bluuebunny/crossref_metadata_2025 huggingface dataset:
Popliteal Artery Occlusion Secondary to Cystic Adventitial Disease: A Rare Etiology of Lower Extremity Ischemia in a Marathon Runner
Authors: Wolk Seth W. , Lampman Richard M. , Misare Bruce D. , Erlandson Errol E. , Whitehouse Walter M.
Published: June 2007

A 44-year-old marathon runner was referred with a 2-week history of the sudden onset of severe left calf claudication. Angiography showed a 3- to 4-centimeter focal nearocclusion of the left midpopliteal artery. Magnetic resonance imaging showed a cystic structure in the left popliteal artery wall. A left popliteal artery exploration revealed popliteal artery occlusion secondary to cystic adventitial disease. Excision of the cyst resulted in restoration of pedal pulses. This rare disease of uncertain etiology should be suspected in young adults presenting with ischemia. Various noninvasive techniques in conjunction with arteriography result in reliably diagnosing cystic adventitial disease. Excision of the cyst usually provides adequate treatment. Resection of the diseased arterial segment with autogenous bypass may be required.
Renal Artery Stenosis Complicating Polycystic Kidney Disease
Authors: Ihnat Daniel M. , Berman Scott S. , Marek John M. , James Sam , Mills Joseph L.
Published: June 2007

Polycystic kidney disease (PCKD) commonly causes hypertension and leads to chronic renal insufficiency. Correctable renal artery stensosis can coexist with PCKD and contribute to both hypertension and progressive decline in renal function but is often overlooked. To illustrate the diagnostic and therapeutic implications of this unusual combination of pathology, the authors present the case of a 59-year-old woman with severe PCKD who presented with recurrent bouts of malignant hypertension, flash pulmonary edema, and accelerated decline of renal function over a 3-month period. In the course of normal findings from cardiac catheterization, aortography demonstrated severe right renal artery stenosis. Captopril renal scintigraphy confirmed the viability of both kidneys and the physiologic significance of the right renal artery stenosis even in the setting of chronic renal insufficiency. Right renal artery revascularization was achieved by using a hepatorenal bypass with reversed greater saphenous vein. The patient had an immediate improvement in renal function and blood pressure control as evidenced by a decline in creatinine and a reduction of medication requirements, respectively. In 15 months' follow-up, this therapeutic result has been maintained and she has not experienced any further bouts of pulmonary edema. This unusual case emphasizes the need to pursue correctable pathology of the renal arteries despite the presence of chronic renal insufficiency unrelated to vascular occlusive disease in order to preserve renal function and stabilize hypertension. Patients with multiple etiologies of renal dysfunction represent diagnostic and therapeutic challenges that are not insurmountable but require diligence in pursuing repairable lesions when their clinical course deviates from that expected from the uncorrectable pathology.
Development of Postthrombotic Syndrome After Acute Unilateral Iliofemoral Thrombosis: Clinical Dynamics and Hemodynamic Changes
Authors: Lurie Fedor , Makarova Nina Petrovna , Hmelniker Semen Markovich
Published: June 2007

Four hundred thirty-six patients with acute unilateral thrombosis in the iliofemoral venous segment were followed up to establish the relationship between changes in the veins and clinical dynamics of postthrombotic syndrome. Physical examination and ascending phlebography were performed at the time of admission and 1 month later. Follow-up visits (physical examination and venous ultrasound study) were performed annually during 10 years. Cumulative rate of class 0 extremities decreased from 89% at the first year to 59% after 10 years. Progressive dynamics was seen in 41% of cases; 17% of these extremities had occlusions, and 83% had proximal reflux; 59% of the extremities demonstrated stable-type clinical dynamics. Occlusions were found in 41% and reflux in 59% of these cases. Recanalization and valvular incompetence at the site of the initial deep vein thrombosis are more likely to lead to progressive type of the disease. Valvular incompetence in the distal veins does not correlate with severity of the disease.
New Duplex Criteria for Threshold Stenoses Used in the Asymptomatic Carotid Atherosclerosis Study
Authors: Aburahma Ali F. , Pollack James A. , Robinson Patrick A. , Richmond Bryan K. , Alberts Stephanie , Young Lori
Published: June 2007

The current Doppler frequency spectral criteria used to classify internal carotid artery (ICA) stenosis into 1%-15%, 16%-49%, 50%-79%, 80%-99% stenoses may not be applied to stenoses of >60%, which is used by the Asymptomatic Carotid Atherosclerosis Study (ACAS) to justify carotid endarterectomy. Therefore, this study was done to determine the best duplex frequency criteria to identify? 60% stenosis.

Three hundred fifty-six carotid arteries were studied in patients who had both carotid color duplex and arteriography. Correlation of duplex and arteriography was done in blind fashion. Four different duplex criteria were analyzed: (1) the peak systolic frequency (PSF) of the ICA, (2) end-diastolic frequency (EDF) of the ICA, (3) PSF times EDF of the ICA, and (4) the ratio of the PSF of the ICA to the PSF of the common carotid artery.

