Diagnosis, treatment and prevention of aorto-enteric fistulas.
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Aorta, Abdominal↗
Biomedical subjects
J Goldstone
Publications and source records attributed to J Goldstone.
Clinical spectrum of symptomatic external iliac fibromuscular dysplasia.
External iliac fibromuscular dysplasia is a rare and usually asymptomatic disorder. We report eight symptomatic patients seen over a 15-year period and review pathophysiologic mechanisms accounting for the three following distinct lower extremity ischemic sequelae: (1) Emboli--episodic focal digital ischemia (blue toe) was seen in three patients. Resection and primary anastomosis of focal iliac ulcerative fibromuscular dysplasia (one patient) or resection and replacement (two patients) removed the embolic source and relieved the symptoms. (2) Chronic ischemia--gradual onset of full leg claudication in four patients was treated by operative graduated intraluminal dilation in three patients and prosthetic bypass in one. Arteriography subsequently showed a remodeled lumen in the three patients who underwent dilation. (3) Dissection--acute onset leg ischemia resulted from presumed dissection of the external iliac segment. After 4 months of conservative management of antiplatelet agents and exercise, symptoms resolved completely, and arteriogram showed spontaneous restoration of a normal lumen in the dissected segment. The clinical presentation of fibromuscular dysplasia may mimic other arterial processes such as atherosclerosis. Diagnosis is made only by arteriography with specific magnification views of the external iliac arteries and careful surveillance of the renal arteries. Appropriate treatment should be tailored to the clinical presenting symptom. For microembolic disease, resection and replacement are required. For chronic ischemia, intraluminal dilation is generally sufficient and durable and has proved to be a simpler and acceptable alternative to replacement or bypass. In acute dissection, surgical intervention may be deferred if the limb is viable to allow spontaneous healing and remodeling. Persistent symptoms may be the only indication for intervention in this ischemic manifestation of external iliac fibromuscular dysplasia.
Aged↗
Infrarenal aortic occlusion: does it threaten renal perfusion or function?
Proximal propagation of aortic thrombus with resultant impaired renal perfusion has been considered a significant risk of untreated infrarenal aortic occlusion. To investigate this question, we studied 52 patients surviving 1 year or more after surgical interruption of the infrarenal aorta in the course of treatment of aortic graft infection. Blood pressure, renal function, and renal artery anatomy were studied before and after aortic interruption. Preoperatively, 20 patients (38.4%) had treated hypertension, and 11 (21.2%) had impaired renal function (creatinine greater than 1.3 mg/dl). In 46 patients (88.4%) with angiography before aortic interruption, 31 (67.4%) had normal renal arteries, whereas 15 (32.6%) demonstrated renal artery stenosis of less than or equal to 50% (N = 10) or greater than 50% (N = 9). Concomitant renal revascularization (N = 3) or nephrectomy (N = 1) were rare. All patients were monitored after surgery for a mean period of 39.2 months. Thirty-three (63.5%) remain alive and well; 19 (36.5%) have died of causes not related (N = 15) or indirectly related (N = 4) to the original graft infection. Forty-eight patients (92.3%) had late assessment of their blood pressure (N = 44, mean follow-up of 31.0 months) and/or renal function (creatinine) (N = 42, mean follow-up of 26.1 months). Follow-up aortography in 21 patients (40.4%, mean interval of 27.7 months) demonstrated no instance of suprarenal propagation of aortic thrombus. During follow-up 41 patients (78.8%) had no change in either their blood pressure or serum creatinine. Seven patients (13.5%) developed worsening hypertension (N = 3) or a rising creatinine (N = 4).(ABSTRACT TRUNCATED AT 250 WORDS)
Aorta, Abdominal↗
Management of late failures of aorto-femoral reconstructions.
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Aorta, Abdominal↗
Saphenous vein bypass to pedal arteries. An aggressive strategy for foot salvage.
