bluuebunny/crossref_metadata_2025 huggingface dataset:
Successful Limb Reperfusion Using Prolonged Intravascular Shunting in a Case of an Unstable Trauma Patient
Authors: Nalbandian M. M. , Maldonado T. S. , Cushman J. , Jacobowitz G. J. , Lamparello P. J. , Riles T. S.
Published: March 2006

When peripheral vascular injuries present in conjunction with life threatening emergencies, controlling hemorrhage from a peripheral blood vessel may take initial priority, however, sacrificing a limb to preserve life is a well-established dictum. The use of intravascular shunts has allowed arterial and venous injuries to be controlled and temporized while treating other injuries. Typically, intravascular shunts are used for short time periods while orthopedic injuries are repaired or other life threatening injuries are managed. The following case demonstrates the long-term use of an intravascular arterial shunt to treat a traumatic transection of the common femoral artery and vein in a patient with an open pelvic fracture from blunt trauma. A 20-year-old woman fell between a subway platform and an oncoming train. She sustained a crush injury to her lower extremity and pelvis as she was pinned between the train and platform. The patient presented with active hemorrhage from a groin laceration, quickly became hemodynamically unstable, and was brought to the operating room. In addition to a pelvic fracture with massive pelvic hematoma she sustained a complete transection of the bifurcation of the common femoral artery (CFA), the common femoral vein (CFV), and associated orthopedic injuries. Vascular shunts were placed in the common femoral artery and vein. The patient became hypotensive from an expanding retroperitoneal hematoma. Pelvic bleeding was controlled with angioembolization and the venous injury was repaired. At this time the patient became cold, acidotic, and coagulopathic. It was thought unsafe to proceed with the arterial repair and it was elected to keep her arterial shunts in place and perform a planned reexploration in 24 hours after correcting her physiologic status. The patient returned to the operating room for an elective repair of her CFA the following day. Her shunt had remained patent throughout this time. She underwent a reverse saphenous vein graft from her CFA to her SFA. After a prolonged hospital course she was ultimately transferred to a rehabilitation center with intact pulses in both lower extremities. This case demonstrates the effectiveness of prolonged (>6 hours) use of an intravascular shunt as part of damage control surgery for peripheral arterial and venous injuries. In a patient who would otherwise undergo an amputation for their injury, the risk of shunt thrombosis, or infection, during damage control resuscitation may not be a contraindication for placement.
Chronic Abdominal Pain and Upper Gastrointestinal Bleeding Due to Duodenal Perforation Caused by Migrated Inferior Vena Cava Filter
Authors: Mansour John C. , Lee Fred T. , Chen Herbert , Turnipseed William D. , Weber Sharon M.
Published: March 2006

The authors describe an unusual case of a 41-year-old man presenting with chronic abdominal pain and gastrointestinal bleeding caused by a migrated inferior vena cava filter eroding into the duodenum.
Renal Artery Stenosis and a Functioning Hilar Paraganglioma: A Rare Cause of Renovascular Hypertension
Authors: Chandra V. , Thompson G. B. , Bower T. C. , Taler S. J.
Published: March 2006

Surgically correctable causes of hypertension are uncommon. Simultaneous occurrence of 2 such causes in the same individual is extremely rare. The authors describe a 25-year-old woman with congenital erythrocytosis, renal artery stenosis, and a paraganglioma. The possible mechanisms of renal artery stenosis in the presence of a catecholamine-secreting tumor are discussed.
Medical Management of Intermittent Claudication
Authors: Casey Kevin , Tonnessen Britt H. , Sternbergh W. Charles , Money Samuel R.
Published: March 2006

The symptoms of intermittent claudication (IC) lead sufferers to seek medical attention, potentially leading to substantial workup and invasive testing. However, only a minority of people with IC develop limb-threatening ischemia or symptoms of significant lifestyle-limiting claudication. Patients with IC have a substantial risk of concomitant cardiovascular and cerebrovascular disease. Assessment of co-morbidities and control of risk factors reduce the cardiovascular risk of these patients. A multitude of drugs have been developed and tested in numerous trials for the symptoms of IC. Although no drug alone offers a “cure” to IC, some are used as adjuvant therapy to reduce claudication symptoms.
Initial Experience with Endovascular Aortic Aneurysm Repair Without Cardiologists or Radiologists—Do Vascular Surgeons Really Need Them?
Authors: Chang Jeanette K. , Calligaro Keith D. , Dougherty Matthew J.
Published: March 2006

