bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of Carotid Endarterectomy Critical Pathway on Surgical Outcome and Hospital Stay
Authors: Schneider Joseph R. , Droste Julie S. , Golan John F.
Published: June 2007

Carotid endarterectomy (CEA) is associated with substantial consumption of hospital days and other resources. Although surgical outcomes in their practice compared favorably with published benchmarks, the authors were concerned that postoperative stays were unnecessarily long and that patients were receiving unnecessary tests and pharmaceuticals. Recent studies suggest that within the bounds of safe practice, efforts to standardize care may increase quality and patient satisfaction and reduce consumption of resources. They examined their practice of CEA in an effort to discover the potential for quality improvement and decreased utilization of resources.

A CEA critical pathway (CP) was designed, the primary goal of which was elimination of a possibly unnecessary second postoperative hospital day for most patients and superfluous perioperative testing and medications. Data were recorded prospectively both for Pre-CP patients during the year prior to CP initiation and for subsequent CP patients during the subsequent 13-month period. CP patients were interviewed and the pathway was described prior to surgery.

Pre-CP and CP patients were indistinguishable with respect to indications for CEA and medical comorbidities. A single operative death occurred due to myocardial infarction (Pre-CP). Perioperative stroke and other complications occurred in similar numbers of Pre-CP and CP patients. CP resulted in a 0.5-day decrease in hospital stay overall. CP was also associated with a 22% decrease in direct costs. One early readmission for neck hematoma on postoperative day 2 (1 day postdischarge) might have been preventable. A second readmission on postoperative day 2 was secondary to a drug reaction and would likely have occurred prior to initiation of the CP as well.

CP resulted in significant decreases in resource utilization and with the possible exception of a single readmission did not appear to adversely affect outcome. Preoperative education and expectation that patients will be ready for discharge 1 day after CEA are critical to patient acceptance and satisfaction. Further modification of the CP may further decrease utilization of resources. CP is an excellent mechanism to understand how surgeons practice and it facilitates quality improvement.
Coagulopathy After Ruptured Abdominal Aortic Aneurysm
Authors: Meissner Mark H. , Chandler Wayne C. , Nicholls Stephen C.
Published: June 2007

Although potentially treatable, coagulopathy is often included among the predictors of a poor outcome after ruptured abdominal aortic aneurysm (rAAA). The purpose of this review was to define the incidence of coagulopathy among patients presenting with rAAA and to identify the factors contributing to its development.

The medical records of 89 consecutive patients presenting with a rAAA were retrospectively reviewed. Laboratory results (international normalized ratio [INR], partial thromboplastin time [aPTT], platelet count, fibrinogen, and fibrin degradation products [D-dimer]) measured on admission and perioperatively were recorded and related to features of the patients' prehospital and hospital course.

At least one admission coagulation study was obtained in 70 of 89 patients. All measured coagulation values were within the normal range in only 10 (14%) patients, whereas at least one value was in the coagulopathic bleeding range in 17 patients (24%). Profound abnormalities of the INR (> 2.0) were present in 24%, of the aPTT (> 60 sec) in 12%, and of the platelet count (< 50) in 7% of patients. In a multivariate model, hematocrit was the only significant predictor of an INR > 2.0, while hematocrit and degree and duration of hypotension predicted an aPTT > 60 sec. Fluid volume prior to admission did not independently predict either the INR or aPTT, although it was the only significant predictor of a platelet count <50. Admission D-dimer levels were elevated in 79% of patients and were not significantly associated with either the degree of hemorrhage or volume resuscitation. All coagulation studies showed deterioration following admission, with profound abnormalities observed in 90% and 52% of patients intraoperatively and postoperatively, respectively. Mortality was 74% among those undergoing operation and was significantly associated with advanced age and lowest systolic blood pressure, but not with admission INR or aPTT.

The majority of rAAA patients present with disordered coagulation, profound abnormalities being more related to the degree of hemorrhage than to the volume of fluid resuscitation. Evidence of intravascular fibrinolysis is even more common and may be more closely related to the aneurysm itself than to acute hemorrhage.
Inferior Pancreaticoduodenal Artery Aneurysm in Association with Celiac Axis Occlusion
Authors: de Virgilio Christian , Donayre Carlos , Sadra Maher , White Rodney
Published: June 2007

True aneurysms of the inferior pancreaticoduodenal artery (IPDA) are rare. Nearly half present with rupture. Stenosis or occlusion of the celiac axis is well recognized in association with IPDA aneurysm. The authors report a case of nonruptured IPDA aneurysm that presented with postprandial abdominal pain. Arteriography revealed celiac axis occlusion. The patient was successfully managed by aortohepatic bypass and aneurysm exclusion.
Implications of Serum Cholesterol Measurement for the Vascular Surgeon
Authors: Wijesinghe Lasantha Dinesh , Ahmed Ishtiaq Mehmood , Gilbey Stephen , Berridge David Charles , Scott David Julian Ashbridge
Published: June 2007

Objective: To measure the serum total cholesterol in new patients with intermittent claudication and to assess the proportion with ischemic heart disease and untreated hypercholesterolemia.

Design: A prospective study with patient history corroborated by a general practitioner telephone questionnaire.

Setting: A vascular surgical center in a major teaching hospital.

Subjects: Seventy-six consecutive claudicants were studied (median age, 66; range, 46 to 94; 45 men and 31 women), of whom 41 (54%) had ischemic heart disease.

Results: The median serum total cholesterol concentration was 6.35 mmol/L (IQR, 5.60 to 7.05 mmol/L). Forty-nine (65%) patients had never had their serum cholesterol assayed before this study despite 24 of them having ischemic heart disease.

