bluuebunny/crossref_metadata_2025 huggingface dataset:
Bilateral Extracranial Aneurysm of the Internal Carotid Artery
Authors: Bemelman M. , Donker D. N. J. , Ackerstaff R. G. A. , Moll F. L.
Published: June 2007

The authors report a case study of a 78-year-old man with a bilateral extracranial atherosclerotic aneurysm of the internal carotid artery. The patient was treated surgically with resection of the aneurysm and restoration of the flow with a polytetrafluoroethylene (PTFE) graft. The postoperative period was uneventful. Histologic tests demonstrated almost complete destruction of the elastin fibers. The potential hazards of an aneurysm of the internal carotid artery indicate that surgical treatment is warranted.
Endovascular Repair of a Traumatic Infrarenal Aortic Transection
Authors: Voellinger David C. , Saddakni Souheil , Melton Sherry M. , Wirthlin Douglas J. , Jordan William D. , Whitley David
Published: June 2007

Blunt abdominal aortic trauma occurs in up to 0.04% of all nonpenetrating traumas. Although uncommon, mortality from this injury ranges from 18% to 37%. Seat belt injury is associated with almost 50% of reported blunt abdominal aortic traumas. The authors present the case of a 21-year-old man, a restrained passenger who was involved in a high-speed motor vehicle accident. In the emergency room, he had obvious evidence of lap-belt injury. His peripheral pulses were normal and there was no pulsatile abdominal mass. Computer tomography (CT) revealed a large amount of free intraperitoneal fluid throughout with signs of mesenteric avulsion and fracture/dislocation of T11-T12. The patient underwent an exploratory laparotomy. Right hemicolectomy and resection of small bowel was performed. CT angiography revealed an aortic transection and surrounding pseudoaneurysm 2 cm above the aortic bifurcation. The patient returned to the operating room for endovascular repair. Via a right femoral cutdown, a 14 mm x 5.5 cm stent-graft was placed across the distal abdominal aorta. Followup arteriogram revealed complete obliteration of the pseudoaneurysm without evidence of leak. There were no complications related to the aortic stent-graft in the postoperative period. The patient was discharged in good condition. As this case demonstrates, endovascular repair of traumatic aortic injury is feasible and may represent an improved treatment in certain settings.
Clinical and Hemodynamic Outcomes in Patients with Chronic Venous Insufficiency After Oral Micronized Flavonoid Therapy
Authors: Ting Albert C. W. , Cheng Stephen W. K. , Wu Lisa L. H. , Cheung Grace C. Y.
Published: June 2007

The aim of this study was to prospectively investigate the clinical efficacy of Daflon therapy in patients with mild to moderate chronic venous insufficiency (CVI) (clinical class 1-4) and to assess the changes in venous hemodynamics by using air plethysmography (APG). Fifty-six limbs in 28 patients were studied. They all had primary venous insufficiency with no venous obstruction, and mixed deep and superficial venous incompetence was found in 64% of the limbs. There was a significant decrease in symptom score for swelling and heaviness after 6 months of Daflon therapy. The symptom score for cramps also showed improvement though it did not reach statistical significance. Pain was significantly reduced with a mean pain score of 21.8 + 19.3% before comparing to 10.4 ±20.2% after 6 months of Daflon therapy (p<0.01). This was also associated with a decrease in mean calf circumference from 37.0 ±4.3 to 36.4 ±4.3 cm (p<0.001). There was no significant change in the venous filling index (VFI), ejection fraction (EF), and residual volume fraction (RVF) before and after 6 months of Daflon therapy (VFI: 3.7 ±3.5 vs 3.4 ±2.5 mL/s, EF: 54.5 ±15.9% vs 57.7 +19.7%, RVF: 41.4 ±19.2% vs 39.4 ±24.2%). The clinical improvement without associated changes in venous hemodynamics as measured by APG suggests that Daflon mainly works by modifying the microcirculatory environment not detected by APG and this microcirculatory change is associated with clinical improvement. In this regard, Daflon would be especially useful for symptomatic relief in patients with functional venous insufficiency who do not have clinical evidence of varicose veins but suffer from symptoms of venous insufficiency.
Five-Year Follow-up of an Endovascular Program Initiated by Vascular Surgeons
Authors: Calligaro Keith D. , Young Laurence , Dougherty Matthew
Published: June 2007

Strategies developed by vascular surgeons to establish an endovascular program and the 5-year results of the program are reported. In 1994, the operating room was chosen as the site for the endovascular suite. With this strategy, vascular surgeons would be able to 1) govern appropriate indications for intervention, 2) perform procedures independently and direct the course of the intervention, 3) treat unexpected findings during traditional surgical repair with endovascular techniques, and 4) teach these techniques to vascular surgery fellows. Initial procedures were performed under the supervision of radiologists or other vascular surgeons experienced with these techniques. Endovascular catheters were obtained with operating room capital. During a 5-year period (1/1/94-12/31/98), 224 balloon angioplasties (including placement of 65 stents) were performed for stenoses in 84 failing lower extremity arterial bypasses; 58 iliac, 35 femoral, 19 popliteal, 10 tibial, 7 aortic, and 7 subclavian arteries; and 3 subclavian veins and 1 superior vena cava. Ninety-eight procedures were performed concomitantly with an open surgical procedure and 102 interventions were performed as the sole intervention. There were ten (4%) technically unsatisfactory results treated with immediate surgery and two (0.8%) hematomas that required surgery. One-month primary patency was 94%. Endovascular skills gained with this experience has enabled the performance of endovascular aortic aneurysm repair independently. Developing an endovascular suite using the above model is a safe and effective approach. The operating room may be the most practical location to establish an endovascular suite for many vascular surgeons.
Color Duplex Ultrasonography of the Superior Mesenteric Artery After Placement of Endografts with Suprarenal Stents
Authors: Kalliafas Stavros , Travis Simon J. , Macierewicz Jan , Yusuf Syed W. , Whitaker Simon C. , Davidson Ian , Hopkinson Brian R.
Published: June 2007

