Recurrent carotid artery stenosis.
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Carotid Artery, Internal↗
Biomedical subjects
G A Sicard
Publications and source records attributed to G A Sicard.
Femoropopliteal bypass for claudication: vein vs. PTFE.
The vascular graft of choice for femoropopliteal bypass in patients with intolerable claudication is controversial. We retrospectively reviewed our experience with 239 patients suffering from claudication secondary to superficial femoral artery obstruction. Femoropopliteal reconstruction was performed with saphenous vein to the below-knee popliteal artery in 66 patients (BK-vein). Polytetrafluoroethylene (PTFE) was used in 128 patients as a bypass graft to the above-knee popliteal artery (AK-PTFE) and 45 patients had a PTFE graft to the below-knee popliteal artery (BK-PTFE). All patients were enrolled in a postoperative graft surveillance program with graft revision when appropriate. There was one perioperative death (0.4%). Primary patency at 5 years for AK-PTFE, BK-PTFE, and BK-vein was 58.0%, and 60.3%, respectively, and was not significantly different among the graft groups. Graft revision for failed/failing grafts resulted in 5-year secondary patency rates of 79.2% (AK-PTFE), 73.3% (BK-PTFE), and 74.4% (BK-vein). These secondary patency rates were not statistically different. Eventual conversion to a vein graft in patients initially treated with PTFE maximized patency in the femoropopliteal segment with 5-year patency rates of 84.6% and 93.0% for the AK-PTFE and BK-PTFE graft groups, respectively. Major leg amputation was necessary during the entire course of the study in eight (3.3%) patients. We conclude that long-term patency rates for femoropopliteal bypass in patients with intolerable claudication are similar for PTFE and autologous saphenous vein grafts.
Aged↗
Revascularization of the solitary kidney: a challenging problem in a high risk population.
BACKGROUND: Patients with significant atherosclerotic stenosis involving the artery to a solitary functioning kidney present a clinical challenge. METHODS: From August 1987 through August 1995, 35 of these patients (average age, 68.4 +/- 6.9 years) were treated. Comorbid conditions included previous myocardial infarction in 23% of the patients, congestive heart failure (CHF) in 34%, chronic obstructive pulmonary disease in 20%, and diabetes in 20%. The average creatinine level of the patients was 2.5 +/- 1.5 mg/dl. Indications for revascularization were hypertension in 86%, hypertensive crisis with CHF in 17%, and renal insufficiency in 69%. Procedures performed included 19 extra-anatomic bypasses, 8 concomitant with infrarenal aortic reconstruction and 2 concomitant with thoracoabdominal aortic aneurysm repair; 1 visceral segment endarterectomy; 1 renal artery endarterectomy with reimplantation; I superior mesenteric to renal artery bypass; 1 aortorenal bypass; and 2 percutaneous angioplasties with staged nephrectomies. RESULTS: At discharge, 91% of patients had stable or improved renal function with an average creatinine level of 1.7 +/- 0.8 mg/dl. Hypertension was cured or improved in 85%. Perioperative mortality was 6%, and major morbidity was 43%, including the need for permanent (9%) and temporary (9%) dialysis, respiratory insufficiency (18%), two early reoperations, six cardiac complications, one case of gastrointestinal bleeding, and one stroke. In the follow-up period (mean duration, 39.2 months), survival has been 73%, and no additional patients have required dialysis. CONCLUSIONS: Although significant perioperative morbidity exists in this high risk population, the long-term preservation of renal function and improvement in hypertension make solitary renal revascularization worthwhile.
Aged↗
Insulin-like growth factor-I attenuates delayed graft function in a canine renal autotransplantation model.
BACKGROUND: Insulin-like growth factor-I (IGF-I) has been shown to accelerate recovery in animal models of ischemic or toxic acute renal injury. Ischemic renal injury is frequently encountered after cadaveric transplantation manifested as delayed graft function. This study was performed to determine whether perfusion of kidneys with preservation solution supplemented with IGF-I would improve the course of renal injury in a canine autotransplantation model of delayed graft function. METHODS: Dogs underwent unilateral nephrectomy with kidneys perfused and stored in Euro-Collins solution supplemented with vehicle (n = 11) or IGF-I (n = 8). After 24 hours of kidney preservation, a contralateral nephrectomy was performed and the stored kidney was autotransplanted. Renal function was examined for 5 days after the transplantation, and an inulin clearance was obtained at the time of death. RESULTS: Compared with dogs that received kidneys preserved in the vehicle, dogs receiving the IGF-I preserved kidneys had significantly lower daily serum creatinine and blood urea nitrogen levels during the course of 5 days after transplantation. Inulin clearance at death was nearly double in the IGF-I treated animals compared with the vehicle-treated controls (1.37 +/- 0.16 ml/min/kg versus 0.77 +/- 0.13 ml/min/kg; p < 0.05). CONCLUSIONS: Perfusion and storage of kidneys with preservation solution supplemented with IGF-I can attenuate the course of delayed graft function in a canine renal autotransplantation model. IGF-I may have potential for use in cadaveric human renal transplantation.
