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Biomedical subjects

R H Clauss

Publications and source records attributed to R H Clauss.

At least 19 recordsLinked to original sources
PubMed1993

Functional foot salvage after extensive plantar excision and amputations proximal to the standard transmetatarsal level.

PURPOSE: It is generally accepted that when necrosis extends proximal to the transmetatarsal level a viable and functional foot can no longer be preserved and a major (above- or below-knee) amputation must be performed. However, with continuing advances in operations for limb salvage we felt the need to reexamine this concept. METHODS: In 1983 we initiated a prospective study to evaluate the role of extended foot amputations. All ambulatory patients with necrosis extending proximal to the transmetatarsal level (but not involving the whole foot) were included in the study. Among the 21 patients studied amputations ranged from open guillotine transmetatarsal amputation to removal of the medial or lateral three fifths of the foot. Five of these patients had adequate pedal circulation by clinical and laboratory criteria. The remaining 16 required vascular reconstruction to improve pedal flow. RESULTS: Eighteen (86%) of 21 patients had complete healing of the foot amputations and were ambulatory at the time of discharge from the hospital. Two patients required early above- or below-knee amputations. Three additional patients sustained limb loss in the follow-up period. The cumulative graft patency rate was 94% at 12 months. The cumulative limb salvage rate at 24 months was 84%. The operative mortality rate was 1 (5%) of 21. CONCLUSION: Our experience in a small number of patients suggests that functional foot salvage is possible even when necrosis or gangrene extends proximal to the transmetatarsal level.

Aged↗
PubMed1993

Cervical aortic arch associated with tetralogy of Fallot.

Forty-seven cases of cervical aortic arch have been reported in the literature. Eleven of these patients had congenital cardiac defects, including tetralogy of Fallot in three. An additional case of cervical aortic arch and tetralogy of Fallot is presented along with a brief review of the literature pertaining to this rare condition.

Adult↗
PubMed1992

Meticulously restored lumina of injured veins remain patent.

We report our experience with 38 major venous injury repairs in 37 patients between January 1981 and December 1989. The injuries were caused by gunshot (n = 27), shotgun (n = 3), knife (n = 5), blunt trauma (n = 1), and dog bite (n = 1). These involved 27 femoral, 10 popliteal, and one brachial veins. Thirty patients had associated major arterial injuries and seven had major long bone fractures. Retrospective analysis yielded two groups. Group I consisted of 17 patients who underwent meticulous restoration of venous lumina ensured by intraoperative postreconstruction venography (IPV) in all patients. Two of these required revision on the basis of IPV findings. Late patency of venous repair was confirmed by postoperative venography (n = 10) or duplex scans (n = 7). All 17 venous repairs were patent (100%). In group II none of the 20 patients (21 veins) underwent IPV. Fifteen of the 20 patients underwent venography and five patients (six veins) underwent duplex scanning after surgery. Eight veins were occluded and 13 (62%) were patent. The difference in patency rates of venous repair between groups I and II was significant (p = 0.02). Three (37.5%) of eight patients with occluded venous repair required delayed fasciotomy, but only 1 (3.4%) of 29 limbs (30 veins) with patent lumina required fasciotomy (p = 0.03). We conclude that meticulous restoration to normal-caliber venous lumina, confirmed by IPV, can achieve high patency and low morbidity rates.

Adolescent↗
PubMed1991

Subclavian artery to innominate vein fistula after insertion of a hemodialysis catheter.

Insertion of hemodialysis catheters for temporary use is now preferentially performed by percutaneous infraclavicular subclavian vein catheterization. This method involves passage of a stiff dilator and a peel-away sheath over a guide wire, and is usually carried out without fluoroscopy. For the most part this has proved to be a valuable and safe approach. However, a small incidence of major complications occurs, which needs to be emphasized. Sixteen cases of arteriovenous fistulas between the subclavian artery or its branches and the subclavian vein have been reported so far in the literature. To date only one case of subclavian artery to innominate vein fistula has been reported. We report the second case with this complication and suggest possible preventive measures.

