bluuebunny/crossref_metadata_2025 huggingface dataset:
The Case for an in Situ Lesser Saphenous Vein Bypass
Authors: Oderich Gustavo S. , Panneton Jean M.
Published: June 2007

In situ lesser saphenous vein (LSV) graft has been advocated in cases where the greater saphenous vein is not available and the target arteries are confined to the lower leg. This is often the case of diabetic patients, whose occlusive disease pattern typically affects the tibioperoneal vessels, sparing the femoropopliteal segment. The in situ technique offers the potential advantages of decreasing surgical trauma to the vein and its vasa vasorum, better size-matching between vein and artery at the anastomoses, and improving hemodynamics. The authors reviewed the use of in situ LSV graft with attention to its indications and technical requirements. A 73-and a 76-year-old man presented with critical limb ischemia. Both had a history of diabetes, chronic renal failure, and previous use of the greater saphenous veins for coronary or peripheral bypasses. Both had good femoropopliteal inflow and tibioperoneal disease with single runoff through the distal peroneal and common plantar arteries, respectively. Venous mapping showed diminutive veins, with exception of an adequate ipsilateral lesser saphenous vein. The patients were placed in prone position for a posterior approach. The lesser saphenous veins were exposed through a longitudinal incision. Proximal anastomosis was based on the popliteal artery, exposed through the same incision. A successful in situ lesser saphenous vein bypass was performed by using the common plantar and the distal peroneal artery as target vessels. Both bypasses were patent at 24 and 18-months' follow-up, respectively. Selection criteria for in situ LSV bypass are patent femoral arteries; accessible target vessels in prone position through a medial, posterior, or lateral approach; and adequate LSV in diameter and length. In the authors' experience, in situ LSV bypass is a safe and simple option that offers successful distal revascularization.
Endovascular Treatment of Mycotic Hepatic Artery Aneurysm in the Hostile Abdomen
Authors: Georges Renee N. , Lipman Steven , Silvestri Fred , Sussman Barry , Dardik Herbert
Published: June 2007

Mycotic hepatic artery aneurysms are rare. This report documents a case in which a mycotic hepatic artery aneurysm was associated with Crohn's disease, renal adenocarcinoma, and a urinary tract infection. Endovascular management of this mycotic hepatic artery aneurysm was successful in the setting of a hostile abdomen based on multiple previous operations, a stoma, and a scarred abdomen.
Bypasses to Tibial Vessels Using Polytetrafluoroethylene as the Solo Conduit in a Predominantly Diabetic Population
Authors: Hamdan Allen D. , Rayan Sunil S. , Hook Shannon C. , Campbell David R. , Akbari Cameron M. , LoGerfo Frank W. , Pomposelli Frank B.
Published: June 2007

The authors reviewed the Vascular Surgery Registry at the Beth Israel Deaconess Medical Center between 1990 and 1996 and identified 45 patients (47 limbs) who underwent bypass with polytetrafluoroethylene alone to infra-popliteal vessels. This represented only 2.6% of total tibial bypasses performed during that time. Sixty-nine percent of patients had diabetes. Indication for bypass was limb salvage in 96% of patients. Primary and secondary patency rates at 30 days, 1, 3, and 5 years were 87%, 87%; 58%, 60%; 41%, 43%; and 36%, 39%; respectively. Limb salvage rates at 30 days, 1, 3, and 5 years were 91%, 68%, 63%, and 63%. Cumulative survival rates at 3 and 5 years, however, were 53%, and 42%. The 29 grafts (64%) that were postoperatively anticoagulated with sodium warfarin showed trends in improved primary patency (47% vs 19%, p = 0.07), secondary patency (49% vs 20%, p = 0.03), and limb salvage (67% vs 58%, p = 0.06), at 3 years. There were no significant differences between diabetics and non-diabetics except in a trend toward decreased patient survival at 3 and 5 years in the diabetic population. Postoperatively, there were no deaths but there were two (4.2%) major cardiac complications. These data support the judicious use of tibial vessel bypass using PTFE in selected patients for limb salvage when autologous vein is not available. Diabetic patients appear to have similar results to non-diabetics and the postoperative use of sodium warfarin is beneficial.
B-Mode Ultrasound Measurement of Carotid Bifurcation Stenoses: Is It Reliable?
Authors: Mackenzie Kent S. , French-Sherry Eilleen , Burns Karen , Pooley Tom , Bassiouny Hisham S.
Published: June 2007

