Search PubMed⌕ Search

Biomedical subjects

D F Fisher

Publications and source records attributed to D F Fisher.

At least 19 recordsLinked to original sources
PubMed1991

Limb salvage versus traumatic amputation. A decision based on a seven-part predictive index.

In severe traumatic injuries to the lower extremity, it is often a difficult decision to attempt heroic efforts aimed at limb salvage or to amputate primarily. To answer this question, the authors performed a 5-year review of 70 limbs in 67 patients. Patients were identified as presenting with major lower extremity trauma and an associated arterial injury. Nineteen (27%) of the 70 limbs were amputated. Limb salvage was not related to the presence or absence of shock and order of repair (orthopedic or vascular). No statistical difference was noted between the time of injury to operative repair in either the amputated or limb salvage group. Limb salvage was related to warm ischemia time and the quantitative degree of arterial, nerve, bone, muscle, skin, and venous injury. A limb salvage index (LSI) was formulated based on the degree of injury to these systems. All 51 patients with an LSI score of less than 6 had successful limb salvage (p less than 0.001). All 19 patients with an LSI score of 6 or greater had amputations (p less than 0.001). Although statistics cannot replace clinical judgment, this index can be a valuable objective tool in the evaluation of the patient with a severely traumatized extremity.

Adolescent↗
PubMed1990

Hip disarticulation. An 11-year experience.

Thirty-eight hip disarticulations performed in 34 patients were retrospectively reviewed. The indications were ischemia secondary to atherosclerosis in 17 cases, femoral osteomyelitis in 10, and trauma in 11. Patient ages ranged from 20 to 95 years. The mortality was 60% in patients with ischemia with preoperative infection, 20% in patients with ischemia without preoperative infection, 22% in patients with femoral osteomyelitis, 100% in patients with trauma with preoperative infection, and 33% in patients with trauma without preoperative infection. The overall mortality was 44%. Postoperative wound infections were frequent (63%) and had poor correlation with the presence of a preoperative wound infection. No patient was able to use a prosthesis after hip disarticulation, but most were independent in wheelchairs.

Activities of Daily Living↗
PubMed1990

The Syme amputation: success in elderly diabetic patients with palpable ankle pulses.

The Syme amputation is an old operation that has been used during this century primarily as a means of treating traumatic injuries to the forefoot in military patients. In 1984 we made a deliberate attempt to perform the operation in a highly selective group of dysvascular patients with forefoot necrosis who happened to have a palpable posterior tibial pulse. We reviewed the charts of 26 patients who underwent a one-stage (3 patients) or two-stage (23 patients) Syme amputation. The mean age was 60 years, (range 32 to 74 years). There were 17 insulin-dependent diabetic patients, and 3 diet-controlled diabetic patients. Twenty-two patients (85%) had a palpable posterior tibial pulse before surgery. Fourteen patients (54%) underwent a preliminary Ray (4) or transmetatarsal (10) amputation to rid the forefoot of an active infection. Overall, 20 patients (77%) had successful Syme amputations. Nineteen of 22 patients (85%) with a palpable posterior tibial pulse had a successful amputation in contrast to one out of four patients (25%) who did not have a palpable pulse before surgery (p = 0.04). The mean follow-up of all patients was 23 months. The durability of the operation was demonstrated in finding that only one patient in 20 initially successful Syme amputations required revision to the below-knee level. The two-stage Syme amputation can be a very gratifying operation with success rates approaching 85%, even if offered to elderly diabetic patients. The single most important feature for success is to limit the operation to those patients with a palpable posterior tibial pulse before operation.

Amputation, Surgical↗
PubMed1989

Results of in-situ saphenous vein bypass to the foot.

To determine the efficacy of extending vascular reconstruction to the pedal vessels, the records of 115 in-situ saphenous vein bypasses to the infragenicular vessels were examined. Ninety-four percent were performed for limb-threatening ischemia and 6 percent for claudication. Ninety-one bypasses were to tibial vessels in the calf (Group 1), whereas severe disease of the tibial vessels in the calf necessitated bypass to arteries at the ankle and beyond in 24 (Group 2). Life-table analysis was used to calculate limb salvage, graft patency, and functional status for Group 1 and Group 2 36 months postoperatively; there were no statistical differences between groups with regard to these variables (p = 0.38). Diabetes had no impact on the success of reconstruction, and preoperative noninvasive testing was not predictive of graft failure in either group. Significantly, limb salvage closely paralleled graft patency and functional status, illustrating the severe disease in all patients. Patients with severe tibial-peroneal atherosclerosis may benefit from bypass grafting to the pedal arteries with a success rate equal to those done to more proximal sites.