After endovascular repair of abdominal aortic aneurysm with endografts with suprarenal stents, the proximal uncovered stent may cross the origin of the superior mesenteric artery. Effects on splanchnic circulation are unknown and may include development of stenosis at the vicinity of the stent. The criteria of high-grade superior mesenteric artery stenosis using color duplex ultrasonography have been previously reported. The purpose of this study is to examine the incidence of high-grade superior mesenteric artery stenosis in patients with endografts with suprarenal stents using color duplex ultrasonography. Candidates for the study were patients who had placement of an aortic endograft with a suprarenal stent and were able to undergo ultrasonography of the superior mesenteric artery. After reviewing computed tomography scans, patients who had the origin of the superior mesenteric artery crossed by the suprarenal stent underwent color duplex ultrasonography of this vessel. Presence of turbulence or narrowing of the superior mesenteric artery, or a peak systolic velocity greater than 2.75 m/sec, or an end-diastolic velocity greater than 0.45 m/sec were considered significant for the presence of high-grade superior mesenteric artery stenosis. There were 24 patients (21 males, three females), median age 71 years (range, 59-83). The suprarenal stent was crossing the superior mesenteric artery in 17 of 24 patients (71%). Color duplex ultrasound was technically successful in 13 of 17 (76%). The test was performed after a median follow-up of 9 months (range, 3 days to 34 months). No patient had evidence of turbulence or narrowing of the superior mesenteric artery during ultrasonography. The median peak systolic velocity was 0.92 m/sec (range, 0.53-1.21 m/sec). No patient had peak systolic velocity greater than 2.75 m/sec. The median end-diastolic velocity was 0.10 m/sec (range, 0.09-0.14 m/sec). No patient had end-diastolic velocity greater than 0.45 m/sec. Color duplex ultrasonography did not demonstrate the presence of high-grade superior mesenteric artery stenosis during early follow-up of patients with endografts with suprarenal stents. Longer follow-up of larger series of patients is needed to determine the long-term effects of suprarenal stents on splanchnic circulation.
Endovascular Repair of Thoracic Aortic Aneurysms: A Paradigm Shift in Standard of Care
Authors: Rachel E. S. , Bergamini T. M. , Kinney E. V. , Jung M. T. , Kaebnick H. W. , Mitchell R. A.
Published: June 2007

The standard open surgical treatment of thoracic aortic aneurysms is associated with significant morbidity and mortality. Endovascular repair is less invasive and potentially less morbid for patients with multiple risk factors. The authors report their results in 9 consecutive high-risk patients treated with endovascular grafts from January 1998 through June 2000. There were 7 men and 2 women patients with an average age of 75 years. Mean aneurysm diameter was 7.1 cm. All aneurysms were repaired with Gianturco Z-stent polytetrafluoroethylene prostheses. There were no perioperative deaths. Mean length of stay was 6.3 days. Technical success was achieved in all 9 patients. Two patients had neurologic complications following repair (1 patient with transient lower extremity numbness related to spinal arthritis and 1 patient with bowel and bladder incontinence). Both patients were independent with ambulation. Mean follow-up was 15.8 months. There was no evidence of endoleak or stent migration during the follow-up period. These findings support endovascular treatment of high-risk patients with thoracic aneurysm.
Vascular Complications Arising from Maldeployed Stents
Authors: Kitchens Cliff , Jordan William , Wirthlin Douglas , Whitley David
Published: June 2007

The authors present 6 unusual vascular complications secondary to maldeployed or undeployed vascular stents. They retrospectively reviewed patients referred for complications of vascular stent placement from September 1998 to March 1999. Information on patient history was obtained from a computerized database and clinical document file. Radiographic information was obtained from arteriograms, ultrasound, and computed tomography imaging. Case 1 describes an undeployed stent in the superior mesenteric artery with subsequent thrombosis in addition to celiac occlusion secondary to attempted balloon angioplasty. Case 2 refers to a malpositioned stent placed in the aortic arch and proximal left common carotid artery. Case 3 involves an undeployed coronary stent that migrated to the right distal posterior tibial artery, causing vascular occlusion and chronic pain. In Case 4, an attempted stent placement into the left iliac artery resulted in an undeployed stent lodged across the aortic bifurcation. Case 5 illustrates a partially deployed stent occluding the left renal artery that was unamenable to further angioplasty. Case 6 demonstrates arterial dissection with a pseudoaneurysm following stent placement for right subclavian stenosis. Five patients required operative intervention. Increased use of stents may escalate the number of complications requiring operative intervention. Foreign bodies can migrate distally and potentiate thrombotic occlusion of vessels. Caution must be used not only at the time of deployment but also in the follow-up period. Continued surveillance becomes important after vascular stent placement.
Prophylactic Antibiotics Prior to Bacteremia Decrease Endovascular Graft Infection in Dogs
Authors: Kirksey Lee , Brener Bruce J. , Hertz Steven , Parsonnet Victor
Published: June 2007

