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Biomedical subjects

B S Cutler

Publications and source records attributed to B S Cutler.

At least 37 records · Page 2Linked to original sources
PubMed1994

Extended evaluation of the titanium Greenfield vena caval filter.

PURPOSE: The purpose of this study was to evaluate the long-term safety and efficacy of the titanium Greenfield filter-modified hook for prevention of pulmonary embolism. METHODS: We conducted a prospective study in 173 patients from four institutions who underwent clinical examination, abdominal radiography, and duplex ultrasound examinations of the vena cava and lower extremities. If indicated by protocol or clinical presentation, computed tomography scans, pulmonary angiograms, or venacavograms were obtained. RESULTS: The most common procedural event was filter limb asymmetry (10%), which had no clinical significance. A variety of other minor procedural events occurred in another 10% of cases. Early follow-up (< 6 months) was completed in 149 patients, and long-term evaluation was completed in 113 (> 12 months). Deaths in 24 patients were from nonembolic causes in all but one. There were four suspected or confirmed recurrent pulmonary emboli, for an incidence of 3.5% (four of 113), with one death (0.9%). Four patients had inferior vena cava occlusion at early follow-up and at long-term evaluation, only one remained occluded (1%). Insertion site venous thrombosis was seen in only two patients (2%). CONCLUSION: The titanium Greenfield filter provides protection comparable to the standard stainless steel Greenfield filter after 1 year with a low incidence of recurrent pulmonary embolism (3.5%) and a high caval patency rate (99%).

Cohort Studies↗
PubMed1993

Experimental femoral vein reconstruction with expanded polytetrafluoroethylene grafts seeded with endothelial cells.

The effect of endothelial cell seeding on the patency of small-caliber expanded polytetrafluoroethylene (ePTFE) grafts used for venous replacements in a canine experimental model was evaluated. Grafts were implanted bilaterally in 12 dogs as femoral vein interpositions. In each animal, one graft was seeded with enzymatically derived homologous endothelial cells which had been cultivated for 3 days in vitro before implantation, whereas the contralateral graft was not seeded. In five dogs, venography was performed at 2 weeks, and grafts were then excised. In the remaining seven dogs, venography was performed at both 2 and 4 weeks, with graft excision at 4 weeks. Graft patency at 2 weeks for seeded grafts was 75% (nine of 12) compared with only 33% (four of 12) for unseeded grafts (P < 0.02). There were no new episodes of thrombotic occlusion between 2 and 4 weeks. Five dogs with thrombus in the control graft did not develop thrombus in the contralateral seeded graft. Furthermore, each dog with a patent control graft had no thrombus in the seeded graft. It is concluded that the early patency of seeded ePTFE grafts is superior to that of unseeded ePTFE grafts in the femoral vein.

Animals↗
PubMed1992

Prediction of late cardiac events by dipyridamole thallium imaging in patients undergoing elective vascular surgery.

Dipyridamole thallium scintigraphy has previously been shown to have prognostic value in the preoperative assessment of patients scheduled to undergo vascular surgery, but its effect on the long-term outcome is less well-defined. In the largest series to date, dipyridamole thallium scanning was performed in 360 patients before elective vascular surgery and survivors were followed for a mean of 31 months. In the 327 patients who underwent vascular surgery, operative death and nonfatal myocardial infarction occurred in 4.9 and 6.7%, respectively. A cardiac event (nonfatal myocardial infarction or cardiac death) occurred in 14.4% of patients with a transient thallium defect, as opposed to 1% with a normal scan (p < 0.001). Logistic regression analysis revealed that the best predictor of a perioperative event was the presence of a reversible thallium defect, elevating the risk by 4.3-fold. Late cardiac events occurred in 53 (15.2%) surgical survivors or nonsurgically treated patients. Patients with a fixed perfusion abnormality had a 24% late event rate, compared with 4.9% in those with a normal dipyridamole thallium study (p < 0.01). Cox analysis demonstrated that a fixed thallium defect was the strongest factor for predicting a late event and increased the relative risk by almost fivefold. A history of congestive heart failure was the only significant variable that contributed additional value to that of a fixed defect alone. Life-table analysis confirmed the strong relation of a fixed defect to cardiac event free survival (p < 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1992

Do graduated compression stockings and pneumatic boots have an additive effect on the peak velocity of venous blood flow?

