bluuebunny/crossref_metadata_2025 huggingface dataset:
Techniques for Managing Complications of Arterial Closure Devices
Authors: Kalapatapu Venkat R. , Ali Ahsan T. , Masroor Farzad , Moursi Mohammed M. , Eidt John F.
Published: June 2007

According to data reported by the American Heart Association, more than 5 million diagnostic and therapeutic catheterizations are performed each year in the United States. The number of catheterizations has tripled since 1979. It has been estimated that complications related to the access site result in more than 75,000 surgical procedures annually. Thus, improved management of the access site itself is essential to achieve the greater goals of improved care and reduced cost. Manual compression directly over the site of arterial puncture usually results in adequate hemostasis but has several significant drawbacks. Manual compression is uncomfortable for the patient, is fatiguing and time-consuming for staff, and necessitates several hours of costly in-hospital observation. In addition, it may be ineffective in achieving hemostasis, especially in the setting of systemic anticoagulation or following the use of large-bore devices. Based on the perceived need for an improved method of managing the arterial access site following catheterization, various vascular sealing devices have been developed. There are at least 8 (and the number is increasing) hemostatic vascular closure devices that are currently approved by the FDA for access site closure after femoral arterial catheterization. The chief advantage attributed to vascular sealing devices is accelerated access site hemostasis, even in the setting of anticoagulation, leading to earlier ambulation and hospital discharge following arterial catheterization. The most important drawbacks related to vascular sealing devices include the cost of the devices and the possibility of increased access site complications. Despite the paucity of properly designed studies supporting their use, it is estimated that over one million vascular sealing devices are used annually in the United States, a number that has increased dramatically in the past 5 years.In this review, we present a brief description of the design and function of the most widely used devices, describe the most common mechanisms of failure, and recommend strategies for management of access site complications including hemorrhage, arterial obstruction, and infection.
Clinical Impact of Chronic Renal Insufficiency on Endovascular Aneurysm Repair
Authors: Park Brian , Mavanur Arun , Drezner A. David , Gallagher James , Menzoian James O.
Published: June 2007

Endovascular aneurysm repair of abdominal aortic aneurysms has become a viable alternative to open repair. A significant proportion of this patient population has chronic renal insufficiency. The surgical outcomes associated with endovascular repair in 342 patients, with and without chronic renal insufficiency, are reported. Perioperative mortality, length of admission, length of intensive care unit admission, and rates of acute renal failure, congestive heart failure, myocardial infarction, conversion to open surgery, progression to hemodialysis, and incidence of endoleaks were retrospectively reviewed and analyzed. Endovascular repair demonstrated higher rates of acute renal failure, longer length of stay, and longer intensive care unit admissions in patients with chronic renal insufficiency. Patients with severe renal dysfunction demonstrated markedly elevated mortality and morbidity. These results indicate that chronic renal insufficiency is not an absolute contraindication to endovascular repair in patients with moderate renal dysfunction, but patients with severe renal dysfunction perform poorly after aortic reconstruction.
Aortoenteric Fistula: A Late Complication of Endovascular Repair of an Inflammatory Abdominal Aortic Aneurysm
Authors: Ratchford Elizabeth V. , Morrissey Nicholas J.
Published: June 2007

Endovascular repair provides a reasonable alternative to open repair for the treatment of abdominal aortic aneurysms in select cases. Although the endovascular approach may be preferable for inflammatory aneurysms, aggressive surveillance is needed to monitor for long-term complications. A 61-year-old man underwent endovascular exclusion of a symptomatic inflammatory abdominal aortic aneurysm with an AneuRx bifurcated aortic prosthesis. He presented with gastrointestinal bleeding 51/2 months later and was found to have an aortoenteric fistula involving the third portion of the duodenum. The aneurysm had expanded significantly at the proximal neck. The patient underwent successful removal of the device, aortic ligation, and extraanatomic bypass. Aortoenteric fistula is a rare but now established complication of endovascular aneurysm repair. The pathophysiology in these cases remains unclear. The presence of inflammation and endoleak may predispose to further aneurysmal degeneration.
Multiple Penetrating Atherosclerotic Ulcers of the Aorta: Report of a Case
Authors: Tsuji Yoshihiko , Okita Yutaka , Sugimoto Koji , Yamashita Teruo , Hino Yutaka , Tanaka Hiroshi , Taniguchi Takanori , Matsumori Masamichi
Published: June 2007

A 69-year-old hypertensive man who had 7 pseudoaneurysms caused by penetrating atherosclerotic ulcers underwent 2-staged endovascular grafting in the thoracic and thoracoabdominal aorta and a conventional graft replacement of the abdominal aorta. He had an uneventful postoperative course; follow-up computed tomography demonstrated that all aneurysmal lesions treated by endovascular grafting completely disappeared. He has been free from any aortic events 20 months after the last surgery.
Catheter Thrombolysis of Thrombosed Hepatic Arteries in Liver Transplant Recipients: Predictors of Success and Role of Thrombolysis
Authors: Saad Wael E. A. , Davies Mark G. , Saad Nael E. A. , Westesson Karin E. , Patel Nikhil C. , Sahler Lawrence G. , Lee David E. , Kitanosono Takashi , Sasson Talia , Waldman David L.
Published: June 2007

