Biomedical subjects
Publications and source records attributed to J P Archie.
Sixty-one needle catheter jejunostomy procedures have been performed in a community hospital setting with no morbidity. The procedure has been used as an adjunct to a variety of surgical procedures. Upon review of patients receiving a needle catheter jejunostomy, we believe that there should be a wider application of this technique especially in the area of trauma and malignant disease.
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A patient with an atherosclerotic common iliac artery occlusion had acute onset of femoral neuropathy, which resolved after revascularization. This case indicates that ischemia can cause femoral neuropathy and that ischemia may be the explanation for some previously unexplained postoperative femoral neuropathies.
To define cerebral perfusion pressure during carotid clamping, carotid back and jugular venous pressures were measured in 100 consecutive carotid endarterectomies in 92 patients. The mean +/- 1 SD was 40.5 +/- 16.0 mm Hg for carotid back pressure, 11.8 +/- 4.8 mm Hg for jugular venous pressure, and 28.7 15.4 mm Hg for cerebral perfusion pressure. A number of variables affect jugular venous pressure, including jugular vein compression, patient position, and the anesthetic type. The lower the carotid back pressure, the more likely that back pressure alone is poor determinant of cerebral perfusion pressure and, hence, of the adequacy of collateral cerebral blood flow. To accurately use the carotid back or stump pressure method. The jugular venous pressure must also be measured, and the cerebral perfusion pressure must be calculated. Based on established safe levels of cerebral blood flow, it is probable that patients who undergo a carotid endarterectomy with a cerebral perfusion pressure of less than 18 mm Hg have cerebral ischemia and may require a shunt. Selective shunting, based on the cerebral perfusion pressure, gave a 1% mortality and 2% permanent neurologic deficit in this series.
We have described a 70-year-old man with rupture of a previously ligated hypogastric aneurysm. The first operation for multiple abdominal aneurysms was an aorto-bifemoral bypass with endoaneurysmorrhaphy of bilateral iliac aneurysms and proximal ligation of a right hypogastric artery aneurysm. Five months later, after the previously ligated hypogastric artery aneurysm ruptured into the rectum, endoaneurysmorrhaphy and suture ligation of all feeding orifices, creation of a Hartmann's pouch, and end-on colostomy were done. The patient is doing well at nine months' follow-up. We recommend aggressive surgical ablation of hypogastric artery aneurysms, with endoaneurysmorrhaphy and suture ligation of all "feeding" orifices.
The ability of common femoral artery Doppler blood flow velocity waveforms to predict the hemodynamic significance of aortoiliac artery stenosis was determined by comparing intraoperative pressure gradient and flow measurements with two noninvasive nondimensional Doppler velocity waveform indices. The Doppler velocity waveforms of 63 common femoral arteries were recorded preoperatively, and iliac artery pressure gradients and blood flows were measured intraoperatively in 48 nonoccluded arterial segments. The mean iliac artery pressure gradient at double resting flow was calculated for comparisons between patients. Two Nondimensional Doppler velocity waveform indices were calculated: the minimum to maximum velocity amplitude ratio and the maximum to mean velocity amplitude ratio. Both Doppler velocity ratios successfully distinguish arteries with minimal or no hemodynamically significant stenosis from arteries with hemodynamically significant stenosis (mean pressure gradient at double resting flow resting flow greater than 6 mm Hg). A minimum to maximum Doppler velocity ratio of less than 0.185 or a maximum to mean Doppler velocity ratio greater than 2.10 indicates hemodynamically significant aortoiliac stenosis. Superficial femoral artery occlusion was indistinguishable from mild iliac stenosis by the two Doppler velocity waveform ratios but was clearly distinct from significant iliac stenosis.
Common femoral artery atherosclerotic occlusion in the absence of significant aorto-iliac stenosis is unusual. It commonly presents by history and physical examination and noninvasive testing as aorto-iliac disease, and thus the diagnosis is usually made by arteriography. In this article, we describe seven patients with this lesion who underwent revascularization because of ischemia. The six patients who had endarterectomy and patch angioplasty were treated successfully.
The relationship between two variables may be mathematically coupled if either one or both variables are derived and/or calculated, and this can lead to erroneous results and invalid conclusions. The purpose of this report is to identify four types of mathematic coupling of data. Type 1 coupling involves directional changes in two variables which are mathematically coupled. Type 2 coupling is the functional relationship between two calculated variables which have one or more common component variables. Type 3, the most common type of mathematic coupling, is direct algebraic coupling between two variables, when one or more of the variables is derived and/or calculated. Type 4 is indirect coupling or physiologic coupling. The common problem in each type of mathematic coupling is that one variable either directly or indirectly contains the whole or components of the second variable. Statistical techniques, when properly applied to the relationship between the two variables, further obscure the underlying mathematic coupling, and tend to support the erroneous results. Recognition of mathematic coupling is imperative for correct data analysis and accurate interpretation.