Endovascular placement of vascular stent grafts in the aorta and peripheral vessels has become a prominent tool in the armamentaria of the vascular surgeon. Despite, several reports of stent graft infection, no current guidelines exist regarding the administration of antibiotics prior to episodes of potential bacterial seeding. We sought to clarify the role of prophylactic antibiotics in preventing stent graft infection after the parenteral administration of Staphylococcus aureus (S. aureus) at various intervals following device placement. A stent graft device was constructed from a 4 mm thin-walled polytetrafluoroethylene (PTFE) graft attached to the outside of a balloon expandable 394-Palmaz stent (Johnson and Johnson Interventional Systems, Warren, NJ). It was then inserted into the common iliac artery through an 1 IF peal-away sheath placed in the femoral artery. Sixty grafts were placed into 30 dogs. There were 5 groups of equal number (groups A-E). In group A, six dogs received intravenous injection of 3 cc X 104 CFU (colony forming units), biotype 31375 5. aureus, 1 day after stent graft implantation. An identically treated group B received antibiotic prophylaxis (1 gm cefazolin 30 minutes prior to bacterial challenge). Group C received bacterial injection 7 days after graft implantation with no antibiotic prophylaxis. Group D received bacterial injection 7 days after graft implantation with antibiotic prophylaxis. A control group E received no antibiotics and was not infected. All infected animals were sacrificed 7 days following bacterial challenge and the stent graft complex cultured. One half of the control group was sacrificed at 7 days and the other half at 14 days. The overall stent graft patency was 90%. Four of the six graft occlusions occurred in group A. Eleven of 12 (92%) dogs cultured S. aureus (biotype 31375) from the explanted stent graft complex. Two localized perforations occurred at the site of the infected complex. In group B, C, and D, no explanted graft complex cultured S. aureus. One graft occluded in group C and D. No stent graft in the control (group E) cultured S. aureus. A stent graft infection model can be consistently produced. In the canine model, the stent graft is more susceptible to infection in the early postoperative period and becomes less susceptible to bacterial seeding at one week after implantation. The authors recommend the use of prophylactic antibiotics in the prevention of endovascular graft infections in the early postoperative period during times when bacterial seeding may occur. They postulate that pseudointima formation during graft incorporation into the vessel wall may be responsible for the resistance to infection.
Abnormalities Associated with Aberrant Right Subclavian Arteries
Authors: Epstein David A. , DeBord James R.
Published: June 2007

An aberrant right subclavian artery (ARSA) is an anomaly with a reported incidence of 0.5% to 2%. Usually the aberrant artery follows a retroesophageal course; rarely it takes a course anterior to the esophagus or the trachea. Most patients with an ARSA remain asymptomatic; however, progressive dysphagia develops occasionally. The choice of approach depends on the presence or absence of aneurysmal disease, the urgency of the operation, and the surgeon's experience. A case is reported of a 33-year-old white male patient who had a 3-year history of progressive dysphagia to the point that he was only able to swallow liquids. A barium swallow demonstrated a posterior extrinsic compression of the esophagus. Angiography was performed, which demonstrated an ARSA with a common origin of the right and left common carotid arteries. Surgical correction was performed via a right supraclavicular neck incision. The proximal aberrant artery was mobilized behind the esophagus. The distal, right subclavian artery was exposed, transected, and transposed with reimplantation into the right common carotid artery. An aberrant right thoracic duct was encountered and ligated. The English language literature from 1960 to present was reviewed via a Medline search. Reported anomalies associated with ARSAs include a nonrecurrent right inferior laryngeal nerve, a common origin of the common carotid arteries, a replaced right or left vertebral artery, coarctation of the aorta, a right-sided thoracic duct, and a right-sided aortic arch. It is important to be aware of these associated anomalies and how they impact the operative approach involved in the correction of dysphagia lusoria.
True Aneurysm Formation in Axillofemoral Bypass with a Reinforced ePTFE Graft
Authors: Oz Bilgehan Savas , Yilmaz Ahmet Turan , Gunay Celalettin , Bulakbaşi Nail , Tatar Harun
Published: June 2007

Since improvement in reinforced expanded polytetrafluoroethylene (ePTFE) grafts, true aneurysm and pseudoaneurysm formation have become relatively rare complications after axillofemoral reconstruction. This is a case report of a true aneurysm of an axillofemoral graft. The true aneurysm occurred 29 months after insertion of a reinforced ePTFE graft for aortoiliac occlusive disease. A mid-graft true aneurysm was identified during examinations without any trauma history. Continuous long-term follow-up is recommended for these reinforced ePTFE grafts because of rare aneurysm formation, preferably using duplex ultrasonography.
Factors Related to Short Length of Stay After Carotid Endarterectomy
Authors: Hernandez Nathalie , Salles-Cunha Sergio X. , Daoud Yahya A. H. , Dosick Steven M. , Whalen Ralph C. , Pigott John P. , Seiwert Andrew J. , Russell Todd E. , Beebe Hugh G.
Published: June 2007

