bluuebunny/crossref_metadata_2025 huggingface dataset:
Percutaneous Venous Stenting for Thoracic Outlet Syndrome
Authors: Ibrahim Ibrahim M. , Lipman Steven P. , Alasio Teresa , Berry Silvia M. , Wolodiger Fred A.
Published: June 2007

The thoracic outlet syndrome (TOS) is manifested by symptoms of venous compression or thrombosis in approximately 4% of the time. Even with early recognition and aggressive anticoagulant therapy about 25% of patients continue to complain of residual disability. Historically failure to restore venous patency in TOS was due to incomplete understanding of the pathology and therefore incomplete management. Thrombectomy or thrombolytic therapy is often inadequate unless the underlying etiology is corrected. Chronic venous compression results in scarring, not relieved by widening the outlet via rib resection, scalenectomy or abnormal band lysis. The authors describe a twenty-sevenyear-old woman who underwent successful subclavian and axillary vein thrombolysis with urokinase but remained symptomatic. Persistent subclavian venous stenosis was confirmed by sonography and angiography. Transaxillary first rib resection was performed with no relief of stenosis. Percutaneous transbrachial angioplasty with stent placement across the stenotic area resulted in complete sonographic, angiographic and symptomatic relief. One year later she remains asymptomatic. Subclavian venous patency is confirmed sonographically. The combination of clot lysis, external decompression and internal widening is crucial. If internal stenting results in long term patency then these three modalities may afford an expeditious, durable and cosmetically acceptable therapy for this frustrating disorder.
Isolated Iliac Artery Dissection Secondary to Fibromuscular Dysplasia
Authors: Harler Mary Beth , Weyman Albert , Capt. Raymond Bozman, , Sullivan Deborah , Patterson Robert
Published: June 2007

Among the nonatherosclerotic vascular diseases leading to ischemic complications in young adults, fibromuscular dysplasia (FMD) is relatively common. Manifestations of this abnormality most frequently occur secondary to stenosis, aneurysm formation, or embolization of the renal or internal carotid arterial beds. Although 3 cases of external iliac artery dissection (2 with confirmed FMD) have been reported, no reports exist of isolated dissection of the common iliac artery in the absence of a more proximal aortic entry point.

Three otherwise healthy men were diagnosed with acutely symptomatic isolated iliac artery dissection (2 common iliac, 1 external iliac). Two patients required arterial bypass grafting for the relief of ischemia; histologic examination demonstrated FMD. The third patient had early findings on arteriography of associated renal arterial FMD. Although a dissection of the common iliac artery was confirmed in this patient on imaging studies as well as arteriography, he manifested no ischemic symptoms or aneurysmal dilation and is being managed nonoperatively.

The diagnosis of arterial dissection secondary to FMD should be strongly considered in the differential diagnosis of young patients with signs and symptoms of lower extremity ischemia. Noninvasive diagnostic modalities (computerized tomography [CT], magnetic resonance imaging [MRI], and duplex scans) will establish the diagnosis, but arteriography remains essential to delineate the extent of involvement. The associated finding of FMD in other vascular beds may help to confirm the diagnosis as well as contribute to the future management of these patients.
Asymptomatic Popliteal Vein Aneurysms
Authors: Labropoulos Nicos , Volteas Spiridon K. , Giannoukas Athanasios D. , Touloupakis Emanouel , Delis Kostas , Nicolaides Andrew N.
Published: June 2007

Popliteal vein aneurysms represent a rare vein abnormality. There is agreement on the etiology, symptomatology (thromboembolism), and diagnosis (color duplex scanning). Surgery is the treatment of choice in symptomatic cases, but management in asymptomatic cases remains uncertain.

Seven cases (5 women and 2 men with a mean age of fifty-nine years) of asymptomatic popliteal vein aneurysms are presented. The diagnosis and follow-up were made by color flow duplex imaging (CFDI).

All aneurysm were of a saccular type, fully compressible, without evidence of thrombus in the sac, and with a maximal diameter ranging from 2.0 to 2.8 cm. In all but 1 case the popliteal valve was located in the aneurysmal sac and minor reflux was detected. Superficial vein incompetence was found in 6 patients, whereas in the seventh patient reflux was found in the superficial femoral vein. No treatment was offered and close surveillance with CFDI every four months was performed. So far, all patients remain asymptomatic over a period of two months to two years. Asymptomatic cases may remain without treatment under close surveillance with CFDI and regular clinical follow-up.
Input Impedance of Revascularized Skeletal Muscle, Renal, and Mesenteric Vascular Beds
Authors: Schwartz Lewis B. , Purut Cemil M. , Craig Damian M. , Smith Peter K. , Mccann Richard L.
Published: June 2007

Input impedance describes the relationship between pressure and flow in a vascular system and, hence, characterizes the outflow bed. The purpose of this investigation was to measure input impedance spectra in vascular reconstructions of skeletal muscle, renal, and mesenteric beds.

Input impedance was measured in 107 vascular reconstructions in 96 patients. Reconstructions were performed at the aortofemoral/aortoiliac (AF, n = 20), femoropopliteal (FP, n=18), femorodistal (FD, n=41), infrapopliteal-inframalleolar (IM, n = 6), renal (REN, n = 16), or mesenteric (MES, n= 6) level. Grafts were constructed from autologous vein in all cases except AF bypasses in which bifurcated woven Dacron grafts were employed. Input impedance was measured intraoperatively after reperfusion. For impedance calculation, simultaneously acquired intraluminal pressure (transducer-tipped pressure catheter) and blood flow (electromagnetic probe) waveforms of ten-second duration were digitized at 200 Hz and subjected to Fourier transformation in near real-time.