In the majority of cases, duplex ultrasonography (DU) is the sole imaging study necessary before carotid interventions. Duplex-derived internal carotid artery (ICA) peak systolic velocity (PSV), ICA end-diastolic velocity (EDV) and ICA/common carotid artery (CCA) PSV ratio are the most commonly utilized parameters for predicting critical carotid stenoses. However, the role of direct B-mode image measurement of maximal ICA narrowing is ill defined. The images and records of 192 patients who underwent both arteriography and duplex ultrasonography (DU) of 375 carotid arteries from January 1995 to November 2000 were reviewed. All DUs were performed by registered vascular technologists (n = 6). Maximum arteriographic stenosis was determined according to the NASCET study design. With arteriography as the “gold standard,” B-mode image (BMI) measurement of the maximal ICA luminal narrowing relative to the carotid bulb (n = 162) as well as the peak systolic velocity in the internal carotid artery (PSVICA) (n = 330), end-diastolic velocity in the internal carotid artery (EDVICA) (n = 198), and the ratio of the PSVs in both the ICA and the CCA (PSVICA/CCA) ratio (n = 319) were subjected to receiver operator characteristics (ROC) curves for 3 clinically relevant stenoses thresholds: 50-99%, 60-99%, and 70-99%. A strong correlation was found between B-mode image (BMI) and the NASCET arteriographic measures of carotid stenosis (r=0.80; p<0.001) and was similar among the 6 technologists (r=0.74-0.89; p>0.2). The overall accuracy of BMI measurement to diagnose 50%, 60%, and 70% arteriographic carotid stenosis was 85.3%, 82.2%, and 87%, respectively. BMI measurement was similar to the most accurate PSVICA, EDVICA, and PSVICA/CCA ratio at all 3 threshold stenoses levels (p>0.3). When combined with the velocity criteria, BMI measurement improved the positive predictive value (PPV) for all arteriographic stenoses thresholds by an average of 12.6% for PSVICA, 21.2% for EDVICA, and 14.2% for PSVICA/CCA ratio. BMI measurement of carotid bifurcation narrowing is as reliable as duplex-derived velocity criteria in evaluating clinically relevant threshold ICA stenoses. The routine use of B-mode ultrasound in conjunction with the velocity parameters enhances the PPV of carotid DU. Our experience suggests that with current refinements in B-mode resolution, BMI stenosis measurements are accurate among experienced technologists and are a useful adjunct to duplex-derived velocity parameters.
Anglographic Access Site Complications in the Era of Arterial Closure Devices
Authors: Meyerson Shari L. , Feldman Ted , Desai Tina R. , Leef Jeffrey , Schwartz Lewis B. , Mckinsey James F.
Published: June 2007

Coronary and peripheral angiography is associated with a low but significant risk of access site complications. While percutaneous devices have been shown to permit more rapid puncture site closure, previous reports have suggested the incidence and severity of complications associated with these devices are greater than with manual compression. This study compares access site complications with and without closure devices in the current era. The authors conducted a retrospective review of patients with access site complications after coronary or peripheral angiography between 1998 and 2000. Forty-five complications requiring vascular surgical consultation were identified in the 4,800 procedures performed during this time period. Fourteen complications occurred in 1,536 procedures (0.9%) using suture-mediated or collagen devices and 31 occurred in 3,264 procedures without devices (0.9%). The types of procedures and catheter sizes (mean 7 Fr) used were not different in the 2 groups. Other than complications involving a retained device, there was no difference between device and manual compression with respect to incidence or types of complication, requirement for operation, type of operation, or outcome. Access site complications identified included pseudoaneurysm (n = 22; 49%), bleeding or hematoma (n = 8; 18%), arteriovenous fistula (n =5; 11%), arterial thrombosis (n = 4; 9%), infection (n = 4; 9%), and retained device (n = 2; 4%). Twenty-four patients (71% vs 45%; p=NS) required operative intervention including pseudoaneurysm repair, hematoma drainage, and thrombectomy. Eleven patients (26%) underwent successful ultrasound-guided pseudoaneurysm compression and 9 patients (21%) required no intervention. These data demonstrate that closure devices facilitate arterial puncture site repair without an increase in access site complications. These devices can be safely utilized when rapid hemostasis is desired after coronary or peripheral angiography.
Iliac Graft Access to Facilitate Endovascular Repair of a Ruptured Thoracic Aortic Aneurysm
Authors: Schmidli J. , Do D. D. , Triller J. , Widmer M. K. , Savolainen H. , Carrel T.
Published: June 2007

Arterial access for endovascular aortic aneurysm repair is usually gained through a common femoral artery approach. In small femoral arteries this can be difficult or even impossible owing to the large size of the introduction sheath of the delivery system. In such cases the iliac arteries or the abdominal aorta can be used for vascular access, although, in heavily calcified arteries, even this can be hazardous. The authors report an 81-year-old woman with a contained rupture of the thoracic aorta in whom a polyester graft was used to facilitate vascular access to the common iliac artery for a safe two-stage endovascular repair of the aneurysm.
Coronary Artery Bypass Grafting for Patients with Aortoiliac Occlusive Disease
Authors: Hirose Hitoshi , Nakano Hidetaka , Amano Atsushi , Takahashi Akihito
Published: June 2007

Harvest of the internal thoracic artery (ITA) in patients with aortoocclusive disease carries a risk of leg ischemia. Staged revascularization of the lower extremities and coronary artery in patients with aortoiliac occlusive disease with collateral vessels to the lower extremities via the ITA is reported. Revascularization of the aortoiliac occlusion prior to coronary artery bypass grafting can be performed in stable patients with appropriate perioperative coronary precautions. In patients with unstable angina and aortoiliac occlusion with collateral vessels to the leg via the ITA, coronary artery bypass grafting should be performed without using the ITA.
Mycotic Carotid Artery Pseudoaneurysm Following Stenting
Authors: Grazziotin Marcello U. , Strother Charles M. , Turnipseed William D.
Published: June 2007

Carotid stenting is assuming an important role in the management of carotid disease. Surgeons although hesitant to embrace catheter treatment for the management of primary carotid artery disease, are more enthusiastic regarding it's use in the treatment of recurrent stenoses. This report suggests that caution should be exercised in the selection of patients to be treated with carotid stenting for recurrent disease.
Ophthalmologic Findings as Predictors of Carotid Artery Disease
Authors: Lawrence Peter F. , Oderich Gustavo S.
Published: June 2007