Endovascular abdominal aortic aneurysm repair (EVAR) has been predominantly accomplished by teams of multidisciplinary interventionalists, frequently under the primary direction of cardiologists and radiologists. The purpose of this paper was to examine the feasibility and safety of an initial experience of EVARs performed by vascular surgeons at a single institution without other interventionalists. The authors reviewed the first 50 EVARs performed solely by vascular surgeons at our hospital, which we believed represented a fair and sizable enough learning curve for this new procedure. The operations were performed in an endovascular operating room and the surgeons had prior endovascular experience. The EVAR protocol included preoperative abdominal computed tomography (CT) scans and aortograms, same-day admissions, epidural anesthesia, transfer to the ward the day of surgery, and discharge the first postoperative day. CT scans were performed on postoperative day 1 and then annually, unless duplex ultrasound (DU) suggested an endoleak. DU was performed 1 week postoperatively, every 3 months for the first year, and then every 6 months thereafter. Of the first 23 patients, 3 required immediate conversion to open repair because of device malfunction (all in a Phase III FDA trial) and 1 underwent conversion 3 weeks after initial graft placement during treatment of a failing endograft limb as diagnosed by duplex ultrasonography. None of the next 27 cases required conversion. In 2 (4%) patients, graft limb occlusions occurred postoperatively and were treated with femorofemoral crossover grafts. There were 5 (10%) endoleaks: 2 were treated endovascularly, 1 closed spontaneously, and 2 were followed. Several advanced adjunctive endovascular procedures were performed concomitantly during EVAR including internal iliac artery coil embolization using aortic crossover catheters in 16% (8/50) of patients, proximal or distal extension cuff placement in 16% (8/50), and graft limb stenting in 50% (25/50). The average length of stay for patients who underwent uncomplicated aortic stent grafts was 1.9 days (range, 1–4 days) compared to 2.3 days for all patients (range 1–13 days). In no case were other interventionalists necessary for intraoperative assistance. These results of EVAR performed solely by vascular surgeons are comparable to reports by multidisciplinary teams and support the premise that vascular surgeons with endovascular skills have the knowledge and capability to begin performing EVAR independently of other specialists.
Management of Juxtarenal Aortic Aneurysms and Occlusive Disease with Preferential Suprarenal Clamping Via a Midline Transperitoneal Incision: Technique and Results
Authors: Ryan Sean V. , Calligaro Keith D. , McAffee-Bennett Sandy , Doerr Kevin J. , Chang Jeanette , Dougherty Matthew J.
Published: March 2006

Surgical management of juxtarenal aortic (JR-Ao) aneurysms and occlusive disease may include supraceliac aortic clamping, a retroperitoneal approach, or medial visceral rotation. The authors report their results using preferential direct suprarenal aortic clamping via a midline transperitoneal incision. Between July 1, 1992, and July 31, 2001, they treated 58 patients with JR-Ao disease (44 aneurysmal, 14 occlusive) via a midline incision without medial visceral rotation. Preferential suprarenal aortic clamping was used in 53 cases (42 proximal to both renal arteries, 11 proximal to the left renal artery only) and supraceliac or supramesenteric clamping in 5 cases when there was insufficient space for an aortic clamp between the superior mesenteric artery and renal arteries. This strategy avoided mesenteric ischemia associated with supraceliac clamping in the majority of cases and afforded better exposure of the right renal artery than obtainable with a left retroperitoneal approach or medial visceral rotation. Eleven patients underwent concomitant renal revascularization. Critical adjuncts included the following: (1) selective left renal vein (LRV) division if the vein stump pressure was <35 mm Hg (suggesting sufficient renal venous collaterals existed), (2) bilateral renal artery occlusion during aortic clamping to prevent thromboembolism, (3) flushing of aortic debris before restoring renal perfusion, and (4) routine administration of perioperative intravenous mannitol and renal-dose dopamine. Patients with type IV thoracoabdominal aneurysms, ruptured aneurysms, or JR-Ao disease approached via a retroperitoneal incision (severely obese patients, re-do aortic surgery) were excluded. No patients died or required dialysis during their hospital stay. The LRV was divided in 12 (21%) cases and reanastomosed in 2 cases (elevated stump pressures). The average suprarenal clamp time was 26 minutes (range, 10–60). Postoperative serum creatinine remained >0.5 ng/dL above baseline in 3 (5%) patients. These results support suprarenal aortic clamping with a midline transperitoneal incision as the optimal strategy for treating juxtarenal aortic aneurysms and occlusive disease. The authors believe that selective left renal vein division enhances juxtarenal aortic exposure, and routine administration of renal protective agents, along with occlusion of both renal arteries during suprarenal aortic clamping, are critical adjuncts in performing these operations.
Vascular Reconstruction in Limbs with Malignant Tumors
Authors: Nishinari Kenji , Wolosker Nelson , Yazbek Guilherme , Zerati Antônio Eduardo , Nishimoto Inês Nobuko , Penna Valter , Lopes Ademar
Published: March 2006

Patients with tumors in limbs who undergo surgical treatment may present involvement of major vessels. Major arteries must be reconstructed for limb salvage. Major veins may be reconstructed to avoid the onset of venous hypertension. The objective of this study is to analyze the results from surgical treatment of malignant tumors associated with vascular reconstruction in limbs. A prospective follow-up was made of 20 patients with malignant tumors involving major vessels in limbs who underwent vascular reconstruction. Arterial and venous reconstructions were performed in 11 patients, arterial reconstruction in 7, and venous reconstruction in 2. The vascular substitutes utilized were: greater saphenous vein (21), expanded polytetrafluoroethylene (ePTFE) prosthesis (5), and Dacron prosthesis (5). Vascular complications occurred in 9 patients: 1 rupture of the arterial graft, 4 occlusions of the venous graft, and worsening of previous edema in 4 patients. Nonvascular complications occurred in 6 patients: infection (2), neurologic deficit (2), partial necrosis of the flap (1), and enteric fistula (1). Four patients presented local recurrence, and 1 of them underwent transfemoral amputation. Seven patients presented pulmonary metastases, of whom 4 died. Arterial revascularization in association with the resection of limb neoplasm is a safe procedure with a low rate of complications. Venous revascularization should be performed using an autologous substitute.
Factor XIII Contrasts the Effects of Metalloproteinases in Human Dermal Fibroblast Cultured Cells
Authors: Zamboni Paolo , De Mattei Monica , Ongaro Alessia , Fogato Luisella , Carandina Sergio , De Palma Massimiliano , Tognazzo Silvia , Scapoli Gian Luigi , Serino Maria Luisa , Caruso Angelo , Liboni Alberto , Gemmati Donato
Published: March 2006

