Biomedical subjects

K Ouriel

Publications and source records attributed to K Ouriel.

At least 37 records · Page 2Linked to original sources

PubMed2001

Hemodynamic conditions at the carotid bifurcation during protective common carotid occlusion.

OBJECTIVES: Carotid angioplasty and stenting procedures are associated with an obligatory release of particulate debris into the distal cerebral circulation. Although most of the emboli are small and do not result in symptomatic neurologic deficits, some may be large enough to cause stroke. For this reason, a variety of filters and balloon occlusion devices have been employed as adjuvants to decrease the risk of distal embolization during carotid stenting. Some of these devices rely on the arrest of antegrade blood flow with the use of inflow arrest. The present study was undertaken to investigate the hemodynamic conditions that exist at the carotid bifurcation during common carotid artery (CCA) occlusion. METHODS: Internal carotid artery (ICA) and external carotid artery (ECA) stump pressures were measured in 29 patients undergoing carotid endarterectomy. Duplex ultrasound scanning was used to measure the direction and velocity of blood flow in the ICA and ECA with the CCA cross-clamped but the ICA and ECA open, a clinical scenario analogous to CCA balloon occlusion at the time of carotid angioplasty and stenting. The direction and magnitude of ICA and ECA flow were compared with the stump pressures to determine whether a correlation existed between these variables. RESULTS: The mean stump pressure in the ICA and ECA averaged 56 +/- 16 and 53 +/- 12 mm Hg, respectively. The ICA systolic stump pressure was lower than the ECA systolic stump pressure in six patients (21%), and all of these patients had persistent antegrade systolic duplex blood flow by duplex interrogation during CCA occlusion. The ICA systolic stump pressure exceeded the ECA systolic stump pressure in 19 patients (66%), and all of these patients had retrograde ICA flow during systole. Diastolic flow was also well correlated with the magnitude of the ICA/ECA stump pressure differential, with antegrade diastolic ICA blood flow in all nine patients with an ICA diastolic stump pressure less than the ECA diastolic stump pressure. None of the 10 patients with ICA diastolic stump pressure greater than ICA diastolic stump pressure maintained antegrade ICA diastolic flow, but four of these patients had flow to zero in diastole. Overall, 13 of 29 patients (45%) could be surmised to be at risk for distal embolization to the brain based on the persistence of some element of either systolic or diastolic antegrade ICA flow during common carotid occlusion. CONCLUSIONS: Common carotid occlusion alone appears insufficient to protect against distal embolization during manipulations of the carotid bifurcation. Persistent systolic or diastolic antegrade blood flow occurs in a high proportion of patients, lending credence to the use of additional protective strategies to ameliorate the risk of embolic complications.

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PubMed2001

Peripheral artery occlusion: treatment with abciximab plus urokinase versus with urokinase alone--a randomized pilot trial (the PROMPT Study). Platelet Receptor Antibodies in Order to Manage Peripheral Artery Thrombosis.

PURPOSE: To evaluate the combination of a platelet glycoprotein IIb/IIIa complex receptor inhibitor and urokinase for treatment of recent (<or=6 weeks) arterial occlusion of the legs. MATERIALS AND METHODS: Seventy patients with lower extremity arterial occlusion of less than 6 weeks duration were randomly separated into two treatment groups: urokinase plus abciximab or urokinase plus placebo. Primary end points were the rate of major complications at 30 days after randomization and the rates of amputation-free survival and survival without open surgery or major amputation at follow-up of 90 days. Two readers unaware of the patients' treatment group assignments analyzed digital subtraction angiograms as they related to the study end points, with a final consensus reading. RESULTS: Thrombolysis relative to clot length was faster in the urokinase-plus-abciximab group (odds ratio, 0.52; 95% CI: 0.35, 0.76; P < .001). There were no procedure-related deaths or intracranial hemorrhages, but the rate of nonfatal major bleeding was higher with urokinase plus abciximab (four of 50 patients) than with urokinase alone (none of 20 patients; P = .32). At 90 days, amputation-free survival was 96% (48 of 50 patients) in the urokinase-plus-abciximab group compared with 80% (16 of 20 patients) in the urokinase alone group. The hazard ratio for the two Kaplan-Meier curves was 0.42 (95% CI: 0.16, 0.96; P = .04). CONCLUSION: In patients with lower extremity arterial occlusion who were undergoing urokinase thrombolysis, adjunctive abciximab treatment resulted in faster thrombus dissolution and improved amputation-free survival, despite an increase in major bleeding.

