Biomedical subjects
R Berguer
Publications and source records attributed to R Berguer.
Vascular surgery: what was and what will be.
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The silent brain infarct in carotid surgery.
The destructive potential of carotid artery disease is underestimated by the clinical classification that surveys only that part of the brain with clear somatic representation. Asymptomatic patients are found to have brain infarctions on CT scan for which there is no history or symptom. To assume "benign" behavior of a carotid lesion, a patient must be both asymptomatic and "asignomatic." Likewise, when the morbidity of carotid operations is reported, silent infarcts must somehow be taken into account. We investigated this "silent" disease in a prospective study of 100 carotid operations done on 91 patients over a 9-month period in our service. All patients had arch and four-vessel selective arteriography. Detailed neurologic examinations and CT scans were done before and after surgery. Of the 91 patients, 78 (86%) had a history of neurologic problems. Preoperative CT scans showed infarction in 21 patients, but only 57% of the infarctions correlated with symptoms and/or history. Among patients with a history of transient ischemic attack (TIA), 19% had an infarction seen on CT scan; however, among those patients who had lateralizing TIAs, the incidence of unsuspected infarction was higher (26%). Arteriography showed a lesion in all carotid systems supplying a symptomatic or infarcted hemisphere. Following 100 operations, four patients had neurologic abnormalities--two had transient hemianopsia and two had hemiparesis. CT scan showed a new infarct in all four patients as well as in eight other patients without neurologic findings; two of these silent postoperative infarctions were found in the hemisphere opposite the side of the operated carotid artery.(ABSTRACT TRUNCATED AT 250 WORDS)
Idiopathic ischemic syndromes of the retina and optic nerve and their carotid origin.
Most eye problems referred to vascular surgeons for workup of carotid disease are either transient (amaurosis fugax) or partial (retinal branch artery occlusion) visual loss. Patients with more severe total infarcts of the retina (central retinal artery occlusion) or of the head of the optic nerve ("ischemic optic neuropathy") are seldom suspected of carotid disease and, in the latter case, are generally labeled idiopathic. An explanation for the difference in attitude towards these conditions is suggested. A prescribed carotid etiology for these various ischemic syndromes of the eye and optic nerve was explored in a study of 20 consecutive patients who had acute ischemic eye/optic nerve problems. Special visualization of the neck, orbital, and retinal vasculature was obtained. Sixty percent had ipsilateral and 50% had contralateral carotid artery disease. The ophthalmic artery and the posterior ciliary arteries showed intrinsic lesions each in 25% of cases. Our pilot study concludes that there is strong evidence that most of these ischemic eye syndromes are related to carotid artery disease, which is found in the majority of patients. In a minority of them ischemic problems may be due to arteritis or to intrinsic disease of the ophthalmic artery. A more cohesive approach to the study and treatment of these different entities is supported by the suggestion of a common etiology for most of them. Close collaboration with ophthalmologists will be needed to improve the present management of these eye conditions.
Distal vertebral artery bypass: technique, the "occipital connection," and potential uses.
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Management of an infected aneurysm of the groin secondary to drug abuse.
Fifty-three infected aneurysms of the groin in known drug abusers have been treated since 1970. There was a recent history of attempted intravenous drug injection into the femoral vein in 50 patients. Twenty-three patients underwent revascularization immediately preceding or following excision and ligation of the mycotic aneurysm. Five graft infections, resulting in one death and three amputations, occurred in this group. Three grafts became occluded, resulting in one additional instance of an amputation within six months of operation. Thirty patients underwent excision and ligation only. Five extremities were amputated in the immediate postoperative period because of irreversible ischemic changes. Six patients underwent delayed reconstruction five days to two months postoperatively because of rest pain or gangrene limited to the forefoot. No deaths and no graft infections occurred in this group. In infected aneurysms of the groin from drug addiction, we recommend initial excision with ligation and delayed selective revascularization, if indicated.
Surgical reconstruction of the vertebral artery.
Thirty-five vertebral artery (VA) reconstructions are reviewed. Detailed neurologic, medical, and angiographic information was obtained for all patients. Various reconstructive techniques were used: VA bypass or reimplantation of the VA into subclavian or common carotid sites. Although endarterectomy of severe internal carotid artery lesions in patients with vertebrobasilar insufficiency is often curative, our experience has shown that in patients with normal or minimally diseased internal carotid arteries and severe bilateral VA disease, a single VA repair results in cure in 83% and improvement in an additional 10% of all patients. Simultaneous VA reimplantation in the course of internal carotid endarterectomy is appropriate in selected instances. There were no deaths or central neurologic deficits among the patients in our study. Lymphocele (11%) and partial Horner's syndrome (14%) are the most frequent complications, and some technical considerations to avoid these problems are described. VA reconstruction in carefully selected patients is a successful and safe technique.
Arteriovenous vertebral fistulae: cure by combination of operation and detachable intravascular balloon.
The direct surgical treatment of vertebral arteriovenous fistulae (AVF) presents serious difficulty and risk. Techniques for intravascular occlusion or embolization have made the treatment of AVF safer and effective. However, the occlusion of an AVF involving the segment where the vertebral vein becomes a single vessel may result in pulmonary emoblization by the occluding material. A combined procedure involving ligation of the vertebral vein and detachable balloon occlusion of the fistula was used in two instances without complications and with complete cure of the AVF.
Experience with popliteal-infrapopliteal bypass grafting.
