Severe graft-versus-host disease in a liver-transplant recipient.
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Graft vs Host Disease↗
Biomedical subjects
B A Perler
Publications and source records attributed to B A Perler.
Blue toe syndrome: treatment with anticoagulants and delayed percutaneous transluminal angioplasty.
The spontaneous onset of a painful unilateral blue toe is usually caused by fibrinoplatelet microemboli arising from an upstream stenotic or occlusive lesion of the iliac or femoral artery. This constellation of findings is referred to as the blue toe syndrome (BTS). In 12 patients who experienced 14 spontaneous episodes of BTS, angiography demonstrated 15 proximal atherosclerotic arterial lesions, which were presumed to be the source of the microemboli. Fourteen of the 15 lesions were short-segment stenoses or occlusions distal to the aortic bifurcation. Six lesions were treated with antiplatelet or anticoagulant drugs followed by delayed percutaneous transluminal angioplasty (PTA) 6-12 weeks later. Three lesions were treated with surgical bypass, three with long-term anticoagulation, and one with transcatheter clot aspiration and immediate PTA. Two were treated with immediate thrombolytic therapy and had embolic complications. Antiplatelet and anticoagulant therapy followed by delayed PTA may be an effective alternative to surgery for treating BTS.
Adult↗
Simple instrument occlusion of the anterior visceral branches of the aorta during en bloc renal allograft procurement.
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Aorta↗
Should we perform carotid endarterectomy synchronously with cardiac surgical procedures?
From Jan. 1, 1979 through July 31, 1987, 63 patients had carotid endarterectomy (CEA) concurrently with cardiac surgical procedures including coronary artery bypass grafting (CABG) in 61, CABG plus mitral value replacement in one, and aortic valve replacement in one. Among the 62 patients having CABG, unstable angina had been present in 36 (58%), left main coronary artery disease in 21 (34%), and both unstable angina and left main coronary artery disease in 13 (21%). Indications for carotid surgery included previous stroke, amaurosis fugax, or hemispheric transient ischemic attacks (TIAs) in 33 patients (52%); bilaterally significant carotid disease was noted in 48% of the patients. Major neurologic complications occurred in three patients (4.8%), including perioperative stroke in two (3.2%) (fatal in one) and a TIA in a third patient. Bilateral carotid lesions, a contralateral total carotid occlusion, previous cerebrovascular symptoms, and intraaortic balloon pump support did not increase neurologic risk. Seven patients died postoperatively (11%). The mortality rate was 2.8% in patients younger than 65 years vs 22% in patients 65 years or older, 19% in patients with left main coronary artery disease vs 7.3% in patients without, 13.3% in men vs 5.6% in women, 25% in patients with a history of congestive heart failure vs 7.8% in patients without failure, and 6.2% in patients with unilateral carotid disease, 17% in patients with bilateral carotid disease, and 23% in patients with bilateral disease including a contralateral carotid occlusion. A mortality predictive index (MPI) was developed to summarize individual risk for a fatal outcome.(ABSTRACT TRUNCATED AT 250 WORDS)
Age Factors↗
The multiple sequential distal bypass graft: seven-year follow-up.
Thirty-nine infrainguinal bypass grafts with multiple sequential distal anastomoses were performed on 35 patients ranging in age from 32 to 79 years (mean 65.8 years) with severe femoropopliteal occlusive disease. Thirty-eight procedures were performed for limb salvage indications. Distal anastomoses were performed to the popliteal-anterior tibial arteries in seven procedures, the popliteal-posterior tibial arteries in six, the popliteal-peroneal arteries in six, the anterior tibial-peroneal arteries in eight, the posterior tibial-peroneal arteries in 10, and the posterior tibial-anterior tibial arteries in two. Saphenous vein was the graft material in 31 procedures (in situ in two), polytetrafluoroethylene (PTFE) in four, and saphenous vein-PTFE composite in four. The mean Doppler ankle-arm index was 0.38 +/- 0.14 preoperatively and 0.89 +/- 0.13 postoperatively. The early (30-day) graft patency rate was 93%. With life-table analysis, the long-term primary patency rate was 70% at 1 year, 61% at 3 years, and 52% at 7 years for saphenous vein grafts; the secondary patency rate was 65% at 7 years for saphenous vein grafts. The secondary patency rate for PTFE and PTFE-vein composite grafts was 75% at 1 year, 50% at 3 years, and 17% at 5 years. Cumulative life-table limb salvage rates were 91% at 1 year, 85% at 5 years, and 61% at 7 years. The multiple sequential distal bypass graft is durable and highly efficacious in achieving limb salvage.
Adult↗
Emergency gastroduodenal-renal artery bypass. An extra-anatomic approach for salvage of the solitary kidney.
A 68-year-old woman had acute anuric renal failure and congestive heart failure. Angiography demonstrated occlusion of the renal artery to the known solitary right kidney and severely ulcerative aortic arteriosclerosis. She underwent an emergency gastroduodenal-renal artery saphenous vein bypass graft with almost immediate restoration of urine output and eventual dramatic improvement in renal function. She remains well two years postoperatively. This is the first report of gastroduodenal-renal bypass performed in the emergency setting for salvage of a solitary kidney.
