Biomedical subjects

K Ouriel

Publications and source records attributed to K Ouriel.

At least 145 records · Page 8Linked to original sources

PubMed1987

Revascularization of the distal profunda femoris artery in the reconstructive treatment of aortoiliac occlusive disease.

The distal profunda femoris artery is frequently spared from atherosclerosis and can be used as a recipient vessel in the absence of a satisfactory common or superficial femoral artery. During a 15-year period 53 inflow procedures were done to the distal profunda femoris artery at a point more than 3 cm from its origin. The ankle-brachial systolic pressure index increased an average of 0.27 +/- 0.04 postoperatively. Limb salvage was achieved in 33 of 37 threatened extremities (89%) and claudication improved in 10 of 14 cases (71%). Symptomatic improvement was dependent on an open popliteal segment and a low profundapopliteal collateral index. The overall 4-year patency by life-table methods was 76%, with a patency of 100% for femoroprofunda crossover grafts, 96% for aorto- and ilioprofunda grafts but only 26% for axilloprofunda grafts. Bypass to the distal profunda femoris artery represents a viable alternative when the common and superficial femoral arteries are unsuitable for outflow, with results comparable to procedures done to a healthy common femoral artery.

Aged↗

PubMed1986

Endarterectomy for localized lesions of the superficial femoral artery at the adductor canal.

Although femoropopliteal bypass is the accepted treatment for diffuse atherosclerotic disease of the superficial femoral artery, endarterectomy may be appropriate for short segmental lesions at the level of the adductor tendon. Over a 25-year period, 94 patients underwent localized endarterectomy of short (less than 15 cm) segments of the distal superficial femoral artery. There were two perioperative deaths in the series, for an operative mortality rate of 2.1%. The long-term patency rate was substantial, with 66% of the reconstructions open at 3 years and 57% open 7 years after operation. Improved results were obtained when a semiclosed method was possible with a transverse distal arteriotomy to prevent subintimal dissection. There was a trend toward improved patency in patients with claudication and those who underwent endarterectomies less than 7.5 cm in length. Patency appeared independent of popliteal outflow. Amputation was initially avoided in 82% of patients presenting with threatened limbs. These results suggest that superficial femoral endarterectomy may be a viable alternative to femoropopliteal bypass when the disease is localized to the adductor canal.

Adult↗

PubMed1986

Carotid endarterectomy for nonhemispheric cerebral symptoms: patient selection with ocular pneumoplethysmography.

Carotid endarterectomy fails to ameliorate nonhemispheric cerebral symptoms in an unacceptably high proportion of patients, specifically those patients with minor, hemodynamically insignificant carotid lesions. Ocular pneumoplethysmography (OPG) has been shown to accurately predict the hemodynamic significance of carotid lesions, but its use has not been applied to the subset of patients with nonhemispheric symptoms. Preoperative OPG studies were obtained in 43 patients with nonhemispheric symptoms. Postoperatively, 72% of patients with OPG suggestive of hemodynamically significant carotid lesions were relieved of symptoms. By contrast, only 32% of patients with normal OPG were asymptomatic after carotid surgery (p less than 0.05, life-table methods, 24-month follow-up). These data suggest that OPG is a useful test to determine which patients with nonhemispheric cerebral symptoms will benefit from carotid revascularization.

Aged↗

PubMed1986

Embolic lesions from the subclavian artery causing transient vertebrobasilar insufficiency.

Thirteen patients with transient vertebrobasilar insufficiency caused by emboli from a proximal subclavian artery lesion were treated over a 5-year period. This group was characterized by the absence of significant carotid disease (12 of 13 patients) and equal arm pressures bilaterally in most patients (8 of 13 patients). An isolated supraclavicular bruit (12 of 13 patients) and a history of ipsilateral digital ischemia (5 of 13 patients) were common. Arch angiography demonstrated proximal subclavian lesions in 12 patients, with obvious ulcerations in 10 cases and thrombus in an old carotid-subclavian bypass graft in one case. Surgery directed at removal or exclusion of the lesion was successful in all cases. Isolated lesions in the subclavian artery can be a source of emboli into the vertebrobasilar circulation. These lesions are effectively treated by exclusion and vascular reconstruction.

