Presidential address: the development and purpose of a regional vascular society.
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Societies, Medical↗
Biomedical subjects
C B Ernst
Publications and source records attributed to C B Ernst.
Durability of thrombectomy of occluded aortofemoral graft limbs.
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Adult↗
Prevention of intestinal ischemia following abdominal aortic reconstruction.
Prevention of ischemic bowel complications following abdominal aortic reconstruction requires identification of the patient at high risk for developing the complication; on precise, gentle, meticulous operative technique; on knowledge of bowel blood supply; on determining when the IMA must be reconstructed or when it can be safely ligated; and on methods of preserving or preventing damage to bowel blood supply. Patients at greatest risk for developing bowel ischemia following aortic reconstruction include those with a history of visceral angina, those with a patent IMA (40% to 52%), those being treated for ruptured aneurysm, those whose postreconstructive IMA stump mean blood pressures are less than 40 torr, those in whom Doppler flow signals cease following division or occlusion of the IMA, and those who have SMA occlusive disease and arteriographic documentation of IMA to SMA flow in the MMA (Table II). Patients at least risk include those in whom the IMA is already occluded (48% to 60%), those whose postreconstructive IMA stump pressures are more than 40 torr, those in whom Doppler flow signals persist after IMA occlusion, those who have flow in the MMA from the SMA to the IMA (provided this vessel is not injured), and those undergoing aortic reconstruction for aortoiliac occlusive disease.
Aorta, Abdominal↗
Suppression of lymphocyte function after aortic reconstruction. Use of nonimmunosuppressive anesthesia.
Serial estimations of lymphocyte responses to antigens and mitogens and in mixed lymphocyte culture in 13 major vascular surgical patients were carried out before and after operation, which was performed using anesthetic agents that have been shown not to depress lymphocyte function. All responses were significantly depressed up to five to eight days, and some up to nine to 11 days. Such depression, attributable to surgical trauma, may underline the vulnerability to infection of these patients who are having prostheses inserted.
Aged↗
Vascular surgical manpower. Too much? Enough? Too little? Unknown?
To determine vascular surgical rates and respective manpower requirements in the United States, data from the National Center for Health Statistics and the national and regional vascular societies were reviewed. Vascular operative rates increased 117% during the study period, 1970 through 1978. How long these increases will continue is unknown. In 1982, approximately 1,900 surgeons hold membership in the 18 regional and national vascular societies. How many of these surgeons actively practice vascular surgery is not known. How many nonvascular society surgeons perform arterial reconstructive procedures is also unknown. Currently, approximately 57 fellows are graduated yearly from 42 training programs in vascular surgery. How these figures will change or how they should change in the future has not been defined. Uncertainties of existing vascular manpower data make it impossible to predict future needs, and past forecast attempts must be regarded with skepticism. Clearly, an accurate date base is necessary for rational planning. Therefore, it is suggested that established vascular organizations assume responsibility to obtain such information so that future manpower requirements may be identified.
Forecasting↗
Secondary aortoenteric fistula. A 20 year experience.
During a 20 year period at the Johns Hopkins Medical Institutions, 17 patients were operated on for secondary aortoenteric fistula. The interval from initial operation to the onset of symptoms varied greatly and averaged 2.8 years. Symptoms included not only gastrointestinal bleeding but also sepsis and abdominal or back pain. Associated advanced cardiovascular disease was common. Helpful preoperative diagnostic studies included esophagogastroduodenoscopy, aortography, barium contrast gastrointestinal series and groin sinography. However, a high index of suspicion was the most important element of diagnosis. Overall operative mortality was high (47 percent). All six patients with a graft left in the retroperitoneum had an unsatisfactory result (four instances of recurrent aortoenteric fistula). Successful repair was accomplished only in those patients undergoing graft excision and axillofemoral bypass.
Aged↗
The "in vitro skin test": a reliable and repeatable assay of immune competence in the surgical patient.
