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R J Stoney

Publications and source records attributed to R J Stoney.

At least 37 records · Page 2Linked to original sources
PubMed1995

Neurogenic thoracic outlet decompression: rationale for sparing the first rib.

A total of 168 primary supraclavicular decompressions were performed on 146 patients with neurogenic thoracic outlet syndrome. This report compares the results of rib resection (supraclavicular anterior and middle scalenectomy and first rib resection) with rib-sparing (supraclavicular anterior and middle scalenectomy alone) operations. All patients with cervical ribs were excluded. In total, 125 rib resections and 43 rib-sparing procedures were performed between 1983 and 1992 by a single surgeon. The patients were otherwise comparable in symptoms and physical signs. During surgery there was a significantly higher proportion of pleural injury associated with rib resection (59%) than with rib-sparing (40%) procedures. The mean hospital stay was also prolonged by 1 day in patients undergoing rib resection (p = 0.005). There was no significant difference in early success between the two groups (83% for rib resection, 91% for rib sparing) and no difference in those resuming employment (52% and 63% respectively). Life-table analysis showed that the two groups have similar long-term results (69% and 76% at 2 years). The only important factor determining clinical outcome in primary supraclavicular thoracic outlet syndrome decompression was the duration of symptoms before operation. Some 83% of patients with symptoms less that 2 years had a successful result compared with only 68% in those with symptoms longer than 2 years (p < 0.05). Spontaneous or post-traumatic neurogenic symptoms responded to operation identically. The theoretical benefit of first rib resection to relieve mechanical compression of the brachial plexus is not evident from this review. Thorough removal of the scalene musculature and other myofascial anomalies, preferably through the supraclavicular approach, leads to less patient morbidity, shortens hospitalization, and is recommended for patients with neurogenic thoracic outlet syndrome requiring operative intervention.

Adult↗
PubMed1995

Durability of cross-femoral grafts after aortic graft infection: the fate of autogenous conduits.

PURPOSE: Revascularization for the treatment of aortic graft infection is usually accomplished by remote prosthetic axillofemoral bypass combined with cross-femoral bypass. When infection at the femoral level precludes placement of a prosthetic cross-femoral graft, we have used a variety of autogenous tissue conduits to restore circulation to the contralateral leg. To determine which of these conduits offers the most durable reconstruction, we have reviewed 78 patients treated for aortic graft infection. METHODS: Between 1980 and 1991 we used either autogenous saphenous vein (ASV, n = 34), endarterectomized superficial femoral artery (SFA, n = 14), or direct ilioiliac anastomosis (iliac, n = 10) to provide cross-femoral flow. We compared the performance of these tissue conduits with a concurrent patient group with aortic graft infection in whom a prosthetic cross-femoral graft was used (prosthetic, n = 20). RESULTS: Follow-up was available for 98.7% of patients, average 3.8 +/- 2.9 years, and was not different between the four groups. Bleeding complications occurred exclusively in the ASV group (n = 3, 8.8%) and were all in the perioperative period. In addition one ASV and one iliac conduit developed multiple false aneurysms. Hemodynamic conduit failure (thrombosis or stenosis) occurred in nine (26.5%) ASV conduits, six (42.8%) SFA conduits, and one iliac conduit, but not in the prosthetic group. When all of these adverse events were combined for each conduit group, both ASV and SFA conduits had a higher rate of conduit failure when compared with the prosthetic conduits (p < 0.05, log-rank test). Limb loss resulting from cross-femoral conduit failure occurred in six (17.6%) patients in the ASV group, four (28.6%) patients in the SFA group, and one patient each in the iliac and prosthetic groups. These differences were not significant. CONCLUSIONS: We conclude that ASV and SFA conduits do not provide stable long-term cross-femoral revascularization and should be regarded as bridge grains until femoral infection is eradicated. When femoral infection mandates their use, frequent postoperative conduit surveillance is required. If ASV or SFA caliber is marginal, consideration should be given to the use of a larger autogenous conduit, such as superficial femoral vein.

Aged↗
PubMed1995

Knowledge, know-how, and vascular surgeons.