AF grafts exhibited the highest blood flow (443 ± 72.8 mL/minute) followed by MES (300 ± 30.4), REN (172 ± 43.9), FP (91.6 ± 20.0), FD (59.3 ± 5.09), and IM grafts (22.4 ± 5.44 mL/minute). A similar (inverse) trend was observed with respect to resistance (Rin), ie, MES≈AF<REN<<FP<FD<<IM(15.7 ± 2.2=23.7 ± 6.5<69.2 ± 12.2 < < 120 ± 31.9 < 137 ± 13.0 < < 337 ± 75.8 x 103 dyne•s•cm-5). As expected, AF grafts exhibited the lowest characteristic impedance (Z0 3.5 ± 0.8 x 103 dyne•s•cm-5). However, the Z0 of REN (20.2 ± 3.7 x 103 dyne•s•cm-5) grafts exceeded that of FP and MES grafts (10.5 ± 1.1 and 12.4 ± 4.0 x103 dyne•s•cm-5) and more closely approximated that of FD (22.2 ± 2.2 x 103 dyne•s•cm-5). The highest Z0 was seen in IM grafts (42.1 ± 15.8 x 103 dyne•s•cm-5). Therefore, the highest ratios of Z0/Rin were observed with MES (0.75 ± 0.23) and REN (0.33 ± 0.04) grafts as compared with the other groups (AF 0.23 ± 0.03, FP 0.12 ± 0.13, FD 0.19 ± 0.02, IM 0.16 ± 0.06).

As expected, Rin of vascular reconstructions follows the general trend of MES ≈ AF < REN < < FP < FD < < IM. However, examination of the high-frequency components of the impedance spectra reveals that Z0 follows a different pattern, AF < FP MES < FD ≈ REN < < IM and the ratio of ZO/Rin is highest in REN and MES vascular beds compared with skeletal muscle beds. Thus, although the REN and MES beds are “privileged” (ie, maximally dilatated with low arteriolar tone), the intrinsic properties of the graft and larger blood vessels are no different than those of a femorodistal bypass.
Spontaneous Carotid Artery Dissection: Case Reports and Review of the Literature
Authors: Calaitges John G. , Deshmukh Narayan
Published: June 2007

A review of the authors' experience with spontaneous carotid artery dissections and a comparison of their management strategies and outcomes with a review of the recent literature are presented. A retrospective chart analysis revealed 5 cases over the past nine years. All were treated in a conservative fashion. Two underwent anticoagulation, 2 received antiplatelet therapy, and 1 was merely observed. Their ages ranged from thirty-eight to eighty-three and all were men. Four of the 5 (80%) went on to an uneventful recovery. One patient receiving anticoagulation developed total occlusion of the left internal carotid artery associated with an acute stroke.

Angiography is the gold standard for diagnosis, but the role of duplex ultrasound for diagnosis and follow-up has strengthened.

Of patients with spontaneous carotid artery dissection, 85-90% have an uneventful recovery, and surgical intervention is rarely indicated.
Diagnostic Accuracy of Radionuclide Venography in the Assessment of Incompetent Perforating Veins of the Legs
Authors: Rulli Francesco , Muzi Marco , Sanguigni Valerio , Giordano Alessandro , Zanella Everardo
Published: June 2007

The purpose of this study was to evaluate the accuracy of radionuclide venography (RV) (with 99mTc-marked red blood cells) in the identification of incompetent perforating veins (IPVs) of the legs in patients with chronic venous insufficiency. After informed consent, RV, followed by contrast phlebography (CP), of the symptomatic leg was performed in 14 patients (20 legs). The results of RV were compared with those of CP, which was considered the standard technique in detecting IPVs of the leg. The sensitivity of RV was 92.3%; the specificity, 93.7%; the positive predictive value, 96%; the negative predictive value, 88.2%; and the accuracy, 92.9%. The authors conclude that RV has a high diagnostic accuracy in detecting IPVs of the leg.
Intraarterial Adenosine Administered During Reperfusion Preserves Endothelium-Dependent Relaxation in the Rabbit Hindlimb
Authors: Farooq Michael M. , Freischlag Julie A. , Carlsen Brian T. , Cambria Robert A. , Seabrook Gary R. , Towne Jonathan B.
Published: June 2007

Consumption of adenosine triphosphate (ATP) during ischemia leads to the failure of cell membrane ATP-dependent ion pumps, cell lysis, and activation of the inflammatory cascade, which contributes to endothelial injury during reperfusion. Adenosine is a lipidsoluble precursor in ATP metabolism that may be depleted during reperfusion, exacerbating this injury. The purpose of this study was to examine the effect of adenosine administration with reperfusion on endothelium-dependent relaxation in the rabbit superficial femoral artery.

New Zealand white rabbits underwent 3 hours of complete unilateral hindlimb ischemia followed by 2 hours of reperfusion. Animals received an intraarterial infusion of adenosine (0.35 mg/kg/min) or an equivalent volume of normal saline (1 cc/min) during the first 20 minutes of reperfusion. A sham group underwent aortoiliac collateral ligation and 5 hours of anesthesia without ischemia. A control group underwent immediate superficial femoral artery explantation with no collateral ligation or prolonged anesthesia. The superficial femoral arteries were explanted and suspended as 3 mm segments upon isometric force transducers within organ bath chambers. Contraction was evaluated with potassium chloride (KCl) and maximal norepinephrine (NE). Acetylcholine (Ach) relaxation was determined after NE submaximal contraction.