Vascular events that occur in the brain also occur in the eye, giving rise to different ophthalmologic manifestations that range from amaurosis fugax to complete blindness due to central retinal artery occlusion. The objective of this study was to ascertain the relative frequency and predictive value of ocular findings suggestive of carotid occlusive disease in patients being investigated for carotid endarterectomy. The charts of 366 patients undergoing carotid angiography for evaluation of cerebrovascular or visual symptoms over a 5-year period were reviewed. The presence of eye symptoms, neurologic symptoms, cervical bruits, and ophthalmologic findings on admission was recorded and correlated with the presence of significant carotid artery stenosis (? 50%). Positive eye findings included retinal plaques, rubeosis iridis, neovascular glaucoma, venous stasis retinopathy, central and branch retinal artery occlusion, ischemic optic neuropathy, and asymmetric hypertensive retinopathy. Seventy-five patients (21%) presented with amaurosis fugax; 41 patients (11%) were found to have one or more ocular findings consistent with carotid artery disease. All patients with positive eye findings were diagnosed by ophthalmologists, who were consulted in 94 cases. Of these 41 patients, 29 (70.3%) were subsequently shown to have greater than 50% stenosis of the common or internal carotid artery. Ten patients had amaurosis fugax, a carotid bruit, and positive eye findings. All were shown to have a significant carotid stenosis. This study shows that ocular pathology, if diagnosed, is correlated with carotid stenosis, especially if other contributing history and physical findings are also considered.
Noninvasive Measurement of Shear Rate in Autologous and Prosthetic Bypass Grafts
Authors: Setty Shaun P. , Salles-Cunha Sergio , Scissons Robert , Begeman Garett , Farison James , Beebe Hugh G.
Published: June 2007

There is a major difference in thrombogenicity between lower extremity prosthetic and autologous vein bypass grafts, and arterial blood flow shear rate is known to influence thrombus formation. Despite this association, there has been little direct clinical observation of shear rates in bypass grafts. The authors developed a new noninvasive method to quantitate human arterial shear rate and used it in a pilot study to characterize differences in lower extremity bypasses. Shear rates were measured in 10 prosthetic and 14 autologous vein femoropopliteal bypass grafts. With CVI-M-mode color flow ultrasonography in resting supine patients, a velocity profile was recorded from a midgraft longitudinal section in the ultrasound beam direction. Shear rates were calculated by using a mathematical-graphic computer program at the anteromedial (near) and posterolateral (far) graft walls by averaging values immediately before and after peak systolic velocity (PSV). Comparison between prosthetic and autologous graft groups respectively revealed that differences in age (67 ± [S] vs 71 ± 10 yr), male gender (60% vs 43%), prevalence of hypertension (50% vs 71%), diabetes (40% vs 64%), smoking (50% vs 50%), hypercholesterolemia (30% vs 29%), coronary artery disease (60% vs 50%), and critical ischemia (60% vs 86%) did not reach statistical significance (p>0.19). Median PSVs were significantly less in prosthetic than in autologous vein bypasses (37 ± 13 vs 57 ±22 cm/s, p = 0.018). Prosthetic and autologous graft diameters were not statistically significantly different (6.3 ± 1.1 vs 5.6 ± 1.3 mm, p = 0. 18). Shear rates were significantly less in prosthetic than in autologous vein bypasses both at the near wall (382± 146 vs 698 +271 s-1, p=0.003) and at the far wall (551 ±235 vs 827 ±339 s-1, p=0.037). This mathematical model can be used to calculate shear rate from observed ultrasound flow patterns. Prosthetic bypass grafts had lower shear rates than autologous vein grafts.
Prediction of Arteriovenous Access Steal Syndrome Utilizing Digital Pressure Measurements
Authors: Papasavas Pavlos K. , Reifsnyder Thomas , Birdas Thomas J. , Caushaj Philip F. , Leers Steven
Published: June 2007

Steal syndrome is a well-known complication of arteriovenous (AV) access placement. To assess the derangement in hemodynamics of the upper extremity after AV access creation, brachial and digital pressures were performed before and after operation. Thirty-five patients (ages 20-88 years) with end-stage renal disease requiring new upper extremity hemodialysis AV access were prospectively evaluated. Values were obtained preoperatively, on the day of surgery, and 1 month postoperatively. Follow-up at 1 year was obtained on all patients. Of the 35 patients, 19 (54%) were diabetic and 9 (26%) had had a prior AV access. The AV accesses created included the following: autogenous brachial-cephalic (n = 14, 40%), autogenous radialcephalic (n = 10, 29%), brachial-basilic transposition (n =5, 14%), prosthetic brachial-antecubital forearm loop (n = 3, 9%), autogenous brachial-axillary saphenous vein translocation (n = 2, 6%), and 1 (3%) prosthetic brachial-axillary. After AV access creation the digital brachial index (DBI) dropped in 28 (80%) of the 35 patients. Six patients (17%) developed a symptomatic steal, 3 of which (9%) eventually required revision. In those patients without ischemic steal symptoms (n=29) the mean DBI decreased from 0.9 to 0.7 (p<0.01) immediately and decreased no further at 1 month. For those with a symptomatic steal the DBI decreased from 0.8 to 0.4 (p < 0.01) immediately and decreased no further at 1 month. Utilizing a DBI less than 0.6, the sensitivity was 100%, the specificity 76%, the positive predictive value 46%, and the negative predictive value 100%. Hemodynamic steal after AV access creation is very common, with symptomatic steal occurring nearly a fifth of the time. Utilizing digital pressure measurements, a DBI less than 0.6 obtained on the day of surgery can reasonably predict which patients are at risk for the development of a symptomatic steal.
Surgical Intervention for Acute Intestinal lschemia: Experience in a Community Teaching Hospital
Authors: Char Daniel J. , Cuadra Salvador A. , Hines George L. , Purtill William
Published: June 2007

