bluuebunny/crossref_metadata_2025 huggingface dataset:
Peripheral Atherosclerotic Disease: Aging and Risk Factors
Authors: Fabris Fabrizio , Zanocchi Mauro , Bo Mario , Poli Leone , Fonte Gianfranco
Published: June 2007

The aim of this study was to assess the prevalence of peripheral atherosclerotic disease (PAD) and its relation to principal cardiovascular risk factors, at different ages, in a sample of the general population. Ultrasonographic methods (continuous wave Doppler and high-resolution B-mode Doppler) were used to evaluate the ankle-to-arm ratio and to investigate the femoral district in 457 free-living subjects (231 men and 226 women, mean age 55.4 ±18.7 years) resident in the metropolitan area of Turin. PAD, detected by ankle-to-arm ratio, was observed in 148 subjects (32.4%). Femoral plaques were found in 180 subjects (39.4%). The overall prevalence of atherosclerosis, number of plaques, and percentage of stenosis were observed to increase with age (P < 0.0001). In the multiple logistic regression model, analysis of subjects under sixty-five years of age showed independent associations between femoral atherosclerosis and age (P < 0.0001), LDL cholesterol (P < 0.01), cigarette smoking (P < 0.05), and years of exposure to smoking (P < 0.05); analysis of subjects over sixty-five years of age showed positive and independent associations only with age (P < 0.001), male gender (P < 0.01), and cigarette smoking (P < 0.05).

The authors conclude that there is a high prevalence of asymptomatic lower limb atherosclerosis in the general population, particularly among the very old. The association between risk factors and femoral atherosclerosis is less pronounced in the elderly than in younger subjects.
Magnetic Resonance Angiography and Duplex Scanning Concordance in Detecting Severe Carotid Stenosis
Authors: Reed James F. , McCullough Sean , Wasser Thomas
Published: June 2007

In this meta-analysis, the authors examine published studies on the consistency (homogeneity) of study outcomes of magnetic resonance angiography (MRA), conventional angiography (XRA), and duplex ultrasound (DU) scanning in assessment of the degree of carotid artery disease.

The sensitivity, specificity, and accuracy of the MRA as a noninvasive diagnostic test are exceptional. Given an adequate two-dimensional time-of-flight (2D-TOF) study, it provides a robust test for the evaluation of carotid stenosis. The authors conclude from this meta-analysis that MRA is at least as accurate as DU in a selected group of patients. The question of superiority for all patients with suspected carotid artery disease is not, however, answered by this meta-analysis. Another question not answered is the question of DU/MRA-XRA concordance/discordance. If DU and MRA were concordant across all, rather than a selected group of patients, would the clinical decision tree be in favor of elimination of XRA? The cost for a DU scan is approximately one third of the cost of an MRA and, from an economic point of view, one could not argue the use of MRA over DU. However, as MRA technology and accuracy improve and when the cost of MRA approaches that of DU, MRA may replace DU as a screening method.

Clearly, a consecutive series of all patients suspected of having carotid artery disease needs to be evaluated by use of the best available diagnostic technologies. A comprehensive protocol would include an evaluation of the sources of difficulties in conducting these tests.
Sutureless Vascular Anastomoses by Polydioxanone Connector
Authors: Erk M. Kâmuran , Başyiğit Ismail , Kolbakir Ferşat , Keçeligil Tahsin , Yilman Mahmut
Published: June 2007

Usually a single end-to-end anastomosis on a middle-size vessel cannot be performed in less than twenty minutes with either separate or continuous suture technique. For easy and quick anastomoses the authors studied 12 dogs with a sutureless concept. With this method proximal and distal ends of a vessel were joined by means of a polydioxanone tube connector. The sutureless procedure took approximately five minutes to complete. Six months after the operation the anastomoses were examined and more than 41% of the vessels were found patent. The authors' opinion is that, if polydioxanone tube is prepared more properly, the rate of patency will be higher than this.
Chylous Ascites Following Repair of Abdominal Aortic Aneurysm with Recurrent Aortocaval Fistula
Authors: Samy A. K. , Duncan J.
Published: June 2007

Few rare complications of the abdominal aortic aneurysm and its management are combined together in a single case in which breathlessness of congestive cardiac failure resulting from an aortocaval fistula was the presenting complaint. Five weeks following a successful repair, the patient developed persistent chylous ascites initially refractory to conservative treatment, shunting, and external drainage. The condition was further complicated by perforated cecum, recurrence of the fistula, and bleeding duodenal ulcer, which were surgically treated by three separate laparotomies. Eventual full recovery lasted for only three and half months, after which the patient died by rupturing his thoracic aneurysm.
An Unusual Obstruction of the Left Renal Vein Caused by “Nutcracker” Phenomenon: Repair by Renocaval Bypass Procedure
Authors: Hiekata Tomizo , Takei Hiroshi , Koyama Teruyuki , Ogawa Noboru , Kimura Kanako
Published: June 2007

Compression of the left renal vein (LRV) between the superior mesenteric artery (SMA) and the aorta has been termed the nutcracker phenomenon. Although often asymptomatic, this phenomenon rarely results in hematuria and flank pain. The mechanisms of the compression found in the surgical cases have included a simple compression by the SMA, the fibrous tissue entrapping the LRV, and dorsal ptosis of the left kidney. Previous surgical approaches have thus included division of the fibrous band, renocaval reimplantation or external stenting procedures, and medial nephropexy. The authors report a case of a twenty-eight-year-old woman who had suffered from massive hematuria with resultant anemia and intractable flank pain caused by nutcracker phenomenon, which had resulted in unusual organic obstruction of the lumen of the LRV by intimal adhesion. Renocaval bypass with a prosthetic graft with supplemental nephropexy and resection of periureteral varices were successfully performed. The pathogenesis of the fibrous band and intimal adhesion could be considered to be the results of reactions to the mechanical stress by the SMA. Dorsal renal ptosis may be an additional contributing factor. Conclusion on the indications for excision of the pelviureteral varices awaits further surgical experiences.
Continuous Intra-arterial Blood Gas Monitoring in Patients Undergoing Suprarenal Aortic Surgery
Authors: Gordon George , Flaherty Paul , Strafford Maureen , Belkin Michael , O'Donnell Thomas F. , Bojar Robert
Published: June 2007