Four optimum criteria were noted: (1) PSF of the ICA of >5 kHz with 98% sensitivity, 75% specificity, 83% positive predictive value (PPV), 96% negative predictive value (NPV), and 87% overall accuracy; (2) EDF of ICA of?2.5 kHz with 82% sensitivity, 96% specificity, 96% PPV, 81% NPV, and 89% overall accuracy; (3) PSF x EDF of the ICA of 15 kHz with 84% sensitivity, 96% specificity, 97% PPV, 83% NPV, and 89% overall accuracy; (4) the ratio of the PSF of the ICA/PSF of the common carotid artery of?2.7 with 85% sensitivity, 86% specificity, 89% PPV, 82% NPV, and 86% overall accuracy. There was no statistically significant difference among these four parameters. A PSF of the ICA of?6.5 kHz had a PPV of 95% and an overall accuracy of 87%, which can be used for clinicians who perform carotid endarterectomy without a preoperative arteriogram.

A PSF of the ICA of?5.0 kHz, an EDF of the ICA of >2.5 kHz, and a ratio of the PSF of the ICA/PSF of the common carotid artery of?2.7 have the best overall accuracy in identifying?60% carotid stenosis. A PSF of the ICA of?6.5 kHz had a PPV of 95%, which can be used for clinicians who perform a carotid endarterectomy without preoperative arteriography.
Primary Vascular Access for Chronic Hemodialysis: A Comparison of Arteriovenous Fistulae with PTFE Grafts
Authors: Turnbull Robert G. , Lewis Greg M. , Karim Mohamud A. , Taylor David C. , Salvian Anthony J. , Chambers G. Keith , Strandberg Sandra , Hsiang York N.
Published: June 2007

The purpose of this study was to compare patency rates of arteriovenous fistula (AVF) and polytetrafluoroethylene grafts (PTFE) for hemodialysis and the complications associated with each. All new permanent vascular access procedures for hemodialysis performed at one institution between January 1989 and December 1993 were reviewed with follow-up to December 1995. Patient demographics, secondary operations, complications, and length of stay were compared between the two types of access strategies. Seventy-seven PTFE and 89 AVF were performed in 166 patients. Age, sex, and frequency of diabetes were similar between the two groups. Primary patency rate at 36 months for AVF was 53%, compared with 16% for PTFE (p<0.01). Secondary patency rate at 36 months was 70% for AVF and 50% for PTFE (p<0.02). PTFE was associated with more hospital days per patient per year (26 vs 6.9), more infections (12 vs one during secondary patency interval), and a higher initial failure rate (19 vs eight) as compared with AVE. Patient survival rate at 4 years was higher for those with AVF (65% vs 52%). We conclude that an AVF as the primary access procedure for new renal dialysis patients is preferable to PTFE whenever possible.
Anomalous Origin of the Inferior Mesenteric Artery from the Right Common Iliac Artery
Authors: Sher Scott , Mukerjee Adhip , Skillman John J. , Kim Ducksoo
Published: June 2007

The authors discuss a 69-year-old man who presented for preoperativc assessment of an abdominal aortic aneurysm. An abdominal aortogram demonstrated a 3.5-cm infrarenal fusiform abdominal aortic aneurysm with anomalous origin of the inferior mesenteric artery off the fight common iliac artery. A literature review indicates that this specific type of anomalous origin has not been reported.
Prospective Trial of Low-Molecular-Weight Heparin Versus Unfractionated Heparin in Moderately Injured Patients
Authors: Cohn Stephen M. , Moller Beth A. , Feinstein Ara J. , Burns Gerard A. , Ginzburg Enrique , Hammers, Lynn W.
Published: June 2007

The safety and efficacy of low-molecular-weight heparin (LMWH) was compared with those of conventional unfractionated heparin (UH) in preventing deep venous thrombosis (DVT) in trauma patients with moderate injuries in a prospective double-blind, randomized trial at a level I trauma center. After informed consent, trauma patients meeting inclusion criteria (age > 45 or requiring > 2 days' bedrest) received LMWH or UH twice daily in a double-blind, randomized trial. Patients were excluded if they had severe brain injuries or bleeding injuries not accessible to hemostatic control (eg, severe visceral contusions). Clinical examination and weekly venous duplex ultrasound evaluations were performed to identify DVT. One hundred four patients were randomized, 53 to receive UH and 51 to receive LMWH; 32 UH and 34 LMWH patients completed the study (mean injury severity score [ISS] = 12). There were no significant differences between groups with regard to age, sex, ISS, mechanism of injury, or doses of drug given. Outcome measures such as length of stay in the surgical intensive care unit and hospital days were similar. There were two patients with DVT in the UH group, none in the LMWH group (p = 0.493 by Fisher's exact test). This was not a statistically significant difference. There were five major bleeding complications in each group. The incidence of DVT in injured patients receiving prophylaxis appears to be quite low if individuals such as those with severe head injury or visceral contusions are excluded. LMWH is not clearly beneficial when compared with UH in this moderate-risk trauma population.
Fatal Esophago-aortal Fistulous Bleeding Following Feeding Tube “Rub-Raw” Lesion on an Anomalous Right Subclavian Artery
Authors: Lieske Klaus , Schulz Friedrich
Published: June 2007

This article provides a case report on a 45-year-old man with severe thoracic trauma after a traffic accident. Twenty-five days later, nontreatable esophago-aortal fistulous bleeding by a focal decubital fricton (“rub-raw”) lesion occurred, caused by feeding tube treatment after 14 days. An abnormal right subclavian artery was responsible for the complication. Arterial bleedings after 3 weeks of feeding tube treatment is pathognomonic for patients with an anomalous right subclavian artery. The bleeding can only be controlled for a short time by a Sengstaken-Blakemore tube. Pathogenesis, avoidance, and medical/legal aspects are discussed.
Propagation of Tibial Vein Thrombus in Patients Systemically Anticoagulated or Receiving Antiplatelet Therapy
Authors: Hirko Mark K. , Kasirajan Karthikeshwar , Turner John J. , Rubin Jeffrey R.
Published: June 2007

