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Biomedical subjects

F J Veith

Publications and source records attributed to F J Veith.

At least 253 records · Page 14Linked to original sources
PubMed1987

Reoperation for polytetrafluoroethylene bypass failure: the importance of distal outflow site and operative technique in determining outcome.

Of 724 bypasses with polytetrafluoroethylene grafts performed for critical ischemia during a 6-year period, 165 (23%) failed and necessitated reoperation for continued limb salvage. Forty-three failures occurred in 199 femoral-above-knee-popliteal bypasses (F-AKP), 33 failures in 177 femoral-below-knee-popliteal bypasses (F-BKP), 52 failures in 182 femorodistal bypasses (F-D), 28 failures in 85 axillofemoral bypasses (Ax-F), and nine failures in 81 femorofemoral bypasses (F-F). Our reoperative approach consisted of dissection of the distal anastomosis, longitudinal incision in the hood of the graft directly over the anastomosis, and proximal graft thrombectomy. Intimal hyperplasia was treated by patch angioplasty, proximal or distal progression of atherosclerosis was treated by a graft extension, and thrombectomy alone was performed when no cause of graft failure was identified. More recently, a totally new bypass was constructed in 27 cases of F-BKP or F-D failures. Reoperations featuring graft salvage for failed extra-anatomic and F-AKP bypasses yielded 3-year patency rates from the time of first reoperation of 71% and 52%, respectively, whereas for F-BKP and F-D reoperations, 3-year patency rates were 13% and 15%, respectively, at 3 years. However, totally new grafts to a different outflow artery in these settings had 3-year patency rates of 48% and 39%. These data support the aggressive use of reoperation with graft salvage when F-AKP or extra-anatomic graft failure reproduces critical ischemia. Conversely, a new bypass to a virginal outflow site, preferably with autologous vein, should be performed when a polytetrafluoroethylene F-BKP or F-D bypass fails.

Adult↗
PubMed1986

Infrapopliteal bypasses to heavily calcified rock-like arteries. Management and results.

Of the 355 consecutive infrapopliteal bypasses for limb salvage performed over a 5 year period at our institution, 116 (Group I) were to noncalcified vessels, 203 (Group II) were to vessels of varying degrees of calcification (mild to moderate), and 36 (Group III) were to heavily and circumferentially calcified arteries. A new intraoperative fracture technique was used to overcome the rigidity of the arterial wall in the latter group. Three year cumulative patency rates for Groups I, II, and III were 45 percent, 58 percent, and 47 percent, respectively. Comparable limb salvage rates for Groups I, II, and III were 66 percent, 73 percent, and 75 percent. No significant difference in patency or limb salvage results could be elicited between the three groups by the log-rank test. These findings suggest that arterial calcification is an invalid predictor of failure in small vessel bypasses. Even circumferentially calcified arteries, which are generally thought to be surgically unapproachable, should not be a deterrent to limb salvage attempts.

Adult↗
PubMed1986

Lung transplantation.

Over the past 20 years, many advances in surgical methods, transplantation immunology, donor organ procurement and preservation techniques, and postsurgical care regimens have influenced greatly the field of lung transplantation. The single remaining obstacle to widespread clinical success is donor lung availability. Improved methods of ex vivo lung preservation, organ donor maintenance, and donor lung retrieval after the completion of cardiac donation should help to ameliorate this problem.

Bronchi↗
PubMed1986

Six-year prospective multicenter randomized comparison of autologous saphenous vein and expanded polytetrafluoroethylene grafts in infrainguinal arterial reconstructions.

Autologous saphenous vein (ASV) and polytetrafluoroethylene (PTFE) grafts were compared in 845 infrainguinal bypass operations, 485 to the popliteal artery and 360 to infrapopliteal arteries. Life-table primary patency rates for randomized PTFE grafts to the popliteal artery paralleled those for randomized ASV grafts to the same level for 2 years and then became significantly different (4-year patency rate of 68% +/- 8% [SE] for ASV vs. 47% +/- 9% for PTFE, p less than 0.025). Four-year patency differences for randomized above-knee grafts were not statistically significant (61% +/- 12% for ASV vs. 38% +/- 13% for PTFE, p greater than 0.25) but were for randomized below-knee grafts (76% +/- 9% for ASV vs. 54% +/- 11% for PTFE, p less than 0.05). Four-year limb salvage rates after bypasses to the popliteal artery to control critical ischemia did not differ for the two types of randomized grafts (75% +/- 10% for ASV vs. 70% +/- 10% for PTFE, p greater than 0.25). Although primary patency rates for randomized and obligatory PTFE grafts to the popliteal artery were significantly different (p less than 0.025), 4-year limb salvage rates were not (70% +/- 10% vs. 68% +/- 20%, p greater than 0.25). Primary patency rates at 4 years for infrapopliteal bypasses with randomized ASV were significantly better than those with randomized PTFE (49% +/- 10% vs. 12% +/- 7%, p less than 0.001). Limb salvage rates at 3 1/2 years for infrapopliteal bypasses with both randomized grafts (57% +/- 10% for ASV and 61% +/- 10% for PTFE) were better than those for obligatory infrapopliteal PTFE grafts (38% +/- 11%, p less than 0.01). These results fail to support the routine preferential use of PTFE grafts for either femoropopliteal or more distal bypasses. However, this graft may be used preferentially in selected poor-risk patients for femoropopliteal bypasses, particularly those that do not cross the knee. Although every effort should be made to use ASV for infrapopliteal bypasses, a PTFE distal bypass is a better option than a primary major amputation.