Adult↗
PubMed1989

Efficacy of prophylactic antibiotics in vascular surgery: an arterial wall microbiologic and pharmacokinetic perspective.

This prospective study examined microbiologic features of arterial tissue and pharmacokinetics and bioactivity of cefamandole and cefazolin in patients undergoing elective primary prosthetic aortoiliofemoral/infrainguinal reconstruction. Double-blind, randomized, perioperative prophylaxis (1 gm intravenously every 6 hours for nine doses) with cefamandole or cefazolin was administered to 47 patients. Specimens of blood serum, subcutaneous fat, thrombus, atheroma, and arterial wall were obtained for culture and minimal inhibitory concentration and drug level analysis by high-pressure liquid chromatography. The serum half-life (hr +/- SEM) was 1.43 +/- 0.36 for cefamandole and 2.22 +/- 0.40 for cefazolin. Over the first 2 hours of surgery and for all time intervals combined, the serum concentration of cefazolin was significantly higher (p less than 0.025) than cefamandole. Irrespective of sampling time, the tissue concentration of cefazolin was significantly greater (p less than 0.005) than cefamandole. Positive arterial tissue cultures were obtained in 12 of 29 patients (41.4%) from 23 of 116 (19.8%) arterial tissue specimens. Coagulase-negative Staphylococcus was the predominant isolate, 64 of 93 (68.8%). Twenty-five of the 51 coagulase-negative staphylocci tested (49%) were slime-producers. During surgery, the arterial tissue concentration of cefamandole fell below the geometric mean minimal inhibitory concentration against all organisms combined, and against S. aureus (with the highest minimal inhibitory concentration of the prevalent isolates), significantly more often than the concentration of cefazolin. The data show that a significant number of primary elective aortoiliofemoral/infrainguinal reconstructions are associated with positive arterial tissue cultures, which represent a potential source of graft infection.(ABSTRACT TRUNCATED AT 250 WORDS)

Arteries↗
PubMed1989

Vein patch versus primary closure for carotid endarterectomy. A randomized prospective study in a selected group of patients.

During a 4-year period, 136 patients undergoing 152 carotid endarterectomies consented to be randomized to primary or saphenous vein patch closure of the arteriotomy. At operation, before randomization, careful assessment of arterial dimensions and anatomy was made. Patients who had an internal carotid artery (ICA) diameter less than 5 mm, arteriotomy extending more than 3 cm beyond the origin of the ICA, or tortuous or kinked ICAs were not randomized; they received obligatory vein patch closure (necessary in 20% cases). All patients were followed up every 3 months for 1 year and every 6 months thereafter with duplex scanning, ocular pneumoplethysmography, and neurologic assessment. The incidence of atherosclerotic risk factors was equal in the groups and all except one of the patients were male. Perioperative morbidity was not significantly different among those having primary closure (n = 60), saphenous vein patch closure (n = 62), and obligatory vein patch closure (n = 30). Operative time among patients having primary closure (122 +/- 4 minutes) was significantly less (p less than 0.001) than among those having saphenous vein patch closure (150 +/- 3 minutes). Three perioperative strokes were evenly distributed among the groups (2% for all procedures); no deaths and no acute postoperative occlusions occurred. Recurrent disease occurred in 12.9% of patients having saphenous vein patch closure compared with its occurrence in 1.7% of those having primary closure (p less than 0.05). However, most recurrences were moderate stenoses (25% to 50% diameter reduction), all were smooth-surfaced, and none required a second operation. All except one of the recurrences among those patients with saphenous vein patch closure were in the bulb and the origin of the ICA; two had evidence of regression. This finding suggested that thrombus layering in the dilated part of the saphenous vein patch reconstruction was the cause. This study demonstrates that in men with carotid arteries of predetermined minimal dimensions undergoing carotid endarterectomy routine saphenous vein patch closure does not produce superior results, is associated with a higher incidence of early recurrence, and increases operative time. In selected patients with anatomic risk factors for recurrent disease or acute postoperative occlusion, saphenous vein patch closure is appropriate.

