bluuebunny/crossref_metadata_2025 huggingface dataset:
The Use of Stents in the Treatment of Intimal Flaps: An Experimental Study
Authors: Wolosker Nelson , Rosoky Ruben Ayzin , Anacleto Alexandre Maieira , Puech-Leão Pedro
Published: June 2007

The routine use of arteriography and duplex scan in arterial trauma has improved the diagnosis of asymptomatic arterial lesions. Specifically, in cases of blunt arterial lesions, intimal flap is the most frequent type of occult arterial trauma and usually follows an arterial contusion. Treatment of traumatic intimal lesions is controversial owing to its unknown natural history. Current therapeutic options include arterial reconstruction and clinical observation. The development of angioplasty catheters and stents has opened a new venue for the treatment of intimal flaps. The goal of this study was to evaluate the efficacy of endoprosthesis in the prevention of arterial thrombosis following traumatic intimal flap.

The study was performed on 12 female mongrel dogs weighing more than 15 kg each. The common (CF) and superficial (SF) femoral arteries were exposed from the inguinal region to the midportion of the thigh in both posterior limbs. The SF was first crushed with a hemostatic forceps to induce a severe arterial contusion. A longitudinal arteriotomy of 2 cm was performed distal to the clamp site. A 5 mm deep intimal flap was than created along the 2 cm segment. The arterial wall was than sutured with prolene 7-0. The same procedure was performed on both SF. One of the arteries was randomized to receive a Palmaz Stent while the other was kept untreated for control. After 3 weeks, palpation, ultrasound Doppler and macroscopic studies were performed on both arteries to determine whether the arterial lumen was occluded or not. All arteries treated with stents were patent after 3 weeks, while five of the 12 untreated arteries were occluded (p < 0.05).

Large intimal flaps are potentially thrombogenic. The use of stents is a good alternative in this situation, preventing arterial thrombosis, in the first 3 weeks after the trauma.
Long-Term Results After Percutaneous Low-Dose Streptokinase Treatment for Acute Arterial Thrombosis
Authors: Yilmaz E. N. , Vermeulen E. G. J. , van den Berg F. G. , Vahl A. C. , Rauwerda J. A.
Published: June 2007

The objective of this study was to evaluate the immediate efficacy and long-term results of a standard protocol of percutaneous, low dose, intraarterial streptokinase treatment in acute arterial thrombosis. This involved analysis of 48 consecutive patients with acute peripheral arterial thrombosis, treated with thrombolysis between October 1988 and August 1997. There were 30 men and 18 women patients, with an average age of 66.5 years. There was thrombosis of the native artery in 32, thrombosis of an aneurysm in seven, and graft occlusion in nine. After the occlusion was defined by arteriography, the low-dose streptokinase (10,000 units per hour) was continuously infused into the thrombosed segment following a bolus injection of 10,000 units. The initial success rate (defined as partial or complete lysis) was 79.6%. Additional therapy after lysis consisted of percutaneous transluminal angioplasty in 18, bypass surgery in six, anticoagulant therapy in seven, and amputation in seven owing to irreversible ischemic damage. One patient died of myocardial infarction before additional therapy. Of the 20.4% failures to fibrinolysis, two patients received bypass surgery, two surgical thrombectomy, three sympathectomy, and three had amputations. Local bleeding complications were seen in five (10%) patients. Only one patient needed surgical exploration. Allergic reaction to streptokinase was seen in five patients (10%) and fibrinolytic therapy was continued with urokinase in three. In the follow-up (1-107 months) eight patients died and three amputations were performed after a mean time of 17 months after thrombolysis owing to progression of arteriosclerosis. This resulted in a limb salvage rate of 76% after 1 year and 65% after 5 years (Kaplan-Meier).

Low-dose, local, intraarterial streptokinase therapy is an effective preliminary step in management of acute arterial thrombosis. Especially with adequate additional treatment, it is possible to achieve satisfactory long-term patency rates.
Does Preoperative MIBI Scanning Lead to Improved Outcomes in Patients Undergoing Abdominal Aortic Aneurysm Surgery?
Authors: Chen Jerry C. , Salvian Anthony J. , Taylor David C. , Hsiang York N.
Published: June 2007

Dipyridamole sestamibi nuclear scanning (MIBI) is a commonly used test to screen for cardiac disease in patients undergoing elective abdominal aortic aneurysm (AAA) surgery. However, its routine use for all patients is controversial. The purpose of this study was to determine whether MIBI scanning could identify high-risk patients and lead to decreased myocardial infarction (MI) and cardiac death when compared with patients who did not receive MIBI scanning preoperatively. The authors reviewed 212 consecutive patients undergoing elective AAA repair between January 1990 and December 1993. Data regarding preoperative cardiac status, MIBI scan results, and cardiovascular outcomes were collected. During this period, 92 patients had MIBI scans preoperatively while 120 patients underwent AAA surgery without MIBI scanning. The average ages for these two groups were 70 ±8 and 71 ±9 years, respectively. The frequency of coronary artery disease, angina, and previous MI in the MIBI group was 47%, 26%, and 29%, respectively. In the non-MIBI group, these frequencies were 39%, 23%, and 28%, respectively. Eleven patients were identified in the MIBI group to have moderate or large reversible defects. Of these, five underwent cardiac revascularization with no morbidity. The frequency of postoperative MI and death for the MIBI group was 1.1% (1/92) and 0%, respectively. In the non-MIBI group, it was 3.3% (4/120) and 1.7% (2/120), respectively (p=0.54). Preoperative MIBI scanning identified high-risk patients for AAA surgery. Following coronary revascularization for these high-risk patients, the overall MI and mortality rates were similar to those in patients who did not receive MIBI preoperatively.
Bilateral Femorodistal Bypass Grafting with Bilateral Free Tissue Transfer for Limb Salvage
Authors: Scott D. J. A. , Knight S. L. , Mercer K. G.
Published: June 2007