The authors used an on-line, real-time, continuous blood gas monitor in 5 patients undergoing elective suprarenal aortic reconstruction. They retrospectively analyzed data to evaluate its utility in acid-base management and in detection of dynamic changes in oxygenation. Seven sets of data were analyzed since 1 patient underwent two additional periods of aortic crossclamping. A similar group of 7 patients undergoing elective suprarenal aortic surgery without continuous blood gas monitoring was analyzed and served as a control group. There was a highly significant mean decrease in partial pressure of oxygen (P02) of 158 mm Hg (P = 0.0060) with unclamping. In 1 patient the P02 dropped from 218 to 63 mm Hg within sixty seconds of unclamping, and this required immediate reinstitution of two-lung ventilation. Continuous availability of pH permitted accurate therapy with bicarbonate infusion during clamping. As a result there was no significant change in pH between preclamp and immediately after unclamping (P = 0.97). In the control group the pH decreased from a mean of 7.38 to a mean of 7.24 (P = 0.0005) between preclamp and after unclamping.

In summary, dynamic changes in oxygenation and pH are observed during suprarenal aortic surgery. Continuous blood gas monitoring provided data resulting in improved management of acid-base status and early detection of significant decreases in oxygenation.
Exercise-Induced Urinary and Fecal Incontinence: An Exceedingly Unusual Presentation of Aortoiliac Occlusive Disease
Authors: Dardik Alan , Perler Bruce A.
Published: June 2007

Fecal and urinary incontinence is an exceedingly unusual manifestation of aortoiliac occlusive disease, with only 4 previous cases having been reported in the literature. The authors report the case of a sixty-two-year-old woman with a long history of bilateral lower extremity claudication and exercise-induced urinary and fecal incontinence. Angiography demonstrated a complete infrarenal aortic occlusion. Following aortofemoral bypass, peripheral perfusion normalized and the patient experienced complete relief of claudication and incontinence. The authors propose that the patient's incontinence was due to intermittent pelvic ischemia as a consequence of her aortoiliac disease. In contrast to the cauda equina syndrome, a “steal” mechanism is the most likely explanation for the pathophysiology of exercise-induced pelvic ischemia, which may be completely eradicated by aortoiliac revascularization.
Treatment of Unreconstructible Upper Extremity Arterial Occlusive Disease by Spinal Cord Stimulation
Authors: Bartels Claus , Claeys Luc , Ktenidis Kiriakos , Bechtel Matthias , Horsch Svante
Published: June 2007

Spinal cord stimulation (SCS) of peripheral arterial disease (PAD) of the lower limbs has been shown to be effective for pain reduction, limb salvage, and improvement of blood supply; however, treatment of PAD of the upper extremity by SCS has never been performed. Ten patients with unreconstructible severe PAD of the upper extremity were treated by SCS at the authors' institution.

Transcutaneous oxygen tension index (chest TcPo2/hand TcPo2), Doppler wrist pressure index (WPI), capillary microscopy (red blood cell velocity, capillary density), and a patient's pain score graded from 1 to 10 (1 =no pain) were used as follow-up parameters.

Pain reduction after SCS was excellent in all patients. TcPo2 index decreased from 1.95 ± 0.87 prior to implantation to 1.5 ± 1.1 at eighteen months. No significant improvement of capillary microscopy parameters or Doppler WPI could be observed.

SCS effectively reduced pain and provided limb salvage in patients with severe unreconstructible PAD of the upper extremity; however, reduction of pain was not paralleled by improvement of the studied microcirculatory parameters.
Management of the Failed Primary Infrainguinal Reconstruction: Treatment Options and Long-Term Outcome
Authors: Akers Donald L. , Hewitt Robert L.
Published: June 2007

Patients presenting with critical limb ischemia following failed infrainguinal grafts have been reported to have a significant amputation rate and reduced long-term survival. The authors reviewed their three-year experience with 33 patients with failed infrainguinal reconstruction. The median age was 63.1 years of age (range forty-three to eighty-seven years). There were 19 women and 14 men. Risk factors included the following: hypertension 31 (94%), diabetes 21 (64%), and tobacco use 30 (91%). All patients had limbthreatening ischemia,15.had gangrene (45.4%),8.had ulceration (24.2%), and 10 had rest pain 10 (30.3%). There had been 42 previous revascularizations (1.27 per patient, range 1 to 6). The authors performed 45 revascularization operations (1.36 per patient, range 1 to 4). Inflow was as follows: common femoral artery in 29 (64.4%), superficial femoral artery in 9 (20%), profunda femoris in 4 (8.9%), aortobifemoral graft limb in 2 (4.4%), and femoral-femoral bypass graft in 1 (2.2%). Outflow was as follows: posterior tibial artery 12 (26.7%), peroneal artery in 17 (37.8%), anterior tibial artery in 7 (15.6%), popliteal artery in 5 (11.1%), and tibioperoneal trunk in 4 (8.9%). The conduits were as follows: great saphenous vein (GSV) from the opposite lower limb in 8 (17.8%), GSV/lesser saphenous vein (LSV) composites in 8 (17.8%), expanded polytetrafluoroethylene in (ePTFE) 5 (11.1%), LSV composite in 10 (22.2%), ePTFE/GSV composite in 5 (11.1%), cadaveric vein in 2 (4.4%), superficial femoral vein/ePTFE composite in 2 (4.4%), endarterectomized superficial femoral artery/GSV composite in 1 (2.2%), GSV/upper limb vein composite in 1 (2.2%); and upper limb vein in 3 (6.7%). There was one perioperative death (2.2%). Six patients died during the follow-up period (74.1% survival). Limb salvage was obtained in 28 patients (83.1%). Cumulative secondary patency was 73.2% at three years. These results indicate that: (1) aggressive revascularization for failed infrainguinal grafts can result in significant limb salvage, and (2) long-term survival is common in this patient population.
Intrathoracic Bifurcation of the Left Common Carotid Artery with a Symptomatic Internal Carotid Artery Stenosis
Authors: Mohan Chittur R. , Sharp William J. , Hoballah Jamal J. , Schueppert Michael T. , Kresowik Timothy F. , Corson John D.
Published: June 2007