Carotid Arteries↗
PubMed1988

Emergency operation in patients with symptomatic abdominal aortic aneurysms.

To assess the need for routine preoperative computerized tomography scanning to discern patients with rupture among those presenting with acutely symptomatic abdominal aortic aneurysms, a retrospective review was performed. During a 5-year period, all patients presenting with symptomatic aneurysm underwent emergency operation without preoperative computerized tomography. The mortality rate was not significantly different among patients with symptomatic, intact aneurysms undergoing emergency operation (3 percent) and those without symptoms having elective operation (5 percent). The mortality rate of patients with ruptured aneurysms was 68 percent. We concluded that the addition of preoperative computerized tomography to the clinical evaluation would not have improved these results. Furthermore, since it is expensive and delays emergency operation in patients with ruptured aneurysms, computerized tomography seems rarely indicated in symptomatic patients with obvious aneurysms.

Aged↗
PubMed1988

Postoperative follow-up of renal artery reconstruction with duplex ultrasound.

We evaluated the accuracy of duplex ultrasound in the postoperative follow-up of patients after renal revascularization. Between May 1976 and December 1987, 125 adult patients underwent 153 renal reconstructive procedures for renovascular occlusive disease. Technically satisfactory duplex scans were obtained in 49 of 59 patients (84%) at an average follow-up of 32 months (maximum 11 years). Arteriograms were available for correlation in 51 arteries or bypasses in 36 patients. Duplex scans accurately classified 8 of 10 stenotic (greater than 60% diameter reduction) or occluded vessels and 36 of 41 patent vessels. The overall diagnostic accuracy was 86%, sensitivity was 80%, and specificity was 87%. We confirmed previous reports that decreased diastolic flow correlated with advanced renal parenchymal dysfunction. We conclude that a normal duplex scan makes it highly unlikely that arteriography will reveal significant recurrent disease. An abnormal duplex scan, particularly in the presence of hypertension or deteriorating renal function, warrants arteriography.

Angiography↗
PubMed1988

One-stage versus two-stage amputation for wet gangrene of the lower extremity: a randomized study.

Although the two-stage amputation technique entails an additional operation, several authors have advocated this approach to deal with wet gangrene because it allows primary wound closure with a reduced chance of wound infection. To examine this issue, 47 patients with necrotizing wet gangrene of the foot were randomized prospectively to receive either a one-stage amputation (definitive below- or above-knee amputation with delayed secondary skin closure in 3 to 5 days) or a two-stage amputation (open ankle guillotine amputation followed by definitive, closed below- or above-knee amputation). Antibiotic coverage was standardized with clindamycin and gentamicin used in all patients. Preoperative blood cultures and intraoperative foot cultures were obtained, as well as cultures from the deep muscle and lymphatic area along the saphenous vein to determine the presence of bacteria at the level of initial amputation. Twenty-four patients (11 diabetic and 13 nondiabetic) were randomized to the one-stage procedure. Twenty-three patients (14 diabetic and nine nondiabetic) were randomized to the two-stage procedure. Five of 24 patients in the one-stage group (21%) had positive muscle cultures vs 10 of 23 patients in the two-stage group (43%). Two of 24 patients in the one-stage group (8%) had positive lymphatic cultures vs 7 of 23 patients in the two-stage group (30%). Five of 24 patients in the one-stage group (21%) had wound complications attributable to the amputation technique vs none of 23 patients in the two-stage group (p = 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1987

Collateral mesenteric circulation.

The origins of historical terms, such as "Arc of Riolan" and "marginal artery of Drummond" are traced herein with emphasis on the inherent confusion caused when these terms are used. Basic mesenteric anatomy is briefly mentioned and pathologic anatomy with its altered direction of blood flow induced by atherosclerosis is stressed. The significance of the meandering mesenteric artery as the main collateral vessel between the superior and inferior mesenteric artery is emphasized along with preoperative and intraoperative ways to ascertain whether or not the origin of this latter vessel can be safely ligated. Specific operations, such as abdominal aortic aneurysmorrhaphy and sigmoid colectomy, which can potentially interfere with blood flow in the meandering mesenteric artery, are discussed in an attempt to prevent postoperative necrosis of any portion of the intestine that may have deficient mesenteric blood flow.