Free flap transfer is a technically feasible adjunct to wound healing in tissue loss in vascular reconstructive surgery. The authors present the case of a 68-year-old diabetic who underwent successful femorodistal bypass and free flap transfer on both of his legs with successful bilateral limb salvage at 25 and 17 months, respectively.
The Influence of Carotid Plaque Morphology on the Development of Cerebral Symptoms
Authors: Axisa B. , Naylor A. R. , London N. , Bell P. R. F. , Thompson M. M.
Published: June 2007

Background: Large randomized trials such as the European Carotid Surgery Trial (ECST) and North American Symptomatic Carotid Endarterectomy Trial (NASCET) have defined a role for carotid endarterectomy in symptomatic patients with severe carotid artery stenosis. Data from the same trials also shows that a subgroup of patients with less severe stenosis with a higher risk of stroke might benefit form carotid endarterectomy. In recent years, it has become apparent that besides the degree of stenosis, the morphology of the plaque itself plays a significant role in its potential for development of symptoms, and noninvasive methods of assessing plaque morphology are currently being developed. This paper reviews the literature regarding the relationship between carotid plaque morphology and the potential for development of clinical symptoms.

Methods: A Medline search and a meta-analysis of the literature was carried out. Intraplaque hemorrhage and plaque ulceration were both found to be associated with a higher risk of stroke development (p = 0.001 and 0.0001, respectively). Intraluminal thrombus was not found to be associated with an increased risk of symptom development in the data analyzed. A possible explanation for this incongruous finding is discussed. In addition, the paper also discusses the role of noninvasive plaque characterization as a method of identifying unstable plaques in the future.

Conclusion: Certain characteristics of plaque morphology correlate with a higher risk of development of symptoms and better noninvasive identification of plaque characterization will lead to better patient selection and may be especially useful identifying patients with lower degrees of stenosis but with potentially unstable plaques who might benefit from carotid endarterectomy but do not qualify for surgery using currently accepted criteria.
Evaluation of Skeletal Muscle Metabolic Responses Following Exercise Training in Patients with Intermittent Claudication
Authors: Back Martin R. , Kluess Heidi A. , Huber Thomas S. , Stopka Christine B. , Scott Katherine N. , Ballinger J. Raymond , Welsch Michael A. , Bruner Angela P. , Lyles Teresa , Harward Timothy R. S. , Seeger James M.
Published: June 2007

Objective: Factors responsible for the exercise intolerance occurring in patients with peripheral arterial occlusive disease (PAOD) manifesting intermittent claudication (IC) and contributing to the observed improvements in walking capacity after exercise training have not been elucidated. The authors characterized the resting and exercise responses of high-energy phosphate species in affected calf skeletal muscle as detected by phosphorus (P)-31 magnetic resonance spectroscopy (MRS) to determine whether metabolic derangements were present in patients with mild to moderate PAOD and IC and whether these abnormalities could be altered by training.

Subjects: Thirteen patients evaluated for IC with resting ankle-brachial indices (ABIs) < 0.9 and positive exercise testing were enrolled in a supervised 10-week walking exercise program (IC training). Separate control groups were composed of (1) patients with PAOD and IC (IC control, n = 4) and (2) healthy, age-matched individuals (n = 4) without PAOD or IC who did not undergo exercise training.

Outcome Measures: Resting ABIs and constant-load treadmill testing were performed prior to and following exercise training. ABIs, ankle pressure drop, and calf muscle bioenergetic response (P-31 MRS) of the most symptomatic limb were measured during inmagnet, lowand high-intensity calf exercise done before and after training.

Results: Compared with healthy controls, patients with PAOD and IC before training had lower resting ABIs (0.66 ±0.11), larger ankle pressure drops (35 ±15%), shorter symptom-free walking distances during treadmill testing and significantly slower phosphocreatine recovery (Pcr t½) during in-magnet low-intensity (61 ±46 v. 36 ±40 sec, p=0.05) and high (119 ±93 v. 31 ±10 sec, p=0.003) exercise but had otherwise similar bioenergetic responses. Despite improved symptom-free walking distance (1,080 ±316 v. 498 ±367 ft, p < 0.001), patients with PAOD and IC exhibited no changes in resting ABI, ankle pressure drop or high-energy phosphate responses after training. Furthermore, no significant correlation was found between high-energy phosphate species and limb hemodynamics.

Conclusions: The relatively subtle abnormalities in high-energy phosphate muscle metabolism present in patients with PAOD and IC may only partially account for their marked exercise intolerance and do not appear to contribute to the observed improvement in walking capacity after supervised training.
Local Application of Beta-Particle Radiation to Reduce Venous Anastomotic Intimal Hyperplasia in Polytetrafluoroethylene Arteriovenous Fistulas
Authors: Erzurum Victor Z. , Hafeli Urs O. , Hirko Mark K. , Schmidt Steven P. , Rubin Jeffrey R.
Published: June 2007

The long-term patency of arteriovenous fistulas (AVF) created for hemodialysis is limited, especially when prosthetic implants such as polytetrafluoroethylene (PTFE) are used. Since intimal hyperplasia (IH) at the venous anastomosis is the most common cause of AVF demise, a therapeutic technique to safely diminish this hyperplastic response would be valuable to dialysis patients. Recently, pure beta-emitting stents were shown to be effective in decreasing IH in coronary arteries after angioplasty. This study was designed to assess the ability of a newly developed beta-emitting external foil to inhibit IH at the venous anastomosis in PTFE AVFs in a canine model.

