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Biomedical subjects

J P Boland

Publications and source records attributed to J P Boland.

At least 19 recordsLinked to original sources
PubMed1995

Cross-filling of circle of Willis and carotid stenosis by angiography, duplex ultrasound, and oculopneumoplethysmography.

PURPOSE: To evaluate the filling of the Circle of Willis on preoperative arteriograms and to correlate this observation with the results of oculopneumoplethysmography (OPG) and severity of carotid stenosis as determined by duplex ultrasonography and angiography. PATIENTS AND METHODS: Ninety-five patients underwent OPG, duplex ultrasonography, and selective carotid and vertebral arteriography. RESULTS: In all, 45 (88%) patients with a positive OPG had interhemispheric cross-filling of the middle cerebral artery and anterior cerebral artery from a contralateral carotid injection in contrast with 10 (23%) patients with a negative OPG (P < 0.001). Of patients with carotid stenosis > or = 80% on duplex ultrasound, 39 (91%) had cross-filling from a contralateral carotid injection in contrast with 16 (31%) patients with < 80% stenosis (P < 0.001). Of patients with carotid stenosis > or = 80% on arteriogram, 37 (90%) had cross-filling from a contralateral carotid injection in contrast with 18 (33%) patients with < 80% stenosis (P < 0.001). CONCLUSION: These data suggest that the Circle of Willis is frequently incompetent as a collateral pathway and that arteriographic cross-filling is not a reliable index of this pathway. Patients with a positive OPG and corresponding carotid stenosis are likely to have a physiologically incompetent collateral pathway. Perhaps these patients should undergo surgery, even if the stenosis is less than 80%.

Adult↗
PubMed1995

A case study of abdominal angina secondary to celiac compression syndrome.

Celiac compression syndrome occurs when the median arcuate ligament of the diaphragm and/or periarterial neural tissue causes extrinsic compression of the celiac axis. In rare cases, this syndrome can cause upper abdominal angina. The classic triad of celiac compression syndrome consists of abdominal pain, an epigastric bruit, and angiographic evidence of celiac compression. Operative therapy consists of thorough exploration, transection of the median arcuate ligament, and either celiac dilatation or a bypass. This article describes a case of celiac compression syndrome which was treated successfully by transection of the median arcuate ligament and aortosplenic bypass.

Abdominal Pain↗
PubMed1994

Sympathectomy for reflex sympathetic dystrophy: factors affecting outcome.

This study includes our 12-year experience with chemical sympathetic blocks and surgical sympathectomies for causalgic pain of reflex sympathetic dystrophy (RSD) with emphasis on factors affecting clinical outcome. Medical records of patients undergoing sympathectomies for causalgic pain were analyzed. The patients were classified according to Drucker et al. as stage I, II, or III. Results of chemical and surgical sympathectomies were analyzed using both univariate and multivariate methods. Twenty-one patients had lumbar and seven had cervicodorsal sympathectomies for RSD. The mean duration between initial injury and chemical sympathetic block was 10 months with a mean of 11.4 months to surgical sympathectomy. Ten patients (36%) had overt extremity trauma as the precipitating event. Ten patients (36%) had a lumbar laminectomy, three of whom developed the syndrome bilaterally. There was no operative mortality; however, 25% had transient postoperative sympathetic neuralgia. The early and late (> 6 months) satisfactory outcomes after surgical sympathectomy were 82% and 71%, respectively. Patients with stage II presentations were significantly more likely to have satisfactory early (92%) and late (79%) outcomes than stage III patients, 0% and 0% (p = 0.019). Patients with an excellent response to chemical sympathetic block were more likely to have satisfactory early and late surgical outcomes. The time between injury and chemical block and surgical sympathectomy was significantly shorter in patients who had satisfactory early and late surgical outcomes (p < 0.0001). Multivariate analyses demonstrated that the most important independent factor in determining early and late satisfactory outcomes of sympathectomy was the time between injury and sympathectomy (p = 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1994

Laparoscopic staging laparotomy with intra-abdominal manipulation.

We describe a method for performing laparoscopic staging laparotomy. We believe this minimally invasive approach can ease the transition between purely open and laparoscopic surgery, and it is applicable to a variety of intra-abdominal problems. The results are comparable to those of a standard staging laparotomy, with improvement in access morbidity and decreased hospitalization time.

Abdomen↗
PubMed1993

Therapeutic and prophylactic vena caval interruption for pulmonary embolism: caval and venous insertion site patency.