Blood Vessel Prosthesis↗
PubMed1986

Is external carotid endarterectomy a durable procedure?

Thirteen patients with internal carotid occlusion underwent 14 primary external carotid revascularization procedures over a 31 month period. Ten patients had obliteration of their internal carotid stump combined with patch angioplasty of the external carotid artery, and 3 had vein bypasses from the common carotid artery to the external carotid artery. Eleven patients were symptomatic with either amaurosis fugax or hemispheric transient ischemic attacks. Two patients were asymptomatic. All patients had serial carotid noninvasive tests (B-mode ultrasonography, spectral analysis, and oculoplethysmography). The mean follow-up was 22 months. Recurrent amaurosis fugax secondary to recurrent stenoses developed in two patients. These were correctly predicted by B-mode imaging and altered flow characteristics on spectral analysis. Both patients were successfully treated with reoperative procedures to prevent failure of the primary reconstruction. External carotid revascularization is a safe and durable procedure, but careful periodic follow-up is necessary to detect stenoses developing at or remote from the initial operative site. Carotid noninvasive tests appear to be helpful in detecting recurrent disease. Carotid revascularization is superior to other forms of therapy in patients who have development of neurologic symptoms ipsilateral to a chronically occluded internal carotid artery.

Aged↗
PubMed1986

Morphogenesis and clinicopathologic characteristics of recurrent carotid disease.

The histopathologic characteristics of primary plaques and recurrent carotid disease were studied in 32 patients. These data were related to symptoms, recurrence interval (6 to 176 months), arteriographic anatomy, and in situ operative findings. A striking predilection was noted for recurrent lesions to be located in the internal carotid artery near the origin, but still within the confines, of the original endarterectomy site and suture line. Although recurrence was frequently associated with a long primary arteriotomy, evidence of technical faults or periarterial fibrosis was rare. Early recurrent lesions (recurrence interval less than 36 months, n = 13) had significantly more smooth muscle cells and proteoglycans (p less than 0.001) than late recurrent lesions (recurrence interval greater than 36 months, n = 19). As previously reported, features of atherosclerosis (abundant collagen, calcium deposits, and foam cells) were more pronounced in late recurrences (p less than 0.001). However, the histopathologic differentiation between early and late recurrent carotid disease was indistinct. A continuum was noted whereby characteristics of late recurrent lesions increased in proportion to recurrence interval. All recurrent lesions were easily distinguished from primary plaques in that recurrences had a less orderly arrangement of all elements and lacked the classic topographic features of advanced atherosclerosis. An important feature that differentiated primary and recurrent lesions was the presence of surface and intraplaque thrombus in 90% of recurrent lesions (p less than 0.001). In early recurrent disease, luminal surface thrombus was striking; this was frequently platelet-rich and showed organization devoid of neovascularity. Intraplaque thrombus was more common in late recurrent disease, consisted almost entirely of fibrin, and was often contiguous with luminal surface thrombus. No discernible relationships were noted between thrombus associated with recurrent lesions and the presence or absence of symptoms, treatment with antiplatelet agents, and hypertension. This finding suggests that thrombus was a continuous and intrinsic component of recurrent disease rather than a secondary, complicating feature. Recurrent carotid disease is a progressive lesion that stems from ongoing thrombogenesis occurring at the endarterectomy site. Organized thrombus and smooth muscle cell proliferation comprise the bulk of the lesion, which undergoes atherosclerotic change with time.

Aged↗
PubMed1986

Tuberculous aortitis with associated necrosis and perforation: treatment and options.