In the past decade, expected in-hospital length of stay (LOS) after carotid endarterectomy (CEA) has decreased from 4 days to 1. Long LOS is associated with known complications and factors affecting severity of the patient's condition. Factors affecting an intermediate stay of 2 to 4 days need further clarification. The vascular registry at Jobst Vascular Center includes data on manifestation of disease; cardiovascular history; operation and discharge dates; surgeon; surgical details such as patching, shunting, and completion arteriography; and complications. Univariate chi-square and ANOVA and multivariate logistic regression were applied to analyze 635 CEAs performed in 1998, 1999, and 2000. Statistical significance was at a p value less than 0.05 (two-sided). Overall morbidity rate was 8.2% with three (0.5%) inhospital neurologic complications and one death for a 0.16% mortality rate. Fifty-eight percent of the patients were discharged in 1 day. Patients staying 1 day were 3 years younger. Female gender and prior cerebrovascular accident were factors extending LOS to 2 and 3 days. History of angina, heart failure, valve disease, and vein patch or no patch contributed to LOS of 3 or 4 days. Completion arteriography had an association with LOS of 2 days. The relative percentage of patients with complications increased with LOS. No significant relationship was found for symptoms, smoking, myocardial infarction, atrial fibrillation, cardiac revascularization, or surgeon. Insulin-treated diabetes mellitus, cardiac risk factors, cerebrovascular accident, and vein patch or no patch correlated with prolonged hospitalization. Factors were identified that may alter a clinical pathway designed for discharge 1 day after CEA. Focused management of patients with cardiac and cerebrovascular accident history or requiring vein patch and a better understanding of CEA in women may further increase the percentage of patients discharged 1 day after CEA.
Validation of Two Risk Models for Perioperative Mortality in Patients Undergoing Elective Abdominal Aortic Aneurysm Surgery
Authors: Kertai Miklos D. , Steyerberg Ewout W. , Boersma Eric , Bax Jeroen J. , Vergouwe Yvonne , van Urk Hero , Habbema J. Dik F. , Roelandt Jos R. T. C. , Poldermans Don
Published: June 2007

The authors validated 2 clinical risk models for perioperative mortality in patients scheduled for elective open abdominal aortic aneurysm surgery (AAA surgery). They studied 361 patients who underwent elective AAA surgery between 1991 and 1999 (validation population). Two clinical risk models were validated. The first was developed in 238 patients from Leiden University Hospital (Leiden risk model). The Leiden risk model was modified to provide predictions for the validation population based on 6 predictors including age, gender, a history of previous myocardial infarction, congestive heart failure, renal disease, and pulmonary disease. The second was a recently published simpler risk model developed in 820 patients in the UK Small Aneurysm Trial (UK risk model) and included 3 predictors (age and renal and pulmonary comorbidity). Logistic regression was used to quantify the relationship between predictors and outcome (mortality within 30 days of surgery). Validation further included the concordance statistic (c-statistic) for discriminative ability and the Hosmer-Lemeshow test for model reliability. The perioperative mortality in the validation population was 6.6% (24/361). Predictors had similar odds ratios, with particularly strong effects of congestive heart failure, pulmonary disease, and renal impairment. The Leiden risk model had reasonable good ability (c-statistic 0.72) and showed adequate calibration (X2 = 3.3, p = 0.97). It could particularly identify a low-risk group. The UK risk model did not perform well (c-statistic 0.60), showing statistically significant lack of fit (X2 = 64.9, p < 0.001). This study showed similar predictive ability of previously identified predictors for perioperative mortality. The Leiden risk model could identify a low-risk group, while the UK risk model showed a relatively poor performance. The current study supports the use of the Leiden model for preoperative risk assessment.
Morphometric Analysis of the Popliteal Artery for Endovascular Treatment
Authors: Ebaugh J. L. , Matsumura J. S. , Morasch M. D. , Pearce W. H. , Nemcek A. A. , Yao J. S. T.
Published: June 2007

This study intended to determine the precise diameter of the popliteal artery in patients at risk for popliteal aneurysms. Accurate sizing is necessary to develop devices for endovascular treatment of popliteal aneurysms. Fifty-four patients with abdominal aortic aneurysms (AAAs) had computed tomography (CT) scans of the popliteal arteries. Ageand gendermatched control subjects were measured by ultrasound. NIH Image was used to measure the minor diameter at the adductor hiatus (proximal) and femoral condyles (midpopliteal artery). There were 4 unsuspected popliteal aneurysms (7.4%). The proximal popliteal artery was ectatic in these patients: 13.4 ±5.2 mm. Proximal and midpopliteal arteries were significantly larger in the other patients with AAAs compared with controls: 9.6 ±1.8 mm vs 7.9 ± 1.1 mm at the hiatus (p<0.001) and 10.2 ±2 mm vs 7.9 ±0.9 mm at the condyles (p<0.001). The popliteal artery was focally larger in patients with AAAs without popliteal aneurysms. The popliteal artery was larger in men compared with women; 9.8 ±1.8 mm vs 8.8 ±1.9 mm at the hiatus (p = 0.024) and 10.5 ±1.9 mm vs 9.0 ±2.4 mm at the condyles (p = 0.005). The proximal popliteal artery was 2 mm larger in patients at risk for popliteal aneurysms and 5 mm larger in patients with popliteal aneurysms compared to controls. Focal ectasia of the midpopliteal artery was common. Planning for endovascular treatment of popliteal aneurysms must incorporate this striking enlargement.
Single-Center Review of Infections Associated with 1,574 Consecutive Vascular Access Procedures
Authors: Schild A. Frederick , Simon Sean , Prieto James , Raines Jeff
Published: June 2007