Although anticoagulation remains the treatment of choice for acute pulmonary embolism, vena caval interruption represents an alternative for patients with contraindications and complications or in whom anticoagulation fails. The purpose of this study was to evaluate the effectiveness and safety of two types of caval interruption devices: the original stainless steel Greenfield filter and the Adams-DeWeese clip. Emphasis has been placed on maintaining caval patency with filters and clips and the patency of the femoral vein vs. the jugular vein after filter insertion. We retrospectively reviewed 161 patients who underwent caval interruption (92 filters and 69 clips) for both therapeutic and prophylactic reasons. The operative mortality and morbidity rates were 0% and 3.3% for filter patients and 8.7% and 2.9% for clip patients; no procedure-related mortalities occurred. The late caval patency rate as documented by duplex ultrasonography/venography was 100% for filter patients and 88% for clip patients (p = 0.011). Seven percent of the filter patients and 20% of the clip patients experienced late limb swelling postoperatively (p = 0.05). The incidence of recurrent late pulmonary embolism was 2.5% in the filter group and 1.9% in the clip group. In the filter group, 10% of patients experienced postoperative thrombosis at the femoral vein insertion site and 0% at the jugular vein insertion site. We found that both devices were effective in preventing pulmonary embolism, the filter provided better caval patency than the clip, and the jugular vein had a better patency than the femoral vein after filter insertion.

Adult↗
PubMed1993

Management of deep vein thrombosis of the lower extremity in pregnancy.

Deep vein thrombosis (DVT) of the lower extremity during pregnancy is infrequent, but its complication, pulmonary embolism, remains an important cause of maternal mortality. To evaluate the best method of caring for patients with DVT, we reviewed the records of patients at the Charleston Area Medical Center from 1987-1992 who were treated for this condition. Twelve patients were treated with conventional continuous intravenous heparin for 7 days-10 days followed by subcutaneous heparin until 6 weeks-8 weeks after delivery. The other group consisted of nine patients who were treated with lower dose subcutaneous heparin for 7 days-10 days and maintained as the first group, but a Greenfield filter was inserted for patients with iliofemoral DVT. The patients who received low-dose heparin and Greenfield filters tended to do better than those who received high-dose conventional heparin treatment. However, since there were so few patients evaluated, further verification is needed.

Adult↗
PubMed1992

Adjunctive intraoperative linear extrusion (Fogarty-Chin) balloon angioplasty.

Eighty-nine patients with 94 stenotic segments (mostly iliac or femoral) underwent balloon angioplasty with the first-generation (no guidewire) linear extrusion (Fogarty-Chin) system, in an adjunctive mode, and the overall long-term patency rate (mean follow-up: 21 months) was 81%. Patients were grouped into those having iliac or superficial femoral artery (SFA) lesions and subdivided according to the length of lesions. The overall primary and late success rates for iliac lesions were 95% and 86%, respectively, and for SFA lesions 91% and 76%, respectively. The primary and late success rates for iliac lesions less than 2 cm were 100% and 96%, respectively, and for iliac lesions 2 cm to less than 5 cm 92% and 80%, respectively. The primary and late success rates for SFA lesions less than 2 cm were 100% and 100%, respectively; for lesions 2 cm to less than 5 cm 100% and 83%, respectively; and for lesions 5 to 10 cm 83% and 67%, respectively. A stratified analysis by vessel and segment length reveals that, in SFA lesions with a segment length greater than 5 cm, there is a significantly lower patency rate (67%) when compared with the combined results of the Fogarty-Chin balloon angioplasty system in iliac and femoral artery lesions less than 5 cm (92%). In comparing the composite results presented in a recent text on endovascular surgery by Moore and Ahn as the base data for the standard coaxial (Gruntzig) balloon system, our results (short and long term) are similar.

Aged↗
PubMed1992

Safety of arteriography by direct puncture of a vascular prosthesis.

A total of 122 catheterizations were performed in 105 patients with femoral grafts. Ninety-five femoral grafts were punctured. The mean follow-up time was 21 months. Sixty-one patients had follow-up duplex ultrasounds of the graft puncture site at 6 months. The complication rates for patients with direct graft puncture were comparable to those of patients without grafts undergoing femoral catheter arteriography. Twenty-seven cases with femoral grafts had arteriography using the transaxillary technique. The overall complication rate for the 95 cases with graft puncture was 12% (8% were minor complications) in contrast to 30% (22% were major complications) for the 27 cases with the transaxillary approach. The local, nervous system, and major complication rates were all significantly less in patients with graft puncture than in patients with the transaxillary approach. There was no evidence of early or late pseudoaneurysm formation, disruption of the suture line, or late graft infection in patients with graft puncture. Direct graft puncture arteriography is safe and preferable to the transaxillary approach.