Acute Kidney Injury↗
In situ saphenous vein bypass grafts: angiographic evaluation and interventional repair of complications.
In situ saphenous vein grafts are being used with increasing frequency for bypass procedures involving the femoral and popliteal arteries. Complications of these procedures include anastomotic stenoses and persistent arteriovenous fistulae that may result in failure of the graft. Balloon angioplasty and embolotherapy with detachable balloons were employed successfully in three or four recent cases of patients with complications from in situ grafts. Tailored angiography is essential for evaluating in situ grafts, and interventional techniques are extremely useful for managing complications.
Aged↗
Transgraft hemorrhage: a serious complication of low-dose thrombolytic therapy.
A 71-year-old woman came to the hospital with a 24-hour-old occlusion of the left limb of an aortoiliac knitted Dacron graft and was treated with an intra-arterial infusion of urokinase, 40,000 U/hr. Although the graft limb was successfully recanalized in 16 hours, the patient suffered a massive retroperitoneal hemorrhage through the wall of the graft. Clinicians must be aware of this potentially serious complication of thrombolytic therapy in patients with thrombosed, knitted Dacron grafts.
Aged↗
Percutaneous transluminal angioplasty and transaxillary first rib resection. A multidisciplinary approach to the thoracic outlet syndrome.
A 33-year-old man with the thoracic outlet syndrome complicated by recurrent upper extremity deep venous thrombosis underwent venographic and dynamic venous pressure studies that suggested both extrinsic and intrinsic venous obstruction. The patient was treated with transaxillary first rib resection and percutaneous transluminal angioplasty of the involved subclavian vein stenosis and is symptom-free at 16 months follow-up. To our knowledge this is the first case in which such a multidisciplinary approach to the thoracic outlet syndrome has been performed.
Adult↗
Low-dose thrombolytic therapy for infrainguinal graft occlusions: an idea whose time has passed?
Despite the growing enthusiasm for low-dose intra-arterial thrombolytic therapy, the efficacy and risks in specific clinical situations have not been defined. During the past 13 months, 10 infrainguinal bypass graft occlusions occurred in nine patients 2 to 48 months postoperatively and were treated with local infusions of either streptokinase or urokinase. The grafts treated included two saphenous vein femoropopliteal grafts, two expanded polytetrafluoroethylene (PTFE) femoropopliteal grafts, four saphenous vein femoro-anterior tibial grafts, one saphenous vein-PTFE composite femoro-anterior tibial graft, and one saphenous vein-PTFE composite femoroperoneal graft. The graft occlusions occurred 2 to 14 days prior to initiation of treatment. The infusion failed to restore flow completely in seven grafts; and of the three successes, two patients required surgical treatment of complications. All successful recanalizations occurred within 48 hours of the initiation of thrombolytic therapy. Of the seven failures, two patients had viable limbs and were discharged, whereas two required amputation (one above and one below knee). Three patients underwent surgical thrombectomy and revisions that were successful in two and resulted in a below-knee amputation in the other. Despite all precautions, complications occurred in five patients. Low-dose intra-arterial thrombolytic therapy is a poorly efficacious, risky method of infrainguinal graft occlusion management.
Adult↗
The safety of carotid endarterectomy at the time of coronary artery bypass surgery: analysis of results in a high-risk patient population.
From Jan. 1, 1979, to Dec. 31, 1983, 37 patients have undergone simultaneous carotid endarterectomy and myocardial revascularization. There were 27 men and 10 women, and their ages ranged from 45 to 74 years (mean 61.3 years). Unstable angina was present in 61%, significant stenosis in the left main coronary artery in 27%, and either unstable angina or disease of the left main coronary artery in 70% of these patients. All patients had hemodynamically significant stenosis of the carotid artery on the operated side and 14 patients (38%) had bilaterally significant disease; three patients (8%) had a contralateral total occlusion of the carotid artery. There were no deaths resulting from neurologic factors, no permanent, and only one transient (2.7%) neurologic deficits. There were three deaths from cardiac causes (8.1%). Carotid endarterectomy may be performed safely at the time of myocardial revascularization in a patient population with a high incidence of unstable angina and disease of the left main coronary artery. The evolution of and rationale for the combined surgical approach to coexistent carotid and coronary artery disease is discussed and the literature reviewed.
Aged↗
Abdominal aortic aneurysms: diagnosing and treating on time.
Recent evidence demonstrates that the notion of a "safe" aneurysm is a fallacy. The incidence of rupture, even in small aneurysms, is alarmingly high. Up to half of patients with abdominal aortic aneurysms are asymptomatic before rupture and death. Lateral lumbosacral spine film using bone technique is ideal for rapid evaluation of an an aneurysm. About three-fourths of abdominal aortic aneurysms contain sufficient calcium to allow detection by this method, and estimation of aneurysm size is accurate.
Aged↗
Oculoplethysmography and supraorbital Doppler evaluation of carotid disease. A reappraisal.
