Management of renal artery stenosis in conjunction with aortic aneurysm.
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Aortic Aneurysm, Abdominal↗
Biomedical subjects
J L Ballard
Publications and source records attributed to J L Ballard.
Transperitoneal medial visceral rotation.
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Aorta, Abdominal↗
Open operative balloon angioplasty of the internal carotid artery: a technique in evolution.
Open operative balloon angioplasty is a treatment alternative for certain nonatherosclerotic lesions of the internal carotid artery (ICA) including fibromuscular dysplasia (FMD). Standard operative exposure of the carotid bifurcation is performed with atraumatic passage of a guidewire and balloon through a carotid bulb arteriotomy. Under direct fluoroscopic guidance, precise dilatation of the involved area is possible with minimal risk of intimal tear/flap or distal embolization as compared with graduated intraluminal dilatation or percutaneous balloon angioplasty. Vascular control of the common and external carotid arteries lessens the risk of embolization resulting from the constant backflow of blood through the ICA before, during, and after balloon angioplasty, adding to the overall safety and efficacy of the procedure. We report a case of asymptomatic critical carotid artery stenosis associated with FMD successfully treated with open operative balloon angioplasty and review the current literature regarding treatment options for FMD of the ICA.
Aged↗
Stenting without thrombolysis for aortoiliac occlusive disease: experience in 14 high-risk patients.
Stenting without thrombolysis of 16 occluded iliac artery segments and one occluded infrarenal abdominal aorta was attempted in 14 patients. All patients were either considered to be prohibitive operative risks or had contraindications to thrombolytic therapy. Indications for limb reperfusion included rest pain, disabling claudication, or dry gangrene. Successful recanalization was achieved primarily in 13 patients with self-expandable Wallstents, balloon-expandable Palmaz stents, or a combination of the two stents. Follow-up was carried out in all patients in whom recanalization was successful. All stented patients showed symptomatic improvement, and the mean preprocedure ankle/brachial index, which was 0.31, improved to 0.78 after the procedure (p = 0). Complications included a vertebrobasilar stroke during the procedure in one patient, perforation during angioplasty of a stenotic but nonoccluded external iliac artery in one, and dissection of the distal external iliac artery in one. Distal embolization did not occur. Percutaneous recanalization of aortoiliac occlusions without initial thrombolysis is possible and has a high potential for technical success. Additional data and longer follow-up are still needed, but this procedure may provide a reasonable, less invasive option in some patients at high surgical risk or in patients who have contraindications to thrombolytic therapy.
Aged↗
Autologous saphenous vein popliteal-tibial artery bypass for limb-threatening ischemia: a reassessment.
BACKGROUND: The purpose of this review was to ascertain the cumulative primary and secondary graft patency rates, the cumulative limb salvage rate, and the frequency of atherosclerotic disease progression proximal to the graft origin, in patients with autologous saphenous vein popliteal-tibial artery bypass grafts whose operative indication was limb-threatening ischemia. PATIENTS AND METHODS: Forty-three short autologous saphenous vein grafts originating from the popliteal artery were retrospectively reviewed. The life-table method was used to determine primary and secondary graft patency and limb salvage rates. Atherosclerotic disease progression proximal to the graft origin was assessed via follow-up arteriography, segmental limb pressures, or pulse-volume recordings. All other data were compared by chi-square analysis. RESULTS: The cumulative primary graft patency rate at 1, 3, and 5 years (86%, 66%, 58%) was similar to the cumulative secondary patency rate (90%, 70%, 62%) and the cumulative limb salvage rate (80%, 55%, 55%). No patient developed hemo-dynamically significant atherosclerotic disease proximal to the graft origin during the follow-up period. CONCLUSIONS: The similarity of the life-table data suggests graft-dependent, poorly collateralized limbs; it is therefore not uncommon for these patients to require major amputations shortly after bypass failure. There was no evidence of critical proximal disease progression that might warrant a more proximal graft origin. Poplitealtibial artery bypass grafts are durable, with acceptable graft patency and limb salvage rates.
Adult↗
A prospective evaluation of transcutaneous oxygen measurements in the management of diabetic foot problems.
