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Biomedical subjects

G L Moneta

Publications and source records attributed to G L Moneta.

At least 37 records · Page 2Linked to original sources
PubMed1998

Predictors of outcome of forefoot surgery for ulceration and gangrene.

BACKGROUND: Surprisingly little is known about the long-term outcome of forefoot surgery for limb salvage. METHODS: From January 1, 1992 through December 31, 1996, patients requiring toe amputation or forefoot surgery were prospectively entered into a computerized database and followed up for healing, need for repeat foot surgery, or major amputation (below or above knee). RESULTS: A total of 162 patients (mean age 65 years), 72% diabetic, 10% with end-stage renal disease (ESRD), and 73% without palpable pulses, were entered into the study. Mean follow-up was 25 months. Of patients without palpable pulses (n = 98), 83% underwent concomitant or subsequent limb revascularization. Eleven of 98 revascularization procedures (11%) were hemodynamically unsuccessful. Nonhealing of the initial forefoot procedure occurred in 14%, and late repeat foot surgery (following initial healing) was required in an additional 14%. Major amputation was eventually required in 30 (18.5%) patients. Multivariate analysis indicated that unsuccessful revascularization, but not diabetes or ESRD, predicted nonhealing and major amputation (P <0.0001). Patients presenting with palpable pulses and neuropathic ulcers were at risk for late, repeat foot surgery, but not major amputation (P = 0.0015). CONCLUSIONS: In patients requiring toe or partial forefoot amputation, success of revascularization is the primary predictor of initial healing and freedom from major amputation. Neuropathic ulceration predicts need for repeat foot surgery following healing.

Adult↗
PubMed1998

Surgical treatment of infected aortic aneurysm.

BACKGROUND: We report results of infected aortic aneurysms treated by a single group over 20 years. METHODS: Retrospective review. RESULTS: Seventeen patients were treated, 10 with infrarenal and 7 suprarenal infections. All had abdominal/back pain, 88% were febrile, 71% had leukocytosis, and 24% were hemodynamically unstable. The most common responsible organism was Staphylococcus aureus (29%) followed by Salmonella organisms (24%). All suprarenal infections were gram-positive organisms. Infrarenal infections were treated with preliminary axillofemoral bypass followed by aortic resection. Suprarenal infections were treated with either in situ prosthetic graft or patch repairs. Operative survival was 90% for infrarenal and 57% for suprarenal infections. Operative deaths occurred in the setting of overwhelming sepsis and/or severe preoperative hemodynamic instability. There was no limb loss, renal failure, or intestinal ischemia. Late deaths occurred in 4 patients at 1.3 to 6.3 years postoperatively and were unrelated to their aortic repairs. Nine patients remain alive with a median follow-up of 2 years. There have been no late aortic or graft infections. CONCLUSIONS: In the absence of hemodynamic instability and uncontrolled sepsis, infected aortic aneurysms can be successfully repaired with durable results.

Adult↗
PubMed1998

Inferior epigastric artery pseudoaneurysm: a complication of paracentesis.

Two patients had inferior epigastric artery pseudoaneurysms after therapeutic paracentesis for ascites caused by portal hypertension. The first patient, a 62-year-old man, had a two-week history of left lower quadrant pain, tenderness, and nonpulsatile mass after a paracentesis for ascites. A left inferior epigastric artery pseudoaneurysm measuring 10 cm in diameter and 20 cm in length was diagnosed by means of Duplex ultrasound and arteriography. The patient was treated with percutaneous embolization, with successful thrombosis of the pseudoaneurysm. The second patient, a 33-year-old woman, had a six-week history of left lower quadrant pain, tenderness, and nonpulsatile mass after a paracentesis for ascites. Computerized tomography and arteriography showed a left inferior epigastric artery pseudoaneurysm, measuring 7 cm in diameter and 9 cm in length. The patient was treated with percutaneous embolization with successful thrombosis of the pseudoaneurysm. Both patients were discharged in good condition 2 days after embolization. Inferior epigastric artery pseudoaneurysm is a complication of paracentesis, and percutaneous embolization may be preferable to surgical repair in patients with chronic liver failure and portal hypertension.

