bluuebunny/crossref_metadata_2025 huggingface dataset:
Transcutaneous Oxygen and Carbon Dioxide Levels with Iloprost Administration in Diabetic Critical Limb Ischemia
Authors: Melillo Elio , Ferrari Mauro , Balbarini Alberto , Pedrinelli Roberto
Published: June 2007

Iloprost, a prostacyclin analogue, is a treatment option for surgically unsuitable diabetic chronic critical limb ischemia (CLI), although its outcome is difficult to be anticipated clinically. Whether transcutaneous (tc) oxygen tension (PO2) predicts the response to iloprost in diabetic CLI is unclear at this point and, in that same context, the prognostic role of tc carbon dioxide tension (PCO2), another ischemia-sensitive parameter, is unknown. Supine and dependent tcPO2 and tcPCO2 were measured at baseline and after 4 weeks of iloprost treatment in 31 limbs of 26 type-2 diabetic arteriopaths with CLI not amenable to surgery. Success was defined as pain relief and significant reduction of analgesics. Clinical outcome was stratified by baseline tcPO2 and tcPCO2 tertiles, and likelihood ratios (LR) quantified the increase from pretest chances given a certain result. Iloprost succeeded in 16 (52%) and failed in 15 limbs (48%) and post-treatment tcPO2 followed a parallel course. Failures increased by ascending baseline tcPCO2 and descending tcPO2 tertiles; successes behaved specularly. Predictions of failure based on elevated tcPCO2 (>53 mm Hg) were more efficient than relying on depressed tcPO2 (LR 10.7 vs 3.6); success was almost certain when tcPO2 was >23 mm Hg (LR = 17.8). Dependent determinations were less useful than supine measurements for prognostic use. Elevated tcPCO2 predicted failure efficiently and high tcPO2 was a useful prognostic tool for success of iloprost, suggesting that their combined use may allow better prognostic stratification and improve the therapeutic approach to diabetic CLI.
Endovascular Repair of an Infrarenal Abdominal Aortic Aneurysm with a Dominant Middle Mesenteric Artery
Authors: Falkensammer Juergen , Hakaim Albert G. , Paz-Fumagalli Riccardo , Oldenburg W. Andrew
Published: June 2007

The middle mesenteric artery is a rare anomalous mesenteric vessel that may supply variable segments of the colon. Occlusion of this artery during endovascular aortic aneurysm repair may bear a significant risk of bowel ischemia. We report the successful interventional treatment of a patient with a 5.3 cm infrarenal abdominal aortic aneurysm, sparing a dominant middle mesenteric artery.
Endovascular Coil Embolization for Large Femoral False Aneurysms: Two Case Reports
Authors: Abisi S. , Chick C. , Williams I. , Hill S. , Gordon A.
Published: June 2007

Ultrasound-guided compression and thrombin injections are reliable for the management of small and medium-sized false aneurysms. However, owing to technical limitations, large false aneurysms often necessitate surgical intervention, which is associated with significant postoperative morbidity and mortality. Endovascular coil embolization is an evolving minimally invasive technique that can be used as a safe option for large false femoral aneurysms. We report our experience with 2 cases of large false femoral aneurysms treated by using coils to occlude the aneurysm's feeding tract successfully.
Iatrogenic Limb Ischemia Caused by Angiography Closure Devices
Authors: Derham Chris , Davies John F. , Shahbazi Raashid , Homer-Vanniasinkam Shervanthi
Published: June 2007

Described are 2 cases of lower limb ischemia that resulted after deployment of 2 different arterial closure devices. One patient presented acutely with lower limb ischemia after an Angio-Seal (St Jude Medical, Minnetonka, Minn) device deployed at the conclusion of cerebral artery aneurysm embolization. The second patient, who underwent angioplasty for aortic recoarctation, presented with claudication 1 week after deployment of the Perclose (Perclose, Redwood City, Calif) device. The use of such devices can result in significant complications, and cardiologists, interventional radiologists, and vascular surgeons are advised to have a high index of suspicion for such complications and work in close conjunction to provide prompt and adequate treatment.
A Survey of Vascular Access for Hemodialysis
Authors: Tedoriya Takeo , Urayama Hiroshi , Katada Shouichi , Watanabe Yoh
Published: June 2007

To analyze the current status of various techniques for vascular access in patients with chronic renal failure requiring hemodialysis, a retrospective review of 113 patients over a period of nineteen years undergoing either radiocephalic (direct) shunts or polytetra-fluoroethylene (PTFE) shunts was conducted. Accessibility rate was determined as total time of graft function until ultimate failure. Direct shunt was undergone by 93 patients (82%). Accessibility was 89% and 80% at one and five years, respectively. Twenty patients (18%) underwent PTFE shunts. Accessibility was 61% and 29% at one and five years, respectively. Thrombosis, which was the main complication accounting for graft failure, occurred earlier and more frequently in the PTFE group. Results in patients with diabetes mellitus (DM) were also significantly worse. A direct shunt at the most peripheral site is the most favorable option for vascular access for hemodialysis. Because of poorer results with PTFE, more proximal native vessels (ie, brachial artery to antecubital vein) are preferable if distal shunts are not possible.
Surgical Management of Bilateral Familial Form of a Carotid Body Tumor
Authors: Böke M. Erkmen , Atasoy Şevket , Hazan Eyüp , Dogan Riza
Published: June 2007

A patient with bilateral carotid body tumor who underwent a two-stage operation is presented. Diagnosis is based on bilateral selective carotid angiography. On the right side resection was easy, but on the left side, the internal carotid artery and hypoglossal nerve were resected, together with the tumor, and a reversed saphenous vein graft was used to permit the continuity of the internal carotid artery. Hypoglossal nerve reconstruction was done by a neurosurgery team.
Effect of Embolization of Major Aortopulmonary Collateral Arteries on Cardiopulmonary Circulation in Congenital Heart Disease
Authors: Okuda Yasuyuki , Takeda Kan , Tagami Tomoyasu , Matsumura Kaname , Ooi Maki , Nakagawa Tsuyoshi
Published: June 2007

