Angioscopic control of in situ bypass: technical considerations.
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Angioscopy↗
Biomedical subjects
J T Mehigan
Publications and source records attributed to J T Mehigan.
Early experience with cryopreserved saphenous vein allografts as a conduit for complex limb-salvage procedures.
PURPOSE: The lack of a suitable alternative to autogenous vein is often the limiting factor for complex lower extremity vascular reconstruction, especially when previously placed grafts have failed. Cryopreserved saphenous vein allografts have been used as an alternative conduit. This report reviews our early experience with this conduit in a series of complex redo revascularization procedures for limb salvage when no suitable autogenous vein was available. METHODS: Thirty-five patients underwent 39 lower extremity bypass grafts on 36 limbs. These patients had undergone a combined total of 72 prior revascularization procedures on the symptomatic limb, an average of two procedures per patient. Only five bypasses were performed as a primary procedure. There were 18 men and 17 women with a mean age of 71 years. Sixteen of the patients had diabetes. Thirty-four bypasses were performed for rest pain or ulceration, four for disabling claudication, and one for replacement of an aneurysmal vein graft. There were 35 femorotibial, three below-knee femoropopliteal, and one femoropedal reconstruction. Twenty-five grafts were constructed with cryopreserved vein only, whereas 14 were composite grafts; 10 were constructed with polytetrafluoroethylene, one with Dacron, and three with spliced native saphenous vein. The mean follow-up was 9 months (range 1 to 25 months). RESULTS: There was one early death (< 30 days) and two late deaths. Two patients died with a patent graft. There have been 12 early graft closures and an additional 17 late failures, resulting in primary cumulative graft patency rates of 67%, 56%, 43%, 28%, and 14% at 1, 3, 6, 12, and 18 months, respectively. Surgically correctable causes, including technical error and anastomotic stenosis, could be identified in 13 of the 29 graft failures. Salvage of failed grafts resulted in secondary cumulative graft patency rates of 87%, 77%, 61%, 46%, and 37% at these same intervals. There was no significant difference in primary or secondary graft patency rates related to diabetes, ABO graft compatibility, graft composition or orientation, indication for surgery, state of the outflow tract, or site of distal anastomosis. Limb salvage was attained in 24 (67%) of the 36 limbs. Two amputations were necessary despite patent grafts. CONCLUSIONS: Because of the poor overall graft patency rates, cryopreserved saphenous vein allografts should be used only as a last resort when no alternative autogenous conduit is available. Unless patency rates superior to those achievable with currently available prosthetic or biologic conduits can be attained by adjunctive measures such as routine anticoagulation or immunosuppressive therapy, the use of cryopreserved saphenous vein allografts for lower extremity revascularization should be deferred until improved preparation techniques provide a more durable conduit.
Adult↗
Monorail system for percutaneous repositioning of the Greenfield vena caval filter.
The authors describe a technique for removing or repositioning a malpositioned Greenfield inferior vena caval filter. A "monorail" system was used, in which a wire was passed from the femoral vein through the apical hole in the filter and out the internal jugular vein; the wire was held taut from above and below and thus facilitated repositioning or removal of the filter. The technique was used successfully in two cases.
Adult↗
The vascular war of 1988.
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Angioplasty, Balloon↗
Diffuse arterial narrowing as a result of intimal proliferation: a delayed complication of embolectomy with the Fogarty balloon catheter.
Most complications of embolectomy with the Fogarty balloon catheter are recognized early and have received ample attention in the surgical and radiologic literature. However, the delayed complication of diffuse arterial narrowing causing severe ischemia has received little emphasis, perhaps because follow-up arteriography is not always performed. This report describes five patients--women 43 to 62 years of age--with progressive leg ischemia discovered 2 to 4 months after embolectomy with the balloon catheter. Angiography showed a characteristic pattern of severe, smooth narrowing of that portion of the artery in which balloon embolectomy was performed. Pathologic examination of arterial specimens, available in two of the five patients, revealed marked intimal cellular proliferation, which narrowed the arteries severely without evidence of thrombosis, significant atheromatosis, or active arteritis. The cause appears to be intimal damage by the balloon. Embolectomy with the balloon catheter should be done especially carefully in relatively young women.
