Biomedical subjects

J L Ballard

Publications and source records attributed to J L Ballard.

At least 19 recordsLinked to original sources

PubMed2005

Delayed development of a traumatic superior mesenteric arteriovenous fistula following multiple gunshot wounds to the abdomen.

Traumatic visceral arteriovenous fistulae are rare and pose a diagnostic and therapeutic challenge. We present the case of a 20-year-old male who sustained multiple gunshot wounds to the abdomen, injuring the inferior vena cava, duodenum, stomach, and small bowel. The patient was taken emergently to the operating room for repair of his injuries, which required primary small bowel repair, duodenal repair, and inferior vena cava ligation due to exigent hemorrhage. At the initial operation there was a normal pulse in the superior mesenteric artery at the base of the small bowel mesentery, with no evidence of hematoma or thrill in the small bowel mesentery. The patient was subsequently returned to the operating room several times for bowel exploration and abdominal wall closure with mesh. Ten days after his initial injury, the patient was noted to have an abdominal bruit on physical exam. Arteriography demonstrated a fistula between the proximal superior mesenteric artery and vein with significant portal hypertension. The patient underwent surgical repair of the superior mesenteric artery and vein with closure of the fistula. The patient had no further complications and was discharged from the hospital 1 month later, after abdominal wall skin grafting, in good condition. The patient remains in good health 12 months later. Continued vigilance and careful physical examination are important in the identification of delayed vascular injuries and allow timely treatment and avoidance of untoward long-term sequelae.

Abdominal Injuries↗

PubMed2001

Renal artery endarterectomy for treatment of renovascular hypertension combined with infrarenal aortic reconstruction: analysis of surgical results.

From June 1995 to February 2000, 16 patients with renovascular hypertension had bilateral transaortic renal artery endarterectomy (RA TEA) combined with either infrarenal aortic aneurysm repair (8 patients) or infrarenal aortodistal bypass for occlusive disease (8 patients). Aortic clamp level for RA TEA was supraceliac in eight patients and suprarenal in eight patients with a mean clamp time of 19 min (range 14 to 25 min). Perioperative complications occurred in four patients. These included respiratory insufficiency with prolonged intubation (1 patient), prolonged intubation with transient renal failure requiring temporary dialysis (1 patient), acute thrombosis of right limb of aortofemoral bypass graft (1 patient) and major left hemispheric cerebrovascular accident (1 patient). Results from this contemporary patient series demonstrate acceptable perioperative morbidity and mortality when RA TEA for treatment of renovascular hypertension is combined with infrarenal aortic reconstruction. In this setting, either supraceliac or suprarenal aortic clamping for short time periods appears to be well tolerated. Clinical outcome is enhanced by salvage of renal function, decrease in medication requirement, and improvement in blood pressure control.

Aged↗

PubMed2001

Management of sterile para-anastomotic aneurysms of the aorta.

The history of surgical reconstruction of the aorta for aneurysmal and occlusive disease now spans over 50 years. The continued performance of these operations with minor modifications attests to their durability and efficacy. Despite this, some late complications do occur. One such complication is the development of a sterile para-anastomotic aneurysm. This has been reported in 1% to 4% of patients; however, the true incidence of para-anastomotic aneurysms of the aorta (PAAA) may be closer to 25% as evidenced by studies with standardized long-term surveillance. PAAA include true and false aneurysms, which occur in the absence of infection. Computed tomography (CT), magnetic resonance imaging (MRI), and labeled white blood cell scans are vital in excluding the presence of infection and differentiating PAAA from infected false aneurysm, aortic graft infection, and aorto-enteric fistula. The surgical approach to PAAA may require complex reconstruction of the suprarenal or supraceliac aorta similar to thoracoabdominal aortic aneurysm repair. Results of surgery are improved with asymptomatic detection and elective repair of PAAA. Methods of prevention rely mainly on technical perfection, but even with this PAAA likely will never be eliminated. This review will cover the incidence, pathophysiology, presentation, diagnosis and operative treatment of sterile para-anastomotic aneurysms of the aorta. Implications for prevention and the role of surveillance will also be discussed.