Angiography↗
PubMed1992

Laparoscopic Ripstein procedure.

An endolaparoscopic technique to perform a proctopexy is reported. This procedure appears to be ideally suited for this approach and, furthermore, it can be performed safely and effectively. Long-term predictions of morbidity, mortality and recurrence rates cannot yet be made, but those parameters might not be different from what would be expected with the open approach.

Aged↗
PubMed1992

Bronchial carcinoid tumor: experience over 20 years.

Nineteen cases of bronchial carcinoid tumor seen over 20 years in a 1,000-bed, tertiary medical center were retrospectively reviewed. They consisted of 0.4 per cent of all patients with lung tumors. Initial complaints were hemoptysis, persistent pulmonary infection, chest pain, and diarrhea. Two of the five patients with atypical carcinoid tumors came to the hospital with diarrhea as a result of their chemically active tumors. However, seven patients (36%) were asymptomatic and were diagnosed after an abnormal chest radiograph was noted incidentally. Of 13 patients receiving bronchoscopic examination, 9 (69%) had visible tumors. Bronchial biopsy was performed in 7 patients and led to a diagnosis in all seven. Significant bleeding was noted in 3 patients as a result of biopsy. Lobectomy was the most common surgical procedure in this series. Follow-up of these patients was from 6 months to 15 years. The general outcome for patients with typical carcinoid was good. However, all patients with atypical carcinoid died as a result of dissemination.

Academic Medical Centers↗
PubMed1992

Heparin-induced thrombocytopenia with thrombotic complications.

Heparin-induced thrombocytopenia with thrombotic complications is a serious clinical problem. The diagnosis is confirmed by a positive heparin-induced platelet aggregation test and/or detection of white clots upon pathological exam after a presumptive diagnosis based on these criteria: (1) Development of thrombocytopenia of less than 100,000 mm3 while receiving heparin therapy; (2) Normalization of the platelet count after an interruption in heparin therapy; (3) The presence of thrombotic complications; and (4) Exclusion of other causes of thrombocytopenia. Eight patients with heparin-induced thrombocytopenia were encountered at the Charleston Area Medical Center, Memorial Division, in a recent 20-month period. Various types of heparin, routes of administration, and indications were implicated. The mean platelet nadir was 25,750 mm3 and the mean time to onset of of heparin-induced thrombocytopenia was 4.9 days. Thrombotic complications included seven patients with arterial occlusions of the legs, six with deep-vein thrombosis of the legs (three had pulmonary embolism), and five with combined arterial and venous thrombosis. Treatment strategies included discontinuation of heparin in all patients; intravenous infusion of dextran in five patients, followed by arterial thrombectomy in three patients; urokinase therapy in two patients for arterial thrombotic complications; and insertion of Greenfield filters in four patients for venous thrombotic complications. All surviving patients were given warfarin. The mortality rate was 25 percent and the morbidity rate was 38 percent. In conclusion, an initial platelet count should be obtained on all patients prior to receiving heparin, followed by repeat platelet counts every two to three days. Once thrombocytopenia or thrombosis is diagnosed, heparin should be discontinued and other therapeutic modalities considered.

Adult↗
PubMed1992

Brachiocephalic revascularization: a comparison between carotid-subclavian artery bypass and axilloaxillary artery bypass.

Sixty-seven patients who underwent carotid-subclavian bypass (CSBP) (28 CSBPs only and eight with carotid endarterectomy) or axilloaxillary artery bypass (n = 31) with polytetrafluoroethylene grafts were followed up for a mean of 69.2 and 71.9 months, respectively. Indications for surgery in the CSBP group included hemispheric transient ischemic attack (TIA)/cerebrovascular accident in five, nonhemispheric TIA in seven, upper extremity ischemia in 15, and combined TIA and arm ischemia in nine patients. In the axilloaxillary artery group, two patients had hemispheric TIA, five had nonhemispheric TIA, 12 had upper extremity ischemia, and 12 had combined TIA and arm ischemia. Graft patency was determined clinically and confirmed by segmental Doppler pressures, duplex ultrasonography, or angiography. The 30-day mortality rate was approximately 3% in both groups. The 30-day complication rate was 3% for the axilloaxillary artery group and 8% for the CSBP group (not statistically significant). Relief of symptoms was achieved in 100% of patients in both groups; however, 20% of the patients in the axilloaxillary artery group had a recurrence of symptoms, in contrast to 5.6% in the CSBP group. The cumulative 10-year primary and secondary patency rates, calculated by life-table analysis, were 66% and 84.6% for the axilloaxillary artery procedures and 93.8% and 93.8% for the CSBP procedures, respectively (statistically significant). Concomitant carotid endarterectomy with CSBP did not influence graft patency. In conclusion, both bypasses have comparable morbidity and mortality rates; however, the CSBP has a statistically significantly better primary patency rate than the axilloaxillary artery bypass. Therefore CSBP should be the procedure of choice and the axilloaxillary artery bypass should be restricted to high-risk patients.