Conclusions: Previously undiagnosed hypercholesterolemia is commonly revealed in the vascular surgical assessment of patients with intermittent claudication. The cardiac morbidity and mortality of these patients is high and surgeons should therefore be proactive in the instigation of cholesterol-lowering therapy.
Intravascular Papillary Endothelial Hyperplasia: Challenge in Diagnosis and Vascular Reconstruction
Authors: Csank George A. , Curletti Eugene L.
Published: June 2007

Intravascular papillary endothelial hyperplasia (IPEH) is a rare, benign nonneoplastic vascular lesion. A case of IPEH occurring in a 41-year-old woman is described. Suspicion for malignancy prompted the taking of an intraoperative frozen section, which disclosed this unusual pathologic diagnosis. Since the tumor growth involved the bifurcation of the brachial artery, the vascular reconstruction was technically challenging. Descriptions of IPEH are not widely published in the vascular surgical literature since these lesions are usually small and their excision does not require vascular reconstruction. Vascular surgeons should be aware of this benign vascular malformation since it resembles a lowgrade angiosarcoma.
Smoking Cessation Reverses Arterial Endothelium-Dependent Relaxation Injury
Authors: Mays Bradley W. , Ripple Timothy , Eginton Mark T. , Seabrook Gary R. , Cambria Robert A. , Towne Jonathan B. , Freischlag Julie A.
Published: June 2007

Chronic smoking is associated with acetylcholine-dependent endothelial dysfunction, an early marker of atherosclerosis. The purpose of this study was to determine whether this effect of smoke exposure on blood vessel endothelium is reversible. New Zealand White rabbits were placed in a 240 cubic-foot air flow chamber for 3 hours per day, 5 days per week, over a 4-week period and were exposed to smoke produced by a robotic smoke generator. After the 4-week period, rabbits (n=four, Smoked) were killed and their superficial femoral arteries (SFAs) were cut into 3-mm segments. The rings were suspended from tension transducers and the maximal contraction of one ring was recorded following stimulation with norepinephrine (NE). The remaining rings were contracted to 50% of the maximum. Relaxation of these rings was determined by adding increasing doses of acetylcholine. The remaining rabbits were placed in and out of the chamber without smoke exposure for an additional 4 weeks (n=five, Reverse-smoked), and then the SFAs were harvested. Control (n=six) SFAs were explanted from rabbits not exposed to smoke. KCl induced increased contractility in the smoked group when compared with the controls, and NE induced increased contractility in the smoked group when compared with the reverse-smoked rabbits. Acetylcholine-dependent relaxation was significantly reduced in the rings from the smoked rabbits when compared with the controls. The percentage ring relaxation in the reverse-smoked rabbits was similar to the control rings.

The impaired acetylcholine-dependent endothelium relaxation in the smoked group verifies endothelial injury. However, the improved relaxation in the reverse-smoked group suggests that endothelial injury is reversible.
Impaired Peripheral Vasodilation in Ischemic and Nonischemic Limbs of Patients with Unilateral Arteriosclerosis Obliterans
Authors: Makita Shinji , Nakamura Motoyuki , Ohira Atsushi , Ito Shigehiro , Yoshioka Kunihiro , Hirose Atsuo , Nakajima Takayuki , Komoda Kenji , Kawazoe Kouhei , Hiramori Katsuhiko
Published: June 2007

Limb vessel vasodilation plays an important role in the regulation of skeletal muscle blood flow during exercise. However, little documentation is available that describes the vasodilatory response of peripheral vessels in patients with arteriosclerosis obliterans (ASO). This study investigates possible impairment of basal blood flow and response in ischemic and nonischemic legs of patients with ASO, and the effect of revascularization on leg hemodynamics.

Basal calf blood flow and reactive hyperemic response to femoral occlusion were measured plethysmographically in 20 patients with unilateral ASO (20 stenotic legs and 20 nonstenotic legs) and eight healthy subjects (eight control legs). Eight stenotic legs underwent percutaneous transluminal angioplasty or surgical revascularization. Basal calf blood flow and peak hyperemic flow was significantly lower in stenotic and nonstenotic legs than in control legs. After revascularization, basal flow was unchanged in stenotic legs but elevated in nonstenotic legs (from 2.5 ±0.3 to 3.4 ±0. 4 mL/min/dL tissue, p<0.01). Peak flow in both legs was significantly elevated (stenotic legs, from 12.8 ± 1.9 to 17.6 ± 1.6 mL/min/dL tissue, p<0.01; nonstenotic legs, from 14.3 ± 1.0 to 20.0 ±1.6 mL/min/dL tissue, p<0.01), although still below control values.

Basal blood flow and maximum vasodilatory response of resistance vessels are impaired irrespective of the side of conduit vessel involvement. The vascular response of the nonstenotic side is significantly enhanced after revascularization of the contralateral stenotic lesions. These suggest that neural or circulating vasoacting factor(s) originating from the stenotic limb may contribute to peripheral circulatory disturbance in claudicants.
Treatment of Recurrent Carotid Stenosis: Angioplasty with Stenting versus Reoperative Carotid Surgery
Authors: Lepore Michael R. , Jordan William D. , Fisher Winfield S. , Voellinger David C. , Redden David , McDowell Holt A.
Published: June 2007