Abciximab↗

PubMed2001

Initial experience of platelet glycoprotein IIb/IIIa inhibition with abciximab during carotid stenting: a safe and effective adjunctive therapy.

BACKGROUND AND PURPOSE: Abciximab has been shown to decrease periprocedural ischemic complications after coronary intervention. However, the adjunctive use of abciximab in carotid stenting has not been adequately studied. We sought to determine the efficacy and safety of abciximab in carotid stenting. METHODS: Carotid stenting was performed in 151 consecutive patients determined to be at high surgical risk by a vascular surgeon. Of these, 128 consecutive patients received adjuvant therapy with abciximab (0.25 mg/kg bolus before the lesion was crossed with guidewire and 0.125 micro. kg(-1). min(-1) infusion for 12 hours.). A heparin bolus of 50 U/kg was given, and activated clotting time was maintained between 250 to 300 seconds. All patients received aspirin and thienopyridine. Procedural and 30-day outcomes were compared between the control (n=23) and abciximab (n=128) groups. RESULTS: The 2 groups had similar baseline characteristics. Procedural events were more frequent in the control group (8%; 1 major stroke and 1 neurological death) compared with the abciximab group (1.6%; 1 minor stroke and 1 retinal infarction; P=0.05). On 30-day follow-up, 1 patient presented with delayed intracranial hemorrhage in the abciximab group. There were no other major bleeding complications. CONCLUSIONS: Adjunctive use of abciximab for carotid stenting is safe with no increase in the risk of intracranial hemorrhage. This adjunctive therapy with potent glycoprotein IIb/IIIa inhibition may help to reduce periprocedural adverse events in patients undergoing carotid stenting.

Abciximab↗

PubMed2001

Endovascular management of visceral artery aneurysm.

PURPOSE: To retrospectively review our experience with visceral artery aneurysms (VAAs) treated with percutaneous coil embolization techniques. METHODS: Patient records were retrospectively reviewed between 1988 and 1998 for VAA cases treated with catheter-based techniques. Nine patients (5 women; mean age 64 +/- 11 years) with 12 (8 false and 4 true) VAAs were identified. The majority (67%) of these patients presented with symptoms of aneurysm rupture. The etiology of the aneurysm was iatrogenic in 4, pancreatitis in 4, and idiopathic in 4. Ten cases involved the hepatic artery; the other 2 aneurysmal arteries were the middle colic and the gastroduodenal. Selective and superselective catheter techniques were used to obtain access to the VAA. A variety of microcoils were delivered to entirely fill saccular aneurysms, whereas fusiform aneurysms were thrombosed by occluding the inflow and outflow vessels. RESULTS: Aneurysm exclusion was achieved in 9 (75%) of the 12 cases. The 3 technical failures resulted from the inability to cannulate the aneurysm neck. Coil embolization of the neck of the aneurysm sac did not result in occlusion of the native vessel, with a single exception. No procedure-related complications or deaths were noted. All patients remained symptom free during a mean follow-up of 46.0 +/- 29.6 months. CONCLUSIONS: Percutaneous transcatheter coil embolotherapy is an effective alternative to open surgery for the management of VAAs. This therapy may decrease the morbidity and mortality associated with an open surgical procedure in patients with ruptured aneurysms and pseudoaneurysms, selectively thrombosing the aneurysm while preserving flow in the native vessel.

Aged↗

PubMed2000

Ultrasound-guided thrombin injection for the treatment of postcatheterization pseudoaneurysms.