A forty-eight-year-old woman was evaluated for left hemispheric and transient left monocular symptoms referable to the carotid bifurcation. She was found to have an intrathoracic bifurcation of the left common carotid artery. The angiogram showed a 95% stenosis of the proximal left internal carotid artery arising at an intrathoracic location off a short trunk of the left common carotid artery. She had a history of a Blalock-Taussig shunt and a later total correction of Fallot's tetralogy. Operative correction of the carotid lesion consisted of cervical transposition of the left internal carotid artery to the left external carotid artery. Her postoperative course was uneventful, and follow-up for nearly a year continues to demonstrate a widely patent reconstruction with resolution of her symptoms.

The carotid bifurcation may be found at varying locations in the neck; however, a review of the English literature did not disclose any reports of an intrathoracic carotid bifurcation. Given the potential for misdiagnosis, this abnormality should be considered when the bifurcation is not found in its more usual locale on duplex interrogation of this artery.
Nonaneurysmal Aortoarteritis
Authors: Singh Chanderdeep , Barth Werner F. , Ludmer Lynn M. , Simsir Sinan A. , Kohlman-Trigoboff Debra , Jelinek James , Smith Bruce M.
Published: June 2007

Aortoarteritis is an uncommon form of retroperitoneal inflammation, which is not associated with an aortic aneurysm or luminal stenosis. The authors report 3 patients with periaortic inflammation whose presentations were initially suggestive of a symptomatic aortic aneurysm. All 3 patients had pain, an epigastric mass, and weight loss. The correct diagnosis was suggested by imaging techniques and confirmed by computerized (CT) -directed needle biopsy in 2 of the patients. Aortic caliber was not altered significantly in any patient. They were all treated with corticosteroids with prompt relief of symptoms and rapid resolution of the periaortic inflammation as confirmed by CT. There has been no recurrence of symptoms in follow-up. Aortoarteritis appears to be one expression of the spectrum of inflammatory retroperitoneal diseases and is distinct from inflammatory aortic aneurysms and retroperitoneal fibrosis. The authors suggest a logical classification scheme of retroperitoneal inflammation based on the extent of aortic and retroperitoneal involvement. Differentiation between these entities is critical because, in contrast to inflammatory aneurysms and retroperitoneal fibrosis involving the aorta, aortoarteritis can be managed without surgery. Magnetic resonance imaging displays the most detail of the periaortic mass and provides information about intra-aortic flow. Corticosteroids are rapidly effective and are the treatment of choice in aortoarteritis when the diagnosis is established.
Immune Response to Gelatin- and Collagen-Impregnated Aortic Dacron Grafts
Authors: Schmiedt Walther , Neufang Achim , Scholl Edmund , Schmid Franz Xaver , Oelert Hellmut
Published: June 2007

Dacron grafts are very common in vascular surgery. Primarily sealed grafts have been available for ten years. These improve handling and reduce intraoperative blood loss. Despite a widespread use all over the world, it has as yet not been clarified whether coating (sealing) substances might cause an immune response, especially in situations of fever or other unexplained events in the postoperative course after graft implantation. In this study, 37 patients with a gelatin-impregnated (Unigraft) and 33 with a collagen-impregnated (Hemashield) graft for aortic or aortoiliac replacement were compared. Serum samples were investigated for collagen antibodies at operation, one week and three months postoperatively. An enzyme-linked immunosorbent assay (ELISA) test could not demonstrate the development of antibodies against type I, II, or III collagen in the perioperative period or three months postoperatively.
Myocardial Revascularization with a Free Skeletal Muscle Flap
Authors: Beyer M. , Hoffer H. , Beyer U. , Hannekum A.
Published: June 2007

Based on encouraging experimental evidence, a new myocardial revascularization procedure was, for the first time, used on a sixty-six-year-old patient. This patient suffered from unstable angina (NYHA class III-IV). He had diffuse peripheral coronary artery stenosis (three-vessel disease). Bicycle ergometry showed ischemic ST segment changes at 25 W. After two myocardial infarctions, his prognosis for life was very bad. Therefore, he underwent this new surgery. After a median sternotomy, a free latissimus dorsi muscle flap was grafted onto the anterior wall of the heart. The flap artery was anastomosed end-to-side to the aorta, and venous flow was directed into the right atrium. The graft was fixed with sutures to the epicardium and pericardium. The chest was then closed. The patient had two anginal episodes on the third and fourth postoperative days. Up to the present, these were his last anginal attacks. Eight weeks postoperatively a bicycle ergometry evinced no signs of ischemia at 120 W. Angiographically, a fine vascular network originating from the graft had penetrated into the heart. Four months later, he was able to perform a 10 km walk in one day. Eight months later, he went back to work. His quality of life was 100% improved, although dyspnea on exertion still persists. Up to the present, a year and a half after the intervention, he has had no more anginal episodes. Thus, myocardial revascularization can be achieved with this new aortomyocardial bypass.
Value of Color Flow Duplex Imaging in Detection of Subtotal and Total Internal Carotid Artery Occlusion
Authors: Labropoulos N. , Androulakis A. , Allan R. , Giannoukas A. D. , Touloupakis E. , Tegos T. , Al Kutoubi A. , Nicolaides A. N.
Published: June 2007