Adult↗
Video angioscopy as an alternative to intraoperative arteriography.
Improved technology has made available the technique of video angioscopy. When applied routinely, it can provide a high yield of important technical detail in a graphically precise and easily applicable manner, at the time of a great variety of vascular reconstructions, and complications are rare. Although not entirely replacing intraoperative arteriography, its multiple attractive characteristics make it substantially more useful in many circumstances. Familiarity with the technique will enable vascular surgeons to more rapidly utilize new methods of therapy, such as lasers, as well as improve already existing ones.
Angiography↗
Prosthetic graft infection: limitations of indium white blood cell scanning.
The lack of a rapid, noninvasive, and accurate method to confirm or rule out prosthetic graft infection continues to constitute a compelling and vexing clinical problem. A host of adjunctive diagnostic techniques has been used in the past, but early promising results subsequently have usually not yielded acceptable sensitivity (reflecting false negatives) and specificity (reflecting false positive) data. White blood cell (WBC) indium 111 scanning has recently been added to this list. The utility and accuracy of 111In WBC scans were assessed by retrospective review of WBC scan results in 70 patients undergoing evaluation for possible prosthetic graft infection over a 7-year period. Operative and autopsy data (mean follow-up, 18 months for survivors with negative scans) were used to confirm the 22 positive, 45 negative, and three equivocal WBC scans. The false positive rate (+/- 70% confidence limits) was 36% +/- 6% (n = 8) among the 22 patients with positive scans (44% +/- 6% [11 of 25] if the three equivocal scans are included as false positive), yielding a specificity of 85% +/- 5% and an overall accuracy rate of 88% +/- 4% (80% +/- 5% and 84% +/- 5%, respectively, if the three equivocal cases are considered as false positive). All three patients with equivocal scans ultimately were judged not to have prosthetic graft infection. As implied by the high accuracy rate, the sensitivity of the test was absolute (100% [14 of 14]); there were no false negative results. (ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Popliteal artery stenosis caused by a Baker's cyst.
Popliteal artery compression may be caused by a Baker's cyst as documented by this case report. Typically this occurs in a relatively young patient without other evidence of atherosclerosis. The ischemic symptoms may be intermittent. Treatment should include resection of the offending cyst and any damaged popliteal artery.
Constriction, Pathologic↗
Nature of the renal injury following total renal ischemia in man.
The effects of total renal ischemia (TRI) of 15-87 min duration due to suprarenal clamping of the aorta were studied in 15 mannitol-treated patients undergoing abdominal aortic surgery. 15 patients undergoing similar surgery but requiring only infrarenal clamping served as controls. 1-2 h following TRI, GFR was reduced to only 39% of that in controls, 23 +/- 5 vs. 59 +/- 7 ml/min (P less than 0.001). This could not be ascribed to impaired renal plasma flow (RPF), which was mildly reduced to 331 +/- 71 and was not different from the value in controls, 407 +/- 66 ml/min. However, impaired PAH extraction (43 +/- 7%) and isosthenuria, not present in controls, suggest a primary role for tubular injury in lowering GFR at this time. 24 h following TRI, the GFR remained depressed below controls, 45 +/- 8 vs. 84 +/- 8 ml/min (P less than 0.005), while the transglomerular sieving of neutral dextrans was significantly enhanced (radius interval, 24-40 A). A theoretical analysis of transcapillary solute exchange revealed that these findings could be largely explained by a selective reduction of either RPF (-61%) or of transmembrane hydraulic pressure difference (-18%) below control values. Alternately, a combination of these two factors with changes of smaller magnitude could explain the findings. In contrast, a selective increase in oncotic pressure or decrease of the glomerular ultrafiltration coefficient could be excluded as a cause of hypofiltration 24 h after TRI. These observations lead us to suggest that the transient azotemia observed following TRI is due to a self-limited injury to the nephron that is identical to that seen in overt and sustained forms of acute renal failure.