Bilateral PTFE bridge graft AVFs were placed from the femoral artery to vein in adult mongrel canines. A metallic stainless-steel foil coated with the beta-emitter rhenium 188 was placed around the venous anastomotic site of one AVF in each animal. Twelve weeks after AVF implantation each animal was sacrificed and samples of each anastomosis analyzed histologically.

Eight venous anastomoses were analyzed (four test and four control). An analysis of neointimal hyperplasia was performed with image analysis software. Although not statistically significant, there was a trend toward diminished IH observed in the irradiated versus control anastomoses (132.36 ±36 μ vs 159 ±22 μ). However, a foreignbody response was noted external to the vein and anastomosis on the implant side, leading to decreased diameter in the irradiated versus control veins (1.52 ±0.21 mm vs 3.80 ±1.02 mm).

Venous IH may be attenuated in canine PTFE AVFs with the use of an external betaemitting foil. Further larger studies to determine the ideal dosimetry and implant material to maximize vein contact yet minimize foreign body response are necessary. This technology could result in a safe and effective way to improve performance in AVFs.
Intraoperative Evaluation of Success and Failure of Vascular Reconstruction by Monitoring the Transcutaneous Partial Pressure of Oxygen
Authors: Qian Shuixian , Iwai Takehisa
Published: June 2007

This investigation was to determine whether intraoperative monitoring of the transcutaneous partial pressure of oxygen (tcPo2) can be used to assess the success or failure of vascular reconstruction. A total of 347 limbs in 224 patients were studied, including 136 limbs without ischemic symptoms or signs, 173 limbs with intermittent claudication, and 38 limbs with ischemic rest pain, ulceration, or gangrene. The tcPo2 values were determined just before surgery, just before vascular declamping, at 5-minute intervals for 30 minutes after declamping, and just after surgery. A stable tcPo2 value of ≥ 45 mm Hg within 30 minutes after declamping indicated a good outcome, while graft failure or poor distal vascular runoff was suggested by a tcPo2 level of ≤ 45 mm Hg. Extremely poor results were indicated by persistent tcPo2 levels of < 10 mm Hg. Continuous tcPo2 measurement can be used to sensitively reflect distal tissue perfusion and determine the success or failure of vascular reconstruction.
Giant Renal Artery Aneurysms
Authors: Cikrit Dolores F. , Szwed James J. , Burkhart Harold M. , Dalsing Michael C.
Published: June 2007

Renal artery aneurysms (RAAs) are rare, relatively small, and do not need to be treated in most instances. Giant RAAs (> 5.0 cm in diameter), however, may require a different approach. Two women, both 75 years old, were treated at the authors' institution for giant RAAs. One patient, with a single kidney, was diagnosed with acute renal failure as a result of ureteral obstruction by a 6.0-cm RAA. The other RAA was found incidentally on a plain abdominal radiograph performed for right flank pain; severe hypertension was present in this patient. Computerized tomography (CT) scan in this patient demonstrated a left RAA with a maximal diameter of 6.5 cm. Arteriography was obtained in both patients. Both aneurysms were located adjacent to the hilum of the kidney arising from a major branch of the main renal artery near the branch's origin. Both had evidence of partial calcification within the wall.

The patients were treated surgically with partial excision and ligation. In the first patient, surgery was necessary to relieve ureteral obstruction, whereas hypertension control was the main goal in the other. The patients did well with maintenance of renal function postoperatively.

Giant RAAs may cause pain, obstruction of the ureter, or renal vascular hypertension. Resolution of these symptoms can be expected with proper surgical intervention as well as elimination of the potential risk for rupture.
Primary Duodenocaval Fistula with Associated Venacaval Thrombus and Septic Pulmonary Emboli
Authors: DeTurris Stanley , Martin Harold , Bowers Susan , Simso Lee , Melin M. Mark
Published: June 2007

Primary duodenocaval fistulae are exceedingly rare and associated with high morbidity and mortality rates. The authors report a 56-year-old man with a duodenal ulcer and sepsis associated with persistent Vancomycin-resistant enterococcal (VRE) bacteremia and respiratory distress caused by recurrent pulmonary emboli. Computerized tomography scanning and caval venography identified a suprarenal thrombus and duodenocaval fistula. At laparotomy, caval thrombectomy, internal jugular patch angioplasty, and primary duodenal closure were performed. Microscopic examination disclosed gram-positive bacteria and vegetable matter within the thrombus. Sepsis resolved postoperatively.

Duodenocaval fistulae are a rare clinicopathologic entity with only 23 previously published cases, six from duodenal ulcers. Other inciting conditions include trauma, renal cell cancer with subsequent nephrectomy and irradiation, foreign body ingestion, and caval filter presentation. The clinical presentation is typically sepsis and gastrointestinal hemorrhage. Mortality rate is greater than 50%. The existence of caval thrombus associated with duodenal ulcer and subsequent thrombectomy has not been described previously.