Graduated compression stockings and intermittent pneumatic compression boots reduce the incidence of deep vein thrombosis. Recent studies suggest that the simultaneous use of these devices may have a synergistic prophylactic effect; however, conflicting reports also exist. Using duplex imaging, we analyzed the effect on peak venous velocity in the superficial femoral vein produced by the individual and simultaneous use of graduated compression stockings and intermittent pneumatic compression boots. Normal volunteers and postoperative patients were examined. The use of intermittent pneumatic compression boots significantly increased the peak venous velocity relative to rest, whereas the use of graduated compression stockings did not alter the peak venous velocity. Also, the addition of graduated compression stockings to legs already being treated with intermittent pneumatic compression boots did not produce a further augmentation of peak venous velocity. This study demonstrates that the simultaneous use of graduated compression stockings and intermittent pneumatic compression boots does not produce a synergistic augmentation of peak venous velocity in the superficial femoral vein.

Bandages↗
PubMed1992

A prospective randomized study comparing surgical and percutaneous removal of intraaortic balloon pump.

This prospective randomized study of 50 patients compares the prevalence of complications between surgical and percutaneous methods of removal of intraaortic balloons. All patients who had percutaneous placement of a 9.5F intraaortic balloon during a 6-month period were eligible for the study. Patients were excluded if the intraaortic balloon was placed surgically, if a coagulopathy was present, or if acute leg ischemia developed at any time after insertion. After informed consent, 25 patients were randomized to each method of removal. Two complications occurred in the surgical group, including a wound infection and a lymph fistula. In one patient in the percutaneous group, a false aneurysm of the femoral artery developed. There was no significant difference between the mean of 59 minutes for percutaneous removal and 47 minutes for operative removal of the balloon (p = 0.74). The percutaneous method is therefore more cost-effective, because it does not require the use of operating room personnel or equipment necessary for surgical removal. The results of this study indicate that the majority of percutaneously placed intraaortic balloons may be safely removed percutaneously. Surgical removal of 9.5F intraaortic balloons is recommended for patients with bleeding diatheses, hemorrhagic or ischemic complications, or for those in whom the intraaortic balloon was inserted with a surgical procedure.

Aged↗
PubMed1992

Dipyridamole-thallium scintigraphy predicts perioperative and long-term survival after major vascular surgery.

The purpose of this study was to evaluate the ability of dipyridamole-thallium scintigraphy to predict perioperative and late cardiac events after peripheral vascular operations. A total of 262 patients had dipyridamole-thallium scintigraphy before 87 infrainguinal reconstructions, 108 abdominal aortic aneurysm operations, and 67 aortobifemoral bypass grafts that were placed for occlusive disease. Follow-up extended to 5 years (mean, 31.1 months). Logistic regression analysis selected dipyridamole-thallium scintigraphy redistribution as the best predictor of perioperative events. Fixed defects were not predictive. A Cox proportional hazards model for a variety of clinical risk factors and scan parameters identified fixed defects and a history of congestive heart failure as the strongest predictors of late cardiac events. The presence of greater than 1 or 2 fixed segments were the best predictors in patients with an abnormal scan; redistribution did not predict late events. The risk of combined perioperative or late cardiac events was 29% for infrainguinal, 19% for abdominal aortic aneurysm, and 7.5% for aortobifemoral operations. Life-table analysis showed that after a cluster of perioperative events that occurred primarily in patients with dipyridamole-thallium scintigraphy redistribution, most of the late cardiac morbidity and deaths occurred in patients with fixed defects.

Aged↗
PubMed1990

Transatrial interruption of the inferior vena cava.

Transatrial placement of a Greenfield filter at the time of cardiac surgery was performed on three patients with recent femoral venous thrombosis and unstable angina, and at the time of pulmonary embolectomy on four others. The filter carrier was passed through the right atrial cannulation site under fluoroscopic guidance into the inferior vena cava. A preliminary venacavogram was performed through the carrier or a previously placed angiographic catheter. Two complications were encountered: the first was misplacement of a filter in the right renal vein before routine venacavography was employed; the second was caudal displacement of a filter by a right atrial venous drainage cannula that projected into the inferior vena cava. The latter complication can be prevented by the use of a right atrial "sump" drain that does not protrude into the inferior vena cava.

