, treatment option in these challenging cases.
Endoluminal Repair of Ruptured Abdominal Aortic Aneurysms Under Local Anesthesia: Initial Experience
Authors: Rubin Brian G. , Sanchez Luis A. , Choi Eric T. , Sicard Gregorio A.
Published: March 2006

Open surgical repair is the standard treatment for a ruptured infrarenal abdominal aortic aneurysm (rAAA). This approach is associated with mortality rates of up to 70%, with significant surgery-related morbidity among survivors. In selected patients, endoluminal repair (ER) of an rAAA under local anesthesia may allow emergent aneurysm repair with reduced perioperative stress, ideally resulting in improved outcomes. The authors report their initial experience using a commercially available bifurcated endoluminal stent-graft to treat patients with rAAA under local anesthesia. Five of 8 patients (63%) with rAAA in a 1-year interval (June 2000–May 2001) were treated with ER. Criteria for ER were the following: (1) suitable aortic anatomy based on preoperative computed tomography (CT) imaging and (2) a hemodynamic state not requiring immediate aortic control. Mean size of ER rAAAs was 8 cm. Four of 5 patients underwent ER under local anesthesia. All 5 ER patients survived the initial surgery, and 4 patients survived to discharge. The expired patient was a Jehovah’s Witness who had a successful ER but was profoundly anemic postoperatively and refused transfusion. On postoperative CT imaging, no endoleaks were noted and no AAA enlargement had occurred. In a selected but significant subset of rAAA patients, emergent repair using a commercially available bifurcated endograft under local anesthesia is feasible, and clinical outcomes are acceptable. These promising initial results suggest that a further evaluation of the role of endoluminal repair in the treatment of ruptured infrarenal AAAs is warranted.
In-Vitro Evaluation of a New Inferior Vena Cava Filter—The Stent-Filter
Authors: de Godoy Josè Maria Pereira , Braile Domingo Marcolino
Published: March 2006

Inferior vena cava filters are indicated for the prevention of pulmonary embolism when anticoagulation using heparin has failed or is contraindicated. The aim of this study was to assess in an in-vitro setting the efficiency of a new inferior vena cava filter to intercept emboli. The new filter, stent-filter, was inserted into a pulsating flow circuit. Then thrombi were produced by introducing sheep's blood into silicon tubes with 3 mm diameter. A combination of 9% saline solution with 40% glycerol was used as the isosmotic fluid in the circuit. A total of 150 thrombi were introduced into the circuit in 3 stages of 50 events each. The flow rate in each of the 3 stages was altered; initially a rate of 1.0 liter per minute was chosen, and after this, it was increased to 1.5 liters and finally 2.0 liters per minute. The percentage of interceptions was used for statistical analysis. In the in-vitro experiment, the filter captured 94%, 90%, and 92% of the thrombi at flow rates of 1.0, 1.5, and 2.0 liters per second, respectively. In conclusion the new filter was effective in the interception of the thrombi when it was evaluated in in-vitro conditions.
Hand-Assisted Laparoscopic Aorto-Aortic Bypass: Initial Experience in a Porcine Model
Authors: Elkouri Stephane , Gloviczki Peter , Prieto Mikel , Park Woosup M. , Noel Audra A.
Published: March 2006

Videoscopic surgical techniques have been developed to reduce morbidity of open aortic reconstructions. The advantage of hand-assisted laparoscopic surgery (HALS) technique is the introduction of the surgeon's hand into the peritoneal cavity. The aims of this study were to assess the feasibility and to examine the learning curve, limitations, and pitfalls of the HALS technique to perform aortic reconstruction in a porcine model for training purposes. HALS aorto-aortic 8 mm polytetrafluoroethylene (PTFE) interposition grafts were placed in 12 pigs. Proficiency was judged by measuring operative time points, satisfactory completion of the operation, and the need to convert to open procedure. The strength of the relationship between order number in which a procedure was performed and the various surgical time point measures was described with the Spearman rank correlation. HALS aortic grafting was successful in the last 8 pigs. The first 2 pigs required conversion to open repair, and the graft of the third and fourth animals occluded early. Median operative time was 115 minutes (range: 75 to 205), median intestinal retraction time was 28 minutes (range: 10 to 40), median aortoiliac dissection time was 30 minutes (range: 20 to 60), and median aortic cross-clamp time was 48 minutes (range: 35 to 82). The Spearman rank correlations and p values between the order of the procedure and the intestinal retraction time, aortoiliac dissection time, clamping time, and total operative time were –0.62 (0.06), –0.47 (0.17), –0.69 (0.03), and –0.83 (0.03), respectively. HALS facilitates intestinal retraction and completion of laparoscopic aortoiliac dissection. It offers adequate exposure in pigs for aortic grafting and allows open sutured aortic anastomosis. The learning curve for HALS aortic surgery in a porcine model is short and within reach of surgeons with standard laparoscopic surgery skills, since no laparoscopic suturing is required. Training on this porcine model may be an efficient and safe way to introduce surgeons to HALS for aortoiliac reconstruction.
Outcome from Traumatic Injury of the Portal and Superior Mesenteric Veins
Authors: Coimbra Raul , Filho Alvaro Razuk , Nesser Rogerio A. , Rasslan Samir
Published: March 2006