Anastomosis, Surgical↗

PubMed2000

Cost-effective aortic exposure: a retroperitoneal experience.

In this study we investigated whether the surgical approach to infrarenal aortic aneurysm (IAA) repair significantly affects in-hospital morbidity and cost. The study comprised a consecutive series of 96 patients with elective repair of an IAA by two vascular surgeons using an established protocol from March 1995 to March 1999. The outcomes and costs for 50 patients with transperitoneal (TP) exposure were compared with those for 46 patients with retroperitoneal (RP) exposure, all of whom were in a tertiary care center, in a university hospital. Hospital and ICU days, perioperative complications, and cost were measured. All patients followed the same protocol except for intraoperative aortic exposure. There was no significant difference between TP and RP groups with regard to demographic features (all p-values > 0.12), mean IAA size (p = 0.41) or mean operative blood loss (p = 0.89). Incidence of postoperative complications was similar between the groups (11 in TP and 6 in RP; p = 0.29). However, a trend without statistical significance was noted in the incidence of pulmonary complications (7 in TP and 2 in RP; p = 0.11). Mean ICU days (4 vs. 2; p = 0.004) and hospital days (11 vs. 6; p = 0.002) were significantly longer after TP aortic exposure than after the RP approach. Mean total hospital cost was significantly reduced for patients having RP IAA repair compared to TP IAA repair (mean cost difference = $5,527; p = 0.016). Retroperitoneal exposure for IAA repair is associated with decreased pulmonary complications, significantly shorter ICU and hospital days, and significantly decreased hospital cost compared to transperitoneal aortic exposure. In the future, RP exposure for IAA repair should be the benchmark for comparison of any new techniques.

Aged↗

PubMed2000

Minimally invasive approach for aortic arch branch vessel reconstruction.

Minimally invasive aortic arch branch vessel reconstruction was successfully accomplished in four patients over the past 3 years. There were no operative complications. Three patients had an uneventful hospital course, ranging from 3 to 5 days. The fourth patient with multiple medical problems and severe peripheral vascular disease had a prolonged hospital course for reasons unrelated to the surgical procedure. This minimally invasive surgical exposure can be used to effectively and safely repair innominate and left common carotid artery lesions.

Adult↗

PubMed2000

Extracorporeal techniques in thoracoabdominal aortic surgery.

Most complications related to thoracoabdominal aortic reconstruction stem from ischemia-induced injury to the viscera, kidneys, and spinal cord. In addition to adjunctive methods designed to minimize metabolic demands of the spinal cord during aortic cross-clamping, a variety of extracorporeal techniques have been developed that provide supplemental blood flow to vital end organs during the period of clamp-induced ischemia. These techniques represent a broad range of design complexities and command significant operator expertise to optimize their benefit. This section briefly describes commonly used extracorporeal circulation methods in thoracoabdominal aortic surgery.

Aorta, Abdominal↗

PubMed1999

Vascular reconstruction and major resection for malignancy.

HYPOTHESIS: Complications of vascular procedures performed for tumor infiltration of major vessels or for the rescue of complex tumor resections may significantly affect perioperative patient outcome and long-term patient survival rate. DESIGN AND PATIENTS: Retrospective review of 39 patients undergoing major resection for malignancy between April 1980 and April 1998; 35 patients underwent major-vessel reconstruction, 3 patients underwent extra-anatomic bypass, and 1 patient underwent major venous thrombectomy. SETTING: University hospital tertiary referral center. MAIN OUTCOME MEASURES: Vascular complications and patient survival rate. RESULTS: Vascular complications included major stroke (3), carotid artery blowout (2), acute graft thrombosis (1), bowel infarction (1), and anastomotic disruption (1). Factors such as patient demographics, preoperative irradiation, tumor stage, resection for recurrent disease, and vessel or graft type had no bearing on the occurrence of a vascular complication (P>.05 in all cases). Eight patients (21%) died within 30 days of surgery, and 2 (5%) died after 30 days but before hospital discharge. Five of these deaths were directly related to vascular problems (P<.001). Cumulative patient survival rate was 44%, 26%, and 10% at 1, 3, and 5 years, respectively. CONCLUSIONS: The long-term patient survival rate is poor when resections for carcinoma are associated with maj or-vessel infiltration or a complication that necessitates an emergent vascular procedure. In this setting, in-hospital mortality is negatively affected by the incidence of a major vascular complication.