Angina, Unstable↗
PubMed1990

Postoperative complications in patients with disabling psychiatric illnesses or intellectual handicaps. A case-controlled, retrospective analysis.

The purpose of this study was to quantitate the operative risk and costs encountered in the surgical treatment of institutionalized patients. Operative complications and duration of hospitalization for 200 institutionalized patients were compared with those in a control group of patients matched for age, sex, and type of operation drawn from the general hospital population. Postoperative complications occurred in 53 (26.5%) of the patients in the study group compared with 15 (7.5%) of the patients in the control group. Elective laparotomy was followed by a complication in 48% of institutionalized patients compared with 11.6% of matched controls. Emergency celiotomy carried a 75% complication rate in the study group. Atelectasis and pneumonia accounted for 50% of the postoperative complications and occurred with greatest frequency following intra-abdominal procedures. The median hospital stay for all institutionalized patients was 3 days more than for matched controls. A strategy for postoperative treatment is presented, with particular emphasis on prevention of pulmonary complications.

Anesthesia↗
PubMed1990

Clinical management of the symptomatic but unruptured abdominal aortic aneurysm.

Pain or tenderness of an abdominal aortic aneurysm is widely believed to signify acute expansion and imminent rupture. To assess the potential benefit of emergency operation for the group of patients with an acutely expanding aneurysm, the clinical course of 19 patients with a symptomatic but unruptured expanding abdominal aortic aneurysm was compared with 117 patients undergoing elective abdominal aortic aneurysm resection, and 69 patients having operation for a ruptured abdominal aortic aneurysm. Postoperative morbidity was high in the patients with an expanding abdominal aortic aneurysm, and included a 21% incidence of myocardial infarction, a 10% incidence of stroke, a 37% risk of ventilatory failure, and a 31% incidence of acute renal failure, which was not statistically different from the results in patients having ruptured abdominal aortic aneurysm resection. Patients undergoing elective abdominal aortic aneurysm resection had only an 8% risk of myocardial infarction, and only a 2% risk of stroke, ventilatory failure, or renal failure. The mortality rate for expanding abdominal aortic aneurysm resection was 26% compared to 35% for ruptured abdominal aortic aneurysm (p = 0.31). Both emergency operations had a mortality rate more than five times greater than the 5.1% after elective procedures (p = 0.008). Our findings emphasize the need for early and aggressive treatment of abdominal aortic aneurysm in the elective setting, even in the patient at high risk, and suggest that the preoperative assessment and modification of risk factors is important to prevent the cardiac, cerebrovascular, pulmonary, and renal complications seen accompanying an emergency operation of this magnitude.

Acute Kidney Injury↗
PubMed1989

Extended indications for placement of an inferior vena cava filter.

To study the morbidity and mortality rates after placement of an inferior vena cava filter and to define the appropriate indications for interruption of the inferior vena cava, the records of all patients who underwent insertion of a Greenfield filter during the decade January 1978 to December 1987 were reviewed. Patients were designated as having either a traditional or extended indication for placement of an inferior vena cava filter. Two hundred sixty inferior vena cava filters were placed in 264 attempts, with no deaths related to insertion of the filter. An extended indication was the primary reason for placement of the Greenfield filter in 66 (25%) of the patients. In patients with extended indications there were no cases of air embolism or filter misplacement and only three wound complications (4.5%). Pulmonary embolism after insertion of the inferior vena cava filter occurred in three patients (4.5%), with one fatality (1.5%). Inferior vena cava occlusion was documented in three cases (4.5%), and manifestations of the postphlebitic syndrome in early follow-up were present in two patients (3.0%). As the procedures to prevent fatal pulmonary embolism have become safer, more efficacious, and less morbid, the number of patients in whom the potential benefits of insertion of an inferior vena cava filter outweigh the risks has become larger. Our results support the liberalized use of Greenfield filters in those patients who do not necessarily have one of the traditional indications for placement of an inferior vena cava filter but are at a high risk of having a fatal pulmonary embolus.

Anticoagulants↗
PubMed1988

Long-term survival and quality of life following ruptured abdominal aortic aneurysm.