Aged↗
Continuous ambulatory peritoneal dialysis. Technique of catheter insertion and management of associated surgical complications.
Fifty-seven patients initiated continuous ambulatory peritoneal dialysis. All patients were generally pleased with this form of dialysis and particularly enjoyed the greater mobility and decreased dietary restriction. Complications associated with continuous ambulatory peritoneal dialysis include peritonitis, pericatheter infection, catheter malfunction, dialysate leak, and hernias of the abdominal wall.
Catheterization↗
Snuffbox arteriovenous fistula for hemodialysis.
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Arteriovenous Shunt, Surgical↗
Diagnosis of arterial prosthetic graft infection by indium-111 oxine white blood cell scans.
Early and accurate diagnosis of infected prosthetic arterial grafts is difficult, despite the application of diverse diagnostic modalities. Delay in making the diagnosis is largely responsible for the high amputation and mortality rates associated with this complication. In nine patients with suspected graft infections, indium-111 white blood cell scanning was useful and accurate. Graft infection was proved in five cases and ruled out in three. One false-positive scan was due to a sigmoid diverticular abscess overlying the graft. Indium-111 white blood cell scans may improve the accuracy of diagnosing infected prosthetic grafts, which may result in better limb and patient salvage rates.
Adult↗
Carotodynia associated with carotid arterial disease and stroke.
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Adult↗
Planned approach to the management of malignant invasion of the carotid artery.
A planned approach to the evaluation and management of patients with tumor involvement of the cervical carotid artery is presented. Preoperative arteriography and determination of carotid back-pressure permitted a rational approach in these high risk patients. One patient found to have an extremely low carotid back-pressure was advised not to undergo carotid resection. Six patients with satisfactory carotid back-pressure tolerated carotid resection and reconstruction.
Blood Pressure↗
Calcified aortic plug syndrome.
Five women are described with an extremely rare manifestation of atherosclerosis. All presented with upper extremity hypertension and diminished femoral pulses. Three had intermittent claudication. Plain radiography and arteriography demonstrated focal, heavily calcified, mass-like, obstructing lesions that caused a functional coarctation of the aorta. These lesions involved both the thoracic and abdominal aorta. Three patients had visceral artery involvement. Atherosclerosis was diagnosed in the four patients who underwent endarterectomy or bypass surgery.
Adult↗
The carotid "string" sign. Differential diagnosis and management.
Seventeen patients with arteriographic findings consistent with the carotid "string" sign are presented. Five separate clinicopathologic categories were present, and each required special consideration for proper management. The arteriographic findings alone were insufficient to allow categorization or to predict intraoperative findings. Special emphasis is placed on the importance of examining the apparently occluded carotid artery for signs of the carotid string sign which, if found, indicates continued patency. Familiarity with the broad spectrum of clinicopathologic entities associated with the carotid string sign facilitates management of these often complicated problems.
Aged↗
Carotid back pressures in conjunction with cerebral angiography.
A method for obtaining carotid back pressures at the time of cerebral angiography is described. These preoperative measurements were compared to intraoperative measurements in 18 patients. Preoperative mean carotid back pressures (usually common carotid pressures) were obtained by occluding the artery with a double-lumen balloon catheter and recording the pressure distal to the balloon. Although the mean arterial blood pressure and the arterial carbon dioxide tension proved to be variables, the correlation of the pressures measured at angiography and at surgery was high (p less than 0.001).
Arteriosclerosis↗
Subclavian-carotid transposition for the subclavian steal syndrome.
The clinical experience with twelve patients who underwent subclavian-carotid transposition for the subclavian steal syndrome is related. The technical details of the procedure as well as the satisfactory clinical results are described, and the characteristics making it out procedure of choice are summarized.
Adult↗