Surgical treatment of recurrent carotid stenosis (RCS) requires additional decision making as compared with the treatment of primary carotid disease. The thromboembolic risk of the lesion may vary according to the time interval from the original carotid endarterectomy to the recurrence of stenosis. Percutaneous transluminal angioplasty with stenting (PTAS) has been offered as an alternative to reoperative carotid endarterectomy (RCEA). A retrospective analysis of a computerized registry identified 43 patients who underwent treatment for 50 recurrent carotid stenoses between 1986 and 1997, 28 by PTAS and 15 by RCEA. The time interval from previous endarterectomy until secondary treatment was less than 2 years for 16 arteries (32%) and more than 2 years for 34 arteries (68%). Indications for treatment were asymptomatic high-grade stenosis in 31 patients (72.1%), transient ischemic attack (TIA) in 10 patients (25.6%), and stroke in 1 patient (2.3%). Neurologic results in the PTAS group (28) included three patients who experienced TIAs (10.7%), five patients with strokes (17.9%), but no deaths. In the RCEA group (15), no patients experienced TIAs, one patient died from a fatal stroke (6.7%), and one patient had a cranial nerve injury (6.7%). Neurologic benefit provided by PTAS for the treatment of recurrent carotid stenosis cannot be identified when compared with RCEA in this limited series.
Video-Assisted Vein Harvest: A Single Institution's Experience of 103 Peripheral Bypass Cases
Authors: Voellinger David C. , Jordan William D.
Published: June 2007

Traditional harvesting of the greater saphenous vein (GSV) has meant a long, continuous incision with the potential for increased morbidity, pain, and hospital stay. The authors have used a minimally invasive video-assisted technique in an attempt to reduce these complications. In this report, they retrospectively analyze a series of 103 cases of videoassisted saphenous vein harvests for vascular bypass procedures. All patients from September 1994 to May 1997 who underwent video-assisted saphenous vein harvest were reviewed for vein harvest time, hospital length of stay, surgical complications, graft patency, and clinical outcome. Operative technique used limited incisions, video-assisted dissection, and two different subcutaneous retractors-endoplastic (Type I) (Snowden Pencer, Tucker, GA) and endosaphenous (Type II) (Ethicon Endosurgery, Cincinnati, OH).

Ninety-six patients underwent 103 operations for lower and upper extremity vascular disease. For all patients, the average time of vein removal was 0.74 cm vein/minute operative time, for procedures with the Type I retractor 0.63 cm vein/minute, for procedures with the Type II retractor 1.07 cm vein/minute (p≤0.0001). Postoperative length of stay (LOS) averaged 7.7 days (median 5 days) for all patients and was longer between patients with rest pain (6.4 days) and tissue loss (10.1 days) vs claudicants (4.4 days) (p<0.05), between patients with tibioperoneal anastomoses (10.0 days) vs patients with popliteal anastomoses (6.0 days) (p<0.05), and between Type I patients (8.3 days) and Type II patients (6.9 days) (p=0.03). Nine wound complications occurred (8.7%), two of which (1.9%) were directly related to the video-assisted technique. Cumulative graft patency was 84% ±9% after 18 months. According to the International Society for Cardiovascular Surgery reporting standards for lower extremity occlusive disease, patient outcome averaged +2.03 for all patients, and was improved between patients with claudication (+2.82) vs patients with rest pain (+1.50) (p<0.05) and between Type II patients (+2.36) vs Type I patients (+1.64) (p=0.01).

Video-assisted saphenous vein harvest can be accomplished with low morbidity and provides a satisfactory conduit. The patients had a short postoperative LOS, a satisfactory wound complication rate, and a good operative outcome. The Type II saphenous vein retractor decreased operative time, shortened hospital LOS, and improved outcome.
Surgical Management of Extraparenchymal Renal Artery Aneurysms
Authors: Kreienberg Paul B. , Darling R. Clement , Chang Benjamin B. , Paty Philip S. K. , Lloyd William , Papanicolaou George , Shah Dhiraj M.
Published: June 2007

Renal artery aneurysms are being encountered with increasing frequency owing to the more liberal use of sensitive diagnostic imaging. Despite numerous historical reports, some controversy exists regarding the clinical significance of small (<2.5 cm) renal artery aneurysms. At their institution the authors favor an aggressive approach in the management of extraparenchymal renal artery aneurysms. This study comprises their experience over the last 7 years. From 1989 to the present, 22 renal artery aneurysms were discovered at their institution. All patients were offered surgical repair, and three of the 22 refused surgery. Two of the patients who refused had asymptomatic aneurysms < 2 cm in size, and the other eventually expired from aortic dissection. The surgically treated patient population consisted of seven men and 12 women with a mean age of 56.9 years (range 11-79). Seven patients were asymptomatic, two presented with pain, eight were hypertensive, five had an associated abdominal aortic aneurysm, one had occlusive disease, and one patient had neurofibromatosis. The aneurysms had a mean size of 2.4 cm (range 1.5-4.0) and occurred at the main renal artery (seven patients), or at the hilar bifurcation (11 patients), or at a secondary bifurcation (one patient). All surgical repairs were performed via a retroperitoneal approach. Procedures included 11 arterioplasties, four polytetrafluoroethylene (PTFE) bypasses based on aortic replacement grafts, one renal artery reimplanted into the aortic replacement graft, two aortic based Goretex bypasses, and one interposition vein bypass. Operative mortality for these patients was 0%. No patient had worsening of renal function based on values preoperative and postoperative blood urea nitrogen/creatinine values. Four patients with preoperative hypertension and with saccular-type bifurcation aneurysms who underwent arterioplasty are now normotensive and require no antihypertensive medication. Mean follow-up for these patients is 1.5 years and duplex ultrasound revealed all reconstructed arteries or bypasses to be patent. These data suggest that extraparenchymal renal artery aneurysms can be safely repaired operatively with minimal morbidity and mortality rates.
Rehabilitation of Lower Extremity Amputation Due to Peripheral Arterial Occlusive Disease in Patients with End-Stage Renal Failure
Authors: Lucke Caroline , Beindorff Nicole , Roy Thomas , Hoy L. , Lucke Christoph
Published: June 2007

