Biomedical subjects
Publications and source records attributed to C B Ernst.
We describe a technique for removal of a thrombotic plug from an occluded aortofemoral bypass limb that only requires operative exposure of the involved graft limb and that utilizes a balloon-tipped catheter and a Cannon endarterectomy loop. This method assures pulsatile inflow and avoids extended reconstructive procedures.
Six patients who had hepatic duct lesions, five who had strictures, and one who had a right hepatic duct transection underwent repair by sutureless mucosal graft hepaticojejunostomy. All patients had initial improvement, and five have maintained excellent biliary-intestinal continuity after an average 25-month follow-up. In one patient, recurrent symptoms developed and she died of cholangiocarcinoma. This technique is simple and fulfills the criteria for successful high hepatic duct reconstruction. The promising early results in these patients suggest that this procedure may provide a superior approach to this difficult problem.
Management of popliteal arterial injuries remains a challenging problem. Early recognition and treatment, arteriography, fasciotomy, and repair of concomitant popliteal venous injuries are modalities that have contributed to improved results. Systemic heparin sodium anticoagulation and selected extra-anatomic vein graft bypass of the popliteal area are two additional measures that have contributed to a 91% success rate in treatment of popliteal arterial injuries and five of six blunt injuries were treated successfully in this time period. A limb salvage rate of only 46% was attained in the previous five-year period. There were no operative deaths. No complications attributable to systemic anticoagulation or extra-anatomic bypass graft occurred. These adjuncts are recommended to all who manage vascular injuries.
Explore the source record for details and available documents.
Fifty-two patients undergoing nonemergent abdominal aortic aneurysmectomy were prospectively studied to determine when the inferior mesenteric artery (IMA) could be ligated without subsequent development of ischemic colitis. Cannulation of the severed distal IMA for blood pressure measurement (IMA stump pressure) before and after aortic reconstruction was attempted in all and possible in 39 individuals. In 13 the IMA was thrombosed precluding pressure measurement. Prereconstruction and postreconstruction mean IMA stump and systemic arterial blood pressure measurements were computed and mean IMA/systemic pressure ratios were calculated. All patients underwent postoperative colonoscopy. One patient developed postoperative ischemic colitis. Her postreconstruction ratio was 0.37 and her postreconstruction mean IMA blood pressure was 33 mmHg, the only individual with a ratio and pressure less than 0.40 and 40 mmHg, respectively. Internal iliac arterial pulsations could not be restored in two patients. Although postresection indices were less than preresection indices in both, postresection indices were greater than 0.40 and 40 mmHg. In this study, if the IMA was thrombosed or if postresection pressures and ratios measured greater than 40 mmHg and 0.40 respectively, ischemic colitis did not develop following abdominal aortic aneurysmectomy. This simple test may prove useful in identifying patients at risk for developing postoperative ischemic colitis or if IMA revascularization is required.
The present report is a retrospective review of 23 patients admitted to the University of Kentucky Medical Center during 1975 and 1976, selected because they had sustained renal trauma as ascertained by hematuria, intravenous pyelography (IVP), or operative intervention. The value of IVP was determined by the patients' eventual hospital course. Of five patients with penetrating injuries, all had hematuria and an intravenous pyelogram on admission. One of these patients did not require an operation. Among the 18 patients with blunt abdominal trauma, six of the 14 patients who had hematuria and an IVP on admission were spared operation. Four patients did not have hematuria, but all four had a renal lesion. Two of these patients required an operation: one for inspection of a traumatic left nephrectomy; the other for bilateral renal artery occlusion, successfully repaired after 16 hours. Whenever feasible all patients sustaining abdominal trauma should have an IVP regardless of whether or not hematuria is present.
Aortoduodenal fistula following renal revascularization is a rare and frequently lethal event. This report records the first known survivor of aortoenteric fistula following renal revascularization alone. Four previously reported cases followed secondary operations such as nephrectomy or autotransplantation necessitated by thrombosis of aortorenal bypass grafts. Synthetic prosthetic material led to the fistula in all instances. Infection occurred in only one. This complication may be prevented by the use of autogenous tissue grafts, monofilament suture, and interposition of viable tissue between anastomosis and gastrointestinal tract. When massive upper gastrointestinal bleeding occurs following aortic-prosthetic vascular procedures and standard studies prove nondiagnostic, prompt celiotomy is recommended.