Animals↗
Pulseless arm in association with totally displaced supracondylar fracture.
Seven children (3-10 years of age) were treated for a type III supracondylar fracture of the humerus. All fractures were reduced and pinned. Closed reduction was performed in four patients; three required open reduction. Before reduction six of the seven patients did not have a distal palpable pulse in the involved forearm. After reduction of the fractures all patients had a pulseless arm and a seemingly viable hand. Doppler pulses were absent or greatly diminished compared with the normal side in all involved extremities. Six patients underwent immediate antecubital fossa exploration of the brachial artery without arteriogram; one patient, referred to us from another facility, underwent angiography followed by immediate exploration. In three patients the brachial artery was directly damaged or transected and was repaired via saphenous vein graft, with reestablishment of distal pulses in each case. In the other four patients the brachial artery was kinked or entrapped at the fracture site, necessitating microdissection to mobilize the vessel and reestablish pulses in each case. At an average follow-up of 30 months, all seven patients had normal circulatory status, including a radial pulse. All fractures had healed, and all extremities had a normal carrying angle and normal elbow motion. Immediate exploration of the antecubital fossa should be considered if an extremity remains pulseless (to palpation and Doppler) after reduction and stabilization of significantly displaced supracondylar fractures of the humerus.
Algorithms↗
Donor-specific transfusions have long-term beneficial effects for human renal allografts.
From April, 1980 to November, 1988, 163 one or two haplotype-mismatch living related (LR) or living unrelated (LUR) potential renal transplant recipients received three 200 ml aliquots of donor specific transfusion (DST) at biweekly intervals with concomitant azathioprine (2 mg/kg/day). Following transplantation, only prednisone and azathioprine were given for immunosuppression. The results for the DST group are compared with those for HLA identical living recipients (57 patients) transplanted during this same interval (1980-1988). Comparison is also made with a group of one or two haplotype-mismatched living donor recipients (54 patients) not treated with DST but with triple drug therapy (prednisone, azathioprine, cyclosporine) and antithymocyte globulin (ATG) or OKT-3 induction. Permanent T cell crossmatch sensitization occurred in 11 of 163 patients (7%). Successful DST donor transplants were performed between 121 one HLA haplotype-mismatched, 14 two HLA haplotype-mismatched LR, and 7 two haplotype-mismatched LUR pairs. Actual one- and five-year graft survivals were 94%, 100%, 100%, and 72%, 85%, and 71%, respectively, for these three subgroups of DST treated patients. The graft survival for all DST pretreated recipients at one, five, and ten years was comparable to the HLA-identical group (94%, 79%, 64% vs. 91%, 80% and 77%). At a mean follow-up of 10 1/2 years, 54% (80 patients) of the entire group of 147 patients transplanted after DST have functioning transplants with a mean serum creatinine of 1.7 mg/dl. Fifteen percent of DST patients (21 patients) died with a functioning graft 2 to 132 months after transplantation, 26% (37 patients) rejected the DST graft after 1 to 128 months, and 6% (9 patients) were lost for nonimmunological reasons. No lymphoproliferative disease developed in the DST group and the incidence of cytomegalovirus sepsis was only 2% (3 patients). The long-term beneficial effects of DST on renal allograft survival and function and the lower incidence of the complications of nonspecific immunosuppression should encourage increased utilization of DST in renal transplantation.
Azathioprine↗
Transesophageal echocardiography in the detection of cardiovascular sources of peripheral vascular embolism.
The purpose of this study was to determine the impact of transesophageal echocardiography (TEE) on the management of patients with peripheral vascular emboli. We prospectively evaluated the role of TEE in 15 patients with documented peripheral emboli and no evidence of occlusive peripheral vascular disease. The patients were divided in two groups for analysis: group 1 (n = 8) had no clinical evidence of heart disease and group 2 (n = 7) had clinically significant heart disease. TEE provided information regarding the source of embolism in four (50%) patients in group 1, and these findings significantly affected the management of all. Three patients underwent thoracic surgery to remove the source of embolism (aortic valve mass in one and a thrombus in the descending thoracic aorta in two); the other patients was treated with thrombolytic agents. TEE findings had high diagnostic value in all patients in group 2, but the results had a possible effect on clinical management in only two of these patients. TEE provides diagnostic information in most patients with peripheral vascular emboli and this information has a significant influence on management, particularly in those without clinically evident heart disease. TEE should be performed in all patients with documented peripheral embolism.