BACKGROUND: This prospective study was designed to assess the safety and efficacy of using bovine thrombin injection to treat pseudoaneurysms. METHODS AND RESULTS: From April 1998 through December 1999, 70 pseudoaneurysm were injected with bovine thrombin under the guidance of color duplex ultrasound. The most superficial pseudoaneurysm chamber was entered with a 1.5-inch, 19- to 22-gauge or spinal needle. Bovine thrombin, in a 1000 U/cc solution, was injected into the chamber. A total of 36 women and 34 men underwent ultrasound-guided thrombin injection (UGTI). Their mean age was 69.5 years. Most pseudoaneurysms were associated with diagnostic cardiac catheterization or percutaneous coronary intervention (80%). Two pseudoaneurysms arose from the brachial artery; the remainder were in the groin. Twenty-one patients were being treated with either heparin or warfarin, and the majority of the others were on antiplatelet therapy with aspirin or clopidogrel. UGTI was successful in 66 of the 70 patients (94%). The first patient in the series had 2 attempts at thrombin injection and refused further attempts. Two patients had undergone stent graft placement and had short, wide tracts. Both of these patients required surgical repair of their pseudoaneurysms. The fourth patient had a nearly complete pseudoaneurysm thrombosis and was lost to follow-up on discharge. No arterial thrombotic events occurred. One patient had a soleal vein thrombosis in the ipsilateral leg. CONCLUSIONS: UGTI was safe and effective in 94% of patients with postcatheterization pseudoaneurysms. Anticoagulant use did not hinder successful thrombosis. UGTI should be the initial treatment of choice for patients with postcatheterization pseudoaneurysms.

Adult↗

PubMed2000

Acute Arterial Occlusion.

Acute peripheral arterial occlusion is associated with a high risk of limb loss and death. The high mortality rate is as much a function of the multiplicity of baseline comorbidities as it is a result of the insult from the peripheral ischemia and reperfusion. Less invasive methods of restoring arterial perfusion have been used in an attempt to lower the morbidity and mortality rates; in this regard, percutaneous procedures have been investigated as alternatives to primary operative revascularization. The catheter-directed infusion of thrombolytic agents and the use of percutaneous mechanical thrombectomy devices can effect recanalization of the occluded vessel, unmasking the underlying culprit lesion responsible for the occlusive event. The lesion can then be treated with an endovascular approach such as balloon dilatation or stenting; alternatively, a limited open surgical approach can be performed on an elective basis. Several studies have documented a lower rate of death using this approach compared with conventional treatment with primary operation. Although recent randomized trials have failed to confirm reductions in the number of deaths, a similar rate of death and amputation has been achieved with thrombolysis versus operative therapy, concurrent with a substantial reduction in the need for open surgical procedures over midterm follow-up. These observations suggest that an initial course of catheter-directed thrombolysis with or without percutaneous mechanical thrombectomy is an appropriate first step for patients who present with acute peripheral arterial occlusion.

Journal Article↗

PubMed2000

Delayed onset of ascending paralysis after thoracic aortic stent graft deployment.

Delayed spinal cord ischemia after thoracic aortic aneurysm repair is an infrequent but devastating complication. The use of stent grafts to exclude aortic aneurysms is thought to decrease the incidence of the neurologic deficit because there is no period of significant aortic occlusion. We report a case of paraplegia that progressed to quadriplegia occurring 48 hours after the apparently successful deployment of a thoracic aortic stent graft.

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PubMed2000

Complications associated with the use of urokinase and recombinant tissue plasminogen activator for catheter-directed peripheral arterial and venous thrombolysis.

PURPOSE: Catheter-directed thrombolytic dissolution of peripheral arterial and venous thrombus is in widespread use, yet the frequency and nature of associated complications remain ill defined. In an effort to better characterize the complications associated with urokinase (UK) and recombinant tissue plasminogen activator (rt-PA), the clinical course of patients treated for lower extremity vascular occlusions at a single institution was reviewed. MATERIALS AND METHODS: Over a 9-year period, 653 consecutive patients were treated for lower extremity arterial (527 patients) or venous (126 patients) occlusions with catheter-directed UK (483 patients), rt-PA (144 patients), or both (26 patients). Decisions regarding the choice of thrombolytic agent were made by the clinician. In-hospital complications were subcategorized into hemorrhagic and nonhemorrhagic events and the rate of intracranial hemorrhage was specifically tabulated. RESULTS: There were no significant differences in the demographics or clinical presentation of patients treated with either UK or rt-PA. Bleeding complications occurred less often in the patients treated with UK (insertion site hematoma 21.9% vs. 43.8%, P<.0001, any bleeding necessitating transfusion 12.4% vs. 22.2%, P = .004, and intracranial hemorrhage 0.6% vs. 2.8%, P = .031). Cardiopulmonary complications necessitating transfer to the intensive care unit occurred more frequently in the patients treated with rt-PA (4.9% vs. 1.5%, P = .015). The risk of mortality was not statistically different between the UK and rt-PA treated patients (2.7% vs. 6.2%, P = .221). CONCLUSIONS: Thrombolysis appears safer with UK than with rt-PA, with a lower incidence of hemorrhagic complications. It is possible that this finding is related to differential dosing regimens or intrinsic pharmacologic differences between the agents. The observations of this retrospective analysis require confirmation with a prospective, randomized evaluation.