The objective of this study was to establish accurate infection rates and causes for vascular access procedures and provide information helpful in identifying means of reducing infections. Between January 1, 1996, and December 31, 2001 (60 months), a single surgeon (AFS) performed 1,574 consecutive vascular access procedures (850 patients) in 1 academic medical center. Recently, a retrospective review of these records revealed that 87 patients (10.2% of this population) underwent removal of access grafts or fistula for infection. In these 87 patients, 131 grafts and 1 fistula were removed. Thus, 8.4% (132/1,574) of the total surgeries were for infection. This review included evaluation of repeat infection, causative organism, and HIV status. Cause of infection fell into 5 major categories. Of the 87 patients, 26 had multiple graft infections. Diabetes and hypertension lead to increased end-stage renal disease, requiring more vascular access procedures. Following thrombosis, infection is the most common complication in vascular access. Therefore, mechanisms to reduce infection would be well received. These data suggest that operative infection accounted for only 6% of infective procedures, and when the entire population is considered, the operative infection rate was 0.51%. However, infections secondary to routine dialysis make up more than 50% of this infective operative population. The authors note that 17% of the infective operations were in previously infected grafts that were not initially completely removed and 23% developed in nonfunctional grafts. Multiple graft infections played a significant role in the investigation and warrant further evaluation.
Temporary Hypotension Following Endarterectomy for Severe Carotid Stenosis: Should We Treat It?
Authors: Gibbs Benjamin F.
Published: June 2007

In patients with severe carotid stenosis, the author has observed that temporary low blood pressure often occurs in the postoperative period. The hypotension typically develops 2 to 4 hours following operation, is asymptomatic, and resolves within 12-24 hours. In recent years treatment has consisted of simple observation, avoiding the use of vasopressors. Other reports of hemodynamic instability following carotid endarterectomy emphasize high blood pressure. The author rarely observes postoperative hypertension in his practice and has wondered if technical factors explain the difference. A consecutive series of primary carotid endarterectomies recently performed by the author was prospectively studied to determine the incidence of postoperative hypotension. Forty-nine of 180 consecutive patients (27%) developed hypotension below 90 mm Hg systolic (range 65-90). All had severe stenosis as an indication for operation. Only 1 patient required treatment for symptoms related to the low blood pressure. Simple observation of the remaining 48 patients with postoperative hypotension did not result in complications nor delay discharge. Data management, selection of patients, surgical technique, and results are discussed. Temporary postoperative hypotension in patients with severe carotid stenosis is common and appears to be benign. The author speculates that this phenomenon may protect ischemic brain tissue from sudden hyperperfusion, and as such should not be treated with vasopressor medication unless symptoms are present.
Acute Thrombosis of Abdominal Aortic Aneurysms
Authors: Suliman Ahmed S. , Raffetto Joseph , Seidman Craig S. , Menzoian James O.
Published: June 2007

An acutely thrombosed abdominal aortic aneurysm (AAA) is a rare but devastating complication of aortic aneurysms. Incidence in reported series is approximately 0.7-2.8% of surgically managed AAA cases with an associated mortality rate of 50%. To date there have been only 46 cases of acutely occluded AAAs reported in the literature. We present our experience of 2 additional cases of acute AAA thrombosis and discuss the mechanism of thrombosis and management. The size of the aneurysm seems to be a better predictor of rupture than of thrombosis. Strong risk factors for thrombosis are the presence of concomitant iliac artery and cardiac disease. Although this complication is rare, its high mortality rate makes it an important disease to understand, recognize, diagnose, and treat for a successful outcome.
Primary Aortogastric Fistula After Nissen Fundoplication
Authors: Kougias Panagiotis , Baltazar Ulises , Battle Wayne J. , Rush Daniel S. , Browder I. William , Katras Tony
Published: June 2007

Aortogastric fistulas are a rare but usually fatal entity that presents as an acute gastrointestinal bleeding. The authors present the case of a 65-year-old man who had undergone a Nissen fundoplication and presented in the emergency room with syncope secondary to massive upper gastrointestinal tract bleed. Despite aggressive resuscitation and prompt operative intervention with repair of the gastric ulcer and closure of the aortic side of the fistula, he succumbed to the complications of hypovolemic shock. Overview of the pertinent literature with discussion of the most common causes of aortogastric fistulas as well as guidelines for intraoperative management are also presented.
Aneurysm Formation of a Dorsal Superficial Antebrachial Artery Due to Sports Injury
Authors: Ishimoto Tadao , Shindo Shunya , Satoshi Nagasaka , Inoue Akihiko , Kobayashi Junya , Ishikawa Hitoshi , Takagi Atsuhiko
Published: June 2007

A 17-year-old man noted a painful mass on his wrist while fencing (Kendo). An aneurysm of a dorsal superficial antebrachial artery, which is an anomalous branch of the radial artery in the distal forearm, was diagnosed. He was successfully treated by excision with primary anastomosis; pathologic examination revealed a pseudoaneurysm. The anomalous location of this artery placed it at risk for civilian injury as it ran in the subcutaneous tissue of the dorsal forearm.
Duplex Ultrasound Imaging with an Ultrasound Contrast Agent: The Economic Alternative to CT Angiography for Aortlc Sten tGraft Surveillance
Authors: Bendick Phillip J. , Zelenock Gerald B. , Bove Paul G. , Long Graham W. , Shanley Charles J. , Brown O. William
Published: June 2007