No difference in contractile response to KCl was observed among the four groups. A significant increase in contraction to maximum NE was observed for vessels in the adenosine group (P<0.05). A significant increase in relaxation was noted over four consecutive doses of Ach administered to vessels from the adenosine, sham, and control groups when compared with the saline group (P<0.05).

Adenosine administered during reperfusion preserved endothelium-dependent relaxation after ischemia and reperfusion in the rabbit superficial femoral artery. Adenosine may act as a substrate for ATP resynthesis and maintain cellular integrity during reperfusion. This form of pharmacologic therapy may prove clinically useful in the treatment of extremity ischemia/reperfusion injury.
Endovascular Surgery: An Integral Component of Treatment for Infected Aortobifemoral Bypass Grafts
Authors: Elmore James R. , Franklin David P. , Youkey Jerry R.
Published: June 2007

Endovascular reconstruction may be used alone or in combination with standard vascular techniques in dealing with infected grafts. This case report concerns a 53-year-old man who presented with sepsis 3 years after undergoing aortobifemoral bypass. The bypass was performed after two failed angioplasties. The proximal anastomosis was performed in an end-to-side fashion.

One year prior to presenting with sepsis, the patient developed acute myelogenous leukemia and underwent chemotherapy with subsequent remission. Eight months later, the patient developed low-grade fever and chills and was treated for pulmonary infection. Persistent mild symptoms prompted a Gallium scan that raised the possibility of an infected aortic graft. Subsequent computed tomography (CT) scan, magnetic resonance imaging (MRI), and Indium scan were normal. Admission was prompted when he presented with biopsy-documented septic emboli to the right leg. Repeat CT scan suggested aortic graft infection localized to the proximal graft segment.

Operative repair included a right common femoral endarterectomy, a right iliac balloon angioplasty, insertion of a right iliac Wallstent, and a right-to-left femoral-femoral polytetrafluoroethylene (PTFE) bypass. The well-incorporated femoral graft limbs were detached and the groins closed. Abdominal exploration identified a jejunal-aortic graft erosion with a localized abscess. The infected graft was removed and the aortotomy repaired with a patch fashioned from an endarterectomized portion of the occluded left external iliac artery. Small bowel resection with primary anastomosis and omental flap completed the operation. Four days postoperatively, the Wallstent required further expansion with an open balloon angioplasty to establish palpable pedal pulses. The patient recovered uneventfully and received a total of 6 weeks of broad-spectrum intravenous antibiotics.

This case illustrates the use of adjunctive endovascular techniques in handling difficult vascular graft infections and stresses their importance as an integral component of the vascular surgeon's armamentarium.
Outcome of the Contralateral Carotid Artery in Patients Having Undergone Ipsilateral Carotid Endarterectomy: Results of Selective Management
Authors: Eklof Bo G. , Kistner Robert L. , Masuda Elna M. , Wong Howard P.
Published: June 2007

Purposes: To evaluate the natural history of the carotid artery in patients who have undergone endarterectomy of the opposite carotid artery, study its relation to new neurologic events by clinical follow-up and serial duplex scanning, review the literature for management guidelines at present, and evaluate the impact on these guidelines from recently published prospective, randomized trials.

Methods: A retrospective study of 275 consecutive patients who underwent carotid endarterectomy (CEA) from December 1985 through December 1992.

Results: Of 275 patients, 115 were excluded (lost to follow-up, preoperative contralateral carotid occlusion, perioperative death or stroke) leaving 160 patients as the final study group. Progression of contralateral stenosis from <50% to 50-79% occurred in 13/113 patients (11.5%), all asymptomatic; from 50-79% to 80-99% in 10/38 patients (26.3%), (two symptomatic-one transient ischemic attack [TIA] and one stroke-<50% to 80-99% in one patient who was asymptomatic); no patient progressed to total occlusion. All nine patients with an initial contralateral stenosis 80-99% remained asymptomatic prior to subsequent CEA. Neurologic events referable to the contralateral carotid distribution occurred in 10 patients of 160 (6.3%) at a mean of 12.8 months after initial surgery, six TIAs and four strokes, none of which was heralded by TIA. Thus 24 patients showed progression of stenosis, with two (8.3%) manifesting symptoms. Of the other 136 patients without progression of stenosis, eight (5.9%) developed symptoms.

Conclusions: Our data and a review of the literature does not support an aggressive approach to the contralateral carotid artery stenosis. Based on NASCET and ACAS, however, new guidelines for management are suggested.
Ultrasound-Guided Compression for Treatment of latrogenic Arteriovenous Fistulae
Authors: Massie Mitchell T. , Rohrer Michael J. , Cardullo Paul A. , Cutler Bruce S.
Published: June 2007

Pseudoaneurysms and arteriovenous fistulae (AVF) are the two most common vascular complications following percutaneous common femoral artery cannulation. Encouraged by favorable results using ultrasound-guided compression (UGC) to treat iatrogenic femoral pseudoaneurysms, we prospectively evaluated UGC for the treatment of iatrogenic AVF. AVF were identified in 13 patients between September 1, 1995 and March 31, 1997. Eleven agreed to a trial of UGC. UGC was continued for 60 minutes with color-flow duplex scanning to monitor the adequacy of compressions. There were 13 attempts to thrombose AVF in 11 patients. Two patients had unsuccessful UGC while anticoagulated. In both cases, a second UGC was unsuccessful after correction of the coagulation profile.