Hepatic artery thrombosis is an uncommon complication of liver transplantation. However, it is a major indication for re-transplantation. The use of transcatheter thrombolysis and subsequent surgical revascularization as a graft salvage procedure is discussed. Four of 5 cases (80%) were successful in re-establishing flow and uncovering underlying arterial anatomic defects. None were treated definitively by endoluminal measures due to an inability to resolve the underlying anatomic defects. However, 2 of 5 cases (40%) went on to a successful surgical revascularization and represent successful long-term outcome of transcatheter thrombolysis followed by definitive surgical revascularization. We conclude that, definitive endoluminal success cannot be achieved without resolving associated, and possibly instigating, underlying arterial anatomical defects. However, reestablishing flow to the graft can unmask underlying lesions as well as asses surrounding vasculature thus providing anatomical information for a more elective, better planned and definitive surgical revision.
Endovascular Abdominal Aortic Aneurysm Sizing and Case Planning Using the TeraRecon Aquarius Workstation
Authors: Lee W. Anthony
Published: June 2007

The gold standard for preoperative evaluation of an aortic aneurysm is a computed tomography angiogram (CTA). Three-dimensional reconstruction and analysis of the computed tomography data set is enormously helpful, and even sometimes essential, in proper sizing and planning for endovascular stent graft repair. To a large extent, it has obviated the need for conventional angiography for morphologic evaluation. The TeraRecon Aquarius workstation (San Mateo, Calif) represents a highly sophisticated but user-friendly platform utilizing a combination of task-specific hardware and software specifically designed to rapidly manipulate large Digital Imaging and Communications in Medicine (DICOM) data sets and provide surface-shaded and multiplanar renderings in real-time. This article discusses the basics of sizing and planning for endovascular abdominal aortic aneurysm repair and the role of 3-dimensional analysis using the TeraRecon workstation.
Patterns of Venous Reflux and Obstruction in Patients With Skin Damage Due to Chronic Venous Disease
Authors: Labropoulos Nicos , Patel Parag J. , Tiongson Jay E. , Pryor Landon , Leon Luis R. , Tassiopoulos Apostolos K.
Published: June 2007

Identified were characteristics of individuals with skin damage related to chronic venous disease. Patients with chronic venous disease (n = 164) were evaluated with duplex ultrasound imaging and were placed in classes 4, 5, and 6 according to the CEAP classification. Their findings were compared with 100 class 2 controls. The prevalence of deep venous thrombosis was higher in the study group (23.7%) versus controls (5.1%; P < .0001), as was the prevalence of deep, perforator, and combined patterns of disease ( P < .0001, P < .0007, and P < .0001). The mean duration of disease in controls 2 was shorter compared with the study group ( P = .0019). The prevalence of reflux and obstruction within the study group was higher than in controls ( P = .0021). Skin changes accurately reflect severity of chronic venous disease. Superficial and perforator vein reflux is the major cause of disease.
The Association Between a Surgeon’s Learning Curve With Endovascular Aortic Aneurysm Repair and Previous Institutional Experience
Authors: Forbes Thomas L. , DeRose Guy , Lawlor D. Kirk , Harris Kenneth A.
Published: June 2007

The purpose of the present study was to determine whether an institution’s prior endovascular experience influenced the learning curve of subsequent surgeons. A prospective analysis of the initial 70 endovascular abdominal aortic aneurysm repair (EVAR) cases attempted by an individual surgeon was performed with the primary outcome variable being achievement and 30-day maintenance of initial clinical success. Along with standard statistical analyses, the cumulative sum failure method (CUSUM) was used to analyze the learning curve, with a predetermined acceptable failure rate of 10%. Seventy elective EVAR cases were performed by this surgeon during a 4-year period (2000-2004) (mean age, 73.7 ∓ 5.4 years; mean aneurysm diameter 63.3 ∓ 7.2 mm). Initial clinical success was achieved in 68 of 70 cases (97%), which differed significantly with that of our initial surgeon (88.5%, P = .01). Causes of failure in the present series included 1 early mortality (1.4%) and 1 case of conversion to open repair with no instances of type I endoleak or endograft limb thrombosis. Both surgeons’ cases were plotted sequentially with CUSUM curves revealing a significantly shorter learning curve for the second surgeon. Optimal results were achieved following 10 to 20 EVAR cases, as opposed to 60 cases in the initial series. Such an analysis confirms that as an institution’s experience with EVAR increases, an individual surgeon’s learning curve shortens considerably.
The Relationship of Human Saphenous Vein Smooth Muscle Contractile Responses to Donor Age and Gender
Authors: Brockbank Kelvin G. M. , Davies Mark G. , Fields Shirley M. , Hagen Per-Otto
Published: June 2007

The smooth muscle contractile properties of 100 human saphenous veins derived from healthy tissue and organ donors were investigated. No significant changes in the contractile responses of saphenous veins to potassium chloride, serotonin, and norepinephrine were associated with age. In contrast, comparison of contractile responses between males and females demonstrated significantly less response to potassium chloride in female veins (P<0.05). Female contractile responses to serotonin (P=0.74) and norepinephrine (P= 0.29) did not differ significantly when compared with male responses. These observations support the conclusion that gender may be an important variable in saphenous vein biology.
A Comparison of Vascular Pulsatility and Resistive Indices in Gynecological Tumor Detection Using Transvaginal Ultrasound
Authors: Carter Jonathan R. , Lau Manhot , Twiggs Leo B.
Published: June 2007