Adult↗
PubMed1998

Prophylactic repair of renal artery stenosis is not justified in patients who require infrarenal aortic reconstruction.

PURPOSE: Simultaneous prophylactic repair of asymptomatic renal artery stenosis (ARAS) in patients who require infrarenal aortoiliac reconstruction is controversial. This study documents the natural history of ARAS in patients who require aortic reconstruction. METHODS: Two hundred patients who required aortic reconstruction from 1985 to 1990 for indications other than hypertension or renal salvage were identified. ARAS was not repaired. Preoperative angiograms were available for 171 of 200 patients and were reviewed for renal artery stenosis. Patients were assessed for atherosclerotic risk factors, survival, preoperative and follow-up blood pressure, serum creatinine level, antihypertensive medication usage, and need for dialysis. RESULTS: The mean duration of follow-up was 6.3 years. Twenty-four of 171 patients (14%) had preoperative unilateral 70% to 99% diameter reduction ARAS, and eight (5%) had bilateral 70% to 99% ARAS. Clinical features associated with > or =70% ARAS included coronary artery disease, increased age, and a diagnosis of hypertension (p < 0.05). Patients with > or =70% ARAS did not have a decreased 7-year survival rate (66% vs 84%; p = 0.10) but had higher systolic blood pressures (153 +/- 25 vs 138 +/- 30 mm Hg; p < 0.05) as well as increased numbers of antihypertensive medications at follow-up (1.1 +/- 0.2 vs 0.7 +/- 1; p < 0.05). The mean serum creatinine level (1.1 +/- 0.3 preoperative vs 1.4 +/- 0.8 mg/dl; p = NS) was not increased. One patient (0.58%) with polycystic kidney disease and minimal renal artery stenosis required dialysis. CONCLUSIONS: High-grade ARAS in patients who are undergoing infrarenal aortic reconstruction is associated at late follow-up with increased systolic blood pressure and a need for increased numbers of antihypertensive medications, but not decreased survival rate, dialysis dependence, or an increase in serum creatinine level. These data do not support renal artery repair in patients with ARAS who undergo infrarenal aortic reconstruction.

Aorta, Abdominal↗
PubMed1998

Interposition grafting for reoperation on the common femoral artery.

PURPOSE: This report details our experience with common femoral artery resection and Dacron interposition grafting in the management of vascular reoperations involving the common femoral artery. DESIGN: Retrospective review. SETTING: University teaching hospital. SUBJECTS: Consecutive reoperative patients who had common femoral artery interposition grafting for arteriosclerotic occlusive disease from 1986 to 1997. INTERVENTIONS: Common femoral artery resection and interposition grafting. MAIN OUTCOME MEASURES: Operative morbidity and mortality rates and long-term patency, limb salvage, patient survival, freedom-from-graft-infection, and freedom-from-reoperation rates. RESULTS: Ninety-nine common femoral arteries (16 bilateral) were resected and replaced with Dacron interposition grafts in 83 patients (50 male, 33 female; mean age, 65 years) who had had 237 previous ipsilateral common femoral artery operations (mean, 2.4 operations; range, 1-9 operations). Simultaneous infrainguinal bypass grafts were performed in 52 operations (53%), and 60 operations (61%) were performed in patients who had had previous ipsilateral proximal bypass grafts. Operative mortality was 2%, with a 14% rate of perioperative wound complications. Mean follow-up time was 22 months. One- and 3-year assisted primary patency rates for the interposition grafts were 90% and 77%, respectively. Both 1- and 3-year life-table-determined limb salvage rates were 95%. One- and 3-year life-table-determined freedom-from-reoperation rates were 74% and 43%, respectively. One- and 3-year life-table-determined freedom-from-infection rates were 99% and 92%, respectively. One- and 3-year life-table-determined survival rates were 82% and 73%, respectively. CONCLUSIONS: Common femoral artery resection and Dacron interposition grafting are safe, and they obviate many difficulties associated with reoperative common femoral artery surgery with satisfactory long-term results.