Matrix metalloproteinases (MMPs) are overexpressed in venous leg ulcers, determining a breakdown of the main extracellular matrix (ECM) components owing mainly to collagenase activities, and so playing a crucial role in ulcer pathogenesis. The authors studied the effects of coagulation factor XIII (FXIII), which cross-links collagen and other ECM components, in human fibroblast cultured cells in the presence and in the absence of matrix metalloproteinases from Clostridium histolyticum collagenase. Clostridium collagenase at concentrations of 2.0, 1.0, and 0.5 mg/mL was added to normal human dermal fibroblasts cultured in the presence of 0.0, 1.0, and 5.0 U/mL of FXIII concentrate (Fibrogammin P, Aventis Behring). Cell counting and metabolically active fibroblast evaluation in the cultures were monitored for 72 hours, by means of trypan-blue dye and MTT test, respectively. The MTT test showed that at the highest collagenase concentration (2.0 mg/mL), the cell number decreased more than 95% in 72 hours of treatment and no significant differences were observed regardless of the FXIII concentrations utilized. At lower collagenase concentration (1.0 mg/mL), in absence or in presence of FXIII (1.0 U/mL), the cell number decreased by about 80% in 72 hours. In contrast, in the presence of higher FXIII levels (5.0 U/mL), cells suffered globally significantly less collagenase effects (p=0.011) and the gain was appreciable at each time tested. Finally, at 0.5 mg/mL of collagenase concentration, in the absence of FXIII, the cell number decreased by about 60% in 72 hours, whereas in presence of FXIII 1.0 U/mL and 5.0 U/mL, cells decreased significantly less, by about 35% and 20%, respectively (p<0.025 and p<0.01, respectively). These data were also confirmed by direct cell counting utilizing the trypan-blue test. Factor XIII contrasts effectively the detrimental action of Clostridium collagenases in human fibroblast cultured cells. These results support several in vivo reports about the effectiveness of its topical application in order to enhance the venous ulcer healing processes.
Endoscopic Subfascial Perforator Vein Surgery for Patients with Severe, Chronic Venous Insufficiency
Authors: Baron Howard C. , Wayne Michael G. , Santiago Cesar A. , Grossi Robert
Published: March 2006

Before 1985, surgery on incompetent perforator veins in patients with severe, chronic, venous insufficiency and venous ulcerations was generally performed utilizing long skin incisions through diseased skin and subcutaneous tissues. Known as “the Linton operation,” wound infections and poor healing complicated this procedure. In 1985 G. Hauer demonstrated a new surgical technique for identifying and ligating incompetent perforator veins using an endoscopic approach in the limbs’ subfascial space. This seminal contribution marked the advent of subfascial endoscopic perforator surgery (SEPS). From 1996 to 2003 our group prospectively collected data on 86 patients with chronic venous insufficiency (CVI) who underwent a SEPS procedure. Preoperative assessment consisted of color-flow duplex ultrasound scanning and ascending and descending phlebography. The patient’s ages ranged from 42 to 82 years (mean 60). A total of 98 limbs underwent the SEPS procedure from the cohort group of 86 patients. The CHEAP classification of the limb disease was used: 45 limbs were classified as group C5, 53 limbs group C6. Ninety-eight SEPS procedures were performed without significant morbidity on 86 patients. Of the 53 limbs in class C6, 41 had ulcer healing within 12 weeks. The remaining 12 limbs in class C6 had ulcer healing within 6 months. In this latter group, 9 had ulcers greater than 4 cm in widest diameter. These patients underwent a split-thickness skin graft at the time the SEPS procedure was performed. The grafts have remained intact after 2 years in this cohort group. The results of this study demonstrate that the SEPS procedure incorporated into the overall treatment plan for patients with CVI produces excellent healing with minimal postoperative complications. The study also underscores the important role incompetent perforator veins have in the formation of venous ulcers.
Duplex Ultrasound Recognition of Spontaneous Carotid Dissection
Authors: Adkins Amy L. , Zelenock Gerald B. , Bendick Phillip J. , Shanley Charles J.
Published: March 2006

Spontaneous dissection of the internal carotid artery is an uncommon entity with a variable clinical presentation. A high index of suspicion is required to make the diagnosis, and prompt diagnosis and treatment with anticoagulation are essential for improved patient outcomes. Duplex ultrasound provides a safe and reliable imaging modality for early diagnosis and followup. The authors present a case of spontaneous internal carotid artery dissection with duplex ultrasound findings and a review of the literature.
Celiomesenteric Trunk Compression and Absence of Collateral Vessels in the Large Intestine
Authors: DeWitt R. Chance , Cooley Denton A.
Published: March 2006

The authors report the case of a rare mesenteric anomaly in a 71-year-old man who presented with a preexisting abdominal aortic aneurysm (AAA) and a progressive history of postprandial abdominal pain and 10-lb weight loss. Aortography revealed a common celiomesenteric trunk, an absent middle colic artery, and a stenotic inferior mesenteric artery. At operation, neural fibers compressing the common celiomesenteric trunk were lysed, the AAA was repaired, and the inferior mesenteric artery was subjected to endarterectomy and then reimplanted. The patient remains well and free of symptoms 1 year after operation. This rare case demonstrates the many different causes of intestinal angina and its surgical relief.
Splenic Artery-to-Superior Mesenteric Artery Bypass for Chronic Mesenteric Ischemia
Authors: Mukherjee Dipankar , Hendershot Kimberly M.
Published: March 2006