The use of endovascular stent graft repair for aortic aneurysmal disease has become increasingly common, with the added requirement for close postoperative surveillance to detect the presence of endoleaks or graft migration. The most commonly used technique for surveillance is computed tomography (CT) angiography, with the need for intravenous contrast posing 1 limitation in those patients with renal dysfunction and the cost of this testing presenting an economic limitation. Early results of duplex imaging in the authors' Vascular Laboratory using an intravenous ultrasound contrast agent have shown sensitivity and specificity equivalent to those of CT angiography, with no evidence of any related morbidity. They have evaluated the cost effectiveness of using duplex ultrasound imaging as the primary surveillance technique for postoperative follow-up in aortic stent graft patients. Surveillance protocols now require that 8 follow-up examinations be performed in the first 3 years after stent graft placement. The charges for CT angiography in their institution average $2,779 per study, for a 3-year total of $22,232 per patient. The charges for aortic duplex ultrasound average $525 per study, with a 3-year total of $4,200 per patient. Adding the cost of routine abdominal radiographs to confirm stent graft position ($147 per study) would bring this 3-year total to $5,376, a savings of $16,856 per patient. For every 100 patients who are followed up after stent graft placement, this represents a 3-year savings of more than $1.6M. Promising early results of duplex ultrasound imaging with an intravenous contrast agent show sensitivity and specificity equivalent to those of CT angiography in detecting aneurysm size and graft endoleaks or other hemodynamic abnormalities. If these results can be demonstrated in larger patient series, this technique should become the method of choice for stent graft surveillance, for it offers very significant economic advantages and avoids the complications of intravenous contrast-induced renal dysfunction.
Mycotic Aneurysm of the Internal Carotid Artery
Authors: Angle Niren , Dorafshar Amir H. , Ahn Sam S.
Published: June 2007

Extracranial internal carotid artery (ICA) mycotic aneurysms are rare entities that may result in significant neurologic morbidity and mortality. Several operative techniques have been described in the literature for the management of this difficult condition. This case report describes a contained ruptured mycotic aneurysm of the extracranial ICA associated with Proteus mirabilis infection successfully treated by an end-to-end spatulated interposition saphenous vein graft.
Endovascular Treatment of Traumatic Thoracic Aortic Rupture Combined with Diaphragmatic Rupture
Authors: Zeebregts Clark J. , Klaase Joost M. , Geelkerken Robert H.
Published: June 2007

The purposes of this report are to describe the immediate repair of a diaphragmatic rupture and subsequent endovascular treatment of a thoracic aortic rupture secondary to blunt chest and abdominal trauma and to discuss the outcome in the light of the trauma scores. A 29-year-old man was injured in a car collision. There were signs of a left diaphragmatic rupture and spleen injury. After urgent laparotomy, the diaphragm was repaired. The spleen appeared uninjured; however, there was a dissection with a transmural tear of the thoracic aorta, which was subsequently treated intraluminally by using a TalentT' endovascular graft and two AneuRx” aortic extension cuffs. The patient fully recovered, and the thoracic endograft showed no evidence of endoleak both 1 month and 1 year after treatment. Fourteen months after the operation, the patient is doing well. Endoluminal techniques can be used successfully in the immediate repair of thoracic aortic injuries, even in the presence of a diaphragmatic rupture. With the introduction of advanced repair modalities, such as endovascular techniques, mortality rates will decrease and may eventually alter injury-scoring systems such as the Injury Severity Score.
Clinical Application of Eversion Carotid Endarterectomy
Authors: Friedman Steven G.
Published: June 2007

The results of 250 eversion carotid endarterectomies (ECEAs) in 227 consecutive patients in 1 institution were evaluated. The outcomes of 250 consecutive ECEAs at North Shore University Hospital by a single surgeon, between January 1998 and August 2001, were recorded prospectively. In the single series of 250 ECEAs the 30-day operative mortality was 0.4% and the perioperative stroke rate was 0.8%. During a mean follow-up of 23 months, the recurrent stenosis rate was 0.8%. A reduction in stroke and mortality rates is often observed with ECEA.
Laparoscopic Exclusion of a Splenic Artery Aneurysm
Authors: Muscari Fabrice , Bossavy Jean-Pierre , Chaufour Xavier , Ghouti Laurent , Barret André
Published: June 2007

Splenic artery aneurysm is a rare but serious vascular disease. The mortality risk is 36% when one is ruptured. Surgical therapy has traditionally consisted in resection through a laparotomy. The authors' experience of a case of laparoscopic exclusion of a splenic artery aneurysm is reported. This surgical approach is simple, safe, and minimally invasive. This procedure should increase the indication for surgical treatment of a splenic artery aneurysm.
The Baltimore Activity Scale for Intermittent Claudication: A Validation Study
Authors: Gardner Andrew W. , Montgomery Polly S.
Published: June 2007

The purpose of this study was to develop and cross-validate the Baltimore Activity Scale for Intermittent Claudication (BASIC) questionnaire in patients with peripheral arterial disease limited by intermittent claudication, and to determine whether the BASIC questionnaire score changed following a supervised program of exercise rehabilitation. A total of 702 consecutive patients with peripheral arterial disease and stable intermittent claudication were characterized on physical activity level using the BASIC questionnaire and an accelerometer. The first 351 patients tested were included in the validation group, whereas the final 351 patients were included in the cross-validation group. Subsequently, 61 of these patients participated in a randomized, controlled trial in which 28 patients completed 6 months of exercise rehabilitation and 24 patients completed usual care control. The sum of 5 questions from the BASIC questionnaire (0-10 point scale) was predictive of daily physical activity using the following regression equation: Daily Physical Activity (kcal/day) = 102.2 + (49.6 × BASIC score); R = 0.76, R2 = 0.58, standard error of estimate = 52.0 kcal/day, P < .0001. This equation was successfully cross-validated on an independent group of patients, as the predicted daily physical activity (339 - 181 kcal/day, mean - SD) was similar (P = .501) to measured daily physical activity (347 - 266 kcal/day, mean - SD). Furthermore, the BASIC score increased 38% following 6 months of exercise rehabilitation (P < .01), whereas no change was observed in the control group (P > .05). A composite of 5 questions obtained from the self-administered BASIC questionnaire accurately estimates daily physical activity in patients with peripheral arterial disease limited by intermittent claudication, and is sensitive to change in physical activity following a program of exercise rehabilitation.
Large Uterine Fibroids Causing Mechanical Obstruction of the Inferior Vena Cava and Subsequent Thrombosis: A Case Report
Authors: Hawes Jenny , Lohr Joann , Blum Barry , Bhati Anant , Bhaskaran Jayapandia , Engel Amy
Published: June 2007