The aim of this retrospective study was to estimate the predictive value of color flow duplex imaging (CFDI) in the detection of near-total and total internal carotid artery (ICA) occlusion. The authors reviewed all diagnoses of 95-99% ICA stenosis and ICA occlusion made by CFDI from 1991 to 1994 at St. Mary's Hospital. One hundred thirtyseven patients with CFDI diagnosis of ICA occlusion and 42 with 95-99% stenosis had also been subjected to intraarterial digital substraction angiography during the same period and within one month from the CFDI. They compared the results of both methods to estimate the positive predictive value (PPV) of CDFI in the detection of ICA occlusion and 95-99% stenosis. Furthermore, they compared the PPV of CDFI diagnoses during 1991-1993 with that of 1994 for the same spectrum of ICA disease.

CFDI had 96% PPV in the diagnosis of carotid occlusion (95% confidence interval, 94-97.9%, false-positive rate 3.6%) and 83% in the diagnosis of 95-99% stenosis (95% confidence interval 63.4-88.9%, false-positive rate 17%). Although there was improvement of CFDI's ability in the diagnosis of occlusion during 1994 in comparison with the 1991-1993 period, this was not statistically significant (PPV 95.9% and 97.4% respectively).

CFDI may slightly underestimate or overestimate the degree of tight ICA stenosis. However, in the diagnosis of ICA occlusion CFDI is highly reliable.
Infected False Aneurysm After Carotid Endarterectomy
Authors: Dougherty Matthew J. , Calligaro Keith D. , DeLaurentis Dominic A.
Published: June 2007

Infected false aneurysm after carotid endarterectomy is extremely rare, with only 14 cases having been reported in the English-language literature. These can occur even in the absence of prosthetic material. Presentation may be early or delayed, and most patients will develop a tender, pulsatile cervical mass. Surgical therapy can be challenging, with aneurysm excision and autologous interposition grafting the favored approach. The authors report herein a case of postendarterectomy carotid artery infection diagnosed by color-duplex ultrasound, and they review the published experience with this entity.
Limited Utility of Dipyridamole-Thallium for Predicting Adverse Cardiac Events After Vascular Surgery
Authors: de Virgilio Christian , Kirby Laurel , Lewis Roger J. , Donayre Carlos , Baker J. Dennis , White Rodney , Stabile Bruce E.
Published: June 2007

The objective of this retrospective study was to determine the value of dipyridamolethallium (PTHAL) and Eagle criteria (Q wave on ECG, ventricular ectopy, diabetes, congestive heart failure, age >70, angina) in predicting cardiac events after vascular surgery at a Veteran Affairs hospital. The main outcome measures were adverse cardiac events. Of 211 vascular procedures, 148 were performed without, and 63 performed with, preoperative PTHAL. Thirty-six patients had redistribution on PTHAL, but only two underwent preoperative coronary revascularization. There were 10 cardiac events (4.8%), five in each group (p=NS). Cardiac events were increased with?one Eagle criteria (6.7% vs 0% with no Eagle, p=0.04), but not with PTHAL redistribution. Conclusions: Prior to elective vascular surgery: (1) PTHAL redistribution did not predict cardiac events. (2) Cardiac morbidity was increased with >one Eagle criteria. (3) Cardiac testing is not indicated in patients without Eagle criteria.
Ruptured, Infected Popliteal Pseudoaneurysm
Authors: Robey James W. , Kohlman-Trigoboff Debra , Simsir Sinan A. , Molina Hector G. , Smith Bruce M.
Published: June 2007

An unusual case of ruptured, infected pseudoaneurysm of the popliteal artery presumed secondary to remote blunt trauma in a young man with no history of intravenous drug abuse is presented. The etiology and management of infected peripheral pseudoaneurysms are discussed.
Changing Patterns in the Diagnosis and Treatment of Pancreaticoduodenal Artery Aneurysms
Authors: Roberts Andrew B. , Roslyn Joel J. , Gahtan Vivian , Kerstein Morris D. , Bradford Susan , Weiss Jeffrey
Published: June 2007

An aneurysm of the pancreaticoduodenal artery was identified in a 60-year-old woman with the primary complaint of epigastric pain that radiated through to her back. A computerized tomography (CT) scan with contrast established the initial diagnosis; an angiogram confirmed the diagnosis and vascular anatomy. The aneurysm was opened and a reverse saphenous vein reestablished circulation.
May-Thurner Syndrome: Three Patients Treated with Catheter-Directed Thrombolysis and Stent Placement
Authors: Henderson Aphrodite M. , McIntyre Kenneth E. , Hunter Glenn C. , Walser Eric , Schaper Diann
Published: June 2007