Chronic mesenteric ischemia (CMI) is a serious vascular condition that if left untreated may progress to acute ischemia resulting in bowel necrosis and high surgical morbidity/mortality rates. Elective intervention has been shown to prevent this progression and relieve symptoms. Current open surgical intervention involves arterial bypass using a vein or synthetic graft conduit with the inflow originating from the aorta or iliac artery. In some circumstances, the splenic artery provides an additional treatment option for revascularization of the superior mesenteric artery. In certain cases, the splenic artery has several advantages over traditional surgical options. The splenic artery is an arterial conduit much like the internal mammary artery used in coronary artery bypass grafting. These grafts are known for their long-term patency and in selected clinical circumstances are preferred over venous grafts. Because the splenic artery has a natural inflow, only a single vascular anastomosis at the outflow vessel (the SMA) is necessary. This lessens the risk of anastomotic stenosis by decreasing the number of anastomoses created and it makes the procedure shorter in duration. The fact that the inflow is provided by the splenic artery makes cross-clamping of the aorta unnecessary, thereby lessening the risk of producing cardiac ischemia and declamping hypotension. A disadvantage is the risk of splenic ischemia with the possible need for splenectomy. The majority of individuals will have adequate collateral supply to the spleen via the short gastric arteries. The risk to the patient of splenectomy versus the benefits of a less complicated arterial reconstruction with avoidance of aortic cross-clamping must be weighed on a case-by-case basis. Preventing the progression to acute mesenteric ischemia with its increased mortality by timely restoration of adequate vascular supply is an important principle in treating patients with CMI. Controversy still exists over the best treatment option for these patients, whether it be antegrade versus retrograde bypass, single-vessel versus multivessel reconstruction, or open surgical repair versus endovascular intervention. In selected patients, the use of the splenic artery can be considered as an additional option for arterial reconstruction of the SMA.
Endovascular Management of Traumatic Axillary Artery Dissection
Authors: Valentin Marlene D. , Tulsyan Nirman , James Kevin
Published: March 2006

A 43-year-old man was admitted to this hospital with a cool, slightly numb, left upper extremity after trauma. Physical examination revealed a cool left forearm and hand, with no distal pulses. An intraoperative angiogram demonstrated short-segment dissection and occlusion of the left axillary artery. A 10 mm x 40 mm self-expanding stent was placed across the intimal flap to reinstitute peripheral flow. Early postoperative duplex scanning showed normal flow through the axillary artery.
Carotid Blowout with Infection: Management with Endovascular and Open Vascular Approaches
Authors: Hertz Jeffrey A. , Valentino Joseph , Kwolek Christopher J. , Endean Eric D.
Published: March 2006

The management of patients with head and neck cancer can be complicated by massive carotid artery hemorrhage, often requiring ligation owing to the emergent conditions and scarring from previous surgery and radiation. A case of emergent endovascular management of carotid artery hemorrhage in a patient treated for pharyngeal carcinoma is described. Hemorrhage was controlled, but on follow-up the patient developed a carotid-cutaneous fistula with exposure of the coils. Further management required the use of autogenous vein to replace the involved vessels. This case demonstrates that endovascular control of carotid hemorrhage can be successful, but close follow-up is necessary to identify potential subsequent complications.
Efficacy of Dextran Solutions in Vascular Surgery
Authors: Abir Farshad , Barkhordarian Siamak , Sumpio Bauer E.
Published: March 2006

The purpose of this paper is to discuss the role and efficacy of dextran in vascular procedures using evidence-based data from the review of surgical literature. A MEDLINE search using “dextran,” “vascular surgery,” and “antiplatelet therapy” as keywords was performed for English-language articles. Further references were obtained through cross-referencing the bibliography cited in each work. Dextran is commonly used in carotid endarterectomy (CEA) patients where the embolic rate is reduced by 46%, resulting in fewer procedure-related strokes. As a prophylactic agent against thrombosis, multiple randomized studies have reported its benefit over other antithrombotic medications. Dextran is also particularly useful in “difficult” infragenicular lower extremity bypasses where artificial grafts (such as polytetrafluoroethylene [PTFE] or umbilical vein) are used in the setting of poor outflow vessels, or those with composite grafts and small-caliber venous conduits. Distal bypasses with adjunctive procedures (eg, arteriovenous fistula or anastomotic cuffs) also have a better outcome with the addition of dextran. Dextran has numerous important implications in vascular surgery, in particular with CEA patients or “difficult” infragenicular bypasses. Its effectiveness with endovascular stents remains unknown.
Chronic Visceral Ischemia: Symptom-Free Survival After Open Surgical Repair
Authors: English William P. , Pearce Jeffrey D. , Craven Timothy E. , Edwards Matthew S. , Geary Randolph L. , Plonk George W. , Hansen Kimberley J.
Published: March 2006