In vitro blast transformation of human peripheral lymphocytes was tested using standard skin test antigens, the mitogens PHA and Con A, and the mixed lymphocytes reaction. The study group included 15 patients with multiple trauma, 40 with major burns, six following cholecystectomies, six following aortic reconstruction, and 30 normal volunteer controls. Repeated skin testing may sensitive patients to candida and streptokinase-streptodornase (SKSD), and desensitize them to mumps antigen. Blast transformation in response to PPD did not correlate with the clinical status of the patients; similarly, blast transformation in response to stimulation by the mitogens PHA and Con A could not reliably predict the occurrence of septic complications. Reactivity in response to stimulation by the soluble antigens SKSD and mumps and in the one-way mixed lymphocyte reaction accurately predicted the clinical course of patients. This method of "in vitro skin testing" is a reliable and repeatable method of monitoring the immunologic status of patients whose illness or injury requires longitudinal study.
Antigens↗
Aorta-left renal vein fistula: hemodynamic monitoring and timing of operation.
The spontaneous rupture of an abdominal aortic aneurysm into an adjacent major venous structure is an unusual occurrence. A case of an aorta-left renal vein fistula is presented, and seven previously reported cases are reviewed. Hemodynamic monitoring as an integral part of patient care is discussed, with emphasis on the optimal timing of operative intervention.
Aged↗
Morbid implications of above-knee amputations. Report of a series and review of the literature.
In a retrospective review of 100 consecutive patients requiring above-knee amputation for arterial occlusive disease, the operative mortality was 15%. An additional 26% mortality occurred during a two-year follow-up period. Principal causes of death were sepsis in 54%, heart disease in 16%, and stroke in 11%. The poor prognosis of patients requiring amputation was related to progression of systemic diseases and to generalized debility among these patients.
Aged↗
Use of Doppler pressure measurements in predicting success in amputation of the leg.
Fifty-five patients underwent amputation of the leg. Fifty-eight percent of the amputations were above-knee and 32 percent below-knee. Preoperative Doppler ankle blood pressure measurements and ankle/brachial ratios were compared and correlated with wound healing in patients with below-knee amputation. Statistical analysis documented that such measurements were significant in predicting wound healing. If blood pressure greater than 55 mm Hg at the knee, greater than 70 mm Hg at the incision site or greater than 70 mm Hg at the ankle or an ankle/brachial ratio of at least 0.3 is documented, satisfactory healing will follow amputation.
Aged↗
Inhibition of renin secretion by HCl is related to chloride in both dog and rat.
To determine if inhibition of renin release by HCl is related to acidosis or to Cl-, the effects of peripheral venous infusions of HCl and H2SO4 on plasma renin activity (PRA) were compared in the dog and the rat. In NaCl-deprived, pentobarbital-anesthetized dogs, either 0.15 M HCl (n = 10) or 0.075 M H2SO4 (n = 7) was infused for 60 min. In 5 of the 10 HCl-infused dogs (group A), urine Cl- excretion increased (P less than 0.01) during HCl infusion. In the remaining five dogs (group B), Cl- excretion did not increase. Cl- excretion also did not increase during H2SO4 infusion. Comparable acidosis was produced in all three groups. PRA decreased (P less than 0.01) in response to HCl in group A but did not change (P greater than 0.8) in group B HCl-infused dogs or in H2SO4-infused dogs. In NaCl-deprived, anesthetized rats, PRA was suppressed (P less than 0.05) by HCl (from 40.6 +/- 9.4 to 27.4 +/- 5.3 ng . ml-1 . h-1 (SE)) but not H2SO4 (from 37.1 +/- 4.2 to 37.0 +/- 6.3 ng . ml-1 . h-1), despite comparable acidosis. Cl- excretion increased only in HCl-infused rats. In conclusion, inhibition of PRA by acute infusion of HCl is specifically related to Cl-.
Animals↗
Letters of William Halsted and René Leriche: "Our friendship seems so deep".
The friendship of William Halsted and René Leriche is little appreciated in the annals of surgery. Although Halsted was Leriche's senior by almost 30 years, they enjoyed a relationship on both professional and surprisingly personal levels. Halsted's sincere concern for his younger French colleague was manifested by a constant fostering of Leriche's surgical research and creative ideas. Leriche was to become a life-long admirer of Halsted's surgical philosophies. He often stated that a 3-day visit with Halsted in 1913 persuaded him to stop considering surgery as a purely clinical and technical subject. During their 10-year relationship, extensive correspondence was maintained. This article will explore their friendship through analysis of their personal letters, recently found in the archives of the Johns Hopkins Medical Institutions. Written in French, they remained undisturbed for 65 years. Their present translation into English represents the first time they have been published. Vascular surgery was the major topic of discussion. Included among the many topics are surgical management of aneurysmal disease, utilization of sympathectomy, and investigations into physiologic effects of arterial ligation. In addition, many aspects of the savagery of World War I, as encountered by Leriche at the French front, and Halsted's views on various events of the conflict, are chronicled. The letters reveal a deep and abiding association between the two men which is of interest because Halsted shared his nonsurgical life with very few younger men. Their insight into specific areas of experimental surgery and ideas about various medical problems and other medical personalities are recounted.