Actuarial Analysis↗
PubMed1986

Transplantation of pediatric donor kidneys to adult recipients. Is there a critical donor age?

Cadaver kidneys remain a scarce resource, yet single pediatric donor kidneys are underutilized at some centers. Between 1967 and 1984, 133 single pediatric and 318 adult donor cadaver transplants were performed. Patient and graft survival, renal function, and complications in adult recipients grouped by donor age were compared. Recipient age for all groups was similar (34-36 years). Life table analysis revealed no difference in graft survival in recipients of kidneys from donors aged 2, 3, 4, 5-10, and 11-15 when compared with adult donors. Graft survival in these groups improved over time with current 1-year survival over 75%. Recipients from donors less than 24 months of age demonstrated significantly poorer results, with no kidney surviving greater than 2 months. Serum creatinine of grafts functioning greater than 6 months was similar in all groups. It is concluded that single pediatric kidneys from donors greater than 2 years of age can be successfully transplanted to adults with good long-term results.

Adolescent↗
PubMed1986

ALG treatment of steroid-resistant rejection in patients receiving cyclosporine.

Thirty-one episodes of biopsy-proved acute rejection (R) in 28 patients maintained on cyclosporine did not respond to high-dose steroids and were treated with antilymphocyte globulin (ALG). Cyclosporine was discontinued in all but three during ALG administration. (A) Twenty-four patients received 26 courses of ALG within 90 days of transplant (11 1st R, 15 2nd or 3rd). Seven treatment courses were cut short due to infection (4), ongoing R (2) and a combination of infection and rejection (1). Only 1 of 7 has a functioning graft. Of the remaining 19 full ALG courses (17 patients) (8 1st R, 11 2nd or 3rd), 13 (11 patients) responded (7 1st R, 6 greater than 1st). The remaining 6 patients lost their grafts to ongoing acute rejection. (B) Five patients were treated after 6 months posttransplant; two responded but no grafts currently function. (C) Overall 7 patients developed systemic infection (7 viruses, 1 Candida) with 1 death, and 2 additional patients developed severe thrombocytopenia and leukopenia. Patients responding to their ALG course were restarted on cyclosporine. We conclude that ALG is not as effective in reversing steroid-resistant rejection in patients maintained on cyclosporine as it has been in patients maintained on azathioprine. However, more than 50% of steroid-resistant rejection episodes are reversed.

Adolescent↗
PubMed1986

Prevention and management of ischemic complications of vein harvest incisions in cardiac surgery--case reports.

Leg wound complications following saphenous vein harvest for coronary revascularization are uncommon. We have encountered five patients in whom unrecognized arterial occlusive disease contributed to wound necrosis. All required vascular reconstruction in addition to local wound care to achieve healing. Careful preoperative attention to symptoms of arterial insufficiency is recommended and appropriate modification of lower extremity incisions may reduce the frequency of this complication. Prompt recognition and appropriate arterial revascularization should avoid prolonged morbidity if ischemic necrosis of leg wounds does occur. If arterial reconstruction is required, PTFE is an acceptable graft material if the remaining saphenous vein is inadequate for use.

Adult↗
PubMed1986

Limb salvage in octogenarians and nonagenarians.