Emergency Treatment↗

PubMed1999

Mycotic aneurysms of the tibioperoneal arteries.

This case report describes a pediatric patient with mycotic aneurysms of both posterior tibial arteries and the right peroneal artery associated with an episode of endocarditis. To our knowledge, this case represents the first reported occurrence of multiple mycotic aneurysms of the tibioperoneal arteries. It is also unique in that the pathogen was Brucella canis instead of the usual gram-positive pathogens associated with intravenous drug injection. Vascular reconstruction can be accomplished; however, management of this complex problem should be individualized.

Adolescent↗

PubMed1999

Thoracoabdominal aortic aneurysm repair with sequential visceral perfusion: A technical note.

The aim of this study was to develop a method for type III and type IV thoracoabdominal aortic aneurysm (TAA) repair that reduces ischemia time to the abdominal viscera, spinal cord, and lower extremities. Over a 25-month period, five type IV TAAs and three type III TAAs were repaired with a trifurcated polytetrafluoroethylene (PTFE) graft to bypass three of four visceral vessels and another graft to reconstruct the thoracoabdominal aorta. The trifurcated graft was sewn end-to-side to an unaffected area of descending thoracic aorta. Sequential end-to-end bypasses to the left renal, superior mesenteric, and celiac arteries followed this anastomosis. The remaining TAA was then replaced with a Dacron tube or bifurcated graft by clamping distal to the trifurcated graft so as to maintain visceral and left renal artery perfusion. Implantation of the right renal artery into the Dacron graft completed visceral artery reconstruction. The postoperative results indicate the feasibility of type III and IV TAA repair using tangential thoracic aortic clamping, individual aortic branch vessel reconstruction, and separate distal revascularization. This operative technique decreases ischemia time to the abdominal viscera, spinal cord, and lower extremities.

Aged↗

PubMed1998

Aortoiliac stent deployment versus surgical reconstruction: analysis of outcome and cost.

PURPOSE: The purpose of this study is to compare complication rate, primary patency, and cost of stent deployment with direct surgical reconstruction for the treatment of severe aortoiliac occlusive disease. METHODS: From March 1, 1992, to May 31, 1996, 119 patients receiving treatment for aortoiliac occlusive disease were analyzed after exclusions. Sixty-five patients had stent deployment and 54 patients had surgical reconstruction. Data were evaluated within and between the groups by univariate and multivariate logistic regression, life-table, t-test, and cross tabulation with chi2 analysis. RESULTS: There was no significant difference between the groups with regard to demographic features or presenting symptoms (all p values > 0.07). Incidence of procedure-related complications was similar (p = 0.30). However, there were more systemic complications in the surgery group (15 versus 2; RR = 5.5, p < 0.01) and more vascular complications in the stent group (16 versus 3; RR = 12, p < 0.002). Incidence and type of late complications were not appreciably different (all p values > 0.05). Cumulative primary patency rate of bypass grafts was significantly better than stented iliac arteries at 18 months (93% versus 77%), 30 months (93% versus 68%) and 42 months (93% versus 68%); p = 0.002, log rank. Multivariate analysis identified female gender (RR = 4.6, p = 0.03), ipsilateral SFA occlusion (RR = 5.6, p = 0.01), procedure-related vascular complication (RR = 9.7, p = 0.002), and hypercholesterolemia (RR = 5.0, p = 0.02) as independent predictors of bypass graft or stent thrombosis. Mean total hospital cost per limb treated did not differ significantly between surgery and stent deployment groups ($9383 versus $8626, respectively; p = 0.66, t-test). CONCLUSIONS: Treatment of severe aortoiliac occlusive disease by surgical reconstruction or stent deployment has a similar complication rate. Mean hospital cost per limb treated is essentially equal. However, cumulative primary patency rate of bypass grafts is superior to stents. Therefore, considering the elements of cost and patency, surgical revascularization has greater value. The benchmark for cost-effective treatment of severe aortoiliac occlusive disease is direct surgical reconstruction.