Humans↗

PubMed1986

Revision of failed infrainguinal bypass graft: principles of management.

Our experience with 112 patients whose infrainguinal bypass grafts (IIBPGs) failed more than 30 days after insertion was reviewed. Cumulative patency rates (CPRs) after graft revision (GR) were 71% at 6 months, 62% at 12 months, 57% at 24 months, 54% at 36 months, and 46% at 48 months. CPRs of IIBPGs that failed more than 12 months after insertion were higher than those of grafts that failed earlier (60% vs. 36% at 36 months (p less than 0.05). Failure of the initial GR did not preclude a successful secondary revision. The 3-year CPR of the initial GR was 31% compared with 49% for secondary GR (p = no significance). The results of GR are significantly better when graft failure is diagnosed before graft thrombosis. Revision of the 37 hemodynamically failed but patent grafts resulted in a CPR of 89% at 12 months and 77% at 36 months compared with a CPR of 33% at 12 months and 26% at 36 months after revision of the 75 thrombosed grafts (p less than 0.01). Hemodynamically failed but patent grafts occurred in 36 of 68 patients (53%) with failed autogenous veins but only 1 of 44 patients (2%) with a failed prosthetic graft had GR before thrombosis of the graft. There is a significant improvement in early CPR when a new bypass graft is inserted as compared with original graft thrombectomy and angioplasty. The CPR for new bypass grafts at 6 and 12 months was 61% and 41%, respectively, compared with a CPR of 26% and 20% for the same time intervals with graft thrombectomy and angioplasty (p less than 0.05). The presence of thrombus in the outflow artery at the site of GR is a contraindication to anastomosis at that site even if arterial thrombectomy reestablishes backflow. When distal arterial thrombus was not present, the CPR after GR was 62% at 6 months, 42% at 12 months, and 33% at 36 months. When distal arterial thrombectomy was necessary, the CPR after GR was only 14% at 6 months and zero at 12 months (p less than 0.05).

Blood Vessel Prosthesis↗

PubMed1986

Carotid endarterectomy in the elderly patient.

Although the segment of the population at the highest risk for cerebral ischemic events is more than 75 years old, there has been hesitancy in performing carotid revascularization in these patients because of an increased risk of perioperative morbidity. Over a period of 54 months, 77 (16 per cent) of 470 carotid endarterectomies performed were upon patients more than 75 years old. There were no differences between age groups with respect to perioperative morbidity or mortality, with three strokes (3.9 per cent) and no deaths in the patients more than 75 years old and 12 strokes (3.1 per cent) and two deaths (0.5 per cent) in the patients less than 75 years old. Postoperative follow-up study ranged from 30 days to five years (a mean of 25 months) in elderly patients. The over-all three and five year survival rate was 78 and 60 per cent, respectively. No patient experienced a stroke during follow-up study. Recurrent symptoms developed in 18 per cent of the elderly patients at three years of follow-up study, and the occurrence was dependent upon the preoperative symptom category (hemispheric 10 per cent and nonhemispheric 33 per cent). We conclude that the low perioperative morbidity and mortality, and subsequent results of carotid endarterectomy in the elderly patient justify operative intervention when significant lesions are encountered.

Actuarial Analysis↗

PubMed1985

Use of computerized cerebral tomography in selection of patients for elective and urgent carotid endarterectomy.