Although advanced age has often been a relative contraindication to attempts at limb salvage, we have not regarded it as an important deterrent to arterial reconstruction. Our 6-year experience with 168 consecutive patients over 80 years of age who underwent arterial reconstruction or percutaneous transluminal angioplasty represented 18% of all patients treated with limb-threatening ischemia during this period. The average age was 84 years, with 14 patients over 90 years of age. Sixty-eight patients were men (41%) and 100 were women (59%). Indications for treatment in 189 limbs were restricted to limb salvage. One hundred eighty-two operative procedures were performed consisting of 84 femoropopliteal, 72 femorotibial, 12 axillofemoral, 11 femorofemoral, two axillopopliteal and one iliofemoral bypass. Percutaneous transluminal angioplasty was performed in 12 iliac and 14 femoral or popliteal arteries as an alternative (seven) or adjunct (19) to vascular reconstruction. The 30-day procedural mortality rate was 6%. The cumulative life table survival rate of all patients who underwent an attempt at limb salvage was 78% at 1 year, 65% at 2 years, and 54% at 3 years. Cumulative life table limb salvage rates were 84% at 1 year, 74% at 2 years, and 71% at 3 years. Overall graft patency for 182 arterial reconstructive operations was 80% at 1 year and 62% at 3 years. Of patients in whom limb salvage was attempted, 65% lived more than 1 year and 51% more than 2 years with a functional limb. Of patients who died within 5 years of treatment, 76% did so with their previously threatened limb intact. These data support an aggressive approach to arterial reconstruction in elderly patients and indicate that advanced age alone should not be considered a contraindication to attempts at limb salvage.

Actuarial Analysis↗
PubMed1986

Definition, diagnosis, and management of rejection in the second to sixth months posttransplant--an overview.

CsA immunosuppression has resulted in decreased graft loss from rejection. However, rejection episodes do occur and, in fact, rejection remains as the major cause of graft loss in the CsA-treated patient. CsA, itself, has added to the differential diagnosis of renal dysfunction following transplantation. In the majority of circumstances, rejection can be differentiated from CsA nephrotoxicity as well as other causes of renal dysfunction by a combination of clinical presentation, renal scan and sonography, CsA levels, and percutaneous allograft biopsy. In some circumstances, a therapeutic trial of lowering the CsA dose may be indicated before extensive laboratory study. Most acute rejection episodes will respond to increased steroid doses. In patients with low CsA levels, increasing the CsA dose may be advised. Steroid-resistant rejection frequently responds to ALG. Patients with repeated episodes of renal dysfunction may be stabilized by using the combination of prednisone, azathioprine, and CsA.

Adrenal Cortex Hormones↗
PubMed1986

Concanavalin A-dependent cell-mediated cytotoxicity in bronchoalveolar lavage fluid. Correlation with lung allograft rejection in mongrel dogs during cyclosporine dose tapering.

Although cyclosporine (CsA) is widely used as the primary agent for inhibiting the rejection of organ allografts in man, the ideal immunosuppressive regimen for utilizing this drug is still uncertain. To investigate this question, a concanavalin A (con A)-dependent cell-mediated cytotoxicity (CDCMC) assay was used to examine the development of intragraft and peripheral blood cytolytic T lymphocyte activity during CsA dose tapering. These studies were conducted in a canine single-lung transplantation model that facilitates serial examination of intragraft effector cells by bronchoalveolar lavage (BAL). A remarkable correlation of increased intragraft CDCMC and clinical evidence of lung allograft rejection was observed during CsA dose tapering in some recipients. In other recipients CDCMC remained low and evidence of rejection was not observed during drug tapering. In contrast, peripheral blood CDCMC did not correlate well with evidence of rejection. Rejection phenomena observed after termination of CsA therapy were reversed by resumption of CsA treatment but were not reversed by administration of methylprednisolone. Furthermore, the increased level of CDCMC was diminished by reinstitution of CsA therapy at the initial dosage. Following termination of CsA therapy, a prolonged period of unresponsiveness was observed in nearly two-thirds of the recipients, and 60% of these latter dogs had unlimited survival of their lung allografts (median greater than 496 days). Intragraft CDCMC remained low during the periods of unresponsiveness and increased upon onset of rejection. We conclude that measurement of intragraft CDCMC is a useful in vitro method of monitoring lung allograft rejection, and therefore provides a technique for adjusting CsA dosage schedules to achieve maximally effective immunosuppression. The use of this assay for monitoring rejection of other organ grafts requires further investigation.

Animals↗
PubMed1986

Successful conservative therapy of severe limb-threatening ischemia: the value of nonsympathectomy.

Fourteen patients with severely ischemic extremities but relatively minor degrees of pedal gangrene or ulceration were managed without surgery. Contraindications to direct arterial reconstruction included significant intercurrent illness or generally poor surgical risk, the need for reoperative or difficult distal reconstruction, or the favorable characteristics of the actual lesion. Management consisted of bed rest, simple saline soaks, occasional gentle debridement, and antibiotics when indicated. Seven patients had complete resolution of their lesions for 3 to 48 months, and seven had improvement or stabilization for 3 to 18 months. Only three of the 14 patients have eventually required surgery with limb salvage in one. Revascularization remains the method of choice for managing most severely ischemic extremities. However, the conservative approach described represents an alternative to early amputation, attempts at revascularization, or lumbar sympathectomy in some patients with advanced ischemia. Studies of sympathectomy and pharmacologic agents as effective treatment for ischemic ulcers or gangrene should include control groups treated with the conservative measures outlined herein.