Successful treatment of duodenocaval fistulae requires a high index of suspicion and rapid assessment. Early surgical intervention is the only definitive management strategy.
Phlegmasia Cerulea Dolens in a Patient with Ulcerative Colitis Treated by Iliofemoral Venous Thrombectomy
Authors: Nackman Gary B. , Feuer David S. , Stefan Todd M. , Ciocca Rocco G. , Graham Alan M.
Published: June 2007

The authors present the case of a 17-year-old woman with ulcerative colitis who presented with phlegmasia cerulea dolens (PCD) of the right leg. On examination, the compartments of her right leg were tense, sensory and motor function were greatly diminished, and pedal pulses were absent. Venous duplex revealed extensive venous thrombosis from the tibial veins to the external iliac vein. Treatment consisted of anticoagulation with systemic heparinization, and she was brought to the operating room for intraoperative venography, inferior vena caval filter placement, and four-compartment fasciotomy. Arterial pulses did not return; therefore, venous thrombectomy was performed by extrusion of distal thrombus with an Esmarch bandage, and fluoroscopic guided balloon catheter thrombectomy of the distal inferior vena cava and iliac veins proximally. Completion venography revealed the absence of residual thrombus. Postoperatively, the patient developed a lower gastrointestinal hemorrhage and anticoagulation was terminated. The fasciotomy skin incisions underwent delayed closure on postoperative day 6, and the patient was subsequently discharged with compression stockings. Total abdominal colectomy with creation of a J-pouch was performed 1 month following discharge. After 1 year, the patient had no complaints related to her leg. On examination, no evidence of venous insufficiency was present. Venous duplex demonstrated a patent deep venous system with no evidence of reflux. Uncomplicated PCD responds to heparin therapy in 50-80% of patients, but the risk for developing the postphlebitic syndrome is high. Venous thrombectomy has been reported to provide better long-term functional outcome. Catheter-directed thrombolysis has the added theoretical benefit of preserving endothelial and valvular function, and high technical success rates have been reported. No long-term functional outcome results for thrombolysis are available. Thrombolysis is contraindicated if compartment syndrome or venous gangrene is present. The aggressive surgical management of PCD may result in improved outcome.
Acute Iliac Artery Occlusion Caused by Chronic Lymphocytic Leukemia
Authors: D'Angelo Anthony J. , Siegel David N. , Faust Glenn R.
Published: June 2007

Peripheral arterial occlusion due to leukostasis is a rare but serious complication of leukemia. A review of the literature reveals only sporadic cases of large-vessel occlusion secondary to leukemia, usually associated with significant morbidity or mortality. The authors present a case of acute arterial occlusion in a man with chronic lymphocytic leukemia who was treated with thrombolytic therapy. He had an excellent outcome when compared with other patients in the literature who were treated surgically. To the best of their knowledge, this is the first case of chronic lymphocytic leukemia causing largevessel thrombosis. Thrombolytic therapy must be considered a treatment option for patients presenting with acute arterial insufficiency due to leukostasis.
Mycotic Aneurysm of the Carotid Bifurcation Secondary to Pseudomonas Infection
Authors: Morrison Daniel M. , Celani Victor
Published: June 2007

Mycotic aneurysms of the extra-cranial carotid artery are rare in clinical practice. Trauma, atherosclerotic disease, and a prior history of carotid surgery are common predisposing factors. Staphylococcus and Streptococcus species are most often found, with additional reports in the literature of various gram negative rods. These lesions are secondary to bacteremic episodes or extension of local infection. Patients present with tender, enlarging neck masses and fever. Treatment involves debridement of all infected tissue, reconstruction with autologous material, if possible, and long-term culture-determined antibiotic therapy. The authors present a unique case of a mycotic carotid aneurysm secondary to Pseudomonas infection following a tooth extraction.
Multiple External Iliac and Femoral Aneurysms that Developed After Closure of a Traumatic Arteriovenous Fistula
Authors: Ikebuchi Masahiko , Tachibana Maromi , Maeda Teruo , Kanaoka Yasushi , Ohgi Shigetsugu , Mori Tohru
Published: June 2007

A 65-year-old man who underwent closure of a traumatic arteriovenous fistula presented with pulsating masses in the right femoral region. A diagnosis of multiple aneurysms from the right external iliac artery to the superficial femoral artery complicated by ipsilateral varicosis of the short saphenous vein was made. Stripping of the short saphenous vein and iliopopliteal bypass with reimplantation of the profunda femoris artery were performed in two stages. Hemodynamic factors are considered to be involved in the mechanism of aneurysm formation following treatments for traumatic arteriovenous fistula, and long-term follow-up is needed after their closure.
Visceral Artery Pseudoaneurysms Secondary to Pancreatitis
Authors: Kudva Annappa , Mylarappa Prasad , Rao Ananda
Published: June 2007

Upper gastrointestinal hemorrhage is an infrequent complication of acute and chronic forms of pancreatitis. Aneurysmal degeneration of contiguous splanchnic arteries due to pancreatic inflammation, with subsequent rupture into the intestinal lumen is a rare occurrence. These vascular lesions present major clinical problems, both in terms of timely diagnosis and appropriate surgical therapy.1