Transvaginal Doppler ultrasound was applied to 85 patients to determine whether pelvic malignancy could be predicted by pulsatility (PI) and resistive indices (RI) of intratu-moral, ovarian, and uterine vessels. Thirty-five of the patients in the study were confirmed to have malignant tumors of the cervix, uterus, or ovary. The mean intratu-moral PI and RI from malignant tumors were 0.81 (SD 0.24; range 0.3-1.2) and 0.54 (SD 0.10; range 0.27-0.62), respectively. They were significantly lower than those of the benign group (both with P < 0.05, Student's t test). Thresholds of intratumoral PI < 1.0 and RI < 0.6, which differentiate malignant from benign tumors, were determined by using two receiver operating characteristic (ROC) curves. These gave a sensitivity of 94% and specificity of 63% for PI and a sensitivity of 71% and specificity of 63% for RI. The mean PI and RI from individual ovarian and uterine vessels were also significantly lower for the malignant group than those for the benign group. The authors conclude that PIs and RIs from intratumoral, ovarian, and uterine vessels are all useful in differentiating malignant tumors from benign ones, but universal thresh-olds for this purpose are far from determined. Also, comparison of intratumoral PI and RI showed that neither PI nor RI was statistically better than the other in malignancy prediction, because the areas under the two ROC curves were not statistically different (P > 0.2, chi-square method).
Effects of Increased Pressure and Oxygen on the Growth Rate of Cultured Endothelial Cells Derived from Human Saphenous Vein
Authors: Liau Chiau-Suong , Chen Ming-Fong , Lee Chii-Ming , Chen Wen-Jone , Wu Chau-Chong , Chu Shu-Hsun , Lee Yuan-Teh
Published: June 2007

In order to study the possible mechanisms of atherosclerotic changes involving the saphenous vein graft in coronary bypass surgery, endothelial cells were cultured from human saphenous vein and used in experiments. The intimal surface of human saphenous vein was treated with collagenase followed by mechanical scraping with a surgical scalpel. The endothelial cells obtained were cultured in M 199 medium supplemented with 20% human serum. In experiments, different ambient pressures (either normal or increased at 100 mmHg) and oxygen tensions (either 20% or 5.3%) were applied to the cultured endothelial cells to study the effects on cell proliferation. Four experiments were performed. It was found that the growth rate of endothelial cells was constantly and significantly decreased in high ambient pressure. Increase in oxygen did not significantly affect cell growth. The culture condition closest to the venous environment rendered best cell growth. It is concluded that growth rate of cultured endothelial cells derived from human saphenous vein can be affected by changes in ambient pressure. The changes may play some role in the pathogenesis of bypass graft atherosclerosis.
Coronary Artery-Coronary Sinus Fistulae Associated with a Large Hepatic Hemangioma
Authors: Kanda Yoshinobu , Takahashi Toshiyuki , Yokoyama Ikuo , Momomura Shin-ichi , Serizawa Takashi
Published: June 2007

A case of coronary artery-coronary sinus fistulae associated with a large hepatic hemangioma is presented. Aortography and coronary arteriography revealed a large left circumflex artery-coronary sinus fistula and a small right coronary artery-coronary sinus fistula. The left main trunk and left circumflex artery were markedly enlarged (3 cm in diameter), while the sizes of the left anterior descending and right coronary arteries were normal. Abdominal angiography and noninvasive imaging techniques demonstrated a huge hepatic hemangioma (8 cm in diameter) in the S5 region of the liver.
Vascular Complications in Allogeneic Renal Transplantations
Authors: Storck M. , Mickley V. , Hutschenreiter S. , Schilling M. , Abendroth D.
Published: June 2007

Background. The incidence of vascular complications during allogeneic renal transplantations ranges from 5% to 15%. They may be donor related (additional polar arteries, multiple renal arteries, multiple renal veins, injured arteries or veins), recipient related (severe atherosclerosis, venous thrombosis, previous transplantation), or technical. In a retrospective study of 666 kidney transplantations, the incidence and treatment of vascular complications were analyzed.

Patients/Results. All transplantations were performed in end-to-side technique with aortic patch if available; all kidneys were obtained from brain-dead donors. A total of 89 operations included vascular complications (13.4%). In 46 patients (6.9%), the problem arose intraoperatively, 33 complications (5%) occurred within three weeks, and another 10 (0.3%) were seen later after successful transplantation. In 17 kidneys, major additional polar arteries were encountered, 7 of which were reanastomosed, 10 were ligated. Three kidneys were lost owing to insufficient blood supply to the ureter. In 7 patients, intraoperative vascular service operations had to be carried out owing to stenosis of the iliac artery or massive kinking. Early postoperative complications included bleeding after biopsy, anastomotic leakage, and arterial or venous thrombosis (1 successful venous thrombectomy; 18 of 33 organs were removed). As for late complications, the authors observed 9 transplant renal artery stenoses (TRAS); 8 were treated by percutaneous transluminal angioplasty. One patient developed an iliac aneurysm owing to chronic patch rupture.