Patients with forefoot ischemia and severe tibial artery disease present a major challenge to revascularization and foot preservation. Encouraged by the success of saphenous vein bypass to the more proximal arteries of the lower leg, we extended this technique to the pedal arteries. Between February 1986 and September 1988, we performed 26 bypasses in 24 men (mean age, 66 years) with critical foot ischemia. Sixty-three percent of the patients had diabetes mellitus, 50% had hypertension, and 71% were actively smoking. Angiography invariably revealed multiple tibial artery occlusions with reconstitution of the pedal arteries. The foot salvage rate was 83% (mean survival, 14 months), primary patency was 83% (mean survival, 9 months), and survival was 86% (mean, 12 months). There were 11 wound complications (42%); two resulted in disruptions of the distal anastomosis and eventual graft failure. Bypass to the pedal arteries yields a high rate of foot salvage and is comparable with more proximal bypass procedures; however, wound complications are common and require special technical considerations.
Aged↗
Altered pharmacokinetics of antibiotics during vascular surgery.
Prophylactic antibiotics significantly decrease the incidence of infection in various surgical procedures. Although antibiotics must be administered preoperatively to be effective, it is unknown whether therapeutic concentrations are necessary throughout the operation to prevent infection. Furthermore, the pharmacokinetics of antibiotics during surgical procedures is not well understood. Several factors, including blood loss, fluid redistribution, and changes in renal blood flow may alter the pharmacokinetic disposition of the antibiotic. In a controlled investigation of intraoperative antibiotic pharmacokinetics, cefamandole was studied in eight patients undergoing elective surgery of the abdominal aorta and peripheral vasculature. Both elimination half-life (67 +/- 19 minutes versus 93 +/- 23 minutes) and the volume of distribution (16.8 +/- 5.3 liters versus 25.2 +/- 11.9 liters) increased when compared with the preoperative state. The increased volume may be due, in part, to redistribution of fluid. Plasma concentrations of antibiotic were low at the time of graft placement in those patients with normal renal function. Additional antibiotic dosing may be warranted prior to prosthesis insertion in these patients.
Aorta, Abdominal↗
Renal endarterectomy through the transected aorta: a new technique for combined aortorenal atherosclerosis--a preliminary report.
The optimal surgical management of combined aortic and renal atherosclerosis has not been defined. A modified technique of renal endarterectomy performed through the transected aorta before anastomosis of the aortic prosthesis is presented. The surgical course and early follow-up results of the first 44 consecutive patients treated by this technique are reported. Twenty-three patients (25%) had symptomatic coronary artery disease, 36 patients (82%) had arterial hypertension, and 28 patients (64%) had elevated serum creatinine levels (mean 2.10 mg/dl). Primary indications for operation related to aortic disease in 39 patients (89%) and to poorly controlled hypertension in five patients (11%). Seventy-five renal arteries were revascularized; 11% of these arteries were occluded. Revascularizations were bilateral in 27 patients (61%), involved a solitary kidney in three patients (6%), and were unilateral in 14 patients (32%). Aortobifemoral bypass grafting was performed in 16 patients (36%), aortoiliac bypass was performed in 15 patients (34%), and infrarenal aortic replacement was performed in 11 patients (25%). Postoperative complications developed in 14 patients (32%). There were two postoperative deaths (4%). Nineteen patients had transient increases in serum creatinine levels greater than 0.5 mg/dl. Two patients required postoperative dialysis, neither related to failure of their renal revascularization. There were five late deaths, all as a result of myocardial infarction. Renal function improved in four patients and remained stable in 22 patients. Blood pressure was improved in 64% of patients previously hypertensive. These preliminary results indicate that renal endarterectomy through the transected aorta along with aortic reconstruction is a safe, efficient, and effective means of treating these complex lesions.
Adult↗
The effect of posture and abdominal binding on respiratory pressures.
We examined the effect of posture on the generation of respiratory pressures in 6 highly trained subjects. Transdiaphragmatic pressure was measured at FRC during bilateral percutaneous phrenic nerve stimulation (twitch Pdi) and maximal sniffs (sniff Pdi), with the abdomen bound and unbound. Maximum static inspiratory (PImax) and expiratory (PEmax) mouth pressures were measured with the abdomen unbound. Three postures were examined: seated (Se), semi-supine (30s), and supine (Su). Changes of posture did not significantly alter twitch Pdi. By contrast, sniff Pdi and static mouth pressures were significantly reduced in the Su posture. Abdominal binding significantly increased twitch Pdi only. We conclude that voluntary respiratory manoeuvres requiring activation, recruitment and coordination of different muscle groups are performed better in the Se position. We suggest that posture be standardised for serial comparative measurements of voluntary respiratory pressures in a given subject.