Vascular surgeons know vascular disease and its treatment, yet uncertainties about the future of their specialty require an examination of its two basic components: knowledge and know-how. Knowledge, or understanding, flows from research efforts, and expands the scientific basis of our medical knowledge. It is imperative that new knowledge through funded research continues so that vascular surgical science progresses. Know-how, or skill, is a crucial component of the vascular surgeon's armamentarium and has been recognized through our history as a criterion of a surgeon's proficiency. The vascular fellowship program provides the vascular surgical trainee with the knowledge and know-how necessary to become accomplished and qualified for certification in this specialty. Future progress in vascular surgery depends on new knowledge and know-how and their innovative application to human vascular disease. This may involve a formal cooperative relationship between the two national vascular societies and our colleagues in interventional radiology to develop a comprehensive vascular health care program. The societies together must continually evaluate the forces for change that are prevalent in the health care environment to expand this program. This will ensure a healthy forecast for our dynamic specialty in the twenty-first century.

Clinical Competence↗
PubMed1995

Secondary aortoenteric fistula: contemporary outcome with use of extraanatomic bypass and infected graft excision.

PURPOSE: The standard treatment for secondary aortoenteric fistula (SAEF) has been infected graft removal (IGR) and extraanatomic bypass (EAB), an approach criticized for its high rate of death, amputation, and disruption of aortic closure. Recently, graft excision and in situ graft replacement has been proposed as a safer treatment alternative. Because the current outcome that can be achieved by use of the standard treatment of SAEF has really not been established, we reviewed the records of 33 patients treated for SAEF at our institution during a contemporary time interval (1980 to 1992). METHODS: Thirteen patients (39.4%) were admitted with evidence of gastrointestinal bleeding and infection, whereas nine (27.3%) only had bleeding, 10 (30.3%) only had signs of infection, and one SAEF was entirely occult (graft thrombosis). Four patients required emergency operation. The fistula type was anastomotic in 13 (39.4%) patients, paraprosthetic in 15 (45.5%), and not specified in 4 cases. Thirty-two patients underwent EAB followed immediately by IGR (n = 16, 48.5%) or followed by IGR after a short interval, averaging 3.9 days (n = 16, 48.5%). The final patient underwent IGR, followed by EAB. RESULTS: Follow-up on 31 patients (93.9%) averaged 4.4 +/- 3.7 years. There were nine deaths (27.3%) resulting from the SAEF, six perioperative and three late. Three patients (9.1%) had disrupted aortic closure. There were four amputations in three patients (9.1%), two perioperative and two late. Late EAB infection occurred in five patients (15.2%), leading to one death and one amputation. EAB failure occurred in six patients, two during operation and four late, leading to one amputation. The cumulative cure rate for this SAEF group was 70% at 3 years and thereafter. Compared with our earlier SAEF experience, this is a decline of 21% in the mortality rate, 19% in aortic disruption, and 27% in limb loss. CONCLUSIONS: We conclude that outcome reports based on SAEF series extending over long time intervals do not accurately represent the results that are currently achieved with standard SAEF treatment with use of EAB plus IGR. This improved outcome is attributed to wide debridement of infected tissue beds, reduced intervals of lower body ischemia, and advances in perioperative management. To determine whether any new treatment approach actually offers improved outcome in the management of SAEF, comparison with EAB plus IGR should be limited to patients treated within the last decade at most.

Aged↗
PubMed1995

Histopathological characteristics of explanted human prosthetic arterial grafts: implications for the prevention and management of graft infection.

OBJECTIVE: to study the histopathological characteristics of prosthetic vascular graft infection. DESIGN: prospective clinical study over 2 years. SETTING: University Hospital. MATERIALS: 36 infected and 29 uninfected (control) chronically implanted vascular prostheses (half aortic) were removed and 352 sections prepared. CHIEF OUTCOME MEASURES: light microscopy (multiple stains), scanning electron microscopy (SEM), and multiple culture techniques to identify characteristics of healing, infection, and microorganisms. MAIN RESULTS: Acute inflammation (AI) (neurophils, granulocytes and necrosis) were seen in 75% of infected grafts, were most prominent in the perigraft tissue and rarely seen on the luminal surface. These were usually well localised, leaving the remainder of a graft well incorporated with no signs of infection. In 25% of clinically infected, culture-positive grafts there was no significant acute inflammation. Chronic inflammation (CI) (macrophages, lymphocytes, monocytes, giant cells) was seen in 70% of both control and infected grafts. In 50% of both groups a significant lymphocytic population was composed exclusively of T-lymphocytes suggesting a true host vs graft response. Unincorporated chronically implanted grafts (> 1 yr) were seen with equal frequency in the two groups although more diffusely unincorporated grafts were infected. Microorganisms were cultured from 23 infected grafts (64%) and were, at microscopy, mostly found outside the graft and nerves on the luminal side. CONCLUSIONS: This data cast doubt on criteria commonly used to distinguish graft infections and host vs. graft reactions from normal graft healing. Acute and chronic inflammation are not predictive of infection.

