The role of renal revascularization in ischemic nephropathy.
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Angioplasty, Balloon↗
Biomedical subjects
F A Weaver
Publications and source records attributed to F A Weaver.
Candida thrombosis of the innominate vein with septic pulmonary emboli.
Thrombosis of central veins has become more prevalent because of increased use of long-term central venous catheterization. Candida superinfection of the thrombus can occur particularly in patients on long-term antibiotic therapy and on parenteral nutrition. Removal of the catheter, thrombolytic therapy, anticoagulation, and antifungal therapy with amphotericin B will usually eradicate the candidemia and restore venous patency. Occasionally this therapeutic regimen fails. This case report illustrates such a failure in which multiple pulmonary emboli could have caused death. Surgical thrombectomy of the innominate vein effectively removed the source of the Candida sepsis and maintained patency of a major vein. Thrombectomy should be considered as a therapeutic option in septic central vein thrombosis.
Adult↗
Regarding: "Complications of missed arterial injuries".
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Arteries↗
Advances in the treatment of phlegmasia cerulea dolens.
Phlegmasia cerulea dolens (PCD) is an uncommon, severe form of lower extremity deep venous thrombosis characterized by extremity swelling, cyanosis, and pain. Progression of the thrombotic process may result in extremity gangrene, amputation, and death. The relative value of specific therapeutic regimens in the treatment of this disease remains uncertain. Twelve patients, 9 females and 3 males, with PCD were treated during a 10-year period. Eighteen lower extremities were involved. Pre-existing conditions included malignancy (eight), postoperative state (four), diabetes (three), previous deep venous thrombosis (three), and hypercoagulation (two). Venous gangrene was present in four patients. All patients were treated initially with bedrest, fluid resuscitation, extremity elevation, and systemic high-dose heparin therapy. Five patients had complete resolution with this regimen alone. One patient required cessation of heparin therapy due to heparin-induced thrombocytopenia and developed gangrenous toes. Two patients whose condition failed to respond to heparin therapy underwent catheter-based delivery of urokinase with marked clinical improvement. Four patients, two with venous gangrene, died, three of whom had disseminated malignant disease. A significant percentage of patients with PCD will respond to extremity elevation, fluid resuscitation, and aggressive systemic anticoagulation therapy. Thrombolytic therapy selectively administered is beneficial in patients whose disease fails to respond promptly. Venous thrombectomy should be reserved for patients with contraindications to thrombolysis.
Adult↗
Refining the indications for arteriography in penetrating extremity trauma: a prospective analysis.
PURPOSE: Five hundred fourteen consecutive patients with an isolated upper or lower extremity penetrating injury were entered into a prospective study designed to refine the indications for diagnostic arteriography. METHODS: Twenty-two (4%) patients with limb-threatening ischemia who required immediate operation and 23 (4%) who refused arteriography were excluded from subsequent analyses. The remaining 469 patients were classified as being at high, intermediate, or low risk for an arterial injury. RESULTS: Two hundred thirteen patients who were at low risk were observed for 24 hours, discharged, and monitored as outpatients. No delayed complications of an arterial injury developed in any patient in this group. The intermediate-risk group of 151 patients and the high-risk group of 105 patients underwent arteriography. Seventy-seven injuries were identified; 24 were major (limb-threatening) and 53 were minor. Fourteen major injuries required operative repair or transcatheter embolization; the remaining 10 nonocclusive major injuries were observed without sequelae. CONCLUSIONS: By step-down logistic regression only pulse deficit (p < 0.01) and an ankle/brachial or wrist/brachial index less than 1.00 in the injured extremity (p < 0.03) were found to be significant predictors of an arterial injury. The presence of either of these two clinical variables successfully predicted all major arterial injuries. This prospective study supports the proposition that arteriography that is limited only to those patients who have either a pulse deficit or minimum ankle/brachial or wrist/brachial index less than 1.00 successfully detects all significant arterial injuries.
Adolescent↗
Angiotensin II increases glucose utilization during acute hyperinsulinemia via a hemodynamic mechanism.
