bluuebunny/crossref_metadata_2025 huggingface dataset:
Technique for Retrieval of a Guidewire Lodged in a Vena Cava Filter
Authors: Wholey Michael , Toursarkissian Boulos , Velez George , Morales Robert P. , Cadavid Gilberto
Published: June 2007

A case in which the guidewire used to place a percutaneous jugular central line became entangled in the limbs of a Trapease inferior vena cava filter is presented. A 7F sheath introducer was fashioned into a monorail system to uncurl the wire's J tip and remove the wire without disturbing the filter's position. This report highlights an increasingly frequent clinical scenario and an inexpensive effective method for resolution.
Operative and Endovascular Management of Extracranial Vertebral Artery Aneurysm in Ehlers-Danlos Syndrome: A Clinical Dilemma
Authors: Sultan Sherif , Morasch Mark , Colgan Mary-Paula , Madhavan Prakash , Moore Dermot , Shanik Gregor
Published: June 2007

The most prevalent lesion of the vertebral artery is an atheromatous plaque located at its origin from the subclavian artery. A case of successful management of a symptomatic vertebral artery aneurysm due to Ehlers-Danlos syndrome is reported. The patient had asymptomatic posterior intracerebral artery dissection on the contralateral side. A common carotid artery to V-3 segment bypass using reversed saphenous vein graft was carried out. Avulsion of the V-2 segment occurred peroperatively and endovascular coil embolization of the vertebral artery aneurysm was performed. Endovascular equipment and training must be in the armamentarium of vascular surgeons as more complex cases are being treated, which demands new approaches for ultimate clinical success. This unique case outlines what might unexpectedly occur. Endovascular intervention as an adjuvant procedure provides a satisfactory outcome in what could have been a catastrophe.
Combined Percutaneous Endovascular and Open Surical Approach in the Treatment of a Persistent Sciatic Artery Aneurysm Presenting with Acute Limb-Threatening Ischemia
Authors: Maldini Gregorio , Teruya Theodore H. , Kamida Curtis , Eklof Bo
Published: June 2007

Persistent sciatic artery (PSA) is a continuation of the internal iliac artery into the poplitealtibial vessels and provides the major supply to the lower limb bud in early embryologic development, and its remnants participate in the formation of the inferior gluteal, deep femoral, popliteal, peroneal, and pedal vessels. When the femoral artery develops, the PSA involutes. In rare circumstances it persists and has a bilateral location in 22% of cases of PSA. This rare vascular anomaly is associated with aneurysmal formation in 15% to 46% of cases. Persistent sciatic artery aneurysm (PSAA) was first described in 1864. At present 87 cases, including this case, have been reported in the international literature. The authors describe a patient affected with PSAA and treated with a combination of thrombolysis, arterial reconstruction, and aneurysm embolization in a staged fashion. Embryology, anatomy, pathology, clinical presentation, diagnosis, and treatment of this rare disease are briefly discussed.
Distal Venous Arterialization for Limb Salvage
Authors: Gasparis Antonios P. , Noor Sonya , Da Silva Monica S. , Tassiopoulos Apostolos K. , Semel Lawrence
Published: June 2007

The reperfusion of an ischemic limb in the absence of a suitable target artery remains a formidable task. The authors report a case of an ischemic limb in a patient whose distal arteries were identified intraoperatively as unsuitable for conventional revascularization. A distal arteriovenous fistula was created between the already arterialized in situ greater saphenous vein conduit and the inframalleolar superficial venous system of the foot. The flow through the superficial venous system salvaged the limb and continues to perfuse the foot 4 years postoperatively with resolution of rest pain.
Monitoring Aspirin 1 00 mg and Clopidogrel 75 mg Therapy with the PFA-1 00 Device in Patients with Peripheral Arterial Disease
Authors: Mueller Thomas , Haltmayer Meinhard , Poelz Werner , Haidinger Dieter
Published: June 2007

A tool to identify vascular patients who receive antiplatelet therapy and to distinguish between responders and non-responders to antiplatelet therapy could be of clinical importance. The present observational study was designed to investigate whether the PFA-1 00± device (Dade Behring) is suitable to detect long-term therapy of aspirin (100 mg/d) and/or clopidogrel (75 mg/d) in a cohort of patients with peripheral arterial disease (PAD). A total of 150 consecutive patients with PAD were studied; 34 patients were excluded from the study due to irregular intake of antiplatelet therapy or due to method limitations. Of the remaining 1 16 patients, 42 had no antiplatelet therapy, 47 had daily aspirin (100 mg) intake, 19 were administered clopidogrel 75 mg daily, and 10 received a medication with 100 mg aspirin plus clopidogrel 75 mg daily, all for at least 10 days. Nonparametric Kruskal-Wallis test with post hoc comparisons showed that collagen plus epinephrine (CEPI) closure times of the patient group receiving aspirin and the group receiving aspirin plus clopidogrel were similar (p > 0.05). In contrast, both patient groups exhibited prolonged CEPI values compared to patients without antiplatelet therapy and patients taking clopidogrel (p <0.001). Finally, both patients without antiplatelet therapy and patients with clopidogrel did not show marked differences with respect to their CEPI values (p>0.05). However, Kruskal-Wallis test results revealed that collagen plus adenosine-5'-diphosphate closure times were not significantly different in all four patient groups (p=0.257). In conclusion, the PFA-100' device may be a suitable tool for monitoring aspirin 100 mg therapy, but it is not appropriate for the detection of clopidogrel administration in its current setup. Although it appears plausible that patients with PAD could benefit from monitoring platelet inhibition, clear evidence for this concept is still lacking.
Lelomyosarcoma of the Inferior Vena Cava
Authors: Bonamigo Telmo Pedro , Becker Monica , Faccini Felipe Puricelli , Cantisani Guido Pio Gracco , Pereira Wagner Michael , de Napoli Gilberto , Ilha Darcy de Oliveira
Published: June 2007