Adult↗
PubMed1998

Late clinical and hemodynamic sequelae of isolated calf vein thrombosis.

PURPOSE: Despite the frequent occurrence of isolated calf vein thrombosis (ICVT), little is known about the long-term clinical and hemodynamic sequelae of this condition. This study was conducted to determine late clinical symptoms and vascular laboratory abnormalities in patients after ICVT. METHODS: Of 146 patients in whom ICVT was documented by color flow duplex scanning between 1989 and 1994, 37 were reexamined. Data included history, physical examination, venous recovery time (VRT), and duplex valve closure time (DVCT). A control group with no history of venous disease also underwent identical clinical and hemodynamic testing. RESULTS: Thirty-seven patients (18 male and 19 female) with a median age of 56 years (range, 22 to 76 years) were examined at a mean follow-up of 3.4 years (range, 2.2 to 5.8 years) after the diagnosis of ICVT in 39 extremities. Seventeen subjects (34 extremities) were recruited as normal controls. Presenting symptoms at the time of ICVT included calf pain in 17 patients, calf swelling in seven, pain and swelling in seven, pulmonary symptoms in four, pulmonary symptoms and calf pain in one, and no symptoms in one. In the patients with ICVT, VRT was abnormal in 23% of extremities with ICVT and in 9% of extremities without ICVT. None of the extremities in the control group had an abnormal VRT (p < 0.05). DVCT was abnormal in one or more venous segments in 26% of extremities diagnosed with ICVT and in 6% of control extremities (p < 0.05). Follow-up clinical examination in patients with ICVT revealed 13 (35%) with reticular veins, 10 (27%) with varicose veins, two (5.4%) with edema, one (2.7%) with pigmentation and ulcer (contralateral extremity to ICVT with a previous history of proximal deep venous thrombosis), 13 (35%) with mild discomfort, and one (2.7%) with severe pain. All symptoms attributable to ICVT were mild in nature except in one patient who had severe pain and no physical or hemodynamic vascular laboratory abnormalities at follow-up. CONCLUSION: At an average of 3.4 years after ICVT, approximately one third of patients showed evidence of mild to moderate venous valvular insufficiency, but mostly in segments not involved with ICVT, and few had significant clinical symptoms attributable to venous disease.

Adult↗
PubMed1998

Patient recovery after infrainguinal bypass grafting for limb salvage.

PURPOSE: The outcome of infrainguinal bypass surgery for limb salvage has traditionally been assessed by graft patency rates, limb salvage rates, and patient survival rates. Recently, functional outcome of limb salvage surgery has been assessed by patient ambulatory status and independent living status. These assessments fail to consider the adverse long-term patient effects of delayed wound healing, episodes of recurrent ischemia, and need for repeat operations. An ideal result of infrainguinal bypass surgery for limb salvage includes an uncomplicated operation, elimination of ischemia, prompt wound healing, and rapid return to premorbid functional status without recurrence or repeat surgery. The present study was performed to determine how often this ideal result is actually achieved. METHODS: The records of 112 consecutive patients who underwent initial infrainguinal bypass surgery for limb salvage 5 to 7 years before the study were reviewed for operative complications, graft patency, limb salvage, survival, patient functional status, time to achieve wound healing, need for repeat operations, and recurrence of ischemia. RESULTS: The mean patient age was 66 years. The mean postoperative follow-up was 42 months (range, 0 to 100.1 months). After operation 99 patients (88%) lived independently at home and 103 (92%) were ambulatory. There were seven perioperative deaths (6.3%), and wound complications occurred in 27 patients (24%). By life table, the assisted primary graft patency and limb salvage rates of the index extremity 5 years after operation were 77% and 87%, respectively, and the patient survival rate was 49%. At last follow-up or death, 73% of the patients (72 of 99) who lived independently at home before the operation were still living independently at home, and 70% (72 of 103) of those who were ambulatory before the operation remained ambulatory. Wound (operative and ischemic) healing required a mean of 4.2 months (range, 0.4 to 48 months), and 25 patients (22%) had not achieved complete wound healing at the time of last follow-up or death. Repeat operations to maintain graft patency, treat wound complications, or treat recurrent or contralateral ischemia were required in 61 patients (54%; mean, 1.6 reoperations/patient), and 26 patients (23.2%) ultimately required major limb amputation of the index or contralateral extremity. Only 16 of 112 patients (14.3%) achieved the ideal surgical result of an uncomplicated operation with long-term symptom relief, maintenance of functional status, and no recurrence or repeat operations. CONCLUSIONS: Most patients who undergo infrainguinal bypass surgery for limb salvage require ongoing treatment and have persistent or recurrent symptoms until their death. A significant minority have major tissue loss despite successful initial surgery. Clinically important palliation is frequently achieved by bypass surgery, but ideal results are distinctly infrequent.