Two types of AVF were identified. A “direct” communication between the adjacent walls of the artery and vein was present in 10 patients. The other patient had a 2-cm “indirect” fistulous tract between the artery and vein. Direct communications were associated with peak spectral flow velocities ranging from 128 to 500 cm/sec (mean, 331 cm/sec), whereas the peak spectral flow velocity in the patient with the fistulous tract was only 70 cm/sec. UGC was only successful in the patient with the indirect tract. No complications occurred as a result of these compressions. Of the 10 who failed UGC, nine underwent operative repair, with spontaneous closure observed in the remaining patient. UGC is not effective for AVF, which have a direct arteriovenous communication with high-velocity blood flow. UGC is most likely to be successful when there is an indirect fistulous tract with a low-flow velocity.
Carotid Reconstruction for Ocular Ischemic Syndrome Can We Predict the Visual Outcome?
Authors: Ino-ue Masanori , Yamamoto Misao , Asada Masahiro , Tamaki Norihiko
Published: June 2007

Ocular ischemic syndrome is a progressive disorder that results from ocular ischemia in occlusive diseases of the carotid system. Ocular manifestations of 16 patients with ocular ischemic syndrome were evaluated retrospectively before and after carotid artery surgery. Although carotid endarterectomy (CEA) and carotid bypass surgery were beneficial to stabilize the ocular manifestations of nine eyes with amaurosis fugax and hypoperfusion retinopathy, ipsilateral blindness due to retinal artery occlusion developed following CEA in one eye. Conversely, carotid artery surgery in ocular ischemic syndrome with iris neovascularization has not been successful in stabilizing the ocular manifestations. As expected, carotid bypass surgery did not resolve neovascular glaucoma due to iris neovascularization in two eyes and was followed by an elevation of normal intraocular pressure in one eye. One eye with iris neovascularization developed an intractable glaucoma following CEA. The presence of iris neovascularization suggests poor visual prognosis after carotid artery surgery. The development of retinal artery occlusion and secondary glaucoma after CEA should be listed as postoperative ocular complications of carotid artery surgery. In conclusion, carotid artery surgery is effective for ocular ischemic syndrome before the onset of iris neovascularization. Presence of iris neovascularization needs careful indication of carotid artery surgery to prevent the elevation of intraocular pressure.
Ruptured Abdominal Aortic Aneurysms in the 1990s: Resource Utilization, Long-Term Survival, and Quality of Life After Repair
Authors: Eskandari Mark K. , Bowles Stephen A. , Webster Marshall W. , Steed David L. , Makaroun Michel S. , Muluk Satish C. , Rhee Robert Y. , Chelluri Lakshmipathi
Published: June 2007

Ruptured abdominal aortic aneurysm (RAAA) is a lethal disease. The aim of this study was to assess resource use, long-term outcome, and functional status of patients surviving repair of RAAAs. A retrospective review was made over a 42-month period. Functional status was assessed by use of the Medical Outcomes Study Short Form 36 (MOS SF-36) at a mean follow-up time of 29 months. Fifty-seven patients with an RAAA underwent surgical repair. The overall in-hospital mortality rate after surgical repair was 39%. Risk factors predictive for a poor hospital outcome were preoperative systolic blood pressure less than 90 mmHg, hematocrit less than 25%, transfusion requirements greater than 15 units, renal failure, and need for perioperative cardiopulmonary resuscitation (CPR). Total hospital costs were significantly higher for survivors compared with nonsurvivors. Hospital cost per survivor was $86,977. Intensive Care Unit, laboratory, and blood bank costs accounted for 50% of total hospital costs. Based on the eight domains of the MOS SF-36, no significant difference was found between the functional status of those patients surviving emergent repair of RAAAs and that of the general population of a similar age.
Determinants of Peroneal Artery Bypass Failure
Authors: Paty Philip S. K. , Darling R. Clement , Kreienberg Paul B. , Lloyd William E. , Chang Benjamin B. , Papanicolaou George , Shah Dhiraj M.
Published: June 2007

Although the peroneal arteryyoften remains patent despite occlusion of other infrageniculate arteries, there is skepticism regarding its use for dista Jl bypass for salvage when a patent inframalleolar artery ispreent. The authors reviewed their experience with lower extremity arterial bypass for-occlusive disease to determine-predictors of peroneal artery bypass failure. The records of all patients undergoing bypass to the peroneal artery for atherosclerotic occlusive disease were reviewed. Patient demographics, operative indications, and the quality of peroneal runoff were evaluated for their contribution to bypass failure.

Between 1976 and 1996, 925 bypasses were performed to the peroneal artery. The indications for operation were limb salvage in 875 (95%). The graft patency rate was 89% and 77% and the limb salvage rate was 96% and 93% at 1 and 5 years, respectively. Bypass conduits included in situ vein (66%), excised vein (31%), and synthetic graft (3%). There were 139 bypass occlusions, of which 27 were revised. The causes of bypass occlusion were conduit failure (66%), inflow lesion (12%), and outflow lesion (22%). There were 18 hemodynamic failures. Thirteen (72%) of these were secondary to inadequate perfusion of the foot. However, 69% of these patients achieved salvage with a jump bypass to a patent more distal vessel. Revisions were performed equally for inflow disease, conduit stenosis, and hemodynamically significant arteriovenous fistulae. Patient demographics; operative indication, including the site of tissue loss; or quality of peroneal artery runoff did not predict bypass occlusion or hemodynamic failure.