The charts of 181 patients who underwent computerized cerebral tomography (CCT) prior to carotid endarterectomy were reviewed. Findings on cerebral tomography were correlated with clinical presentation, frequency of intraoperative changes in the electroencephalogram (EEG), and occurrence of postoperative neurologic deficits. In the elective group (154 patients), while there was a significant (p less than 0.001) increase of positive ipsilateral CCT findings in stroke patients, 36% of patients with clinical stroke had a negative CCT scan and 21% of patients who were clinically asymptomatic had a positive CCT scan. Results of CCT did not correlate with the incidence of EEG changes (p greater than 0.2) or postoperative stroke rate (3.2%) (p greater than 0.5). Results of urgent carotid endarterectomy were directly related to the findings on preoperative CCT scan. A negative CCT scan was associated with clinical improvement in 88% of patients, one case of neurologic deterioration (5.8%) and no mortality (p less than 0.05). Only 50% of patients operated on acutely with a positive CCT scan showed neurologic improvement while there was a 40% increase in neurologic morbidity and 10% mortality in this group (p less than 0.01). CCT plays a limited role in the preoperative evaluation of patients with clear-cut clinical evidence of thrombo-embolic stroke or transient cerebral ischemia. Findings on CCT scan were of no help prognostically in selecting patients for elective carotid endarterectomy. In contrast, CCT scans have been extremely helpful in planning therapy for patients with acute neurologic problems and evidence of significant extracranial vascular disease.

Brain↗

PubMed1985

Preservation of myocardial function with mannitol reperfusate.

Reperfusion of the globally ischemic myocardium with mannitol has been shown to preserve myocardial function. However, it remains unclear whether the mechanism of mannitol protection relates to its hyperosmolar or free radical scavenging properties. Three groups of isolated, perfused rabbit hearts underwent 45 min of normothermic ischemia without cardioplegia in an experimental paradigm analogous to the clinical situation of coronary artery thrombosis with subsequent reperfusion. Six hearts were reperfused with an isosmolar solution, eight hearts were reperfused with a mannitol-containing solution (20 mOsm/liter), and five hearts were reperfused with a solution containing additional sodium chloride (10 meq/liter, 20 mOsm/liter) to control for the hyperosmotic effects of mannitol. Left ventricular developed pressure, its derivative dP/dt, and diastolic compliance were all significantly improved in the mannitol-reperfused hearts when compared with the hypertonic saline and control groups (p less than .05). There were no intergroup differences in myocardial edema formation, oxygen consumption, or lactate production. These data indicate that mannitol reperfusion offers significant myocardial protection independent of hyperosmolar properties. Free radical scavenging activity appears to be the most credible explanation for these observations, although confirmation of this mechanism awaits further biochemical and cellular investigation.

Animals↗

PubMed1985

Protection of the kidney after temporary ischemia: free radical scavengers.

Free radicals have been implicated in the damage caused by tissue ischemia and reperfusion. Canine kidneys were subjected to a 60-minute period of normothermic ischemia. One group of animals received intra-arterial superoxide dismutase (SOD, 17.6 mg/50 ml, 50,000 units) at the end of the ischemic period, whereas a second group received albumin (17.6 mg/50 ml). The kidneys treated with SOD demonstrated significantly less edema formation (1.0 +/- 0.3% wet weight vs. 1.8 +/- 0.2%, mean +/- SEM, p less than 0.05) and lower renovascular resistance (44.0 +/- 5.6 dynes-sec/cm5 vs. 64.0 +/- 12.0, p less than 0.05). The SOD group displayed greater preservation of both glomerular filtration rate (45.9 +/- 6.1% of baseline vs. 23.7 +/- 5.8%, p less than 0.05) and urine flow (1.3 +/- 0.4 ml/min vs. 0.3 +/- 0.1, p less than 0.05). We conclude that the free radical scavenger SOD provides significant protection of the kidney during ischemia and reperfusion.

Albumins↗

PubMed1984

Adenocarcinoma of the small intestine.

Sixty-five patients with adenocarcinoma of the small intestine were encountered over a 31 year period. The duodenum was the most common location, with a decreasing frequency distally. Associated malignancies were present in a fourth of the patients. Presenting signs and symptoms were vague and related to either obstruction or bleeding. Barium contrast examination and endoscopy for duodenal tumors were the primary diagnostic modalities. Curative treatment was wide resection of bowel and mesentery for jejunal and ileal tumors and pancreaticoduodenectomy for duodenal tumors. Favorable prognosticators included jejunal location, absence of nodal metastases, and a well-differentiated grade. Stage for stage, the prognosis of patients with adenocarcinoma of the small intestine parallels that of patients with adenocarcinoma of the colon. With greater awareness of this tumor, it is possible that earlier detection will lead to improved overall survival.