Major aortopulmonary collateral arteries (MAPCAs) may affect pulmonary hemodynamics significantly in patients with cyanotic congenital heart diseases. Occluding such collateral arteries is expected not only to diminish systemic-to-pulmonary shunt but also to increase pulmonary perfusion via the central pulmonary artery. The authors performed coil embolization of MAPCAs communicating with the central pulmonary artery or its branches in 3 patients aged from three to fifteen years (2: tetralogy of Fallot, 1: pulmonary atresia with ventricular septal defect). On chest roentgenogram, the cardiac size diminished after embolization in 2 subjects owing probably to decreased systemic-topulmonary blood flow. The pulmonary perfusion scintigram with Tc 99m macroaggregated albumin was performed before and after embolization. Before embolization, multiple segmental or lobar perfusion defects or hypoperfusion areas were observed in all cases. After embolization, however, the scintigrams unexpectedly did not show any improvement. These results suggest that the occlusion of MAPCAs is effective in decreasing systemic-to-pulmonary blood flow but not effective in increasing lung perfusion. The authors speculate that obliterative and irreversible pulmonary vascular damages might have occurred in all cases.
Delayed Jejunal Artery Pseudoaneurysm: An Unusual Sequela of Penetrating Abdominal Trauma
Authors: Gupta N. , Fitzgerald S. D. , Peterson G. J.
Published: June 2007

Posttraumatic pseudoaneurysm of the mesenteric vasculature is rare. The authors describe the case of a forty-seven-year-old man with a jejunal artery pseudoaneurysm eleven years after a stab wound to the abdomen. The patient underwent exploratory laparotomy and ligation of the pseudoaneurysm. Late sequelae of missed superior mesenteric artery injury include superior mesenteric arteriovenous fistula and pseudoaneurysm.
Popliteal Entrapment Syndrome
Authors: Jaworski Roman
Published: June 2007

A case of concomitant anterior tibial artery entrapment and popliteal artery entrapment is reported. This is believed to be the first report of a case of anterior tibial artery entrapment.
Delayed Sternal Closure Following Operation of Type-A Acute Aortic Dissection
Authors: Shimokawa Shinji , Toyohira Hitoshi , Saigenji Hideaki , Fukuda Shigeru , Moriyama Yukinori , Koga Masaaki , Iwamura Hiroshi , Toda Riichiro , Masuda Hiroshi , Taira Akira
Published: June 2007

In 7 patients with type-A acute aortic dissection, the sternum was not closed because of excessive hemorrhage after grafting. Only the skin was closed, the sternal edges being left apart and the anastomotic sites being packed with dry gauze in the mediastinum to control the life-threatening sequela. All patients except for 1 who died of uncontrollable bleeding had successful delayed sternal closure within three days after the first operation. One patient who had late chest wound infection died, but the remaining 5 patients had neither mediastinitis nor chest wound infection and are now in good or fair clinical condition. The authors conclude that delayed sternal closure is an effective method of dealing with excessive postbypass bleeding following operation of type-A acute aortic dissection.
Diagnosis of Atrial Baffle Obstruction Following Senning Repair by Intraoperative Transesophageal Echocardiography
Authors: Yee Lawrence L. , Cohen Amram J. , Vernalis Marina N. , Lovett Etheridge J. , Crowl Frank D.
Published: June 2007

Intraoperative transesophageal echocardiography identified the site of pulmonary venous obstruction and assessed the adequacy of surgical repair in a patient scheduled for revision of a Senning repair. Preoperatively, this abnormality was not clearly delineated by other imaging modalities.
Embolization of Ruptured Aneurysm of the Pancreaticoduodenal Artery Secondary to Long-standing Stenosis of The Celiac Axis
Authors: Savastano Sergio , Feltrin Gian Piero , Miotto Diego , Chiesura-Corona Matteo , Sandri Paola
Published: June 2007

Long-standing stenosis of the celiac axis is a rare cause of aneurysm of the inferior pancreaticoduodenal artery, which serves as a collateral pathway; the etiology is believed to be due to turbulence from increased blood flow. The authors describe 2 cases of such aneurysm, which ruptured in the retroperitoneum and were treated with transcatheter embolization.
Atherosclerotic Aneurysm of the Superficial Femoral Artery
Authors: Öztuirk Ömer Y. , Çiçek Sertaç , Yolyapan Aykut , Tatar Harun , Narbay Diindar R.
Published: June 2007

True aneurysms of the superficial femoral artery (SFA) are rarely seen. The authors report a case of SFA aneurysm associated with an aneurysm of the abdominal aorta, and they review the literature. These aneurysms mostly occur in the elderly as compared with other peripheral aneurysms. The majority of these aneurysms remain silent and present with the onset of serious complications. Since the mortality and morbidity after surgical repair are quite low, the presence of the aneurysm itself should prompt surgical repair even in the asymptomatic patient.
Post-Carotid-Endarterectomy Intracerebral Hemorrhage: A Continuing Challenge
Authors: Perler Bruce A. , Williams G. Melville
Published: June 2007