Abdomen↗
Does compliance mismatch alone cause neointimal hyperplasia?
To define the relationship between compliance mismatch and the development of neointimal hyperplasia, one 3 cm segment of common iliac artery was externally banded in seven dogs, thereby fixing the arterial diameter at end diastole. To quantify compliance, end-diastole diameter and its change with pulse pressure were measured by induction angiometry. This technique uses intravascular soft trifilar wire probes introduced through distally placed polytetrafluoroethylene sidearms. Compliance was checked in the banded and contralateral undissected unbanded control iliac arteries at 3 and 6 months, at which times the vessels were fixed by perfusion, excised, and examined histologically. Sustained (6-month) compliance mismatch was successfully induced within the banded segments (p less than 0.0001), and no compliance mismatch was seen in the control segments (p = 0.357). The intima of all banded vessels was virtually indistinguishable from that in controls grossly and histologically. Mild focal intimal thickening, less than 3 cell layers thick involving less than 5% of the vessel circumference, was typically seen in both banded and control vessels (range 6.57 +/- 6.80 micron to 38.86 +/- 57.16 micron). In marked contrast, at the sites of the polytetrafluoroethylene-to-femoral artery anastomosis, near-occlusive neointimal hyperplasia (1714 +/- 415.47 micron) was seen in all animals. Residual lumen area in the banded and control vessels was only minimally abnormal (range 98.65% +/- 2.18% to 99.96% +/- 0.08%). These data indicate that compliance mismatch alone is an insufficient stimulus for the development of neointimal hyperplasia in the canine model.
Animals↗
Particle size distribution of lipoproteins from human atherosclerotic plaque: a preliminary report.
It is commonly believed that low-density lipoproteins (LDLs) carry cholesterol into the artery wall. In addition, some epidemiologic studies have suggested that triglyceride-rich lipoproteins, such as very-low-density lipoproteins (VLDLs), may be much less important than LDLs in atherogenesis. To determine if VLDLs or their metabolic remnants could have a direct role in the formation of atherosclerotic plaque, we examined lipoproteins isolated from endarterectomy specimens. Atherosclerotic plaque was obtained from eight subjects who underwent aortoiliac endarterectomy (4), aortic aneurysm repair (2), or visceral/renal endarterectomy (2). Plaques were washed extensively, minced, and incubated with a buffered saline solution. Lipoproteins were recovered from this solution via a selected-immunoaffinity column by means of a polyclonal antibody to human LDL (apolipoprotein B-100). Particle sizing from electron photomicrographs of negatively stained specimens indicated that 8% of the lipoprotein particles were the size of plasma VLDL (350 to 800 nm). Thirty-six percent were the size of plasma VLDL remnant particles (250 to 350 nm), and 56% were consistent in size with plasma LDL (175 to 250 nm). We conclude that VLDL- and VLDL remnant-sized particles appear to comprise a significant percentage of the lipoproteins found in human atherosclerotic plaque and could have a direct role in the atherosclerotic process.
Aged↗
Effect of hemodilution on brain tissue during global ischemia.
This study evaluates the effect of blood volume and hematocrit changes on brain tissue during temporary global ischemia. Normal saline was administered intravenously to 55 gerbils to achieve hypo-, normo-, and hypervolemic hemodilution and uniform 30% hematocrit reduction. Each group had unilateral carotid artery ligation and temporary (20 minute) contralateral carotid occlusion. After ten days or death, brains were harvested, preserved in formalin, sectioned in a manner which provided adequate samples of both cortex and hippocampus, and stained with H&E and luxol fast blue. They were then examined and staged microscopically for white and gray matter infarction, edema, and neuronal injury and loss. Histologic studies were performed in a randomized and blinded manner and were classified by one of four categories: normal, minimal, moderate, and severe changes. Three of ten (30%) controls survived ten days but had severe neuronal loss, minimal cerebral edema and a minimal to moderate number of white matter strokes. Survival was best in animals treated with hypovolemic hemodilution (43%). Other rates were: normovolemic (33%), controls (30%), and hypervolemic (8.3%). The degree of brain tissue damage was markedly less in the normovolemic group. In this model, normovolemic hemodilution followed by hypovolemic hemodilution offered the best overall cerebral protection during global ischemia.
Animals↗
Improved management of aortic graft infection: the influence of operation sequence and staging.