Rehabilitation of elderly patients with lower limb amputation and additional severe disease gives rise to controversy. End-stage renal disease (ESRD) is an example of such a disease, frequently leading to local complications of prosthetic fitting due to considerable changes in limb volume. In this retrospective study the authors present data on rehabilitation outcome of a large group of patients with end-stage renal failure and amputation of the lower limb due to peripheral arterial occlusive disease. Often diabetes with its additional comorbidities is the common underlying cause for both. From 1987 to 1996, 30 patients (aged 50 to 89, average 65 years) with ESRD and either unilateral or bilateral amputation were referred for in-patient rehabilitation (group I). The control group consisted of 319 patients without severe renal disease (group II). Both groups were similar regarding distribution of age and gender. There was no statistically significant difference with respect to prosthetic restoration and duration of rehabilitation between the two groups. The difference in the overall rehabilitation rate between the groups, with 77% of limb-wearers in group I compared with 62% in group II, was not statistically significant. The percentage of diabetics in group II was 56%, but as high as 77% in group I (p < 0.05), in 57% with signs of diabetic microangiopathy. With belowknee amputation (BKA) in only 34% in group II compared with 77% in group I, this number is disproportionally low (p < 0.05), unfortunately representing the amputation rates of surgical units in the city. When matched for level of amputation, subgroup analysis revealed no significant difference for clinical outcome in terms of prosthetic fitting or length of stay. The authors conclude that rehabilitation of elderly patients with ESRD with lower limb amputation is worthwhile and justifiable in view of anticipated lower budgets.
Bilateral Renal Artery Stenosis with Abdominal Aorta Coarctation in a Child with Severe Hypertension
Authors: Mocan Hilal , Dinç Hasan , Özcan Fahri
Published: June 2007

This report describes the clinical course, diagnostic evaluation, and management of a 12-year-old child with bilateral renal artery stenosis (RAS) and concurrent narrowing of the abdominal aorta. The child was presented with a 2-day history of headache, vomiting, seizures, and right hemiparesis with normal findings from fundoscopic examination. There were no clinical or laboratory features suggesting the etiology of hypertension, nor had there been any diagnostic procedures in screening for hypertension due to bilateral RAS. Abdominal aortography confirmed the diagnosis of bilateral RAS and abdominal aorta coarctation. The hypertension was severe and resistant to combination of several antihypertensive agents. Aortobilateral renal bypass with autogenous saphenous grafts and midaortic angioplasty with polytetrafluoroethylene (PTFE) was performed. Histopathologic studies revealed subintimal fibrosis.
Surgical Repair of Ruptured Thoracoabdominal Aortic Aneurysm in a Renal Allograft Recipient
Authors: Zeebregts C. J. A. M. , Schepens M. A. A. M.
Published: June 2007

The surgical repair of a ruptured thoracoabdominal aortic aneurysm in a 59-year-old man with a transplanted kidney is reported. To reduce detrimental sequelae to the kidney resulting from ischemia during simple crossclamping of the aorta, perfusion of the renal allograft was ensured by using an aorta-to-left-femoral-artery bypass with a centrifugal pump. The employed method was found to be a safe and efficacious means of circulatory support to the renal transplant in the patient described here. Thirty-six reports (concerning seventy patients) of aortic repair in renal transplant recipients are briefly reviewed with a discussion of management alternatives.
The Occlusion and Shunt Times for Carotid Endarterectomy with Primary Closure, Patch Angioplasty, and Adjunctive Reconstructive Procedures
Authors: Archie Joseph P.
Published: June 2007

This is a report of the carotid occlusion and shunt times utilized to perform carotid endarterectomy (CEA) with primary closure, patch reconstruction, and interposition bypass grafting. The times needed for two ancillary procedures, inversion plication repair of the endarterectomy-produced common carotid step and eversion plication shortening of the endarterectomized internal carotid artery, are also reported. Over 15 years, 1,326 primary CEAs were performed. In 144 (10.9%) of these a shunt was utilized. Reconstruction was by primary closure in 137 (10.3%); patching in 1,171 (88.3%), of which 903 (77.1%) were with autologous vein, 241 (20.6%) with Dacron, and 27 (2.3%) with polytetrafluoroethylene (PTFE); and interposition bypass grafting with reversed saphenous vein in 18 (1.4%). The carotid occlusion times for nonshunted CEAs, the shunt times, the occlusion times for arteriotomy and shunt placement and for shunt removal and closure, and the total operative times were prospectively recorded. Common carotid steps >2 mm were reconstructed in 92 (6.9%) of CEAs. The internal carotid was shortened in 63 (4.8%) CEAs. Both ancillary procedures were performed in 19 (1.4%) CEAs. The occlusion and total shunt times for all CEAs was 27.4 ± 6.7 min (m +1 s.d.). The mean shunt time plus two short occlusion times were 5 to 6 minutes longer than the mean occlusion times for nonshunted CEAs. The carotid occlusion time was 20.9 ±5.2 minutes for primary closure and 27.4 ±6.3 minutes for patch reconstruction (31% longer). The occlusion and shunt times for CEAs with each of the three patch materials were essentially identical. The occlusion times for patched CEAs without and with step reconstruction were 27.1 ±6.2 and 31.5 ±6.0 minutes, respectively (16% longer), and without and with shortening, 27.8 ±6.1 and 29.4 ±8.0 minutes, respectively (6% longer). Arteriotomy length correlated with occlusion and shunt times (p<0.001 for slope, r=0.41). The total operative time was 70.6 ±8.3 minutes for all CEAs. Perioperative stroke was not associated with occlusion time or shunt use. Patch reconstruction adds approximately 6 to 7 minutes to carotid occlusion time and total shunt time when compared with primary closure. Common carotid step repair adds approximately 4 minutes and internal carotid shortening 2 minutes to occlusion and shunt times. The increased occlusion times necessary for patch angioplasty and ancillary reconstructive procedures are relatively short and do not predispose patients to increased risk of perioperative stroke.
Late Secondary Infrainguinal Bypass for Reocclusion after Laser Angioplasty: A Ten-Year Follow-up
Authors: Onohara Toshihiro , Maekawa Takafumi , Arnold Thomas E. , Matsumoto Teruo , Kerstein Morris D.
Published: June 2007