A retrospective review of patients treated with a history of chronic visceral ischemia (CVI) was made to determine primary patency of open surgical repair and estimated symptom-free survival. Patients with CVI between 1990 and 2003 were reviewed. Included were those with chronic symptoms alone (C-CVI) and acute-on-chronic symptoms (A-CVI). Data were obtained from a vascular database. Symptom-free survival and graft patency were estimated by using product limit estimates. Fifty-eight patients (13 men, 45 women; mean age: 63 years) were treated surgically for C-CVI (34 patients) and A-CVI (24 patients). All patients had postprandial abdominal pain and weight loss (mean: 17 kg). One fourth reported food fear. Preoperative imaging demonstrated disease of the superior mesenteric artery (SMA) (100%; 64% occluded), celiac axis (89%; 37% occluded), and inferior mesenteric artery (IMA) (54%; 60% occluded). Multiple vessels were involved in 95% of patients (mean: 2.3 vessels/patient). Operative management included antegrade revascularization of 80 vessels. Combined aortic and/or renal procedures were performed in 7 patients. Patient demographics and visceral disease did not differ for C-CVI and A-CVI; however, perioperative mortality differed significantly (10% for C-CVI vs 54% for A-CVI [p<0.001]). Intestinal gangrene at presentation was associated with perioperative (hazard ratio [HR]: 7.6; 95% CI: 2.7–21.6; p=0.0002) and follow-up death (HR: 7.8; CI 2.8–21.9; p< 0.0001). Follow-up (mean: 34 months) was complete for 54/68 vessels (79%). Estimated primary and primary assisted patency at 5 years were 81% and 89% respectively. Estimated symptom-free survival for hospital survivors was 57% at 70 months. Open antegrade methods of visceral artery repair for CVI were durable and associated with 57% symptom-free survival at 70 months. Patient demographics and distribution of visceral artery anatomy were similar; however, perioperative mortality for C-CVI and A-CVI differed dramatically. Improved outcomes for A-CVI require recognition and treatment of CVI before onset of intestinal gangrene.
TrapEase Inferior Vena Cava Filter Placement: Use of the Subclavian Vein
Authors: Stone Patrick A. , AbuRahma Ali F. , Hass Stephen M. , Hofeldt Matthew J. , Zimmerman William B. , Deel John T. , Deluca John A.
Published: March 2006

The purpose of this paper was to evaluate the safety and technical success of TrapEase inferior vena cava filter placement via the subclavian vein. As of yet, no reports in the literature have specifically investigated the use of the subclavian vein as a route for deploying TrapEase vena cava filters. Retrospective chart review was conducted of 135 patients with attempted TrapEase inferior vena cava filter placement over a 2-year period. In a majority of cases, the choice of subclavian vein approach was based primarily on surgeon preference. Other circumstances for subclavian vein deployment included cervical immobilization secondary to trauma, desire for concomitant placement of a subclavian long-term central venous access catheter, and patient body habitus limiting exposure to the internal jugular vein. One hundred and thirty-five filters were placed over this 2-year period. The internal jugular vein approach was used in 56 patients, the femoral vein approach in 39 patients, and the subclavian vein approach in 40 patients. Thirty-nine of the 40 TrapEase filter placements using the subclavian vein were successful. Twenty-six were deployed through the right subclavian vein and 14 through the left subclavian vein. The single failed subclavian deployment was due to the inability to pass the guidewire adequately into the inferior vena cava after successful cannulation of the right subclavian vein. The average deployment time for subclavian vein placement was 26 minutes when TrapEase filter placement was the only procedure performed. No insertional complications were encountered, specifically no pneumothoraces confirmed by chest radiography or fluoroscopy. The subclavian vein provides an alternative site of access for the TrapEase inferior vena cava filter. This route is comparable to other alternative methods evaluated both in average deployment time and complication occurrence. Furthermore, the subclavian vein route is valuable in patients with limited central access and where combined long-term central venous catheter placement using the subclavian vein is desirable.
Does Repeat Duplex Ultrasound for Lower Extremity Deep Vein Thrombosis Influence Patient Management?
Authors: Ascher Enrico , DePippo Patrick S. , Hingorani A. , Yorkovich W. , Salles-Cunha S.
Published: March 2006

The clinical significance of lower extremity deep vein thrombus (DVT) propagation in the setting of anticoagulation therapy remains unclear. The purpose of this study is to compare results of thrombus outcome found with repeat duplex ultrasonography to the incidence of pulmonary embolism and mortality. During a recent 18-month period, 457 patients were diagnosed with lower extremity DVT with duplex ultrasonography and their data were retrospectively analyzed. Repeat examinations were available for review in 118 patients (51 men, 67 women). Results of repeat duplex exams were divided into 4 groups: resolved, improved, unchanged, or extended proximally. All patients received heparin and warfarin therapy. Ventilation-perfusion (V./Q.) scans were obtained only for signs and symptoms of pulmonary embolism (n=30). Mortality, the prevalence of high-probability V./Q. scans, frequency of intracaval-filter insertion, gender, mean age, mean prothrombin time (PT), mean partial thromboplastin time (PTT), mean number of repeat ultrasounds per patient, and mean time over which the repeat ultrasounds took place were compared among the 4 groups. Patients who had proximal extension of DVT (19%) on repeat duplex ultrasound had an increased prevalence of pulmonary embolism (p<0.05). Also, patients whose DVT resolved were younger (p<0.05). There was no difference among the 4 groups in mortality, placement of Greenfield filters, mean PT, mean PTT, mean number of ultrasound exams per patient, or mean follow-up time over which the exams took place. Proximal extension of DVT documented by repeat duplex ultrasound is a significant risk factor for pulmonary embolism. Repeat duplex ultrasound can identify a group of patients who may benefit from insertion of an intracaval filter device.
Saphenofemoral Junction Ligation Supplemented by Postoperative Sclerotherapy: A Review of Long-Term Clinical and Hemodynamic Results
Authors: Recek CestmÌr
Published: March 2006