The authors report 3 cases of bleeding visceral artery pseudoaneurysms (2 cases of pancreaticoduodenal pseudoaneurysms and 1 case of gastroduodenal artery pseudoaneurysm) secondary to pancreatitis. Early diagnosis was possible because of angiographic evaluation, resulting in timely surgical intervention.
Increased Intimal Hyperplasia After Carotid Endarterectomy in Spontaneously Hypertensive Rats
Authors: Drouilhet John Charles , Southern Fred , Williams D. Keith , Brown Aliza T. , Eidt John , Moursi Mohammed M.
Published: June 2007

This study evaluated the effects of hypertension on postoperative intimal hyperplasia using a rat carotid endarterectomy (CEA) model with spontaneously hypertensive rats (SHR) and normotensive Sprague-Dawley rats (SD). SHR and SD rats underwent left carotid exposure and CEA via an arteriotomy, scoring and removal of the intima, followed by arteriotomy closure. The rats were then sacrificed two weeks postoperatively. The left carotid artery was harvested and underwent elastin and double immunohistochemical staining. The percent of lumenal stenosis was calculated using morphometric measurements, and stained cells within the intimal hyperplasia were counted. The means and standard deviation of the means were calculated, and the two groups were compared using a 2-sample t test. The systolic blood pressure was 228 +35 mm Hg in the SHR group and 108 ±8 mm Hg in the SD group (p < 0.00001). The percent of lumenal stenosis was 82.6 ±17.l10% in the SHR group and 21.2 ±13.7% in the SD rats (p value <0.0001). The percentage of cells staining for aSM actin was equal in the SHR group and the SD group (> 91%) but the percentage of these cells staining for BrdU was 38.2 +8.4% in the SHR group and 10.7 +5.8% in the SD group (p<0.0000 1). Hypertension in the SHR rats was associated with an increased lumenal stenosis due to increased intimal hyperplasia. The increased intimal hyperplasia was due to enhanced and accel-erated replication of smooth muscle cells. Hypertension may be associated with increased restenosis rates after CEA.
Technique for Iliac Artery Reconstruction in Abdominal Aortic Aneurysm Repair
Authors: Matsumoto Kenji , Nakamaru Makoto , Obara Hideaki , Hayashi Shinobu , Harada Hirohisa , Kitajima Masaki
Published: June 2007

The aim of this retrospective study was to evaluate the technique for iliac artery reconstruction in abdominal aortic aneurysm repair, when external and internal iliac arteries were required to reconstruct individually. Among 203 elective infrarenal abdominal aortic aneurysm repairs,22.patients (10.8%) required individual reconstruction of bilateral or unilateral iliac arteries, including 56 external or internal iliac arteries. Mainly, three types of procedures were performed: (1) the external iliac artery was anastomosed to the end of the bifurcated graft limb in an end-to-end manner, and the internal iliac artery was attached to the side of the external iliac artery, (2) the external iliac artery was anastomosed to the end of the bifurcated graft limb in an end-to-end manner and the internal iliac artery was bypassed with the use of a straight prosthetic graft extending from the limb of the bifurcated graft, and (3) the internal iliac artery was anastomosed to the end of the bifurcated graft limb in an end-to-end fashion, and the external iliac artey was sewn to the side of the graft limb. In these three types of procedures, the third technique was the easiest and simplest anatomically.
Saddle Embolus -the Need for Intensive Investigation and Critical Evaluation
Authors: Mercer K. G. , Berridge D. C.
Published: June 2007

Embolic aortoiliac occlusion is associated with high mortality and morbidity rates. In this case of saddle embolism the embolic source was identified only by persistent investigation, and the importance of investigation is highlighted.
Converting from General Anesthesia to Cervical Block Anesthesia for Carotid Endarterectomy
Authors: Calligaro Keith D. , Dougherty Matthew J. , Lombardi Joseph , Krug Richard , Raviola Carol A.
Published: June 2007

Between January 1, 1992 and June 30, 1998, vascular and general surgery residents performed 401 carotid endarterectomies (185 cervical block, 216 general anesthesia) under supervision of vascular attending surgeons. In January 1995, cervical block anesthesia was newly instituted. Initially anesthesiologists were randomly assigned to these cases and anesthetic technique was not standardized. At the surgeons' insistence later in the series, three specially trained anesthesiologists routinely administered cervical block anesthesia. As experience grew, surgeons realized that operating time greater than 2 hours and high neck dissections requiring mandibular retraction were poorly tolerated by cervical block anesthesia patients but that repeat carotid endarterectomies could be safely performed. Shunts were selectively inserted if significant electroencephalographic changes occurred or carotid stump pressures were less than 50 mm Hg systolic when general anesthesia was used; neurologic changes occurred when cervical block anesthesia was used; or there was a history of ipsilateral stroke for either anesthetic method.

Despite an initial learning curve with cervical block anesthesia, the stroke-mortality rate was similar between the two groups (general anesthesia: 1.9% [four cerebrovascular accidents, two deaths]; cervical block anesthesia: 1.6% [two cerebrovascular accidents, two deaths]). Eight (12%) of the first 66 cervical block anesthesia patients were converted to general anesthesia compared to 2 (1.7%) of the most recent 119 patients with cervical block anesthesia (p=0.03). After cervical block anesthesia was initiated, seven of the first eight repeat carotid endarterectomies were performed using general anesthesia compared to one of the most recent six repeat cases (p=0.02). As surgeons' comfort with cervical block anesthesia increased, 94% (100) of the most recent consecutive 106 carotid endarterectomies were performed using this technique.