The objective of this study was to evaluate the incidence of infrapopliteal deep vein thrombus propagation in postoperative orthopedic patients. This was a retrospective study of patients undergoing noninvasive venous testing to rule out phlebothrombosis. Venous duplex scans and Doppler studies to record thrombus location were performed at the end of treatment, which lasted from 2 weeks to 1 year (mean: 6 months). The study included 28 postoperative orthopedic patients; 21 men and seven women with a mean age of 52 years (range: 14 to 92 years). Patients received three different treatment regimens. Group I received heparin and warfarin (n = 17; 60.7%); Group II received warfarin (n = seven; 25%); Group III received aspirin (n = four; 14.3%).

Isolated tibial vein thrombosis was found in 10 patients, (36%) and 18 patients (64%) exhibited multiple tibial veins involvement. Follow-up venous duplex and Doppler studies revealed a single episode (5.9%) of thrombus propagation from an isolated tibial vein to multiple tibial veins in Group I. There were four Group II patients with isolated and three with multiple tibial vein thrombi. Clot propagation occurred in three (42.9%) instances; two originated from isolated tibial vein thromboses and all extended into the popliteal and femoral veins. No propagation occurred in the limbs of Group III. Statistical analysis of treatment protocols revealed a significant difference in outcome (clot propagation) based on management. Warfarin therapy alone (Group II) resulted in a significantly increased risk for clot propagation (p < 0.04), whereas there was no difference in the incidence of clot propagation based on the number of involved tibial veins (p < 0.12).

Warfarin treatment alone was not found to be an effective method of preventing thrombus propagation in postoperative orthopedic patients with tibial vein thrombosis. The treatments using heparin/warfarin or aspirin alone were found to be equally effective for preventing this complication.
Pulmonary Atelectasis from a Posttraumatic Pseudoaneurysm of the Thoracic Aorta
Authors: Sakakibara Yuzuru , Gomi Seigo , Mihara Wahei , Jikuya Tomoaki , Onizuka Masataka , Mitsui Toshio
Published: June 2007

Atelectasis of the left lung due to tracheobronchial compression is a rare complication of posttraumatic pseudoaneurysms of the thoracic aorta. We describe the case of a 57-year-old man with a chronic posttraumatic pseudoaneurysm of the thoracic aorta with acute progressive dyspnea and complete atelectasis of the left lung. The patient underwent aneurysmectomy with an interposition of a Dacron graft using both median sternotomy and lateral thoracotomy. A diagnosis of posttraumatic aneurysm should be considered in patients with both acute left pulmonary atelectasis and a history of major chest trauma. A review of the literature regarding this clinical condition is also discussed.
Recurrent Hypertension After Migration of a Renal Artery Stent
Authors: Mallon Lawrence I. , Endean Eric D.
Published: June 2007

The use of angioplasty and intravascular stenting has been applied to a variety of arterial lesions including atherosclerotic renal artery stenosis (RAS). The authors describe a patient with renovascular hypertension who underwent angioplasty and subsequent right renal artery stent placement for proximal RAS. Recurrent hypertension 4 months after the procedure led to arteriography that documented distal migration of the stent into the renal hilum and restenosis of the proximal vessel. Operative stent removal and revascularization was required to correct the problem.
Evaluation of Collagen-Coated Woven Velour Polyester and Expanded Polytetrafluoroethylene Grafts During Early Lytic Therapy in an Animal Model
Authors: Rummel Mark C. , Ikeda Yasuharu , Ierardi Ralph P. , Grotkowski Caroline , Khoury Paul A. , Matsumoto Teruo , Kerstein Morris D.
Published: June 2007

This study was conducted to determine the relative safety of early urokinase lytic therapy in expanded polytetrafluoroethylene (ePTFE) and collagen-impregnated woven velour polyester (CIWVP) grafts. Twelve mixed-breed dogs were selected and implanted with thin-wall ePTFE and CIWVP grafts in the external iliac artery position. At 3, 4, 6, and 12 weeks, three dogs were selected for lytic therapy. After exposure of the previously implanted grafts, lytic therapy was initiated with a bolus of 100,000 units of urokinase, followed by 4000 units/minute for two hours, then reduced to 2000 units/minute for a subsequent two hours. Hypertension was induced by methoxamine hydrochloride at the conclusion of lytic therapy. Direct observation and angiography were used to assess for bleeding and contrast extravasation hourly until completion. The animals were then sacrificed and the grafts excised and microscopically examined for incorporation, pseudointimal deposition, and accelerated collagen layer degradation. None of the implanted grafts showed evidence of transluminal or suture line bleeding or extravasation of contrast material. Hypertension did not change these results. Analysis demonstrated a thicker pseudointimal, giant cell infiltration, extensive incorporation, and occasional fragmentation of the CIWVP graft when compared with the ePTFE grafts.