This review article summarizes information found in the literature concerning long-term results following high ligation supplemented in the postoperative period by sclerotherapy. Subjective complaints, recurrent reflux, and recurrent varicose vein rates as well as changes in venous hemodynamics are reviewed and compared with results after high ligation and stripping. The fate of the greater saphenous vein trunk after high ligation, the question whether it could actually be used as a graft in arterial and coronary artery reconstructions, and the relevance of saphenous vein saving surgery are discussed. The trunk of the greater saphenous vein, when incompetent preoperatively, continues to be patent and incompetent after surgery in most cases. It is not diffusely degenerated and could be used as an arterial substitute. However, ligation of the saphenofemoral junction alone provokes a higher recurrence rate in comparison with high ligation and stripping. The excellent hemodynamic improvement achieved immediately after high ligation deteriorates progressively during the follow-up owing to recurrent reflux. Sclerotherapy can compensate this undesirable feature, because it is itself capable of reducing or even abolishing reflux and improving venous hemodynamics, although only transitorily, but repeated sclerosing injections can restore improvement at any time, if necessary, during the follow-up period. The improvement of venous hemodynamics and subjective symptoms achieved with the combined procedure (high ligation plus sclerotherapy) is comparable with that after high ligation and stripping.
Advances in the Management of Iliac Artery Occlusive Disease: A Short Review
Authors: Liapis Christos D. , Tzortzis Elias A.
Published: March 2006

There have been considerable advances in the management of patients with aortoiliac occlusive disease. While endovascular procedure is the treatment of choice for Trans-Atlantic Inter-Society Consensus (TASC) type A and is more often used in TASC type B iliac lesions, recent studies report encouraging results in patients with intermittent claudication suffering from TASC type C and D iliac disease. Modern surgical techniques have been proposed for the treatment of high-risk subjects with critical limb ischemia due to advanced aortoiliac disease. Combined or hybrid interventions involving endovascular and open procedures performed either successively or intraoperatively are becoming more popular as vascular surgeons acquire endovascular skills. However, the long-term results of these therapies especially in the presence of multilevel occlusive lesions still remain uncertain.
Hormone Replacement Therapy and Peripheral Vascular Disease in Women
Authors: Nguyen Liz , Liles Debra R. , Lin Peter H. , Bush Ruth L.
Published: March 2006

Women have been shown to have a lower incidence of vascular disease when compared to men. However, the incidence of vascular disease increases as women progress through menopause and reaches an incidence similar to that of men later in life. Women with peripheral vascular disease often have a delay in diagnosis, a higher incidence of asymptomatic disease, and poorer outcome after interventions. The differences in outcome have been attributed to a number of factors such as anatomic and hormonal differences. It is thought that estrogen deficiency is at least partially responsible for the increased risk of developing vascular disease after menopause, and thus hormone replacement therapy has been considered as a method to prevent progression of vascular disease. Conclusions drawn from a number of recent studies have resulted in a divergent view of hormone replacement therapy (HRT). This article explores the risk of peripheral vascular disease in women and the current state of research on hormone replacement therapy. The aims of this review are to present current perspectives on gender differences in the pathogenesis and outcomes of peripheral arterial disease (PAD). The effect of estrogen on atherogenesis, the role it plays in modulating the vascular endothelium, and the current evidence of the effects of HRT on vascular pathology is discussed. The most recent HRT clinical trials and present evidence for the benefits and risks of postmenopausal hormone replacement therapy are summarized. The effect of these issues on treatment practices is explained and suggestions are made for future directions of HRT and PAD research.
Left Subclavian Artery Aneurysm: Surgical Repair Via a Sternal Incision
Authors: Balar Nilesh , Ganatra Vipul , Sampson Lawrence N. , Reitknecht Felice , Gupta Sushil
Published: March 2006

For trauma, the traditional approach to the proximal left subclavian artery is through a posterolateral thoracotomy. The purpose of this study was to evaluate the feasibility of accessing the proximal left subclavian artery through a partial sternotomy approach. Anatomical review of 52 subclavian arteries was performed on 52 randomly picked computed tomography (CT) scans of the thorax. The depth of the origin of the subclavian artery was measured from the lateral thoracic wall and from the sternum. It was noted that the distance from the sternum to the origin of the left subclavian artery was 4.71 cm as compared to the posterolateral wall, which was 8.87 cm. This is in contrast to the belief that the left subclavian artery is a posterior structure in the mediastinum. A subclavian artery aneurysm was repaired through the sternal approach and was noted to have an adequate exposure required for the procedure. This approach was necessitated owing to the fact that the patient had significant chronic obstructive pulmonary disease. From these data, the authors conclude that in elective circumstances it is easier and appropriate to use the partial sternotomy approach to access the proximal left subclavian artery, especially in patients who have reduced pulmonary function.
Gastrointestinal Bleeding as the Initial Manifestation of a Polyarteritis Nodosa-Associated Hepatic Artery Aneurysm-Duodenal Fistula
Authors: Shuster Thomas A. , Almeida Jose , Coats Richard , Kalra Ajay , Silver Donald
Published: March 2006