Activities of Daily Living↗
PubMed1997

Upper extremity ischemia from subclavian artery aneurysm caused by bony abnormalities of the thoracic outlet.

OBJECTIVE: To describe our experience with surgical therapy for upper extremity ischemia incident to emboli from aneurysms of the subclavian artery. DESIGN: Retrospective review case series. SETTING: Vascular surgery practice at a university hospital-based tertiary referral center. PATIENTS: All patients treated for upper extremity ischemia caused by embolism from a subclavian artery aneurysm from January 1, 1990, to July 31, 1996. INTERVENTION: All patients underwent detailed history and physical examination, screening for immunologic and hypercoaguable disorders, noninvasive vascular laboratory evaluation, and arteriography of the aortic arch in both arms and hands. Surgical treatment consisted of rib excision or fracture plating, aneurysm excision, and interposition vein grafting, with additional saphenous vein bypasses to brachial or forearm arteries as needed to provide uninterrupted circulation to the wrist. RESULTS: Twelve patients (6 males; mean age, 37 years) were treated. All had episodic upper extremity ischemia with an initial misdiagnosis of primary vasospastic disorder. Rest pain and/or ischemic ulceration developed in 3. Duration of symptoms before correct diagnosis averaged 7 months (range, 1-36 months). All patients had bony abnormalities of the thoracic outlet (8 cervical ribs, 3 abnormal first ribs, and 1 unstable clavicular fracture). All aneurysms contained intraluminal thrombus, and all patients had multiple ipsilateral distal arm, forearm, and/or hand arterial occlusions indicating chronic and repeated embolization. All patients underwent aneurysm excision and interposition vein grafting, with additional vein bypass to the brachial (3 patients) and/or forearm arteries (5 patients). Mean follow-up was 18 months (range, 2 weeks to 63 months). Eleven patients had complete symptomatic relief, and 1 patient improved. All subclavian interposition grafts remained patient. Two distal bypass grafts occluded in patients with preoperative arteriograms demonstrating no patient forearm arteries. There has been no limb loss. CONCLUSIONS: Hand ischemia caused by embolization from a subclavian artery aneurysm occurs in young patients without atherosclerosis and is frequently misdiagnosed as vasospasm. Despite advanced disease and multiple chronic distal arterial occlusions, surgical treatment by resection of bony abnormalities, aneurysm excision and grafting, and distal bypass grafting produces excellent results.

Adolescent↗
PubMed1997

Ability of ankle-brachial index to detect lower-extremity atherosclerotic disease progression.