This report identifies acute severe systemic hypertension during surgical procedures as a potential life-threatening event. If the increased myocardial oxygen demand is not met by adequate oxygen supply, either because of underlying coronary artery disease or a hemodynamic state that does not allow adequate augmentation of diastolic coronary blood flow, then subendocardial myocardial ischemia and perhaps infarction will occur, particularly if the described events go unrecognized and untreated. Recognition of severe intraoperative hypertension by hemodynamic monitoring, and early treatment by afterload reduction with vasodilators and perhaps subsequent catecholamine support, are indicated and may save both myocardium and life.
Between June 1977 and November 1980, we performed portal systemic shunt operations on eight patients for esophageal bleeding secondary to portal venous hypertension. One patient had operation as an emergency and the other seven semi-electively during the same hospitalization as admission. The patient operated upon as an emergency was the only hospital death. Life table analysis on this small group of patients indicates that semi-elective portal systemic shunt surgery after hemodynamic stabilization, nutritional support, and improvement of hepatic function is a viable alternative to emergency operation that can be done effectively in a community hospital.
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The hemodynamic significance of stenosis was defined by intraoperative measurement of pressure and flow across 22 profunda femoris and 44 iliac artery segments. Measurements were taken at rest and during papaverine-induced vasodilation, and the mean pressure gradient across the arterial segment at double resting flow was calculated. Profunda femoris artery mean pressure gradients at resting flow were less than or equal to 3 mm Hg for stenoses up to and including 75%. The mean pressure gradient at double resting flow increased significantly in profunda femoris arteries with greater than 60% stenosis and was greater than 10 mm Hg in 7 of 10- profunda femoris arteries with 60% to 70% stenosis. Resting mean iliac artery pressure gradients were less than 10 mm Hg in 38 of 39 arteries with less than 90% stenosis and less than 5 mm Hg in 35 of 39. The mean iliac artery pressure gradient at double resting blood flow exceeded 10 mm Hg in 11 of 12 arteries with greater than 70% stenosis and was greater than 8 mm Hg in all 12. Four of 19 iliac arteries in the range of 20% to 65% stenosis as measured by arteriography had pressure gradients at double resting flow greater than 10 mm Hg. These results indicate that the hemodynamic significance of profunda femoris artery stenosis can be determined by intraoperative measurement of mean pressure gradients at double resting blood flow. Mean iliac artery pressure gradients at double resting blood flow may be useful for estimating the hemodynamic significance of iliac stenosis in situations where angiographic findings show mild-to-moderate iliac stenosis.
A new digitalized differential pulse timing oculoplethysmograph was used to detect the presence or absence of significant carotid artery stenosis in 95 consecutive patients undergoing bilateral selective carotid arteriograms. The test had an over-all accuracy rate of 88 to 93 per cent. the unilateral or eye-to-eye time delay was the applicable criteria in 87 patients. If this time delay is seven milliseconds or less, there is a 95 per cent probability that the patient has normal carotid arteries. Time delays equal to, or greater than, eight milliseconds indicate a stenotic carotid artery, the most patients in this category have time delays of greater than 15 milliseconds, a highly specific finding with a 98 per cent or greater confidence in the interpretation of significant carotid artery stenosis.
To better define the hemodynamic significance of internal carotid artery stenosis, intraoperative electromagnetic blood flow measurements were taken in 47 patients before and after carotid endarterectomy. When the ratio of pre- to postendarterectomy blood flew (Qpre/Qpost = Y) is compared to the fractional percent of internal carotid artery stenosis (X), the linear regression lines for the 25 arteries with Qpre/Qpost less than 0.70 are Y = -2.67 x +2.59 and Y = -10.10 x +10.06, respectively, for diameter and area stenosis. The intercepts of the regression lines with (a) Qpre/Qpost = 1 (normal blood flow) are 60% diameter and 90% are stenosis, (b) Qpre/Qpost = 0.60 (40% reduction in blood flow) are 75% diameter and 94% are stenosis and (c) with Qpre/Qpost = 0.36 (64% reduction in blood flow) are 84% diameter and 96% area stenosis. These data indicate that a critical or hemodynamically significant internal carotid artery stenosis may be of a higher grade than previously appreciated and that a stenosis greater than 75% diameter or 94% area may be necessary to symptomatically reduce cerebral blood flow.
The effect of coronary artery disease (CAD) on hemodynamic response to infrarenal aortic cross-clamping was studied in 25 patients undergoing either aortofemoral bypass or abdominal aortic aneurysmectomy. Ten patients had evidence of CAD and 15 did not. Systemic, pulmonary artery (PAP), and pulmonary capillary wedge pressures (PCWP), thermodilution cardiac output, and heart rate were measured immediately before, and 2 and 5 min after infrarenal aortic cross-clamping. Heart rate decreased and arterial pressures and pulmonary and systemic vascular resistances increased in both CAD and non CAD groups after aortic clamping. Cardiac index decreased after clamping in both groups and was significantly lower in the patients with CAD. However, PCWP decreased after clamping in patients without CAD as compared to a significant increase in the patients with CAD. The significantly lower cardiac index (1.8-1.9 L/min x M2) and increased PCWP (13-15 torr) in patients with preexisting CAD scheduled for aortofemoral surgery may suggest that this subgroup is at greater risk for myocardial dysfunction immediately after aortic cross-clamping.
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