PURPOSE: To test the hypothesis that lower extremity transcutaneous oxygen (TcPO2) measurements can accurately predict severity of foot ischemia and can be used to select appropriate treatment (conservative versus operative) for patients with diabetes and tissue necrosis or ischemic rest pain. METHODS: Fifty-five patients with 66 limbs were prospectively treated from June 1993 to July 1994. Noninvasive hemodynamic arterial assessment and TcPO2 mapping of the involved limb were obtained before treatment was selected. If the transmetatarsal TcPO2 level was 30 mm Hg or greater, the patient's foot problem was managed conservatively with local wound care, debridement, or a minor foot amputation. If the transmetatarsal TcPO2 level was less than 30 mm Hg, arteriography was performed with the anticipated need for vascular reconstruction. The endpoints for determining treatment success or failure were complete wound healing or relief of ischemic rest pain. RESULTS: Thirty-one of 36 (86%) limbs with an initial transmetatarsal TcPO2 level of 30 mm Hg or greater were treated successfully with conservative care, including 73% (11 of 15 feet) of limbs without a palpable pedal pulse. After either bypass or angioplasty, 20 of 24 (83%) limbs achieved a transmetatarsal TcPO2 level greater than 30 mm Hg and had complete resolution of their presenting foot problem. An initial or postintervention transmetatarsal TcPO2 level of 30 mm Hg or greater was more accurate (90%, p = 0.001) than a palpable pedal pulse (65%, p = 0.009), in predicting ultimate wound healing or resolution of rest pain. CONCLUSIONS: TcPO2 mapping is a useful noninvasive modality that can prospectively determine severity of foot ischemia, aid in selecting appropriate treatment for patients with diabetes and foot salvage problems, and decrease the total cost of such care.
Adult↗
Wrist squareness and median nerve impairment.
Previous research indicated that a wrist-squareness ratio (thickness/width) greater than .7 is likely to indicate a median nerve sensory latency greater than 3.7 ms, usually a predictor of carpal tunnel syndrome (CTS). In this study, wrist thicknesses and widths were measured and wrist-squareness ratios were calculated for a sample of 417 railroad maintenance workers. Electrodiagnostic testing, in accordance with American Academy of Electrodiagnostics Medicine guidelines, was performed on both motor and sensory fibers of the median nerve to evaluate subjects for the presence of median nerve impairment typical of CTS. Results of this study indicate that wrist squareness is not a useful predictor of median nerve impairment typical of CTS in the railroad maintenance workers tested.
Adult↗
The diagnostic accuracy of duplex ultrasonography for evaluating carotid bifurcation.
BACKGROUND: In many medical centers the standard preoperative study for patients undergoing carotid endarterectomy is four-vessel carotid arteriography, but duplex scanning of the carotid bifurcation is also reported to be highly accurate for detecting stenotic or occluded carotid arteries. METHODS: The diagnostic accuracy of duplex ultrasonography was evaluated in a study of 774 carotid bifurcations, in 400 patients comparing the degree of predicted internal carotid artery (ICA) stenosis found using that technique, with that found by contrast arteriography. Agreement between the predicted degree of ICA stenosis and the arteriographic measurement was evaluated using the Spearman rank order correlation. Accuracy statistics for duplex scanning as a diagnostic modality were assessed using 2 x 2 tables. RESULTS: The Spearman rank order correlation coefficient was 0.74 (P = 0) for the symptomatic group, 0.65 (P = 0) for the asymptomatic group, and 0.68 (P = 0) for the total group. The accuracy of duplex ultrasonography for detecting all grades of ICA stenosis ranged from 80% to 97%. CONCLUSIONS: Duplex ultrasonography of the carotid bifurcation is a reliable diagnostic tool and can be used as the sole preoperative study for selected patients with extracranial cerebrovascular disease. Our current algorithm is discussed in conjunction with a critical analysis of this large database.
Algorithms↗
Popliteal-tibial bypass grafts in the management of limb-threatening ischemia.