The peroneal artery remains an excellent choice of infrageniculate arterial bypass for occlusive disease. The quality of the venous conduit rather than proximity of the distal anastomosis to an area of tissue ischemia should be the primary concern in deciding on distal bypass. No other variables correlated with bypass failure.
Smoking Increases Proteolytic Activity in the Human Abdominal Aorta
Authors: Parra Jose R. , Cambria Robert A. , Freischlag Julie A. , Seabrook Gary R. , Towne Jonathan B.
Published: June 2007

To determine the mechanism of smoking on the development of abdominal aortic aneurysms, the authors evaluated the proteolytic activity and quantity of matrix metalloproteinase enzymes in human aortic tissue. Abdominal aortic specimens of normal caliber were harvested from 13 organ donors, eight of whom had a history of smoking. Tissue samples were snap frozen in liquid nitrogen, pulverized, resuspended in a protein isolation buffer, and centrifuged to obtain the protein fraction. Gelatin substrate zymography was performed to determine proteolytic activity. Western immunoblotting using monoclonal antibodies directed against matrix metalloproteinase-2 (MMP-2) and matrix metalloproteinase-9 (MMP-9) was also performed. A significant increase in proteolytic activity was noted on zymography at 68 kilodaltons (kDa) in samples from smoking patients. Proteolytic activity at 96 kDa was not different between smokers and nonsmokers. No differences in the quantity of MMP-2 or MMP-9 were noted on immunoblots between the smoking and nonsmoking groups. These data establish a link between smoking and increased proteolytic activity in the human aortic wall and implicate smoking in the etiology of aortic aneurysms.
Insertion Technique and Placement Site for Greenfield Filters: Does it Make Any Difference?
Authors: Kopatsis Anthony , Solis Ricardo L. , Cernaianu Aurel C. , Riina Louis H. , Davidson Paul G. , D'Anna John J. , Pomper Stuart , Ferzli George , Silich Robert J.
Published: June 2007

The clinical outcome and complication rates related to the choice of technique and insertion site in the placement of a Greenfield filter (GFF) is still controversial. Moreover, there is no consensus as to which technique and placement site produces the best outcome. This study evaluated the charts of 364 patients who received GFFs during a 5-year period. Seventy-one filters were placed surgically and 293 were placed percutaneously in the operating room by general and vascular surgeons. Seventy-eight were placed using the femoral approach and 296 were placed using the jugular approach. Demographics were recorded as well as preoperative, intraoperative, and postoperative variables. All immediate complications were examined including failure of the GFF to open, suboptimal placement, multiple attempts at placement, abandoned procedures, guidewire related difficulties, hematoma, bleeding, phlegmasia cerulea dolens, pneumothorax, arrhythmia, and death. There was no statistically significant difference between complications derived from surgical placement versus percutaneous placement. There were no statistically significant differences among variables based on jugular versus femoral placement. There was a statistically significant difference in the time required for the percutaneous placement versus the open surgical procedure (33 ± 28 min. vs 45 ± 27 min., p < 0.05). These findings suggest that the technique and site of the GFF insertion can be left to the discretion of the surgeon based on each patient's profile.
Permcath as Temporary Vascular Access for Hemodialysis
Authors: Al-Wakeel Jamal S. , Malik Ghulam Hassan , Al-Mohaya Suleiman A. , Shareefi Osama , Mitwalli Ahmad Hassan
Published: June 2007

The efficacy and complications of 30 cuffed, double-lumen silastic catheters (Permcaths) inserted in 24 patients with chronic end-stage renal failure were studied prospectively at the Security Forces Hospital in Riyadh from June 1992 until March 1996. The causes of end-stage renal failure in the 24 patients were diabetes mellitus (10), glomerulonephritis (5), hypertension (2), amyloidosis (1), and bilateral small kidneys of unknown cause (6). Local anesthesia was used in 27 and general anesthesia in 3 patients. Internal jugular, external jugular, and subclavian veins were used in 13, 12, and 5 instances, respectively. The number of dialysis sessions varied from 1 to 292, with a mean of 59 ± 60 sessions. The blood flow was 200 to 350 (280 ± 42) mL/minute. The duration of catheter function varied from 4 to 682 (150 ± 160) days. Six catheters developed poor blood flow due to thrombosis in one of the two lumens. In two, blood flow improved after use of streptokinase 15000 IU/lumen, and four had to be changed. Four patients developed exit-site infection. Staphylococcus aureus was isolated from three of these patients, and all of them improved with systemic antibiotics and local dressing. Acinetobacter was isolated from one exit site and the catheter was changed because there was no response to antibiotics. Four patients developed septicemia; S. aureus was isolated from two, Acinetobacter from one, and one had negative culture. Catheters were removed in two of these patients because there was no response to antibiotic therapy. One patient developed right internal jugular vein thrombosis. The reasons for removal of a Permcath were: poor blood flow (4), death of the patient (3), bleeding and hematoma (2), renal transplantation (2), septicemia (2), exit-site infection (1), use of arteriovenous fistula (1), patient's request (1), and primary failure (1). Eleven catheters were functioning until the end of the study. Two patients were lost for follow-up.