Traumatic injuries to the portal vein (PV) and superior mesenteric vein (SMV) are rare and carry a high mortality rate, and the best approach and method of repair is still subject to debate. The objective of the present study was to analyze risk factors for mortality in portal and superior mesenteric venous injuries. A retrospective analysis of 18 patients during a 5-year period was performed. Mechanism of injury, shock upon admission, Revised Trauma Score (RTS), Injury Severity Score (ISS), intraoperative fluid requirements, classification of venous injury severity, and associated injuries were analyzed as potential predictors of outcome. All patients were male, 9 were victims of gunshot wounds, and 11 were in shock at the time of admission. Eight patients sustained PV, and 12 sustained SMV injuries. The great majority of patients had more than 1 associated injury and 61% had an associated vascular injury. Mortality rate correlated with injury severity. Overall mortality rate was 72%. Nonsurvivors had higher ISS than survivors (24 ±0.4 and 20 ±1.7, respectively; p= 0.006). Uncontrollable intraoperative hemorrhage was the cause of death in 5 of 13 patients (38.4%). Six patients died during the postoperative period from complications of prolonged shock and multiple organ failure, and 2 died of sepsis. The physiologic status upon admission, the number of associated injuries, and the severity of the vascular injury are the most important factors related to mortality in PV and SMV injuries.
Mega-Aneurysmal Degeneration of a Saphenous Vein Graft Following Infrainguinal Bypass
Authors: Corriere Matthew A. , Passman Marc A. , Guzman Raul J. , Dattilo Jeffery B. , Naslund Thomas C.
Published: March 2006

True aneurysm formation in infrainguinal autologous vein grafts is rare. The authors report a case of a patient presenting with extensive aneurysmal degeneration of a femoropopliteal bypass vein graft 13 years after the original operation and 8 years after graft revision and thrombolysis for acute occlusion. Over a 2-year period, the vein graft aneurysm expanded from 2.7 to 4.5 cm maximal diameter. He underwent exclusion and partial resection of the vein graft aneurysm with placement of a new femoropopliteal bypass using reversed saphenous vein from the contralateral leg. Histopathologic examination of the aneurysm revealed intimal fibrosis, medial degeneration, and inflammation. This case and review of the literature suggests that true infrainguinal vein graft aneurysms occur infrequently and massive aneurysm degeneration is even more uncommon. Because of the rarity of true infrainguinal vein graft aneurysms, their etiology remains unclear.
Failed Angioplasty of a Popliteal Artery Stenosis Secondary to Cystic Adventitial Disease
Authors: Khoury Michael
Published: March 2006

The purpose of this case review is to describe treatment options for arterial occlusive disease secondary to a popliteal cyst. The occurrence of this disease is significantly less than atherosclerosis as the cause of claudication. The clinical presentation, natural history, and treatment options are reviewed.
Fate of Great Saphenous Vein After Radio-Frequency Ablation: Detailed Ultrasound Imaging
Authors: Salles-Cunha Sergio X. , Rajasinghe Hiranya , Dosick Steven M. , Gale Steven S. , Seiwert Andrew , Jones Linda , Beebe Hugh G. , Comerota Anthony J.
Published: March 2006

Radio-frequency ablation (RFA) of the great saphenous vein (GSV) is an endovascular alternative to stripping. To determine long-term effectiveness, the fate of GSV treated for valvular insufficiency with RFA was evaluated in detail with ultrasound imaging (US). One hundred lower extremities were examined with high-resolution color flow US, an average of 8 months after RFA treatment of an incompetent GSV. For every cm of the RFA-treated segment, the US observation was classified as follows: absent, occluded, or recanalized. Lengths of vein segments in each class were added and percentages of absent, occluded, or recanalized segments were calculated. Five groups were identified. Group I (n=15): segment of treated GSV was absent. Group II (n=4): segment of treated GSV was visualized and occluded (these vein segments had no flow and were shrunk and “fibrotic” or thrombosed without clear evidence of significant shrinkage). Group III (n=1): segment of treated GSV was recanalized. Group IV (n= 27): segment of treated GSV was obstructed (absent or occluded). Group V (n=53): segment of treated GSV was partially recanalized, on average being 53% absent, 32% occluded, and 15% recanalized. Maximum recanalization was 50% of treated segment. RFA was successful in obliterating all of the GSV treated segment in 46% of veins (groups I, 15%, plus II, 4%, plus IV, 27%) and obliterated more than half of the treated vein segment in 53% of the cases (group V). A dynamic process of recanalization and thrombosis warrants further evaluation to determine if and how a collateral network may develop.
Homocysteine, a Risk Factor for Carotid Atherosclerosis, Is Not a Risk Factor for Early Recurrent Carotid Stenosis Following Carotid Endarterectomy
Authors: Samson Russell H. , Yungst Zachary , Showalter David P.
Published: March 2006