A 35-year-old woman presented with severe left leg swelling and pain after a spontaneous abortion of a 20-week fetus. Duplex ultrasound imaging confirmed venous thrombosis of the left iliac, common femoral, superficial femoral, deep femoral, greater saphenous, posterior tibial, and popliteal, peroneal, and soleal veins. A computed tomography scan showed large uterine fibroids that were completely compressing the distal inferior vena cava and both ureters, with associated hydronephrosis. A magnetic resonance venography showed the inferior vena cava proximal to the mechanical obstruction was free of thrombosis but was dilated at 27 mm in the suprarenal location. A hysterectomy was performed and an 8-pound uterus was removed. Intraoperative ultrasound of the inferior vena cava showed a patent crescent shaped vein with no thrombus and adequate venous blood flow. Pathology of the uterus showed a large leiomyoma with necrosis. Her lower extremity symptoms resolved.
Techniques for Preserving Vertebral Artery Perfusion During Thoracic Aortic Stent Grafting Requiring Aortic Arch Landing
Authors: Woo Edward Y. , Bavaria Joseph E. , Pochettino Alberto , Gleason Thomas G. , Woo Y. Joseph , Velazquez Omaida C. , Carpenter Jeffrey P. , Cheung Albert T. , Fairman Ronald M.
Published: June 2007

Thoracic endografting offers many advantages over open repair. However, delivery of the device can be difficult and may necessitate adjunctive procedures. We describe our techniques for preserving perfusion to the left subclavian artery despite endograft coverage to obtain a proximal seal zone. We reviewed our experience with the Talent thoracic stent graft (Medtronic, Santa Rosa, CA). From 1999 to 2003, 49 patients received this device (29 men, 20 women). Seventeen patients required adjunctive procedures to facilitate proximal graft placement. We performed left subclavian-to-left common carotid artery transposition (6), left common carotid-to-left subclavian artery bypass with ligation proximal to the vertebral artery (7), and left common carotid-to-left subclavian artery bypass with proximal coil embolization (4). Patients who had anatomy unfavorable to transposition or bypass with proximal ligation (large aneurysms or proximal vertebral artery origin) were treated with coil embolization of the proximal left subclavian artery in order to prevent subsequent type II endoleaks. Technical success rate of the carotid subclavian bypass was 100%. Patient follow-up ranged from 3 to 48 months with a mean of 12 months. Six patients had follow-up <6 months owing to recent graft placement. Primary patency was 100%. No neurologic events occurred during the procedure or upon follow-up. One patient had a transient chyle leak that spontaneously resolved in 24 hours. Another patient had a phrenic nerve paresis that resolved after 3 weeks. We believe that it is important to maintain patency of the vertebral artery specifically when a patent right vertebral system and an intact basilar artery is not demonstrated. Furthermore, we describe a novel technique of coil embolization of the proximal left subclavian artery in conjunction with left common carotid-to-left subclavian artery bypass. This circumvents the need for potentially hazardous mediastinal dissection and ligation of the proximal left subclavian artery in cases of large proximal aneurysms or unfavorable vertebral artery anatomy.
Evaluation of Thrombogenicity by Indium-111 Platelet Scintigraphy in Endografting for Abdominal Aortic Aneurysms
Authors: Shimazaki Taro , Kawaguchi Satoshi , Yokoi Yoshihiko , Makimura Susumu , Saiki Naozumi , Watanabe Yoshiko , Ishimaru Shin
Published: June 2007

Obstruction of the endograft limb by thrombosis has often been reported and may cause fatal complications such as leg necrosis or myonephropathic metabolic syndrome. The purpose of this study was to evaluate endograft antithrombogenicity by indium-111 platelet scintigraphy. Seventeen patients with abdominal aortic aneurysms were treated by endografting. Thirteen patients were treated with conventional open surgery using an artificial graft. The endograft was constructed from a self-expanding Z-shaped stent and woven polyester fabric. Autologous platelets labeled with indium-111 were injected at 2 weeks postoperatively. At 24 hours and 72 hours postinjection, the ratio of scintillation count of the endograft or graft to that of the native artery was calculated to assess platelet deposition. The normalization ratio was calculated as follows: (scintillation count per pixel of endograft or graft/circumference)/(scintillation count per pixel of the native femoral artery). Platelet factor 4 and beta-thromboglobulin were measured to evaluate the systemic platelets activity at 2 weeks postoperatively. There was no significant difference in platelet counts or labeling efficiency between the groups. The ratio was significantly higher in the endografting group than in the open surgery group at 72 hours postinjection (2.5-0.7 vs 3.9-1.1, P<.001). There was no significant difference in platelet factor 4 and beta-thromboglobulin between the groups. Although there was no difference in systemic platelet activity, endografting was associated with lower antithrombogenicity. It remains unclear whether lower antithrombogenicity causes thromboembolism as a complication of the procedure. The authors recommend the administration of antiplatelet drugs to prevent endograft obstruction in patients with very narrow iliac arteries.
Iron Deficiency in the Acute-Phase Reaction After Open Aortic Surgery
Authors: Solis J. V. , Portero J. L. , Diaz J. , Garcia R. , Ligero J. M. , Vazquez E. , Lodeiro C. , Ballesteros L.
Published: June 2007