The aim of this study was to evaluate the current management of acute mesenteric ischemia secondary to thrombotic or embolic occlusion of visceral vessels in a community teaching hospital. Between October 1997 and July 2000, a review of all hospital discharges revealed 83 patients with a discharge diagnosis of “acute vascular insufficiency-intestine.” Among these 83 patients, 22 cases of acute mesenteric ischemia were confirmed. Management of these 22 patients was divided into 2 groups for analysis. In Group A, 14 patients were aggressively treated with visceral angiography (n = 10), visceral artery bypass (n = 8), visceral embolectomy (n = 4), and bowel resection (n = 7). In 8 of 14 of these patients, surgical intervention occurred in less than 24 hours from presentation. In Group B, 8 patients were managed with supportive care because of advanced age (mean age = 86 ±7 years), comorbid conditions, or patient and family preference. Postoperative morbidity in Group A consisted of cardiac events (n = 3), pulmonary insufficiency (n = 5), and prolonged gastrointestinal tract dysfunction (n = 3). Twelve of 14 patients in Group A survived and were discharged, whereas only 2 of 8 patients in Group B survived and were discharged from the hospital. Although the literature suggests that there can be a significant delay in the diagnosis and treatment of acute mesenteric ischemia, the early recognition and aggressive treatment of acute mesenteric ischemia resulted in a good survival rate. Supportive management of very elderly and debilitated patients needs to be considered on a case-by-case basis. Although the outlook for such patients is dismal, survivors are possible as demonstrated by this series.
Intraoperative Thermographic Monitoring During Neurogenic Thoracic Outlet Decompressive Surgery
Authors: Ellis Wladislaw , Cheng Stephen
Published: June 2007

This article reports the use of thermography to monitor 123 plexus decompressions for neurogenic thoracic outlet syndrome. The diagnosis and management of this disease continues to be controversial. Questions about pathologic mechanisms, the extent and frequency of muscular entrapment, scar, and interdigitations, as well as their relative contributions, remain. Thermographic visualization of the operated extremity allowed us to map and correlate thermal changes with specific surgical manipulations, as well as to analyze the tissues resected to better answer these questions. Initial thermal abnormalities indicating, usually, ulnar entrapments or irritation, normalized sequentially as discrete entrapments were resected. Thermographic monitoring continues to provide surgically useful information in one third of operations.
Primary Utilization of Stents in Angioplasty of Superficial Femoral Artery
Authors: Wolosker Nelson , Nakano Lívio , Anacleto Marcia Maria Morales , Puech-Leão Pedro
Published: June 2007

Percutaneous transluminal angioplasty (PTA) of infrainguinal arteries has been frequently reported in the literature. Independent of the technical feasibility, the results, in shortand long-term follow-up differ among published series. The objective of this article was to assess the long-term results of angioplasty in small, (<3 cm) segmental lesions of the superficial femoral artery treated with primary stenting. Eighteen patients (12 men, 6 women) with lesions of the superficial femoral artery smaller than 3 cm were selected for endovascular treatment and follow-up. The median patient age was 65 years (range, 54 to 84). The indication for treatment was intermittent claudication in 7 patients and critical ischemia (ischemic pain associated with trophic lesions) in 1 1 patients (62%). Of these, 13 lesions were stenoses and 5 total occlusions. The run-off was good in 15 patients who had more than 2 distal arteries and 3 had only 1 patent artery. During follow-up, all patients were observed with physical examination, progressive exercise treadmill test; pulse volume was measured with Doppler and duplex scan after 1, 3, and 6 months, and then twice a year. There was only 1 primary failure; the initial success rate was 94%. During follow-up of 40 months (6 to 70 months), only 1 patient presented with thrombosis of the stent 6 months after the procedure. There was no symptomatic restenosis in our study. One patient suffered an acute myocardial infraction after 45 months and died. The primary patency after 1 and 3 years was 88%. No patient was lost to follow-up. Primary stenting of segmental lesions (less than 3 cm) of the superficial femoral artery produced satisfactory results immediately and during long-term follow-up.
Small Ruptured Abdominal Aortic Aneurysm with Renal Failure: Endovascular Treatment
Authors: Melissano Germano , Moura Marcelo R. L. , Tshomba Yamume , Marone Enrico Maria , Chiesa Roberto
Published: June 2007

The successful endovascular exclusion of a ruptured 3-cm diameter atherosclerotic abdominal aortic aneurysm (AAA) in a high-risk patient with renal failure is reported. An 82-year-old man with chronic renal failure and other comorbidities was admitted for acute abdominal pain. Duplex scan and computed tomography showed a ruptured 3-cm diameter atherosclerotic AAA. As a consequence of the patient's high surgical risk combined with signs of rupture, despite the progressively decreasing renal function, an emergency exclusion of the AAA was performed by means of a bifurcated Excluder (W. L. Gore and Associates) endovascular graft. The procedure was performed by minimizing administration of iodinated contrast medium using a guidewire into the lowest renal artery as a marker of proximal deployment. Intravascular ultrasound was used to confirm correct deployment. The postoperative recovery was characterized by acute renal insufficiency and bowel ischemia, which were treated with ultrafiltration and medical therapy, respectively, with complete resolution.
Role of Residual Defects Following Carotid Endarterectomy in the Occurrence of Cerebrovascular Symptoms
Authors: Liapis Christos D. , Paraskevas Kosmas I.
Published: June 2007