BACKGROUND: Accurate determination of progression of lower-extremity arterial occlusive disease (LEAOD) is required for natural history studies and evaluation of therapies for atherosclerosis. OBJECTIVE: To determine if changes in the ankle-brachial index (ABI) correlated with progression of LEAOD as determined by arteriography or duplex scanning. DESIGN: In patients with prior suprainguinal or infrainguinal lower-extremity revascularization, progression of LEAOD in native arteries was determined by comparing a preoperative (baseline) arteriogram with late follow-up arteriography or duplex scanning. Superficial femoral and popliteal arteries were graded as having less than 50% stenosis, 50% to 99% stenosis, or as being occluded. Tibial arteries were graded as continuously patent or occluded. Operated and nonoperated extremities were included in the study. The baseline ABI was performed postoperatively and repeated at follow-up arteriography or duplex scanning. Progression of LEAOD by the ABI was defined as a decrease in the ABI of 0.15 or greater. Progression of LEAOD by imaging studies was defined as an increase in 1 category of stenosis. Extremities with suprasystolic pressures were excluded. SETTING: Tertiary vascular surgical service. EXTREMITIES AND PATIENTS: One hundred ninety-three extremities were studied in 114 patients during a mean follow-up of 3.3 years. RESULTS: Seventy-two lower extremities (37.3%) showed progression of atherosclerosis by late follow-up arteriography or duplex scanning. Using the imaging studies as the criterion standard, the ABI had 102 true negatives, 29 true positives, 42 false negatives, and 20 false positives (sensitivity, 41%; specificity, 84%; positive predictive value, 59%; negative predictive value, 71%; and accuracy, 68%) for determining the progression of LEAOD. CONCLUSIONS: The ABI is relatively insensitive in identifying the progression of LEAOD as demonstrated by the use of imaging studies. In studies of natural history or therapy for atherosclerosis, imaging studies should be used in preference to the ABI to evaluate the progression of LEAOD accurately.

Adult↗
PubMed1997

Duplex ultrasonography in evaluation of splanchnic artery stenosis.

Duplex ultrasonography accurately identifies high-grade stenoses in the SMA. Analysis of velocity data reveals few false positives and virtually no false negatives in the determination of high-grade SMA stenosis by duplex scanning. We therefore utilize duplex scanning to perform early screening studies of patients with symptoms suggestive of chronic visceral ischemia. If the duplex findings are negative, we recommend evaluating for other sources of abdominal pain. If the findings are positive, prompt angiography is indicated. It is important to remember that although duplex scanning can identify mesenteric artery stenosis, it cannot diagnose intestinal ischemia. By establishing duplex scanning as a useful and accessible noninvasive screening tool, it is hoped that the time between onset of visceral ischemic symptoms and diagnosis of chronic visceral ischemia will be shortened significantly, potentially reducing the morbidity and mortality of the disease.

Blood Vessel Prosthesis↗
PubMed1997

Pulmonary embolism is associated with the combination of isolated calf vein thrombosis and respiratory symptoms.

PURPOSE: Overall prevalence of pulmonary embolism (PE) in patients with deep venous thrombosis (DVT) isolated to calf veins is low. However, the prevalence of PE in the subgroup of patients with respiratory symptoms and isolated calf vein thrombosis (CVT) is unknown. Such information is important in determining whether patients with CVT only and respiratory symptoms should undergo evaluation for PE. The purpose of this study was to determine the prevalence of PE in patients with respiratory symptoms and isolated CVT. METHODS: From 1992 through 1994, all patients assessed by duplex scanning for lower extremity DVT were reviewed, and those found to have isolated CVT and lower extremity or respiratory symptoms were identified. Patients who had respiratory symptoms or later developed respiratory symptoms in addition to lower extremity symptoms underwent pulmonary angiography or ventilation/perfusion (V/Q) scanning. Positive results on pulmonary arteriograms or "high probability" V/Q scans were considered diagnostic of PE. RESULTS: There were 105 patients with isolated CVT and symptoms. Twenty-six patients had respiratory symptoms; nine (35%) had PE and two died. Seventy-nine patients had only lower extremity complaints; five later developed respiratory symptoms. All five had PE and none had progression of CVT on repeat duplex scanning. Neither age, gender, prior DVT/PE, obesity, pregnancy, medication, known malignancy, smoking, recent surgery, or trauma predicted PE. CONCLUSIONS: Patients with respiratory symptoms and duplex diagnosed isolated CVT have a high prevalence of PE and require pulmonary angiographic or V/Q scanning to rule out PE.