To evaluate the late long-term results of secondary vascular procedures after failed laser angioplasty, 64 infrainguinal bypasses performed for reocclusions occurring after laser angioplasty of the superficial femoral artery were reviewed. In 56 of 64 (88%) limbs, the superficial femoral artery lesion undergoing initial laser angioplasty was an occlusion greater than 20 cm in length. Concurrent popliteal stenotic lesions were present in 24 of the 64 (38%) limbs, which were simultaneously angioplastied with a balloon catheter but without laser. Thirty-two (50%) limbs had a less-than-2-vessel tibial-peroneal runoff. The mean interval between the initial laser angioplasty and the secondary bypass operation was 14.5 months. Secondary infrainguinal reconstructions included 38 abovethe-knee, 20 below-the-knee, and 6 femorotibial-peroneal bypasses. At the secondary procedures, no early graft failures or deaths occurred within 30 postoperative days. Oneyear primary patency and limb-salvage rates for the secondary bypass were 60% and 66%, respectively. Laser angioplasty did not preclude the possibility but did limit durability of secondary bypass operations.
Impaired Endothelium-Dependent Dilatation Precedes Early Arterial Wall Change in Symptom-Free Smokers
Authors: Labropoulos Nicos , Webb K. Michael , Mansour M. Ashraf , Kang Steven S. , Baker William H.
Published: June 2007

Smoking is one of the known risk factors associated with atherosclerosis. Endothelial cell dysfunction is an early event in the development of atherosclerosis, and diminished nitric oxide production has been found to be a marker of this dysfunction. The aim of this study was to investigate the effect of smoking on the endothelial function before the development of early atherosclerotic wall changes.

Twenty symptom-free smokers (> 10 cigarettes per day) and 22 symptom-free, ageand sex-matched volunteers were included into the study. Subjects with diabetes, hypertension, a known history of cardiovascular disease, or those who had a plaque (isolated irregular luminal lesion > 1.5 mm thick) or an intima-media thickness > 0.8 mm in the carotid bifurcation were excluded. By means of high-resolution ultrasound, the diameter of the brachial artery at rest, during reactive hyperemia (endothelium-dependent dilatation), and after sublingual glycerin trinitrate (endothelium-independent dilatation; five controls and five smokers) were measured. All the tests were performed with acclimatized subjects in the supine position. The entire test was recorded on super VHS video. Diameter measurements (average diameter of five cardiac cycles), incident with the R wave on the electrocardiogram, were taken from the near to far wall. Reproducibility measurements in eight subjects (five volunteers and three smokers) showed a coefficient of variation ranging from 1.6% to 3.2% for intraobserver and 1.8% to 3.9% for interobserver variability. Brachial artery endothelium-dependent dilatation was present in all the symptom-free volunteers (10.8 ±3.4%, range 3.4 to 18.2) and reduced or abolished in smokers (3.5 ± 2.9%, range 0 to 7.6; p > 0.001). Glycerin trinitrate induced comparable dilatation in both smokers and controls, indicating that the dysfunction is endothelium dependent. Endothelial dysfunction is present prior to arterial wall changes in smokers, suggesting early arterial damage.
Insights in the Development of Primary Venous Reflux
Authors: Labropoulos Nicos , Giannoukas Athanasios D. , Stavridis George , Bailey David , Glenville Brian , Nicolaides Andrew N.
Published: June 2007

Purpose: The relation between vein wall fibrosis and presence of primary venous reflux was investigated.

Methods: Twenty-eight limbs of 27 patients undergoing coronary bypass surgery without history of superficial or deep venous thrombosis and without clinical evidence of varicose veins were subjected preoperative ultrasonic investigation of the long saphenous vein (LSV) and its tributaries in order to detect presence of reflux. Histologic examination of vein specimens, harvested perioperatively from premarked sites of the LSV (ankle, knee, and midthigh) and its tributaries, was carried out. The specimens were classified according to the fibrotic content of the wall on histology as normal, mildly, moderately, and severely affected.

Results: Sixteen limbs (57%) had reflux. Saphenofemoral junction (SFJ) incompetence alone was not seen, and this always was present in association with an incompetent LSV (3/16, 19%). Reflux was equally distributed (37.5%) in the above(6/16) and belowknee (6/16) segments, whereas in three limbs it was present throughout the LSV. Fibrosis was seen in the majority of the specimens taken from the LSV (62/65, 95%) and its tributaries (21/32, 66%), irrespective of the presence or absence of reflux. Different grades of fibrosis were found on histology in different sites of the same vein.