Aged↗

PubMed1998

Carotid endarterectomy and abdominal aoritc aneurysm repair: are these reasonable treatments for patients over age 80?

Due to the aging of America, increased numbers of very elderly patients require peripheral vascular surgery. From April 1980 to November 1997, 191 patients age 80 years or older had carotid endarterectomy (CEA) and/or abdominal aortic aneurysm (AAA) repair at Loma Linda University Medical Center. The total perioperative stroke and death rate in the CEA group was 2.9 per cent. Mean postoperative cumulative survival in this group was 8.4 years. The cumulative stroke-free survival rate was 95.5 per cent for all yearly postoperative intervals up to 12 years. The perioperative mortality rate was 10.7 per cent in the nonruptured AAA group and 53.8 per cent in the ruptured AAA group (P < 0.00001). Mean cumulative survival was 8.6 years in the nonruptured AAA group and 1.1 years in the ruptured AAA group (P = 0.0001). These data support the conclusion that CEA and nonemergent AAA repair in octo- and nonagenarians are safe and effective in prolonging stroke-free and rupture-free survival. The utility of ruptured AAA repair in this age-group is less clear.

Aged↗

PubMed1998

Cervicothoracic vascular injuries.

Arterial and venous trauma of the cervicothoracic region continues to present challenging problems for the surgeon, despite advances in vascular diagnostics and surgical technique. Whether due to penetrating or blunt mechanisms, overall incidence of these injuries is low, whereas morbidity and mortality remain high. Despite collective experience from busy trauma centers, there still remain controversies regarding diagnostic evaluation, operative approach, and surgical treatment of these potentially devastating injuries. Therefore, this article compares and contrasts recent literature and controversies surrounding the treatment of cervicothoracic trauma. Pros and cons of duplex ultrasonography and angiography in the diagnosis of carotid and vertebral artery injury are highlighted, and selective versus mandatory neck exploration for zone II penetrating injuries are discussed. Increasing awareness of blunt carotid artery injury is emphasized, including management dilemmas that frequently accompany this type of injury. In addition, we review interventional radiological techniques for the management of vertebral artery injury and surgical approaches for aortic arch branch vessel or major cervicothoracic vein injury.

Aorta, Thoracic↗

PubMed1997

Cost-effective evaluation and treatment for carotid disease.

OBJECTIVE: To compare carotid endarterectomy (CEA) based solely on Duplex ultrasonography (DU) with CEA based on DU and arteriography. DESIGN AND SETTING: Retrospective case series analysis in a regional tertiary care center. PATIENTS: Consecutive sample of 194 patients undergoing 218 CEAs from January 1, 1993, through June 30, 1995, with either preoperative DU plus arteriography (165 CEAs) or DU only (53 CEAs). MAIN OUTCOME MEASURES: Concordance of the 2 diagnostic imaging techniques and influence of these on the conduct of surgery, surgical outcome, and resource cost. RESULTS: There was agreement (kappa = 0.85) between DU and arteriography in the detection of a carotid occlusion or a stenosis greater than 45%. Arteriography demonstrated 26 aortic arch branch lesions (15.8%), 22 intracranial abnormalities (13.3%), and 6 type C ulcers (3.6%), in addition to 1 nonoccluded internal carotid artery (ICA) (0.61%) and 1 contralateral severe ICA stenosis (0.61%) inaccurately estimated by Duplex. These findings prompted 3 changes (1.8%) in surgical therapy, including 2 decisions in favor of CEA and 1 subclavian-carotid bypass added to CEA. There was no difference in the stroke and death rate for CEA based solely on DU compared with CEA based on DU and arteriography (P = .43). The mean total hospital cost was $5,534 for DU only CEA vs $7,608 for DU plus arteriogram CEA (mean difference = $2,074, P < .01). CONCLUSIONS: The addition of carotid arteriography to a diagnostic Duplex ultrasound study that already suggested the need for CEA did not change the operative plan in 98% (162/165) of the cases. Carotid endarterectomy based solely on DU is appropriate and cost-effective.