To determine whether hemodynamic changes can modulate insulin action in vivo, we administered angiotensin II (AII) to normal men under three separate, euglycemic conditions. First, in the presence of physiological hyperinsulinemia (approximately 115 microU/ml), infusion of AII at rates of 2, 10, and 20 ng/min per kg caused significant elevations of blood pressure, whole-body glucose clearance, and plasma insulin concentrations in an AII dose-dependent manner. Second, in the presence of plasma insulin concentrations that stimulate glucose transport maximally (approximately 5,000 microU/ml), AII infusions increased whole-body glucose clearance without enhancing glucose extraction across the leg. Third, in the presence of basal insulin concentrations (approximately 13 microU/ml), AII infusions had no effect on whole-body glucose turnover or leg glucose extraction. Thus, AII enhanced whole-body glucose utilization without directly stimulating glucose transport in a major skeletal muscle bed. To evaluate a possible hemodynamic mechanism for the effects of AII on glucose utilization, we measured blood flow to two areas that differ in their sensitivity to insulin: the kidneys and the leg. We found that AII redistributed blood flow away from the predominantly insulin-independent tissues of the kidney and toward the insulin-sensitive tissues of the leg during both sham and hyperinsulinemic glucose clamps. The redistribution of flow had no effect on whole-body glucose turnover when leg glucose uptake was unstimulated (sham clamps). However, when leg glucose uptake was activated by insulin, the redistribution of flow caused a net increase in whole-body glucose utilization. Our findings indicate that hemodynamic factors can modulate insulin action in vivo. Furthermore, our results suggest that variable activity of the renin-angiotensin system may contribute to inconsistencies in the association between insulin resistance and hypertension.
Adult↗
Safe, compact and portable system for regional chemotherapeutic hyperthermic perfusion procedures.
Perfusion techniques utilizing hyperthermic chemotherapy have been established as a successful modality of therapy for isolated metastatic malignant melanoma. The combination of chemotherapeutic agents (Dactinomycin, thiotepa and Mechlorethamine HCl) given in high doses, not possible systemically, combined with hyperthermia (40-42 degrees C) in an isolated extremity has shown greater tumor regression compared with systemic medication only. Many of the isolated limb perfusion procedures are performed in non-cardiac centers, especially at specialized cancer institutions. This often presents new obstacles for the perfusionist including lack of adequate perfusion equipment and disposables. Other obstacles include unfamiliarity of the operating room staff with the heart-lung machine and inappropriate and/or unsafe handling of the perfusion circuit. In order to overcome these obstacles and enhance safety, portability and effectiveness, the authors have developed an isolated limb perfusion system. The purpose of this study was to compare the parameters of treatment and long term outcomes demonstrated by our system and method, to previously published data. The qualitative comparative analysis was performed between eight treatments with this type of perfusion system and outcome data previously published. It is the authors' conclusion that the portable isolated limb perfusion system achieved all of the required parameters to provide safe and effective treatment for this type of melanoma. No demonstrated variation of the long term clinical results in our patient population was seen when compared to previously published data.
Adult↗
Vascular considerations in extremity trauma.
Effective diagnosis and management of associated vascular injuries is imperative to minimize morbidity after extremity trauma. An algorithm is presented for the diagnostic evaluation of patients with extremity trauma. The value of physical examination and Doppler indices in identifying occult injuries is discussed. The natural history of certain occult, nonocclusive injuries suggests that nonoperative management may be considered. The intraoperative management of major arterial and venous injuries, including current controversies, is addressed also.
Algorithms↗
Transcatheter embolization of an aortocaval fistula caused by residual renal artery stump from previous nephrectomy: a case report.
An arteriovenous fistula between the renal artery and vein is a rare complication of nephrectomy. We report the first case of direct inferior vena cava to renal artery fistula after nephrectomy. In addition, this was the first use of the Amplatz "spider," a vascular obstructing device used to trap coils during transcatheter embolization of a high-flow fistula. The patient's fistula was embolized successfully, with immediate improvement of symptoms and without pulmonary embolization.
Aged↗
Examination of the patient with a knee dislocation. The case for selective arteriography.