Conclusions: Venous wall fibrosis very often exists in the absence of reflux and venous insufficiency occurs at any segment of the LSV with minor involvement of the SFJ. Thus, primary venous reflux seems to be a locally developing process.
The Role of Percutaneous Transluminal Angioplasty Following Intraarterial Thrombolytic Therapy for Limb-Threatening Ischemia
Authors: Ierardi Ralph P. , Kerstein Morris D. , Wada Hiroya , Khoury Paul , Matsumoto Teruo
Published: June 2007

The purpose of this study was to evaluate the role of regional intraarterial thrombolytic therapy (IATT) followed by percutaneous transluminal angioplasty (PTA) in the management of acute limb-threatening ischemia. From March 1989 to July 1994, 28 of the 130 (22%) patients who underwent IATT had lesions amendable to immediate PTA. The duration of ischemia was less than seven days in all patients. PTA was performed for multiple lesions in 15 (54%) patients to yield a total of 46 stenotic areas. Stenoses were all less than 5 cm in length (mean: 2.1 cm). A mean follow-up period of 17.6 months was achieved in all patients. Immediate PTA success was achieved in 25 of 28 (89%) patients. Primary patency rates at 6-, 12-, 18-, and 24-month intervals were 63%, 49%, 31%, and 23%, respectively. Secondary patency rates at the same time intervals were 79%, 65%, 59%, and 52%, respectively. The limb-salvage rate was 64% at 12 months. Secondary surgical procedures were performed in 12 (43%) patients at a mean interval of 336 days from time of PTA. In patients with poor run-off (zero to one vessel patent), six-month primary patency rate was 33% compared to 77% in patients with good run-off (two to three vessels patent) (P < 0.05). PTA following IATT for limb-threatening ischemia is associated with limited long-term patency rates, particularly in patients with poor run-off.
Internal Iliac Artery Aneurysm Presenting as Severe Constipation
Authors: Mencia Andres J. , Hines George L.
Published: June 2007

This is a case report of an elderly man who presented with a history of increasing constipation. He was found to have a leaking aneurysm of his right internal iliac artery. The patient underwent repair of the aneurysm with subsequent relief of his constipation. Although genitourinary obstruction is a well-known symptom of internal iliac aneurysms, constipation is a very unusual manifestation of this disorder.
Pseudoaneurysm of the Superior Mesenteric Artery Secondary to Ergot Therapy
Authors: Charpentier Kevin P. , Welch Harold J. , Namyslowski Jan
Published: June 2007

Ergotism is a relatively rare, but well described, arterial disease affecting primarily the lower extremities, although involvement of other arteries have been reported. The authors describe a case of a 50-year-old pharmacist who self-treated his migraine headaches with ergot preparations and developed abdominal pain. Evaluation of the patient with arteriography revealed a pseudoaneurysm and segmental branch stenoses of the superior mesenteric artery. Surgical exploration discovered a spontaneous dissection of the SMA treated with aorto-SMA bypass. This case, and a review of the literature, is presented.
Treatment of Acute Aortic Dissection Complicated by Atherosclerotic Aortic Aneurysm
Authors: Moriyama Yukinori , Iguro Yoshihumi , Hisatomi Kouichi , Watanabe Shunichi , Masuda Hiroshi , Shimokawa Shinji , Toyohira Hitoshi , Taira Akira
Published: June 2007

This study was designed to clarify the clinical characteristics and optimal management of patients who have acute aortic dissections accompanied by atherosclerotic (true) aortic aneurysm. Between January 1992 and August 1996, a total of 132 patients (Stanford type A/B = 72/60) had surgical repair or medical treatment of acute aortic dissection at our institution. Seventeen (type A/B: 5/12) of them had concurrent or previously repaired true thoracic or abdominal aortic aneurysms. There were 14 men and three women patients, ranging in age from 58 to 79 years with a mean of 70 years. Five patients developed type A dissections that affected preexisting true aneurysms located on the aortic arch (n=four) and infrarenal aorta (n=one). They all underwent emergency operations: four patients had total arch repair with resection of aortic arch aneurysms resulting in one death due to myocardial infarction, and the remaining one patient had a hemiarch repair that was followed by resection of an enlarged abdominal aortic aneurysm (AAA) 2 years later. Twelve patients developed type B dissections. Five of them had preexisting true aneurysms affected by dissection: there were three descending thoracic aortic aneurysms (DTAA) and two AAAs; rupture occurred in three patients (DTAA/AAA=one/two) while awaiting surgery. The other two patients successfully underwent emergency graft replacements of the descending thoracic aorta containing true aneurysm and dissection. No patient among the remaining seven with type B dissections, who had AAAs not affected by dissection, had an unfavorable outcome because of the presence of concurrent dissection and true aneurysm. The risk of rupture appears to be high in patients with an aortic segment where true aneurysm is affected by acute dissection. Hence, surgical repairs should be done on an emergency basis in those patients irrespective of the type of dissection.
Femorofemoral Bypass: An Analysis of 53 Femorofemoral Grafts
Authors: Maekawa Takafumi , Kerstein Morris D. , Onohara Toshihiro , Arnold Thomas E. , Ierardi Ralph , Matsumoto Teruo
Published: June 2007