Conclusion. The majority of intraoperative complications were due to injury of the kidney during donor nephrectomy (21/46). Polar arteries should be reconstructed if possible, especially lower polar arteries, because of the danger of ureteral necrosis. In times of increasing donor organ shortage, only experienced surgeons should perform explantation and transplantation of kidneys to avoid technical faults in a considerable number of organs.
Somatization Tendencies in Surgically Treated Neurogenic Thoracic Outlet Syndrome Patients
Authors: Hameed S. Morad , Grewal Raji P. , Urschel John D.
Published: June 2007

Vascular thoracic outlet syndromes have well-defined objective diagnostic criteria. Most patients diagnosed with neurogenic thoracic outlet syndrome (NTOS) do not have objective neurologic findings or electrophysiologic abnormalities. The authors have subjectively noted somatization tendencies in many of their NTOS patients. A retrospective case control study was done to identify features of somatoform disorders in their surgically treated NTOS patients. Records of patients admitted for NTOS surgery were retrieved. Patients admitted with spontaneous pneumothorax, another common benign thoracic surgical condition, were used as controls. Thirty patients with NTOS were randomly matched by age and sex to 30 patients with pneumothorax. Patients with NTOS had more previous operations for unrelated conditions (NTOS mean 2.9, pneumothorax mean 1.3, P < 0.005) and took more medications (NTOS, 1.2; pneumothorax, 0.6, P < 0.025) than pneumothorax patients. NTOS patients also had more medication allergies (NTOS, 0.7; pneumothorax, 0.4; P < 0.16), but the difference was not statistically significant.

The findings suggest either a greater frequency of organic illness or a greater tendency to undergo medical and surgical treatment in the NTOS group. The authors suspect that some patients with NTOS have coexisting somatoform disorders and that surgical intervention in these patients is inappropriate. Because objective quantification of NTOS severity is usually not possible, patient selection for surgery remains difficult.
Inguinal Lymphorrhea Following Arterial Puncture and Pseudoaneurysm Resection
Authors: Kiev Jon , Rummel Mark , Kerstein Morris D. , Matsumoto Teruo
Published: June 2007

Lymphorrhea, the abnormal drainage of lymphatic fluid, may lead to a discrete collection of lymph (lymphocele) or to a draining lymphatic fistula, depending on the nature of the injury to the involved lymphatic chain. The authors present a recent case, review the current surgical literature, and make recommendations regarding surgical therapy.
Successful Cavoatrial Bypass for Inferior Vena Caval Occlusion in A Patient with Behçqet's Disease
Authors: Oba Jun'ichi , Yasuda Keishu , Sakuma Makoto , Kajitani Michio , Matsui Yoshiro , Tanabe Tatsuzo
Published: June 2007

Behçet's disease is a systemic process of unknown etiology that features a prolonged, intractable course. Characteristic pathologic findings include recurrent orogenital ulcers and ocular and cutaneous inflammatory lesions. The disease may also involve the articular, neurologic, gastrointestinal, and cardiovascular systems. Vascular lesions reportedly vary from arterial occlusions and aneurysms to thrombophlebitis. Budd-Chiari syndrome due to thrombosis of the inferior vena cava (IVC) has been rarely reported. Here the authors report a thirty-six-year-old Japanese woman with Behçet's disease who developed Budd-Chiari syndrome secondary to inferior vena cava thrombosis. She was treated successfully by cavoatrial bypass. Although the graft was thrombosed, she has been asymptomatic for five years after surgery. Cavoatrial bypass could be considered as a surgical option to immediately relieve hepatic congestion due to caval thrombosis.
Diagnosis of Internal Carotid Pseudo-occlusion by Use of Color-Coded Duplex Scanning
Authors: Martin P. J. , Gaunt M. E. , Nydahl S. , Ratliff D. A.
Published: June 2007

The differentiation of “pseudo” from complete carotid artery occlusion is still widely considered to be an indication for intraarterial angiography. The authors report a case in which color-coded duplex ultrasound revealed a persisting string-like lumen that was not adequately demonstrated by angiography. The duplex diagnosis of “pseudo” occlusion requires the use of low-pulse repetition frequencies and in future may reduce the need for invasive imaging techniques. If angiography is undertaken, even delayed films may fail to demonstrate the residual lumen adequately.
Combined Approach for the Management of Hemangiomatous Malformation of the Loin
Authors: Ahmed Zahoor , Mohyuddin Zahoor
Published: June 2007

Surgery alone for lesions like hemangiomatous malformations can be difficult, incomplete, and hazardous. Preoperative embolization in combination with surgery may be a preferable and safer therapeutic option.
Spontaneous Spinal Epidural Hematoma After Combined Urokinase and Heparin Thrombolytic Therapy for Deep Venous Thrombosis
Authors: Krieger Nancy R. , Mehigan John Thomas
Published: June 2007

The literature clearly supports the view that all anticoagulation therapy is associated with a significant risk of hemorrhagic complications. Combining anticoagulation and fibrinolytic therapy further adds to this risk. Moreover, in the treatment of deep venous thrombosis the combined use of heparin and fibrinolytic therapy is not necessarily associated with a better outcome. Close monitoring of the clotting profile has not eliminated the risks since a correlation between laboratory parameters and bleeding complications has not been demonstrated. Furthermore, the appropriate total dose and duration of therapy remain unclear.

The authors report an especially devastating complication of spinal epidural hematoma with resultant paraplegia after combined use of heparin and urokinase for iliofemoral venous thrombosis in an otherwise healthy young woman. The dramatic nature of the complications illustrates the need for continued analysis of this therapeutic strategy.
Preliminary Experience writh Cryopreserved Saphenous Vein Allografts as a Conduit for Femoropopliteal Revascularization
Authors: Mastroroberto Pasquale , Chello Massimo , Zofrea Saverio , Cirillo Francesco , Marchese Antonietta R.
Published: June 2007

The saphenous vein, either reversed or in situ, has become the conduit of choice for femoropopliteal revascularization. In fact the patency rates with use of prosthetic (polytetrafluoroethylene or Dacron) or other autogenous veins (umbilical, cephalic, and basilic) bypass grafts to the inafrageniculate vessels have been disappointing.