Homocysteine has been proposed as a risk factor for atherosclerotic disease and recurrent coronary stenosis due to neointimal hyperplasia following angioplasty. In order to evaluate homocysteine's role in human carotid neointimal hyperplasia, we have compared homocysteine levels in patients who have not developed restenosis with those who have within 2 years of carotid endarterectomy (CEA). One hundred and fifty-four patients were divided into 3 groups based on duplex scans performed 2 years after CEA. Group I (88) were patients in whom all scans showed no evidence of restenosis. Group II (35) patients exhibited some restenosis, but this did not exceed 49% diameter reduction based on our duplex criteria. Group III (31) patients developed a restenosis of >50% within 2 years. One hundred and thirteen Dacron patches (73 Group I [83%], 22 Group II [63%], and 18 Group III [58%]) were used according to surgeon preference but did not affect the statistical relevance of homocysteine evaluation. The groups were otherwise identical in terms of age, sex, smoking history, and cholesterol levels. All patients were receiving antiplatelet medication postoperatively, and none had consumed added pharmacologic folate. The average homocysteine value for the entire study group was elevated at 12.5 µmol/L. The homocysteine values for the 3 groups were not statistically different (p>1): (I, 12.5; II, 12.2; and III, 12.9 µmol/L). Elevated homocysteine levels (>10 µmol/L) appear to be associated with carotid atherosclerosis, but at levels < 30 µmol/L do not appear to play a role in restenosis following CEA.
Endovascular Management of Central Venous Stenoses in the Hemodialysis Patient: Results of Percutaneous Therapy
Authors: Surowiec Scott M. , Fegley Allison J. , Tanski William J. , Sivamurthy Nayan , Illig Karl A. , Lee David E. , Waldman David L. , Green Richard M. , Davies Mark G.
Published: March 2006

The purpose of this study was to determine the functional results of transvenous angioplasty for the treatment of central venous stenoses in patients with failing upper extremity arteriovenous access. Two hundred consecutive patients presented with threatened arteriovenous access from January 1999 through July 2002. Angiographic evidence of central venous stenosis was present in 35 patients (18%) (superior vena cava 5, brachiocephalic veins 14, and subclavian veins 18). Follow-up averaged 873 days from the date of initial intervention. The initial technical success rate was 89%. Primary patency for each intervention was 85% at 30 days, 55% at 6 months, 43% at 1 year, and 0% at 2 years. Assisted primary patency rates were 88% at 30 days, 80% at 1 year, and 64% at 2 years. Freedom from central venous dialysis catheter placement was 82% at 30 days, 63% at 3 months, 51% at 1 year, 37% at 2 years, and 25% at 3 years. Freedom from a dialysis catheter was superior in those patients with autogenous arteriovenous fistulas. Transvenous angioplasty appears to be beneficial for hemodialysis patients with central venous stenoses, and it helps preserve functional access in the affected extremity, particularly in patients with autogenous fistulas.
Proliferative Capacity of Venous Ulcer Wound Fibroblasts in the Presence of Platelet-Derived Growth Factor
Authors: Vasquez Ricardo , Marien Brian J. , Gram Christopher , Goodwin David G. , Menzoian James O. , Raffetto Joseph D.
Published: March 2006

Growth factors have been demonstrated to increase the proliferation of wound fibroblasts. Platelet-derived growth factor (PDGF) is a potent cell mitogen. However, the role of PDGF in chronic venous ulcers is inconclusive. This study investigated whether PDGF stimulates venous ulcer fibroblasts to proliferate. Fibroblasts (fb) were isolated from 8 venous ulcers wounds (w-fb) and normal skin (n-fb) of the ipsilateral thigh via punch biopsies. Fibroblasts were plated at 1,500 cells/dish in Dulbecco's Modified Eagle Medium + 10% calf serum (CM) and treated with/without PDGF-ab (10 ng/mL) for 15 days. Growth rates were calculated. Western blotting and immunocytochemistry staining determined basal levels for PDGF-a and-b receptors, respectively. Growth rates were significantly lower in w-fb than in n-fb (1,579 ±546 vs 13,782 ±5,882 cells/day, p = 0.019). PDGF-ab treatment caused n-fb to increase their proliferative capacity relative to complete media (20,393 ±6,572 vs 13,782 ±5,882 cells/day, p= 0.005). However, PDGF-ab had no significant effect on w-fb proliferation over CM (1,030 ±264 and 1,579 ±546 cells/day, p=0.15). In the presence of PDGF-ab, w-fb had a significantly attenuated growth rate over n-fb (1,030 ±264 vs 20,393 ±6,572 cells/day, p=0.019). Western blot and immunocytochemistry analysis revealed diminished basal levels of PDGF-a and-b receptors, respectively, in ulcer fibroblasts. Venous ulcer fibroblasts had decreased proliferation. PDGF-ab had no effect on the growth rate of venous ulcer fibroblasts. In venous ulcers, decreased basal levels of fibroblast PDGF-a and-b receptors may explain reduced proliferation. Further clinical studies are needed to elucidate the role growth factors may play in venous ulcers.