The systemic fibrinolytic state did not cause collagen layer degradation. No evidence existed of suture line or transluminal bleeding from CIWVP or ePTFE grafts during urokinase lytic therapy conducted at 3, 4, 6, or 12 weeks in a canine model. Microscopic examination demonstrated a difference in pseudointima, graft incorporation, and inflammatory response when the two conduits were compared. Urokinase did not appear to accelerate collagen layer breakdown.
Pathogenesis of Homeostatic Disorders Following Surgery for Aortic Arch and Thoracoabdominal Aneurysm During Profound Hypothermia and Circulatory Arrest
Authors: Dementieva Inna I. , Roitman Eugene V. , Belov Jury V.
Published: June 2007

This study examined dynamics for blood gas, parameters of acid-base equilibration, water-and-electrolyte balance, glucose, hemocoagulation, and blood rheology at surgery for aortic arch and thoracoabdominal aneurysm during profound hypothermia and circulatory arrest.

Frequency for development of homeostatic disorders was related to the temperature (r = -0.71; P < 0.05), and to the duration of circulatory arrest period (r - 0.77; P <0.05). Also, it established the dependencies from duration of cooling time (r = 0.59; P < 0.05), and from warming time when temperature has attained more than 28±C (r = -0.65; P < 0.05). It was shown that long hypoxia and reperfusion disorder stipulated the decrease of utilization for main metabolites, the increase of oxygen failure in tissues, the increase of the permeability of cells membranes, and the increase of blood viscosity and disseminated intravascular coagulation (DIC), which are the main reasons for homeostasis disorders during the same surgery. In the period from the start to the end of the second extracorporeal circulation, there exists the heaviest probability for hypoxic failure in tissues and thrombohemorrhagic complications. For aortic aneurysm surgery with circulatory arrest and profound hypothermia, the adequacy for the correction of homeostatic disorders is expressed only in complex therapy of hypoxical and thrombohemorrhagic complications that enable one to execute simultaneous reduction of the tissue's oxygen deficit and failures of hemocoagulation and blood rheology.
Reversible Left Renal Vein Obstruction Caused by an Abdominal Aortic Aneurysm
Authors: Butler Daniel A. , Dorner Douglas B. , Stubbs David H.
Published: June 2007

The authors document a unique cause for left renal vein hypertension and hematuria in a 66-year-old woman presenting with abdominal pain, pulsatile mass, and hematuria. A computer tomographic scan of the abdomen revealed, in association with a 5.3-cm fusiform abdominal aortic aneurysm, a compressed left renal vein as well as dilatation of the left gonadal vein and the pelvic venous plexus. Arteriography confirmed functional occlusion of the left renal vein by the juxtarenal enlargement of the abdominal aortic aneurysm. This created centrifugal flow to the inferior vena cava through the left gonadal vein, the pelvic venous plexus, and the hypogastric veins. The patient underwent abdominal aortic aneurysm repair with complete recovery. A postoperative abdominal computer tomographic scan confirmed restored patency of the left renal vein and normalization of centripetal venous flow on the left side. While a number of mechanisms of renal vein obstruction have been reported, collateralization and hematuria secondary to stretching and compression of the left renal vein by an aortic aneurysm have not previously been described. Although left renal vein hypertension and hematuria are rarely associated with an aortic aneurysm, it should be recognized that a juxtarenal aneurysm may cause this syndrome.
Intravascular Fasciitis Clinically Mimicking an Axillary Peripheral Nerve Sheath Tumor
Authors: Sheikh Salwa , Henderson Fraser , Gomes Mario N. , Montgomery Elizabeth
Published: June 2007

Intravascular fasciitis is one of the benign myofibroblastic pseudosarcomatous proliferations, among which nodular fasciitis is the prototype. These lesions are important as they may mimic a variety of sarcomas and other lesions on both clinical and pathologic grounds. This report describes the features of one such lesion that arose within the brachial artery and invested nerve trunks of the brachial plexus. The patient presented with symptoms of arm fatigue and hand numbness. There were no neurological or vascular findings on physical examination. The clinicopathologic differential diagnosis is discussed. Also, surgeons are cautioned to involve a vascular etiology in their differential diagnosis and seek the help of a vascular surgeon when the lesion juxtaposes the axillary artery or vein.
Is Clinical Examination an Adequate Predictor of Respiratory Dysfunction After Bilateral Carotid Endarterectomy?
Authors: Ozsvath Kathleen , Darling R. Clement , Kreienberg Paul B. , Paty Philip S. K. , Chang Benjamin B. , Lloyd William E. , Shah Dhiraj M.
Published: June 2007

One of the most feared complications in performing bilateral carotid endarterectomies on patients with bilateral high grade stenosis is vocal cord paralysis with resultant respiratory dysfunction. This has led most surgeons to perform staged carotid endarterectomies separated by 4 to 6 weeks. The purpose of this study is to evaluate respiratory risks postoperatively in patients who have undergone bilateral carotid endarterectomies during the same admission with clinical examination to evaluate vocal cord function. From January 1993 to January 1998, a total of 512 bilateral carotid endarterectomies were performed in 256 patients during a single admission. Operative indications included asymptomatic carotid stenosis 334 (65%), transient ischemic attacks (TIAs) 71 (14%), amaurosis fugax 34 (6.6%), and 33 (6.5%) previous stroke. Data were collected prospectively and included patient demographics, indications for surgery, and operative complications. Patients were evaluated following initial carotid endarterectomy by physical examination. Those patients with hoarseness were then examined by direct laryngoscopy to evaluate the presence of vocal cord paralysis. If no contraindications were found on physical examination, patients underwent contralateral carotid endarterectomy within 48 hours of the initial procedure. Operative mortality rate was 1.6% (four patients). There was one permanent neurologic deficit and one cranial nerve injury after second carotid endarterectomy (0.3%). Six patients had contralateral surgery delayed secondary to hoarseness (2.3%), four with vocal cord dysfunction, and 10 (3.9%) had transient neurologic deficits that improved by the time of their discharge from the hospital. No patient in this study period had respiratory collapse or was compromised after bilateral carotid endarterectomy during the same admission. Bilateral carotid endarterectomy can be performed safely with acceptable results during one hospital admission. There does not appear to be an increased incidence of upper respiratory dysfunction after bilateral carotid endarterectomy that is performed during the same hospital admission. Clinical examination appears to be adequate in predicting respiratory and vocal cord dysfunction postoperatively.
Management of the Femoral Artery After Transluminal Repair of Abdominal Aortic Aneurysms
Authors: Smith Bruce M. , Gray Richard J. , Laird John R. , Kohlman-Trigoboff Debra , Deforty Debra , Stanford Jon L.
Published: June 2007