This paper presents a patient successfully treated for leiomyosarcoma of the vena cava, with no recurrence or symptoms on an 8-year follow-up. A 56-year-old woman presented with chronic and progressive periumbilical and right upper abdominal pain. Physical examination and laboratory tests revealed no abnormalities. Computed tomography showed a high-density image inside the vena cava. Cavography showed a filling defect with complete occlusion of the vena cava involving the renal veins and greatly developed collateral circulation through lumbar veins. Laparotomy was performed and a large caval mass involving the renal veins was dissected and resected. Venous reconstruction was undertaken using a 19-mm bovine pericardium prosthesis (Labcor®, MG-Brazil) interposed as a substitute to the vena cava, and the renal veins were anastomosed to the side of the graft. Pathologic examination confirmed a leiomyosarcoma with free surgical margins. The postoperative course was uneventful and the patient was discharged on postoperative day 8. The venous flow through the inferior vena became normal, as confirmed by later cavography. This paper presents a case of successfully managed leiomyosarcoma of the vena cava with a thorough review of the literature. The treatment of such patients and the use of bovine pericardium are also discussed.
Mesenteric evnous Thrombosis in a Patient with Prothrombin 20210A Mutation and Anttthrombin III Deficiency: Challenges to Conventional Anticoagulation
Authors: Johnson Chatt A. , Parker Mary V. , Goff James M.
Published: June 2007

Mesenteric venous thrombosis presents as vague abdominal pain in patients with a medical or family history suggestive of a hypercoagulable state. Classic computed tomography findings will often confirm the diagnosis, and the presence of persistent abdominal pain or tenderness will determine the need for surgical intervention. Expeditious anticoagulation is the treatment of choice. This case demonstrates the CT findings for mesenteric venous thrombosis and discusses the challenges of anticoagulation in a patient with 2 hypercoagulable disorders.
The Engineering of Endovascular Stent Technology: A Review
Authors: Whittaker David R. , Fillinger Mark F.
Published: June 2007

The evolution of minimally invasive endovascular technology has initiated a significant paradigm shift in the treatment of vascular disease. A fundamental understanding of the science and engineering behind the technology of endovascular stents is a key to their appropriate implementation in practice. Furthermore, the rapid influx of new devices into the field requires practitioners to make their decisions on a foundation of the relative strengths and weaknesses of the various products. Although the principles of their use are not complex, the device design can have a profound effect on the device's functionality. Shape, thickness, coating, material selection, and imaging are just a few of the factors to consider in stent design. Subtle differences may have profound results. This review is designed to provide the reader with an overview of fundamental concepts that will aide the assessment of new technology.
Femoral Pseudoaneurysms
Authors: Stone Patrick A. , AbuRahma Ali F. , Flaherty Sarah K. , Bates Mark C.
Published: June 2007

Iatrogenic pseudoaneurysms will continue to be a problem associated with arterial cannulation procedures. With the increasing trend toward minimally invasive procedures, vascular surgeons, as well as interventionalists will be performing more cannulation procedures; hence we will be more involved in the management of this complication more frequently. Treatment trends and efforts aimed at preventing iatrogenic pseudoaneurysms have evolved over the past decade. This article reviews the history and available literature on the subject, in conjunction with the experience of a center that performs over 10,000 cannulation procedures annually.
Surgical Management of Chronic Mesenteric Venous Thrombosis
Authors: Akingba A. G. , Mangalmurti C. S. , Mukherjee D.
Published: June 2007

Although mesenteric venous thrombosis is an uncommon disease, it is a diagnostic dilemma and if left untreated results in significant morbidity and mortality. The clinical presentation of mesenteric venous thrombosis (MVT) is varied and depends on the etiology. Prompt recognition and treatment is important as this may limit the progression of thrombosis. Even though medical management is the current mainstay of therapy, there have been reported cases of clinical improvement with operative management. The authors describe an improved outcome following mesenteric-systemic shunting in a symptomatic patient with acute-on-chronic MVT affecting the proximal superior mesenteric vein.
Barriers to Endovascular Aortic Aneurysm Repair: Past Experience and Implications for Future Device Development
Authors: Moise Mireille A. , Woo Edward Y. , Velazquez Omaida C. , Fairman Ronald M. , Golden Michael A. , Mitchell Marc E. , Carpenter Jeffrey P.
Published: June 2007