One hundred fifteen patients with a unilateral knee dislocation underwent arteriography to examine the popliteal artery. The incidence of popliteal artery injury was 23% (27 patients). Clinically, 29 (25%) of the 115 patients had an abnormal ipsilateral pedal pulse and 23 (79%) of these 29 patients had an arteriographically identified popliteal artery injury. Twenty-two arteries were surgically repaired and one was treated without surgery. Eight-six patients had normal pulses; the arteriogram showed no abnormalities in 77, demonstrated spasm in five, and revealed an intimal flap in four. All 86 patients were treated without surgery and had no delayed vascular complications. This demonstrates that the vascular examination is an accurate predictor of major popliteal artery injury following knee dislocation. Patients with an abnormal pedal pulse warrant arteriography due to a high incidence (79%) of popliteal artery injury. Patients with normal pulses may be monitored by clinical examination only. Popliteal artery injuries in this group are minor and rarely require intervention.
Adolescent↗
Surgical treatment of Takayasu arteritis.
The role of surgical therapy for Takayasu arteritis remains controversial. From 1973-1991, 23 patients with Takayasu arteritis have been treated at the University of Southern California. Twelve patients have required 17 arterial reconstructions for symptomatic complications of arterial disease refractory to medical therapy. Indications for operation have included renovascular hypertension (7), extremity ischemia (5), cerebrovascular insufficiency (2), dilated ascended aorta with aortic insufficiency (1), thoracic aortic aneurysm (1), and abdominal aortic aneurysm (1). Long-term clinical follow-up has demonstrated uniform symptomatic improvement. Fifteen of seventeen arterial reconstructions are still patent. Surgical treatment of symptomatic Takayasu arteritis is highly effective. Excellent long-term graft patency can be expected following arterial reconstruction.
Adolescent↗
Clinical results of decompressive dermotomy-fasciotomy.
Seventy-three dermotomy-fasciotomies (DFs) were performed in 68 patients from 1986 to 1991. A database record was compiled on each patient. Variables included age, mode of injury, method of initial wound closure, and associated injuries. A multivariate stepwise logistic regression analysis was performed to determine which variables were associated with wound complications. Thirty-eight percent of patients who underwent DF developed wound complications. One hundred percent of those patients with postoperative arterial or graft thrombosis developed wound complications (p less than 0.01) as did 78% of those with thromboembolic disease (p less than 0.05). Conversely, only 5% of those who underwent closure of their DF wounds utilizing skin grafts developed wound complications (p less than 0.01) as compared with 51% of those who underwent secondary or primary closure only. Subsequent analysis of the remaining patients, excluding those with severe soft tissue injury, showed an association between location of DF (upper versus lower extremity) and the development of wound complications that approached statistical significance (p less than 0.06). DF is frequently necessary in the treatment of patients with compartment syndrome but is associated with significant morbidity. This study suggests that closure of DF wounds utilizing skin graft allows for continued osteofascial decompression while concomitantly minimizing invasive sepsis.
Adolescent↗
Magnetic resonance imaging of a post-traumatic arteriovenous fistula in the lower extremity.
Currently, magnetic resonance (MR) is most useful as a means of providing distinct images of gross abnormalities in major blood vessels. While new advances and further refinements will continue, MR has proven its value as a convenient and effective diagnostic tool for the recognition and delineation of vascular abnormalities, such as acquired arteriovenous fistulae (AVFs). We report a case of a chronic, post-traumatic AVF, in which MR angiography provided excellent anatomic detail and angiographic correlation.
Adult↗
Management of postoperative lymphatic leaks by use of isosulphan blue.
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Aorta↗
Efficacy of the dorsal pedal bypass for limb salvage in diabetic patients: short-term observations.
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Arteries↗
Extra-anatomic bypass of failed traumatic arterial repairs.
Arterial injuries are best treated by primary repair or anatomically placed interposition grafts. Occasionally, these repairs fail due to adverse local factors, such as soft-tissue infection or enteric contamination. In these instances, limb salvage may require extra-anatomic arterial reconstruction. Between 1979 and 1989, 13 extra-anatomic bypasses were performed in ten male patients following nine failed primary repairs and one ligation of a traumatic arterial injury. The sites of arterial injury were: aorta (two), iliac (five), femoral (two), popliteal (one). Enteric contamination was present at initial operation in six patients; the remaining four had sustained massive soft-tissue injury. Reoperation was required for hemorrhage (seven), pseudoaneurysm (two), and arteriovenous fistula (one). All patients had developed local wound problems that militated against another anatomic repair. Extra-anatomic bypasses performed were: axillo-femoral (three), femoro-femoral (four), obturator (one), and two extra-anatomic femoral to popliteal saphenous vein grafts routed around an infected field. A second extra-anatomic reconstruction was performed for recurrent hemorrhage in three patients, (axillo-femoral--two, obturator--one). One patient with a neuropathic extremity and a functioning graft underwent amputation at 2 months following the initial injury. Two patients died of systemic sepsis. Seven patients (70%) have functional extremities with intact pulses at 2 to 24 months post bypass (mean, 7 months). Limb salvage after secondary disruption of secondarily infected arterial repairs can be achieved by appropriate extra-anatomic arterial reconstruction. In such cases, limb loss is due to soft-tissue sepsis or neuro-skeletal injuries and not vascular insufficiency.