Over the past decade, 2 men and 2 women, ranging in age from sixty-two to seventy-seven (mean, 69.8) years, experienced strokes due to intracerebral hemorrhage within the first four days following uncomplicated carotid endarterectomy (CEA). All operatedon lesions were greater than 90% stenotic, and the contralateral internal carotid artery (ICA) was completely occluded in 3 patients and greater than 90% stenotic in the other patient. All 4 patients had a history of transient ischemia, including hemispheric transient ischemic attacks (TIAs) in 2, hemispheric and nonhemispheric TIAs in 1, and nonhemispheric TIAs in the fourth patient. None had experienced a prior stroke, and computed tomography (CT) scans of the head performed preoperatively in 2 patients were negative. Three patients had a history of hypertension and all 4 required pharmacologic treatment for hypertension intraoperatively and/or during the first postoperative day in the intensive care unit. Three patients died and the fourth recovered. Intracerebral hemorrhage is an infrequent and serious potential complication of CEA. Patients who undergo operation for critical ICA stenoses in the setting of severe contralateral ICA disease appear particularly vulnerable.
Effect of Normovolemic Hemodilution on Fatal Postoperative Pulmonary Embolism in Major Elective Orthopedic Surgery. A Retrospective Analysis on 4653 Patients
Authors: Bombardini Tonino , Borghi Battista , Montebugnoli Milena , Picano Eugenio , Caroli Gian Carlo
Published: June 2007

It has been suggested that the benefits of transfusion are currently greatly overrated, with physicians reflexively administering blood in the nearly unchallenged view that failure to transfuse would have dire consequences. As a matter of fact, the tolerability and safety of normovolemic anemia have been well documented for many years in several anesthesiologic settings.

Objective: To assess the impact of normovolemic hemodilution on blood bank resources and in-hospital mortality in major elective orthopedic surgery.

Methods: The authors therefore retrospectively analyzed in-hospital mortality of patients submitted to elective surgery for total hip replacement in the Rizzoli Institute since 1979. From 1979 to 1983, 1488 patients underwent a standard treatment (without normovolemic hemodilution), whereas 4653 patients submitted to surgery from 1984 to 1993 underwent normovolemic hemodilution-up to extreme accepted values of hemoglobin > 6 g/dL.

Results: Homologous blood transfusion was required in 1220/1488 patients of Group I and in 977/4653 patients of Group II (82% vs 21%, P < .001). The number of blood units required for each transfused patient was 2.8 in the 1220 transfused patients of Group I, and 2.1 in the 977 transfused patients of Group II (P < .001). There were 6 deaths in Group I and 7 deaths in Group II (0.4% vs 0.15%, P < .05). The overall incidence of fatal pulmonary thromboembolism was 4/1488 in Group I and 1/4653 in Group 11 (0.27% vs 0.02%, P < .001).

Conclusions: Normovolemic hemodilution was extremely well tolerated in patients undergoing major elective orthopedic surgery and allowed substantial sparing of blood bank resources. It had no detectable unfavorable effect on surgical outcome, but rather it was associated with a dramatic decrease in perioperative mortality of patients under-going total hip replacement, owing to a thirteen-fold reduction in fatal pulmonary thromboembolism.
Ultrasound-Guided Compression of a Brachial Artery Pseudoaneurysm
Authors: Green Samuel , Ramaswamy Devanhalli , Neville Richard F.
Published: June 2007

The proliferation of invasive diagnostic and therapeutic procedures requiring arterial catheterization has led to a number of vascular complications. Recognized complications of brachial percutaneous techniques include arterial thrombosis, arteriovenous fistula, hematoma, and pseudoaneurysm. As with femoral artery complications, surgical repair is required for significant brachial artery pseudoaneurysms. Color-flow duplex ultrasound-guided compression has been described as a noninvasive and inexpensive treatment modality for femoral pseudoaneurysms. The authors describe a case of a brachial artery pseudoaneurysm successfully treated by ultrasound-guided compression.
Ruptured Extracranial Carotid Artery Aneurysm
Authors: Wandschneider W. , Deutsch M.
Published: June 2007

The authors report a case of spontaneous rupture of an atherosclerotic aneurysm of the extracranial internal carotid artery. The aneurysm was successfully resected, and blood flow to the brain was restored by vein graft interposition.
Intractable Glaucoma After Carotid Endarterectomy
Authors: Geyer Orna , Almog Yehosua , Michaeli-Cohen Adi , Lazar Moshe , Shifrin Edward
Published: June 2007

Ocular ischemic syndrome is caused by chronic insufficiency of the blood supply to the eye as a result of severe bilateral carotid artery stenosis or occlusion. The signs of ocular ischemia syndrome include retinopathy (retinal microaneurysms, hemorrhages, and veindilatation), cataract, iris neovascularization (rubeosis iridis), and neovascular glaucoma. The role of carotid endarterectomy in stabilizing and improving vision in patients with ocular ischemic syndrome is controversial. The authors describe 2 patients with ocular ischemic syndrome and rubeosis who, following carotid endarterectomy, developed an intractable rise of intraocular pressure, which led to visual loss. The presence of rubeosis suggests poor visual prognosis and thus should be considered before a decision is made about carotid endarterectomy.
A New Less-Invasive Method to Estimate the Viability of Severely Ischemic Skeletal Muscle
Authors: Asami A. , Orii M. , Shirasugi N. , Yamazaki M. , Akiyama Y. , Kitajima M.
Published: June 2007

Estimation of the viability of ischemic tissue is important for appropriate revascularization. In the present study, microdialysis combined with HPLC (high performance liquid chromatography), a new, simple less invasive method, was used to estimate the viability of anterior tibial muscle of rat hind limb (n= 18).

Purines, adenosine triphosphate (ATP) degradation products, were continuously measured by this method during the ischemic period. Purines were measured by analyzing the dialysate from a needle-type microdialysis probe inserted into the muscle. The purine concentration of the dialysate reflected that of the interstitial fluid of the muscle.