In conclusion, Permcath can be used as a temporary as well as a long-term vascular access. It combines the advantages of being able to be used immediately and for an indefinite period that varies from weeks to months.
Five-Years' Experience with Revision of Failing Peripheral Vein Bypasses
Authors: Nielsen Tina G. , Vogt Katja C. , Rasmussen John Grønvall , Schroeder Torben V.
Published: June 2007

The aim of this study was to assess the results of surgical and endovascular treatment of failing or failed infrainguinal vein bypasses. Eight hundred seventy-five patients with peripheral vein bypasses performed during a 5-year period were followed up prospectively by ankle blood pressure measurements and/or duplex scanning at 3, 6, 9, 12, 18, 24, 36, and 48 months. A total of 59 (7%) grafts required revision during the study period. Fifty-six juxtaanastomotic or intragraft stenoses in 46 failing but patent bypasses were electively revised. Thirty-one predominantly proximal and midgraft lesions in 28 grafts were treated surgically by patch angioplasty (n= 17), interposition/jump grafting (n= 10), or thromboendarterectomy (n= 4). Twenty-five predominantly distal stenoses in 18 grafts were treated by percutaneous transluminal balloon angioplasty (PTA). With this approach, surgery yielded a higher 12-month “primary” bypass patency after revision (72% vs 37%, P=0.02), a higher secondary patency (81% vs 48%, P=0.05) and a better limb survival (96% vs 64%, P=0.03) than PTA. Following thrombectomy (n=12) or thrombolysis (n= 1) of 13 occluded bypasses, a 6-month “primary” patency after revision of 31%, a secondary patency of 38%, and a limb survival of 61% were achieved. In conclusion surgical repair appears to be the most durable procedure in the management of threatened infrainguinal vein bypasses. PTA of distal vein graft lesions was associated with a high risk of restenosis and graft failure.
Further Experience with Computerized Topographic Brain Mapping and Selective Shunting During Carotid Endarterectomy
Authors: Pickett Taylor King , Eldrup-Jorgensen Jens , Dillihunt Richard Charles , Leschey William Hart , Bredenberg Carl Eric
Published: June 2007

Computerized topographic brain mapping (CTBM) is a method of identifying cerebral ischemia and can be used to select patients for temporary shunt placement during carotid endarterectomy (CEA). The purpose of this article is to review our experience with CEA and CTBM. From 1990 to 1993, 279 elective CEAs were performed using intraoperative CTBM. The indications for surgery were TIA, amaurosis fugax, and/or previous stroke in 84% of patients. Overall, the permanent deficit rate (including one death) was 1.1%. The temporary deficit rate was 1.8%. Postoperative transient ischemic attacks were seen in 1.1%. No ischemic changes were seen with carotid clamping during 237 CEAs (85%). The rate of postoperative neurologic deficits in this group was 1.7%, compared to 9.5% of the 42 CEAs (15%) with ischemic changes, p<0.00). Of the 86 patients with contralateral high-grade stenosis (>80%) or occlusion, the deficit rate was 7.0%, versus 1.0% in the remaining 193 patients who had mild to moderate contralateral stenosis, p<0.001. The frequency of CTBM changes leading to shunt placement, as well as the frequency of shunt placement by surgeon's preference, decreased throughout the study period (23% to 11% and 10% to 1.4%, respectively). In conclusion, CTBM is a safe, sensitive and reliable method of identifying cerebral ischemia during CEA that may be used to minimize shunt placement. Patients with significant contralateral carotid artery disease are at increased risk for intraoperative cerebral ischemia and postoperative neurologic events.
Prevention of Anastomotic Intimal Hyperplasia in Infrainguinal PTFE Bypass Grafts with Distal Arterial Segment Interposition
Authors: Mobin-Uddin Kazi , Vincent Gilford S. , Evans William E.
Published: June 2007

Anastomotic intimal hyperplasia (AIH) is a common cause of graft failure after femoropopliteal polytetrafluoroethylene (PTFE) bypass. Compliance mismatch between the PTFE graft and the native artery may be a significant factor causing AIH. This study examines whether reduction of compliance mismatch by interposition at the distal anastomosis of a segment of superficial femoral artery after eversion endarterectomy could reduce or eliminate AIH and improve graft patency. Between July 1989 and June 1996, PTFE grafts with a distal arterial segment (AS) were used to revascularize 51 limbs in 45 patients (12 men and 33 women). Twenty-five grafts were above-knee (AK) and 26 below-knee (BK). Disabling claudication was the indication in 32 limbs (AK 20, BK 12) and limb-threatening ischemia in 19 (AK 5, BK 14). Physical examination, measurement of ankle-brachial index, and duplex scanning were used to follow up patients at regular intervals. For those patients who had recurrent symptoms and/or reduction of ankle/brachial index (ABI), arteriography was performed. Follow-up ranged from 1-54 months (mean 20 months) for AK grafts and 1-76 months (mean 19 months) for BK grafts.

The overall primary patency rate at 4.5 years was 57.2%. There appears to be no significant difference between AK and BK primary patency survival distributions (64.8% vs 48.5%). The primary patency failure distributions for the two ischemic conditions are statistically significant (69.8% vs 31.9%). The limb salvage rate at 4.5 years was 80%. Of the 51 grafts, the causes of the 19 failures included progression of disease in eight, thromboembolus in three, stenosis of the AS in three, poor runoff in one, AIH at the proximal anastomosis in one, and unknown in three.

This pilot study suggests that the femoropopliteal PTFE bypass with distal AS interposition provides improved graft patency and limb salvage rates when compared with those published in the literature for PTFE bypass without the AS. Further evaluation is warranted.
Ruptured Abdominal Aortic Aneurysm and Inferior Vena Cava Occlusion in Behqet's Disease
Authors: Rabee Hussien , Al-Saleh Mervat S. , Al-Salman Mussaad M. S.
Published: June 2007

Behqet's disease is a rare, multisystem disorder characterized by widespread vasculitis on both the arterial and venous side of the circulation. The authors report a very rare case of associated leaking abdominal aortic aneurysm and Budd-Chiari syndrome secondary to inferior vena cava occlusion in a 25-year-old woman with complicated Behqet's disease. To our knowledge, this is the fourth case to be reported in the English literature with such a combination.
A Clip System for Vascular Anastomoses
Authors: Matsumoto Kenji , Nakamaru Makoto , Obara Hideaki , Hayashi Shinobu , Harada Hirohisa , Morisue Atsushi , Kitajima Masaki
Published: June 2007

The aim of this study was to test a clip system for vascular anastomoses. Clinical use of these clips in 102 vascular reconstructions was performed in 70 patients with or without a prosthetic graft.