Cryopreserved saphenous vein allografts have been used as an alternative conduit for arterial reconstruction since the 1960s, and more recently the improvement in treatment and cryopreservation techniques has produced good long-term results.

From January 1993 to July 1994 the authors used saphenous vein allografts in 12 patients and 16 extremities with femoropopliteal arterial disease diagnosed angiographically.

Allografts were used because the patients had peripheral varicose veins, had had previous saphenous vein thrombophlebitis, had had previous saphenous vein stripping, or had had saphenous vein used for coronary artery bypass grafting. Allograft veins were prepared from selected saphenous veins in isotonic solution, stored at 4°C, and kept frozen until arrival in the operating room. The femoropopliteal bypass grafts were performed as follows: 6 monolateral and 2 bilateral above the knee, and 2 monolateral and 2 bilateral below the knee. Patients received ticlopidine (250 mg/day) after surgery. Duplex ultrasound graft surveillance was routinely performed.

There were no early or late deaths. At the follow-up, ranging from one to eighteen months, all the grafts were patent. Although some authors do not recommend the use of cryopreserved saphenous vein allografts, particularly for complex limb-salvage procedures, the present authors believe that these conduits can be used with good graft patency rates in the absence of a suitable alternative.

The authors expect that long-term results will supply further information on the graft patency rates and on possibly greater use of venous allografts in arterial surgery of the lower extremities.
Aortic Graft Infections and Aortoenteric Erosions/Fistulae
Authors: Mackey William C.
Published: June 2007

Aortic graft infections and graft enteric complications are among the most challenging problems faced by vascular surgeons. Prompt, accurate diagnosis and definitive treatment are essential if major morbidity and mortality are to be avoided. In this paper, the clinical presentation, diagnostic evaluation, and contemporary surgical management of aortic graft infections and graft enteric complications are reviewed. Traditional management techniques (extraanatomic bypass with complete graft removal) are described in detail. Newer and more controversial techniques (management of infected aortofemoral graft limb without graft removal and in situ replacement of infected aortic grafts) are discussed and their results compared with those of traditional treatment.
Does Relief of Critical Arterial Stenosis Accelerate Distal Atherosclerosis?
Authors: Lyon Ross T. , Davis Harry R. , Runyon-Hass Art , Glagov Seymour , Zarins Christopher K.
Published: June 2007

Progression of atherosclerosis following balloon angioplasty, arterial bypass, or endarterectomy often limits long-term success of revascularization procedures. Therefore, the authors studied the effect of stenosis and relief of stenosis on the development of distal atherosclerosis in a primate model of diet-induced atherosclerosis. Severe stenosis (78 ± 2% diameter reduction) was produced in the midthoracic aorta in 14 cynomolgus monkeys by a constricting band. In 8 monkeys, the stenosis was left in place for three months, after which the distal aorta was revascularized by removal of the constricting band and by balloon angioplasty of the residual stenosis. The results in this group were compared with those in 6 animals whose stenoses were not reversed and with those in 10 animals with no preexisting stenosis. All three groups received an atherogenic diet for three months with no difference in serum cholesterol (836 to 1059 mg/o) during the three-month diet period. Animals with a stenosis had a significant decrease in surface atherosclerosis in the distal aorta (7 ± 6%) compared with control animals (51 + 8%, P < 0.05). This was accompanied by marked reduction in mural cholesterol content (1.5 ± 0.4 mcg/mm2 vs 6.3 ± 1.8 mcg/mm2 in controls, P < 0.05) and a decrease in intimal thickness (0.04 ± 0.02 mm vs 0.07 ± 0.01 mm in controls, P < 0.05). After relief of the stenosis, the percent surface atherosclerosis (58 ± 8%), mural cholesterol (5.4 ± 1.0 mcg/mm2), and intimal thickness (0.09 ± 0.01 mm) were no different from controls. Thus, severe stenosis protects the distal vascular tree from intimal plaque formation, despite marked hypercholesterolemia. Following reversal of a stenosis, distal plaque progression does not occur at an accelerated rate but instead occurs at the same rate as without a preexisting stenosis.
Ehancement of the Fibrinolytic Activity of Intact Saphenous Veins by the Luminal Application of Urokinase
Authors: Toma Naoto , Sobel Michael
Published: June 2007

Could the fibrinolytic activity of autogenous vein grafts be enhanced by the luminal application of a plasminogen activator such as urokinase? To understand the effects of pharmacologic concentrations of urokinase-type plasminogen activator on endothelial fibrinolytic activity, the authors exposed the luminal surface of paired fresh human saphenous veins to urokinase 500 U/mL or control solutions. To measure the fibrinolytic activity of intact endothelium, a new assay system was devised in which vein pieces were suspended in solution and the supernatant was assayed for plasmin activity by use of a chromogenic substrate. Net fibrinolytic activity (including the effects of plasma inhibitors) was estimated by performing the assay in plasma, while total fibrinolytic activity was estimated by using a plasma-free assay with purified plasminogen as the substrate.