Adult↗
Limb salvage and patency after aortic reconstruction in younger patients.
PURPOSE: The purpose of this report was to compare patient characteristics, treatment, and outcome in younger and older patients with aortoiliac occlusive disease. METHODS: The medical records of 56 patients < or = 50 years of age (Group < or = 50) were retrospectively reviewed and compared to the records of 128 patients > or = 60 years of age (Group > or = 60). All patients were examined and treated between April 1987 and April 1994. Postoperatively, they were enrolled in a vascular laboratory surveillance program to serially monitor the status of the vascular reconstruction. Follow-up averaged more than 3 years in both groups and was available on greater than 90% of patients. RESULTS: Patients in Group < or = 50 had a higher incidence of smoking (68% versus 51%) and a lower incidence of hypertension (29% versus 50%) than patients in group > or = 60 (smoking P = 0.03, hypertension P = 0.007). No other significant differences were noted among cardiovascular risk factors. Preoperative indications for surgery were similar among patients in both groups. An aortoiliac endarterectomy was more commonly used to revascularize the lower extremities in younger patients than in their older counterparts (23% versus 7%, P = 0.002). Graft revisions were more frequently necessary after aortic reconstruction in Group < or = 50 than in Group > or = 60 (29% versus 8%, P = 0.0003); however patency rates computed by life table analysis were not significantly different. The primary patencies for Group < or = 50 and Group > or = 60 at 5 years were 64% and 67%, respectively; their secondary patency rates at 5 years were 84% and 89%, respectively. No significant difference was found in major limb amputation (8% in Group < or = 50 versus 5% in Group > or = 60, P = 0.46). We conclude that aortoiliac reconstruction for occlusive disease can be performed with similar secondary patency and amputation rates in young and old patients. However, close postoperative surveillance and frequent surgical revision are necessary to maintain patency and minimize amputation.
Adult↗
Alternatives in renal revascularization.
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Adult↗
Retroperitoneal aortoiliac reconstruction.
The retroperitoneal approach to the aorta and the iliac arteries provides excellent exposure for reconstruction of these vessels for aortoiliac occlusive disease. Furthermore, the weight of evidence in the literature indicates that this approach is associated with fewer complications, a shorter length of stay in the hospital, and lower costs. The major drawback to this approach at present appears to be a lack of familiarity with the technical aspects of this exposure. It is our hope that this article helps familiarize surgeons with this exposure and encourages them to use it more frequently for "routine" aortoiliac reconstruction.
Aorta, Abdominal↗
Transabdominal versus retroperitoneal incision for abdominal aortic surgery: report of a prospective randomized trial.
PURPOSE: The purpose of this study was to perform a randomized, prospective trial that compares the transabdominal with the retroperitoneal approach to the aorta for routine infrarenal aortic reconstruction. METHODS: From August 1990 through November 1993, patients undergoing surgery for abdominal aortic aneurysm (AAA) disease or aortoiliac occlusive disease (AIOD) were asked to participate in a randomized trial comparing the transabdominal incision (TAI) to the retroperitoneal incision (RPI) for aortic surgery. One hundred forty-five patients were randomized, with 75 (41 with AAA and 34 with AIOD) in the TAI group and 70 (40 with AAA and 30 with AIOD) in the RPI group. There were no significant differences between the groups in terms of age, sex, postoperative pain control (epidural vs patient-controlled analgesia), or comorbid conditions, except for a higher incidence of chronic obstructive pulmonary disease in the TAI group (21 vs 8 patients). RESULTS: The incidence of intraoperative complications was similar for both groups. After surgery, the incidence of prolonged ileus (p = 0.013) and small bowel obstruction (p = 0.05) was higher in the TAI group. Overall, the RPI group had significantly fewer complications (p < 0.0001). The overall postoperative mortality rate (two deaths) was 1.4%, with both occurring in the TAI group (p = 0.507). The RPI group also had significantly shorter stays in the intensive care unit (p = 0.006), a trend toward shorter hospitalization (p = 0.10), lower total hospital charges (p = 0.019), and lower total hospital costs (p = 0.017). There was no difference in pulmonary complications (p = 0.71). In long-term follow-up (mean 23 months), the RPI group reported more incisional pain (p = 0.056), but no difference was found in incisional hernias or bulges (p = 0.297). CONCLUSIONS: We conclude that the RPI approach for abdominal aortic surgery is associated with fewer postoperative complications, shorter stays in the hospital and intensive care unit, and lower cost. There is, however, an increase in long-term incisional pain. Current methods of postoperative pain control seem to decrease the incidence of pulmonary complications.