Despite improvements in endovascular aortic aneurysm repair (EVAR) devices and techniques, significant anatomic constraints still preclude successful EVAR in a large number of patients. The authors sought to identify the current barriers to EVAR and examine their evolution over time. Patients were evaluated for potential endovascular repair by computed tomography angiography (CTA) with or without supplemental conventional arteriograms. The patient population was separated into 2 groups (A and B) based on early and late time periods in the experience with EVAR, corresponding to the availability of various devices. Group A (early) consisted of the Guidant Ancure, Medtronic Talent, and AneuRx devices and comprised patients presenting between April 1997 through June 2000. Group B (late) consisted of the Medtronic AneuRx, Cook Zenith, Edwards Lifepath, Gore Excluder, and Endologix PowerLink devices and comprised patients presenting between July 2000 and December 2003. Patient demographics and anatomic reasons for rejection were recorded in a database for statistical analysis. In total, 547 patients were evaluated (463 men, 84 women). Of these, 346 patients (63%; 312 men, 34 women) were deemed suitable candidates for EVAR and 201 (37%; 151 men, 50 women) were rejected. There was no significant difference in the overall rate of rejection in the early vs the late time period (34% A, 41% B, p= 0.08), but the number of exclusion criteria per patient decreased over time; patients rejected for EVAR had an overall average of 1.6 exclusion criteria (Group A, 1.9; Group B, 1.2). The reasons for rejection did significantly change over time. Specifically, rejection on the basis of inadequate arterial access, presence of extensive iliac artery aneurysms, or an inadequate proximal neck decreased. A disproportionate number of women were excluded throughout the study: Group A, 56% of women compared to 30% of men (p= 0.0003); Group B, 63% of women compared to 36% of men (p= 0.0022). Women were more likely than men to have inadequate arterial access routes. In addition, patients with high operative risk were also more likely to be excluded from EVAR, a finding that persisted over time. Anatomic constraints continue to pose significant challenges to aortic endografting. Progress has been made in that technological advances have conquered some of the previous anatomic challenges, chiefly those of arterial access and treatment of concomitant iliac aneurysm disease. However, the overall rate of rejection for EVAR remains the same. The chief anatomic barriers continue to be the difficult aortic neck and management of branched vascular segments.
The Application of Split-Thickness Skin Graft as an Autogenous Arterial Conduit in a Goat (Capra Hircus) Model
Authors: Pichakron Kullada O. , Bui Phiet T. , Pickard Brian J. , Perlstein Jon , Mathis Derek , Muir-Padilla Jeannie , Ihnat Daniel M.
Published: June 2007

Adequate autogenous vein is often the limiting factor in achieving a successful infrainguinal bypass. Attempts have been made to find alternative conduits; however, these alternatives have demonstrated inferior patency rates. We attempt to show that a split-thickness skin graft conduit provides a feasible autogenous arterial conduit. Neoconduits were prepared with an autogenous split-thickness skin graft (STSG) tubularized for a length of 5-6 centimeters with an appropriate caliber match to native artery. The deep dermal side of the graft was randomized to form either the external surface or the luminal surface. The neoconduit was placed as an interposition graft in the left common carotid artery. Grafts were studied in vivo with duplex ultrasonography and ex vivo by histopathology and immunohistochemistry. Feasibility study involved 4 animals with grafts harvested for study at 24 hours (n= 2) and 7 days (n= 2). Two subsequent groups were studied to evaluate 3-month (n= 8) and 6-month (n= 5) patency. All grafts (n= 4) in the feasibility phase of the study were patent at the time of harvest without evidence of aneurysmal degeneration. In the subsequent 8 goats, grafts with the deep dermal side forming the extraluminal surface (n= 4) had a propensity to ulcerate and rupture or to become aneurysmal (75%). The patency rate of these grafts at 6 weeks was 25%. In contrast, grafts with the deep dermal side forming the intraluminal surface (n= 4) demonstrated 75% patency at 6 weeks. Because of these results the remaining goats underwent placement of neoconduits with the deep dermal side forming the luminal surface. These grafts maintained a patency rate of 80% at 6 months. Neoconduits implanted with a diameter greater than 1.5 times the native arterial diameter became aneurysmal. Histopathology demonstrated neointimal formation in all grafts patent for longer than 7 days. Immunohistochemical staining for Factor VIII/von Willebrand’s factor (vWF) was reactive in the endoluminal cells of these grafts. Immunohistochemical staining for a-smooth muscle actin demonstrated reactivity in conduits patent for greater than 1 month. Split-thickness skin may provide a feasible source for autogenous conduit in arterial reconstructions and warrants further study. Technical factors affecting patency include orientation of the deep dermal surface of the STSG and the diameter of the neoconduit at the time of implantation.
Vertebral Artery Embolic Protection Via Ipsilateral Brachial Approach During Left Subclavian Artery Angioplasty and Stenting
Authors: Gimelli Giorgio , Tefera Girma , Turnipseed William D.
Published: June 2007

The purpose of this report is to explore angioplasty and stenting with cerebral embolic protection as a salvage procedure for a compromised carotid-subclavian bypass in the presence of antegrade vertebral artery flow. A 76-year-old woman with a carotid-subclavian bypass presented with graft infection. Failure of medical therapy to treat the infection prompted surgical removal of the graft. The native subclavian artery was still patent, but a severe complex proximal stenosis was present with antegrade flow into the left vertebral artery. Angioplasty and stenting of the subclavian artery was performed with cerebral protection achieved by positioning a FilterWire EX™ in the left vertebral artery via the left brachial artery approach. Deployment of a filter device in the vertebral artery via the brachial or radial approach can provide embolic protection without interfering with the subclavian artery stenting. The successful treatment of the subclavian artery enabled the complete removal of the infected graft without need for major vascular reconstruction.
Endograft Repair of Traumatic Aortic Transection in a 10-Year-Old
Authors: Aidinian Gilbert , Karnaze Michael , Russo Eugene P. , Mukherjee Dipankar
Published: June 2007