Adult↗
PubMed1989

Compartment syndrome in combined arterial and venous injuries of the lower extremity.

In 9 of 45 patients treated for dual vascular injuries of the lower extremity, concomitant fasciotomies were performed at the time of initial surgery for associated soft tissue injury, fracture, or prolonged ischemia. Eight other patients developed compartment syndrome requiring delayed fasciotomy. In seven of them, vein was either ligated or the repaired vein became occluded. In the eighth patient, peripheral venous hypertension was caused by massive swelling of the thigh. In the laboratory, compartment pressure was monitored by wick catheter in 24 hind limbs of 12 dogs subjected to experimental conditions simulating vascular injuries and their management. There was a significant increase in compartment pressure in a group that simulated arterial and venous injuries managed by arterial repair and venous outflow obstruction. Based on our study, we suggest that obstruction to venous drainage and venous hypertension are major factors in the development of compartment syndrome in dual vascular injuries of the lower extremity.

Adolescent↗
PubMed1989

Liver abscess following superior mesenteric artery revascularization for acute mesenteric ischemia.

A case of pyogenic liver abscess following successful mesenteric artery revascularization is described in a patient with acute mesenteric ischemia. Prior to revascularization, arteriography confirmed celiac and superior mesenteric artery occlusion. Occurrence of liver abscess is explained on the basis of ischemia impairing the barrier function of the intestinal mucosa, contributing to portal bacteremia that seeds ischemic or necrotic liver. In patients with acute mesenteric ischemia, sequential sonographic examination of the liver following mesenteric revascularization is advocated for early diagnosis of liver abscess if there is clinical evidence of the sepsis.

Acute Disease↗
PubMed1989

Incidence and results of arterial complications among 16,350 patients undergoing cardiac catheterization.

A total of 16,350 patients underwent cardiac catheterization from January 1981 to December 1987. The brachial artery was used in 10,500 patients (group I), and the femoral artery was used in 5850 patients (group II). Surgical intervention for complications was necessary in 60 (0.57%) of the group I patients and in 14 (0.23%) of the group II patients. Hand ischemia in group I and bleeding in group II were the most frequent indications for operation. Procedures performed were segmental resection, vein interposition, and long bypass in group I, and simple suture and angioplasty were performed in group II. Fifty-six patients of the total of 74 underwent early repair (within 48 hours), and 18 patients underwent delayed intervention. Only one (1.7%) of the 56 patients who had early repair had a complication. Five of the 18 patients (28%) with delayed intervention suffered significant complications. Cardiac catheterization by the brachial or femoral route has a low incidence of complications. Delayed intervention is associated with high morbidity despite adequate restoration of circulation. Although there were fewer complications in the femoral group, they were far more serious with respect to life- or limb-threatening events.

Adult↗
PubMed1988

Routine revascularization with resection of infection femoral pseudoaneurysms from substance abuse.

Infected femoral artery pseudoaneurysms in narcotic addicts present challenging management options. Our policy of routine revascularization is based on the concern that a high rate of amputations must follow ligation and resection alone or with selective delayed revascularization. Fifteen of 16 patients with infected pseudoaneurysms of femoral arteries, treated with resection and bypass grafts, were observed from 1 to 44 months. Obturator bypass grafts were used in 10 patients, iliac-femoral grafts in three, axillopopliteal in one, and right external iliac crossover to left popliteal in one patient. One limb, unsalvageable at presentation, was amputated primarily, along with resection of pseudoaneurysm and femoral artery ligation, without bypass grafting. One iliac-femoral graft became infected and then thrombosed 4 months after operation. Unsuitable distal arteries and impending necrosis led to above-knee amputation. One late failure among 15 revascularization attempts (7%) is significantly lower than the 11% to 33% amputation rates reported in the literature with resection of pseudoaneurysm alone and delayed selective revascularization. The other 14 patients had functioning limbs without claudication or rest pain. Our experience indicates that revascularization at the time of resection of infected pseudoaneurysm offers better prospects for limb salvage.

Adult↗
PubMed1988

Extended reconstruction rate for limb salvage with intraoperative prereconstruction angiography.