France↗
Continuous heparin anticoagulation in patients with arteriosclerosis and arterial emboli.
Management of arterial emboli occurring in patients having generalized arteriosclerosis presents a therapeutic challenge to the vascular surgeon. Adequate cardiac function must be vigorously supported. Perioperative metabolic alterations must be recognized and corrected. Continuous anticoagulation with heparin sodium appears indicated among such patients with coexisting peripheral arterial occlusive disease, stasis, poor collateral flow and areas of intimal damage secondary to operative trauma. Rarity of wound complications, less than 5 per cent, may be attributed to meticulous operative technique and use of continuous infusion method for the administration of heparin. Improved patient survival and limb salvage rates may be attributed, in part, to continuing heparin therapy in the postoperative period and appears justified among those with arteriosclerosis.
Adult↗
Chylous ascites following abdominal aortic aneurysmectomy. Management with total parenteral hyperalimentation.
Chylous ascites may follow operative injury to retroperitoneal lymphatics. When possible, early reoperation has been advised. This report describes a patient with chylous ascites following emergency abdominal aortic aneurysmectomy. Because the patient was not a candidate for reoperation, total parenteral hyperalimentation was employed in management. This approach resulted in a successful outcome.
Aged↗
Effects of furosemide on renal venous plasma renin activity.
A control study comparing plasma renin activity (PRA) in the renal vein and the inferior vena cava was performed in 50 hypertensive patients before and after furosemide stimulation. In unilateral renal arterial stenosis, furosemide was found to stimulate secretion by the normal kidney more than by the ischemic kidney. When a renal venin PRA ratio of 1.5 or higher was used for lateralization, rates of 30% false-negatives and 60% false-positive resulted. Acute stimulation of renin by furosemide does not increase the predictive value of renal venous renin measurements and may actually result in a higher percentage of false-negatives.
False Negative Reactions↗
Evaluation of a new method for treating segmental renal disease.
Experimental segmental renal artery embolization was performed to evaluate the feasibility of therapeutic segmental renal embolization. In group 1, a two kidney dog model, segmental embolization of the right kidney was performed in ten dogs using Gelfoam, Silastic elastomer and barium sulfate. In group 2, a one kidney dog model, segmental embolization of left kidney was performed using Gelfoam and Silastic elastomer. In the remaining three dogs of group 2, embolization was not done for control. Sequential blood pressure measurements, plasma renin activities and renal arteriograms were obtained. Three dogs in group 2 died following unintentional complete renal embolization. Seventeen of the 18 dogs of the entire study remained normotensive after embolization. One dog had persistent hypertension develop which was controlled by a second, total renal embolization. The results suggest that therapeutic segmental renal embolization is a feasible method for treating segmental renal disease.
Aneurysm↗
Primary aortoduodenal fistula: extra-anatomic vascular reconstruction not required for successful management.
Eleven patients reported in the literature and three patients presented herein have survived treatment of primary aortoduodenal fistula by standard aortic reconstruction with prosthesis placement and duodenal repair. Follow-up of these patients documents that 93% (13 of 14) have had no graft-related complications. Standard aortic reconstruction appears to be justified in the treatment of primary aortoduodenal fistula.
Aged↗
Incidence of ischemic colitis following abdominal aortic reconstruction.
The incidence of ischemic colitis following abdominal aortic reconstruction was determined by postoperative colonoscopy during a three year period. The over-all incidence of colitis was 11 of 163 patients who underwent elective or urgent reconstruction of the abdominal aorta for aneurysmal and occlusive diseases. The incidence of ischemic colitis for patients who survived resection of ruptured abdominal aortic aneurysms was higher, although the colonoscopy rate was lower. The incidence might have been even higher if all patients surviving resection of ruptured abdominal aneurysms had undergone colonoscopy.
Aorta, Abdominal↗