Catheter-based treatment of abdominal aortic aneurysms (AAA), in which an endograft is placed into the aneurysmal aorta through one or more femoral arteriotomies, is gaining acceptance rapidly. This technique has the advantage of avoiding the morbidity and prolonged recovery of conventional repair, but subjects the femoral arteries to significant surgical and catheter trauma that may compromise the outcome of the procedure. We review our experience with management of the femoral arteries following endovascular aneurysmal repair. Thirty patients undergoing endovascular repair of their AAA with the modular bifurcated Aneu Rxg (Medtronic AneuRx, Sunnyvale, CA) endovascular prosthesis had their femoral arteries exposed through bilateral groin incisions to permit insertion of the device. Proximal and distal control of the femoral arteries was achieved, and guidewire passage and sheath access obtained using standard angiographic techniques. The endovascular components, ensheathed in a 22F (primary device) or 16F (secondary device) catheter were positioned and deployed from bilateral common femoral arteriotomies. The 22F insertion system was used in the right femoral artery in 18 and left femoral artery in 12 of the 30 procedures. Repair of the femoral arteriotomies was accomplished following standard vascular surgical principles, and femoral and pedal pulses and ankle-brachial indices (ABI) recorded postoperatively. All 30 patients were men (mean age: 73 ±8 years), and all had evidence of extra-aortic atherosclerosis. The endovascular prosthesis was deployed successfully in 29 of the 30 patients. One limb was lost in the postoperative period secondary to severe pre-existing arterial occlusive disease in the popliteal and tibial arteries, and one patient thrombosed an associated popliteal aneurysm requiring emergent repair on the first postoperative day. No patient experienced a permanent change in the pulse examination or reduction in the ABI. Thirteen of the 60 (22%) arteries required repair other than simple closure of the arteriotomy to restore arterial continuity. Complex repair was more common in the initial 15 (10 of 30 arteries, 33%) patients than in the latter 15 (3 of 30 arteries, 10%, p=0.01) and on the side of the larger, primary device (8 of 30 arteries, p=NS). Technically successful repair was achieved in all vessels.

Although associated with shorter recovery times and brief hospital stays, endovascular repair of AAA, not unexpectedly, may require complex management of the sites of access for the prosthesis. The need for complex repair appears to diminish both with increasing experience with the device and smaller device size. Simplifying management of the femoral artery requires significant advances in the design of the currently available devices.
Superior Mesenteric Artery Dissection: Rationale for a Conservative Approach in Selected Patients
Authors: Wain Reese A. , Kwei Stephanie , Lyon Ross T. , Berdejo George L. , Stampfer Morris , Veith Frank J.
Published: June 2007

The superior mesenteric artery (SMA) is an uncommon location for spontaneous peripheral arterial dissections. In the past, most symptomatic SMA dissections were treated surgically. However, the authors recently treated a healthy 40-year-old man who experienced a symptomatic SMA dissection with anticoagulation therapy alone. The patient had bilateral internal carotid artery (ICA) dissections in the past that were also managed in a conservative fashion. To their knowledge, this is the first patient reported in the literature with both ICA and SMA dissections. In addition, he is one of only a few patients with an SMA dissection who was successfully treated without surgical intervention. From our experience with this patient and a review of the literature, we believe that a trial of anticoagulation therapy is warranted in all patients with uncomplicated, symptomatic SMA dissections.
Comparison of Costs and Healing Rates of Two Forms of Compression in Treating Venous Ulcers
Authors: DePalma Ralph G. , Kowallek Donna , Spence Richard K. , Caprini Joseph A. , Nehler Mark R. , Jensen Jeffrey , Goldman Mitchel P. , Bundens Warner P.
Published: June 2007