To investigate the influence of operation sequence and staging on the outcome of aortic graft infection, we studied the mortality and amputation rates and incidence of new graft infection involving the extra-anatomic bypass (EAB) among 101 patients treated for secondary aortoenteric fistula (N = 43) or primary perigraft infection (N = 58). Patients were retrospectively grouped according to the operative treatment technique. Seven patients underwent infected graft removal (IGR) followed immediately by EAB (traditional). Fifty-seven patients were revascularized first, followed by immediate IGR in 38 patients (sequential) or by delayed IGR in 19 patients (staged). The median interoperative interval for the staged group was 5 days (range 2 to 31 days). Twenty patients underwent simultaneous IGR and in-line autogenous reconstruction (synchronous) and finally in 15 patients treatment consisted of IGR only with no extremity revascularization (none). The mean follow-up interval for all patients was 36.8 months. There was no statistically significant difference in mortality rate (traditional, 43%; sequential, 24%; and staged, 26%) or incidence of new graft infection (traditional, 43%; sequential, 18%; or staged, 16%) among those patients treated with EAB, although there was a trend toward an improved outcome with either sequential or staged treatment. There was a significantly lower amputation rate among sequential patients (11%) (p = 0.038) but not staged patients (16%) (p = 0.171) when compared with traditional treatment (43%). Staged operative treatment was associated with significantly less physiologic stress than sequential treatment as reflected by multiple perioperative metabolic variables (95% confidence limits). The treatment groups were comparable in the incidence of aortoenteric fistulas, culture-negative infections, emergent procedures, and appropriate antibiotic use. We conclude that reversed sequence or staged operative treatment of infected aortic grafts can be performed with no increased patient risk. Although traditional or sequential treatment may be required in the setting of acute hemorrhage, the staged operative approach is recommended for the treatment of chronic aortic graft infections.
Amputation, Surgical↗
Evolving strategies for the repair of complex renovascular lesions.
Fifty-five patients with 59 complex renovascular lesions required two or more branch artery anastomoses during aortorenal grafting. Forty-five reconstructions involving 112 branches were facilitated using hypothermic ex vivo perfusion preservation, whereas 14 involving 28 branches were repaired in situ. Ex vivo repair was used whenever the kidney was considered unreconstructable by in situ techniques. Fibromuscular dysplasia predominated and the branched internal iliac artery was used for renal artery substitution. There were no deaths and only one kidney (ex vivo) was lost. Branch vessel occlusion occurred in two of 140 anastomoses (1.4%). Ninety-eight per cent (51/52) of the heparinized patients had cure or improvement at mean follow-up of 5 years. No late graft dysfunction occurred in postoperative angiographic follow-up. The branched internal iliac artery is uniquely suited and remains the preference of the authors for the replacement of the diseased renal artery and its branches. The in situ repair is ideally suited for lesions limited to the renal artery bifurcation. Ex vivo repair is reserved for complex or reoperative distal arterial lesions. Unique characteristics in the group include: bilateral lesions (25%), solitary kidney (22%), reoperative lesions (16%), children (9%), and coexisting significant aortic disease (7%). In situ and ex vivo repair meet all the challenges of complex renovascular disease. The strategies outlined will achieve outstanding long-term total and segmental renal salvage in the treatment of hypertension or aneurysmal disease. When ex vivo repair is required, it can be accomplished with only one additional simple maneuver, the reanastomosis of the renal vein.
Adolescent↗
The infected infra-renal aortic graft.
Infections involving prosthetic arterial grafts continue to be challenging both for the patient and the surgeon. Preventive measures including perioperative prophylactic antibiotics and meticulous surgical technique are warranted in order to reduce the incidence of this dreaded complication to a minimum. An aggressive diagnostic and therapeutic approach are necessary in order to minimize morbidity and mortality. Factors associated with a favorable prognosis for survival and cure of infection include prompt surgical treatment, complete graft removal, staged graft removal and revascularization, and autogenous reconstructions when feasible. Long-term survival with freedom from infection, i.e. cure, is now an attainable goal in most patients.
Aorta, Abdominal↗
Recurrent carotid stenosis: operative strategy and late results.