Arterial Occlusive Diseases↗

PubMed2000

Mechanical versus chemical thrombolysis: an in vitro differentiation of thrombolytic mechanisms.

PURPOSE: To assess differing mechanisms of thrombolysis determining time to reperfusion, completeness of thrombus dissolution, and embolic potential. MATERIALS AND METHODS: An in vitro perfusion model designed to mimic arterial flow conditions was created. Bifurcated limbs allowed continuous flow through one channel and the placement of radiolabeled (iodine-125) thrombus housed in a 5-cm segment of polytetrafluoroethylene graft in the other. The three experimental groups consisted of a standard continuous urokinase infusion, a pulsed pressurized injection of saline, and a similar injection with urokinase. A continuous infusion of 5% dextrose served as a control group. Time to reflow (as assessed with ultrasonic flow monitoring), completeness of thrombus dissolution (I-125 liberated into solution), and the number and size of embolic particles produced (detected by a series of graduated filter sizes) were analyzed. RESULTS: Time to reflow was significantly faster for both groups when pressurized injections were used (P < .001). There was no reflow in the control arm at 90 minutes. Completeness of thrombus dissolution was higher when a continuous infusion of urokinase was used in comparison to either of the power injection groups or the control (P < .05). The amount of embolic debris produced was significantly lower with a continuous infusion of urokinase compared with either of the power lysis groups (P < .05), but significantly greater than the control arm (P < .001). The size of the embolic particles in the power pulsed lysis groups was significantly decreased by the addition of urokinase (P < .05). CONCLUSIONS: Reflow is more rapidly established by the use of mechanical means. However, a less complete dissolution of thrombus in conjunction with a greater amount of embolic debris is achieved with this approach. The size of the embolic particles produced is reduced by the addition of a thrombolytic agent.

Blood Vessel Prosthesis↗

PubMed2000

An evaluation of the costs to health care institutions of endovascular aortic aneurysm repair.

BACKGROUND: Endovascular graft techniques hold great potential as a less invasive means for the repair of aortic aneurysms, yet the impact of these new modalities remains poorly elucidated. METHODS: Over a 10-month period at a single institution, 139 patients underwent infrarenal aortic aneurysm repair through a traditional open surgical technique (OS group, 94 patients) or an endovascular approach (ES group, 45 patients). Coated polyester prostheses (Hemashield; Boston Scientific Corporation, Boston, Mass) were used in the OS patients, whereas a modular nitinol polyester device (AneuRx; Medtronic, Sunnyvale, Calif) was used in the ES group. The hospital costs exclusive of professional charges were tabulated for the two groups using the hospital cost accounting system. Outliers were included in the data analysis. RESULTS: The mean operating room time was longer in the OS group than in the ES group (285 minutes vs 166 minutes). The average length of stay was also longer in the OS group (9.7 days vs 3.2 days). Hospital costs related to the length of stay were higher in the OS group, including laboratory costs ($327 higher), pharmacy costs ($688 higher), and nursing costs ($780 higher). Anesthesia costs were also higher in the OS group ($493 higher). Despite these marked differences, the total hospital cost averaged $7205 more in the ES group, a finding that was driven by the cost of the implantable devices themselves ($8976 in the ES group vs $597 in the OS group). CONCLUSIONS: Despite reductions in the length of hospitalization, the cost of care was substantially greater in patients undergoing endovascular aneurysm repair than in patients in whom an open surgical technique was used. These differences are driven by the cost of the endograft device itself, a cost that must not exceed $6000 if the economic impact of endovascular repair is to be in parity with traditional methods. Unless these economic disparities can be ameliorated, the economic impact of endovascular aneurysm repair may limit the widespread application of this technology.

Aged↗

PubMed2000

The anatomy of deep venous thrombosis of the lower extremity.