Hypoxanthine and inosine in the muscle increased to 2.34 ± 1.16 and 1.79 ± 0.62 times the preischemic levels, respectively, after five hours of ischemia. Thereafter hypoxanthine continued to increase to 6.53 +2.28 times the preischemic level at ten hours of ischemia, but the inosine level decreased gradually. As a result of the depletion of inosine and the continuous increase of hypoxanthine, the inosine/hypoxanthine ratio decreased significantly after five hours of ischemia, and went down to one eighth of the preischemic level at nine hours of ischemia.

A depletion of inosine means a depletion of ATP, the source of inosine in purine metabolism and an essential factor for maintaining cell function. These results showed a good correlation with the TTC (triphenyl tetrazolium chloride) assay, an established method.

Microdialysis, a new, simple, and less invasive method, is useful for the estimation of ischemic damage and viability of ischemic skeletal muscle.
Abdominal Aortic Injury From Vascular Clamp Application
Authors: Johnson B. L. , Lusby R. J.
Published: June 2007

Vascular clamp application to the abdominal aorta is rarely reported to have any clinical traumatic effects. The authors report the delayed presentation of a false aneurysm secondary to vascular clamp placement on the suprarenal aorta. The effects of vascular clamp application are also reviewed.
Leiomyosarcoma of the Inferior Vena Cava
Authors: Herman Paulo , Pugliese Vincenzo , Machado Marcel Cerqueira Cesar , Vianna Maria Regina , Pinotti Henrique Walter
Published: June 2007

Inferior vena cava leiomyosarcoma is a rare tumor with a recent increase in incidence. The authors describe 2 cases and discuss clinical features, diagnosis, and treatment.

With recent advances in imaging methods and surgical procedures an early diagnosis and radical resection might be possible, leading to a better prognosis or even the cure of the disease.
Rapidly Expanding Aneurysms in Cryopreserved Vein Grafts
Authors: Glasson Julie R. , James David R. , Mehigan John Thomas
Published: June 2007

Cryopreserved saphenous vein allografts have been used as an alternative conduit for lower extremity revascularization when suitable autogenous vein is unavailable. Failure of such grafts has usually been attributed to early thrombosis, resulting in poor overall patency rates. Aneurysmal degeneration, is, however, a disease process occurring in cryopreserved vein grafts that may be life-threatening. The authors have previously reported their early experience with cryopreserved saphenous vein allografts in a series of 39 lower extremity bypass grafts in 35 patients. This report did not describe sudden aneurysmal changes in the cryopreserved vein grafts. Herein they report 3 grafts in 2 patients of the same series that developed rapidly expanding aneurysms necessitating emergency operation. All cases were successfully managed. This experience now prompts them to suggest that frequent duplex imaging of all cryopreserved saphenous vein allografts is prudent and that surgical intervention for even mild aneurysmal changes is appropriate. Although aneurysmal degeneration has not been reported in cryopreserved vein grafts utilized in the aortocoronary position, the consequences of such potential rapid expansion are such that serious consideration of the original indications for placement seems appropriate.
Intraoperative Assessment of Carotid Endarterectomy Utilizing Completion Angioscopy
Authors: Mueller D. K. , Haid S. P. , Painter T. A. , Kornmessor T.
Published: June 2007

Completion angioscopy was performed in 325 patients after carotid endarterectomy for carotid artery stenosis. Indications for operation included asymptomatic stenosis (39%), transient ischemic attack (35%), stroke (24%), and recurrent stenosis (2%). Endarterectomy closure included primary (94) and patch angioplasty utilizing vein, (106), polytetrafluoroethylene (117), and Hemashieldg (8). A fiberoptic angioscope was inserted at the end of the carotid endarterectomy through the remaining opening in the suture line. Sixteen abnormalities were appreciated with angioscopy, which included (1) 6 intimal flaps, (2) 8 thrombi, (3) 1 stenosis, and (4) 1 fibrous debris. Interventions with these abnormalities included (1) revision of all intimal flaps and 5 thrombi, (2) manual extraction of 2 thrombi, (3) irrigation of a thrombus and of the fibrous debris, and (4) excision of an adventitial band causing an internal carotid artery stenosis. Complications included transient ischemic attack (1%), stroke (2.5%), myocardial infarction (1%), nerve injury (6%), but no mortality. Patients with normal-appearing angioscopies had a stroke rate of 7/309 (2%) while those with abnormal-appearing angioscopies had a stroke rate of 1/16 (6%). The authors conclude that completion angioscopy can be safely and easily performed with a low perioperative stroke rate. Abnormalities detected may be corrected immediately. This method is recommended as a valuable adjunct to ensure technical success of carotid endarterectomy.
Vascular Steal in Hemodialysis: Still Unpredictable
Authors: Piotrowski Joseph J. , Alexander J. Jeffrey , Yuhas Joel P.
Published: June 2007

Vascular steal remains a significant cause of morbidity after placement of access for hemodialysis and has been reported to occur at an incidence of 2-8%. The purpose of this study was to identify which factors may predict the development of steal. A retrospective review of new-access placement over a three-year period revealed 275 procedures on 129 patients. There were 225 (82%) prosthetic conduits and 50 (18%) native fistulas placed. Thrombectomies and revisions were excluded. There were 23 cases (8.4% incidence by access) of steal in 19 patients (15% incidence by patient). The consequences of steal included development of a Volkmann's contracture in 4 patients despite ligation of the access in 3, gangrene with loss of digits in 2 patients, decreased motor function in 3 patients, and refusal of dialysis and subsequent death in 1 patient. Five patients had mild symptoms that resolved spontaneously. Thirty-nine percent (n = 9) of the steal cases occurred in secondand third-access placements. By univariate analysis the factors that predicted steal were increased age (63.1 ± 14 years versus 52.0 ± 16.2 years; P = 0.002), female sex (14.4% in women compared with 1.6% in men; P = 0.003). Diabetes mellitus was also more prevalent (12.3% compared with 3.4% in non-diabetics; P = 0.08) but did not reach statistical significance. There was no relationship to type of access performed, conduit used, and location. When combinations of these factors are fitted to a multivariate logistic regression, the best combination results in only 19% of the variation in outcome (steal) being explained (r = 0.43; P = 0.001). Vascular steal remains a common, serious cause of morbidity in dialysis access placement. Although it is more common in elderly diabetic women, accurate prediction based on clinical variables alone is not possible.
Assessment and Quantification of Regional Arterial Perfusion Reserve in Patients with Peripheral Occlusive and Small-Vessel Disease by Rubidium 82-Positron Emission Tomography
Authors: Theiss Alexander , Wierse Gerhard , Goller Veit , Henrich Michael , Reske Sven , Kochs Matthias , Hombach Vinzenz
Published: June 2007