When veins were briefly exposed to urokinase, their net and total fibrinolytic activities were very significantly increased (P < 0.0001) compared with controls. High versus low molecular weight urokinase showed equivalent effects. These results suggest that the exposure of intact endothelium to exogenous urokinase can significantly enhance the subsequent endothelial-dependent fibrinolytic activity of vein grafts, at least temporarily.
Balloon-Expandable Stent Complications During Endovascular Grafting
Authors: Ombrellaro Mark P. , Stevens Scott L. , Kerstetter Kyle , Freeman Michael B. , Goldman Mitchell H.
Published: June 2007

Intraluminal stented grafts are currently the focus of much attention and research. Increasing use of balloon-expandable stents in these devices has resulted in a spectrum of deployment associated complications and new technical challenges for surgeons. The various techniques used to overcome problems during intravascular stented graft deployment are reported.

Deployment complications occurred in 3 of 19 adult hound dogs subjected to endovascular stented graft placement. The stented grafts consisted of a balloon expandable stent sewn to a 6-cm-long,10.mm-diameter, thin-walled polytetrafluoroethylene graft. Reengaging a nondeployed stented graft that slid off an expansion balloon, managing a partially deployed stented graft with inability to disengage a broken angioplasty balloon, and repositioning a free stent within the aorta are described.

Treatment of stented graft complications was associated with no morbidity or mortality and minimal blood loss and added only fifteen to thirty minutes of procedure time. All situations were managed successfully without the need for an open retrieval procedure.

Deployment complications associated with intravascular stented grafts may be successfully managed with endovascular techniques using the existing graft delivery system and additional small-diameter balloon catheters.
Pulsatile Blood Flow Indices in Lower Extremity Arterial Disease: Leg Only Compared with Leg and Cardiac Parameters
Authors: Mayrovitz Harvey N. , Larsen Parry B.
Published: June 2007

The relative diagnostic value of pulsatile leg blood flow and indices with and without normalization to cardiac stroke volume was determined in 100 subjects (200 legs) with and without lower extremity arterial disease (LEAD) who were stratified on the basis of ankle-brachial pressure index (ABI). Leg blood flow parameters (magnetic resonance flowmetry) included absolute pulsatile flow (Q, mL/min), leg flow per stroke (LSV, mL), and an arterial status index (ASI, mL/min/100 cc). Cardiac stroke volume (CSV) was determined by transthoracic bioimpedance cardiography and was used to obtain the normalized leg/cardiac parameter LSV/CSV. Results show that all tested parameters provide significant statistical separation between LEAD and normal limbs (P < 0.001) but that normalization by CSV was least good and offers no benefit as compared with the leg parameters. Further, based on analysis of receiver operator curves, the ASI parameter, which is derived from leg blood perfusion data, provides the best sensitivity (93.7%-98.1%) and specificity (81.8%-77.7%) of all parameters tested.
Seclusion of an Abdominal Aortic Aneurysm in the Presence of an Unusual Horseshoe Kidney
Authors: Liapis Christos , Misiakos Evangelos , Verikokos Christos , Dousaitou Billy , Gugulakis Alexander , Sechas Michael
Published: June 2007

The coexistence of horseshoe kidney and abdominal aortic aneurysm is rare, and technical challenges during aneurysm repair are significant. This is a report of a case of an infrarenal aortic aneurysm associated with a horseshoe kidney with a parenchymatous isthmus draining to a third ureterocaliceal system and an anomalous vascular supply. Surgical management consisted of aneurysm exclusion and use of a bifurcation graft to the common iliac arteries. Arterial supply to the isthmus remained intact during operation and the postoperative clinical outcome was satisfactory.
Baker's Cyst Causing Deep Venous Thrombosis
Authors: Ricci Michael A. , Howe James G.
Published: June 2007

Although Baker's cysts may mimic deep vein thrombosis, it is unusual for the two conditions to coexist in the same patient. The authors report a case of a fifty-eight-year-old man who had repeated episodes of deep venous thrombosis in spite of anticoagulation and arthroscopic joint debridement. Ultimately, total knee arthroplasty corrected the problem so that the patient has had no further recurrence of venous thrombosis upon follow-up. A brief discussion of these two conditions follows the case report.
Major Vascular Injury Secondary to Laparoscopy
Authors: Nault Patrice , Beaulieu R. Claude
Published: June 2007

Laparoscopic procedures are now performed by almost all surgeons. Major vascular injuries secondary to laparoscopy, which were anecdotal before 1990, are now seen more often. This article focuses on the authors' experience with arterial trauma related to laparoscopic procedures.

Their hospital is a regional center with a population base of 350,000 and six peripheral hospitals. Between August 1994 and March 1996, 6 patients inadvertently sustained major vascular injuries in the course of laparoscopic surgery. These incidents were shared by 5 different surgeons in four different hospitals.

Three patients sustained intestinal perforation and aortic transection during laparoscopic cholecystectomy, two related to insertion of the veress needle and one to insertion of a trocar. Two of these injuries were repaired by end-to-end anastomosis, while the third one required a synthetic aortic graft. A fourth patient sustained an aortic perforation during laparoscopic tubal ligation. The fifth and sixth patients had an iliac artery perforation-one during laparoscopic appendectomy and the other during abdominal hysterectomy. Blood lost in these patients varied between 3 and 26 liters, and the length of hospital stay varied from six days to three months. No deaths were reported.