BACKGROUND: The diagnosis, treatment, and long-term sequelae of lower extremity deep venous thrombosis (DVT) depend on the anatomic location and extent of the process, yet a lack of such fundamental knowledge has limited the development of effective protocols for managing patients with DVT. METHODS: Venograms with evidence of acute DVT were evaluated, and the extent of the thrombotic process was recorded and correlated with the clinical presentation. Thrombi were classified according to the venous segments involved and to the thrombus' isolation to one segment or multiple segments. The left-to-right ratio of the DVT was assessed for various etiologic subgroups. RESULTS: Among 2762 venograms performed in 2541 patients over a 10-year period, there were 885 cases (34.8%) of DVT documented. Of these cases, 344 cases (39%) were idiopathic, 307 cases (35%) were postoperative, 84 cases (10%) occurred in the setting of malignancy, and 70 cases (8%) occurred as the result of trauma. Distal thrombi were more common than proximal thrombi, with calf involvement in 734 patients (83%), femoropopliteal involvement in 470 patients (53%), and iliac involvement in 75 patients (9%). The most common site of thrombus was the peroneal vein, which was involved in 595 patients (67%). The ratio of left-to-right-sided DVT was 1.32:1 overall but was greater for proximal thrombi, with a ratio of 2.4:1 for iliac DVT versus 1.3:1 for infrainguinal DVT. The preponderance of left-sided DVT appeared to be related to the high-frequency, left common iliac vein involvement; the left-to-right ratio was much closer to equality (1.09:1) for isolated infrainguinal DVT. The anatomic configuration of the DVT was correlated with the etiologic subgroup; postoperative DVTs were more often distal, whereas DVT developing in the setting of malignancy was more frequently proximal and often right sided. Proximal, left-sided DVTs were common in the idiopathic subgroup, presumably as a result of undiagnosed left iliac vein webs. CONCLUSIONS: The frequency of distal vein involvement greatly exceeds that of proximal involvement in patients with DVTs. Proximal DVTs are more frequently left sided, whereas distal DVTs occur with a more equal left-to-right distribution. The anatomic extent of DVTs appears to depend on the etiology of the process. These observations may shed light on the pathophysiology of venous thrombosis. The findings are of value in planning therapeutic interventions directed at venous recanalization.

Female↗

PubMed2000

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Journal Article↗

PubMed2000

Surgical repair of aneurysms involving the suprarenal, visceral, and lower thoracic aortic segments: early results and late outcome.

OBJECTIVE: The purpose of this study is to review our experience with surgical repair of lower thoracoabdominal and suprarenal aortic aneurysms to determine early and late survival rates and identify factors influencing morbidity and survival among these patients. MATERIALS: From 1989 through 1998, 165 consecutive patients underwent repair of 108 thoracoabdominal (55 group III and 53 group IV) and 57 suprarenal aneurysms. The study group consisted of 109 men and 56 women with a mean age of 70 years (median, 70 years; range, 29-89 years). Mean aneurysm diameter was 6.9 cm (median, 6.5 cm; range, 4-12 cm). There were 125 aneurysms (76%) repaired electively; 40 repairs (24%) were nonelective. The cause of 12 aneurysms (7%) was chronic aortic dissection; the remaining 153 (93%) were degenerative aneurysms. RESULTS: The early postoperative (30-day) mortality rates were 7% (9/125) for elective and 23% (9/40) for nonelective operations (P =.016). For both elective and urgent procedures, early mortality was 1.8% (1/57) for suprarenal aneurysm repair, 11% (6/53) for group IV thoracoabdominal aneurysms, and 20% (11/55) for group III thoracoabdominal aneurysms (P =.013, suprarenal vs group III). Spinal cord ischemia occurred after 6% (10/165) of aneurysm repairs (4% paraplegia, 2% paraparesis). None of the 57 suprarenal aneurysm repairs were complicated by spinal cord ischemia, whereas it occurred in 2% (1/53) of group IV thoracoabdominal aneurysms and 16% (9/55) of group III thoracoabdominal aneurysms (P =.001, suprarenal vs group III; P =. 016, group IV vs group III). Three (25%) of the 12 patients with dissection developed spinal cord ischemia; this compared with seven (5%) of 153 patients with degenerative aneurysms (P =.027). The cumulative 3-year survival rate for the entire series was 71% (95% CI, 64%-79%), and 5-year survival was 50% (95% CI, 40%-60%). CONCLUSIONS: Aneurysms involving the suprarenal, visceral, and lower thoracic aorta may be repaired with acceptable perioperative mortality and late survival rates. The risk of spinal cord ischemia is increased for patients with aortic dissection and may be stratified according to the proximal extent of the aneurysm.