Tuberculous aortitis is a rare entity and its association with necrosis and perforation is even more unusual. Our pulmonary medicine service originally evaluated an elderly woman with a right pleural effusion and upper lobe infiltrate thought to be tuberculosis. An abdominal CT scan performed at that time showed extensive periaortic adenopathy. Isoniazid and rifampin were started, but both were stopped by the patient after less than 6 months of therapy. The patient later had night sweats, a left pleural effusion, and a tender abdominal mass thought to be a symptomatic aneurysm. At operation, the aorta was necrotic and had an inflammatory mass and perforation on the left side. Infrarenal aortic ligation and resection were performed to control infection. A previously placed axillofemoral graft obviated the need for concomitant revascularization. The patient was treated postoperatively with isoniazid and rifampin until hyperbilirubinemia developed, which necessitated alternate therapy with ethambutol and streptomycin. The patient died one month after operation of a presumed pulmonary embolus.

Aged↗
PubMed1985

Water excretion in preeclampsia: behavior as nephrotic syndrome.

Decreased free water excretion and the development of interstitial edema are recognized characteristics of preeclampsia. However, the pathophysiology of decreased urine excretion in preeclampsia is presently controversial: diminished glomerular filtration, renal arteriolar spasm, elevated plasma vasopressin levels, and plasma volume contraction have been suggested as etiologies. We studied seven pregnant patients with a diagnosis of mild preeclampsia to assess the role of vasopressin, serum protein, and glomerular function in the renal excretion of water. The ability to excrete a water load was significantly and directly correlated with serum albumin (P less than 0.05) and protein (P less than 0.02) concentrations. Neither plasma vasopressin nor creatinine clearance correlated with water excretion. The similarity of preeclampsia and the nephrotic syndrome with regard to the renal excretion of water is discussed.

Anuria↗
PubMed1985

Management of patients with symptomatic extracranial carotid artery disease and incidental intracranial berry aneurysm.

Perioperative fluctuation of blood pressure and the use of anticoagulants during carotid endarterectomy may potentiate lethal aneurysm rupture in patients who have symptomatic extracranial carotid artery occlusive disease with incidental, asymptomatic, intracranial berry aneurysms. Ten patients having this combination are described in the present study. Of five men and five women whose mean age was 63 years, nine had symptomatic carotid bifurcation atherosclerosis, one had internal carotid fibromuscular dysplasia, and all had intracranial berry aneurysms ranging from 2 to 13 mm in diameter (mean diameter 6.6 mm). In seven patients, aneurysms were greater than or equal to 6 mm in diameter. Hypertension was present in seven patients and moderately severe in five. Three of the aneurysms were located in the intracranial internal carotid artery, five in the middle cerebral artery, three in the posterior communicating artery, one in the anterior cerebral artery, and one in the superior cerebellar artery. Twelve carotid reconstructive procedures were performed without morbidity related to aneurysm rupture. These included 10 carotid endarterectomies, one of which was combined with Dacron patch angioplasty and one of which was combined with a simultaneous coronary artery bypass; one carotid artery dilatation for fibromuscular disease; and one reoperative carotid endarterectomy with patch angioplasty. Three patients had correction of hemodynamically significant lesions, two of which were proximal to ipsilateral anterior circulation aneurysms. An intraluminal shunt and heparin anticoagulation therapy were used in all patients. Despite a concerted effort to control blood pressure, the patients' perioperative blood pressures ranged from 60/30 to 240/110 mm Hg. Three patients had subsequent elective clipping of intracranial aneurysms.(ABSTRACT TRUNCATED AT 250 WORDS)

Carotid Arteries↗
PubMed1985

Bright-light amaurosis fugax: an unusual symptom of retinal hypoperfusion corrected by external carotid revascularization.

The eye often serves as an important monitor of carotid artery disease by manifesting visual disturbances before cerebral events. The most typical ocular symptom complex is amaurosis fugax characterized by loss of vision in one eye that occurs suddenly and clears within seconds to minutes. This symptom is a hallmark of carotid artery disease and is usually caused by an embolic event. Although monocular visual disturbance on a hemodynamic basis is a more unusual manifestation of carotid artery disease, significant stenosis in combination with a low-flow state can cause transient, unilateral telescoping of vision. This report describes another visual disturbance associated with carotid artery disease in which unilateral visual loss occurred upon exposure to bright light. We term this syndrome bright-light amaurosis fugax and document successful treatment by external carotid artery revascularization in two patients.

Arteriosclerosis↗