Acute Disease↗
PubMed1994

Complex branch renovascular disease: management options and late results.

PURPOSE: The purpose of this report is to review management options and late results of complex renovascular disease managed over the last 22 years. METHODS: Complex branch renal artery disease in 84 kidneys was repaired during 75 operations performed in 68 consecutive patients. There were 61 females (90%) and 7 males (10%) whose predominant pathologic diagnosis was fibromuscular dysplasia manifesting as either renovascular hypertension or aneurysmal degeneration. These patients underwent 15 in situ, 52 ex vivo, and 8 combined reconstructions. In situ repair primarily with use of the bifurcated internal iliac artery autograft was used for primary lesions of the proximal renal artery bifurcation (two branches). Ex vivo repairs, primarily with use of the multibranch internal iliac autograft and hypothermic perfusion preservation, were used for all other patterns of distal renal artery branch disease and reoperative problems. RESULTS: Renovascular reconstruction was successful in salvaging 83 of 84 kidneys (98.8%) in 67 of 68 patients. There were no operative deaths. Two reconstructions thrombosed in the early postoperative period. One was due to severe aortic disease, the other to branch artery dissection after a failed balloon angioplasty. Both patients continued to have hypertension. Before hospital discharge 65 patients had 81 renal revascularizations proven patent by arteriography. Their renal function was assessed and blood pressure was determined in a follow-up extending to 20 years (mean 7.5 years, median 7.9 years). Late arteriograms were obtained in 30 patients (46%) an average of 52 months after operation (range 6 months to 18 years). They demonstrate stable renal artery repair with no evidence of late graft failure in each. Hypertension was cured or improved in 51 of 53 patients (96%) with a proven patent reconstruction. Aneurysms were successfully repaired in 11 patients. Renal function was improved in four patients with ex vivo repairs, unchanged in 59 patients (15 in situ, 44 ex vivo), and persistently worse in only three patients, all of whom had in situ repairs. CONCLUSION: The branched arterial autograft allows the restoration of normal renal arterial anatomy and function when inserted to replace complex distal renovascular disease. This provides a durable repair, essential for younger patients affected by this pattern of disease who anticipate a normal life span after renovascular repair. Successful long-term correction of diastolic hypertension and aneurysmal disease was accomplished without significant morbidity.

Adolescent↗
PubMed1994

Persistent hypoglossal artery: diagnostic and therapeutic considerations concerning carotid thromboendarterectomy.

Fetal anastomotic connections between the developing internal carotid and basilar arterial systems are via the three presegmental arteries: the otic artery, the hypoglossal artery, and the trigeminal artery. After formation of the posterior communicating artery from the caudal branch of the internal carotid artery, the presegmental arteries are generally obliterated. Rarely, however, these primitive carotid-basilar anastomoses will persist into adult life, and may be detected as incidental findings at the time of cerebral angiography during evaluation of the patient with suspected cerebrovascular disease. In addition, persistence of such anastomoses may result in the coexistence of anterior and posterior circulation symptoms, precipitating diagnostic confusion. Two patients with symptoms and persistent hypoglossal artery undergoing carotid thromboendarterectomy are discussed, with emphasis on clinical presentation, diagnostic criteria and intraoperative management.

Abnormalities, Multiple↗
PubMed1994

Supraclavicular reoperation for neurogenic thoracic outlet syndrome.

Thirty-nine reoperations in 38 patients with recurrent symptoms of neurogenic thoracic outlet syndrome were performed by the supraclavicular approach. Scarring around the brachial plexus was the primary cause in 59% of procedure, whereas in 41% of reoperations residual osseous and soft tissue anomalies were identified in the supraclavicular area and were responsible for recurrence of symptoms. Anterior and middle scalenectomy and neurolysis of the brachial plexus were the procedures of choice. Complications included pleural entry (62%), lymphatic leak (10%), brachial plexus and phrenic nerve injuries (5% each), and long thoracic and recurrent laryngeal nerve palsies (3% each). The initial success rate for secondary operations was 74%, and long-term success at 18 months was 45%. Patients who had demonstrable anatomic anomalies had better short- and long-term results than had patients with scarring alone. Compared with the results of primary operations for neurogenic thoracic outlet syndrome, reoperations led to a longer hospital stay and inferior long-term results. Supraclavicular decompression allows maximal exposure of the brachial plexus and identification and correction of causative soft tissue and bony anomalies. For these reasons we recommend this as the approach of choice in both primary and secondary operations for neurogenic thoracic outlet syndrome.