Adult↗

PubMed1997

Early benefits of subfascial endoscopic perforator surgery (SEPS) in healing venous ulcers.

Efficacy of subfascial endoscopic perforator vein surgery (SEPS) in assisting the healing of venous ulcers was determined. During the period June 1995 to May 1996, 19 limbs in 17 patients were treated by SEPS. Thirteen limbs had open ulcers (class 6), five limbs had healed ulcers (class 5), and one limb had severe lipodermatosclerosis (class 4). There were nine male and eight female patients (average age 58, range 33-86). One male had bilateral open ulcers and one female had one open and one healed ulcer. Open ulcers had been present for an average duration of 4.4 years (range 1-14 years). The average ulcer size was 2.8 x 2.2 cm (range 1 x 1 cm to 12 x 6 cm). All operations were conducted on an outpatient basis. At surgery an attempt was made to correct all superficial venous pathophysiology. In addition to SEPS, 12 limbs (63%) had greater saphenous vein (GSV) stripping and 15 patients (79%) had stab avulsion of painful varicose veins. The average number of perforators ligated during SEPS was 3.68 (range 2-8). All active ulcers healed within 90 days. The mean time to healing was 30.5 days (range 6-90 days). Minor postoperative complications (one groin hematoma, three wound infections) occurred in four limbs (21%). There have been no ulcer recurrences during follow-up (mean 8.6 months, range 3-16 months). Outpatient SEPS is an important adjunct in the treatment of chronic venous insufficiency. Experience in this group of 19 limbs strongly suggests that SEPS appears to accelerate the healing of venous ulcers compared to historical controls.

Ambulatory Surgical Procedures↗

PubMed1997

Safety, feasibility, and early efficacy of subfascial endoscopic perforator surgery: a preliminary report from the North American registry.

PURPOSE: The North American Subfascial Endoscopic Perforator Surgery (NASEPS) Registry was established to evaluate the safety, feasibility, and efficacy of minimally invasive endoscopic Linton operations for treatment of chronic venous insufficiency. METHODS: Retrospective analysis was performed on the clinical data of 151 patients who underwent attempt at 158 SEPS in 17 medical centers in the United States and Canada between June 1993 and February 1996. RESULTS: SEPS was completed on 155 limbs of 148 patients, 81 male and 67 female (mean age, 56 years; range, 27 to 87 years). Three procedures were aborted. Seven patients had bilateral procedures (data from one limb were analyzed). One hundred four limbs (70%) had active ulcers, and 22 (15%) had healed ulcers. A single endoscopic port without insufflation was used in 66 procedures (45%) and laparoscopic instrumentation, with two or three ports, in 82 (55%), with CO2 insufflation in 78 (53%). A tourniquet was used on 112 patients (76%). Concomitant venous procedures were performed in 106 patients (72%; saphenous stripping in 71, high ligation in 17, varicosity avulsion in 85). No early deaths or thromboembolism occurred. Complications included wound infections (9), superficial thrombophlebitis (5), cellulitis (4), and saphenous neuralgia (10). Seven patients with wound infection had open ulcers; nine of 10 with neuralgia had concomitant procedures. A roll-on tourniquet caused skin necrosis in one patient. The clinical score improved from 9.4 to 2.9 after surgery (p < 0.0001). Mean follow-up was 5.4 months; 31 patients had > or = 6 months follow-up. Ulcers healed in 88% (75 of 85); recurrence or new ulcer was reported in 3% (4 of 120). CONCLUSIONS: The SEPS modified Linton operation appears safe, with no postoperative deaths or early thromboembolism. Wound infection after SEPS remains important. Early results indicate rapid ulcer healing. Prospective evaluation of long-term results is warranted.

Adult↗

PubMed1996

Combined renal artery stenosis and aortic aneurysm: treatment options.