Compression of the proximal left iliac vein by the right common iliac artery (May-Thurner syndrome) is an unusual cause of iliofemoral thrombosis. Several different surgical approaches have been advocated to alleviate or bypass the compression, but few reports exist of successful treatment using interventional techniques. The authors report three cases of left common iliac vein thrombosis caused by May-Thurner syndrome in two women aged 51 and 36 years, and one man aged 56 years. The two women had long histories of left leg swelling, with recurrent episodes of left iliac venous thrombosis; the man had acute symptoms and no previous history of venous thrombosis or leg swelling. Venography in all patients demonstrated left iliac vein thrombosis associated with large pelvic venous collaterals. Catheter-directed thrombolysis was performed successfully, allowing visualization of the lesions treated with balloon venoplasty and stenting. All three patients were treated with warfarin following stent placement, and all have had improvement or resolution of their symptoms and patent left iliac and femoral veins by duplex scan at 8 to 12 months of follow-up. The authors conclude that (1) Catheter-directed thrombolysis of left iliac vein thrombosis may identify patients with May-Thurner syndrome, which may occur more commonly than previously reported; (2) May-Thurner syndrome may be effectively treated nonoperatively by balloon venoplasty and stenting of the stenotic segment; and (3) the role of warfarin and the long-term results of this treatment are currently unknown.
An Evaluation of the Utility of Intravascular Ultrasound in an Endovascular Practice
Authors: Kulbaski Mark J. , Marshall J. Jeffrey , Kosinski Andrzej S. , Lumsden Alan B.
Published: June 2007

Intravascular ultrasound (IVUS) has been shown to be superior to arteriography for measuring luminal stenosis and characterizing plaque morphology and content. However, IVUS has not been routinely adopted during endovascular interventions, which may be due to the added time, expense, and general perception of the efficacy of arteriography. The authors performed a prospective study to assess the utility of IVUS in a typical vascular surgery practice consisting of open and catheter-based procedures. Over a recent 7-month period, IVUS was used by one vascular surgeon during 21 procedures in 20 patients at the Emory University affiliated hospitals. The procedures included 11 cases of iliac artery angioplasty or stenting (with or without concomitant infrainguinal reconstruction), six diagnostic iliac arteriograms, three cases of supraaortic trunk stenting, and an innominate arteriogram. Useful information given by IVUS was noted. Estimates of the percent cross-sectional area stenoses of 19 lesions were made by IVUS and arteriography for comparison.

In 6 of 21 (29%) of cases, information from IVUS changed or facilitated intraoperative plans that were made on the basis of arteriography. Three modified procedures included redilating an underexpanded iliac artery stent, dilating a fold in an iliac artery stent-graft, and stenting an iliac artery stenosis, all of which were not detected with arteriography. In three additional cases, IVUS proved to be valuable for precisely positioning stents in the supraaortic vessels when intraoperative arteriography was suboptimal. The mean percent cross-sectional area of the stenoses was not significantly different when measured by IVUS (43.7%) or by arteriography (49.1%) (p=0.42).

IVUS is especially advantageous during complicated stenting procedures and supraaortic revascularization and should be available to the surgeon who performs catheter-based interventions. Diagnostic arteriography will detect most hemodynamically significant lesions, but IVUS can be used to clarify the anatomy in selected cases.
Aortic Aneurysmorrhaphy: Establishing Concurrent Results for Comparison with Endoluminal Therapies
Authors: Harris E. John , Dalman Ronald L.
Published: June 2007

The authors began to evaluate endoluminal vascular prostheses in 1991. Since then, market-driven changes in health care delivery have led to shortened hospital stays and intensive care unit (ICU) stays for elective aortic aneurysmorrhapy without increasing morbidity and mortality. They reviewed concurrent results of their open surgery program during this time period to establish a baseline for mortality, morbidity, and overall outcome. Prospective follow-up identified 90 consecutive elective aortic aneurysms repaired by two fellowship-trained vascular surgeons between August 1, 1991, and August 1, 1997. All patients with aortic aneurysms 50 mm or larger presenting to the authors' clinics were offered elective aneurysmorrhaphy with no patients refused operation owing to excessive operative risk. All procedures were performed with resident participation.

Mean patient age was 69.7 years (range 49-83). Risk factors included a significant smoking history in 97%, hypertension in 83%, cardiac insufficiency in 74%, pulmonary insufficiency in 42%, and renal insufficiency in 18% of the patients. There were three juxtarenal and 87 infrarenal aneurysms with a mean diameter of 58 mm (range 45-90 mm). Iliac and femoral artery aneurysmal or occlusive disease was frequent with 72 bifurcated grafts used for repair, and 18 tube grafts. There were 29 concomitant procedures: eight renal artery reimplantations, six renal artery bypasses, three infrainguinal bypasses, five distal artery aneurysm exclusions, three inferior mesenteric artery reimplantations, two nephrectomies, and two renal artery endarterectomies. There were no perioperative deaths. Survival was 97.3% at 6 years by life-table analysis, with a mean follow-up of 25.3 months (range 0.13-70.5 months). Major morbidity prolonging hospitalization occurred in 17.7%; all patients were discharged from the hospital and returned to independent living. No patient required permanent dialysis and all patients were extubated without extraordinary measures. Mean blood loss was 908.7 mL (range 250-5,000 mL). Mean hospital stay was 15.6 days (range 3-55 days) and mean ICU stay was 3.7 days (range 1-18 days). In the last 1.5 years of the study procedures were performed with reduced utilization of resources; mean blood loss 735 mL (range 250-2,500 mL), mean hospital stay 10.96 (range 3-55) days, and mean ICU stay 2.65 (range 1-14) days. Overall primary graft patency at 6 years was 99.2% by life-table analysis.