The objective of this study was to compare healing rates and costs of treating venous ulcers with traditional Unna boots (UB) or a CircAid Thera-Boot (TB). A multicenter, prospective, randomized parallel-group study was performed in three university medical center vascular surgery clinics and three private medical offices. Patients presented with unilateral venous leg ulcers 5 cm or less in diameter. Patients with severe arterial, metabolic, or neuropathic diseases, and those who would not be expected to heal with conservative treatment, were excluded. Conservative treatment of the leg ulcer consisted of a nonadherent topical dressing and compression with either a traditional Unna's boot or a Thera-Boot. The main outcome measures were the following: time to healing, rate of area decrease, rate of percent area decrease, linear healing rate, costs of labor, materials, and overhead. Of 38 enrolled patients seven were withdrawn (five UB, two TB). Three patients were still in treatment when the study was stopped. Eleven UB patients and 17 TB patients completed the study. Healing rates were for UB and TB patients (mean (Meeting ± sd) were, respectively: time to healing (weeks) 9.69 ± 3.28, 7.98 ± 4.41 (p = 0.41), area healing rate (cm2/day) 0.0239 ± 0.0534, 0.0433 ± 0.0910 (p = 0.27),% area healing rate (%/day) 1.0493 ± 1.5583, 2.0357 ± 1.9520 (p = 0.56), and linear healing rate (cm/day), 0.0060 ± 0.0092, 0.0109 ± 0.0125 (p = 0.27). Costs for UB and TB (dollars to completion) were, respectively: clinician labor 331.37 ± 255.75, 201.91 ± 131.17 (p = 0.09), materials 160.86 ± 96.86, 122.79 ±27.59 (p= 0.14), overhead (number of visits) 11.70 ± 6.40, 6.71 ±3.77 (p = 0.02), and total costs 901.73 ± 576.45, 559.41 ±290.75 (p= 0.05).

Treatment of venous ulcers with Circ Aid Thera-Boots is significantly less costly than treatment with traditional Unna's boots. Trends toward faster healing were noted.
Subclavian Steal Syndrome Secondary to Isolated Innominate Artery Stenosis Possibly Due to Fibromuscular Dysplasia
Authors: Hirose Hitoshi , Takagi Masatake , Kugimiya Toshiyasu
Published: June 2007

Subclavian steal syndrome is usually associated with proximal subclavian artery stenosis and is characterized by retrograde perfusion of the vertebral artery to the distal subclavian artery. We encountered an unusual case of transient ischemic attack associated with isolated proximal innominate artery stenosis and angiographic subclavian steal phenomenon. Web-like stenosis found in the innominate artery could represent fibromuscular dysplasia. The patient was treated with an aortoinnominate artery bypass, with successful symptomatic relief.
Acute Aortic Dissection Presenting as Left Upper Limb Ischemia
Authors: Sultan Sherif , O'Donohoe Martin , Deeb Maged El , Din Ahmed Saad El , Mehairy Nabil El
Published: June 2007

Acute upper limb ischemia is most frequently the result of an embolus that originates in the heart. Ascending aortic dissection is a life-threatening vascular emergency that must be treated immediately. Isolated upper limb ischemia secondary to acute aortic dissection has not been previously reported.

Two cases of DeBakey type I aortic dissection presenting as unilateral upper limb ischemia are reported. This presentation may result in delayed diagnosis of aortic dissection and, consequently, in high mortality. The possibility should be borne in mind when dealing with all cases of acute arm ischemia because embarking on a brachial embolectomy which may delay the diagnosis of a more serious and fatal condition. The etiology of this unusual presentation and possible therapeutic interventions are discussed.
Nonadherence to Antiretroviral Therapy Among a Community With Endemic Rates of Injection Drug Use
Authors: Shannon Kate , Kerr Thomas , Lai Calvin , Ishida Tomiye , Wood Evan , Montaner Julio S. G. , Hogg Robert S. , Tyndall Mark W.
Published: June 2007

Highly active antiretroviral therapy (HAART) has resulted in major reductions in HIV-related morbidity and mortality. However, long-term use of HAART is challenging, and substantial numbers of patients discontinue their medications prematurely. The purpose of this analysis is to describe HAART adherence rates among a large urban cohort and examine factors associated with adherence (based on refill compliance). Of the 184 eligible participants, 129 (70%) were less than 95% adherent. Variables independently associated with nonadherence included frequent heroin injection (adjusted odds ratio [AOR] = 2.6, 95% confidence interval [CI], 1.6-4.0), baseline CD4 count less than 200 cells/mm3(AOR = 2.5; 95% CI, 1.9-3.2), and poor treatment by health care professionals (AOR = 1.7; 95% CI, 1.2-3.0). Variables inversely associated with HAART nonadherence included attaining viral load suppression (AOR = 0.3; 95% CI, 0.2-0.5) and methadone maintenance therapy (AOR = 0.5; 95% CI, 0.4-0.9). Innovative strategies that address the social barriers facing marginalized populations are needed to support the long-term continuation of HAART.
Remote Presence Proctoring by Using a Wireless Remote-Control Videoconferencing System
Authors: Smith C. Daniel , Skandalakis John E.
Published: June 2007

Remote presence in an operating room to allow an experienced surgeon to proctor a surgeon has been promised through robotics and telesurgery solutions. Although several such systems have been developed and commercialized, little progress has been made using telesurgery for anything more than live demonstrations of surgery. This pilot project explored the use of a new videoconferencing capability to determine if it offers advantages over existing systems. The video conferencing system used is a PC-based system with a flat screen monitor and an attached camera that is then mounted on a remotely controlled platform. This device is controlled from a remotely placed PC-based videoconferencing system computer outfitted with a joystick. Using the public Internet and a wireless router at the client site, a surgeon at the control station can manipulate the videoconferencing system. Controls include navigating the unit around the room and moving the flat screen/camera portion like a head looking up/down and righttleft. This system (InTouch Medical, Santa Barbara, CA) was used to proctor medical students during an anatomy class cadaver dissection. The ability of the remote surgeon to effectively monitor the students' dissections and direct their activities was assessed subjectively by students and surgeon. This device was very effective at providing a controllable and interactive presence in the anatomy lab. Students felt they were interacting with a person rather than a video screen and quickly forgot that the surgeon was not in the room. The ability to move the device within the environment rather than just observe the environment from multiple fixed camera angles gave the surgeon a similar feel of true presence. A remote-controlled videoconferencing system provides a more real experience for both student and proctor. Future development of such a device could greatly facilitate progress in implementation of remote presence proctoring.
Night Call Does Not Impair Learning of Laparoscopic Skills
Authors: DeMaria Eric J. , McBride Corrigan L. , Broderick Timothy J. , Kaplan Brian J.
Published: June 2007

