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Biomedical subjects

B S Cutler

Publications and source records attributed to B S Cutler.

At least 55 records · Page 3Linked to original sources
PubMed1984

The ischemic exercise test in patients with peripheral vascular disease. Implications for management.

We observed myocardial ischemia in 135 of 808 patients undergoing routine ECG-monitored treadmill tests before vascular reconstructive operations. Postoperative infarction incidence was 27% among 56 patients who had operations regardless of test results. When patients had a lesser procedure, such as extra-anatomic bypass, infarction incidence decreased to 17% (not statistically significant). Ten patients having staged aortocoronary and peripheral reconstruction had no myocardial infarctions postoperatively or during follow-up of up to five years. Of 37 patients asymptomatic for coronary artery disease who had normal ECGs at rest, 24% of those undergoing a standard intra-abdominal operation suffered myocardial infarctions. At present, such asymptomatic but high-risk patients can be identified only by routine ECG stress testing or coronary angiography. Patients with an ischemic response to exercise have the best chance for long-term survival through staged coronary and vascular reconstruction.

Coronary Angiography↗
PubMed1984

Avoidance of homologous transfusion in aortic operations: the role of autotransfusion, hemodilution, and surgical technique.

The transfusion requirement for 138 aortic reconstructive procedures was minimized through the combined use of hemodilution, autotransfusion, and surgical techniques reported to reduce operative blood loss. Elective procedures required an average of 1.65 U and ruptured aneurysms 9.63 U of homologous blood. Transfusion was avoided altogether in 42.6% of elective reconstructions and 8.3% of emergency procedures. Autotransfusion saved only 1.54 U for elective operations and 0.87 U for ruptured aneurysm, probably because of the effectiveness of hemodilution and specific surgical techniques that minimized dissection and consequent blood loss. Nonetheless, it proved to be cost effective, saving an average of $260 per patient in charges for homologous blood. The combined use of multiple blood conservation methods was shown to substantially reduce the need for homologous transfusion (compared to reported figures for blood use in aortic operations) and adds a measure of increased safety for the patient undergoing aortic operation.

Aged↗
PubMed1983

Surgical versus percutaneous removal of the intra-aortic balloon.

In order to determine the best method for removal of the percutaneous intra-aortic balloon (IAB), we divided 38 patients into two groups. The IAB was removed percutaneously in Group I and surgically in Group II. There were two hemorrhagic and four thrombotic complications sufficiently severe to necessitate vascular surgical intervention in Group I. There were no vascular complications in Group II (p less than 0.1). Among the 19 patients in Group II, eight were found to have acute thrombosis of the superficial or deep femoral artery at the time of operation. It is concluded that thrombus development at the site of IAB insertion is a common event and often leads to acute ischemia. Surgical removal of a percutaneously placed IAB is recommended because it provides an opportunity for the detection and removal of thrombotic material, as well as careful closure of the puncture site.

Assisted Circulation↗
PubMed1983

Transvenous interruption of the inferior vena cava.

Transvenous interruption of the inferior vena cava was successful in 45 of 47 consecutive patients treated during a 41/2-year period. Greenfield filters were used in 40, and Mobin-Uddin umbrellas in 5 others. Technical details of the insertion procedure are of particular importance for successful implantation of the Greenfield device. Follow-up data were available for 34 of 36 surviving patients and autopsy findings for 4 of the 11 who had died. Patency of the vena cava was assessed by radionuclide scan, venography, or autopsy. Of 33 patients with Greenfield filters who were evaluated, only one had an occluded filter, for a patency rate of 97%. One of the three patients with a Mobin-Uddin umbrella had caval thrombosis. Severe postoperative venous stasis was seen in one patient with a Greenfield filter and one with a Mobin-Uddin umbrella. Significant distal migration or angulation of Greenfield filters was observed in six patients and is a theoretical cause for recurrent embolization. The 30-day mortality rate for the patients who had transvenous procedures was 13%, but no deaths were attributed to the procedure itself. There were no clinically evident pulmonary emboli during the follow-up period. In the present study we have documented low operative morbidity and mortality rates as well as complete protection from recurrent pulmonary embolism using transvenous interruption of the inferior vena cava. Although the Greenfield filter is somewhat bulkier and more difficult to insert than the Mobin-Uddin umbrella, it has a clear advantage because of its superior long-term patency.

Adult↗
PubMed1982

Suspected deep vein thrombosis. Management by impedance plethysmography.

Controversy exists as to whether patients suspected of having deep vein thrombosis (DVT) can be studied safely without venography, with its attendant expense, inconvenience, and potential risk. We used impedance plethysmography (IPG) in 1,464 consecutive patients suspected of having DVT, with 96% of these patients with normal IPGs, there were no fatal pulmonary emboli (PE). The incidence of nonfatal PE was 1%. In 284 outpatients suspected of having DVT, but discharged without treatment because of normal IPGs, only one patient returned with subsequent symptoms of DVT (0.4%). Noninvasive testing with IPG is a safe and highly cost-effective alternative to venography for routine management of patients suspected of DVT.