Blunt abdominal aortic injury from trauma is extremely rare. It is generally from motor vehicular crashes resulting in dissection, intramural hematoma, or free rupture. Timely recognition and treatment of this injury are essential for a chance for survival. To the authors knowledge, this is the first reported case of successful management of this injury, with use of an intravascular stent-graft, in a child. Although open aortic repair has been the only modality used in children, intravascular stent-graft can be another available option in these injuries.
Endovascular Treatment of False Aneurysm of the Thyrocervical Trunk
Authors: Dwivedi Amit J. , Cherukupalli C. , Dayal R. , Krishansastry K. V.
Published: June 2007

The thyrocervical trunk is the second superior branch off the subclavian artery. Pseudoaneurysm of the thyrocervical trunk has been reported after attempted internal jugular vein cannulation for central venous or hemodialysis access. The treatment of pseudoaneurysms of the thyrocervical trunk depends on the findings from color flow Doppler ultrasonography and angiography. Although pseudoaneurysms of the thyrocervical trunk are rare, the treatment options should be clear. Surgical ligation is an effective technique that is safe and well-defined, but control through a cervical incision may be difficult. Endovascular treatment of the pseudoaneurysm may be accomplished with coil embolization of the artery, which is described.
Primary Intimal Sarcoma of the Aorta Associated With a Dacron Graft and Resulting in Arterial Rupture
Authors: Alexander J. Jeffrey , Moawad John , Cai Daniel
Published: June 2007

Primary arterial neoplasms are rare lesions which have been most frequently associated with local or constitutional symptomatology, and with distal embolization. Perirenal aortic disruption with pseudoaneurysm formation due to an intimal sarcoma adjacent to a previously placed prosthetic graft is reported in a 66-year-old man. This case supports the premise that the presence of a vascular prosthesis might result in the induction of an arterial wall malignancy. This should be considered when an intraluminal mass is identified in the absence of other arterial pathology. Although the prognosis of these tumors is poor, their preoperative recognition may enhance treatment outcomes.
Inferior Vena Cava Filter Placement in Late-Stage Cancer
Authors: Schunn Christian , Schunn Gisa B. , Hobbs Gerry , Vona-Davis Linda C. , Waheed Usman
Published: June 2007

Inferior vena cava (IVC) filters are increasingly used in patients with advanced-stage cancer for prophylaxis of pulmonary embolus. We evaluated the survival benefit of placing IVC filters in patients with late-stage malignancy and assessed their effectiveness in preventing pulmonary embolism. Between 1998 and 2003, 5,970 patients were treated with a primary diagnosis of malignancy at a tertiary care facility. Retrospective analysis identified 55 consecutive patients with stage III or IV malignant disease and venous thromboembolism (VTE) who received IVC filters. Retrospective review of electronic hospital charts identified subsequent pulmonary emboli, procedure-related complications, and survival. In a case control study, 16 patients with VTE but without IVC filter were matched for age, sex, type of malignancy, and stage of disease. IVC filter placement effectively prevented computed tomography (CT) scan or ventilation/perfusion ratio (V/Q) scan-proven pulmonary embolus in 52/55 (94.5%) patients. Complications developed in 4/55 or 7.3% of patients; 13/55 (23.6%) patients with late-stage cancer survived less than 30 days following placement of the filter. Another 23.6% of this group survived longer than 1 year. Ambulatory status differed significantly (p=0.01) between these 2 subgroups. In the case control study, IVC filter placement conferred no survival benefit compared to the control group. One recurrent pulmonary embolism was observed in both the filter group and the control group. No deaths due to thromboembolic complications were observed in either group. In late-stage cancer, patient survival is limited primarily by the malignant process. While IVC filter placement is effective in preventing pulmonary emboli, there may be limited survival benefit in this particular patient population. However, there exists a subset of this population whose functional status predicts longer survival times after filter placement.
Resistance Within Hemodialysis Shunts Predicts Patency
Authors: Bui Trung D. , Gordon Ian L. , Parashar Amish , Vo David , Wilson Samuel E.
Published: June 2007

The authors examined the relationship between patency after thrombectomy of clotted dialysis grafts and intraoperative measurements of flow (Q), pressure gradient (PGR), and longitudinal resistance (RL). Eighteen thrombosed arteriovenous (AV) grafts underwent 21 thrombectomies. Pressures at arterial (P1) and venous (P2) ends of the AV grafts were determined with 22-gauge catheters and standard transducers; flow was measured with transittime probes; arithmetic averaging of waveforms was used to compute mean Q, PGR, and RL. Kaplan-Meier patency curves were analyzed by using log rank methods. Mean patency for all grafts was 164 ±152 days. For each variable, the 21 measurements were split and the patency curve for the grafts with the 11 lowest value grafts was compared to the curve representing the 10 highest value grafts. The difference between high RL versus low RL patency curves was significant with high-resistance grafts having a median patency of 55 days and low-resistance grafts having a median patency greater than 151 days (p=0.0089). In contrast, the high Q group median patency was 151 days versus 174 days for the low Q group (p=0.86). Median patency for the low PGR group was 115 days compared to 62 days for the high PGR group (p=0.162). Longitudinal resistance within AV grafts, but not flow or pressure gradient, showed a significant correlation with patency after thrombectomy. Increased resistance to flow within AV grafts appears to be an important factor affecting the propensity of dialysis grafts to thrombose.
Optimal Medical Management of Peripheral Arterial Disease
Authors: Rice Terry W. , Lumsden Alan B.
Published: June 2007