Adult↗
A review of carotid endarterectomy at a large teaching hospital.
Before 1981, the neurologic morbidity and mortality associated with carotid endarterectomy (CEA) in the Los Angeles County/USC Medical Center public teaching institution was 20 per cent, similar to results from other hospitals. In 1981, a standardized protocol was adopted in an attempt to improve surgical outcome following CEA. Between 1981 through 1990, 89 patients with a mean age of 60.9 years (range 38 to 80 yrs) had 100 consecutive CEAs. Atherosclerotic risk factors included hypertension in 57 patients (61.8%), tobacco use in 57 (64.0%), and diabetes mellitus in 28 (31.5%). Forty-nine patients had a history of ischemic heart disease. Indications for CEA were stroke in 40 cases, transient ischemic attack in 33 cases, and asymptomatic, high-grade stenosis of the internal carotid artery (greater than 85 per cent) in 19. Perioperative and surgical management are detailed in the authors' protocol. Intraluminal shunts were routinely used (99 cases) and 24 arteriotomies were patched. Completion arteriograms were performed in 99 cases, four of which were revised because of arteriographic abnormalities. Three patients sustained postoperative ipsilateral neurologic events. Ten patients had cranial nerve palsies, six of which were transient. Two patients had nonfatal postoperative myocardial infarctions. There were no deaths. The combined stroke and transient ischemic attack (TIA) mortality rate was 3 per cent. In conclusion, the audit and quality assurance process identified unacceptable results following CEA. A protocol was developed that addressed pre, intra, and postoperative details of patient selection, operative technique, and postoperative care. By adhering to the protocol, the major neurologic morbidity and mortality rate has been reduced to 3 per cent.
Adult↗
Clinical applications of carbon dioxide/digital subtraction arteriography.
During an 18-month period 33 patients in whom there were contraindications to the use of iodinated contrast arteriography underwent 40 carbon dioxide/digital subtraction arteriograms for lower extremity ischemia (19), severe hypertension and renal insufficiency (12), or arterial aneurysm (2). Contraindications to iodinated contrast agents included renal insufficiency, congestive heart failure, and contrast hypersensitivity. Sixteen aortic, 15 iliac-femoral-popliteal-tibial, five aorta-iliac-femoral and four aorta-iliac-femoral-popliteal-tibial carbon dioxide/digital subtraction arteriography studies were performed. In 11 studies, imaging of selected arterial segments required the addition of 10 to 60 ml of dilute nonionic contrast. Guided by carbon dioxide/digital subtraction arteriography studies four femoral-tibial bypasses, three aneurysmorrhaphies, two aortorenal bypasses, one aortofemoral bypass and one femoral-femoral bypass were successfully performed in 11 patients. In addition, carbon dioxide/digital subtraction arteriography directed angioplasties of the common iliac (4), superficial femoral (6), popliteal (3), or tibioperoneal trunk (1) were performed in 10 patients. Complications of carbon dioxide/digital subtraction arteriography included transient deterioration in renal function in three patients in whom 20 ml of nonionic contrast was used, a nonfatal myocardial infarction after a popliteal percutaneous transluminal angioplasty in one patient, and transient tachypnea and tachycardia during a carbon dioxide/digital subtraction arteriography study in one patient. Diagnostic arteriograms are obtainable using carbon dioxide as the contrast agent. Carbon dioxide/digital subtraction arteriography permits patients with symptomatic arterial disease at high risk for contrast related complications to safely undergo arteriography and subsequent arterial reconstruction or endovascular intervention.
Adult↗