A variety of noninvasive tests are available for the evaluation of patients with suspected extracranial cerebrovascular disease. Recent emphasis on more sophisticated techniques has raised questions concerning the current utility of older methods, e.g., pulse delay oculoplethysmography (OPG) and supraorbital Doppler (SOD) examination. The results of OPG and SOD examination were compared with the findings of carotid arteriography in 75 consecutive patients. This analysis revealed a sensitivity of 78 per cent, specificity of 92 per cent, false-positive rate of 12.5 per cent, false-negative rate of 15.8 per cent, and overall diagnostic accuracy of 85 per cent for OPG. Although the specificity of SOD was superior (94.3%), the sensitivity (41%) false-positive rate (16.6%), false-negative rate (30.5%), and overall diagnostic accuracy of 71.6 per cent of SOD revealed it to be an inferior test of significant carotid stenosis. Based on its ease of performance, minimum of time required, and high level of diagnostic accuracy, OPG currently remains a valuable screening procedure for carotid disease, particularly in the asymptomatic bruit population.
Adult↗
The effect of vascular fellowships on general surgical residency training.
To answer the controversial question of whether or not vascular fellowships detract from general surgical training, questionnaires were sent to directors of 41 approved vascular fellowship programs, 41 residency directors in the same institutions, and 40 residency directors in university programs without approved fellowships. Overall response rate was 74% (93% of vascular fellowship directors, 63% of same-institution residency directors, and 65% of residency directors without vascular fellowships). Thirty-four per cent of fellowship directors and 38% of same-institution residency directors indicated that the fellowship has reduced the vascular surgery case load of residents. In institutions with fellowships, general surgery residents performed an average of 71 major vascular procedures and first assisted on 44, whereas residents performed 65 major vascular procedures and assisted on 47 in institutions without fellowships. Overall, 79% of fellowship directors and 62% of same-institution general surgical directors indicated that the fellowship improved the quality of vascular surgical training. Only 15% of same-institution residency directors and 3% of fellowship directors felt that the fellowship detracted from the general surgical experience. Fifteen per cent of institutions without approved fellowships have now initiated vascular fellowship programs, and an additional 23% plan to begin such fellowships. No fellowship directors plan to abolish their programs, although 8% plan to decrease the number of fellows in order to increase general surgery resident participation. Among the majority of institutions studied, vascular fellowships have not adversely affected general surgical training, and often enhanced it.
Education, Medical, Graduate↗
Iliac artery occlusion: management with intrathrombus streptokinase infusion and angioplasty.
Chronic and acute unilateral iliac artery occlusions were successfully treated in 7 of 8 patients using low-dose intrathrombus streptokinase infusions ranging from 6 to 43 hours in combination with percutaneous transluminal angioplasty. Angioplasty of an underlying stenosis was performed as soon as clot lysis was maximal and an underlying stenosis was demonstrated. Long-term follow-up to date has been excellent. This approach to unilateral iliac occlusion appears to be safer than previously reported angioplasty of iliac artery occlusion.
Adult↗
Tailored approach for evaluation of peripheral vascular disease: intravenous digital subtraction angiography.
A tailored approach for evaluating patients with peripheral vascular disease has been developed using intravenous digital subtraction angiography (IV DSA). This approach includes a history, physical examination, and correlation with Doppler pressure measurements to predict the location of the dominant lesion. In 60 patients, two views of the aortoiliac segment plus three or four views of the femoral and runoff circulation in the most symptomatic leg were obtained. Of the 60 patients, 36% had percutaneous transluminal angioplasty as a primary form of therapy, 32% were treated surgically, and 32% were followed clinically. Only 10% of these patients required further evaluation by conventional angiography. By omitting inpatient arteriography, considerable financial savings and increased patient comfort result.
Aortic Diseases↗
Massive small bowel infarction. An unusual complication of abdominal aortic surgery.
Only 16 cases of small bowel infarction as a complication of abdominal aortic surgery have previously been reported, with 100 per cent mortality among adults. This case represents the first adult survivor of this unusual complication reported to date. The possible etiologies of this problem including "aorto-iliac steal" phenomena, thromboembolic events, low cardiac output states, operative interruption of important collateral pathways, and mesenteric vasoconstriction secondary to pharmacologic agents are elaborated. The diverse clinical presentations of this devastating complication are likewise reviewed.
Aged↗
Vascular complications of intra-aortic balloon counterpulsation.
Although the intra-aortic balloon pump (IABP) saves many lives, complication rates as high as 36% have been reported. Many of the complications require surgical attention. In 794 patients of the Massachusetts General Hospital in Boston, an IABP was inserted into either the femoral or iliac artery between Nov 1, 1968, and June 30, 1981. Eighty-seven major vascular complications occurred in 70 (8.8%) of them. Of those 70 patients, 95% denied previous symptoms of vascular disease, and 78% had had normal pulses before insertion. The two most common complications were limb ischemia (n = 36) and arterial trauma (n = 20). Other complications included sepsis (n = 14), wound problems (n = 10), and hemorrhage (n = 7). No limbs were lost. Analysis of each group of complications allowed specific conclusions to be drawn concerning prevention, early diagnosis, and the most appropriate treatment.
Adult↗