Patients with peripheral vascular disease are less likely to receive optimal medical management than patients with coronary artery disease. However, early medical treatment is critical because it is profoundly beneficial and the benefits are maximized. Even in patients with advanced disease requiring invasive intervention, medical management has been proven to improve outcome, prolong the success of the intervention, improve functional capacity, and prolong life. The vascular surgeon should be knowledgeable enough to initiate basic medical therapy and to define for their patients the goals that need to be met to optimize their medical management. The vascular surgeon should be instrumental in assuring that the peripheral vascular patient receives medical therapy of the same standard as the patient with coronary disease. The major modifiable risk factors in the vascular patient are: smoking, high blood pressure, hyperlipidemia, physical inactivity, obesity, and diabetes. In addition, the use of beta blockers for patients with coronary disease and antiplatelet therapy as well as angiotensinconverting enzyme (ACE) inhibitors are recommended for all patients with peripheral vascular disease. Statins have favorable effects on multiple interrelated aspects of vascular biology important in atherosclerosis. In particular they have beneficial effects on inflammation, plaque stabilization, endothelial dysfunction, and thrombosis. Statins have also been shown to be beneficial in acute vascular events. Angiotensin-converting enzyme inhibitors have been shown to reduce cardiovascular morbidity and mortality in patients with peripheral arterial disease regardless of the presence or absence of hypertension. A number of the pleiotropic effects of statins are shared by ACE inhibitors. In summary, patients with known vascular disease should be treated aggressively with a combination of a HMG CoA reductase inhibitor, an angiotensinconverting enzyme inhibitor, an antiplatelet agent and a beta blocker if there is a history of coronary disease. They should also receive tight control of their blood pressure and blood sugar. Smokers should be encouraged to stop smoking and should be provided with pharmaceutical and emotional support by their physicians. All of these patients should have their body mass index as close to normal as possible and be on a therapeutic lifestyle diet. Regular aerobic exercise is also indicated. Patients with symptomatic claudication should be considered for cilostazol. Patients with multiple risk factors for vascular disease, but who do not have documented disease should also be on statin therapy. As more studies define the linear relationship between lower LDL-C levels and lowered risk of vascular events, indicating that the lower the LDL-C level, the lower the risk, experts are advocating more aggressive lipid-lowering therapy. In patients with peripheral arterial disease, some experts now advocate lowering the goal of LDL therapy to 70 mg/dL.
Paradoxical Neutrophil Elastase Release in Endovascular Abdominal Aortic Aneurysm Repair
Authors: Rowlands Timothy E. , Homer-Vanniasinkam Shervanthi
Published: June 2007

Endovascular repair of abdominal aortic aneurysm potentially avoids problems associated with prolonged aortic cross-clamping that occurs with open repair, but it appears to have its own biologic consequences, which may relate to neutrophil elastase release. Blood samples of consecutive patients undergoing open or endovascular abdominal aneurysm repair were analyzed for neutrophil elastase/α1-antitrypsin complex and free elastase. Free elastase rose from baseline and fell quickly in open repair patients, returning to baseline by 144 hours. In the endovascular repair group, it continued to increase for up to 144 hours. Bound elastase increased to 24 hours, returning to baseline in endovascular repair patients by 72 hours, but remaining elevated in open repair patients at 144 hours. Open repair patients showed raised elastase/α1-antitrypsin complex and initial raised free elastase levels. High free elastase levels in endovascular repair patients may reflect less bound elastase and may paradoxically lead to a prolonged inflammatory postoperative response.
Endoluminal Management of Arterioportal Fistulae in Liver Transplant Recipients: A Single-Center Experience
Authors: Saad Wael E. A. , Davies Mark G. , Rubens Deborah J. , Sahler Lawrence G. , Patel Nikhil C. , Lee David E. , Kitanosono Takashi , Sasson Talia , Waldman David L.
Published: June 2007

Transcatheter embolization of arterioportal fistulae in liver transplant recipients is restricted to symptomatic arterioportal fistulae. Angiograms of liver transplant recipients from a single university medical center were retrospectively reviewed. Hemodynamically significant arterioportal fistulae were defined as those exhibiting opacification of the main portal vein of the transplanted hepatic graft or its first order branch with or without portal venous changes by Doppler ultrasound imaging. Six arterioportal fistulae were found. Doppler ultrasound imaging detected 50% of all arterioportal fistulae and all 3 hemodynamically significant arterioportal fistulae. Three successful embolizations were performed. Follow-up (37 to 67 months) demonstrated patent hepatic arteries and no parenchymal ischemic changes with graft preservation. High-throughput arterioportal fistulae may require larger intrahepatic artery branch embolization. There is a window of opportunity for embolizing significant arterioportal fistulae before their progression to large symptomatic, high through-put arterioportal fistulae with their added risk of ischemic changes before and after embolization.
Novel Repair of Venous Aneurysms Secondary to Arteriovenous Dialysis Fistulae
Authors: Pierce George E. , Thomas James H. , Fenton James R.
Published: June 2007