The mean time to perform an anastomosis was shortened approximately 10%-60% using the vascular clip system as compared with conventional suturing. No intraoperative complications occurred. During follow-up of 4 to 16 months, there were no deaths, no episodes of bleeding, no infections, and no other severe complications; the vessels and grafts remained patent. Additional studies are needed to determine whether use of the vascular clip system will decrease operative trauma, reduce intimal injury, or increase patency in vascular reconstructions. However, the authors' series shows that the system can be used without complications and that it requires less clamping and anastomotic time than does conventional suturing.
Expression of Tissue Factor in Experimental Anastomotic Pseudoaneurysm
Authors: Soundararajan Krish , Taubman Mark B. , Fallon John T. , Hollier Larry H. , Reis Ernane D.
Published: June 2007

Tissue factor (TF) is a potent initiator of the coagulation cascade and plays a critical role in arterial thrombosis. It is expressed in the adventitia of normal arteries and is induced in medial smooth muscle cells (SMC) by arterial injury. TF is also likely to be expressed in pseudoaneurysms, which are essentially contained disruptions of the arterial wall. The components of the pseudoaneurysm wall and the distribution of TF in particular have not been reported. To examine this we employed an experimental model of pseudoaneurysm in the rat carotid artery. Eight pseudoaneurysms were generated by microsurgical anastomosis and analyzed by histology and immunohistochemistry. Balloon injured carotids and normal carotids were used for comparison. The pseudoaneurysm wall was formed by SMC and extracellular matrix, similar to the neointima of injured arteries. However, TF was found predominantly in the adventitial aspect of the pseudoaneurysm wall, as opposed to a diffuse distribution throughout the neointima of balloon injured arteries. TF antigen was not seen on or near the luminal border of the pseudoaneurysm wall. Microscopic examination and staining for von Willebrand factor antigen showed no evidence of endothelium in the pseudoaneurysm. The authors hypothesize that spontaneous thrombotic occlusion may not occur because TF is not present at the luminal surface. The efficacy of compression therapy for pseudoaneurysm may be dependent on the ability to cause sufficient disruption of the wall to expose TF found in the deeper layers of the arterial wall to circulating blood. The present model may be useful to further define the determinants regulating pseudoaneurysm closure.
Chronic Mesenteric Ischemia with Aortorenal Occlusive Disease: Repair with Trifurcated Aorto/Mesenteric/Renal Bypass and Bifurcated Aortoiliac Bypass
Authors: Twena Mordechai F. , Ballard Jeffrey L.
Published: June 2007

This case report describes the management of chronic mesenteric ischemia in a patient with a single kidney and severe mesenteric, renal, and aortic atherosclerosis. This complex vascular problem became more taxing with the unexpected intraoperative finding of a large supraceliac aortic bleb that was threatening imminent rupture. Mesenteric and renal artery disease were reconstructed by a combination of superior mesenteric artery (SMA) endarterectomy and creation of aortic to inferior mesenteric, left renal, and superior mesenteric artery bypass. A trifurcated 12 x 6 mm polytetrafluoroethylene (PTFE) graft that originated from the side of the distal descending thoracic aorta was used for this reconstruction. Aortobiiliac reconstruction with an in-line 18 x 9 mm PTFE graft excluded the remaining diseased abdominal aorta below the trifurcated graft. This case demonstrates the value of maintaining visceral and renal perfusion through (1) tangential thoracic aortic clamping, (2) individual aortic branch vessel reconstruction, and (3) separate distal revascularization.
Use of Cryopreserved Small Aortic Homografts for Large Vein Replacement
Authors: Molina J. Ernesto
Published: June 2007

Total obstruction, stenosis, or ligation of any large vein is associated with significant morbidity. No synthetic grafts can adequately replace large veins, particularly in areas subjected to motion (flexion or extension). Artificial prosthetic materials usually occlude within a short period.

Since 1987, the author has used cryopreserved allografts of small aortas varying from 1 to 1.7 cm in diameter to replace large vein channels in the upper or lower body. These allografts provide a manageable, pliable conduit with normal endothelium. He implanted grafts bridging gaps from 4 to 30 cm in length, in 14 patients (10 women, 4 men). Veins replaced were five iliac, three iliofemoral, and six subclavian-innominate. The long-term patency rate (follow-up 3 months to 10 years) is 93%.

The use of small aortic cryopreserved homografts for large vein replacement, particularly in mobile areas (groin, thoracic inlet, pelvis) is recommended. These grafts appear superior to any previous grafts used for the same purpose.
Hypothenar Hammer Syndrome
Authors: Custer Timothy , Channer Luke T. , Hartranft Thomas H.
Published: June 2007