Ten patients with severe infrapopliteal arterial occlusive disease at the time of our evaluation underwent 11 vein bypasses confined to the below-knee segment. Previous reconstruction of the femoral and proximal popliteal arteries had been done in three limbs and were all patent at the time we performed the distal bypass. Eight limbs had minimal or no occlusive disease in the femoral and popliteal arteries and had no previous proximal arterial reconstruction. Tissue loss or rest pain was the indication for operation in all patients. There were no deaths. Two grafts occluded within 24 hours. Seven have remained patent from two to 48 months. Arteriography, including complete evaluation of the pedal vasculature, is needed to select these patients properly. Vein bypass grafts limited to the below-knee segment may be a useful alternative in selected patients to the more traditional femoroinfrapopliteal bypass grafts.
Vertebral artery reconstruction. A successful technique in selected patients.
Fourteen patients were selected to have a total of 15 vertebral artery reconstructions in a four-year period. They all had incapacitating neurologic symptoms, and detailed investigations had been done to rule out other possible causes. If more than one lesion was present in the angiogram, priority was given to the reconstruction of carotid lesions. If symptoms persisted, vertebral artery stenoses were considered significant only if they involved greater than or equal to 75% of the cross-sectional area with the other vertebral artery being equally diseased or absent. The preferred operation was a vertebral artery bypass, although four reimplantations were done. Postoperative angiograms showed all grafts to be patent. Patency was confirmed again at 28 +/- 16 SD months by Doppler imaging. There were no operative neurologic deficits or deaths. All patients but one (in whom the selection protocol was not followed strictly) were relieved of their incapacitating symptoms.
Transaxillary sympathectomy (T2 to T4) for relief of vasospastic/sympathetic pain of upper extremities.
Experience with 22 consecutive thoracic sympathectomies is presented. Diagnoses included minor causalgia (12), mixed vasospastic and occlusive disease (4), Raynaud's disease (4), and frostbite with ulceration (2). The operation was a transaxillary resection of ganglia T2, T3, and T4. Both objective and subjective results indicate that this type of sympathectomy is as good as more extensive resections without the risk of a Horner's syndrome. Morbidity was minor but frequent and included dysesthesia, pneumothorax, and compensatory sweating. The success rate of 77%.
Rupture of isolated atherosclerotic aneurysm of lateral femoral circumflex artery.
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Noninvasive diagnosis of reversal of vertebral-artery blood flow.
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Intimal hyperplasia. An experimental study.
Intimal hyperplasia is a common cause of the narrowing and failure of vein grafts in arterial circuits. Various factors may contribute to this. An experimental dog model that isolated the contribution of blood velocity from other possible causes was developed. Intimal hyperplasia was clearly greater in those segments of vein grafts with low-flow velocities.
Bilateral internal carotid artery occlusion. Its surgical management.
Seven patients with symptomatic bilateral internal carotid artery occlusion had 11 extracranial operations involving carotid, vertebral, and subclavian arteries. A priority approach to the extracranial vessels was followed. Priority was given to the correction of subclavian steal when present. An external carotid angioplasty or bypass was given priority if its origin was stenotic or occluded. If both vertebral arteries, or the dominant one, had stenoses at their origin greater than 75% of the cross-sectional area, a subclavian-vertebral artery bypass was performed. When both internal carotid arteries are occluded, the external carotid and vertebrovasilar systems are the main collaterals and are often also stenotic. Correction of these occlusive lesions in the collateral pathways produced complete symptomatic relief in these patients. In two selected cases with specific angiographic findings and a normal blood pressure, immediate internal carotid thromboendarterectomy was performed. No morbidity or mortality was encountered in these seven patients.
Induced thrombosis of inoperable abdominal aortic aneurysm.
On occasions it may be vital to produce controlled thrombosis of an abdominal aortic aneurysm when resection is not possible. A successful technique was evolved to achieve this in a 57-year-old man with malignant lymphoma. The tumor was found to infiltrate massively the retroperitoneum and the wall of a large abdominal aortic aneurysm. The large aneurysm was deemed to be technically unresectable at operation. An approach was devised to thrombose the aneurysm and to proceed safely with chemotherapy of the malignant lymphoma. An axillobifemoral bypass was made with the limbs anastomosed end to end to the common femoral arteries. The external iliac vessels were exteriorized through the abdominal wall. The aneurysmal sac outflow was occluded by balloon catheters introduced through the exteriorized iliac vessels. A right transaxillary catheter was inserted and placed at the level of the renal arteries to induce and to control the progress of thrombus formation in such a way as to ensure patency of the renal vessels. Thrombin was delivered into the sac via this transaxillary catheter. A high urinary output was maintained. Serial angiograms of the clotting process were obtained. Once the sac was thrombosed, the balloon catheters were removed and a final angiogram was obtained which demonstrated the obliteration of the aneurysmal sac and the patency of the renal vessels. The patient has been fully employed for 20 months.
Subclavian artery to external carotid artery bypass graft. Improvement of cerebral blood supply.
External carotid flow may contribute a substantial amount of cerebral flow via collaterals in cases of internal carotid artery occlusion. When common and internal carotid arteries are occluded, the distal portion of the external carotid artery is kept open by collateral flow. Revascularization of the external carotid by means of a bypass graft from the subclavian artery will improve the blood flow through collateral vessels connecting the external and internal carotid territories, and thus increase the cerebral blood supply from the branches of the external carotid artery.