Carotid endarterectomy deals successfully with carotid atheromatous lesions, thus eliminating a potential source of cerebral emboli. At times, however, residual hemodynamic irregularities may occur as a result of technique imperfection or anatomic variations. These irregularities have been associated with a number of immediate and late postoperative complications, such as recurrent cerebrovascular symptoms and secondary episodes of stroke. For this reason, the detection of flow abnormalities or intimal defects in patients undergoing carotid endarterectomy and the achievement of normal intraoperative and postoperative hemodynamics are essential for the elimination of potentially life-threatening perioperative and late cerebrovascular events.
Clamp Before You Cut: Proximal Control of Ruptured Abdominal Aortic Aneurysms Using Endovascular Balloon Occlusion
Authors: Arthurs Zachary , Starnes Benjamin , See Craig , Andersen Charles
Published: June 2007

While the mortality rate for elective abdominal aortic aneurysm (AAA) repair has declined over the last several decades, the rate for ruptured abdominal aortic aneurysm (RAAA) has unfortunately remained disturbingly high. Undiagnosed aneurysms may present with little warning until abdominal pain, syncope, and hypotension signify rupture. Fifty percent of patients with ruptured aneurysms die before reaching a medical facility, and their survival is highly dependent on hemodynamic stability at presentation. The degree of rupture containment and comorbid status of the patient determine hemodynamic stability. Endovascular stent grafting has significantly improved perioperative morbidity and mortality rates for elective AAA repair, and some of the same endovascular techniques can be used to obtain proximal control in patients presenting with RAAA. We describe 3 consecutive cases of RAAA where proximal control was obtained using a percutaneously placed, transfemoral aortic occlusion balloon before induction of anesthesia.
Current Management of Extracranial Carotid Artery Disease
Authors: Faries Peter L. , Chaer Rabih A. , Patel Sheela , Lin Stephanie C. , DeRubertis Brian , Kent K. Craig
Published: June 2007

Stroke is the third most common cause of death in the United States. There are approximately 700,000 strokes/year; 80% are ischemic, and 20-30% of ischemic strokes are secondary to carotid disease. Carotid stenosis is traditionally treated by carotid endarterectomy (CEA). Multicenter, randomized, controlled trials have shown that surgery significantly reduces the risk of ipsilateral stroke in patients with severe symptomatic and asymptomatic carotid stenosis. Endovascular techniques for treating carotid stenosis have been developed over recent years. Carotid angioplasty and stenting (CAS) with cerebral protection has become an alternative to CEA for high-surgical-risk patients and the procedure of choice for stenoses inaccessible by surgery. In this review we summarize the existing data regarding the traditional state of management of extracranial carotid artery stenosis and compare these data to a critical analysis of the recent results of CAS.
Cerebrospinal Fluid Drainage in the Treatment of Spontaneous Spinal Cord Ischemia: A Case Report
Authors: Abisi Said , Sayer Gabriel L. , Tan Justin , Burnand Kevin G.
Published: June 2007

A patient with spontaneous acute spinal cord ischemia successfully treated with cerebrospinal fluid drainage is reported. There are no consensus guidelines on the management of spinal cord ischemia. Various preventive and rehabilitative measures have been suggested, but the best treatment remains unknown.
Traumatic Pseudoaneurysm of the Popliteal Artery After Blunt Trauma: Case Report and a Review of the Literature
Authors: Megalopoulos Aggelos , Siminas Sotirios , Trelopoulos Georgios
Published: June 2007

Pseudoaneurysms of the popliteal artery following trauma are rare lesions. We present 3 cases of pseudoaneurysms of the popliteal artery (4, 20, and 45 years old respectively) with a delayed presentation, following blunt trauma, presenting over a 3-year period, and a short review of the relevant literature. A delayed pattern of presentation, over 2 years after blunt popliteal trauma, was observed in all patients. They presented with a painful pulsatile mass in the popliteal fossa, and their peripheral pulses were normal. Orthopedic and rheumatologic evaluation findings were negative. Diagnostic evaluation included triplex, arteriography, and computed tomography angiography. A posterior popliteal approach was used, and after aneurysmal excision, reversed great saphenous vein and lesser saphenous vein (1 patient) grafts were used. After 2 to 4 years of follow-up, all grafts remain patent and the patients have fully functional limbs. A literature search revealed 70 cases of pseudoaneurysms of the popliteal artery reported in civilian settings. These lesions should be repaired shortly because their complications (rupture, thromboembolic episodes) carry a high risk for limb dysfunction and amputation. Penetrating or blunt trauma is the main causative factor (62.5%), but iatrogenic trauma accounts for an increasing number of reports (37.5%). Strict follow-up of popliteal trauma is essential. A high level of suspicion and awareness can lead to early diagnosis and treatment of pseudoaneurysms of the popliteal artery and prevent the serious complications associated with these lesions.
Current Trends in the Management of Iatrogenic Cervical Carotid Artery Injuries
Authors: Mussa Firas F. , Towfigh Shirin , Rowe Vincent L. , Major Kevin , Hood Douglas B. , Weaver Fred A.
Published: June 2007