A case of blunt abdominal trauma causing injury to the superior mesenteric artery with successful management is presented. The role of aortography in diagnosis is discussed. The patient, with multiple chest injuries sustained in an automobile accident, has recovered following surgical repair of a laceration of the SMA, treatment for respiratory distress, and spontaneous cessation of rectal diverticular bleeding.
Explore the source record for details and available documents.
Eighty patients undergoing abdominal aortic aneurysmectomy were studied to identify sources of potential graft sepsis. All but one patient received perioperative antibiotics. Samples obtained from aneurysm contents in 78 and bowel bag fluid in 45 were cultured for organisms. Twelve of 78 (15%) aneurysm cultures and five of 45 (11%) intestinal bag cultures yielded bacterial growth. Sixteen patients had positive cultures from either source and one from both, an overall incidence of 20%. Forty-four patients had asymptomatic aneurysms, 23 had symptomatic aneurysms, and 13 had ruptured aneurysms. A significantly greater frequency of bacterial growth occurred from ruptured than from non-ruptured aneurysms (p less than 0.05). Two patients (2.5%) developed graft sepsis. Comparing survivors followed a minimum of 6 months in the positive and negative culture groups, the late graft sepsis rate was 10% and 2% respectively. Two heretofore not widely recognized sources for late graft sepsis were identified: aneurysmal contents and intestinal bag fluid. Reasons for difference between potential graft sepsis incidence of 20% and actual incidence of 2.5% may include antibiotic therapy, host resistance, or other unidentified variables. Routine culture of aneurysm and intestinal bag contents is recommended. Upon identifying bacterial growth from such sources, organism-specific antibiotics are required.
Plasma renin reactivity (PRR) is the in vitro rate of angiotensin generation after addition of exogenous renin to plasma. The purpose of the present study is to compare measurements of PRR in venous effluent from the involved and uninvolved kidneys in both experimental and clinical renovascular hypertension. A two-kidney model of experimental hypertension was created by placing an ameroid resin constrictor around one renal artery in each of seven dogs. Plasma renin activity (PRA) in venous plasma from the involved kidney increased (p less than 0.001); comparing PRA in venous effluent from the stenotic and nonstenotic kidneys, the PRA ratio also increased ( p less than 0.005). Renal venous PRR did not change on either side after occlusion of the renal artery (p greater than 0.1), and the renal venous PRR ratio did not differ from the mean control ratio of 1.0 +/- 1 SE (p greater than 0.1). Similarly, in 9 patients with renovascular hypertension, mean PRR in venous plasma from the two kidneys did not differ (p greater than 0.8). These results suggest that measurement of renal venous PRR is not helpful in confirming a diagnosis of renovascular hypertension.
The deep perineal laceration indicates major pelvic injury, especially when associated with pelvic fracture. Survival requires hemostasis, which must be established early by whatever means necessary, including emergency hemipelvectomy if required. Twelve patients with deep perineal laceration are reviewed. Seven patients died. Early deaths were caused by uncontrolled hemorrhage. Late deaths were related to infection in the pelvis. Prompt totally diverting colostomy with irrigation and disimpaction of the defunctionalized rectum and primary repair of urethral injuries are essentials in avoiding septic complications. A technique of rapid totally diverting colostomy that facilitates distal washouts without wound contamination is described.
Two of 70 patients treated for a minimum of six months after renal transplantation developed main arterial stenosis to the allograft. Both underwent transplant revascularization and had follow-up at least six months to document lasting benefit. Amelioration of hypertension and improvement of transplant function proved statistically significant. Collateral vessels were not identified on pre-revascularization arteriographic studies. It is suggested that loss of the potential to develop protective collateral channels to transplanted kidneys mandates aggressive evaluation when hypertension and deteriorating renal function occur in the late follow-up period after renal transplantation. In such instances, arteriography and renin determinations may identify salvagable renal allografts, obviating necessity of subsequent retransplantation.