A prospective study was performed between May 1982 and March 1987 to assess the value of intraoperative prereconstruction angiography (IPA) in limb salvage. Eligibility was limited to patients with rest pain, ischemic ulcers, or gangrene limited to the toes: only candidates for infrapopliteal bypass were included. Seventy-eight such patients were examined with preoperative angiography. Delayed films, selective catheterization, reactive hyperemia, or vasodilators were used routinely. In only 11 of 78 patients (14%) was the runoff adequately visualized, demonstrating the tibial vessels and the pedal arch. The remaining 67 patients (86%) (with nonreconstructable disease by currently accepted outflow criteria) had surgical exposure of a tibial or pedal artery for IPA. In 56 of these patients (84%) good runoff was demonstrated and bypass was performed. The reconstruction rate was 86% (67 of 78 patients), significantly higher than the 33% rate reported by others. The operative mortality rate was 2.8% (2 of 78 patients). We concluded that in severe ischemia preoperative angiography is often inadequate in demonstrating runoff, even with adjunctive measures to dilate the outflow vessels. IPA through the tibial and pedal vessels eliminates all of the proximal vascular resistance, thereby providing a "completion angiogram" before reconstruction. This in turn extends reconstructability to many patients who would otherwise undergo primary amputation.

Angiography↗
PubMed1987

Is limb loss avoidable in civilian vascular injuries?

Limb salvage is virtually guaranteed when arterial injury is associated with a gunshot or stab wound. In this setting, associated injury is limited, and arterial injury is uniformly suspected, deliberately sought, and expeditiously repaired. Blunt trauma and massive injuries to the soft tissue, bones, and joints of the extremities augur amputation. In a patient with blunt trauma and loss of distal pulses, liberal, early use of angiography helps to avoid amputations secondary to missed or delayed diagnosis. Deliberate local anticoagulation and effective venous drainage is recommended in the management of dual-complex popliteal injuries. Discriminate amputation merits consideration when arterial trauma is accompanied by massive soft tissue and bony injuries with extensive loss of soft tissue.

Amputation, Surgical↗
PubMed1987

Adequacy of central hemodynamics versus restoration of circulation in the survival of patients with acute aortic thrombosis.

Acute aortic thrombosis is an infrequent clinical occurrence, but when it does occur, it is a true cardiovascular catastrophe. Our experience with 34 patients over a 12 year period was reviewed and factors influencing outcome were analyzed. Seventeen women and 17 men had various clinical presentations, although 74 percent of the patients had the classic picture of ischemia. Preoperative assessment of left ventricular function was carried out in all but one patient with intraoperative and perioperative monitoring to guide therapy in addition to revascularization procedures. While extent of the preexisting disease and number of additional operations did influence the outcome, the predominant factor for survival was the left ventricular functional state perioperatively. Fifteen of the 16 patients with adequate left ventricular function survived, whereas 15 of the 17 patients with a failing myocardium died (88 percent). Extraanatomic operations are preferable in patients with demonstrated inadequate left ventricular function. Expeditious restoration of circulation alone does not ensure a favorable outcome. The key to successful therapy is understanding, preventing, and effectively treating the mechanical and metabolic dysfunction of the heart. Review of the literature on acute aortic thrombosis revealed only few isolated case reports except for a recent report of eight patients. Our report of 34 patients over a 12 year period represents the largest experience to date from a single institution. Detailed analysis of hemodynamic parameters and the significance of determination of left ventricular function has not been reported so far in this subset of critically ill patients.

Acute Disease↗
PubMed1987

PTFE graft treated with silver norfloxacin (AgNF): drug retention and resistance to bacterial challenge.