Elective open aortic aneurysmorrhaphy can be safely performed in high-risk patients in their seventh, eighth, and ninth decades of life. Improved perioperative management of elective aneurysmorrhaphy procedures has led to decreased hospital and ICU stays while maintaining acceptable morbidity and low mortality rates. Direct comparison of evolving endoluminal aneurysmorrhaphy techniques with open aneurysmorrhaphy techniques must utilize concurrent morbidity and mortality data in preference to historic control data.
Transcatheter Embolization of Inferior Mesenteric Artery Hemorrhage
Authors: al Faruqi Tayma , Khoury Maroon B. , Townsend Ricard N.
Published: June 2007

Treatment of traumatic mesenteric artery injury is surgical. We report a case of traumatic laceration of a branch of the inferior mesenteric artery treated by transcatheter embolization following abdominal surgery.
Critical Ischemia
Authors: Sultan Sherif , O'Donohoe Martin , Colgan Mary-Paula , Moore Dermot , Shanik Gregor
Published: June 2007

Conventional aortic surgery carries a significant mortality and morbidity. Transfemoral endoluminal aortic management (TEAM) offers a minimally invasive alternative. This article reports seven cases of TEAM for aortoiliac disease and abdominal aortic aneurysms with a patency rate of 100% at 24 months. Our data suggests that primary stenting can achieve excellent physiologic results and restoration of blood flow in selected patients with aortoiliac disease. Long-term study and follow-up is essential to determine the place of TEAM in the field of vascular surgery.
The Effects of Intermittent Pneumatic Compression on Systemic and Local Fibrinolysis
Authors: Labropoulos Nicos , Stanley Scott K. , Kang Steven S. , Mansour Ashraf M. , Fareed Jawed , Littooy Fred N. , Baker William H.
Published: June 2007

Intermittent pneumatic compression (IPC) is effective in deep venous thrombosis prophylaxis. IPC prevents venous stasis by collapsing the peripheral venous plexus in an extremity leading to increased venous return. It has been suggested that IPC has an additional effect of enhancing fibrinolysis. This study was designed to evaluate the effect of IPC on both systemic and local fibrinolysis in normal volunteers by measuring the activity of tissue plasminogen activator (t-PA) and plasminogen activator inhibitor-type 1 (PAI-1). In addition, tissue factor pathway inhibitor (TFPI) was measured to assess changes in the extrinsic coagulation cascade. IPC was applied in the foot and calf of 10 healthy subjects and blood was drawn from the antecubital fossa to determine systemic fibrinolytic activity. Local fibrinolysis was assessed in 15 healthy subjects by placing an IPC cuff on the forearm and drawing blood 2 cm above the cuff The IPC maximum inflation pressure was 120 mm Hg lasting for 3 seconds at three cycles per minute. Blood samples were taken at rest, on the 10th minute of active IPC, and 5 minutes after cessation of IPC for both systemic and local measurements. The plasma was analyzed for TFPI, t-PA, and PAI-1 antigen by use of enzyme-linked immunosorbent assays. There were no significant changes in systemic or local fibrinolytic activity before, during, or after application of IPC. TFPI systemic activity before, during, and after was 111 ±24, 118 + 18, and 116 ±22, respectively. Local TFPI activity was 91 ±32, 93 +36, and 91 ± 24, respectively. The t-PA systemic activity before, during, and after was 4.1 ± 1.9, 4.7 ± 2.3, and 5 + 2.8, respectively. Local t-PA activity was 4.5 ± 1.3, 4.5 ± 1.4, and 4.2 ± 1.4, respectively. Systemic PAI-1 activity was 11 ± 9.2, 17 ± 19, and 17 ±31, respectively. Local PAI-I activity was 3.7 ± 3.1, 3 ± 1, and 2.8 + 1, respectively, p > 0.38 for all comparisons in both groups. No evidence was found that IPC enhances systemic and local fibrinolysis or TFPI release. Irrespective of the length of IPC application or the inflation pressure, several studies have reported increased fibrinolysis, whereas others have not found any changes. Although, according to the literature, there is a trend toward increased fibrinolytic activity, further controlled studies with adequate sample size should be performed to provide an answer to this controversial topic.
Mycotic Pseudoaneurysm Involving the Popliteal Arteriotomy After Aspergillus Embolectomy
Authors: Sakakibara Yuzuru , Maruno Hiroko , Unno Hideya , Nose Tadao , Mitsui Toshio
Published: June 2007

Peripheral embolization of Aspergillosis is a rare entity that involves few of the cases with systemic Aspergillosis. The authors report a case of a 54-year-old man with a history of sudden onset of ischemia in the right leg resulting from Aspergillosis embolization. Although the antifungal medication was promptly started and continued for 2 months, recurrence of limb ischemia was noted with pseudoaneurysm formation. This might be an indication for long-term follow-up of patients with peripheral embolization of Aspergillosis, in order to detect the formation of a pseudoaneurysm involving the embolectomy site.
Surgical Management of Renal Artery Stenosis and Aneurysmal Formation Related to Neurofibromatosis
Authors: Bartels Michael , Wahlers Thorsten , Krautzig Steffen , Chavan Ajay , von Smekal Ulrich , Dresler Christoph , Oldhafer Karl J. , Fieguth Hans G.
Published: June 2007

Hypertension in neurofibromatosis can be caused by malformations of the renal artery. A young woman with neurofibromatosis and hypertension due to multiple aneurysms and stenoses of the renal artery was treated by direct vascular operative reconstruction. The diseased arterial segments were replaced by two saphenous vein grafts. During the ischemic period, the kidney was protected by Brettschneider's solution. Postoperatively, the blood pressure decreased to normal values. The case demonstrates a successful treatment of complex renal arterial disease in neurofibromatosis by advanced vascular surgical techniques.
Bilateral Metachronous Rupture of Isolated Iliac Artery Aneurysms
Authors: Dosluoglu Hasan Haldun , Harris Linda
Published: June 2007

