Aberrant right subclavian artery.
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Aneurysm↗
Biomedical subjects
P G Bull
Publications and source records attributed to P G Bull.
Preliminary clinical experience with polyurethane vascular prostheses in femoro-popliteal reconstruction.
Following promising results in animals, implantation of polyurethane vascular prostheses for femoral reconstruction was performed in 15 patients over a 10-month period. This prospective study was carried out to evaluate the patency, limb salvage and complications associated with this type of small diameter conduit for arterial occlusive diseases. The indications for surgery included acute and chronic ischaemia, non-healing ulceration or gangrene. There were five early occlusions, which resulted in a 1-month primary patency rate of 66% and a secondary patency rate of 80%. The mean limb salvage rate at 1 month was 80% and is 66% at the present time. Infection occurred in one patient following multiple attempts at graft thrombectomy. There were no statistically significant differences in patency rates between proximal and distal popliteal graft anastomoses. Two critical phases of healing were identified where the graft was prone to flow deterioration; at 4-6 weeks and at 4-6 months. It is concluded that although this type of graft has many interesting features, e.g. the presence of endothelial cells under poor haemodynamic conditions, excellent graft-host healing and good resistance at the suture site, further investigations on protein absorption and complement activation as well as intensive structural testing are required before further recommendations can be made.
Aged↗
Günther vena caval filter: clinical appraisal.
The mechanical stability of the Günther filter, caval patency, and complications related to filter placement were evaluated in 33 patients. Indications for placement included recurrent pulmonary embolism despite anticoagulation (n = 24) and contraindication to anticoagulation (n = 5). Four filters were placed prior to pulmonary lysis. Filters were positioned via the transfemoral route in 31 patients and via the transjugular route in two. Placement was complicated by pneumothorax in one case and faulty filter position in another. Patients were followed up for 52 months (mean, 12.1 months). Four patients died of nonembolic complications; three patients were lost to follow-up. Among the remaining 26 patients, caudal migration (3-6 cm) occurred in 19 (73%), cephalic migration into the atrium occurred in one, the inferior vena cava occluded in five, and struts perforated the caval wall in five. Pulmonary embolism recurred in one patient. In 11 cases, thrombus caught inside the basket was revealed with computed tomography; in one case a 7-cm floating thrombus was observed. The authors conclude that use of the Günther filter cannot be recommended because of the high prevalence of complications.
Adult↗
Distal popliteal and tibioperoneal transluminal angioplasty: long-term follow-up.
The long-term efficacy of percutaneous transluminal angioplasty (PTA) for treatment of occlusive lesions involving arteries below the knee was evaluated in 168 consecutive patients. The procedure was preceded by intraarterial thrombolysis in 33 patients with failing femorodistal grafts. Indications were disabling claudication in 40 cases (24%), acute ischemia in 18 (11%), rest pain in 49 (29%), and tissue necrosis in 61 (36%). Angioplasty of tandem femoral and/or iliac lesions was performed in 58 cases (34.5%). Major complications were observed in 19 patients (11.3%) and minor complications in 12 others. Five patients died within 30 days (3%). Mean follow-up was 26.1 months (range, 4-72 months). Major amputation was required in 26 cases (15%). The cumulative clinical success at 3 years was 83% for a single stenosis, 76% for multilevel lesions, 44% following lytic therapy, 36% for segmental occlusions, and 14% for anastomotic stenoses. Infrapopliteal PTA is useful in selected patients. Factors associated with poor long-term patency include a single patent tibial artery (P = .039), acute ischemia (P = .03), anastomotic stenosis (P = .01), and, possibly, complete occlusion prior to treatment (P = .091).
Aged↗
Blood viscoelasticity response during carotid endarterectomy.
As demonstrated in many studies ischemic brain injury causes microcirculatory disturbances which is reflected in changes in the rheological behavior of blood. This is caused by multifactorial interaction between blood cells and damaged endothelium in the capillary network with release of tissue metabolites and by-products of cellular injury with resulting increased cellular permeability producing a volume shift into the interstitium and, subsequently, a rise in the hematocrit density. Drop in perfusion pressure produces an increase in whole blood viscosity. By means of an oscillating capillary rheometer and densimeter, the viscous and elastic parts of the complex viscosity of whole blood and plasma were measured from the ipsilateral internal jugular vein in 17 patients with unilateral occlusive carotid lesions during different stages of carotid endarterectomy. Our results show that fluid characteristics deteriorated significantly during carotid clamping with increase in whole blood viscoelasticity and plasma density, although collateral circulation was judged sufficient in the angiogram and cerebral perfusion pressure. These parameters not only returned to their initial value, but a significant amelioration was observed after installation of an intraluminal indwelling shunt as a response to improved orthograde flow and an enhanced shear velocity. We conclude that an increase in whole blood viscosity does correlate with decreased cerebral blood flow. This response is immediate. Hematocrit density increases significantly as a result of fluid shift into the interstitium. These changes are reversible if blood flow is promptly restored.
Aged↗
Deep venous thrombosis: results of thrombectomy versus medical therapy. Presented at the 5th European-American Symposium on Venous Diseases, Vienna, Austria, Nov. 7-11, 1990.
