Fasciotomy--in perspective.
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Compartment Syndromes↗
Biomedical subjects
C B Ernst
Publications and source records attributed to C B Ernst.
Suggested standards for reports dealing with cerebrovascular disease. Subcommittee on Reporting Standards for Cerebrovascular Disease, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery/North American Chapter, International Society for Cardiovascular Surgery.
The evaluation of clinical reports on vascular disease is often made difficult by variations in descriptive terms, clinical classification, and outcome criteria. In 1983 the Joint Council of the Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery created the Ad Hoc Committee on Reporting Standards to address these problems and recommend solutions. Some general problems were addressed in the initial report dealing with lower extremity ischemia. This article concerns clinical standards for reports dealing with cerebrovascular disease, suggests a scheme for clinical classification, and recommends standardized reporting practices for grading risk factors, angiographic and other diagnostic findings, and the results and complications of therapeutic intervention.
Cerebrovascular Disorders↗
Recurrent femoral anastomotic aneurysms. A 30-year experience.
Of the 1771 patients who underwent aortofemoral bypass grafting (AFB) during the 30-year period of 1957-1986, 43 noninfected recurrent femoral anastomotic aneurysms (RFAA) developed in 28 patients. Thirty-six RFAAs were treated surgically, with one death and no amputations occurring. Seven small RFAAs (less than 2.0 cm) were treated expectantly without complications. Using univariate and multivariate analyses, clinical characteristics and other factors influencing results in patients with RFAAs were compared to two control groups: patients who had undergone AFB without the development of femoral anastomotic aneurysms (FAAs) and patients who had undergone FAA repairs but without recurrence of FAA. Comparative analyses suggested: 1) local wound complications after initial AFB or FAA repair increased risk of a RFAA (p less than 0.03); 2) development of an FAA within 4.5 years after AFB increased risk of a RFAA (p less than 0.0002); 3) following an FAA repair, risk of a RFAA was almost three times greater for women than for men (p less than 0.05); and 4) patients with arteriosclerotic heart disease (ASHD) were less likely to develop RFAA than those without ASHD (p less than 0.05). Among the 20 additional variables analyzed--including hypertension, smoking, diabetes mellitus, and etiology of primary vascular disease--no statistically significant influence on the development of RFAAs could be detected.
Aged↗
Renal revascularization in patients with a single functioning ischemic kidney.
From 1965 to 1985, 19 patients with a single, ischemic kidney underwent renal revascularization. Thirteen patients had a single kidney and six had a single functioning kidney. The cause of the renal artery lesions was atherosclerosis in 17 patients and fibromuscular dysplasia in two. All but one were hypertensive with a mean diastolic blood pressure of 119 mm Hg and they were taking an average of 2.6 antihypertensive medications. Most had diminished renal function with a mean serum creatinine value of 3.7 mg/dl (range 0.8 to 9.0 mg/dl) and a mean creatinine clearance of 38 ml/min (range 8 to 75 ml/min). Three patients required preoperative hemodialysis. The first two patients treated died postoperatively, but no deaths have occurred since 1970. Follow-up among the survivors averaged 32.9 months. The mean serum creatinine value decreased significantly to 2.2 mg/dl postoperatively (p less than 0.04); the mean diastolic pressure decreased significantly to 86 mm Hg (p less than 0.001). One patient was normotensive preoperatively. Of the 16 patients surviving operation, 14 had improvement of their hypertension, one was cured, and only one did not benefit. No patient's hypertension was worse. The mean number of postoperative antihypertensive medications decreased significantly to 1.5 medications per patient (p less than 0.02). These data suggest that an aggressive surgical approach is warranted in patients with a single ischemic kidney in need of revascularization because of the gratifying response both in control of hypertension and improvement of renal function.
Adult↗
The impact of vascular surgical training on vascular surgical care.
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Delivery of Health Care↗
Vascular surgery in the United States. Report of the Joint Society for Vascular Surgery--International Society for Cardiovascular Surgery Committee on Vascular Surgical Manpower.