The indications, complications, mortality, and patency rates of 53 femorofemoral (F-F) bypass grafts during a 10-year period were analyzed. Forty-two of the 53 (79%) procedures were for atherosclerotic disease (Group I): 16 (38%) F-F grafts alone, nine (21%) with iliac artery balloon angioplasty (IABA), 13 (31%) with femorodistal (F-D) bypass, and four (10%) with both IABA and F-D bypass. Eleven of the 53 (21%) patients with acute ischemia were treated with F-F grafts alone after intraaortic balloon pumping (IABP) (Group II). Two (4%) occlusions occurred within 30 days in F-F grafts performed with F-D grafts, and seven (13%) occluded late. The cumulative patency rate for F-F grafts alone was 72% at 5 years and 59% at 10 years, and for F-F grafts with additional procedures was 24% at 5 years and 14% at 10 years. Total cumulative patency rate for 5 years was 60%. The 30-day mortality rate was 6%; the 5-year mortality rate was 17% (9/53), and the cumulative 10-year mortality rate was 42% (22/53).
Renal Artery Reconstruction for Fibromuscular Dysplasia During a Living Donor Kidney Transplant
Authors: Borchelt Bret D. , Schweitzer Eugene J. , Bartlett Stephen T.
Published: June 2007

Fibromuscular dysplasia (FMD) of the donor renal artery may be encountered by transplant surgeons during kidney transplantation. Renal artery reconstruction prior to transplantation is indicated to reduce the risk of renovascular hypertension and ischemic nephropathy. The authors report a patient who underwent living donor (LD) transplantation of a kidney with FMD, where the artery was reconstructed with an internal iliac artery interposition graft harvested from the recipient. They conclude that this is a safe procedure that results in a satisfactory outcome. Additionally, there may be a reduced risk of progressive renovascular hypertension in the donor by eliminating FMD.
Ruptured Profunda Femoris Artery Atherosclerotic Aneurysm
Authors: Bohόrquez-Sierra J. Carlos , Martίnez-Leόn J. Ignacio , Sάinchez-Guzmάin Antonio R. , Arribas-Aguilar Felipe , Rodrίguez-Piñero Manuel , Ceijas-Lloreda Fernando , Gόmez-Aragόn Rafael , Bohόrquez-Sierra Cristόbal
Published: June 2007

Profunda femoris artery (PFA) aneurysms are extremely uncommon. In contrast to other peripheral artery aneurysms, they frequently are symptomatic and prone to rupture. Ultrasonography is the diagnostic modality of choice, and is complemented by other imaging methods. Surgical treatment is mandatory both for symptomatic and asymptomatic patients in order to avoid hazardous complications. The authors report a case of a ruptured atherosclerotic PFA aneurysm, emphasizing its clinical features and discussing the accuracy of Duplex scanning as a preoperative study. The techniques employed in surgical management also are described.
A Giant Isolated External Iliac Artery Aneurysm Causing Hydronephrosis and Lower Extremity Weakness
Authors: Wong Simon K. H. , Ho W. S. , Loftus William K. , King Walter W. K.
Published: June 2007

A 75-year-old man was admitted with left lower limb weakness with findings of left isolated external iliac artery aneurysm and left hydronephrosis. Doppler ultrasound and contrasted computed tomography scan demonstrated a large 18 cm iliac artery aneurysm. Endoaneurysmorrhaphy and iliofemoral bypass were performed. The patient was well and discharged 2 weeks after operation. The incidence, natural history, and management of isolated iliac artery aneurysms are discussed and the literature is reviewed.
Duplex Ultrasonography to Predict Internal Carotid Artery Stenoses Exceeding 50% and 70% as Defined by NASCET: The Need for Multiple Criteria
Authors: Kreske Edward D. , Wolk Seth W. , Shanley Charles J. , Lampman Richard M. , Knake James E. , Lange Leslie A. , Erlandson Errol E. , Whitehouse Walter M.
Published: June 2007

Carotid duplex scanning is being used more frequently as the sole preoperative diagnostic imaging modality for patients considered candidates for carotid endarterectomy. The North American Symptomatic Carotid Endarterectomy Trial (NASCET) has demonstrated the benefit of surgical treatment in patients with carotid stenoses exceeding 70%. The purpose of this study was to determine duplex criteria that accurately predict carotid stenoses exceeding 50% and 70% as defined by NASCET arteriographic criteria. One hundred forty-one patients (264 carotid arteries) considered surgical candidates were prospectively studied over a 2-year period by use of both duplex scanning and digital subtraction cerebral arteriography. Carotid artery stenosis was determined by a single radiologist using NASCET arteriographic criteria. Peak systolic velocity (PSV) and enddiastolic velocity (EDV) were measured in the internal carotid (ICA) and common carotid (CCA) arteries by use of duplex scanning. ICA/CCA velocity ratios were calculated for PSV and EDV. Sensitivity, specificity, positive and negative predictive values, and accuracy were calculated. PSVICA/CCA provided the highest sensitivity, and EDVICA the highest specificity in this study. Arteriographic stenoses exceeding 50% and 70% were reliably predicted with use of these duplex criteria. It is concluded that duplex criteria can predict carotid stenoses exceeding 50% and 70% as defined by NASCET arteriographic criteria. These criteria should be independently validated by other vascular laboratories.
Flow-Mediated Dilation in Lower-Extremity Vein Grafts
Authors: Smith Bruce M. , Ellahham Samer , Stanford Jon L. , Kohlman-Trigoboff Debra , Tupas-Habib Maria T. , Molina Hector
Published: June 2007