Adolescent↗
PubMed1982

Pentoxifylline efficacy in the treatment of intermittent claudication: multicenter controlled double-blind trial with objective assessment of chronic occlusive arterial disease patients.

The efficacy, safety, and tolerance of pentoxifylline (Trental, Hoechst-Roussel Pharmaceuticals, Inc.) in the treatment of intermittent claudication associated with chronic occlusive arterial disease (COAD) were evaluated in a double-blind, placebo-controlled, parallel-group, multicenter clinical trial involving a total of 128 outpatients. The response to treatment was ascertained at regular intervals during the trial by measuring the distance walked prior to the onset of claudication when patients were subjected to a standardized treadmill test. Pentoxifylline given orally in doses up to 1200 mg/day was significantly more effective than placebo in increasing both the initial and absolute claudication distances in patients with COAD. Reduction of lower limb paresthesias also suggested greater clinical improvement in the pentoxifylline treated patients. These results support the hypothesis that pentoxifylline reduces blood viscosity by improving red cell flexibility, and thereby enhances blood flow in patients with COAD. White the precise mode of therapeutic action requires clarification, pentoxifylline was well tolerated with minimal unwanted effects.

Aged↗
PubMed1982

Improved myocardial preservation by improved distribution of cardioplegic solutions.

Two groups of elective coronary artery bypass graft (CABG) patients were compared with respect to a single variable: method of cardioplegia administration. All patients had saphenous vein grafts and all distal anastomoses were done with continuous aortic occlusion and intermittent administration of a 4 degrees C cardioplegic solution. One hundred patients in Group I had the distal anastomoses performed before the proximal anastomoses with cardioplegic solution administered only via the aortic root. One hundred patients in Group II had the proximal anastomoses performed first so that cardioplegic solution also perfused beyond coronary obstructions as each subsequent distal anastomosis was completed. Aortic occlusion averaged 6 minutes longer in Group II (46.5 minutes) than in Group I (40.3 minutes) (p less than 0.01). Mortality from cardiac causes was six times greater in Group I than in Group II (6% versus 1% p = 0.027) and overall mortality was eight times greater in Group I than in Group II (8% versus 1%; p = 0.008). We conclude that earlier cardioplegic perfusion of myocardium beyond obstructed coronary arteries substantially improves myocardial protection.

Albumins↗
PubMed1982

Brachial plexus injury following median sternotomy. Part II.

Brachial plexus injury may be a consequence of median sternotomy. In a previous study, we documented that median sternotomy can cause first rib fractures and that the first rib fractures may be associated with brachial plexus injury. In the current study, two groups of patients were compared for the incidence of brachial plexus injury and first rib fracture. In Group A, an Ankeney retractor was used with the crossbar placed caudal to the incision: in Group C, a Cooley sternal retractor was used with the crossbar placed cephalad to the incision. The major effective difference between these two retractors was the more caudal placement of the retractor blades with the Cooley retractor than with the Ankeney retractor. Our previous study showed that first rib fractures were caused by high placement of the sternal retractor and that they could be avoided by placing the retractor at a lower position. In the present study, 33% in Group A and 14% in Group C sustained first rib fractures (p = 0.024). Signs of brachial plexus injury occurred in 18% of Group A and 12% of Group C (p = 0.52). We found no correlation between the presence of rib fracture and the presence of neurologic symptoms, but all patients who had both neurologic symptoms and a rib fracture had the symptoms only on the same side as the rib fracture. We also found that standard chest x-ray films identified only 15% of the rib fractures seen on special first rib views. The study demonstrates that the incidence of first rib fractures following median sternotomy is reduced when the sternal retractor is placed at a lower position and that the incidence of brachial plexus injury may also thereby be reduced.

Age Factors↗
PubMed1981

Noninvasive detection of carotid stenosis following endarterectomy.

Noninvasive diagnostic studies (oculoplethysmography, pulsed Doppler arteriography, and phonoangiography) were used to follow the postoperative courses of 172 patients who had 199 carotid endarterectomies. There were 24 restenotic arteries in 21 patients who underwent 29 operations. Fifteen restenotic lesions in 14 patients were detected solely by noninvasive testing. These patients are being observed closely and remain asymptomatic. One has been operated on for progression of disease. Either transient or permanent neurologic deficits developed in nine as the initial indication of recurrent stenosis or occlusion; three of these subsequently have undergone reoperation. Patients with bilateral disease are at increased risk of restenosis. Routine testing of all patients undergoing carotid endarterectomy is recommended 1, 3, and 12 months postoperatively to detect and observe stenosis on both the side operated on and the contralateral side before clinical symptoms develop.

Aged↗
PubMed1981

Applicability and interpretation of electrocardiographic stress testing in patients with peripheral vascular disease.