Arterial Occlusive Diseases↗
PubMed1992

The judicial use of venous duplex imaging and strain gauge plethysmography (single or combined) in the diagnosis of acute and chronic deep vein thrombosis.

Sixty-eight patients (79 limbs) with clinically suspected deep vein thrombosis were evaluated by duplex imaging, strain gauge plethysmography and venography. The diagnostic accuracies were projected over a spectrum of disease incidences ranging from 10 to 90 per cent of the population. The sensitivity, specificity, positive and negative predictive values, and over-all accuracy in detecting acute deep vein thrombosis were 90.9, 87.1, 83.3, 93.1, and 88.7 per cent, respectively, for venous duplex imaging, and 81.8, 69.6, 56.3, 88.9 and 73.5 per cent, respectively, for strain gauge plethysmography. The positive predictive value and over-all accuracy of venous duplex imaging were statistically significantly higher than that of strain gauge plethysmography. When both tests were combined and compared with venous duplex imaging alone, none of these parameters were statistically significant. For chronic deep vein thrombosis, the sensitivity, specificity, positive predictive value, negative predictive value and over-all accuracy for venous duplex imaging were 75, 86, 80, 86 and 82 per cent, respectively. Fourteen per cent had inconclusive results obtained at venous duplex imaging. When strain gauge plethysmography was combined with venous duplex imaging, the over-all accuracy was 82 per cent. As the true incidence of the disease increases, the positive accuracy differences between strain gauge plethysmography and venous duplex imaging decrease to a negligible level. We concluded that over-all, venous duplex imaging is superior. However, the strain gauge plethysmography has reasonable accuracy and may be used in places where venous duplex imaging is not available. Combined use of venous duplex imaging and strain gauge plethysmography would be helpful in patients with inconclusive results obtained at venous duplex imaging and, as the true incidence increases, the positive accuracy rate of strain gauge plethysmography becomes close to that of venous duplex imaging.

Acute Disease↗
PubMed1991

Diagnostic and therapeutic strategies of white clot syndrome.

This study describes our experience with 12 patients with white clot syndrome encountered during a recent 36-month period. The diagnosis was based on the following criteria: (1) development of thrombocytopenia of less than 100,000/mm3 during administration of heparin therapy, (2) normalization of the platelet count after an interruption in heparin therapy, (3) exclusion of other causes of thrombocytopenia, (4) a positive heparin-induced platelet aggregation test, (5) detection of white clots on pathologic examination, and (6) the presence of thrombotic complications. Of 2,500 patients who received heparin therapy, 12 (0.48%) developed white clot syndrome. Various indications, routes of administration, and types of heparin were implicated. The mean platelet nadir was 26,900/mm3, and the mean time to onset of heparin-induced thrombocytopenia was 5 days. Thrombotic complications included arterial occlusions of the legs in 11 patients, deep vein thrombosis of the legs in 9 patients (4 had pulmonary embolism), and combined arterial and venous thrombosis in 8 patients. Treatment strategies included discontinuation of heparin in all patients and intravenous infusion of dextran, followed by arterial thrombectomy in four patients, urokinase therapy in two patients for arterial complications, and insertion of Greenfield filters in six patients. All patients were given warfarin. The mortality rate was 25% and the morbidity rate was 50%. An initial platelet count should be obtained on all patients prior to receiving heparin, followed by repeat platelet counts every 2 to 3 days. Once thrombocytopenia or thrombosis is diagnosed, heparin should be discontinued and other methods of therapy considered.

Dextrans↗
PubMed1991

Conventional versus thrombolytic therapy in spontaneous (effort) axillary-subclavian vein thrombosis.