Adenocarcinoma↗

PubMed1984

Acute acalculous cholecystitis complicating abdominal aortic aneurysm resection.

Acute acalculous cholecystitis developed in six patients recovering from repair of an abdominal aortic aneurysm. All patients were men with significant concurrent medical illnesses, and three patients had undergone operation for a ruptured aneurysm. Symptoms appeared at a mean of 3 weeks postoperatively and consisted of right upper quadrant pain, fever, leukocytosis, and slight elevation of liver function test results. Treatment consisted of cholecystostomy (three patients) or cholecystectomy (three patients), with an overall mortality rate of 50%. When cholecystitis is suspected after aortic aneurysm repair, early confirmation of the diagnosis should be obtained with ultrasound or a technetium hepatobiliary scan and cholecystostomy or cholecystectomy undertaken if the patient does not rapidly improve with medical management.

Acute Disease↗

PubMed1984

Combined use of Doppler ultrasound and phleborheography in suspected deep venous thrombosis.

Doppler ultrasound and PRG were compared with the results of venography in 216 limbs with suspected DVT. Equivocal or conflicting noninvasive test results were obtained in 40 limbs and thrombi were demonstrated venographically in 18 of these (45 per cent). In the remaining 176 limbs, the sensitivity of the noninvasive test was 88 per cent and the specificity was 99 per cent. Treatment may be confidently chosen without venographic confirmation when the results of Doppler ultrasound and PRG agree. Venography is indicated in the minority of instances when the two noninvasive test results do not agree or are equivocal.

Adolescent↗

PubMed1984

Carotid endarterectomy for nonhemispheric symptoms: predictors of success.

Over a 4-year period 335 patients underwent 402 carotid endarterectomies: 227 (56%) for carotid territory symptoms, 107 (27%) for nonhemispheric symptoms, and 68 (17%) for asymptomatic lesions. In 317 four-vessel arteriograms, proximal subclavian and/or vertebral lesions were found more frequently in the nonhemispheric group (80 of 97, or 82%) than in the carotid territory group (110 of 220, or 50%; p less than 0.05). EEG changes after carotid clamping occurred more often in the nonhemispheric group (15 of 65, or 23%) than in the carotid territory group (16 of 140, or 11%; p less than 0.001). The perioperative stroke rate was independent of whether nonhemispheric or carotid territory symptoms were present preoperatively (2.8% vs. 3.5%). Follow-up ranged from 1 month to 4 years. Carotid endarterectomy was successful in ameliorating symptoms in patients meeting the criteria for "classic" vertebrobasilar insufficiency more often than in patients not meeting these criteria (73% vs 43% asymptomatic at 24 months). Carotid endarterectomy was successful in patients with carotid stenoses of greater than 60% diameter reduction more often than in patients with smaller stenoses (77% vs. 36% asymptomatic at 24 months). Carotid endarterectomy appears justified in patients with nonhemispheric symptoms when classic vertebrobasilar insufficiency and/or hemodynamically significant carotid stenoses are present.

Aged↗

PubMed1984

Prognostic factors of carcinoma of the male breast.

The clinical course of 50 male patients with carcinoma of the breast was reviewed. The disease most commonly presented in the seventh decade of life. The clinical examination of the axilla proved to be inaccurate. Survival time was highly correlated with the pathologic stage of the lesion. The five year survival rate was 80 per cent for patients with Stage I disease and 67 per cent for those with Stage II disease. By contrast, only 25 percent of patients with Stage III disease were alive at five years and all of the patients with Stage IV disease had died of the disease by the five year point. It appears that the prognosis for male patients with carcinoma of the breast is good if the appropriate therapy is undertaken at an early stage.

Adult↗

PubMed1983

Management of cholelithiasis in patients with abdominal aortic aneurysm.