This study was undertaken to elicit the opinion of experts regarding the management of iatrogenic injury to the carotid artery. A text questionnaire was transmitted by electronic mail to members of the Western Vascular Society concerning management of iatrogenic injury to the cervical carotid artery. Participants were asked to submit information regarding practice status and their preferred choices for the management of different clinical scenarios. The scenarios were: (1) large bore sheath (> 8.5F) cannulation of the carotid artery in anesthetized patients, (2) large bore sheath cannulation of the carotid artery in an awake patient, (3) delayed recognition of a misplaced sheath by > 4 hours, and (4) arterial puncture was recognized after only the entry needle (16-gauge) was introduced but before sheath insertion. Finally, the members were asked to comment on the management of abnormal findings on duplex scanning, such as intimal flap or pseudoaneurysm. A response rate of 42% was obtained (45/106 active members). Eighty-two percent of respondents had been in practice for longer than 10 years. Eighty-nine percent had seen this complication and 29% had cared for patients in whom subsequent neurologic deficit developed. The institutional incidence of such injury was 1-5 cases per year for 82% of respondents. Sixteen-gauge needle injury was managed by immediate removal and applied pressure by 98% of respondents. When large-bore sheath injury is recognized within 1 hour of insertion, 62% of respondents would remove the sheath and hold pressure, with or without obtaining a duplex ultrasound examination. However, if injury recognition was delayed for > 4 hours, 82% would proceed to surgery. Only 26% operated on asymptomatic carotid flap found on ultrasound, while the remaining 74% would base their decision on size and flow characteristics on ultrasound. The management of pseudoaneurysm differed significantly. Whereas 31% of respondents would manage this finding expectantly, 69% would proceed to surgery regardless of size or symptoms. Despite awareness of iatrogenic injury to the cervical carotid artery, the institutional incidence remains high. Two thirds of respondents would manage a misplaced sheath in the carotid artery nonoperatively if the injury was recognized immediately. However, if injury recognition was delayed for > 4 hours, the majority of respondents would remove the sheath surgically. While the management of intimal flap largely depended on size and flow characteristics, 69% of respondents would operate on a pseudoaneurysm regardless of size or symptoms. The results of this survey may serve as a guideline for the management of this potentially devastating injury.
Laser Atherectomy for Lower Extremity Revascularization: An Adjunctive Endovascular Treatment Option
Authors: Zhou Wei , Bush Ruth L. , Lin Peter H. , Peden Eric K. , Lumsden Alan B.
Published: June 2007

Excimer laser atherectomy (LA) employs precision laser energy control (shallow tissue penetration) and safer wavelengths (ultraviolet as opposed to the infrared spectra in older laser technology), which decreases perforation and thermal injury to the treated vessels. Though extensively used by cardiologists for severe obstructive coronary artery disease, peripheral interventionalists have not accepted LA as a routine adjunctive technique for stenotic or occluded vessels. We report herein the technical and clinical outcomes with LA for complex peripheral vascular disease in patients deemed high-risk for conventional surgical revascularization. Over a 6-month period, 19 lesions in 15 high-risk patients (mean age 72 ±10 years) were treated with LA (308-nm spectral wavelength) followed by balloon angioplasty for limb-threatening ischemia (n=10) and severe disabling claudication (n=5). The lesions were located at the superficial femoral artery (n=8), popliteal artery (6), and/or tibial vessels (5). The mean occlusion length was 10.3 ±2.3 cm. Laser catheter choice ranged from 1.4 to 2.5 mm depending on the target vessel diameter. Clinical examination, duplex ultrasound, and ankle-brachial indices were performed in follow-up visits. Immediate technical success was achieved in 16 (84%) lesions. In the 3 technical failures, inability to cross the lesion with a wire (n=2) or vessel perforation (n=1) precluded successful LA. Overall, primary patency as assessed by duplex was 57% (superficial femoral artery 71%, popliteal 60%, tibial vessels 25%). Clinical improvement was seen in 10 lesions (77%) that were successfully treated initially. One patient required below-knee amputation. At an average of 2-year follow-up, 6 patients who were initially successfully treated were alive (46%), including 3 patients (50%) with stable symptoms without the need for major amputation. Laser atherectomy is a useful adjunctive revascularization technique for high-risk patients with limb-threatening ischemia. This technique is especially beneficial in the treatment of ostial lesions, which may be prone to distal embolization, as well as total occlusions that can be traversed by a guide wire but not a balloon. Vascular surgeons should add LA to their endovascular armamentarium for the treatment of complex peripheral vascular disease in the high surgical risk patients. Further study of clinical outcome measures and comparison to other interventional techniques are warranted.
Peripheral Arterial Embolism: Prevalence, Outcome, and the Role of Echocardiography in Management
Authors: Gossage J. A. , Ali T. , Chambers J. , Burnand K. G.
Published: June 2007