Hypothenar hammer syndrome is an underdiagnosed disorder that classically has been associated with repetitive occupational trauma. However, a substantial portion of cases can arise from recreational activities or a single acute event. A 15-year-old drummer presented with a 6-month history of a bulge over the hypothenar eminence of his left palm. An angiogram showed a 1.5 x 2.0 cm pseudoaneurysm arising from the ulnar artery just distal to the deep palmar branch and extending into the proximal portion of the superficial palmar arch. The aneurysm was resected and reconstructed with a primary end-to-end anastomosis. The symptoms of hypothenar hammer syndrome are variable and can be related to poor inflow, distal spasm, or emboli. Careful history and physical examination with consideration of anatomical relationships will reveal the diagnosis. Recommendations for further diagnostic testing and specific treatment strategy vary owing to increased understanding of this syndrome combined with a paucity of controlled studies. Clinical aspects and management of this case are discussed in light of the current literature.
Acetazolamide SPECT Scans in the Evaluation of Symptomatic and Asymptomatic Patients with Carotid Occlusive Disease
Authors: Cikrit Dolores F. , Dalsing Michael C. , Burkhart Harold M. , Burt Robert W. , Lalka Stephen G. , Sawchuk Alan P. , Solooki Betty
Published: June 2007

Acetazolamide (ACZ)-enhanced Single Photon Emission Computer Tomography (SPECT) scans can assess both cerebral perfusion and vascular reactivity. Patients with poor reactivity lack perfusion reserve, and are at risk for stroke should perfusion diminish further. This study compared the preoperative ACZ-enhanced SPECT scans of 60 symptomatic to 40 asymptomatic patients with internal carotid artery stenosis (ICAS) in an effort to better define the cause of their symptoms and effects of carotid endarterectomy (CEA) on cerebral perfusion and reactivity in these two groups of patients. Symptomatic patients had at least a 60% (x=84%) ICAS. Asymptomatic patients had at least an 80% (x=90%) ICAS. Preoperative ACZ SPECT scans were obtained usually one week before CEA. All patients underwent CEA. Postoperative ACZ SPECT scans were obtained in 78 of the patients, usually at the first postoperative (-30 days) visit. [Table: see text] Asymptomatic patients demonstrated poorer perfusion than symptomatic patients, which tends to support the premise that most strokes and carotid symptoms are secondary to emboli rather than hypoperfusion. Interestingly, cerebral reactivity was poor in both symptomatic and asymptomatic patients before CEA, suggesting inadequate collaterals and dependency on the ipsilateral carotid. Carotid endarterectomy improved vasoreactivity in 84% of the patients. ACZ SPECT scans provided evidence of the return of cerebral perfusion and reactivity following endarterectomy.
Respiratory Complications and Aortoiliac Surgery: A Retrospective Review from 105 Consecutive Conventional Revascularizations
Authors: Bonneton G. H. , Age B. , Streichenberger T. , Zabot J. M. , Lepine P.
Published: June 2007

The purposes of this study, in view of previous controversial reports, were to assess retrospectively the frequency and severity of respiratory complications in patients undergoing aortoiliac surgery and to delineate the more significant preoperative risk factors. Excluding extraanatomic procedures, the review of 105 consecutive revascularizations, performed between June 1993 and December 1994, included the study of classic perioperative parameters; preoperative general conditions; and risk factors of the patients: age, sex, weight, diabetes, smoking habits, hypertension, coronary disease, and surgical antecedents with previous revascularizations; and type of arterial lesions: aortoiliac occlusive disease (AOID) or aneurysm. More specific perioperative studies included previous respiratory disease history evaluation, chest radiography, pulmonary function tests (PFT) analysis, and blood gas results. Prior to intervention the American Society of Anesthesiologists (ASA) class of patients was ascertained. Intraoperative techniques and conditions including types of incisions and revascularizations, methods of anesthetic monitoring, anesthetic and intubation times, blood and liquids losses and replacements, postoperative course with intensive care stay, and bacteriologic origin of septic pulmonary complications were also reviewed.

The total perioperative mortality was 1.9% (two of 105), exclusively related to respiratory failures without primary cardiac origin or pulmonary embolism history. Major respiratory complications occured in 22 patients (20.9%), with a preeminence of pneumonia in 13. The total respiratory complications rate with favorable outcome was 19% (20 patients). Deaths occurred in patients with respiratory distress syndrome (one) and pneumonia with multiorgan failure (one). Univariate analysis demonstrated that only preoperative pathologic PFT and ASA classification were associated with postoperative respiratory complications. Major respiratory risks included forced vital capacity (FVC) <50%, forced expiratory volume (FEV) <1 1, and partial pressure of arterial carbon dioxide (Paco2) >50 mmHg. Questionable risk factors included intubation time, aortic clamp time, crystalloid replacements, and adjunctive epidural analgesia.
The Optimal Surgical Management of the Super Obese Patient: The Debate
Authors: DeMaria Eric J. , Schauer Philip , Patterson Emma , Nguyen Ninh T. , Jacob Brian P. , Inabnet William B. , Buchwald Henry
Published: June 2007

Optimal management of the super-obese patient (body mass index >50 kg/M2) undergoing weight loss surgery in the new era of laparoscopic treatment is more controversial than ever before. Newer laparoscopic options for treatment of the super obese, including laparoscopic adjustable gastric banding, sleeve gastrectomy, and staging of gastric bypass, are technically easier and may be safer. Concerns that weight loss may be suboptimal or that the procedures will require revision, or both, make these choices controversial. Open access/conversion for established procedures such as long-limb gastric bypass and biliopancreatic diversion with or without duodenal switch are the traditional alternatives when laparoscopic access fails or is deemed too difficult to undertake. The following debate was presented by invited experts in laparoscopic and open bariatric surgery at the 2005 Annual Meeting of the Society of American Gastrointestinal and Endoscopic Surgeons in Florida. The presenters put forth arguments for the various modern options for treatment of the super obese, which are presented in written form. Interactive audience response technology provided a mechanism for polling the audience before and after the presentations. A review of the audience's responses provides insight into the decision-making considerations of a population of laparoscopically oriented bariatric surgeons.