Norfloxacin (NF) and silver norfloxacin (AgNF) were used to coat polytetrafluoroethylene (PTFE) vascular prostheses by using triododecylmethylammonium chloride as a cationic surfactant. The relative retention of the drug on the graft after subjecting it to the biological environment for 3 weeks and antibacterial activity against coagulase-positive Staphylococcus aureus and Escherichia coli were determined. In addition, the ability of AgNF-coated PTFE grafts to sterilize perigraft tissue after mixed bacterial contamination was studied and compared with control PTFE grafts in 10 dogs. At the end of 21 days, 15 and 18% of AgNF were retained on the grafts tested in in vitro and in vivo experiments, respectively. During the same time AgNF-coated grafts from in vitro experiments exhibited significant antibacterial activity (25 mm zone of inhibition (z.i.)), but antibacterial activity was negligible (10 mm z.i.) in the grafts from in vivo experiments. NF retention on the grafts could not be determined because of spectral interference by blood. The antibacterial activity of NF-coated grafts significantly declined after 24 hr in in vivo experiments, hence further evaluation of NF-coated grafts was not done. Seven perigraft sites surrounding AgNF-coated grafts were sterile, but only one perigraft site surrounding control grafts was sterile (P less than 0.05). Cultures from six of nine perigraft infections surrounding control grafts yielded heavy bacterial growth. There was only one wound infection at the site of AgNF graft while there were seven severe wound infections at control graft sites. AgNF-coated grafts exhibited prolonged antibacterial activity compared to NF-coated grafts and offered significant protection against infection from local bacterial contamination.

Animals↗
PubMed1987

Management of kinked extracranial cerebral arteries.

Kinked extracranial carotid and vertebral arteries are observed in 10% to 16% of cerebral angiograms. The hemodynamic significance of some kinked carotid arteries has been shown by investigators who documented oculoplethysmographic and angiographic differences accompanying flexion, extension, or rotation changes of the neck and head. In the 3-year period ending November 1985, we performed operations on seven patients to correct six kinked internal carotid arteries and one kinked vertebral artery at the C-2 level. The final decision regarding optimal operative technique was determined during operation, after observing the relative lengths of dissected arteries, envisioning the results of the procedures selected. We performed five segmental resections and end-to-end anastomoses (one vertebral, two common carotid, and two internal carotid arteries). Transection of the internal carotid artery with reimplantation into the side of the common carotid artery was performed twice. All patients became asymptomatic up to 4 years, irrespective of head and neck positions. There were no complications or deaths in these patients. This experience suggests that arterial kinks may constitute tenable indications for operative treatment in patients with transient cerebral ischemia who lack typical stenotic or ulcerative plaques to account for their symptoms. Kinked arteries can be corrected safely and effectively by appropriate surgical procedures.

Aged↗
PubMed1985

Coexisting carotid stenosis in patients undergoing cardiac surgery: indications and guidelines for simultaneous operations.

The coexistence of critical carotid stenosis with coronary artery or valvular heart disease occurs in a small percentage of patients requiring open heart surgical procedures. Recognition of such combined lesions by noninvasive carotid testing identifies patients at risk for neurologic events. Our experience with 62 patients having combined simultaneous carotid and cardiac operations among 2,400 open heart surgery patients was compared with the results in 110 patients with only carotid endarterectomy operations. The outcomes indicated that carotid endarterectomy can be performed simultaneously with open heart surgical procedures with morbidity and mortality rates similar to those of isolated cervical artery operations. Thus, patients with significant coexisting carotid artery disease defined with specific criteria and coronary artery disease need not be exposed to cerebral ischemic events or to myocardial infarctions that often accompany staged operations.

Carotid Artery Diseases↗
PubMed1985

Pseudoaneurysm of anterior tibial artery after occlusion from blunt trauma: nonoperative management.

The angiographic finding of occluded isolated tibial artery after blunt trauma to the leg generally is ignored. A case of pseudoaneurysm and arteriovenous fistula that evolved from an occluded anterior tibial artery is presented. The pathology was treated successfully by percutaneous transfemoral placement of Gianturco coils in the tibial artery proximal and distal to the aneurysm. The nonsurgical approach in this patient avoided the risks of anesthesia, blood loss associated with a surgical procedure, the dilemma of the surgical approach in the presence of medial and lateral fasciotomy wounds, and of contamination and destabilization of the comminuted tibia-fibular fractures. This report raises the question of the proper management and followup procedures of occlusions of noncritical arteries found on angiography immediately after trauma.

Adult↗