The authors report an unusual case of upper gastrointestinal bleeding from a hepatic artery aneurysm-duodenal fistula in a 21-year-old male. Arteriography revealed multiple visceral artery aneurysms. Biopsy of the hepatic artery aneurysm (HAA) revealed focal areas of necrosis, medial degeneration, fibrosis, and giant cells. The necrotizing vasculitis plus the multiple visceral aneurysms were highly suggestive of polyarteritis nodosa (PAN). This report reviews the pathophysiology and management of PAN and the diagnosis and management of HAA.
Treatment Options of Iatrogenic Pelvic Vein Injuries: Conventional Operative Versus Endovascular Approach
Authors: Zhou Wei , Bush Ruth L. , Terramani Thomas T. , Lin Peter H. , Lumsden Alan B.
Published: March 2006

Iatrogenic injury to the iliac vein or inferior vena cava (IVC), which may occur during abdominal operations or posterior orthopedic procedures, can have devastating consequences. Operative management is challenging and may be associated with significant morbidity. The authors report herein 3 cases of iatrogenic pelvic vein injuries that were managed with different treatment approaches. Both traditional open surgical therapy and endovascular techniques are described.
Endovascular Exclusion of Saphenous Vein Graft Aneurysms Complicating Abdominal Aortic Aneurysm Repair
Authors: Dieter Robert S. , Stevens Scott L. , Rush Daniel S. , Pacanowski John P. , Goldman Mitchell H. , Freeman Michael B.
Published: March 2006

A 64-year-old man was referred for vascular evaluation before renal transplantation for ischemic nephropathy. In the past he had undergone bilateral renal artery revascularizations using saphenous vein. At the time of transplant evaluation, he was found to have bilateral aneurysms of the saphenous veins used to bypass his renal artery stenoses. He underwent successful endovascular exclusion of the aneurysms with 2 endovascular AneuRx extension cuffs. This case highlights both the versatility of endovascular treatments as well as the importance of a comprehensive vascular examination.
Endoluminal Retrieval of a Dislodged Umbilical Vein Catheter
Authors: Gasparis Antonios P. , Santana Dixon , Blewett Christopher , Bohannon W. Todd , Silva Michael B.
Published: March 2006

Endoluminal retrieval of foreign bodies in the pediatric and infant population is an uncommon and challenging procedure for the endovascular specialist. The alternative is an open exploration of these often-fragile patients. The availability of smaller catheter systems allows retrieval with minimally invasive techniques. We report retrieval of a catheter fragment using an Amplatz loop snare through the umbilical vein and review the literature.
Inferior Canine Hindlimb Ischemia and Reperfusion Impairs Femoral Artery Endothelium-Dependent Wall Relaxation
Authors: Joviliano Edwaldo E. , Piccinato Carlos E. , Cherri Jesualdo , Viaro Fermanda , Evora Paulo Roberto B.
Published: March 2006

This experimental investigation was carried out to study the endothelium-dependent ischemiareperfusion injury upon the release of nitric oxide (NO) in the canine femoral artery. The tested experimental model was the inferior canine hindlimb ischemia induced by infrarenal abdominal aortic clamping followed by reperfusion. The research protocol was standardized in four experimental groups (n=6): (1) Control group; (2) Ischemia (120 minutes) group; (3) Ischemia (90 minutes) and reperfusion (60 minutes) group; and (4) Ischemia (120 minutes) and reperfusion (90 minutes) group. The femoral artery vascular reactivity was studied in vitro with the aid of an eight “organ chambers” setup, where segments from 4 to 5 mm, with and without endothelium, were suspended and connected to force transducers. The fundamental data of this study were as follows: (1) Ischemia caused by 120 minutes of infrarenal aortic clamping did not cause femoral artery endothelium dysfunction. (2) Ischemia caused by 90 minutes of clamping followed by 60 minutes of reperfusion also did not cause endothelium dysfunction, with an observed tendency to signal transduction impairment (studied by the sodium fluoride dose response curves). (3) Ischemia caused by 120 minutes of clamping followed by 90 minutes of reperfusion caused endothelium dysfunction, observed by the femoral artery impaired capacity of the endothelium-dependent NO release evoked by acetylcholine, adenosine diphosphate, and sodium fluoride. The present pharmacologic in vitro observations are concordant with the evidence that the NO-release impairment, caused by inferior canine hindlimb ischemia followed by reperfusion, is a consequence of endothelium cell membrane receptors, and G-proteins signal transduction dysfunction.
Is Neck Dilatation After Endovascular Aneurysm Repair Graft Dependent?
Authors: Dillavou Ellen D. , Muluk Satish , Makaroun Michel S.
Published: March 2006