Effort axillary-subclavian vein thrombosis in young patients has produced long-term disability because of the failure of the thrombosed vein to recanalize. Ten consecutive patients treated in our institution were analyzed. All patients were diagnosed by venography. Four patients received thrombolytic therapy. Three of these had complete resolution and one had partial resolution of the symptoms and thrombus, that was confirmed by venography and duplex imaging. The remaining six patients were treated with conventional anticoagulant therapy. Three of these patients had no resolution, one had complete resolution of both symptoms and thrombus, and two had only partial resolution of symptoms but no resolution of thrombus. Thrombolytic therapy appears to be superior to anticoagulation in the dissolution of symptoms in effort vein thrombosis and should be considered in its management if the diagnosis is made early.

Adult↗
PubMed1991

Early diagnosis and survival of ruptured abdominal aortic aneurysms.

The hospital records of patients treated with ruptured abdominal aortic aneurysm in a recent 5-year period were reviewed to collect data on factors which may be associated with mortality. Overall mortality was 62%. Patients with intraperitoneal rupture had a higher mortality (97%) than patients with retroperitoneal rupture (25%). Patients at increased risk were older than 80 years, presented with syncope, experienced a short duration of symptoms prior to emergency department (ED) arrival, had initial systolic blood pressure less than 90 mm Hg, and/or initial hemoglobin level less than eight on arrival at the ED and delay in beginning surgery. Multivariate analysis demonstrated preoperative blood pressure, preoperative hemoglobin, presence of syncope, and the amount of blood transfused were largely reflections of the type of rupture and had only slight independent relationship to mortality. The authors concluded that treating emergency physicians and surgeons have little control over the most important risk factors for mortality after aneurysm rupture, but may improve the prognosis by expediting diagnosis in the ED and surgical therapy.

Academic Medical Centers↗
PubMed1991

Clinical, hemodynamic, and anatomic predictors of long-term outcome of lower extremity venovenous bypasses.

Forty-three patients, 24 with crossover femoral saphenous vein bypasses and 19 with saphenopopliteal vein bypasses, were observed for a mean of 5.5 years. All underwent preoperative and sequential postoperative clinical, hemodynamic and foot venous pressure measurement, and anatomic evaluations (duplex and venography). Seventy-one percent of patients undergoing crossover femoral saphenous vein bypasses and 74% of patients undergoing saphenopopliteal vein bypasses had an abnormal preoperative maximum venous outflow, in contrast to 4% and 11% after operation (p = 0.0183). The mean immediate postoperative maximum venous outflow improvement for patients having crossover femoral saphenous vein bypasses and those having saphenopopliteal vein bypasses was 16 and 17 ml, respectively, and the mean late improvement was 19 and 27 ml, respectively. Ninety percent of the patients undergoing crossover femoral vein bypasses and those having saphenopopliteal vein bypasses had abnormal foot venous pressures in contrast to 18% and 22% after operation. The final clinical outcomes (over 1 year) for both patients having the crossover saphenous vein bypasses and those having saphenopopliteal vein bypasses, respectively, were significant improvement (+3 and +2), 63% and 58%; significant worsening (-2), 4% and 5%. Eighty-eight percent of patients undergoing crossover femoral saphenous vein bypasses and 79% of patients undergoing saphenopopliteal vein bypasses with abnormal preoperative maximum venous outflow measurements had significant clinical improvement. In contrast, 86% of patients undergoing crossover femoral saphenous vein bypasses and 80% of patients undergoing saphenopopliteal vein bypasses with normal preoperative maximum venous outflow had no improvement. Seventy-seven percent of patients having saphenopopliteal vein bypasses and a normal venous refill time had significant improvement, in contrast to 17% for patients with an abnormal venous refill time (less than 10 sec). Sixty-seven percent of patients undergoing crossover femoral saphenous vein bypasses and 78% of patients undergoing saphenopopliteal vein bypasses with abnormal foot venous pressure measurements had significant improvement. The cumulative 7-year patency was 75% for patients having crossover femoral saphenous vein bypasses and 56% for those having saphenopopliteal vein bypasses. The operative mortality rate was 0% for both procedures, and the complication rate was 4% and 10%, respectively. The most important preoperative variables that correlated with a good outcome were a low preoperative maximum venous outflow, venous refill time greater than 10 sec, and venous claudication and iliac vein compression. Patients with a normal maximum venous outflow measurement and severe venous reflux should not be candidates for these bypasses.

Blood Pressure↗