Iliac artery aneurysms are most commonly associated with aortic aneurysms. Isolated iliac aneurysms are less common but are frequently bilateral at time of presentation. The incidence of metachronous iliac aneurysm formation is unknown. The authors present a case report of a patient with metachronous rupture of iliac aneurysms occurring 3 years apart. The presence of a unilateral iliac aneurysm should prompt close surveillance with computed tomography to identify metachronous lesions before they become symptomatic or rupture in order to decrease the morbidity and mortality associated with ruptured iliac aneurysms.
Risk Factors for Venous Thromboembolism Following Prolonged Air Travel: A “Prospective” Study
Authors: Arfvidsson Berndt , Eklof Bo , Kistner Robert L. , Masuda Elna M. , Sato Dean
Published: June 2007

The aim of this study was to analyze patients with air-travel-related venous leg thromboembolism (VTE) concerning the occurrence of patient-related and cabin-related risk factors. Twenty-five patients, still in hospital, with deep-vein thrombosis (DVT) and/or pulmonary embolism (PE) with onset of symptoms during or after air travel were questioned according to a study protocol. There were 14 women and 11 men with an age range of 36-79 years. Flight times were 5-18 hours. All patients had DVT, and nine (36%) had PE as well. The proximal extensions of the thrombus were in tibial vein, five patients; popliteal vein, two patients; superficial femoral vein, three patients; common femoral vein, four patients; greater saphenous vein, four patients; and iliac vein, seven patients. All but two patients (92%) had one or more patient-related risk factors; the mean was three. Overweight was present in 76% of the patients; chronic heart disease in 44%; hormone medication in 40%; chronic disease, except chronic heart disease and malignancy in 32%; history of previous VTE in 28%; malignancy in 28%; smoking in 20%; recent lower limb injury in 16%; and recent surgery in 12%. Only two patients had no known patient-related risk factor. The flight travel itself does not seem to be an important risk factor in healthy individuals. However, when patient-related risk factors are superimposed, there is increasing evidence that cabin-related risk factors, such as immobilization, cramped “coach” position, insufficient fluid intake, low humidity, and hypoxia contribute to development of VTE. Improved information is required so that passengers can prepare their travel in good time. Active precautions are recommended.
B-mode Ultrasound Imaging in Symptomatic Internal Carotid Artery Stenosis: Correlation with Clinical and Operative Findings
Authors: Kim Geun Eun , Cho Yong Pil , Kwon Tae Won , Kim Ho Sung , Hong Hee Sun , Lee Myoung Chong
Published: June 2007

B-mode ultrasound (duplex) imaging is a technique that enables the evaluation of plaque characteristics. The purpose of this study was to determine the accuracy and usefulness of duplex imaging by comparing a relationship between the preoperative clinical neurologic status, preoperative duplex findings, and operative findings in patients who had carotid endarterectomy (CEA) for symptomatic high-grade internal carotid artery (ICA) stenosis.

Sixty patients with symptomatic ICA stenosis who underwent CEA from September 1995 to August 1998 were included in this study. Plaque morphology was categorized in terms of echogenicity by preoperative duplex imaging. A correlation between the frequency of preoperative ischemic stroke and duplex and operative findings was prospectively evaluated.

Thirty-eight patients had recent and multiple cerebral ischemia, and 22 experienced a single episode more than 1 month before CEA. Recent and multiple events occurred in 24 (72.7%) of 33 patients with echolucent plaques, but only 6 (40.0%) of 15 with echogenic plaques (p<0.05). Thirty-six (75%) of 48 patients with soft plaques by operative findings had recent and multiple events, but only two (16.7%) of 12 with calcified plaques experienced recent and multiple events (p<0.01). Overall sensitivity, specificity, and accuracy of duplex imaging were 79.5%, 77.8%, and 79.2%, respectively.

Duplex imaging is reliable in determining ICA plaque characteristics. Recent and multiple cerebral ischemia occurred more frequently in patients with echolucent plaques by preoperative duplex and soft plaques by operative findings. The presence of echolucent plaque may be used as a strong indication for CEA in patients who have asymptomatic high-grade ICA stenosis.
Comparison of Preoperative and Postoperative Duplex Ultrasound Evaluation of the Contralateral Carotid Artery
Authors: Roddy Sean P. , Estes James M. , Harrington Anita P. , Heggerick Paula A. , O'Donnell Thomas F. , Mackey William C.
Published: June 2007