Abdomen↗
Diagnosis of perioperative myocardial infarction with measurement of cardiac troponin I.
BACKGROUND: Perioperative myocardial infarction is the most common cause of morbidity and mortality in patients who have had noncardiac surgery, but its diagnosis can be difficult. The present study was designed to determine whether the measurement of serum levels of cardiac troponin I, a highly sensitive and specific marker for cardiac injury, would help establish the diagnosis of myocardial infarction. METHODS: We obtained preoperative measurements of MB creatine kinase, total creatine kinase, and cardiac troponin I, in addition to base-line electrocardiograms and two-dimensional echocardiograms, in 96 patients undergoing vascular surgery and 12 undergoing spinal surgery. Blood samples were obtained every 6 hours for at least the first 36 hours after surgery, and electrocardiograms were obtained daily; a second echocardiogram was obtained approximately three days after surgery. The appearance of a new abnormality in segmental-wall motion on the postoperative echocardiogram (that is, an abnormality that had not been seen on the preoperative echocardiogram) was considered to be indicative of perioperative infarction. RESULTS: Eight patients who underwent vascular surgery had new abnormalities in segmental-wall motion and received a diagnosis of perioperative infarction. All eight had elevations of cardiac troponin I, and six had elevations of MB creatine kinase. Of the 100 patients without perioperative infarction detected by echocardiography, 19 had elevations of MB creatine kinase, and 1 had a slight elevation of cardiac troponin I. CONCLUSIONS: The measurement of cardiac troponin I is a sensitive and specific method for the diagnosis of perioperative myocardial infarction. It avoids the high incidence of false diagnoses associated with the use of MB creatine kinase as a diagnostic marker.
Creatine Kinase↗
An institutional experience with arterial atheroembolism.
Seemingly minor blue-toe lesions resulting from atheroemboli are associated with unstable atherosclerotic plaques, which are at risk for causing recurrent emboli, tissue loss, and potentially death. At Washington University Medical Center, 62 patients (31 males and 31 females), ranging in age from 38 to 89 years (mean 62.8 +/- 11.7 years), were treated for cutaneous manifestations of atheroembolic disease. Most patients (62%) had spontaneous bouts of atheroembolism, but 13 (21%) had recently undergone an inciting invasive radiologic study, 10 (16%) were on anticoagulation therapy, and one (2%) experienced abdominal trauma. In addition to the cutaneous manifestations, 18 patients (29%) also developed coincidental deterioration in renal function and four (6%) had intestinal infarction from atheroemboli. Arteriography in nearly all patients (97%) implicated the aorta and iliac arteries most commonly (80%), with the femoral (13%), popliteal (3%), and subclavian (3%) arteries less frequently incriminated. Forty-two patients underwent bypass grafting procedures (36 anatomic and six extra-anatomic) after exclusion of the native diseased artery, 20 patients had endarterectomies (six with additional bypass grafts), and five patients had no corrective vascular procedures. The 30-day operative mortality rate was 5% in this series. Nineteen patients (31%) required minor amputations, whereas two required major leg amputations. Thus limb salvage was possible in 86 of 88 (98%) limbs. No further episodes of atheroembolism occurred in the involved limbs during follow-up (1 to 53 months, mean 20.2 months). We advocate urgent arteriography and surgical correction or bypass with exclusion of the offending lesion.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Right retroperitoneal approach to the aorta and its branches: Part II.
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Abdominal Muscles↗
Left retroperitoneal approach to the aorta and its branches: Part I.
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Aorta↗
The influence of anesthetic technique on perioperative complications after carotid endarterectomy.