These results suggest that carotid endarterectomy can be performed as safely using cervical block anesthesia as general anesthesia, specialized anesthesiologists are essential to achieve a successful outcome, selected repeat carotid endarterectomies can be performed using cervical block anesthesia, very cephalad lesions are best treated using general anesthesia, and surgical trainees can safely perform carotid endarterectomy under attending surgeon supervision if the operation is carried out expeditiously.
Does Vascular Stapling Improve Compliance of Vascular Anastomoses?
Authors: Stansby Gerard , Knez Peter , Berwanger Christoph S. , Nelson Karen , Reichert Viktor , Schmitz-Rixen Thomas
Published: June 2007

Elastic properties of vessel walls are altered by vascular anastomoses. Such alterations may lead to neointimal hyperplasia, which is a common cause of reocclusion following vascular surgery. The severity of paraanastomotic hypercompliant zones and anastomotic compliance drop depend on suturing material and on elastic properties of the anastomotic vessel segments. This study compares paraanastomotic hypercompliance and anastomotic compliance drop when using a new vascular closure system (VCS®) and a conventional, continuous suture line in the preparation of end-to-end anastomoses.

Compliance of artery-artery, vein-artery, and polytetrafluoroethylene-artery anastomoses was measured in an artificial circulation system at mean pressures of 60, 90, and 120 mm Hg, comparing conventional suturing and the VCS.

When using the VCS for vein-artery anastomoses, significantly less postanastomotic hypercompliance was achieved at mean pressures of 60 mm Hg (14.2 ±3.8% above remote postanastomotic area), compared to suture (55.1 ±14.8%, p < 0.05). At 90 mm Hg, respective values were 1 1.0 ±2.3% for VCS and 54.7 ±10.1% for suture, p<0.01. At 120 mm Hg, in polytetrafluoroethylene-artery anastomoses, the anastomotic compliance drop was significantly less when using the continuous suture line (93.9 ±1.1% below remote postanastomotic compliance), compared to VCS (97.2 ±0.2%, p< 0.05).

Compared to conventional suturing, use of the VCS reduced postanastomotic hypercompliance in vein-artery anastomoses.
Pulsed Venous Flow Pattern with Hemodilution
Authors: Bombardini Tonino , Borghi Battista , Lorenzini Laura , Pignotti Elettra , Caroli Gian Carlo
Published: June 2007

Venous flow pattern changes and venous flow were assessed in relation to the degree of hemodilution. Femoral vein flow was measured with a duplex scanner in two groups of 11 patients 20 days and 5 days preoperatively, and 1 day postoperatively. In group I, hemodilution was used and patients gave three autologous blood predonations between day 20 and day 5. Perioperative blood loss was reintegrated by electrolyte solution. In group II, hemodilution was not used and autologous blood predonations were not carried out. These patients received a perioperative homologous blood transfusion of 800 mL. Hemoglobin was lower on day 5 (11.3 ±1.4 vs 13.1 ±1 g/dL, p<0.05) and on postoperative day 1 (8.9 ±1.6 vs 10.6 ±1, p<0.05) in group I. The decrease in hemoglobin was associated with an increase in blood flow and a pulsed venous flow pattern in 14 of 22 veins after autologous blood predonation and in 21 of 22 veins on postoperative day 1 (p < 0.05). Increased venous flow in hemodilution is associated with a pulsed venous flow pattern.
Staged Embolization and Operative Treatment of Multiple Visceral Aneurysms in a Patient with Fibromuscular Dysplasia
Authors: Ebaugh James L. , Chiou Andy C. , Morasch Mark D. , Pearce William H. , Yao James S. T.
Published: June 2007

The importance of following a prioritized sequential approach to patients with complex multianeurysm disease cannot be overemphasized. The following patient with multiple visceral aneurysms first had coil embolization of bilateral renal artery aneurysms and then operative excision of her remaining splenic artery aneurysms to minimize the potential morbidity of a larger operation. This case also demonstrates the potential for following levels of specific degradative enzymes associated with aneurysmal disease (matrix metalloproteinase-9 (MMP-9) in this case) preoperatively and postoperatively and in long-term follow-up to monitor for disease recurrence.
Autologous Superficial Femoral Vein for the Repair of Suprarenal Mycotic Aneurysms: A Preferred Conduit?
Authors: Toursarkissian Boulos , Smilanich Robert P. , Sykes Mellick T.
Published: June 2007

The authors report a patient who presented with a ruptured mycotic aneurysm that destroyed the posterior segment of the suprarenal perimesenteric aorta. Initial in-line repair with a rifampin-soaked Dacron prosthetic patch failed 14 days postoperatively with recurrent hemorrhage. At reoperation, the aorta was repaired with a superficial femoral/popliteal vein interposition graft; a segment of superficial femoral/popliteal vein was also used in-line to revascularize the superior mesenteric and celiac arteries. The patient survived with no evidence of recurrence at 8 months postoperatively.
Balloon-Expandable Common Iliac Artery Occluder Device for Endovascular Aneurysm Repair
Authors: Silberzweig James E. , Marin Michael L. , Hollier Larry H. , Mitty Harold A. , Connelly Timothy L.
Published: June 2007