The purpose of this study was to analyze outcomes of two different treatment strategies in patients treated for renal artery (RA) stenosis and a coincidental abdominal aortic aneurysm (AAA). A total of 50 patients were encountered who required treatment for concomitant RA stenosis and an AAA from 1980 to 1994. Simultaneous operative aortic and RA reconstruction was done in 32 patients, whereas 18 patients where treated with preoperative percutaneous transluminal renal artery angioplasty (PTRA). The two groups were well matched with respect to age, AAA size, incidence of hypertension, preoperative creatinine level, and creatinine clearance (all p values > 0.07). Aortorenal bypass (18 RAs), reimplantation (18 RAs), or endarterectomy (2 RAs) was performed to correct a mean RA stenosis of 88%, whereas 23 RAs (91% mean stenosis) were treated with preoperative PTRA. PTRA failed in four patients with RA stenosis, and they were successfully treated with surgery (3 bypasses and 1 reimplantation). Statistical analysis did not demonstrate a significant difference between these four failed PTRA patients, the 14 successful PTRA patients, and the 32 RA reconstruction patients in terms of operating time (p = 0.15), operative blood loss (p = 0.20), intensive care unit days (p = 0.71), or total hospital days (p = 0.94). Among the 40 patients available for follow-up, hypertension was cured in seven, improved in 10, unchanged in 15, and worse in eight with no difference demonstrated between the groups (p = 0.73). These data suggest that preoperative PTRA has no specific advantage over surgical RA reconstruction in patients with concomitant RA stenosis and AAA. Failed PTRA did not preclude or complicate subsequent operative RA revascularization.

Age Factors↗

PubMed1996

Complications of iliac artery stent deployment.

PURPOSE: This study was performed to determine the primary patency, foot salvage, and complication rates associated with iliac artery stent deployment. METHODS: From March 1992 to May 1995, 147 iliac artery stents were deployed in 98 limbs of 72 patients for disabling claudication or limb-threatening ischemia. Procedure-related and late (> 30 days) complications, as well as adjunctive maneuvers required to correct a complication, were tabulated. Stented iliac artery cumulative primary patency and foot salvage rates were calculated with life-table analysis. Factors that impacted early complications, late complications, foot salvage rates, and stented iliac artery primary patency rates were identified with stepwise logistic regression analysis. RESULTS: A procedure-related complication occurred in 19 (19.4%) limbs. Initial technical success, however, was achieved in all but three of 98 limbs (96.9%). Stented iliac artery cumulative primary patency rates were 87.6%, 61.9%, 55.3%, and foot salvage rates were 97.7%, 85.1%, 76.1%, at 12, 18, and 24 months, respectively. External iliac artery stent deployment, superficial femoral artery occlusion before treatment, and single-vessel tibial runoff before treatment negatively affected stented iliac artery cumulative primary patency rates. Stented iliac artery primary patency rates were not significantly affected by age, smoking, coronary artery disease, diabetes, hypercholesterolemia, hypertension, presenting symptom, early complication, number of stents deployed, type of stent deployed, or stent deployment for stenosis versus occlusion. CONCLUSIONS: Limb-threatening and life-threatening complications can be associated with iliac artery stent deployment. Stented iliac artery primary patency rates are affected by distal atherosclerotic occlusive disease and the position of the deployed stent within the iliac system. Stent reconstruction of severe iliac artery occlusive disease is feasible but should be thoughtfully selected.

Adult↗

PubMed1996

Endovascular stent infection.

We report a case of iliac stent infection. Nine days after a 24-hour infusion of urokinase and right iliac artery stent deployment, the patient had fever, in addition to severe groin pain and petechiae isolated to the stented limb. The hospital course was complicated by sepsis, adult respiratory distress syndrome, liver dysfunction, and renal insufficiency. Stent removal and iliac/femoral artery resection, as well as an above-knee amputation, were life-saving. Arterial and stent cultures grew Staphylococcus aureus. Stent infection with arterial necrosis is a devastating, rare endovascular complication. Given its potential seriousness, we would recommend the use of prophylactic antibiotics before stent deployment.

Amputation, Surgical↗