Investigators have looked at the effect of night call on surgical residents but not at learning of laparoscopic skills. The Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR) tests 6 tasks similar to a laparoscopic cholecystectomy. We hypothesized that night call would impair laparoscopic performance and that skills would not improve but rather deteriorate after night call. Seventeen volunteers were tested before and after night call. Data collected included economy of movement, time, and number of errors for each hand/foot. A paired Student t test was used for statistical analysis. On the first 2 tasks, there was an improvement in all parameters post-call, with significance reached in 5 of 18 parameters (P <.05). In the "running of the bowel," 8 of 9 parameters were significantly improved (P < .05). In the final task, 9 of 11 parameters showed a deterioration post-call, but only economy of movement of the foot was significant (P <.05). Most parameters (16) showed improvement rather than deterioration post-call, which is consistent with learning of laparoscopic skills despite lack of sleep from night call.
Mesh Fixation in Laparoscopic Repair of Ventral Hernia: A New Method
Authors: Kumar S. S.
Published: June 2007

During laparoscopic repair of ventral hernia, optimal fixation of the prosthetic mesh to the abdominal wall includes transfascial fixation with sutures in addition to fixation with a stapling, clipping, or tacking device. With the current methods, intracorporeal passage grasping and retrieval of sutures from the abdominal cavity are technically difficult. The reason for this difficulty is the lack of three-dimensional visual feedback during conventional laparoscopy. An easier method is needed. A new method using T-shaped anchors (T-anchors) is described. A T-anchor is a horizontal bar made of rigid titanium that is attached to a vertical limb made of monofilament suture. T-anchors are deployed in pairs, through a needle, and are tied over a musculofascial bridge to achieve transfascial fixation of the mesh to the abdominal wall. This method eliminates the need for intracorporeal grasping and retrieval of the sutures.
Measuring Quality of Life After Surgery
Authors: Urbach David R.
Published: June 2007

Measures of quality of life are used increasingly to evaluate the outcome of surgical care. Impairment in quality of life is a major reason why patients seek surgical care, and changes in health-related quality of life are how patients assess the effect of treatment. Disease-specific measures focus on a particular health condition and are useful for detecting change resulting from treatment. Generic measures cover a wider spectrum of quality of life, provide a global assessment of a patient's overall health, and allow comparisons with other health conditions. Quality of life is not measured directly but is commonly sampled by using measurement scales in the form of questionnaires. The important properties of quality-of-life measurement scales are reliability, the extent to which a measure provides similar values for individuals with similar underlying quality of life; validity, the extent to which it measures what it purports to measure; responsiveness, the extent to which changes in correlate with true changes in quality of life; and sensitivity, the extent to which a measure can detect meaningful changes in quality of life.
The Scientific Method is Dead-Long Live the (New) Scientific Method
Authors: Satava Richard M.
Published: June 2007

The scientific method has been the mainstay of scientific inquiry and clinical practice for nearly a century. A new methodology has been emerging from the scientific (nonmedical) community: the introduction of modeling and simulation as an integral part of the scientific process. Thus, after the hypothesis is proposed and an experiment is designed, modern scientists perform numerous simulations of the experiment. An iterative optimization of the design of the experiment is performed on the computer and is seen in virtual prototyping and virtual testing and evaluation. After this iterative step, when the best design has been refined, the actual experiment is conducted in the laboratory. The value is that the modeling and simulation step saves time and money for conducting the live experiment. The practice of medicine should look to the tools being used by the rest of the scientific community and consider adopting and adapting those new principles.
Endoluminal Methods for Gastrotomy Closure in Natural Orifice TransEnteric Surgery (NOTES)
Authors: Sclabas Guido M. , Swain Paul , Swanstrom Lee L.
Published: June 2007

Natural orifice transenteric surgery (NOTES) is a new and rapidly evolving concept for intra-abdominal operations that offers the potential for a revolutionary advance in patient care. Conceptually, operations that currently require an open or laparoscopic approach could be performed without incisions in the abdomen, with their concomitant pain and scarring. A recent consensus statement by a joint group of gastrointestinal surgeons and gastroenterologists has identified several technical and technologic hurdles that would need to be overcome before NOTES becomes a clinical reality. One of the most significant requirements identified is the need for a very secure closure of the gastrotomy site that is required for scope passage and specimen removal. Although a rapidly expanding variety of transgastric procedures has been reported, only a few reports address the basic problem of gastrotomy closure. Availability of a safe and simple gastrotomy closure device, however, will be essential for the widespread adoption of the new field of NOTES. Unless new safe and simple devices for endoscopic gastrotomy closure are available and have proven efficacy, NOTES will remain in the hands of a few specialists at centers of excellence because the risk of complications due to insufficient gastrotomy closure will not be acceptable for the surgeon and gastroenterologist in general practice. In this article, we describe three new devices in development or newly on the market that are targeted to advance the safe endoscopic closure of gastrotomy from NOTES.
Endoluminal Instrumentation Is Changing Gastrointestinal Surgery
Authors: Ellsmere James , Jones Daniel , Pleskow Douglas , Chuttani Ram
Published: June 2007