Major vascular injuries may arise during laparoscopic procedures. The authors' experience suggests these incidents are underreported. By understanding the way they occur, they believe these injuries are preventable.
Endoscopic Dissection of Incompetent Perforating Veins in the Treatment of Chronic Venous Leg Ulcers
Authors: Wolters Ulrich , Schmitz-Rixen Thomas , Erasmi Heide , Lynch John
Published: June 2007

The role of incompetence of calf perforating veins in chronic venous ulcer is currently becoming better defined. Because the traditional Dodd's and Linton's subfascial surgical eradication is often too traumatic to the compromised skin, the endoscopic subfascial discission of perforating veins is gaining ground as a better surgical alternative. In a prospective observational study, 27 patients who underwent endoscopic surgery for a chronic leg ulcer were followed up over a twenty-four-month period. The healing rate was 92% at three months and 77% at twelve and twenty-four months. The introduction of endoscopic subfascial perforating vein dissection provides a new therapeutic concept at least as effective as other conventional techniques in the treatment of chronic venous leg ulcers.
Association Between Carotid Artery Bifurcation Disease and Risk Factors for Atherosclerosis
Authors: White Douglas B. , Schneider Joseph R. , Hoffman Kevin N. , Size Gail P. , Coats Robert W. , Laubach Maureen , Erickson Elaine J. , Caprini Joseph A. , Golan John F.
Published: June 2007

Patients referred to the vascular laboratory for carotid duplex scanning may have identifiable risk factors for atherosclerosis. The presence of these risk factors may be associated with a higher risk of significant carotid bifurcation atherosclerosis. Furthermore, physicians have widely varying thresholds for requesting duplex scanning, and patient characteristics are likely to be highly variable from one vascular laboratory to another. The authors examined the relationship between significant carotid disease and atherosclerotic risk factors in patients referred to a community hospital vascular laboratory.

Complete information was available for selected atherosclerotic risk factors including gender, diabetes, hypertension, cigarette smoking, cardiac disease, and prior stroke for 68 men and 78 women undergoing initial carotid duplex scanning between 4/1/93 and 11/11/93. The authors examined the possible correlation of these risk factors with the presence of severe carotid disease (> 50% stenosis including internal carotid occlusion) in at least one distal common carotid artery, bulb, or proximal internal carotid. Severe disease was present in 34 (23%) of 146 patients.

Patients with severe carotid disease tended to be older (76.2 ± 1.3 vs 73.4 ± 0.9 years, mean ± SEM), but this difference was not significant (P = 0.11). Patients with severe carotid disease tended to have more total risk factors (3.2 vs 2.1, P < 0.01). Hypertension was the best predictor of severe carotid disease (36% with, 10% without hypertension, P < 0.01). Trends toward greater likelihood of severe carotid disease in men, smokers, and in patients with cardiac disease were not significant.

Risk factors may be valuable predictors of the presence or absence of significant carotid bifurcation disease. Hypertension and the total number of atherosclerotic risk factors were strong predictors of significant carotid disease in the laboratory. However, patient characteristics in individual vascular laboratories may be highly skewed and vastly different from other vascular laboratories and the population. Individual vascular laboratories should tabulate atherosclerotic risk factors in addition to indications for carotid duplex scanning so that the importance of these risk factors in each laboratory may be determined.
Aneurysm of the Inferior Mesenteric Artery
Authors: Gonzalez Angel L. Fernandez , Arnal Daniel T. Luna , Albarova Oscar Gil , Tovar Orlando , Caravajal Jose M. Galbis , Montero José A.
Published: June 2007

The authors report a case of an aneurysm of the inferior mesenteric artery (IMA) associated with an aneurysm of the right internal iliac artery. Resection of both aneurysms was performed through a laparotomy and a retroperitoneal approach. Some aspects of the etiology, diagnosis, and treatment of the IMA aneurysms are discussed.
Management of Femoral Lymphatic Complications Following Synthetic Lower Extremity Revascularization: Early and Late Results
Authors: McShannic Joseph R. , O'Hara Patrick J.
Published: June 2007

Lymphatic complications following synthetic graft placement in the groin may be associated with prolonged drainage leading to the development of wound infection, which may involve the underlying prosthetic graft. To determine associated early and late mortality and morbidity and to develop guidelines for optimal management, the authors reviewed their department's recent experience with this problem.

From 1982 to 1996, 32 femoral lymphatic complications (29 lymphocutaneous fistulas and 3 lymphoceles) were treated in 26 patients (16 men and 10 women, mean age 68 years) who had undergone lower extremity revascularization utilizing synthetic graft material. Patients with clinical evidence of graft infection or those with lymphatic complications following autogenous reconstructions were excluded from analysis. Underlying grafts involved the aortofemoral segment in 63% (20/32), the femorofemoral segment in 16% (5/32), the femorodistal segment in 13% (4/32), and the axillofemoral segment in 9% (3/32). Presenting symptoms were wound drainage in 27 limbs (91%), a groin mass in 3 (9%), and both in 6% (2/32). Management consisted of surgical exploration and lymphatic ligation with or without sclerosis in 24 limbs (75%) and local measures only in 8 (25%). Mean late follow-up was 3.6 years (range 0.1-8.9 years), and one patient was lost to follow-up at 3.1 years.

There were no 30-day postoperative deaths. One patient died of pneumonia at 34 days after treatment. The median interval from treatment to wound resolution was 5 days for the entire series and was significantly shorter (2 days) for the surgically treated limbs than for those treated conservatively (38 days) (P=0.0001). The median interval from treatment to hospital discharge was also shorter for the surgically treated limbs (11 days) than for those treated conservatively (26 days) (P=0.025). There were no late recurrences, amputations, or graft infections. Cumulative 5-year survival for the entire series was 53%.