This report describes the surgical management of 12 hemodialysis patients with arteriovenous fistulae in whom non-infected, fusiform venous aneurysms developed that compromised access for dialysis. The venous aneurysmal changes were too extensive to permit excision and primary veno-venous anastomosis. To avoid the use of synthetic interpositional grafts, the venous aneurysms were left in situ and reduced in size to match the diameters of the veins entering and exiting the aneurysms. After decompression, the lumens of the venous aneurysms were reduced by firing staple lines along the longitudinal axes of the venous aneurysms and excision of the aneurysmal tissue anterior to the staple lines. Twenty-eight aneurysms were repaired by this method of reduction aneurysmoplasty, in 15 operations on 12 patients over the past 10 years. There were no wound infections or dehiscences and no bleeding or hematomas. After the operations, the arteriovenous fistulae were used continuously for hemodialysis until the patients died (7 patients for 36 months ∓ 28 SD), were lost to follow-up (1 patient at 30 days postoperatively), until the arteriovenous fistulae thrombosed following revision of the arteriovenous anastomosis (1 patient at 41 months postoperatively), or until the arteriovenous fistulae was ligated to relieve pain in the upper arm (1 patient at 6 months postoperatively). Two patients continue to use their arteriovenous fistulae until and including the time of this report at 10 and 11 months, respectively. Reduction aneurysmoplasty as described in this report offers an effective and low-risk option for the management of venous aneurysms secondary to arteriovenous fistulae in hemodialysis patients.
Combined Endovenous Ablation and Transilluminated Powered Phlebectomy: Is Less Invasive Better?
Authors: Passman Marc A. , Dattilo Jeffery B. , Guzman Raul J. , Naslund Thomas C.
Published: June 2007

This study was undertaken to evaluate the evolution of operative vein approaches from combined “open” saphenous stripping-stab avulsion phlebectomy to combined “minimally invasive” endovenous ablation-transilluminated powered phlebectomy with a focus on comparing clinical outcomes. All patients undergoing a combined operative approach for concomitant saphenous vein insufficiency and associated varicose tributary veins between January 1, 1998 and December 31, 2005 were identified. Patients were stratified by operative approach into 3 groups: combined saphenous vein stripping-stab avulsion phlebectomy (STRIP-PHLEB); combined saphenous vein stripping-transilluminated phlebectomy (STRIP-TPP); and combined endovenous ablation-transilluminated phlebectomy (EVAB-TPP). Clinical volume, indications, technical details, and complications were retrospectively reviewed. Over the 8-year period, there were 72 limbs in 59 patients treated with STRIP-PHLEB, 92 limbs in 81 patients with STRIP-TPP, and 99 limbs in 76 patients with EVAB-TPP, with a time-dependent transition in operative techniques noted. There was no difference in distribution of CEAP clinical classification between groups, overall with most limbs in the C2-C4 categories (93.1%) and fewer in the C5-C6 categories (6.9%). There was no difference in overall complication rates between STRIP-PHLEB and EVAB-TPP, although the distribution of complications did shift with a trend toward more wound problems noted in procedures involving saphenous stripping (STRIP-PHLEB 5.6%, STRIP-TPP 6.5%, EVAB-TPP 2.0%; P = NS), and more hematomas in procedures involving transilluminated powered phlebectomy (STRIP-PHLEB 5.6%, STRIP-TPP 16.3%, EVAB-TPP 6.9%; P < .05; see Table 2). Complications associated with the endovenous ablation portion were low including technical inability to cannulate 1.6%, saphenous re-cannulation 2.4%, hematoma 2.4%, severe phlebitis 3.1%, venous thromboembolism 0.8%, and no wound or thermal injury problems. With the shift of combined operative vein approaches for concomitant saphenous vein insufficiency and varicose tributary veins towards “minimally invasive” techniques the overall complication rate has remained unchanged. While combined endovenous ablation-transilluminated phlebectomy offers some advantage of “less” invasiveness, this perceived benefit should be balanced against unchanged overall risk over traditional operative approaches.
Cognitive Function After Carotid Artery Revascularization
Authors: Lal Brajesh K.
Published: June 2007

Clinical investigations designed to contrast the efficacy of carotid endarterectomy (CEA) versus best medical therapy and CEA versus carotid artery stenting (CAS) in patients with carotid artery stenosis have been based on the traditional endpoints of stroke, myocardial infarction, and death. Cognitive function is being increasingly recognized as an important outcome measure that affects patient well-being and functional status. However, it has not been evaluated systematically in the context of carotid revascularization. A decline in cognitive function could occur from microembolic ischemia during surgical dissection (CEA) or intravascular instrumentation (CAS). It could also occur from hypoperfusion during clamping (CEA) or balloon dilation (CAS). Conversely, restoring perfusion could improve cognitive dysfunction that might have occurred from a state of chronic hypoperfusion. It is still unclear whether these complex interactions ultimately result in a net improvement or a deterioration of cognitive function. Furthermore, it is not known whether the 2 methods of carotid revascularization have a differential effect on cognitive outcomes. It is becoming increasingly clear, though, that there is a positive relationship between improvement in cognition and improvement in functional outcome of patients. Vascular surgeons will be well served to remain informed and even actively engaged in the development of this field if they wish to continue providing the high-quality, well-informed care they have traditionally offered to patients with carotid stenosis.
Esophageal Stent Erosion into the Common Carotid Artery
Authors: Ali Ahsan T. , Kokoska Mimi S. , Erdem Eren , Eidt John F.
Published: June 2007