The Joint Committee on Vascular Surgical Manpower was established in 1985 by the Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery. It was charged to provide recommendations regarding vascular surgical manpower requirements for the next 15 years. Analysis of National Center for Health Statistics vascular operative rate data and 1690 questionnaire responses from vascular surgeons documented that vascular surgeons performed 235,400 (41%) of the total of 571,000 vascular operations undertaken in 1985. Vascular surgeons performed 87% of 30,000 aortoiliofemoral reconstructions, 77% of 72,000 peripheral vessel bypasses, 75% of 33,000 abdominal aortic aneurysm repairs, 59% of 55,000 angioaccess procedures, and 50% of 107,000 carotid endarterectomies. However, lack of accurate data on caseloads of surgeons who were not vascular specialists precludes precise prediction of manpower requirements for vascular surgery. It is important that surgical leaders and policy makers define the types of vascular surgical procedures that may be undertaken by vascular and other surgeons. Ongoing analyses must include such determinations to establish accurate data for the prediction of future manpower needs for vascular surgery. Furthermore, future manpower studies should be linked to outcome studies to assess not only numbers of surgeons and operations but quality of care as well.
Forecasting↗
An analysis of vascular surgical manpower requirements and vascular surgical rates in the United States.
Inherent in any analysis of vascular surgical manpower must be accurate data on surgical rates and numbers of surgeons who perform vascular operations. For in-depth analysis of age-sex standardized vascular operative rates from 1979 to 1984 and a determination of current manpower levels, data from the National Center for Health Statistics (NCHS) and the American Board of Surgery (ABS) were reviewed. During 1979 to 1984, total vascular surgical procedures increased 50%. In 1983 such operations comprised 11% of all general surgical procedures and 3% of all operations performed in this country. In 1983, 95,000 carotid endarterectomies, 74,000 peripheral bypasses, were performed. Through November 1984, among approximately 1600 surgeons who had applied to take the General Vascular Surgery Examination, 676 took the examination and 545 passed. What percentage of all vascular surgeons these 1600 represent is unknown. Consequently, what percentage of the total vascular operative load their own experiences represent is uncertain. As of May 1985, the Residency Review Committee for General Surgery had approved 42 fellowship positions in 29 vascular training programs. How these training figures will change to meet optimal manpower requirements remains undefined. Although data concerning operative rates have become more precise, forecasting manpower needs will be met with skepticism because of unknown current and future numbers of vascular surgeons and their average caseloads. Regardless of these uncertainties, vascular surgeons, program directors, and health analysts should be aware of such information because until we know how many vascular surgeons are necessary to provide optimal care, training and certification can not rationally evolve.
Forecasting↗
Reversal of postburn immunosuppression with low-dose polymyxin B.
In a randomized study of 28 patients with thermal injury, polymyxin B was administered intravenously in small doses to attempt to block the immunosuppressive effects of endotoxin. When compared with controls, treated patients showed a reduction in septic complications and death, but this reduction is not statistically significant at this time. In vitro measurements of lymphocyte function, however, indicate a statistically significant improvement in the T helper to suppressor ratio, and in the lymphocyte responsiveness to a number of bacterial antigens.
Adult↗
Limitations of the femoral artery pulsatility index with aortoiliac artery stenosis: an experimental study.
Relationships between femoral artery pulsatility index (PI) (a number calculated from Doppler-derived arterial blood velocity waveforms) and three directly measured physiologic parameters (proximal artery stenosis, blood pressure index (BPI), and blood flow) were studied in a canine model. All combinations of stenoses were constructed, including 0%, 25%, 50%, 75%, and 90% reduction in a cross-sectional area in the infrarenal aorta and/or left common iliac artery of 14 animals. PIs, BPIs, and mean blood flows were measured for each stenosis pattern at both the right (control) and left femoral arteries. Three groups were studied--group I, the left femoral artery remained open; group II, the left femoral artery was ligated; and group III, a left femoral arteriovenous fistula was constructed. Correlations between reductions in femoral artery PI and increasing arterial stenosis as well as decreasing BPI and blood flow were obtained. However, positive correlations were weak and only recognized when high-grade stenoses were present. Moreover, these correlations were further influenced by the multiplicity of stenoses present as well as flow velocity into the distal arterial bed. These data suggest that PI lacks the sensitivity to be a clinically useful diagnostic test.
Animals↗
Arteriovenous fistulas after gastrectomy: case report and review of the literature.
Mesenteric-portal arteriovenous fistula is an uncommon complication of gastrectomy. Management of a patient with this entity stimulated a comprehensive review of the 18 previously reported cases in the world literature. While presenting symptoms vary, physical findings are characteristic and include abdominal murmur (100% of patients) and palpable thrill (47%). Arteriography is essential to document mesenteric vascular anatomy. The most common arteries involved are the gastroduodenal and the right gastroepiploic (63%). Absence of portal hypertension is attributed to a normal liver, small-caliber fistulous communication, and normal portal venous compliance. Operative treatment in all reported cases has proved successful and is indicated to alleviate symptoms and prevent fistula rupture.