OBJECTIVES: To ascertain the cumulative rates of primary graft patency and limb salvage and the frequency of proximal arterial disease progression in patients with autologous saphenous vein bypass grafts that originate from the popliteal artery and whose operative indication was limb-threatening ischemia. DESIGN: Five-year retrospective study with follow-up that ranged from less than 1 month to 60 months. SETTING: Tertiary care center. PATIENTS: Twenty-four threatened limbs in 23 patients were reviewed. Surgical indications included gangrene in 15 limbs (63%), rest pain in seven limbs (29%), and a nonhealing ulcer in two limbs (8%). Patients with previous ipsilateral infrainguinal arterial reconstructive procedures were excluded. Mean patient age was 66 years, and 18 patients 78% had insulin-dependent diabetes mellitus. MAIN OUTCOME MEASURES: Percentages of primary graft patency and limb salvage were determined by the life-table method. Proximal arterial disease progression was assessed via follow-up arteriography or segmental limb pressures. RESULTS: The cumulative rates of primary graft patency and limb salvage at 1, 3, and 5 years were 73%, 59% and 59%, and 87%, 57%, and 57%, respectively. No patient developed proximal arterial disease progression that required intervention during the study period. CONCLUSIONS: The cumulative rates of primary graft patency and limb salvage were essentially the same, which indicated poorly collateralized limbs that are solely dependent on the graft. There did not appear to be a critical progression of proximal arterial disease that would warrant a more proximal graft origin. A short autologous saphenous vein graft that originates from the above-knee or below-knee popliteal artery is a durable bypass.
Aged↗
Diabetic fetal macrosomia: significance of disproportionate growth.
Fetal hyperinsulinism in infants of diabetic mothers (IDMs) produces increased fetal growth leading to macrosomia, which may or may not be proportionate. Disproportionate macrosomia refers to excessive weight characterized by a high weight/length ratio. We tested the hypotheses that (1) macrosomia in IDMs would be characterized by a high ponderal index (defined as weight/length ratio) and (2) infants with macrosomia who have a high ponderal index would have increased neonatal morbidity--specifically, hyperbilirubinemia, hypoglycemia, polycythemia, and acidosis. We studied 170 IDMs and 510 non-IDMs matched 1:3 for gestational age, race, and year of delivery. Forty-five percent of IDMs had macrosomia compared with 8% of control infants (p = 0.001), and 19% of IDMs had disproportionate macrosomia compared with 1% of control infants (p = 0.001). The rates of hyperbilirubinemia (p = 0.02), hypoglycemia (p = 0.01), and acidosis (p = 0.01) were greatest in infants with disproportionate macrosomia and least in nonmacrosomic infants. The incidence of polycythemia was not significantly different between the groups. We suggest that disproportionate macrosomia in the IDM is associated with an increased likelihood of neonatal complications.
Acidosis↗
Cervical-to-petrous internal carotid artery bypass procedure. Technical note.
The technique for cervical-to-petrous internal carotid artery saphenous vein bypass is described. This procedure was used in the treatment of three patients with high cervical or skull base vascular injuries. All grafts were patent on follow-up angiography.
Carotid Artery Diseases↗
A critical analysis of adjuvant techniques used to assess bowel viability in acute mesenteric ischemia.
Delayed revascularization and inaccurate assessment of bowel viability in acute mesenteric ischemia can be catastrophic. We reviewed the outcome of three popular adjuvant techniques used to evaluate bowel viability in all 16 patients who had second-look abdominal explorations following revascularization for acute mesenteric ischemia from 1984 to 1989. Each adjuvant technique was reviewed separately and compared with the unequivocal end points of viable or nonviable bowel. The sensitivity (percentage of nonviable bowel correctly identified), specificity (percentage of viable bowel identified), predictive value (percentage of bowel identified as "nonviable" that proved to be so), and overall accuracy (percentage of correct evaluations) were determined for each method. The overall accuracy of clinical judgment, fluorescein fluorescence, and Doppler was 50 per cent, 56 per cent, and 0 per cent, respectively. Based on this critical review, we recommend routine second-look explorations in patients with acute mesenteric ischemia to reassess bowel that has been predicted to be viable or to resect bowel that has progressed to infarction.
Acute Disease↗
Management of small artery vascular trauma.
This 11-year retrospective study reviewed 99 arterial injuries distal to the brachial bifurcation or popliteal trifurcation in 89 extremities in 88 patients. Associated injuries occurred in 78 of 88 (89%) patients, including 10 fractures or dislocations, 66 nerve injuries, and 59 single or multiple tendon injuries. Fasciotomy was performed in 9 upper extremities and 11 lower extremities (23% of patients). The selection of operative treatment by arterial repair or ligation was by surgeon choice (52% repair and 48% ligation). Postoperative patency was found in 45 of 47 (96%) repaired arteries. In cases of isolated single arterial injuries (10), there were excellent results, and there was no difference in the results between repair and ligation. In cases of nonisolated single arterial injuries (69), there were 46% and 36% nonvascular complications in the repaired and ligated groups, respectively. In 10 patients with nonisolated multiple arterial injuries in the same extremity, the results of repair of one artery with ligation of the other artery versus repair of both arteries were identical, and there were no vascular complications. Operative exploration was the key to complete evaluation of vascular and neuro/musculoskeletal injuries. The data suggest that one functional artery distal to the elbow or knee is sufficient for limb viability and vascular function (follow-up range: 0 to 110 months; mean: 12 months). Nerve injury was the single most important factor of extremity injury in terms of the degree of functional loss.