The aims of this study were to review the prevalence and outcome of all surgically treated upper and lower limb emboli presenting to one vascular unit in the last 3 years and to compare transthoracic with transesophageal echocardiography for defining the source of the embolus. All patients who underwent surgical embolectomy for acute limb ischemia from January 2001 to June 2004 were reviewed. Transthoracic and transesophageal echocardiography were carried out on a subset of consecutive unselected patients. Forty-two patients, with a mean age of 80 years, underwent surgical embolectomy from January 2001 to June 2004 (M/F 1:1.8): 27 for lower limb ischemia and 15 for upper limb ischemia. Two thirds of these patients were found to be in atrial fibrillation at presentation (n=28), of whom less than a third were receiving anticoagulants or antiplatelet agents (n=8). The mean hospital stay was 15 days with 36 patients (86%) being fully anticoagulated before discharge from hospital. The 30-day mortality rate was 11% (n=3/27) with 5 patients requiring fasciotomies (12%) and 3 patients requiring an amputation of the lower limb (11%). Postoperatively, 34 patients (81%) had transthoracic echocardiography (TTE), which demonstrated a source or potential source for thrombus in 19 (56%). Fifteen patients (36%) had transesophageal echocardiography (TEE), which changed the subsequent management in 3 patients. All patients in whom TEE altered clinical management would have required this investigation if standard clinical guidelines were followed. TEE did not identify any additional patients with cardiac embolic sources that were not detected by TTE. Arterial limb emboli are still prevalent, but limb salvage and mortality rates appear to be improving. Despite clear guidelines on anticoagulation for patients in atrial fibrillation, many are not receiving appropriate treatment. Transthoracic echocardiography is a good screening tool for detecting a potential cardiac source for peripheral embolism, with transesophageal echocardiography being reserved for specific indications.
Critical Limb Ischemia in the Dialysis-Dependent Patient: Infrainguinal Vein Bypass Is Justified
Authors: Townley W. A. , Carrell T. W. G. , Jenkins M. P. , Wolfe J. H. N. , Cheshire N. J. W.
Published: June 2007

The combination of critical limb ischemia and end-stage renal failure (ESRF, ie, dialysis- dependent) represents severe systemic atherosclerosis and is associated with a very poor medium-term survival. Many nephrologists and surgeons advocate primary amputation. We examined the recent experience in this unit to determine whether infrainguinal bypass in these patients can be justified. Retrospective study of all patients with critical limb ischemia and ESRF undergoing surgery in a regional vascular and renal unit between January 1996 and May 2003. Forty-two patients with ESRF (median age 65 years) were referred with critical limb ischemia. Seventeen patients underwent 24 (7 bilateral) infrainguinal bypasses (17 autologous vein, 7 polytetrafluoroethylene [PTFE] conduit; tissue loss in 21/24, 88%), and 25 patients had primary major amputations of 32 limbs. Early occlusion occurred in 5 grafts (21%, all 5/5 PTFE). In-hospital mortality was 13% in the bypass group, 24% in the amputation group. Median in-hospital stay was 59 days in the bypass group, 46 days in the amputation group. Thirty-day, 1- and 2-year survival was 88%, 50%, and 33% in the bypass group; 83%, 39%, and 35% in the amputation group. The limb salvage rate was 66% at 1 year. Seventy-five percent (18/24) of operated on limbs (15/17 of vein grafts) avoided major amputation at follow-up (median 18 months) or death. The combination of critical limb ischemia and end- stage renal failure carries a poor medium-term survival independent of primary amputation or surgical revascularization. Infrainguinal bypass in selected cases with vein conduit can, however, allow the majority of these patients to avoid major limb amputation.
Cor Triatriatum Dexter Echocardiographic Diagnosis and Successful Surgical Correction in an Infant
Authors: Erk M. Kamuran , Kolbakir Ferşat , Baysal Kemal , Keqeligil Tahsin
Published: June 2007

Cor triatriatum dexter is a very rare cardiac malformation in which the right atrium is subdivided into two distinct chambers. The authors report the case of a three-day-old infant boy with body weight of 2.8 kg, severely symptomatic, with highly obstructive cor triatriatum dexter and patent foramen ovale. The malformation was diagnosed by two-dimensional echocardiography and corrected successfully by surgery.
Pacemaker Malfunction Due to Subcutaneous Emphysema
Authors: Santomauro Maurizio , Ferraro Sergio , Maddalena Giovanni , Fazio Serafino , Covino Elvio , Pappone Carlo , Spampinato Nicola , Chiariello Massimo
Published: June 2007

The authors describe a case of pacemaker malfunction due to a critical increase of impedance resulting from air entrapment in the pacemaker pocket.
Budd-Chiari Syndrome: With Emphasis on Surgical Management
Authors: Yoshioka Hiroaki , Hoover Eddie , Imahori Shiro , Lago Charles , Seibel Roger , Yaukoolbodi Samret , Ricotta John
Published: June 2007

Budd-Chiari syndrome (BCS) is a rare and often fatal disorder characterized by hepatic venous outflow obstruction. The occlusion is most often caused by thrombosis of the major hepatic veins and occasionally involves the inferior vena cava (IVC). This syndrome is associated with a variety of intraabdominal as well as systemic disorders. This report presents 2 cases of BCS in which both patients had polycythemia vera and 1 had a mildly decreased level of antithrombin III. A side-to-side portacaval shunt was performed in 1 patient and a mesoatrial shunt in the other owing to concomitant obstruction of the IVC. Dramatic improvement in the status of the liver was demonstrated by a follow-up biopsy in the latter patient.
Vascular Tone and Contractility During Exposure to Cardioplegia and Hyperkalemic Solutions
Authors: He Guo-Wei , Yang Cheng-Qin
Published: June 2007

Hyperkalemic cardioplegic solutions have been widely used for myocardial protection. A commonly accepted concept is that cardioplegic solutions may evoke vasospasm due to the high potassium (K+) concentration in the solutions. However, little has been known about coronary vascular tone and contractility during ischemia and reperfusion. The present study was designed to test the hypothesis that hyperkalemic cardioplegic solutions may increase the vascular tone during exposure and increase the contractility during reperfusion.