Advances in endoluminal instrumentation and technology are enabling endoscopists to perform increasingly sophisticated procedures. Indications for these procedures are likely to expand as outcomes studies show they are efficacious and cost-effective. This article highlights several recent advances in endoluminal suturing, dissecting, and ligating and discusses the impact of these advances on the practice of gastrointestinal surgery. Endoluminal suturing offers select patients with gastroesophageal reflux disease a safe and effective alternative to laparoscopic surgery. Devices designed for endoluminal hemostasis and endoscopic mucosal resection can be used effectively for a broader range of applications and are already being used to perform transluminal surgery in animal models; human trials are forthcoming. Gastrointestinal surgeons should support efforts to critically evaluate endoluminal techniques because they have an opportunity to improve care. Surgical residents planning careers in gastrointestinal surgery need to understand endoscopic techniques and consider their training opportunities.
The Pretrained Novice: Using Simulation-Based Training to Improve Learning in the Operating Room
Authors: Van Sickle Kent R. , Ritter E. Matt , Smith C. Daniel
Published: June 2007

Enabling trainees to acquire advanced technical skills before they begin the operating room experience benefits both trainee and patient. Whether medical students who had received exclusively simulation-based training could perform laparoscopic suturing and knot-tying as well as senior surgery residents was determined. Simulators were used to train 11 fourth-year medical students with no previous suturing experience to perform intracorporeal suturing and to successfully tie a free-hand intracorporeal knot. Students’ skills were assessed by the performance of the fundal suturing portion of a Nissen fundoplication in a porcine model. Their operative performance was evaluated for time, needle manipulations, and total errors. Results were compared to those of 11 senior-level surgery residents performing the same task. The study concluded that trainees could learn advanced technical skills such as laparoscopic suturing and knot tying by using simulation exclusively. The trainees and senior level surgery residents had a similar number of needle manipulations.
The Future of Teaching Surgical Endoscopy
Authors: Pearl Jonathan P. , Marks Jeffrey M.
Published: June 2007

Gastrointestinal surgery, with its emphasis on endoscopy, has renewed interest in teaching surgical endoscopy. The field is rapidly evolving, with innovative techniques emanating from the laboratory to the operating room and endoscopy suite. To ensure that surgeons spearhead the field of endoscopic surgery, a new strategy for teaching surgical endoscopy to residents and practicing surgeons must be developed.
Simulation for Training With the Autosuture TM Endo StitchTM Device
Authors: Kurenov Sergei N. , Punak Sukitti , Kim Minho , Peters Jörg , Cendan Juan C.
Published: June 2007

The rapid development and deployment of novel laparoscopic instruments present the surgical educator and trainee with a significant challenge. Several useful instruments have been particularly difficult to teach the novice. We have developed a platform that allows the combination of the actual instrument handle with a virtual re-creation of the instrument tip. We chose the AutosutureTM Endo StitchTM device as the prototypical instrument because it satisfies our subjective experience of “useful, but hard to teach.” A software package was developed to support the re-creation of the needle and suture that accompany the device. The apparatus has haptic capabilities and collision detection so that the needle driver is “aware” of suture and instrument contact. The developed virtual environment allows re-creation of the necessary motion to simulate the instrument, the trainee can use the actual instrument handle, and the system can be altered to accommodate other instruments.
Cardiovascular Risk Reduction: We Have the Will, But Do We Have the Way?
Authors: Terre Lisa
Published: June 2007

As Rippe, Angelopoulos, and Zuckley pointed out, coronary heart disease “represents the quintessential lifestyle disease of developed countries,” offering both opportunities and challenges for the routine practice of lifestyle medicine. Although the empirical evidence provides a compelling rationale for the modification of preventable cardiovascular risks, their review prompts discussion of the continuing tendency for practice to lag behind knowledge, the persisting challenges to narrowing this knowledge-practice divide, and the emerging trends that may further advance cardiovascularrisk reduction efforts.
Physical Activity and Fitness in the Prevention of Coronary Heart Disease and Associated Risk Factors
Authors: Zoeller Robert F.
Published: June 2007

Less than half of the adult population in the United States meet the minimum physical activity recommendations of the 1996 surgeon general's report: 30 minutes of moderate-intensity physical activity on most if not all days of the week. There is strong evidence that following these recommendations could potentially reduce the incidence of coronary heart disease and mortality. The benefits of more vigorous exercise are less clear, especially for women. Physical fitness demonstrates an even stronger negative association with coronary heart disease and mortality with a 17% to 20% reduction in mortality for every 1 metabolic equivalent (3.5 mL/kg/min) increase in aerobic power (VO 2max). For prevention or management of diabetes, the American Diabetes Association recommends 150 minutes per week or more of moderate-intensity aerobic exercise and/or 90 minutes per week or more of vigorous aerobic exercise. Weight loss may require 60 to 90 minutes of moderate exercise per day. Regular moderate, but not vigorous, exercise is recommended for the prevention/management of hypertension. Many studies support moderate to high-intensity exercise 3 to 5 times per week for at least 30 minutes per session to manage or improve cholesterol profiles, although changes reported vary and are modest in most cases.