Adolescent↗
Major complications of angioaccess surgery.
Angioaccess procedures at one institution over a 4-year period were retrospectively reviewed to ascertain the frequency of major limb- or life-threatening complications. A total of 435 angioaccess procedures were performed, including 81 Cimino-Brescia fistulas, 166 polytetrafluoroethylene grafts, and 111 thrombectomy/revisions. There were 77 operations for major complications in 53 patients. In addition, five patients required major vascular repair or emergency thoracotomy for complications of central hemodialysis line placement. A significant portion (18% of this series) of the total angioaccess caseload of a vascular surgeon will be utilized in the repair of major complications. The in-hospital (6 patients, or 11%) and long-term (12 patients, or 23%) mortality rates are significant. Although most complications can be repaired without limb loss and with shunt salvage, a small percentage (in our study three patients, or 4%) will have debilitating long-term symptoms.
Adult↗
Bilateral traumatic internal carotid artery dissections: case report.
Bilateral internal carotid artery dissections after blunt cervicofacial trauma are rare, with 16 cases being previously published. Management is presumed to be an extension of the dominant therapy for unilateral dissection, that being anticoagulant therapy; however, bilateral stenoses engender questions of threat to total cerebral blood flow. We herein present a patient who suffered bilateral type B dissections and who then had progression of the process on anticoagulant therapy, resulting in an unusual carotid reconstruction.
Adult↗
New Ballard Score, expanded to include extremely premature infants.
The Ballard Maturational Score was refined and expanded to achieve greater accuracy and to include extremely premature neonates. To test validity, accuracy, interrater reliability, and optimal postnatal age at examination, the resulting New Ballard Score (NBS) was assessed for 578 newly born infants and the results were analyzed. Gestational ages ranged from 20 to 44 weeks and postnatal ages at examination ranged from birth to 96 hours. In 530 infants, gestational age by last menstrual period was confirmed by agreement within 2 weeks with gestational age by prenatal ultrasonography (C-GLMP). For these infants, correlation between gestational age by NBS and C-GLMP was 0.97. Mean differences between gestational age by NBS and C-GLMP were 0.32 +/- 1.58 weeks and 0.15 +/- 1.46 weeks among the extremely premature infants (less than 26 weeks) and among the total population, respectively. Correlations between the individual criteria and C-GLMP ranged from 0.72 to 0.82. Interrater reliability of NBS, as determined by correlation between raters who rated the same subgroup of infants, ws 0.95. For infants less than 26 weeks of gestational age, the greatest validity (97% within 2 weeks of C-GLMP) was seen when the examination was performed before 12 hours of postnatal age. For infants at least 26 weeks of gestational age, percentages of agreement with C-GLMP remained constant, averaging 92% for all postnatal age categories up to 96 hours. The NBS is a valid and accurate gestational assessment tool for extremely premature infants and remains valid for the entire newborn infant population.
Anthropometry↗
Ureteroinguinal hernia: a rare companion of sliding inguinal hernias.
Ureteroinguinal herniation is a rare occurrence with only 54 reported cases in the English literature. This article reviews the literature and reports on a case that typifies the problems posed by ureteroinguinal herniation. General surgeons should be aware of the potential of this condition so that they can prevent ligation or severance of the involved ureter.
Aged↗
Gastric outlet obstruction caused by traumatic pseudoaneurysm of superior mesenteric artery.
Traumatic pseudoaneurysms of the superior mesenteric artery (SMA) are extremely rare. We describe two cases of posttraumatic proximal SMA pseudoaneurysms with symptoms of gastric outlet obstruction. Repair was accomplished by aorta-SMA bypass with saphenous vein. Injuries to the proximal SMA are easily missed at laparotomy, especially if intestinal ischemia or hematomas are absent. Recognition and repair are stressed to avoid the complications associated with pseudoaneurysm formation.
Adult↗