Aged↗
PubMed1985

Collateral back pressure--is it a valid predictor of infrainguinal bypass graft patency?

While it is generally thought that collateral back pressure (CBP) is a reliable predictor of graft patency, this correlation has not yet been validated. We have used a new, simple technique to measure CBP without direct puncture of the recipient artery. After the distal anastomosis is completed, the graft is filled with saline and clamped proximally. A transducer connected needle is then inserted into the distal portion of the graft for CBP measurements (mm Hg). These were obtained in 84 grafts (43 femoropopliteals [FP] and 41 femorodistals [FD]). Outflow resistance (OR) measurements (mm Hg/ml/min) were also obtained in 70 (36 FP; 34 FD) of these grafts by a previously described technique. The mean CBP for FP and FD bypasses was 41 +/- 17 and 26 +/- 19 mm Hg, respectively (P less than 0.001). Although early graft patency (3 months) (13 occluded, 71 patent) did not correlate with angiographic findings of popliteal runoff or integrity of pedal arch, it did significantly relate to CBP. Mean CBP for occluded grafts was 22 +/- 17 mm Hg and for patent grafts it was 36 +/- 19 mm Hg (P less than 0.01). Similarly, mean OR was significantly related to patency, 1.29 +/- 0.23 mm Hg/ml/min for occluded grafts and 0.36 +/- 0.23 mm Hg/ml/min for patent grafts (P less than 0.0001). Moreover, only OR was a significant predictor of infrapopliteal graft patency (P less than 0.01). OR was found to be a better predictor of graft patency than CBP by stepwise logistic regression analysis (P less than 0.0001). We conclude that CBP is a more reliable predictor of graft outcome than angiographic criteria.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1985

Progress in limb salvage arterial surgery: components and results of an aggressive approach.

In the past 9 years, 1,196 patients whose lower extremity was threatened because of infrainguinal arteriosclerosis have been treated at Montefiore Hospital. In the last 6 years, limb salvage was attempted in 679, or 90% of 755 patients. Femoropopliteal (318), small vessel (204) and axillopopliteal (29) bypasses were used along with transluminal angioplasty (128) and aggressive local operations to obtain a healed foot. Immediate (one month) limb salvage was achieved in 583, or 85%, of the 679 patients in whom revascularization was possible. The 30-day mortality rate was 3%. The cumulative life table (LT) survival rate of all the patients undergoing reconstructive arterial operations was 48% at 5 years. The cumulative LT limb salvage rate after all reconstructive arterial operations was 66% at 5 years. The cumulative LT patency rate of femoropopliteal bypasses was not influenced by angiographic outflow characteristics of the popliteal artery but was increased 15% by appropriate reoperations to 67% at 5 years. Cumulative LT patency and limb salvage rates of small vessel and axillopopliteal bypasses were more than 50% at 2 years. Of patients undergoing arterial reconstruction, 88% of those who died within 5 years did so without losing their limbs. Of all the patients in whom limb salvage was attempted, 68% lived more than one year with a viable, usable extremity, and 54% lived over 2 years with an intact limb. We believe this aggressive approach to limb salvage is justified, and can be undertaken with a low cost in mortality, knee loss and morbidity.

Actuarial Analysis↗
PubMed1985

Perioperative noninvasive hemodynamic ankle indices as predictors of infrainguinal graft patency.

Of 129 femoropopliteal bypasses, 40 closed in 0 to 42 months. Early and late closures were not predicted by pre- or postoperative ankle/brachial pressure index (ABPI) or ankle pulse volume recording amplitude (APVR) or their increments (delta). Of 141 femorotibial bypasses, 60 closed in 0 to 12 months, with 46 closing early (less than 1 month). Early failure occurred in 19 of 52 limbs (37%) with pre-ABPI less than 0.2 and 17 of 89 limbs (19%) with pre-ABPI greater than 0.2 (p less than 0.025). Similar significant differences in early patency occurred between limbs with pre-APVR less than 5 and greater than 5 mm (29 of 94 [34%] vs. 7 of 47 [15%], respectively). Late closure was not predicted by either value. Thus in the 44 limbs with pre-ABPI greater than 0.2 and pre-APVR greater than 5 mm, only 11 grafts closed (25%), whereas if pre-ABPI was less than 0.2 or pre-APVR less than 5 mm, 49 of 97 grafts (51%) occluded within 17 months (p less than 0.025). Postoperative or delta indices had no predictive value. Preoperative ABPI less than 0.2 or APVR less than 5 mm was associated with twice the risk of early femorotibial graft closure; however, cumulative life-table patency was still 39% at 24 months.

Ankle↗