Gallstones were detected in 42 of 865 patients with abdominal aortic aneurysm (4.9%). Eighteen patients underwent concomitant aneurysm resection and cholecystectomy. Eleven patients had aneurysmectomy without cholecystectomy. Thirteen patients underwent cholecystectomy alone. There were no significant increases in operative mortality, duration of operation, or length of hospital stay when cholecystectomy was added to aneurysm resection. However, there was one instance of prosthetic infection which occurred in a patient who did not have his graft retroperitonealized prior to cholecystectomy, and who also underwent gastrostomy and drainage of the liver bed. There have been no graft complications in the remaining 17 consecutive patients who had their graft retroperitonealized prior to cholecystectomy. Nine of 11 patients who underwent aneurysmectomy without cholecystectomy experienced an episode of acute cholecystitis during a mean follow-up period of 2.9 years. Two of these episodes occurred in the immediate postoperative period and one patient died of biliary sepsis. On the basis of these findings, concomitant aneurysmectomy and cholecystectomy is advised in those patients with cholelithiasis undergoing aortic aneurysm resection providing no contraindications exist.

Aged↗

PubMed1983

Diverticular disease in the young patient.

The records of 115 patients less than 40 years of age with roentgenographic or operative documentation of diverticular disease were reviewed. Ninety-two patients presented with acute diverticulitis; five, with bleeding diverticulosis, and 18 were asymptomatic. An urgent operation for fistula, abscess or free perforation was necessary upon initial presentation in 16 patients. Nine patients underwent resection during the initial hospitalization after a cooling-off period. The remaining 67 patients were managed medically and discharged. Fifty-five per cent of the medically managed patients required readmission during the follow-up period, 23 per cent having a serious complication. Forty-five per cent of the medically managed patients underwent a subsequent operation. Elective resection after a cooling-off period appears to be the safest alternative for young patients.

Acute Disease↗

PubMed1982

Doppler ankle pressure: an evaluation of three methods of expression.

We studied 133 patients with arteriographic evidence of lower limb arterial disease and 34 normal volunteers to determine the most useful means of expressing ankle pressure. Representative ranges were determined for each of six symptomatic categories. Receiver operating characteristic curve analysis showed that ankle index (ankle to brachial pressure ratio) and brachial-ankle pressure gradient were more valuable than absolute pressure in discriminating between normal and disease extremities. In contrast, absolute ankle pressure was the best predictor of nonviability (limb requiring bypass for salvage or amputation). An absolute pressure cutoff of 6mm Hg correctly identified 86% of viable limbs and 77% of nonviable limbs. Thus, the diagnostic accuracy of the three methods of expressing ankle pressure depends on the context in which they are to be used, and it appears that ankle index and gradient are most appropriate for defining the presence of disease, while absolute pressure correlates best with viability.

Adult↗

PubMed1982

Critical evaluation of stress testing in the diagnosis of peripheral vascular disease.

We studied 218 patients (372 limbs) and 25 normal subjects (50 limbs) with resting ankle index (RAI), treadmill exercise (TE), and postocclusive reactive hyperemia (PORH) to determine whether diagnostic accuracy is improved through the use of stress testing. In addition, we studied 10 patients with stable claudication (20 limbs) to determine the reproducibility of the three measures. RAI was the most reproducible measure, with the smallest variance between testing days (P less than 0.001). RAI differentiated between arteriographically diseased and normal limbs with a sensitivity of 97% and a specificity of 100%, whereas the corresponding values for TE were 97% and 96% and for PORH 89% and 96%. Recovery to baseline index was prolonged in the diseased group compared with normal (p less than 0.001 for both TE and PORH), but this was of limited discriminative value. Receiver-operating characteristic curve analysis documented that RAI was as diagnostically useful as TE and that both were more valuable than PORH (P less than 0.02). However, the routine addition of stress testing increased diagnostic yield by only 1.6% and cost $1100 for each limb correctly diagnosed through the addition of stress testing. RAI is a simple, accurate, and reproducible test. Routine stress testing is not cost effective, adding little diagnostic information to RAI, and it should be reserved for the small subset of symptomatic patients with normal RAI.

Adult↗