The aim of the study was to assess the skeletal muscle blood flow and the regional perfusion reserve by rubidium 82-positron emission tomography (PET) in order to evaluate the functional effects of stenoses and occlusions of lower leg arteries. In 12 patients the authors infused 12 mCi rubidium 82 into the femoral artery (following diagnostic cardiac catheterization) and recorded a dynamic PET sequence of the lower leg at rest and during reactive hyperemia following two minutes of complete arterial blockage by a cuff. Regional perfusion was calculated as the rate of uptake related to the 82 Rb input function. Perfusion reserve was calculated as the regional perfusion during hyperemia related to perfusion at rest. Muscle perfusion at rest was homogeneous in all patients. The regional perfusion reserve was markedly reduced in muscle areas distal to infrapopliteal stenoses or occlusions as compared with muscle areas following nonstenotic arteries and overall reduced in a patient with small-vessel disease. The authors conclude that 82 Rb-PET allows exact measurement of the regional perfusion of the lower leg muscles during rest and reactive hyperemia. Calculation of the regional perfusion reserve gives a quantification of the functional effects of peripheral occlusive artery disease.
Does the Geometry of a Distal Vein Graft Anastomosis Affect Patency?
Authors: Hoballah Jamal J. , Mohan Chittur R. , Chalmers Roderick T. A. , Schueppert Michael T. , Sharp William J. , Kresowik Timothy F. , Corson John D.
Published: June 2007

Between January, 1988, and December, 1992, 336 autogenous vein bypasses were performed on the vascular service at The University of Iowa Hospital. Routine color duplex surveillance (CDS) identified 25 bypasses with a significant distal anastomotic stenosis that developed between one and thirty-one months postoperatively (mean nine months). These 25 „failing bypasses” underwent a revisional procedure following arteriographic confirmation of the location and severity of the lesion. The intraoperative completion arteriograms performed at the time of the original bypass procedure of these revised bypasses were critically analyzed. The length of the distal anastomosis, as well as the diameter of the distal vein conduit and artery (proximal and distal to the anastomosis) were measured in each case. In addition any anastomotic defect seen on the original intraoperative completion arteriogram was also noted. This same analysis was done for 50 consecutive vein bypasses that have remained primarily patent for two years or more and had normal duplex surveillance studies. Vein/artery diameter, anastomotic length/artery diameter, anastomotic length/vein diameter ratios were calculated for both the groups. Demographic characteristics, risk factors (diabetes mellitus, hypertension, coronary artery disease, renal failure, chronic obstructive pulmonary disease), indications for surgery, type of venous bypass conduit, and the outflow of the bypasses were comparable between these two groups. The results are depicted in the following table:

[Table: see text] These data indicate that the geometry of the distal anastomosis does not play a significant role in the development of distal anastomotic stenosis. An uncorrected anastomotic defect on the completion arteriogram is a risk factor for bypass failure. Hence, patients with such defects should have these lesions corrected when they are initially identified at the time of the initial bypass procedure.
A Preliminary Experience with the Human Homologous Vein Graft for Vascular Access
Authors: Gecim I. E. , Ward R. G. , Bakran A. , Aikawa A. , Sells R. A.
Published: June 2007

In a preliminary study, 38 preserved human homologous saphenous vein grafts were used for secondary vascular access in 36 chronic hemodialysis patients. Cumulative oneyear patency was 67%. Twelve grafts failed, 10 owing to thrombosis and 2 owing to infection. Overall complication rate, morbidity, and patency were compatible with the other available graft materials. A prospective randomized trial of Varivas graft against PTFE has been instigated.
Aneurysms of the Extracranial Carotid Artery
Authors: Papachristou Euripides , Antoniades Joseph , Perrakis Evangelos , Papastefanou-Eint Gabriel , Papanastasiou Andreas , Dragojevic Dusan
Published: June 2007

The authors report 9 cases of carotid artery aneurysms in 7 patients from a total of 564 carotid artery operative procedures (1.6%) performed at the Vascular and Thoracic Surgical Clinic of the “Heidehaus” Municipal Hospital of Hannover and the Surgical Department of the West Attica Hospital of Athens Greece. In 4 cases excision of the aneurysm followed by polytetrafluoroethylene 6-mm graft interposition was performed; 1 patient was treated with end-to-end anastomosis, 1 with ligation of the internal carotid artery (ICA), and 3 with excision followed by interposition of vein graft. Histologic examination showed 7 aneurysms to be atherosclerotic, and a female patient had bilateral microcystic degeneration of the middle layer of the ICA.
Internal Carotid Artery Aneurysm: An Unusual Presentation
Authors: Rimoldi P. A. , Romani F. , Barbano P. R. , Palmieri B. , Riolo F. , Sesana G. , Puttini M.
Published: June 2007