A pseudoaneurysm of the common carotid artery was found with computed tomography in a 62-year-old woman with an esophageal stent that had eroded through her skin. The pseudoaneurysm was treated with a self-expanding nitinol stent; after massive hemoptysis, an endograft was placed on the pseudoaneurysm. The patient then underwent ligation of the left common carotid artery, proximal to the carotid bulb, and excision of the endograft and previously placed coils. The esophageal stent wires were so that they could no longer impinge the common carotid artery.
Prolonged Aortic Cross-Clamping Time and Cardiopulmonary Bypass Time Have a Gradient Effect on Early Mortality in Open-Heart Surgery
Authors: Sivertssen Egil , Abdelnoor Michel , Fjeld Nils B.
Published: June 2007

In 1031 consecutive patients (839 men, 192 women) who underwent coronary artery bypass surgery at Ullev'al Hospital in the period 1988-1990, the risk of early mortality increased in a dose response pattern from increasing aortic cross-clamping time and increasing cardiopulmonary bypass time.
The Differential Hemodynamic Effects of Norepinephrine and Methoxamine in Systemic Hypotension Complicating Pulmonary Hypertension
Authors: Ducas John , Bhattacharya Samir , Prewitt Richard M.
Published: June 2007

The authors investigated the acute cardiopulmonary effects of noradrenaline and methoxamine in a canine model in which systemic hypotension complicated an acute increase in pulmonary vascular resistance. In 13 anesthetized ventilated dogs, glass beads were injected to increase right ventricular afterload and to decrease mean blood pressure to approximately 65 mmHg. In the first 7 dogs, corresponding to the decrease in blood pressure, there was a marked fall in cardiac output, from 4.8 to 1 L/minute (P < 0.01). Subsequently, dogs were treated in sequence with norepinephrine and then with methoxamine. Both drugs caused a similar increase in mean blood pressure, from approximately 66 to 121 mmHg (both P < 0.001) and in right ventricular coronary perfusion pressure. However, only norepinephrine increased cardiac output.

To determine whether the differential effects of these drugs on cardiac output was explained by differences in coronary artery flow, in a second group of 6 dogs, right coronary artery flow was measured before and after pulmonary embolization and during infusion of both drugs. Coronary artery flow decreased when blood pressure decreased with embolization. As above, while both drugs caused a similar increase in blood pressure and right ventricular coronary perfusion pressure, only norepinephrine increased cardiac output. Also, values for coronary artery blood flow were similar during infusion of both drugs. Most likely, the improvement in cardiac output with norepinephrine is explained by a direct inotropic effect of this agent.
Pseudo-Malposition of Permanent Pacemaker Electrodes Caused by Pneumothorax
Authors: Mukerji Vaskar , Grady Timothy P. , Alpert Martin A. , Nikas Dimitris J. , Yancey Thomas H.
Published: June 2007

A fifty-two-year-old man received a dual-chamber pacemaker with appropriate positioning of the leads via the right subclavian vein. About four days later he was noted to have developed a large right-sided pneumothorax. The roentgenogram showed displacement of the heart to the left and apparent displacement of the pacemaker leads with loss of the normal “J” configuration of the atrial electrode. On resolution of the pneumothorax, the electrode configurations returned to normal.
Prestenotic and Poststenotic Flow Measurement to Assess Severity of Coronary Artery Stenosis
Authors: Altstidl Robert , Dill Harald , Regenfus Matthias , Lehmkuhl Hans , Bachmann Kurt
Published: June 2007

The purpose of this study was to investigate differences between prestenotic and poststenotic intracoronary Doppler flow velocities and to determine whether these hemodynamic parameters of coronary flow demonstrate a correlation with geometrically measured coronary artery stenosis.

A low-profile (0.018-in.) Doppler angioplasty guidewire capable of providing spectral flow velocity data was used to measure blood flow velocities both proximal and distal of 95 coronary artery stenoses ranging from 15% to 82% in diameter. Percent diameter stenoses were analyzed by quantitative coronary arteriography.

In comparison with prestenotic measurements poststenotic Doppler flow velocities were markedly reduced in coronary artery stenoses with a diameter reduction greater than 50% in quantitative angiography. In stenoses less than 50% no difference between prestenotic and poststenotic parameters of coronary flow could be found. Prestenotic Doppler data demonstrated no correlation to percent diameter stenosis, whereas poststenotic flow data correlated moderately with percent diameter stenosis. Poststenotic Doppler data of stenoses below 50% differed significantly from stenoses above 50%.

In conclusion, intracoronary Doppler flow velocity measurements performed distal to coronary artery stenoses contribute to the evaluation of hemodynamic significances of particular coronary artery stenoses.
Color Doppler Imaging in Adjunct to Contrast Arteriography in Evaluation of Severe Peripheral Vascular Disease
Authors: Alhan H. Cem , Alhan Sibel , Çinar Bayer , Tuygun Abdullah K. , Sezerman Özge
Published: June 2007

Of the 309 patients operated on for revascularization of lower extremities 29 (9.4%) had a conventional contrast arteriography that failed to opacify at least one vessel that was found to be patent by color Doppler imaging plus surgical exploration. The indication for vascular imaging was rest pain in 12 patients, claudication in 7, nonhealing ulcers in 3, and gangrene in 3; 4 patients had more than one indication. In 20 (69%) of 29 patients infrapopliteal runoff vessels were the cause for misdiagnosis. In all patients with failed arteriography a total occlusion proximal to the misidentified vessel was present. As a common finding, peak systolic velocities were less than 0.5 m/second in misdiagnosed suprapopliteal arteries and less than 0.25 m/second in infrapopliteal arteries.