Aged↗

PubMed2000

Claviculectomy for subclavian venous repair: long-term functional results.

OBJECTIVES: The purpose of this study was to determine the long-term functional results after medial claviculectomy and venous patch angioplasty or bypass grafting using internal jugular vein after incomplete thrombolysis of effort thrombosis of the subclavian vein. METHODS: The records of 11 patients with effort thrombosis who were treated over the past 9 years were reviewed. Patients have been followed up between 3 and 9 years at 6-month intervals with duplex imaging and contrast venography when indicated and have had an orthopedic evaluation of their shoulder function. RESULTS: All reconstructed veins are patent, and only one patient complains of any arm swelling after prolonged usage. This patient is one of three with postphlebitic changes at the site of repair and has similar findings in her basilic vein. All patients have returned to their prethrombosis vocation without limitation. Four of the 11 patients have jobs requiring heavy physical labor. No patient describes any limitations of shoulder function, but one man who works as a diesel mechanic complains of shoulder aching with overuse with repetitive pulling. Three patients describe upper extremity paresthesias when lying on the operated side. Two patients (one man and one woman) are bothered by the large scar and indentation at the site of the incision. Every patient considers the overall result completely successful from a functional standpoint. CONCLUSIONS: Early subclavian venous repair performed through a medial claviculectomy is a durable operation with excellent long-term functional results. Half of the patients noted minor but significant symptoms, but all are uniformly able to return to normal function.

Adolescent↗

PubMed2000

Percutaneous endovascular repair of infrarenal abdominal aortic aneurysms: a feasibility study.

BACKGROUND: Endovascular grafting has markedly reduced the invasiveness of the treatment of abdominal aortic aneurysms. By using a modification of technique for available closure devices, we have been able to achieve percutaneous repair of aneurysms. This study reviewed our initial experience with this technique. METHODS: Demographics and background data from patients undergoing endovascular repair of abdominal aortic aneurysms were reviewed from prospectively collected registry data. Operative notes and angiographic and computed tomography scan data were retrospectively reviewed to assess the success of the percutaneous approach. RESULTS: Fourteen patients have undergone percutaneous placement of the AneuRx (Medtronic, Sunnyvale, Calif) endovascular graft, with a modification of the technique for the Prostar (Perclose, Redwood City, Calif) device for access site closure. Main graft body introduction with a 22F sheath proved successful in nine of 12 (75%) deployments. Contralateral limb deployment through a 16F sheath was successful in 10 of 14 deployments (71.4%). Reasons for conversion to open groin incisions include inadequate percutaneous hemostasis (six cases), iliofemoral dissection (four cases), device failure (one case), and compromised distal flow (one case). Percutaneous deployment success appears to be improved with larger iliac artery dimensions, decreased calcification, and limited tortuosity, because of the limitation of complications related to delivering a larger diameter sheath. Of the 13 percutaneous endograft insertions that were attempted, six (46.2%) were completely successful. CONCLUSION: Percutaneous deployment of available devices is technically feasible by using modifications of technique with percutaneous closure devices, despite large introducer sizes. Further experience with this technique offers the potential for identifying patients in whom this will prove successful and for even further reducing hospital stay and recovery times for aneurysm repair.

Aged↗

PubMed2000

Eversion endarterectomy of the carotid artery: technical considerations and recurrent stenoses.