Long-term success of endovascular aneurysm repair (EVAR) relies on a stable proximal neck. The authors' goal was to determine whether neck dilatation after EVAR varies among 4 different endografts and whether it is related to complications of the proximal neck. Core laboratory data from 4 phase II trials of aortic endografts were analyzed for neck diameter changes over time. Patients who had at least 24 months' follow-up were included in the analysis. Neck measurement methodology varied among the 3 core labs used. Values are reported within the parameters used by each lab. Short-axis neck diameter close to 5 mm below the renal arteries, when available, was used for longitudinal comparisons. Dilation was defined as an enlargement of 3 mm or more from the first postoperative scan to the last available follow-up for each patient. Graft migration and late proximal endoleaks were determined by the individual core labs. A limited number of Lifepath grafts had most recent follow-up measurements performed by the authors. Results were compared by using Student's t test, chi-square analysis, and the Pearson correlation coefficient. Postoperative measurements from 729 EVAR patients were examined. Follow-up ranged from 24 to 60 months for 229 Ancure (Guidant) and 258 AneuRx (Medtronic) patients, and from 24 to 36 months for 211 Excluder (Gore) and 31 first-generation Lifepath (Edwards) patients. Neck dilation was noted in 124 patients (17.0%) and did not differ significantly among graft types. The incidences of late proximal endoleaks were similar among graft types, but rates of migration differed (p= 0.01). Dilation was associated with migration in Ancure (p=0.03) and Excluder (p=0.02) grafts. Late proximal endoleaks were seen in 4.1% of patients with and in 0.7% of patients without dilation (p=0.001). Patients with initial neck diameter >25 mm had significantly less dilatation than those with smaller necks (p<0.001). The incidence of neck dilation approached 20% in all EVAR patients after 24 months and was not significantly different among graft types. Neck dilation of 3 mm or more appears to be one risk factor for migration and late proximal endoleak.
Custom-made Stent-Grafts for Aortic Aneurysm Repair Using Gianturco Z Stents and Woven Polyester: Healing in an Animal Model
Authors: Koskas Fabien , Brocheriou Isabelle , Cluzel Philippe , Singland Jean-Dominique , Régnier Bruno , Bonnot Michel , Kieffer Edouard
Published: March 2006

The purpose of this study was to evaluate the healing at 6 months of aortic stent-grafts custom-made by using Z stents and woven polyester in an animal model. Stent-grafts were built by a published method using autoexpandable stainless steel stents continuously compiled with polyester sutures and covered with a woven polyester membrane. Fourteen stent-grafts of 3 different designs were deployed under fluoroscopic control into the thoracic and the abdominal aorta of 7 adult sheep. At 6 months, all the implants of the sheep that survived the implantation were angiographed and harvested for macroscopy and microscopy. All stentgrafts were implanted successfully and remained patent from then to the explantation procedure. All stent-grafts implanted among the 6 of 7 (86%) animals that survived after the implantation remained patent, stayed free from local complications, and did not migrate during more than 6 months. In all these cases during this period, the implant functioned as a satisfactory aortic substitute while the aortic segment containing the graft kept a normal structure. There was no adverse effects of the presence of the implant upon the aorta or the animal. Stent-grafts home-made according to the described methods gave results at 6 months in this animal model compatible with a safe clinical application among humans.
Detection of Peripheral Microemboli Through Collateral Circulation by Doppler Ultrasound Monitoring
Authors: Kudo Toshifumi , Inoue Yoshinori , Nakamura Hiroshi , Hirokawa Masayuki , Sugano Norihide , Iwai Takehisa
Published: March 2006

It is possible for a proximal arterial source to lead to distal atheroembolism even in the presence of chronic occlusive disease. However, no monitoring technique has been established regarding detection of peripheral emboli through the collateral circulation in the lower limbs. We report a 60-year-old woman and a 73-year-old man with iliac stenosis and complete occlusion of the ipsilateral superficial femoral artery in whom Doppler ultrasound successfully detected microembolic signals (MES) at the tibioperoneal trunk during percutaneous transluminal angioplasty (PTA) and stent placement. By means of continuous Doppler ultrasound monitoring, 29 MES were successfully detected immediately after PTA or stent placement (MESp) and 64 MES were detected immediately after the contrast medium administration (MESc). MESc generated significantly higher intensities (median 28, range 7 to 38) as opposed to MESp (median 21, range 5 to 35, p= 0.017). In addition, the intensity of MES after prestent PTA (n=8, 25 dB, 12–35 dB) and stenting (n=18, 22 dB, 9–35 dB) was significantly higher than that of MES after poststent PTA (n=3, 13 dB, range; 5–16 dB), respectively (p=0.041, p=0.034). Iliac PTA and stent placement were successful. Ankle/brachial pressure index and the symptoms improved in both patients, who showed no embolic symptoms after the procedure. This study suggested that it was possible to detect peripheral microemboli through the collateral circulation by Doppler ultrasound monitoring and that this technique would be helpful to investigate the mechanism of embolization in patients with PTA and stent placement.
Persistent Left Superior Vena Cava: An Incidental Finding During Central Venous Catheterization
Authors: Danielpour Payman J. , Aalberg Joshua K. , El-Ramey Margarita , Sivina Manuel , Wodnicki Henry
Published: March 2006

Persistent left superior vena cava (PLSVC) is an uncommon anomaly, estimated to be present in about 0.3–0.5% of the population. It results from an embryological defect involving failure of the left cardinal vein to degenerate. It is present along with a right-sided superior vena cava in 82.2% of the cases reported. The condition most commonly occurs along with other cardiovascular malformations and frequently goes undiagnosed because when not accompanied by other anomalies it is typically asymptomatic. PLSVC is most often discovered subsequent to central venous or pulmonary artery catheter placement.
Mycotic Aneurysm of the Superior Mesenteric Artery: A Delayed Complication from a Neglected Septic Embolus
Authors: Javid Patrick J. , Belkin Michael , Chew David K. W.
Published: March 2006

Mycotic aneurysm formation in a visceral artery carries a significant risk of mortality and morbidity. The authors present a case of a symptomatic superior mesenteric artery aneurysm secondary to a septic embolus in a patient who had undergone aortic valve replacement. The patient initially presented with evidence of acute intestinal ischemia from a presumed embolic source. Although an extensive bowel resection was performed, an adequate search for the embolus was not carried out. Prompt diagnosis and removal of suspected septic emboli must be performed to avoid the formation of delayed mycotic aneurysms.