To document both the long-term survival and the quality of life of patients following surgery for ruptured abdominal aortic aneurysm (AAA), the records of 65 patients with ruptured AAA resection were compared with those of 100 who underwent elective AAA resection. The actuarial survival following ruptured aneurysm surgery was 92%, 51%, and 51% at 1, 5, and 10 years, respectively, and did not differ statistically for patients after elective AAA surgery or for an age- and sex-matched sample from the general population. Based on responses to a quality of life survey, there were no discernible differences in life-style, degree of independence, or productivity following either ruptured or elective AAA surgery. Survivors of ruptured AAA have an excellent long-term prognosis and expectation for a good quality of life.

Age Factors↗
PubMed1988

Placement of two Greenfield filters in a duplicated vena cava.

Congenital anomalies of the inferior vena cava (IVC) are not unusual and may complicate the placement of caval interruption devices. A duplicated IVC was demonstrated by venography in a patient with left iliofemoral venous thrombosis. A Greenfield filter was placed in each cavum from a right internal jugular vein approach. Because anomalies of the IVC are common, ascending venograms should be obtained in all patients who undergo caval interruption to document the number and position of the IVC, the location of the caval bifurcation, and the diameter of the IVC, as well as to identify the presence of thrombus within the lumen of the IVC. Unrecognized anomalies of the IVC may contribute to the incidence of recurrent pulmonary embolus after Greenfield filter placement.

Aged↗
PubMed1987

Sigmoid intramural pH for prediction of ischemic colitis during aortic surgery. A comparison with risk factors and inferior mesenteric artery stump pressures.

We compared intramural pH (pHI) measured through a silicone balloon placed in the lumen of the sigmoid colon with risk factor analysis and inferior mesenteric artery (IMA) stump pressures as predictors of ischemic colitis in 34 patients undergoing elective or emergency operations on the abdominal aorta. All patients had preoperative and postoperative flexible sigmoidoscopy, IMA stump pressure measurements, and serial measurements of pHI. Logistic regression analysis showed that aortic aneurysm, age, and stenosis of the superior mesenteric artery were the only risk factors that bore a statistical relationship to ischemic colitis. Ligation of a patent IMA did not increase the likelihood of ischemic colitis. The IMA stump pressure criteria for predicting ischemic colitis were absent in nine of the ten patients in whom ischemic colitis developed and were present in five of the 24 in whom it did not develop. Intraoperative pHI dropped below 6.86 in all three patients in whom severe ischemic colitis developed. Mild colitis developed in seven patients whose minimum pH was 6.99 +/- 0.12 (mean +/- SD). No colitis developed in the remaining 24, whose minimum pH was 7.21 +/- 0.13. Thus, stump pressure is not a reliable means of predicting ischemic colitis. Aortic aneurysm, age, and superior mesenteric artery stenosis were significant risk factors. The average minimum intraoperative pHI and its duration were the best predictors for the development of ischemic colitis.

Adult↗
PubMed1987

Noninvasive evaluation of cardiac risk before elective vascular surgery.

The prognostic utility for predicting cardiac events was determined for dipyridamole-thallium scintigraphy, exercise stress testing (when possible; n = 69) and multiple clinical variables in 100 consecutive patients admitted for elective surgical repair of peripheral vascular disease. After initial noninvasive evaluation, 11 patients were referred for coronary angiography and the remaining 89 patients had surgery without further cardiac studies. Fifteen patients (17%) had a postoperative myocardial infarction, one of which was fatal. Of these 15 patients, 14 had thallium redistribution and 3 had positive ST segment depression during stress testing. Among the many variables tested, the presence of redistribution on serial dipyridamole-thallium images was the most significant predictor of serious cardiac events. All 11 patients who had coronary angiography had both redistribution and multivessel coronary artery disease. Four of these 11 patients died during follow-up and 6 had coronary artery bypass surgery. It is concluded that dipyridamole-thallium imaging has significant prognostic utility in predicting postoperative myocardial infarction and death in patients with severe peripheral vascular disease, and is superior to exercise testing or clinical variables in determining cardiac risk. The odds for a serious cardiac event were 23 times greater in a patient with thallium redistribution than in a patient without redistribution, strongly suggesting that myocardial imaging may be used as a primary screening test before elective vascular surgery.