Surgical repair of groin lymphocutaneous fistulas and lymphoceles following synthetic graft placement is safe and durable. This approach yields significantly shorter intervals from treatment to wound resolution and requires a shorter postoperative hospitalization period than the conservative approach.
Preliminary Experience with a Self-Centering, Expandable Valvulotome for in Situ Vein Reconstruction
Authors: Dardik Herbert , Silvestri Fred , Rabinowitz David , Ibrahim Ibrahim M. , Kahn Mark
Published: June 2007

A self-centering, expandable valvulotome was employed to establish femoral distal in situ vein reconstructions in 41 patients. The focus of the early follow-up was to assess graft patency and the incidence of incomplete valve closure. Residual arteriovenous fistulas, clearly unrelated to the methodology of valvulotomy, were also noted. Early patency was achieved in all 41. Missed valves occurred in two instances, requiring open direct valve excision in one case and use of a Mills valvulotome in the other. One vein was injured but successfully repaired. The authors conclude that excellent patency results with complete valve cutting can be achieved in the majority of cases for in situ reconstruction in the lower extremity with a new self-centering, expandable valvulotome. The role of angioscopy is uncertain and requires further study.
Psychological Tolerance to Local Block Anesthesia for Saphenous Vein Surgery: Study of 160 Consecutive Cases
Authors: Ouvry P. A. G. , Perrotte P. , Amarouche A. , Ouvry P.
Published: June 2007

The objective of this study was to estimate the psychological tolerance to inguinal block anesthesia using a standard stimulus. Subjects studied included 160 consecutive patients in whom an intervention was performed on the greater saphenous vein at the saphenofemoral junction. The ultimate goal was to identify the causes of intolerance to the anesthesia and to define precise contraindications. The setting was the Department of Angiology in the Clinique Saint Pierre in Dieppe.

Subjects studied were 160 consecutive patients operated on for saphenofemoral junction dysfunction. The study was done to define those who were tolerant and those who were intolerant of the local block anesthesia. A standard stimulus was applied with an electric stimulator. A determination of the tolerant and intolerant patients was done by a simplified form of the French version of the McGill Pain Institute questionnaire previously edited by F. Boureau.7

Of the 160 patients tested, 87% would choose the block anesthetic once again, and 13% regretted having accepted that form of anesthesia.
Early Restenosis After Carotid Endarterectomy with Vein Patch Angioplasty
Authors: Tripathi Sanjay P. , Deshmukh Narayan
Published: June 2007

Restenosis of the carotid artery after endarterectomy is of major concern, for it may increase the risk of cerebrovascular accidents to preoperative levels. The records of 173 consecutive carotid endarterectomy (CEA) cases were reviewed retrospectively, to assess the role of vein patch angioplasty in reducing the incidence of restenosis of the carotid artery after endarterectomy. All patients had patch angioplasty during CEA; 154 operations were done with autogenous vein patch and 19 with synthetic patches. One patient had postoperative carotid thrombosis. Evaluation of 134 carotid arteries with duplex ultrasonography at four to eight weeks postoperatively showed that 8 patients (6%) had recurrent stenosis of more than 40%. Six of these stenoses resolved by one year and one had improved from grade III to grade I stenosis. Of 107 patients followed up at one year, 7 (6.5%) had restenosis, all between 40-60%. In view of the low rate of recurrent stenosis and postoperative thrombosis, similar to that reported by other authors, the authors conclude that vein patch angioplasty should be done during CEA. It also seems that most of the early postoperative (four to eight weeks) duplex abnormalities will resolve over time and do not represent recurrent stenosis.
Electron Microscopic Luminal Surface Characteristics of Carotid Plaques
Authors: Kasirajan Karthikeshwar , Cornu-Labat Gaston , Turner John J. , Rubin Jeffrey R.
Published: June 2007

Luminal surface characteristics in symptomatic and asymptomatic patients with carotid artery disease have not been thoroughly evaluated. Carotid artery atherosclerotic plaques were subjected to a scanning electron microscopic (EM) examination to determine plaque surface morphology. Correlation of clinical presentation, including clinical symptoms, risk factors, and macroscopic plaque appearance, with plaque EM appearance was analyzed for 16 patients. Differences between symptomatic and asymptomatic patients and differences among plaque characteristics were analyzed by use of the two-tailed Fisher's Exact Test or the Mann-Whitney U statistic.

Two predominant types of surface inhabitants were noted, fibrin/red blood cell clumps and collagen and calcium matrix. In all symptomatic patients (n=12) luminal surface fibrin was noted (P=0.007), and 83% of these symptomatic patients had red blood cell clumps (P=0.06). Among asymptomatic individuals (n=4), 3 patients had plaques with collagen (P=0.007). Although platelets were noted in all patients, platelet clumps and accumulations of atherosclerotic debris were noticeably absent. Atherosclerotic risk factors failed to correlate with luminal surface characteristics.

The authors identified specific luminal surface characteristics that correlated well with clinical presentation. Thromboxane inhibitors, such as aspirin, were successful in inhibiting the formation of platelet clumps but were obviously unsuccessful in reducing cellular and matrix accumulations on the luminal surface of carotid arteries.