Internal carotid artery (ICA) aneurysm is rare. The authors describe a seventy-three-year-old woman whose chief complaint was a pulsatile left laterocervical mass, increasing in size over a five-year-period. Duplex scanning, computed tomography, and digital subtraction angiography disclosed a 4-cm aneurysm of the ICA. Surgical resection was performed, and an end-to-end anastomosis between the proximal and distal ICA was created. The patient made an uneventful recovery.
Treatment of Recurrent Carotid Disease
Authors: Plestis Konstadinos A. , Jiang Zhidong , Appel Hope , Howell Jimmy F.
Published: June 2007

The purpose of this study was to determine whether repeat carotid endarterectomy (CEA) poses a greater risk than first-time CEA. The authors analyzed data from 893 consecutive CEA cases (1981-1993). Thirty-three patients (3.7%) had repeat CEA, and 860 (96.3%) had first-time CEA. There were statistically significantly higher incidences of hypertension (60.6% vs 44.6%), smoking (84.8% vs 55%), hypertriglyceridemia (33.3% vs 16.2%), and coronary artery disease (66.6% vs 36%) in the repeat CEA group than in the first-time CEA group.

Symptomatic disease was present in 25 (75.8%) patients in the repeat group and in 576 (67%) patients in the first-time group (P>0.05). The cause of recurrence was atherosclerosis in 25 patients (76%), myointimal hyperplasia in seven patients (21.2%), and intraluminal thrombus without an underlying lesion in one patient (3%). Redo CEA with vein patch angioplasty was performed in 27 patients (82%), vein patch angioplasty alone in five patients (15%), and interposition vein graft in one patient (3%).

The hospital operative mortality was 0% (n=0) in the repeat CEA group and 0.6% (n=5) in the first-time CEA group (P>0.05). The incidence of postoperative stroke was 0% (n=0) in the repeat group and 1.2% (n= 10) in the first-time group (P>0.05). There was one case (3%) of transient ischemic attack (TIA) in the repeat group, and two cases (0.2%) of TIA in the first-time group. There was no difference in the incidence of cranial nerve dysfunction between the repeat group (n=2, 6%) and the first-time group (n=41, 4.8%; P>0.05). Late follow-up data were obtained for 30 patients (mean: 61.4 months, range: 5-158 months) in the repeat CEA group and 501 patients (mean: 55.8 months, range: 17-168 months) in the first-time CEA group. The incidence of late failure (ipsilateral stroke or TIA) was 3.3% (n= 1) in the repeat group and 3.2% (n= 16) in the firsttime CEA group; P>0.05. The overall late mortality was 20% (n=6) in the repeat CEA group and 14.6% (n=73) in the primary CEA group; P>0.05.

Repeat CEA can be performed safely in individuals with severe recurrent carotid stenosis, and perioperative and long-term mortality and neurologic morbidity rates are similar to those for patients undergoing first-time carotid endarterectomy.
Nonoperative Treatment of Budd-Chiari Syndrome Utilizing New Radiologic Interventional Techniques
Authors: Sharma Rajinder P. , Burke Pamela J. , Batra Surinder K. , Venugopal Chandra , Burke Mathew , Shetty P. C. , Kastan David , Burke Thomas
Published: June 2007

Budd-Chiari syndrome (BCS) describes a variety of clinical conditions that result in outflow obstruction of hepatic venous return to the right heart, ultimately leading to liver failure and death if left untreated. The authors present successful management to 24 months of a patient with BCS by radiologic interventional techniques that included percutaneous transluminal angioplasty and placement of metallic stents.
Clinical Results of Infrainguinal Bypass Using Plasma TFE™ Vascular Graft
Authors: Onohara Toshihiro , Kerstein Morris D. , Maekawa Takafumi , Arnold Thomas E. , Maitra Subhahasis , Matsumoto Teruo
Published: June 2007

Twenty-eight infrainguinal bypasses using woven polyethylene terephthalate (PET) vascular graft coated with tetrafluoroethylene (TFE) were evaluated. Distal graft anastomoses were performed to the above-the-knee (AK) popliteal artery in 18 limbs, belowthe-knee (BK) popliteal artery in three limbs, and tibial arteries in seven limbs. No early graft occlusions (within 30 days) occurred in femoropopliteal (FP) bypasses, whereas 5/7 (71%) femorotibial (FT) bypasses occluded postoperatively within five days. During 3 years of follow up, 11 occluded and six failing grafts were detected in the FP bypass group. Average patency times for AK FP, BK FP, and FT bypasses were 619.0 4.5, 226.0 ± 23.0, and 43.4 ±4.5 days, respectively. The cumulative patency rates for AK FP bypass were 81.6 ±.6% at 8 months and 66.7 ±12.3% at 1 year. Seventeen limbs with occluded or failing grafts disclosed six anastomotic stenoses in five (29%) grafts, occlusive lesions in three (18%) inflow and three (18%) outflow host arteries, and thrombosis of two (12%) inflow bypass grafts. No significant lesions were detected in four (23%) occluded grafts following thrombolytic therapy. The results indicated that this graft has acceptable antithrombogenicity in FP position because of no early graft occlusion, and the common causes of graft failure were anastomotic stenoses and occlusive lesions of the host artery.
Splenorenal Bypass as an Emergency Procedure
Authors: Gervaz Pascal , McCollum Peter T. , Naidu Saddhana
Published: June 2007

The role of percutaneous transluminal angioplasty (PTA) in the management of renovascular hypertension is controversial when the cause is known to be atherosclerotic disease. The authors report a life-threatening complication of PTA, wherein renal artery rupture was successfully managed by emergency splenorenal bypass with preservation of the kidney function. Close cooperation between radiologists and the surgical team is a prerequisite for such interventional technique.
Warfarin Skin Necrosis of the Upper Extremity in a Patient with Heparin-Induced Thrombocytopenia
Authors: Syrek Jennifer R. , Calligaro Keith D. , Dougherty Matthew J. , DeLaurentis Dominic A.
Published: June 2007