Autogenous vein bypasses manifest a substantial late stenosis and occlusion rate due, at least in part, to the hostile conditions of the arterial milieu. The present study was undertaken to evaluate flow-mediated dilation (FMD)-a putative measure of endothelial health and, potentially, long-term function-in chronically implanted vein grafts performed for critical lower-extremity ischemia. Eleven patients, four men, seven women (mean age: 64 ±14 years; range: 30 to 81 years), with saphenous vein bypasses performed for critical lower-extremity ischemia a mean of 346 ±457 days previously (range: 47 to 1640 days), had their grafts studied in the resting state, following 5 minutes' tourniquet application to produce hyperemia, and following administration of nitroglycerin. Baseline and maximal postischemic brachial artery and vein graft diameters were determined ultrasonographically. An Atherosclerosis Risk Score (ARS) was calculated by assigning one point for each of six established risk factors for atherosclerosis (smoking, diabetes, hypertension, hypercholesterolemia, male gender, and age >60 years). Vein graft flow and diameter increased significantly with hyperemia (20% ±23%; p=0.04, and 3% ±3%; p=0.01 by paired t-test, respectively). Mean ARS was 3.6 ±1.2 (range: 2 to 5). FMD in vein grafts correlated inversely with ARS (r=-0.66, p=0.03). Seven of the 11 vein grafts demonstrated FMD >1% of baseline diameter. No differences were observed between the seven patients with “reacting” grafts and four with “non-reacting” grafts except in the mean ARS (2.9 ±0.9 vs. 4.3 ±0.5, respectively, p=0.05) and in the frequency of diabetes (33% vs. 100%; p=0.05).

Chronically implanted saphenous vein grafts performed for limb-threatening ischemia exhibit FMD. FMD in vein grafts appears to be influenced adversely by concurrent atherosclerotic risk factors, and is reduced compared to FMD reported in other vessels.
Chronic Acquired Arteriovenous Fistula Associated with Nonhealing Ulceration of the Foot
Authors: Sharp William J. , Nowak Lisa R. , Hoballah Jamal J. , Napierkowski Michael T. , Zamani Tanveer , Corson John D.
Published: June 2007

An unusual case of a nonhealing iatrogenic foot ulcer in a man with a remote history of a gunshot wound to the affected limb is presented. The patient had an untreated arteriovenous fistula of the popliteal artery and vein due to a gunshot wound 36 years ago. The etiology and management of such fistulae are discussed.
Centers of Excellence: A New Dimension in Surgical Education
Authors: Qayumi Karim
Published: June 2007

Surgical education has always been challenging and is being made more difficult with the changes in the surgical environment. In the past decade, the number of patients available for educational purposes has decreased because of the development of technology that has significantly reduced their time of stay in the hospital and has also moved many surgical procedures to ambulatory services. Technologic advances also create the demand for more specialized training. The increased number of undergraduate, postgraduate students, and clinical fellows has also affected the educational mandate of the academic hospitals. Alternative ways to teach medicine, and especially surgery, are becoming inevitable. One such method is to teach students outside the operating room in a simulated environment. This article reports on the developments of surgical education centers and provides guidance for those who might wish to develop such educational facilities. For further information, visit www.cesei.org.
Advanced Visualization Platform for Surgical Operating Room Coordination: Distributed Video Board System
Authors: Hu Peter F. , Xiao Yan , Ho Danny , Mackenzie Colin F. , Hu Hao , Voigt Roger , Martz Douglas
Published: June 2007

One of the major challenges for day-of-surgery operating room coordination is accurate and timely situation awareness. Distributed and secure real-time status information is key to addressing these challenges. This article reports on the design and implementation of a passive status monitoring system in a 19-room surgical suite of a major academic medical center. Key design requirements considered included integrated real-time operating room status display, access control, security, and network impact. The system used live operating room video images and patient vital signs obtained through monitors to automatically update events and operating room status. Images were presented on a “need-to-know” basis, and access was controlled by identification badge authorization. The system delivered reliable real-time operating room images and status with acceptable network impact. Operating room status was visualized at 4 separate locations and was used continuously by clinicians and operating room service providers to coordinate operating room activities.
Therapeutic Endoscopic Retrograde Cholangiopancreatography for the Treatment of Fasciola hepatica Presenting as Biliary Obstruction
Authors: Fullerton James K. , Vitale Michael , Vitale Gary C.
Published: June 2007

Human infection with the Fasciola hepatica liver fluke is a rare cause of biliary obstruction, especially within the United States. Humans can become accidental hosts of this parasite by ingesting contaminated drinking water or plants. Symptoms during the acute phase include fever, right upper quadrant pain, eosinophilia, and hepatomegaly. During the chronic stage of infection, the parasite may remain asymptomatic for many years. This article presents a case of biliary obstruction due to Fasciola hepatica that was diagnosed and treated successfully with endoscopic retrograde cholangiopancreatography.
Comparison of Five Different Abdominal Access Trocar Systems: Analysis of Insertion Force, Removal Force, and Defect Size
Authors: Shafer D. M. , Khajanchee Y. , Wong J. , Swanström L. L.
Published: June 2007

Trocar designs have evolved in response to concerns about complication rates and surgical ergonomics. Functional properties of trocar systems that can be objectively measured include insertion force, removal force and the size of the tissue defect. This study will evaluate these properties in 5 common trocar designs. A porcine model was used to evaluate five different trocar systems for insertion force, removal force, and functional and measured tissue defect. Insertion force was lowest for cutting trocars and highest for radially dilating trocars. Removal force was similar for all trocars. Functional and measured tissue defect size was smallest for the hybrid type and radially dilating trocars. An ideal trocar system incorporates a low insertion force, secure retention, and a minimal tissue defect. Of the systems we tested, the hybrid type trocar has similar wound characteristics to the radially dilating trocar with the benefit of reduced insertion force. Further study is required to determine if these properties translate to an actual improvement in patient outcome.