Adult↗
PubMed1997

Functional outcome after infrainguinal bypass for limb salvage.

PURPOSE: Functional outcome after infrainguinal bypass (IB) has recently been assessed with global health status questionnaires but not by criteria specific to the objectives of IB (i.e., maintenance of independent living and ambulation). Preoperative and postoperative living situation and ambulatory status were evaluated in patients who underwent IB for limb salvage (LS) indications. METHODS: For patients in whom IB was performed for LS from January 1980 to July 1995, living situation (independent or dependent) and ambulatory status were assessed before the onset of the need for LS surgery and 6 months after surgery. The importance of risk factors (age, sex, diabetes, heart disease, hypertension, renal insufficiency or failure, previous leg bypass, indication for surgery, postoperative morbidity, graft patency) was assessed by multivariate analysis. RESULTS: IB for LS was performed in 513 patients. Before the development of the indication for LS surgery, 92% lived independently and 91% were ambulatory. The operative mortality rate was 2.7%. At 6 months, 86% were alive and the assisted primary graft patency rate was 92%. Ninety-nine percent of survivors who lived independently before developing the need for LS surgery remained independent 6 months after surgery, and 97% of those who were ambulatory before developing the need for LS surgery were ambulatory 6 months after surgery. Only one of 25 survivors (4%) who were not living independently before surgery achieved independent living 6 months after surgery. Twenty-one percent of nonambulatory patients (6 of 29) became ambulatory. Multivariate analysis confirmed the importance of preoperative living situation and ambulatory status in predicting outcome at 6 months (p < 0.0001). Amputation and loss of primary patency were predictive of poor ambulatory status at 6 months (p < 0.0001, p = 0.025, respectively). The overall 5-year survival rate was 48.1%. CONCLUSIONS: Preoperative independence and ambulation best predict postoperative independence and ambulation after IB for LS indications. IB procedures performed for limb salvage have a low operative mortality rate and maintain independent living and ambulation in 99% and 97% of patients, respectively. Poor overall long-term outcome and survival in LS patients results from intercurrent illness and not from IB.

Activities of Daily Living↗
PubMed1996

Peroneal bypass is equivalent to inframalleolar bypass for ischemic pedal gangrene.

OBJECTIVE: To determine if peroneal bypass is a suitable alternative to inframalleolar bypass in patients with ischemic pedal gangrene. DESIGN: Review of a prospectively acquired vascular registry. SETTING: University practice limited to vascular surgery. PATIENTS: Patients with chronic lower-extremity ischemia and pedal gangrene evaluated between 1985 and 1995 in whom the only options for arterial reconstruction were bypass to the peroneal or an inframalleolar artery. INTERVENTIONS: Peroneal or inframalleolar reverse vein bypass. MAIN OUTCOME MEASURES: Time to healing and lifetable analyses of survival, primary patency, and limb salvage. RESULTS: Eighty-three peroneal and 46 pedal bypasses were performed for ischemic foot gangrene. The groups were equivalent for sex, diabetes mellitus, heart disease, hypertension, renal failure, hypercoagulable states, previous ipsilateral bypass, smoking, and preoperative ankle-brachial indices. Patients with inframalleolar bypass were younger than patients with peroneal bypass (63.9 vs 71.6 years, P = .005) and had higher postoperative ankle-brachial indices (1.02 vs 0.91, P = .004). However, 3-year survival rates (69.1% inframalleolar vs 60.0% peroneal, P = .35), limb salvage rates at 2 years (70.3% vs 85.8%, P = .10), and time to wound healing (19.7 vs 21.6 weeks, P = .66) were equivalent. CONCLUSION: Peroneal and inframalleolar bypass for ischemic pedal gangrene have equivalent intermediate-term survival, limb salvage, and wound healing. Surgeons should not feel obliged to perform inframalleolar bypass for pedal gangrene if peroneal bypass is possible.