A case of heparin-induced thrombocytopenia and warfarin skin necrosis is reported in a 62-year-old man treated for a subclavian venous thrombosis. These two complications occurring in the same patient have been reported only on two other occasions. Warfarin skin necrosis affecting the upper extremity has been reported only in four other patients.
Evaluation of Efficacy and Safety of Valvulotomes in an “Ex-vivo” In-situ Bypass Model
Authors: Schanzer Harry , Skladany Milan
Published: June 2007

A critical step in the performance of in-situ bypass is to produce incompetence of the venous valves. Currently, there are several commercially available valvulotomes designed to fulfill this task. The purpose of the present work was to evaluate, in an ex-vivo system simulating an in-situ bypass, the efficiency of valve cutting and the degree of luminal damage produced by four of the most commonly used instruments (Reusable LeMaitre, Expandable LeMaitre, Gore Eze-Sit, and Mills).

Cryopreserved cadaveric veins (2.5-6 mm diameter) were mounted in a perfusion chamber and submerged in Ringer's lactate. The same buffer containing 0.6% papaverine was infused at a pressure of 100 mm Hg through a catheter inserted into the proximal end of the vein. The valvulotome to be evaluated was introduced through the distal end of the vein, advanced beyond the most proximal valve and withdrawn at a rate similar to that used clinically through the full length of the vein. The vein was opened longitudinally and the efficacy of valve cutting (expressed as percent of individual valve cut) and presence of luminal damage were carefully evaluated by means of a dissecting microscope.

Thirty-three valves in seven segments of veins (mean size 4.35 ± 0.86 mm) were tested with the Reusable LeMaitre valvulotome. The percent of valvular cutting was 29.9 ± 33.4. The Expandable LeMaitre valvulotome was tested in 22 valves contained in five segments (vein diameter 4.07 ± 1.04 mm) and the percent of valvular cutting was 89.2 ± 15.7. The Gore Eze-Sit valvulotome produced a 80.6 ± 25.5% of cutting in the 32 valves contained in the seven venous segments tested (vein diameter 3.67 ± 0.42 mm). The Mills valvulotome was tested in five segments of vein containing 20 valves and there was a 82.1 ± 24.0% of valve cutting after valvulotomy (diameter 3.67 ± 0.57 mm). Statistical analysis demonstrated a significant difference with less cutting (p < 0.0001) when the results of the Reusable LeMaitre valvulotome were compared against each of the other three valvulotomes. Luminal damage was detected in one instance after use of the Mills valvulotome.

The Expandable LeMaitre, Gore Eze-Sit, and Mills valvulotomes demonstrated consistent efficacy in valve cutting, the Mills valvulotome producing injury to the wall in one occasion. The Reusable LeMaitre valvulotome gave significantly poorer results, most likely related to failure of engagement of the circular blade. Because of the presently demonstrated safety and efficacy, and avoidance of need for long skin incisions, the Expandable LeMaitre and Gore Eze-Sit are the most promising of the four tested valvulotomes.
A New Nd: YAG Laser-Bearing Angioscope is Useful for Visualizing and Treating Lesions of the Superior Vena Cava and the Right-Sided Chambers of the Heart
Authors: Fujisawa Takehiko , Yamaguchi Yutaka , Saitoh Yukio , Sekine Yasuo , Takeda Tsunehiro
Published: June 2007

The utility of a prototype Nd:YAG laser-bearing angioscope was evaluated for the diagnosis and treatment of neoplastic lesions of superior vena cava (SVC) and right-sided chambers of the heart in dogs.

The angioscope had a balloon tightly fixed to the tip with heat shrink tubing and suture ligation. Approximately 96% of the Nd:YAG laser energy penetrated the balloon without rupture when the balloon was inflated with saline solution and was in direct contact with the target.

The internal surfaces of the SVC, inferior vena cava, right atrium, tricuspid valve, right ventricle, and main pulmonary artery were visualized clearly by this angioscopic technique. The Nd:YAG laser was guided successfully under direct vision and a surgically transplanted neoplasm in the SVC was irradiated. Tumor coagulation was confirmed macroscopically and microscopically.

This new angioscope requires further improvement, specifically, to decrease its diameter and improve the durability of the balloon.
Carotid Replacement Grafts for Extracranial Atherosclerotic Disease
Authors: Madera Freddy A. , Razzino Richard A. , Orecchia Paul M. , Calcagno David
Published: June 2007

Carotid artery reconstruction using interposition grafts is usually indicated for management of recurrent stenosis where endarterectomy cannot be performed, where quality of the carotid artery is unsatisfactory following endarterectomy, or where there are aneurysmal changes in the artery. The purpose of this study was to evaluate the perioperative and long-term results in patients who underwent carotid replacement grafts.

The authors conducted a retrospective chart review of 758 operations performed for extracranial carotid disease between August 1987 and February 1995. In 10 of these cases, the quality of the carotid artery following endarterectomy was so thin or had such an irregular surface that replacement grafts were necessary.

In three of these 10 patients, surgery had been performed for recurrent carotid stenosis. Autogenous vein was utilized in seven cases, and prosthetic material was used in three cases (polytetrafluoroethylene [PTFE] in two cases and Dacron in one case). Follow-up was complete in all patients and ranged from 16 to 87 months (mean, 47 months). Serial duplex scans were performed in all cases. All grafts remained patent, but duplex scanning detected severe stenosis in two of the 10 grafts at 7 and 39 months, respectively, after the initial reconstruction. In both cases, contrast angiography confirmed the findings. In both patients, the areas of stenosis occurred in the midportion of a reversed vein graft at a valve site. The stenoses were corrected without further restenosis. There were no postoperative stenoses in the three cases where prosthetic material was used. There were no early or late strokes or deaths.