Aged↗
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↗
Implications of bacterial culture from abdominal aortic aneurysms.
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Aorta, Abdominal↗
Renal revascularization by extra-anatomic bypass.
Patients who suddenly become anuric and in whom no urinary obstruction is found should undergo arteriography both to confirm acute renal arterial occlusion and to plan surgical treatment. In acute renal arterial occlusion collateral circulation is often sufficient to maintain kidney viability and subsequent successful revascularization. Because there are no clinical or radiologic criteria to determine salvageability of the kidney, surgical exploration is advised in these patients. Such individuals who undergo successful renal revascularization often have gratifying return of renal function. Axillofemoral-renal bypass is suggested as a method to accomplish this objective.
Adult↗
Management of arm arterial injuries.
Management, morbidity, and mortality of arterial injuries of the arm are dependent upon site of injury, promptness and accuracy of diagnosis, and involvement of contiguous structures. To determine results and establish principles of management, a retrospective analysis was undertaken of 109 arm arterial injuries from the thoracic inlet to the wrist in 102 patients. Iatrogenic injuries were excluded. Arterial injuries were classified into those affecting the upper arm (subclavian, axillary, and brachial) and those affecting the lower arm (radial, ulnar, and interosseous). This proved to be a useful classification because of differences in management and results at these two levels. Thirty-six or one third of injuries involved the upper arm (13 subclavian, seven axillary, and 16 brachial) and 73 involved the lower arm (30 radial, 29 ulnar, 12 radioulnar, and two interosseous). Of the 19 individuals in hypovolemic shock when first examined, 12 (63%) had sustained upper arm injuries. Fifty-four percent of all patients had nerve involvement when initially examined, the majority (76%) sustaining lower arm injuries. Vein grafts were required during 19 repairs whereas resection and end-to-end repair were successful on 62 occasions. No synthetic grafts were used. Ligation alone was performed 18 times, only among those with lower arm injuries. Two patients died, both of hypoxic brain damage. Twenty-eight percent of patients suffered late disability despite an adequate vascular repair. Overall, 7% of patients with upper arm injuries and 21% of those with lower arm injuries were disabled when last seen. Upper arm arterial injuries are more of a threat to life than are lower arm injuries, but lower arm arterial injuries are more disabling, mainly because of associated nerve involvement.
Adolescent↗
Diagnosis and management of retroperitoneal hematomas after femoral vein cannulation for hemodialysis.
Six patients were identified who suffered retroperitoneal hemorrhage during or after hemodialysis via a femoral vein approach. Hypotension developing during dialysis or lower quadrant abdominal pain was the common presenting symptom. All patients had decreasing hematocrits and five of the six patients required blood transfusions. The method of diagnosis was clinical, with plain abdominal x-ray examination and cystography being the most helpful adjuncts. All patients were successfully treated with volume resuscitation and removal of the femoral vein catheters; none required operative intervention or suffered adverse late effects. Femoral vein dialysis is useful for uremic patients without other peripheral vascular access options, and its associated morbidity may be minimized provided complications are recognized and promptly treated.
Adult↗
Management of vascular soft tissue neoplasms using transcatheter embolization and surgical excision.
Preoperative embolization of highly vascular soft tissue tumors was performed in four patients. Selective catheterization of branch vessels supplying the tumors successfully avoided inadvertent embolization of adjacent normal tissue. Operative blood loss was significantly less than anticipated, permitting an easier, more precise, and quicker operation. Two of the lesions were benign intramuscular hemangiomas; one was a fibrosarcoma, and one, a malignant schwannoma. Three tumors were resected completely. A small portion of one hemangioma could not be removed. All patients were free of recurrence during follow-up periods of 6 to 14 months.
Adolescent↗
Current concepts in angiographic management of gastrointestinal bleeding.
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Angiography↗
Long-term results of aortoiliac angioplasty.
Results of percutaneous transluminal angioplasty of 141 iliac arteries in 112 patients are reported, with a follow-up period extending to 36 months. Initial technical success was achieved in 95.7%, 1-year patency in 91.3%, and accumulated 2- and 3-year patency in 89%. The role of outflow disease and ankle:arm index measurement and the importance of eliminating or significantly reducing the intra-arterial pressure gradients are discussed.
Adult↗