Aged↗
PubMed1987

Dipyridamole thallium 201 scintigraphy to detect coronary artery disease before abdominal aortic surgery.

Dipyridamole thallium 201 scintigraphy (DTS) was used to screen 116 consecutive patients referred for aortic reconstructive surgery for coronary artery disease (CAD). Thallium redistribution was found to have the best statistical correlation with postoperative myocardial infarction (MI). No MIs occurred after aortic operations among 60 patients with normal scans compared with 8 of 31 patients with abnormal ones. The odds of a patient with abnormalities found by DTS having a postoperative MI were 12 times greater than for those with a normal scan. No symptom or combination of symptoms of CAD was as good as an abnormal DTS in identifying patients at risk. The incidence of MI was 7.0% for patients with symptomatic CAD and 8.5% for those who were asymptomatic. Cardiac complications gradually declined as surgeons gained confidence in the use of DTS, to the point where no postoperative MIs occurred during the final year of the study. DTS approaches the ideal preoperative test for CAD in patients with peripheral vascular disease. The test does not require exercise, is minimally invasive, safe, and of sufficient sensitivity to detect myocardial ischemia in the absence of symptoms. Furthermore, it is cost-effective; only those patients with an abnormal scan and an imperative need for aortic surgical treatment need further cardiac evaluation.

Aged↗
PubMed1986

Prediction of the development of sigmoid ischemia on the day of aortic operations. Indirect measurements of intramural pH in the colon.

A deviation in an indirect measurement of intramural pH below the limits of normality (6.86) was used as a diagnostic test for sigmoid ischemia in 25 high-risk patients undergoing abdominal aortic operations. The clinical diagnosis of ischemic colitis was made by the attending physicians in only two of the 25, on the day after operation in one and three months after operation in another. In neither was the ischemic colitis considered to have been a causative factor in their subsequent deaths. In contrast, six patients developed pH evidence of ischemia on the day of operation. All six subsequently developed a transient episode of guaiac-positive diarrhea, four developed physical signs consistent with ischemic colitis, and four died. Of 19 who did not develop pH evidence of ischemia, none developed guaiac-positive diarrhea, none developed any signs of ischemic colitis, and none died. Stepwise logistic regression showed the duration of pH evidence of ischemia on the day of operation to be the best predictor for the symptoms and signs of ischemic colitis and for death after operation.

Aged↗
PubMed1986

Prevention of cardiac complications in peripheral vascular surgery.

The prevalence of severe coronary artery disease in peripheral vascular patients exceeds 50 per cent. It is therefore not surprising that complications of coronary artery disease are the most common causes of mortality following peripheral vascular operations. If the incidence of cardiac complications is to be reduced, it is first necessary to identify patients at risk through screening tests that will reliably detect hemodynamically important coronary occlusive disease. The operative risk can then be reduced by modifying the magnitude of the procedure, taking measures that can enhance the tolerance for a specific operation, or employing a combination of both. Screening methods in current use include risk factor analysis, exercise testing, routine coronary angiography, and dipyridamole thallium-201 scintigraphy. The risk factor approach has the advantage of being widely applicable since it makes use of historical, physical, and electrocardiographic findings that are already familiar to surgeons and anesthesiologists. It is also inexpensive. However, it may overlook the patient who has no symptoms of coronary artery disease, possibly as a result of the sedentary lifestyle imposed by complications of peripheral vascular disease. The electrocardiographically monitored stress test will identify the asymptomatic patient with occult coronary disease and is helpful in predicting operative risk. However, a meaningful test is dependent on the patient's ability to exercise--an activity that is frequently limited by claudication, amputation, or arthritis. Exercise testing also suffers from a lack of sensitivity and specificity when compared with coronary arteriography. Routine preoperative coronary angiography overcomes the exercise limitation of treadmill testing but is not widely applicable as a screening test for reasons of cost and inherent risk. Dipyridamole thallium-201 scanning, on the other hand, is safe and of relatively low cost and does not require exercise. Further, it has a high degree of sensitivity and specificity when compared with coronary arteriography. It appears to be an accurate predictor of postoperative cardiac complications.

Angiography↗