Aged↗
PubMed1996

Upper extremity thromboembolism after axillary-axillary bypass grafting.

Two patients experienced upper extremity thromboembolism after axillary-axillary bypass grafting (AxAG) for symptomatic subclavian artery stenosis. The first patient, a 67-year-old male, presented with left upper extremity thromboembolism 3 years after AxAG with 8 mm externally support PTFE. An arteriogram revealed a patent AxAG, thrombus in the proximal left subclavian arterial stump just distal to its occlusion, and multiple digital artery emboli. The patient was treated with warfarin for 8 months, with resolution of symptoms. The second patient, a 57-year-old male, occluded his AxAG (8 mm knitted Dacron) with minimal return of symptoms. Non-operative treatment was elected and 4 years later the patient presented with right upper extremity (donor side) thromboembolism. Arteriography revealed occlusion of the AxAG, radial artery, and digital arteries of the index, long and ring fingers. Thrombolytic therapy of the right arm was undertaken with minimal improvement. Subsequent detachment of the AxAG and placement of an interposition reversed saphenous vein graft was performed. Both patients continue to be asymptomatic during follow-up of 4.7 and 2.0 years, respectively.

Aged↗
PubMed1996

"Just in time" decision making for ICU care after carotid endarterectomy.

BACKGROUND: Many patients undergoing carotid endarterectomy (CE) do not require active intensive care unit (ICU) care (AIC). Until recently, all patients spent 24 hours postoperatively in an ICU, but many of these patients were simply monitored and did not need unique ICU services. METHODS: To aid in developing a selective policy for ICU admission following CE, we reviewed preoperative risk factors, recovery room course, and total hospital stay of 126 patients for 2 years when postoperative ICU admission was routine. Preoperative assessment included presence or absence of cardiac disease, hypertension, severe respiratory disease, diabetes, arrhythmia, renal failure, and a Goldman cardiac risk score. The operative, recovery room, and ward records were reviewed for conditions requiring AIC. Requirement for AIC was defined as need for infusion of vasoactive, bronchodilator, or antiarrhythmic medication beyond the recovery room period. In addition, treatment for coronary ischemia or MI, need for active diuresis, perioperative neurological event, or requirement for mechanical ventilation were indications for AIC. RESULTS: There were 132 CEs in 126 patients; 37% required AIC as defined above. When patients who required AIC were compared with patients not requiring AIC, the only significant difference was the number of risk factors per patient. Goldman cardiac risk class I patients were at less risk for cardiac morbidity than the combined Class II and III patients. CONCLUSIONS: In an individual patient, preoperative risk assessment does not aid in predicting the need for AIC following CE. Selection of patients for ICU admission following CE can be accurately determined by a short period of recovery room observation.

Aged↗
PubMed1996

Prospective comparison of infrainguinal bypass grafting in patients with and without antiphospholipid antibodies.