PURPOSE: The purpose of this study was to examine the characteristics of residual and recurrent lesions after eversion endarterectomy of the carotid artery (E-CE) and compare these results with those following endarterectomy and patch closure (CE-P). METHODS: We reviewed 274 patients who underwent carotid endarterectomy in 1998 with electroencephalographic monitoring, general anesthesia, completion duplex scan, and 1-year follow-up. CE-P was preferred for patients who required temporary shunting. In the E-CE group an additional proximal 2-cm arteriotomy was made in the common carotid artery (CCA) in 79 patients, a longer arteriotomy was made for extensive involvement of the CCA in 14 patients, and the internal carotid artery was advanced proximally as a patch for the CCA arteriotomy closure in 14 patients. Stenoses of > 50% that were present at 1 month were considered residual, and those of > 50% that were present at 1 year but not at 1 month were considered recurrent. RESULTS: There were five (1.8%) postoperative strokes (four after CE-P and one after E-CE, P = not significant). At 30 days there were 28 patients (10.2%) with residual stenoses > 50% (11 patients [10.2%] in the E-CE group and 17 patients [10.1%] in the CE-P group; P = not significant). The incidence of recurrent lesions of more than 50% was similar (4.6% for E-CE vs 4.7% for CE-P). CONCLUSION: The pattern of residual lesions and recurrent stenoses differs with each technique of endarterectomy. Proximal stenoses are more common after E-CE, and distal stenoses are more common after CE-P at both 1 month and 1 year. The frequency of proximal lesions is reduced in E-CE when either the internal carotid artery is advanced proximally onto the CCA or a long CCA arteriotomy is made. Distal recurrences do not seem to be a problem after eversion endarterectomy.

Angiography↗

PubMed2000

Management of synchronous renal neoplasm and abdominal aortic aneurysm.

OBJECTIVES: Renal neoplasm (RN) and abdominal aortic aneurysm (AAA) are occasionally discovered concurrently. The approach to synchronous malignancy and aortic aneurysm is controversial. METHODS: Between 1981 and 1999, concurrent RN and AAA were diagnosed in 50 patients at the Cleveland Clinic Foundation. Twenty-three patients were managed conservatively because of small asymptomatic AAA or metastatic disease; these patients were excluded from the study. The remaining 27 patients underwent operative management of both entities with a staged or simultaneous approach, and they form the basis of this article. RESULTS: AAA diameter ranged from 4.8 to 13 cm (mean, 6.0+/-1.8 cm). RNs were managed with radical nephrectomy in 11 patients (41%), partial nephrectomy in 10 patients (37%), or both in 6 patients with bilateral renal tumors (22%). The AAA repair was performed at the time of the urologic procedure in 11 patients (41%), before the urologic procedure in 13 patients (48%), or after the urologic procedure in 3 patients (11%). The AAA was addressed with open surgical repair in 24 patients (89%); recently, three patients (11%) underwent endovascular repair of the aneurysm and staged partial nephrectomy. The incidence of major perioperative complications was 23% (6 patients). Acute renal failure was the most common complication (3 [11%]) followed by acute respiratory failure (2 [7.4%]), pulmonary embolism (1 [3.7%]), and stroke (1 [3.7%]). At the mean follow-up of 57 months, there were no graft infections reported. The 5-year overall and cancer-specific survival rates were 62% and 81%, respectively. There was a significant difference in 5-year cancer-specific survival when comparing patients managed simultaneously versus staged (80% versus 35%, P =.007). CONCLUSIONS: The concurrent presentation of RN and AAA should not discourage one from treating both entities simultaneously because long-term survival is common. Endovascular repair of AAA holds promise as an attractive strategy in these complex patients.

Aged↗

PubMed2000

An endoluminal method of hemorrhage control and repair of ruptured abdominal aortic aneurysms.

PURPOSE: To report our initial experience with endovascular grafting to treat ruptured abdominal aortic aneurysms (AAAs). METHODS: Three consecutive patients with severe comorbid illnesses and symptoms of aneurysm rupture and hemodynamic instability were treated with aortomonoiliac grafts. The Z-stent-based devices were implanted with the assistance of an occlusion balloon placed in the distal descending thoracic aorta. RESULTS: All patients survived the procedure with successfully excluded AAAs. Two patients had relatively short hospital stays (4 and 14 days), while the third required prolonged treatment for pre-existing conditions. All patients required blood transfusions; 2 developed significant coagulopathies. Definitive management was delayed significantly by imaging protocols and graft construction. CONCLUSIONS: Endovascular repair of ruptured aortic aneurysms is feasible. Proximal aortic control is readily attainable with the use of an aortic occlusion balloon placed through the left axillary artery. The absence of a laparotomy, extensive retroperitoneal dissection, and aortic cross-clamping likely contributes to patient survival; however, the delay in operative therapy to obtain adequate imaging and construct an endograft could be a hindrance to the ultimate success of this approach. The concepts of alternative aortic imaging techniques and endograft design, construction, and storage must be addressed.

Aged↗