Renovascular hypertension is the most prevalent form of surgically remediable hypertension. With appropriate selection of operative candidates, a high rate of cure or improvement may be anticipated. Favorable results justify revascularization in hypertensive patients with focal arteriosclerotic renal artery disease. The absence of advanced arteriosclerosis provides the most valid basis for predicting long-term survival following revascularization. Patients with clinically demonstrable diffuse arteriosclerotic disease are preferably treated medically; we consider them candidates for surgery only if drug therapy cannot control blood pressure. Renal revascularization does not appear to alter the inexorable progression of concomitant generalized arteriosclerosis. Revascularization rather than nephrectomy is the primary surgical therapy for renal artery stenosis in properly selected patients.
Lateralizing renal venous plasma renin activity (RVPRA) ratios offer a predictive index of success of revascularization procedures for renovascular hypertension. Reliance upon nonlateralizing renin ratios to reject functional significance of renal arterial stenosis may deny some patients benefit of successful operations. To test the hypothesis that RVPRA ratios revert toward unity coincident with development of collateral circulation to an ischemic kidney, the relationship between development of collaterals and RVPRA was studied in nine dogs after gradual unilateral renal arterial occlusion with a constrictor. Arterial blood pressure and arteriographic measurement of collateral channels, RVPRA, and renal surface index (RSI) were measured before and during the 10-week interval after constrictor placement. RSI measurements, documenting changes in volume of the renal parenchyma, reflected changes in renal blood flow. Arterial pressure increased in each animal (p less than 0.0009). The number of collateral vessels to the constricted kidney increased with time (p less than 0.01). During the 4 weeks following placement of the constrictors, RSI ratios (constricted: nonconstricted) decreased (p less than 0.003) and RVPRA ratios (constricted: nonconstricted) increased (p less than 0.005). Subsequently, coincident with development of collateral vessels, RSI ratios increased and RVPRA ratios decreased toward control values. These data suggest that absence of lateralizing RVPRA ratios in the presence of collateral vessels does not mean lack of functional significance of stenotic renal arterial lesions.
With few exceptions, the incidence of left colon ischemia following abdominal aortic reconstruction has been reported to be one to 2 percent. All reports of such ischemic events are retrospective analyses of clinically manifest or autopsy. Fifty patients were studied prospectively to determine more accurately the incidence of this complication. Aortic reconstruction was performed in 23 patients for occlusive disease (OD) and in 27 for aneurysm disease (AD). No emergency operations were performed. All patients underwent colonoscopy within 4 days of operation. Three instances of colon ischemia were noted, an incidence of 6 percent (OD 4.3 percent, AD 7.4 percent). Each patient recovered uneventfully. Two patients had diarrhea, but only after colon ischemia was recognized. Arteriographic opacification of the inferior mesenteric artery by the superior mesenteric artery collateral (meandering mesenteric artery) was documented in 35 percent of patients with OD and in 27 percent of patients with AD. Colon ischemia did not develop when this collateral was identified. The inferior mesenteric artery was patent at the aorta in all who developed colon ischema. Although clinically significant colitis following aortic reconstruction is rare, colonoscopy after operation may prove to be valuable for early recognition of ischemic changes before clinical manifestations preclude effective management.
The fifth successfully treated pseudoaneurysm of the visceral branch segment of abdominal aorta emphasizes individualized management of such complex lesions. Staged operative management of a supraceliac pseudoaneurysm by preliminary axillary-femoral bypass minimized potential intraoperative hazards. Visceral protection during aortic occlusion was simplified by axillary-femoral perfusion.
Differential aorto-femoral pressure gradient is not required to assure axillary-femoral bypass graft patency for a brief period of time. One-hundred twenty-three days elapsed from axillary-femoral graft construction to elective removal of the functioning conduit in an individual without aorto-femoral pressure differential. During this time, reversible "disuse atrophy" of the ipsilateral ileo-femoral arterial system occurred. It is suggested that phasic differences in pulse wave propagation between the aorto-iliac-femoral and axillary-femoral circuits maintained graft patency and accompanying decreased flow volume in the ileo-femoral arterial circuit resulted in "disuse atrophy."