PURPOSE: The antiphospholipid antibodies (APL)-anticardiolipin antibodies (ACL) and lupus anticoagulant (LA)-are widely believed to be associated with decreased lower extremity bypass graft patency rates. To date, no prospective cohort study has confirmed this assumption. A prospective comparison of the result of infrainguinal revascularization procedures performed since 1990 in patients with and without APL forms the basis of this report. METHODS: Patients who underwent elective infrainguinal bypass procedures from 1990 to 1994 were evaluated for hypercoagulable states (ACL, LA, protein C, protein S, and antithrombin III). Patient data were prospectively entered in a computerized vascular registry, and postoperative follow-up was maintained for life. Graft patency, limb salvage, and patient survival rates were calculated by life-table methods. RESULTS: Three hundred twenty-seven lower extremity bypass grafting procedures were performed in 262 patients. APLs were present in 83 patients (32%); 70 patients (84%) had ACLs only, 11 patients (13%) had LA only, and two patients (3%) had both ACLs and LA. There was no significant difference between APL-positive and APL-negative patients with respect to demographics, associated medical conditions, indication for operations, and type of procedures performed. More patients who had APLs had warfarin treatment after surgery (43% vs 24%, p = 0.002). Life table 4-year primary patency rates showed minimal difference (APL-positive, 43%; APL-negative, 59%; p = 0.087), and no significant difference was noted in assisted primary patency rates (APL positive, 72%; APL negative, 73%; p = NS), limb salvage rates (APL positive, 79%; APL negative, 88%; p = NS), and patient survival rates (APL positive, 67%; APL negative, 66%; p = NS). CONCLUSIONS: APLs were found in a surprising one third of the patients who underwent leg bypass grafting procedures. The majority of APLs identified were ACLs (87%). There was minimal difference in graft primary patency rates, and no difference in assisted primary patency, limb salvage, and survival rates between patients with and without APLs who underwent leg bypass grafting procedures. The extreme morbidity rate associated with APLs in previous reports is not confirmed by this prospective study. APLs should not be regarded as a contraindication to indicated leg bypass grafting procedures.

Aged↗
PubMed1996

Improving selection of patients with less than 60% asymptomatic internal carotid artery stenosis for follow-up carotid artery duplex scanning.

PURPOSE: The Asymptomatic Carotid Atherosclerosis Study (ACAS) indicated significant benefit from endarterectomy compared with medical therapy for patients with 60% to 99% asymptomatic internal carotid artery (ICA) stenoses. To date, optimal selection of patients for vascular laboratory follow-up to determine progression from < 60% to > or = 60% asymptomatic ICA stenosis is unknown. To determine which patients with < 60% asymptomatic ICA stenoses are at greatest risk for short-term progression to > or = 60% without symptoms, we reviewed vascular laboratory results and clinical risk factors of consecutive patients who were prospectively observed in a study of atherosclerosis progression. METHODS: Carotid duplex studies were obtained every 6 months and were reviewed for progression from < 60% to > or = 60% asymptomatic ICA stenosis by using criteria that were developed and reported by our laboratory. Clinical risk factors and velocities from initial duplex scans were analyzed for association with progression from < 60% to > or = 60% ICA stenoses without symptoms. RESULTS: Two hundred sixty-three patients (mean age, 66 years) with 434 asymptomatic < 60% ICA stenoses were prospectively observed for a mean of 20 months, with a mean of four examinations per patient. Seventeen patients (6.5%) and 18 ICAs (4%) progressed without symptoms to > or = 60% ICA stenoses at a mean of 18 months. Clinical risk factors associated with progression to > or = 60% asymptomatic ICA stenosis included elevated systolic blood pressure and decreased ankle-brachial index (p = 0.05). The mean initial ICA peak systolic velocity (PSV) in ICAs that progressed to > or = 60% asymptomatic stenoses was 180 cm/sec, compared with 104 cm/sec in asymptomatic ICAs that did not progress to > or = 60% (p = 0.0003). Thirty-one percent of asymptomatic ICAs that had initial PSVs of 175 cm/sec or greater progressed to > or = 60% stenosis, whereas only 1.8% that had initial PSVs less than 175 cm/sec progressed to > or = 60% asymptomatic stenoses (p < 0.001). The life-table-determined rate of freedom from progression to > or = 60% stenosis was 94% at 4 years for asymptomatic ICA lesions that had initial PSVs less than 175 cm/sec, compared with 14% at 3 years for lesions that had initial PSVs > or = 175 cm/sec. CONCLUSIONS: Early progression from < 60% asymptomatic ICA stenoses to > or = 60% asymptomatic ICA stenoses occurs infrequently. Patients who are at the greatest risk of early progression without symptoms to an ACAS-positive lesion can be identified from the ICA PSV at their initial duplex examination. Early vascular laboratory follow-up of asymptomatic ICA stenoses may be limited to a relatively small group.

Aged↗