This study was performed to evaluate the efficacy of a balloon-expandable Palmaz stent common iliac artery occluder device for endovascular stent-graft repair of aortoiliac aneurysms. Eighty-four patients (79 men, 5 women; age range 60-95 yr; mean age, 76 yr) with aortoiliac aneurysms underwent endovascular stent-graft repair. The repair consisted of a stent-graft extending from the abdominal aorta to the iliac or common femoral artery, a cross-femoral bypass graft, and an endovascular arterial occluder device within the contralateral common iliac artery. The occluder device consisted of a 5-cm segment of 6-mm diameter polytetrafluoroethylene (PTFE) graft with a purse-string suture occluding the leading end and a Palmaz stent sutured to the trailing end. The occluder device was delivered through a 17F catheter via an arteriotomy. Eighty-three of the 84 patients received aortic endografts. In one case, infrarenal aortic rupture occurred during deployment of the aortic stent requiring conversion to an open surgical repair. Initial technical success for occluder device insertion was achieved in 78 of the remaining 83 patients. Failure to advance the occluder device delivery sheath through a diseased iliac artery occurred in one patient. Common iliac artery rupture occurred during balloon expansion and occluder device deployment in two patients. Two patients required additional coil embolization of the common iliac artery adjacent to the occluder device at the time of stent-graft insertion to correct incomplete iliac occlusion. Delayed occluder device-related complications included one patient with a postoperative iliac endoleak who required percutaneous coil embolization and one patient with a postoperative iliac endoleak in whom a contained aortic aneurysm rupture developed that was treated by surgical ligation of the common iliac artery. Use of the Palmaz stent-based iliac artery occluder device is an effective technique to induce common iliac artery thrombosis to facilitate endoluminal stentgraft aneurysm repair.
Leukocyte/Endothelium Activation and Interactions During Femoral Percutaneous Transluminal Angioplasty
Authors: Lüdemann Jörg , Schulte Karl-Ludwig , Hader Oliver , Brehme Stefan , Volk Hans-Dieter , Döcke Wolf-Dietrich
Published: June 2007

Recent data suggest that leukocyte-endothelium activation/interactions are important for restenosis after percutaneous transluminal angioplasty (PTA). Ten patients with superficial femoral artery occlusive disease (stage Fontaine llb) were examined after a percutaneous transluminal angioplasty (PTA) versus a preceding aortoangiography (AAG). Blood samples from corresponding femoral arteries and veins were obtained before, immediately after, and 4 hours after each procedure. The authors examined the ex vivo respiratory burst and leukocytic expression of adhesion molecules flowcytometrically, adhesion molecule plasma concentrations, and inflammatory mediators concentrations in plasma and in endotoxin-stimulated whole blood cultures by ELISA, and the leukocyte counts.

After PTA, venous plasma concentrations of soluble (s)L-selectin (148.2 ± 14.7%, p<0.05 vs 100% baseline ± sem), sP-selectin (130.7 ±6.9%, p<0.01; sE-selectin (117.5 ±8.3%, p<0.05 vs arterial), sLFA-3 (130.7 ±15.8%, p<0.05) were increased. Expressions of L-selectin (93.0 ±5.7%, p<0.05 vs arterial), CD11a (98.8 ±3.8%, p=0.06), CD18 (96.9 ±4.0%, p<0.05 vs arterial), and ICAM-1 (89.1 ±7.7%, p<0.05) on polymorphonuclear neutrophils (PMN), and arteriovenous leukocyte counts (arterial: 103.5 ±5.4%, venous: 91.1 ±3.3%, p<0.05) decreased. Venous ex vivo secretions of oxygen radicals (141.4 ±28.1%, p<0.05 vs AAG), PMN-elastase (173.7 ±35.7%, p<0.05 vs AAG), and interleukin (IL)-8 (226.5 ±56.4%, p<0.001; p<0.0001 vs AAG), as well as PMN-elastase (173.7 ±35.7%, p<0.05 vs AAG) and tumor necrosis factor (TNF)-alpha plasma concentrations (124.1 ±11.9%, p=0.06) rose. Four hours after PTA, a leukocytosis and exhausted TNF-alpha (69.8 ±10.4%, p< 0.05) and IL-8 secretions (72.4 ±4.6%, p<0.01) occurred.

PTA induced local leukocyte-endothelium activations (stronger ex vivo mediator productions) and interactions (decreased venous leukocyte counts, increased plasma concentrations, and decreased leukocytic expression of adhesion molecules) with the release of inflammatory mediators (higher plasma concentrations and exhaustions after 4 hours).
Intravenous Pyogenic Granuloma: Immunohistochemical Consideration
Authors: Qian Li-Hua , Hui Yun-Zhong
Published: June 2007

Intravenous pyogenic granuloma is a rare form of pyogenic granuloma in which the whole lesion appears as a single polypoid mass projecting into the lumen of a vein. Histologically, this benign lesion is similar to pyogenic granuloma of other locations and is characterized by lobular proliferation of capillaries embedded in a fibromyxoid stroma. The following report illustrated the classic findings associated with an intravenous pyogenic granuloma in a young woman. A brief review of this rare entity follows the case report. Although the history and physical findings were approximately the same in each patient, they do not seem characteristic enough to allow for a definite preoperative diagnosis. The clinical differential diagnosis of intravenous pyogenic granuloma is varied and requires careful pathologic attention if excised. Complete local excision with a small portion of the vein is the treatment of choice.
Transplanting a Kidney with a Renal Artery Aneurysm
Authors: Chiu Bill , Chiou Andy C. , Leventhal Joseph R. , Stuart Frank P. , Pearce William H.
Published: June 2007

As a rare postoperative complication, renal artery aneurysm has been reported in 0.95% of kidney transplants. A renal artery aneurysm was repaired prior to transplantation of the kidney.
Primary Axillary-Subclavian Venous Thrombosis: Is Aggressive Surgical Intervention Justified?
Authors: Schmacht Dale C. , Back Martin R. , Novotney Michael L. , Johnson Brad L. , Bandyk Dennis F.
Published: June 2007