At operation direct surgical exploration confirmed the diagnosis of color Doppler imaging in all 29 patients. The judgment that the operation was successful was based upon intraoperative arteriography, relief of symptoms, warmness of the feet, palpable pulses, and color Doppler imaging performed one month after the operation. Excellent short-term results were obtained in 27 patients; one early and three late graft occlusions were detected in a mean follow-up of twenty months.

In conclusion, color Doppler imaging is an excellent and convenient technique for evaluation of patients with peripheral vascular disease. It demonstrates suitable blood vessels for revascularization that are not seen on contrast arteriography. In the authors' opinion, color Doppler imaging is a clinically useful adjunct to conventional contrast arteriography and should be performed in patients in whom arteriography has failed to show any suitable target vessel for revascularization.
Portal Vein Replacement with Expanded Polytetrafluoroethylene (e-PTFE) Graft
Authors: Tanaka Koki , Nishimura Akihiro , Ikoma Akira , Ogata Seiji , Nishida Seigou , Taira Akira
Published: June 2007

This study was conducted to assess the efficacy of portal vein reconstruction with an expanded polytetrafluoroethylene (e-PTFE) graft.

Five patients underwent interposition of the portal vein with e-PTFE graft following en bloc resection of the entire pancreas and the portal vein for advanced pancreatic cancer. The length of the excised vein ranged from 5 to 7 cm and that of the implanted graft (8 or 10 mm in diameter), 3 to 7.5 cm. In 4 of the 5 cases, the graft was patent at five to eighteen months following implantation. One patient died of respiratory failure two months after operation, and partial occlusion of the graft was noted at autopsy. Four patients died of recurrence of the original disease five to eighteen months after operation. The implanted graft taken at autopsy eighteen months after operation was covered uniformly with thin neointima on the internal surface. Microscopic examination showed endothelial cells covering the surface of the neointima, and capillary vessels had developed in the neointimal layer.

Experimentally, five grafts, 0.8 cm in diameter and 2.5 cm in length with external ring support, were interposed in the portal vein in pigs. All grafts were patent during a four-month follow-up period.

The authors conclude that the e-PTFE graft is a suitable prosthesis for replacement of the portal vein following its resection.
Surgical Treatment of Abdominal Aortic Aneurysm Due to Vasculo-Behqet's Disease
Authors: Sugimoto Takaki , Ogawa Kyoichi , Asada Tatsuro , Mukohara Nobuhiko , Higami Tetsuya , Obo Hidefumi , Gan Kunio , Kawamura Tsuyoshi
Published: June 2007

A thirty-two-year-old woman was operated on for abdominal aortic aneurysm due to vasculo-Behqet's disease. Her aortography showed an aneurysm of curious eggplant-like configuration. At operation, the aneurysm was found to be adhered to the surrounding organ with the severely thickened wall. The diseased aorta was replaced with Y-shaped Dacron graft. Three anastomosis sites were apart from the inflammation and were rolled up with the Teflon felt for reinforcement. Pathology of the diseased wall showed an infiltration of the inflammatory cells with the small-vessel vasculitis due to Behqet's disease. She has had an uneventful postoperative course with a tapering corticosteroid therapy.
Intraaortic Balloon Pump Entrapment: An Alternative Method of Management
Authors: Harris Linda M. , Guarino Ross L. , Jennings LuJean , Ricotta John J.
Published: June 2007

The intraaortic balloon pump (IABP) is an important component in the management and support of the failing heart. Despite the benefits of the IABP, major vascular complications have been documented to occur. Entrapment of an IABP is a rare, but potentially catastrophic, complication. The authors report a case of IABP entrapment, review the previous reports in the literature, and detail their method of extraction.
Day Care Surgery of Varicose Veins in Elderly Patients
Authors: Canonico Silvestro , Campitiello Ferdinando , Pacifico Fabio , Sepe Dario , Lauletta Vincenzo
Published: June 2007

The objective of this study was to assess the efficacy and the acceptance of day care varicose veins surgery in elderly patients. Forty-six consecutive patients more than sixtyfive years old (51 legs) were operated on for varicose veins under locoregional anesthesia and day care stay: the interventions were 4 saphenectomies, 25 short strippings, 10 crossectomies (proximal saphenous ligation) of which 6 were with short saphenous removal, and 12 varicectomies and interruptions of perforator veins. All patients went home after five to six hours from operation and none required readmission to hospital. Complications were minimal and comprised 2 wound infections. Inquiry into the patients' opinions suggested that both local anesthesia and day care were very acceptable. In conclusion the day care phlebological surgery has been shown to be both safe and acceptable in selected elderly patients.
Combined Use of Endovascular and Standard Operative Procedures for the Treatment of Multiple Aortoiliac Pseudoaneurysms
Authors: Sanchez Luis A. , Marin Michael L. , Veith Frank J. , Suggs William D. , Lyon Ross T. , Chang John B.
Published: June 2007

New endovascular procedures are increasing the options available to the vascular surgeon for the treatment of arterial disease. These techniques, alone or in combination with conventional surgical techniques, may allow the safer treatment of complex aortoiliac pathology, particularly in patients with comorbid medical illnesses who have high morbidity and mortality rates associated with open surgical repair. The authors describe the successful treatment of two noninfected aortoiliac false aneurysms eight years after the original arterial reconstruction with a bifurcated graft. The pseudoaneurysms were treated by use of a combination of endovascular and standard surgical techniques in a patient with significant comorbid medical conditions that limited standard surgical repair.