The late secondary patency of carotid artery replacement grafts is excellent. Intraoperative detection and ablation of venous valves or choosing a vein segment without valves when autologous grafts are used may decrease the incidence of secondary stenosis. Serial duplex scanning is recommended for both short-term and long-term follow-up.
Synchronous Management of Incidental Neck Masses and Carotid Artery Disease
Authors: Kasirajan K. , Obermeyer Robert , Hirko Mark K. , Turner John J. , Rubin Jeffrey R.
Published: June 2007

Incidental identification of neck masses is not uncommon during the workup and management of surgically treatable carotid artery stenosis. Retrospective chart review was made over a 12-month period of all patients who underwent carotid endarterectomy. Twelve patients with incidental neck masses were identified among 227 subjects. Of these 12 patients, three presented with clinically palpable submandibular gland enlargements, eight had sonographic evidence of incidental thyroid nodules, and one patient had significant enlargement of cervical lymph nodes excised at the time of carotid surgery. The last patient was found to have a metastatic squamous cell carcinoma originating from the pyriform sinus. Eleven of twelve patients had successful excisions of the neck mass synchronous with carotid endarterectomy. The postoperative course was uneventful in these 11 patients, but one required postoperative hematoma drainage. All patients were discharged with a length of stay less than 1.5 days. Incidental neck masses are not uncommon. When detected, these can be managed synchronously with carotid endarterectomy demonstrating no significant change in outcome.
The Incidence of Colonic Ischemia with Retroperitoneal Aortic Reconstruction: A Prospective Study Emphasizing Early Selective Endoscopic Intervention
Authors: Brasch Robert C. , Kreienberg Paul B. , Darling R. Clement , Lee Edward C. , Shah Dhiraj M.
Published: June 2007

Colonic ischemia is a significant complication following aortic reconstruction. The incidence of colon ischemia following transabdominal aortic repair is reported to be between 0.5% and 10% for overt ischemia with operative mortality ranging between 48% and 100%. It has been suggested that aortic repair utilizing the retroperitoneal approach may be associated with an increased incidence of colonic ischemia. A prospective study on all patients undergoing retroperitoneal aortic replacement was performed between July 1, 1995, and June 30, 1996. Patients meeting predetermined criteria were evaluated with flexible sigmoidoscopy. In this period, 202 patients (mean age 73 years) underwent retroperitoneal aortic replacement. One hundred and twenty-four (61%) patients were operated on for aneurysmal disease, 17 (8.4%) had symptomatic or ruptured aneurysms, and 61 (30%) had aortic occlusive disease. Colonic viability was assessed intraoperatively with visual inspection and Doppler ultrasound. Flexible sigmoidoscopy was performed in 20 (9.9%) patients between 24 hours and 15 days after aortic reconstruction. Indications for flexible sigmoidoscopy included guaiac-positive stool, unexplained fever, acidosis or leukocytosis, hypotension, and abdominal pain or distention. Eight (4.0%) patients had endoscopically proven colonic ischemia. Of these patients, aortic repair was performed on four patients with aortic occlusive disease and on two patients each with asymptomatic and ruptured aneurysms. Transmural necrosis requiring operation and bowel resection was identified in four patients, two patients with occlusive disease, and two patients with asymptomatic aneurysms. The other four patients had mucosal ischemia managed nonoperatively. Operative mortality rate following bowel resection was zero. Colonic ischemia remains a significant cause of mortality following aortic replacement. However, retroperitoneal aortic replacement does not contribute to an increased incidence of colonic ischemia. Selective, early endoscopy may improve survival with prompt recognition and treatment.
Limitations of Percutaneous Treatment for Peripheral Arterial Vein Graft Stenoses
Authors: Mckinsey James F. , Christian Caprice , Leef Jeffrey , Rosenblum Jordan D. , Szymski George , Piano Giancarlo , Bassiouny Hisham S. , Schwartz Lewis B. , Gewertz Bruce L.
Published: June 2007

Peripheral arterial bypass vein graft stenosis is the leading cause of graft failure within the first 2 years following implantation. These lesions are generally secondary to myointimal hyperplasia and have historically been treated with graft revision or operative patch angioplasty. Unfortunately, graft revision or angioplasty requires reoperation through a scarred incision and usage of additional portions of autologous conduit. The purpose of this study is to assess the effectiveness of percutaneous transluminal angioplasty (PTA) in the treatment of vein graft stenosis. PTA was performed in 17 patent vein grafts in 16 patients for the treatment of perianastomotic and/or midvein graft stenoses occurring 7 ± 1 months (range 0.5-18 months) after graft implantation. Criteria for follow-up and patency adhered to the standards of the Ad Hoc Committee on Reporting Standards of the SVS/NAISCVS.

After a mean follow-up of 17 ±3 months (range 2-44 months), the procedure-specific 18-month primary patency, primary-assisted patency, secondary patency, and limb salvage rates were 48 + 17%, 63 + 12%, 67 ± 12%, and 78 ± 15%, respectively. Subgroup analysis revealed favorable lesions (one or two focal lesions, < 1 cm length) in 11 grafts. Life-table analysis for this subgroup revealed primary patency, primary-assisted patency, secondary patency, and limb salvage rates of 68 ±20%, 90 ±9%, 90 ±9%, and 100%, respectively.

The overall results of PTA for vein graft stenosis are poor and PTA should not be liberally applied to complex lesions. PTA may be a reasonable alternative to operative repair for focal vein graft stenoses in high-risk patients or in patients with limited remaining autologous conduit.