Multimodal (thrombolysis, surgical decompression, venous reconstruction, oral anticoagulation) treatment of primary axillary-subclavian venous thrombosis was reviewed to assess the impact of venous patency on functional outcome. Since 1996, 7 patients (6 men, 1 woman) of ages 16-53 years (mean 33 years) presented with symptomatic acute axillosubclavian venous thrombosis as a result of a recent athletic or strenuous arm activity. Five patients had undergone previous (>2 weeks) catheter-directed thrombolysis and venous angioplasty. Diagnostic contrast venography followed by repeat catheter-directed thrombolysis demonstrated abnormal (residual stenosis [n =6] or occlusion En = I1) axillosubclavian venous segments in all patients. Surgical intervention was performed at a mean interval of 7 days (range 1-19 days) after thrombolysis and consisted of thoracic outlet decompression with scalenectomy and 1st rib resection via a paraclavicular (n =4) or supraclavicular (n = 3) approach. Medial claviculectomy or cervical rib resection was performed in 2 patients. Concomitant venous surgery was performed in all patients to restore normal venous patency by circumferential venolysis (n = 7) and balloon catheter thrombectomy (n = 3), or vein-patch angioplasty (n=2), or endovenectomy (n=5), or internal jugular transposition (n=2). Postoperative venous duplex testing beyond 1 month identified recurrent thrombosis in 4 patients despite therapeutic oral anticoagulation. Subsequent venous recanalization was documented in 3 patients. Poor functional outcome was associated with an occluded venous repair and extensive venous thrombosis on initial presentation. A patent or recanalized venous repair present in 6 of 7 patients was associated with good functional outcome and may justify multimodal intervention in patients with primary axillosubclavian effort thrombosis presenting with recurrent thrombosis and significant residual disease after thrombolysis.
Inflammatory Abdominal Aortic Aneurysm Treated by Endovascular Stent Grafting
Authors: Teruya Theodore H. , Abou-Zamzam Ahmed M. , Ballard Jeffrey L.
Published: June 2007

Despite complications inherent to open surgical repair of inflammatory abdominal aortic aneurysms, there is expected resolution of the retroperitoneal inflammatory process following graft replacement. An endovascular approach could also exclude the aneurysm while potentially avoiding injury to vital structures in the hostile operative field. However, data are limited regarding the role of endovascular stent grafts in the management of inflammatory abdominal aortic aneurysms. Furthermore, postoperative regression of perianeurysmal inflammation is rarely discussed in the few published accounts of endovascular repair of inflammatory aortic aneurysms. The case presented demonstrates successful endovascular treatment of an infrarenal inflammatory aneurysm with resolution of the retroperitoneal inflammation and hydronephrosis.
Restenosis After Carotid Endarterectomy in Patients with Paired Vein and Dacron Patch Reconstruction
Authors: Archie Joseph P.
Published: June 2007

This is an analysis of restenosis after bilateral carotid endarterectomy (CEA) with saphenous vein patch reconstruction on one side and Dacron patch reconstruction on the other. The possibility that differences in reconstruction geometry between vein and Dacron patched sides effected restenosis outcomes was evaluated as was the value of serial common carotid wall thickness measurements in predicting restenosis.

Between 1990 and 1997, 33 bilateral CEA were performed within one year on 22 men and 11 women using a greater saphenous vein patch on one side and a knitted Dacron patch on the other. Interoperative post-CEA geometry was measured. Follow-up was by duplex scans that included wall thickness measurements in the endarterectomized common carotid bulb.

Over a mean follow-up of 43 months 10 (30%) Dacron patched and one (3%) vein patched CEA developed?25% restenosis (p=0.001), seven (21%) Dacron patched and no vein patched CEA developed >50% restenosis (p=0.01) and four (12%) Dacron patched and no vein patched CEA developed >70% restenosis (p =0.1 1). The Kaplan-Meier cumulative >25% restenosis rates for Dacron and vein patched CEA were 22% and 0% at 2 years and 41% and 5% at 5 years respectively (p=0.002). The cumulative >50% restenosis rates for Dacron and vein patched CEA were 16% and 0% at 2 years and 34% and 0% at 5 years respectively (p = 0.003). The cumulative?70% restenosis rates for Dacron and vein patched CEA were 8% and 0% at 2 years and 20% and 0% at 5 years respectively (p = 0.02). For both patients with and without recurrent stenosis the mean within patient between sides differences of the diameters of the internal carotid, internal carotid bulb, common carotid bulb, and common carotid arteries and the lengths of the internal carotid and total patch segments were not significantly different and all were less than 5%. Common carotid bulb wall thickness measured at the time of identification of the nine unilateral Dacron patched CEA restenosis was 1.5 ±0.5 mm compared to 1.4 +0.4 mm (m ± 1 SD) for the contralateral vein patched CEA (p = 0.45 by paired t test). Dacron patched CEA have a significantly higher incidence of mild, moderate and severe restenosis than do saphenous vein patched CEA independent of systemic risk factors. The within patient equality of Dacron and vein patched carotid reconstruction geometry in patients with unilateral restenosis indicates that patch material is the major local risk factor, not adverse hemodynamics produced by variance in geometry. Common carotid bulb wall thickness measurements after CEA are not predictors or indicators of recurrent stenosis.