The objective of this study was to quantify the magnitude of iron deficiency in the postoperative period after open aortic surgery. This was a prospective observational study in 55 consecutive patients. Blood samples were obtained on postoperative days 1, 2, 4, 30, and 45, and the parameters determined were the following: iron, transferrin, transferrin saturation index, transferrin-soluble receptor, ferritin, red cell count, hemoglobin, hematocrit, serum C-reactive protein, fibrinogen, mean corpuscular volume, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, and number of blood units transfused. We performed statistical ANOVA test for repetitive measurements (lower bound) in regard to its basal level. Iron deficiency and its parameters reached the maximum at 48 hours postoperatively (iron: 18.92 g/dL and transferrin saturation index: 11.1%) (P <.05). There was not a complete recovery after 45 days (iron: 51.23 g/dL and transferrin saturation index: 18.0%) (P <.05). A similar evolution was observed in the other measured parameters (red cell count: 3.5 x 106/L.; hemoglobin: 10.4 g/dL; hematocrit: 30.7%) (P <.005), none affecting the values of concentration or volume (P <.05). Transferrin-soluble receptors, normal at first, were increased at postoperative days 30 and 45 (2.7 and 2.4 mg/dL respectively, P <.005). After open aortic surgery there is an important acute-phase reaction, a dramatic iron deficiency, and a lack of its transporters until the 45th analyzed day. The elevation of transferrin-soluble receptors in the 4th and 6th weeks denotes a necessity of iron supplementation for a correct development of the immature hematic cells since blood parameters do not reach normal levels in the 6th postoperative week.
Treatment of Bleeding Varicose Veins of the Scrotum With Percutaneous Coil Embolization of the Left Spermatic Vein: A Case Report
Authors: Costanza Michael , Policha Aleksandra , Amankwah Kwame , Gahtan Vivian
Published: June 2007

Percutaneous coil embolization of the spermatic vein offers a minimally invasive method for treating symptomatic varicose veins of the scrotum. We describe the case of a 63-year-old man with multiple comorbidities and persistent bleeding from scrotal varicosities. Venography revealed significant left spermatic vein reflux and a large left varicocele. Percutaneous coil embolization of the left spermatic vein completely resolved the bleeding from the left side of the patient’s scrotum. Although many vascular specialists possess the technical skills to perform this procedure, they may not be familiar with its use in the treatment of scrotal varicosities and varicoceles.
Embolic Type of Popliteal Entrapment Syndrome
Authors: Bengisun Ugur , Alacayir Iskender , Koksoy Cuneyt , Ceylan Ibrahim
Published: June 2007

A case of popliteal artery entrapment syndrome (PAES) with distal embolization is reported in a twenty-two-year-old man. PAES is caused by an abnormal relationship between vessels and muscle within the popliteal fossa. This syndrome is increasingly described as a cause of lower limb ischemia. Approximately 300 cases have been reported in the world literature. However, distal embolization to the leg and foot vessels is not emphasized. Also presented is a review of 7 other cases with distal embolization found in the literature.
Internal Thoracic Artery Flow in Diabetic Patients
Authors: Aranki Sary F. , Rizzo Robert J. , Adams David H. , Couper Gregory S. , Kinchla Nancy M. , Collins John J. , Cohn Lawrence H.
Published: June 2007

Patients with diabetes mellitus have an increased frequency of atherosclerotic coronary artery disease, plus abnormalities of vascular tone that could be contributed to autonomic, platelet, and endothelial dysfunction. The purpose of this prospective study was to compare the internal thoracic artery (ITA) flow of diabetic and nondiabetic patients, to determine whether any pathophysiologic changes occur that have any bearing on vascular tone and the adequacy of flow of the ITA. In a consecutive group of patients undergoing coronary artery bypass graft (CABG) surgery, 117 patients (group I) were nondiabetic (ND), 18 patients (group II) were noninsulin dependent (NIDDM), and 20 patients (group III) were insulin dependent (IDDM) diabetics. The ITA was mobilized, and following systemic heparinization it was divided and trimmed for the subsequent anastomoses. The first ITA flow measurement was recorded (flow 1). This was followed by an intraluminal injection of 2 mL of dilute papaverine solution (30 mg in 20 mL N/saline), which was enclosed in the artery for fifteen minutes by applying a soft clamp to the distal end. At the end of this period, a second flow measurement was taken (flow 2). Percent increase in flow and flow reserve (flow 2/flow 1) were recorded for each patient. The median values for flow 1 were 48, 46, and 58 mL/minute for groups I, II, and III respectively. For flow 2 the values were 132, 118, and 126 for groups I, II, and III, respectively, with a median percent increase in flow being 138% (47-380%), 179% (100-380%), and 115% (35-470%) for groups I, II, and III respectively (P < 0.0001). ITA flow reserve was similar among the three groups and was 2.4, 2.8, and 2.2 for groups I, II, and III respectively.

The ITA exhibits the same degree of initial spasm, similar relaxation to intraluminal papaverine, and similar flow reserve. No physiologic abnormalities of ITA flow and reactivity are specific to diabetes. The ITA should be used with the same indications or contraindications as in nondiabetic patients.