Between 1.1.1985 and 1.1.1988, 158 patients were referred because of acute deep venous thrombosis. They were 82 women (median age 48.5) and 76 men (median age 56.5). On admission, 4 patients had already a pulmonary embolism in 3 others embolism occurred during hospitalisation. The segment involved was the isolated iliac in 10, iliofemoral in 53, isolated femoral in 7, femorotibial in 47 and isolated tibial in 41 patients. Anticoagulation and compression therapy was undertaken in 102 and mortality was 21%. At follow-up 63% had at least 1 sign of venous insufficiency, in all 16% had no sequelae and were subjectively symptom-free. Thrombolytic therapy was carried out in 25, mortality was 8%. At follow-up, 72% had at least one sign of venous insufficiency. Venous thrombectomy was performed in 31, combined in 4 with balloon dilatation of an iliac spur. Mortality was low with 3%, 58% had at least one sign of venous insufficiency at follow-up and 39% were subjectively symptom-free. Our results show that an objective assessment is insofar difficult because subjective and clinical results do not correlate; 51% with clinically verified post-therapeutic venous insufficiency had normal venous drainage in strain-gauge plethysmography, whilst 41% without subjective discomforts demonstrated an insufficient drainage. Our results show that a full restitution is seldom achieved, thrombectomy does not prevent chronic venous insufficiency. Best results were observed in isolated iliac thrombosis. We conclude that thrombectomy should be restricted to the phlegmasia caerulea dolens form of DVT, while floating thrombus and ascending thrombus extending into the vena cava should be treated with a cava filter or ligation.
Adult↗
Complicated pneumothorax: short- and long-term results of endoscopic fibrin pleurodesis.
Complicated pneumothorax is defined as a recurrent or persistent air leak in the pleural interspace beyond 5 days despite adequate tube drainage. Up to now, this disorder could only be corrected by open thoracotomy. Endoscopic fibrin pleurodesis is shown to be a method that could obviate, in most cases, the need for thoracotomy. In the last 6 years, 138 of 153 patients presenting with complicated spontaneous pneumothorax were treated with this method. The fibrin sealant consists of 2 components: fibrinogen, factor XIII, and albumin dissolved in aprotinin (3,000 KIU/ml), and a thrombin calcium chloride solution, which is applied through the working channel of a thoracoscope and vaporized with nitrous oxide. In this observation period, 6 (4.4%) recurrences were observed, which were subsequently treated with thoracotomy; a second attempt at fibrin pleurodesis was not undertaken. In all cases, endoscopic sealing was followed by prompt reexpansion of the collapsed lung. Long-term follow-up was satisfactory, pulmonary function tests showed no signs of restrictive dysfunction, and pleural fibrosis was not observed on x-ray as reported in other modes of treatment. Following these results, it is concluded that this method is useful in cases of persistent, therapy-resistant, complicated spontaneous pneumothorax; its effects are durable and it has a low rate of recurrence. It produces a physiological healing process without damage to the pleura.
Female↗
Thrombolysis combined with angioplasty for failed femorodistal arterial grafts.
This study examines the long-term clinical success and complications of thrombolysis-angioplasty (TLA) of failed arterial grafts performed in 17 patients (group 1) and matched with 21 patients (groups 2) who had intra-arterial thrombolysis (IAT) followed by graft revision. TLA consists of alternating thrombolysis with percutaneous transluminal angioplasty (PTA) in the treatment of occlusive arterial disease. Failed grafts consisted of 21 vein grafts, 6 ovine collagen grafts, 6 polytetrafluorethylene (PTFE) prostheses, 3 human umbilical veins and 2 polyurethane vascular grafts. All bypasses were below the knee, of which 13 were to the tibial level. Thrombolytic agents used were urokinase in 21 cases, tissue plasminogen activator in 13 cases and streptokinase in 4 cases. Following successful thrombolysis, PTA was performed with a 3 mm to 5 mm balloon catheters. Nine tandem lesions were corrected. In all 24 stenoses were treated: 14 anastomotic stenoses, 4 graft strictures and 5 peripheral stenotic lesions. The combined cumulative patency rate of both groups was 36% (SE 10.8%) at 3 years. The initial technical success rate in group 1 was 70% (12 of 17 grafts). The cumulative patency rate, as revealed by life-table analysis, was 35.6% (SE 10.2%) at one year and 21.3% (SE 9.6%) at 2 years. In all, 10 grafts failed at follow-up and in 6 of these cases secondary intervention was unsuccessful. Mid-graft and isolated lesions responded better than did anastomotic and tandem lesions. In group 2 the cumulative patency rate was 60.4% (SE 5.7%) at one year and 50.3% (SE 12.9%) at 2 years.(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
Combined iliac transluminal angioplasty and femoropopliteal reconstruction for multilevel arterial occlusive disease.
Patients with multilevel arterial disease represent a challenging problem. A retrospective review of 46 consecutive femoropopliteal reconstructions combined with iliac balloon angioplasty was performed. Twenty-five procedures were below-knee and 21 to the above-knee popliteal artery segment. Mean follow-up was 26.8 months (range 4 to 84). There were 2 peroperative deaths and 3 serious complications (10.9%). In the late follow-up 4 significant restenoses and 1 reocclusion occurred for a patency rate of 81% for the inflow procedure at 5 years. Primary and secondary patency rate of combined procedures at 5 years was 61% and 76% respectively. The 5-year limb salvage rate was 93%. The mortality rate, morbidity rate and cumulative patency were not significantly different from a group of 38 patients who underwent 43 aortofemoral bypasses combined with femoropopliteal revascularization. In the latter group, the frequent incidence of anastomotic aneurysm (9.2%) was the main detrimental factor observed at follow-up. The authors conclude that femoropopliteal reconstruction combined with iliac angioplasty is effective for managing patients with multilevel disease. The possibility of intraoperative digital subtraction angioplasty and the use of no-profile co-axial balloon catheter design in the latter years of this study has improved our results.
Angioplasty, Balloon↗