Porcine coronary artery (PCA) and neonatal rabbit aortic (RAO) rings were set up in organ baths under a physiologic pressure. In addition, the effect of reexposure to K+ on contractility was studied in the human internal mammary artery (HIMA). The solutions were continuously aerated with 95% 02 and 5% Co2 to exclude the effects of ischemia and hypoxia. The effect of Krebs containing 5.9 or 50 mM K+, or St. Thomas' cardioplegic solution No. 2 (ST) containing 16 or 50 mM K+ on vascular tone for four hours was examined. In other groups, after two-hour-incubation, the rings (n= 5 in PCA and n= 6 in RAO in each subgroup) were washed and cumulative concentrationcontraction curves were established.

During four-hour-exposure to ST, the rings were relaxed (−0.38 ±0.07 g in PCA and -0.43 ±0.13 g in RAO, n = 6, P ≥ 0.001). In comparison with 50 mM K+ in Krebs, ST with 50 mM K+ induced a significantly reduced contraction with a slow onset in both vessels. After two-hour-exposure to ST the RAOs had almost unchanged contractility whereas those exposed to 50 mM K+ had enhanced contractility. Reexposure to K+ (100 mM) significantly enhanced the contraction in the HIMA.

These results suggest that despite its high K+ concentration St. Thomas cardioplegic solution does not evoke vasoconstriction during exposure in either PCA or RAO. In contrast, it relaxes these vessels during four-hour exposure. The study also demonstrates that although two-hour-exposure to extra−-K±added (50 mM) physiologic or cardioplegic solutions enhances the contractility in RAO, the exposure to ST is unlikely to do so. It remains to study whether microvasculature has similar reaction during and after exposure to hyperkalemia and whether combined factors such as ischemia affect the reaction.
Lower Extremity Amputations in Adults Less Than Forty Years of Age: An Underestimated Risk from Premature Atherosclerosis
Authors: Levy Pavel J. , Hornung Carlton A. , Rush Daniel S.
Published: June 2007

Between 1987 and 1992, 57 patients aged twenty-five to forty (average, 34.0 ±4.5 years) underwent major lower extremity amputations in five community hospitals, including a Level II Trauma Center. Only 19 (33%) patients had traumatic amputations, 3 (5%) had malignant tumors, and 4 (7%) had juvenile-onset diabetes mellitus without atherosclerotic involvement of the large arteries. Thirty (53%) patients had premature atherosclerosis (PAS) of the lower extremities with end-stage renal disease (ESRD) present in half and related to diabetes in 12. All patients with ESRD required continuous dialysis therapy. Overall 19 (33%) patients in this study had diabetes. Of 32 patients < thirty-five years of age, 47% had traumatic amputations, and PAS was diagnosed in 28%. However, PAS was diagnosed in 84% of 25 patients > thirty-six years of age (OR= 14.3; P < 0.001). In total, 67 amputations were done. Twenty-one (68%) of 31 above-knee amputations (AKA) were performed in patients with PAS, and 26% of AKA were related to trauma. Of 10 bilateral amputations, 9 (90%) were done in patients with PAS. Patients with PAS had a high prevalence of risk factors for cardiovascular disease including smoking (87%), diabetes (50%), hypertension (50%), and hyperlipidemia (30%). Nine (30%) of the patients with PAS had hypercoagulable states. PAS was identified as the leading cause for major amputations among young adults in this community and was frequently associated with heavy smoking, diabetes, end-stage renal disease, and hypercoagulability.
Antithrombin III Deficiency and White Clot Syndrome
Authors: Batra Munish K. , Adolph Michael D. , Thornton James C. , Byramjee Aspi M. , Oliver Alan O. , Schreiber Helmut
Published: June 2007

Heparin-induced thrombocytopenia with antithrombin III deficiency can be a severe, fulminant systemic disease leading to disastrous complications and often death. An eighteen-month review of the authors' surgical population revealed 7 cases of heparin-induced thrombocytopenia. They present the diagnosis and management of these patients, as well as a literature review. On the basis of their experience, a platelet count that falls below 17% of the baseline should be the impetus to test for heparin-associated antibodies, protein C and S deficiency, and antithrombin III deficiency. Their newer recommendation, along with the use of saline flush and the start of coumadin early in the postoperative period, has prevented the complications associated with heparin-induced thrombocytopenia in their hospital for the past twelve months.
Oxygen-Derived Free Radicals as Mediators of Varicose Vein Wall Damage
Authors: Farbiszewski Ryszard , Glowinski Jerzy , Makarewicz-Plonska Marzena , Chwiecko Marek , Ostapowicz Roman , Glowinski Stanislaw
Published: June 2007

Varicose saphenous vein segments, segments of those veins with thrombophlebitis, and segments of normal veins obtained during operation on 23 patients were studied to define the pattern of pro-oxidative and antioxidative systems in these tissues. In segments of varicose veins (VV) the activity of superoxide dismutase (SOD) was significantly decreased as compared with normal veins: 7.8 ±2.9 vs 13.5 ±4.3 U/mg of protein (P < 0.05), but it was almost unchanged in the segments of W with thrombophlebitis. The activity of glutathione reductase (GSH-R) in all studied segments was similar and amounted to about 12.0 IU.

The content of free sulfhydryl (SH) groups, the concentration of ascorbic acid, and thiobarbituric acid-reactive substances (TBA-RS) in segments of VV were significantly decreased by 40%, 48%, and 47%, respectively (P < 0.05) as compared with segments of normal veins. The values of ascorbic acid and TBA-RS in the segments of W with thrombophlebitis were increased by 13% and 16%, respectively, as compared with segments of normal veins. Decreased activities of SOD and reduced levels of free SH-groups and of ascorbic acid concentration in W may indicate impaired antioxidant mechanisms in this tissue.