PURPOSE: This study evaluated the influence of anesthetic techniques on perioperative complications after carotid endarterectomy. METHODS: Perioperative complications, the use of a carotid artery shunt, the duration of the operative procedure and postoperative hospital course were retrospectively compared in 584 consecutive patients undergoing 679 carotid endarterectomies with use of either general anesthesia (n = 361) or cervical block regional anesthesia (n = 318). There was no significant difference in the preoperative medical characteristics between the two anesthetic groups. Symptomatic carotid artery disease was the indication for surgery in 247 (68.4%) patients receiving general anesthetics, whereas 180 (56.6%) patients treated with a cervical block anesthetic had a symptomatic carotid artery stenosis (p = 0.02). RESULTS: The perioperative stroke rate and stroke-death rate for the entire series was 2.4% and 3.2%, respectively, and was not significantly different between the anesthetic groups or between patients with symptomatic or asymptomatic disease. A carotid artery shunt was used in 61 (19.2%) patients receiving a cervical block anesthetic and 152 (42.1%) patients treated with a general anesthetic (p < 0.0001). Use of cervical block anesthesia was associated with a significantly shorter operative time, fewer perioperative cardiopulmonary complications, and a shorter postoperative hospitalization when compared with general anesthesia. Multivariate risk factor analysis indicated that age greater than 75 years, operative time greater than 3 hours, and the use of a carotid artery shunt were all independent risk factors for perioperative cardiopulmonary complications. When a carotid artery shunt was not analyzed as a multivariate risk factor, then general anesthesia became a significant risk factor for perioperative cardiopulmonary complications (risk ratio 2.08; p = 0.04). CONCLUSIONS: We conclude that cervical block anesthesia is safer and results in a more efficient use of hospital resources than general anesthesia in the treatment of patients undergoing carotid endarterectomy.
Aged↗
Abnormal expression of plasminogen activators in aortic aneurysmal and occlusive disease.
PURPOSE AND METHODS: Aortic aneurysms are characterized by the destruction of the extracellular matrix of the media, whereas occlusive disease involves excess matrix accumulation within the intima. Plasmin degrades extracellular matrix directly and indirectly by activation of latent metalloenzymes. To determine the expression of tissue- and urokinase-type plasminogen activators, immunoassay, fibrin autography, Northern analysis, and immunohistochemistry were performed on specimens of aneurysmal (n = 12), occlusive (n = 8), and healthy (n = 6) aorta. RESULTS: Immunoassay of tissue-type plasminogen activator revealed 8.7 +/- 0.9 ng tissue-type plasminogen activator/mg extracted protein in aneurysmal aorta, 5.7 +/- 0.3 ng/mg in normal aorta, and 2.5 +/- 0.3 ng/mg in occlusive aorta (p < 0.05 for comparisons between all groups). No urokinase-type plasminogen activator antigen was detected by urokinase-type plasminogen activator immunoassay. Fibrin autography exhibited lytic activity at 64 kDa and 54 kDa attributable to tissue-type plasminogen activator and urokinase-type plasminogen activator. The vast majority of fibrinolysis was secondary to free tissue-type plasminogen activator and was greatest in aneurysmal disease and least in occlusive disease. There was only a small amount of lysis secondary to urokinase-type plasminogen activator. Expression of tissue-type plasminogen activator and urokinase-type plasminogen activators mRNA was comparable in aneurysmal and occlusive aortas. In contrast to occlusive disease, aneurysms had an inflammatory cell infiltrate characterized by the expression of urokinase-type plasminogen activator by specific mononuclear cells. Tissue-type plasminogen activator expression was evident in the intima of normal and diseased aorta and in the media of diseased aorta. CONCLUSION: Differential expression of plasminogen activators within the arterial wall may contribute to the unique pathogenesis of aneurysmal and occlusive aortic disease.
Adult↗
Care of patients with deep venous thrombosis in an academic medical center: limitations and lessons.
PURPOSE: The primary goal of our study was to review the quality of care in patients with deep vein thrombosis,, with emphasis on identifying recurrent and remedial problems. Secondary goals were (1) to evaluate the use of the vascular laboratory and (2) to characterize our patient population with deep vein thrombosis and to identify a subset of patients with uncomplicated deep vein thrombosis who might be candidates for outpatient therapy in the future. METHODS: A retrospective review was performed for all patients with deep vein thrombosis diagnosed with duplex scanning who were treated as inpatients from January 1993 through March 1993. RESULTS: Fifty-four (16%) of 306 duplex scans were positive; 50 patients were treated as inpatients. Forty percent of patients had uncomplicated deep vein thrombosis that was potentially treatable on an outpatient basis. Mean time to obtain a therapeutic partial thromboplastin time was 22 hours (range 4 to 54 hours). Ten (20%) patients had inferior vena cava filters placed. The in-hospital mortality rate was 4%. Management problems occurred in 18 (36%) patients and included difficulty titrating anticoagulation, (10) physician failure to provide treatment after diagnosis, (five) and inappropriate use or complication of inferior vena cava filter placement (three). CONCLUSIONS: Venous duplex examination is liberally but appropriately used. The primary remediable problem resulting in suboptimal management is difficulty titrating anticoagulation; inappropriate placement of inferior vena cava filters and physician failure to provide treatment also occur. In the future a substantial number of patients may be suitable for outpatient therapy.
Academic Medical Centers↗