From 1957 to 1985, 116 consecutive operations for recurrent carotid stenosis were performed in 99 patients at the University of California, San Francisco. Ninety-four patients underwent 103 reoperations for primary recurrent stenosis (nine patients had bilateral repairs). Seventy-two operations (70%) were performed to relieve cerebrovascular symptoms whereas the indication for 31 operations (30%) was high-grade stenosis. The cause of primary recurrent stenosis was myointimal hyperplasia (MIH) in 47 cases, whereas 56 were caused by recurrent atherosclerosis (ASO). Secondary recurrent stenosis developed in six patients from our own series (5.8%) and an additional six patients were referred after reoperation elsewhere. The 12 lesions in this group were evenly divided between MIH (six) and recurrent ASO (six). MIH resulted in a single tertiary recurrent stenosis. Myointimectomy or repeat endarterectomy and vein patch angioplasty were the most commonly used techniques for repair of a primary recurrent stenosis. Secondary recurrent stenosis necessitated resection of the carotid bifurcation and graft interposition when caused by MIH. Secondary recurrent stenosis caused by ASO could be treated by repeat endarterectomy and vein patch angioplasty in five of six cases. Five strokes occurred in the entire series (4.3%), resulting in two deaths. There were 23 cranial nerve palsies, which rarely persisted beyond 3 months. The morbidity and mortality rates for primary and secondary carotid reoperation are comparable to the original procedure and should not deter the vascular surgeon from reoperative carotid reconstruction whenever indicated.
Blood Vessel Prosthesis↗
Intraoperative assessment of renal and visceral artery reconstruction: the role of duplex scanning and spectral analysis.
To refine our ability to assess intraoperatively renal and visceral reconstructions, we have investigated the usefulness of combined duplex scanning and Doppler spectral analysis to determine the technical adequacy and flow characteristics of these repairs. We studied 62 patients (116 arteries) who underwent renal (83 arteries) or visceral (13) reconstruction by transaortic endarterectomy (76), autogenous graft (12) or prosthetic (5) bypass, reimplantation (2), and dilation (1). Twenty-six nonreconstructed vessels were also studied, including preoperative arteries (6), unrepaired arteries (14), and normal renal arteries (donor nephrectomies) (6). Duplex scanning was performed by means of a 7.5 or 10 MHz probe placed in a sterile glove and plastic sleeve. Peak (Vs) and mean (Vm) velocities measured in meters per second were subsequently calculated from frequency spectral analysis. Spectral broadening (SB) and aortic inflow data were also collected and analyzed. There were no complications related to ultrasound scanning. Mean scan time was 7.8 minutes. Fourteen of 26 nonreconstructed vessels (54%) appeared normal by duplex scanning, including all six control (normal) renal arteries. Sixty-five reconstructed arteries (68%) appeared normal, 27 had various minor defects, and four had major defects (three occlusions and one floating thrombus). The major defects were repaired, whereas minor ones were not. Confirmatory studies were obtained in 19 (73%) nonoperated and 73 (76%) operated vessels. There were two false negative duplex studies (sensitivity 89%) and 17 false positive duplex studies--all minor defects (specificity 77%). The predictive value of duplex scans in detecting the presence of confirmed defects was Tau = 0.47 (p = 0.01). Although SB correlated with B-mode imaging alone (Tau = 0.21, p = 0.07), it added no independent value in predicting the results of a confirmatory study. No other variable (Vs, Vm, or aortic inflow) added to the duplex scan in predicting an abnormal confirmatory study. Detailed renal and visceral artery spectral analysis data are provided for validation of this technique and comparison with transcutaneous studies. These data suggest that the requirement for reliable and immediate assessment of renal and visceral reconstructions, particularly those involving transaortic extraction endarterectomy, is satisfied by duplex scanning.
Endarterectomy↗
Toxicity of butylated hydroxytoluene.
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Adult↗
Ischemia of the upper extremity: significance of proximal arterial disease.
Thirty-four patients had upper extremity ischemia due to proximal arterial disease, including subclavian compression at the thoracic outlet, innominate or subclavian atherosclerosis, and other causes. Nineteen lesions caused distal embolization. Although successful arterial reconstructions were performed in all but one patient, there were five major amputations. Four were associated with a delay in diagnosis, which allowed the formation of repeated distal emboli. Since overlooked proximal brachiocephalic arterial lesions can produce devastating consequences, we believe these vessels should be examined in all cases of hand and arm ischemia.
Adolescent↗