Duplex ultrasound has become the dominant imaging modality used in the evaluation and preoperative planning for carotid artery stenosis. Numerous studies have addressed the impact of contralateral stenoses on the accurate assessment of ipsilateral disease. Several of these investigators have employed arteriography as a standard of comparison, but this technique is less commonly used and often underestimates the degree of plaque bulk and stenosis. The authors therefore used duplex ultrasound to examine the postprocedural effect of carotid endarterectomy (CEA) on contralateral velocity measurements. They retrospectively reviewed the noninvasive laboratory records of all patients who underwent CEA from January 1996 to August 1998. Inclusion criteria required a preoperative and postoperative scan within 6 months of surgery and patency of both internal carotid arteries. Velocities were expressed in centimeters per second (cm/sec). Results were categorized into groups according to severity of the stenosis (0-49%, 50-79%, 80-99%). Peak systolic and end-diastolic velocities were recorded, and the difference between contralateral velocities before and after surgery was determined. Ipsilateral systolic and diastolic velocities were compared with the contralateral differences. Paired Student's t test and correlation coefficients were employed in the statistical analysis with significance assumed for a p value <0.05. Seventy-nine patients met the study criteria. The preoperative contralateral carotid systolic velocity ranged from 53 to 516 cm/sec and the diastolic velocity from 0 to 182 cm/sec. The contralateral systolic velocity and diastolic velocities did not change after ipsilateral CEA (p=0.59 and p=0.63, respectively). No significant correlation between changes in either contralateral systolic or diastolic velocities and ipsilateral systolic or diastolic velocities were observed (r <0.13 for all comparisons). After CEA, the contralateral carotid changed categories in 10 patients: six decreased from 50-79% to <50% and four increased from <50% to 50-79%. No changes in patient management resulted from these shifts. There is debate over the accuracy of contralateral duplex evaluation of a carotid artery when ipsilateral disease exists. Even after taking into account the severity of the ipsilateral stenosis, we identified no statistical difference in measured contralateral velocities after CEA. Duplex ultrasound appears to provide an accurate assessment of carotid artery stenosis even in bilateral disease.
Preocclusive Carotid Artery Thrombosis: Pathogenesis and Management
Authors: Takach Thomas J. , Reul George J. , Round Mary E. , Ott David A. , Frazier O. H. , Cooley Denton A. , Cervera Roberto , Hallman Grady L.
Published: June 2007

In this report, the authors review the presentations, angiographic findings, and outcomes of eight cases involving patients who had atherosclerotic compromise of the proximal internal carotid artery and were developing distal thrombosis. They discuss the pathogenesis and implications of such lesions and review the management strategy used at this institution. Between 1994 and 1995, 606 consecutive patients underwent carotid endarterectomy (CEA) at this institution. Among this group, four consecutive patients (0.66%, 4/606) were identified by angiography to have preocclusive carotid artery thrombosis. An additional four patients with the same radiologic finding who had presented between 1980 and 1993 were also identified and included in this series. All eight patients were treated with anticoagulation and emergent CEA and thrombectomy. Complete resolution of presenting symptoms and freedom from perioperative stroke and death were achieved in seven patients (88%, 7/8). In one patient (12%, 1/8) the perioperative course was complicated by development of a carotid artery-cavernous sinus fistula and stroke. The catastrophic potential of preocclusive carotid artery thrombosis mandates immediate intervention. Anticoagulation, CEA, and thrombectomy can result in freedom from the adverse outcomes of stroke and death. However, special care must accompany thrombectomy in order to avoid complications and their associated morbidity.
Cholecystectomy During Abdominal Aortic Aneurysm Repair in Patients with Gallstones
Authors: D'Angelo Anthony J. , Kline Roxana G. , Faust Glenn R. , Cohen Jon R.
Published: June 2007

Background: Simultaneous cholecystectomy for asymptomatic cholelithiasis during abdominal aortic aneurysm (AAA) repair is not widely accepted. We reviewed our data to determine morbidity and mortality in patients with cholelithiasis undergoing AAA repair.

Methods: Over the past 5 years, 320 infrarenal AAA repairs were done in our institution. Twenty-nine patients were identified as having had a prior cholecystectomy, leaving 291 patients in the study group. Forty-seven patients (16%) were found to have cholelithiasis. Thirty patients underwent a cholecystectomy at the time of the AAA repair (GpA), whereas 17 patients did not have their gallbladder removed (GpB). Patient characteristics, postoperative complications, and mortality were compared.

Results: Two patients in GpA died (6.7%), one of renal failure and the other of respiratory failure. In GpB there were three deaths (17.6%) due to postoperative hemorrhage. No deaths in either group were related to the biliary tract. Ten infectious complications occurred in six patients in GpB (35%), compared with only 10% of patients in GpA (p<0.05). Cholecystitis occurred in 24% of patients in GpB, with no cases in GpA (p<0.02). Complications directly related to the biliary tract occurred in 35% of patients in GpB (p<0.02).

Conclusions: These data indicate that asymptomatic gallstones resulted in significant morbidity during the postoperative recovery period from AAA repair. We conclude that patients with asymptomatic gallstones should undergo routine cholecystectomy at the time of the AAA repair.
Effects of Passive Leg Movement on the Oxygenation Level of Lower Limb Muscle in Chronic Stroke Patients
Authors: Jigjid Enkhsaihan , Kawashima Noritaka , Ogata Hisayoshi , Nakazawa Kimitaka , Akai Masami , Eto Fumio , Haga Nobuhiko
Published: June 2007

Objective. To evaluate the effects of passive leg movements on the muscle oxygenation level and electromyographic (EMG) activity in the lower limbs in chronic stroke patients. Methods. With a gait training apparatus, passive movements were imposed on the lower limbs of 15 chronic stroke patients at a frequency of 0.8 Hz for 10 minutes. During the passive leg movements, muscle oxygenation level and muscular EMG activity of the paretic and nonparetic calf muscles were assessed. Results. The passive leg movements caused increases in the EMG activity and muscle oxygenation level in both paretic and nonparetic lower limbs. Although a significant difference was found in the concentration changes of the oxygenated hemoglobin (Oxy-Hb), both paretic and nonparetic sides of the muscle showed enhancement of the tissue oxygenation level (TOI). The degree of the changes of the Oxy-Hb depended on the level of motor recovery after stroke; subjects with good motor recovery showed less difference in the Oxy-Hb level between the paretic and nonparetic sides of the muscle. Conclusion. Passive leg movements have the capacity to induce muscular activity and enhance oxygen metabolism, even in the paretic lower limb muscle of chronic stroke patients. This type of exercise might be a useful and efficient method for the prevention of metabolic deterioration in the lower limb paretic muscles of chronic stroke patients.