Electrocardiographically monitored arterial stress testing was performed before surgery in 130 patients with peripheral vascular disease. When limitations of claudication or pain at rest precluded treadmill exercise, arm ergometry was employed. The electrocardiographically monitored arterial stress test proved a cost-effective, easily applicable means of screening for coronary artery disease in this group of patients. Unlike statistical analyses of historical risk factors, the electrocardiographically monitored arterial stress test evaluates the current functional state of the myocardium. We believe that preoperative electrocardiographic exercise testing should be employed more widely and should be considered in any patient facing major surgery in whom coronary artery disease is suspected on the basis of past history or known risk factors. In patients who have an ischemic response to exercise, particularly at less than 75 percent of the maximum predicted heart rate, coronary angiography and possibly coronary revascularization should be considered before elective major surgery is performed.

Aged↗
PubMed1980

Improved technique for insertion of intra-aortic balloon pump.

Polytetrafluoroethylene (PTFE, Gortex) grafts have several advantages over woven Dacron grafts for the insertion of intra-aortic balloons (IABP). Because of the smooth inner surface of the PTFE graft, an 8-mm graft may be used instead of the 10-mm minimum size with Dacron. The pliability of the PTFE graft makes it easier to sew with fine suture material, and its comformability permits a "blood tight" seal to be obtained with a single Dacron umbilical tape tie. We have used PTFE grafts for IABP insertion in 24 patients, with no infectious or thrombotic complications. This graft material seems to offer substantial technical advantages over woven Dacron for the insertion of IABP and subsequent arterial repair.

Assisted Circulation↗
PubMed1980

Return to work after coronary artery bypass operation.

A societal cost-benefit argument has been made for the coronary artery bypass graft (CABG) operation. Most patients experience improvement in symptoms and many can return to a productive livelihood. To estimate the rate of return to work and identify the factors influencing that outcome, we analyzed the work status before and after operation in a follow-up of 105 patients undergoing CABG operations in a new teaching hospital. Overall, relief or improvement in angina was accomplished in 92% of patients, and there was a 10% net increase to th work force after operation. Of all variables studied, preoperative work status was found to be the most statistically significant predictor of the postoperative return to work; other factors associated with return to work included symptomatic relief or improvement, age, and educational level. Preoperative and postoperative means of support did not play a major role in determining work outcome.

Age Factors↗
PubMed1980

Brachial plexus injury following median sternotomy.

Brachial plexus injuries are annoyingly common after median sternotomies and vary from those causing minor symptoms to those producing major disability. We compared two groups of patients operated upon with the arms either abducted to a 90 degree angle or at the sides and found no difference in the incidence of brachial plexus injury. However, the finding of Horner's syndrome in one patient and the finding in another (at autopsy) of brachial plexus penetration by a fractured first rib caused us to question traction on the brachial plexus as the correct pathogenesis of the injury. A concomitant autopsy study demonstrated fractured first ribs penetrating the brachial plexus in 11 of 15 patients whose sternum was opened with the sternal retractor placed in the usual location, but in none in 15 patients whose sternum was opened with the retractor displaced two intercostal spaces caudally. The injury can be minimized by opening the sternal retractor as little as is necessary and by placing it as caudally as possible commensurate with adequate exposure.

Arm↗
PubMed1979

Limitations of noninvasive evaluation of carotid occlusive disease.

A series of 32 patients examined by two different noninvasive techniques in two different laboratories and by cerebral angiography were retrospectively studied. Significant differences in ophthalmic artery pressures as measured by oculopneumoplethysmography (OPPG), and significant delays in ocular pulse arrival time combined with characteristic recorded bruits as determined by oculoplethysmography/carotid phonoangiography (OPG/CPA) were considered as an index of carotid stenosis. Cerebral angiography was performed on all 32 patients to confirm or refute the diagnosis suggested by noninvasive testing. In this selected group of patients with difficult diagnostic problems, only 67% of significant (greater than 50% diameter) stenoses were detected by OPPG, and only 58% by OPG/CPA. Combining OPPG and OPG/CPA increased the probability of detecting a greater than 50% diameter stenosis to 92%.

Adult↗
PubMed1979

Assessment of operative risk with electrocardiographic exercise testing in patients with peripheral vascular disease.

Doppler ankle blood pressures were performed inere obtained in 100 consecutive patients with peripheral arterial insufficiency after treadmill exercise. A twelve lead electrocardiogram was monitored during and after exercise. Despite a restricted ability to exercise because of peripheral vascular insufficiency, forty-six patients had ventricular dysrhythmia or ischemia, or both, usually without associated symptoms. Electrocardiographic monitoring during treadmill exercise proved a useful predictor of postoperative complications. Thirty-two vascular operations were performed in patients with no electrocardiographic evidence of ischemia. No patient had a postoperative myocardial infarction or died. Sixteen vascular procedures were performed in patients with ischemic responses on exercise electrocardiography. Six patients had postoperative myocardial infarctions, two of which were fatal. Electrocardiographic monitoring during treadmill exercise for peripheral vascular insufficiency in recommended (1) to assess the severity of coronary artery disease and the likehood of postoperative complications, and (2) as a precautionary measure to identify potentially dangerous dysrhthmias or ischemia during exercise before the development of clinical symptoms.

Aged↗