Adult↗
PubMed1994

Optimal exposure of the proximal abdominal aorta: a critical appraisal of transabdominal medial visceral rotation.

PURPOSE: Adequate exposure of the upper abdominal aorta and its branches is a necessary prelude to safe and durable reconstruction of this aortic segment. Although a variety of approaches to this exposure have been described, few outcome data are available to assess the benefits and limitations of the different exposure options. In this series we report the results of the transabdominal medial visceral rotation (MVR) approach to exposure of the paramesenteric and pararenal aorta. METHODS: One hundred eight operations were performed in 104 patients, representing 19.5% of all aortic reconstructions during a 5.5 year interval. Most patients had hypertension (n = 77, 71.3%) or a history of smoking (n = 83, 76.9%). Heart disease was present in one third of patients (n = 33) and a similar proportion had abnormal renal function (elevated creatinine level) before operation (n = 40, 37.0%). One third of patients (n = 34) had undergone previous aortic or aortic branch reconstruction. Eighty percent of procedures were elective (n = 87). Seventy-one patients (65.7%) required renal revascularization, usually for hypertension or elevated creatinine levels, whereas 37 patients (34.3%) underwent visceral reconstruction, most often for symptoms of chronic mesenteric ischemia. Only 22 patients required isolated infrarenal aortic repair. Most of the aortic lesions were aneurysmal (n = 42). Eighty percent of procedures (n = 88) required suprarenal or more proximal aortic clamping. The most frequently used reconstruction techniques were bypass (n = 39, 36.1%), endarterectomy (n = 18, 16.7%), or both (n = 23, 21.3%). RESULTS: There were four intraoperative deaths (3.7%) and 15 postoperative deaths (13.9%). All intraoperative deaths and four postoperative deaths were related to hemorrhage and its complications. Visceral infarction was the most frequent cause of postoperative death. The intraoperative complications that were determined to be related to the medial visceral rotation approach included splenic injury (n = 23, 21.3%), one aortic injury, and one adrenal injury. The aortic injury was associated with substantial intraoperative bleeding and subsequent death. The postoperative complications resulting from MVR included pancreatitis (n = 5), which contributed to death in two patients, and possibly some of the cases of visceral infarction not associated with visceral reconstruction. The other common postoperative complications, cardiac (n = 25, 24.0%), pulmonary (n = 32, 30.8%), renal (n = 20, 19.2%), and infectious (n = 17, 16.3%), were attributed to the procedures performed. CONCLUSIONS: Transabdominal MVR exposure of the upper abdominal aorta provides unrestricted access to the visceral branch-bearing segment of the aorta and places no limitations on the choice of arterial reconstruction technique. The associated morbidity and mortality rates are typical of patients undergoing these complex vascular repairs, but the frequency of splenic injury and postoperative pancreatitis is increased.

Abdomen↗
PubMed1994

Chronic visceral ischemia.

The clinical syndrome of chronic intestinal ischemia has been examined through its evolution over the past century. Particular attention has been paid to the past 40 years and the contributions made by Dr Charles Rob. Although various diagnostic strategies have been introduced, the cornerstone of diagnosis remains the biplanar aortogram. Improvement in non-invasive imaging may allow us to understand the natural history of the disease via surveillance screening programs. Modern treatment, resulting in successful and durable reconstruction, consists of either anterograde bypass or transaortic endarterectomy. The future holds promise for the young investigator interested in solving the questions that persist concerning this unique vascular bed.

Abdominal Pain↗
PubMed1993

Aorta-left renal vein fistula syndrome caused by rupture of a juxtarenal abdominal aortic aneurysm: novel pathologic mechanism for a unique clinical entity.

Spontaneous aorta-left renal vein fistula (ALRVF) caused by abdominal aortic aneurysm (AAA) is a rare form of intravascular aneurysm rupture. The literature series of ALRVF, updated here to 19 reported cases, demonstrates that patients with ALRVF present with a unique clinical syndrome characterized by abdominal or left flank pain (84%), a pulsatile abdominal mass (63%), abdominal bruit or murmur (63%), hematuria (100%), and nonfunction of the left kidney on functional imaging studies (100% of patients studied). Operative findings in ALRVF syndrome have included a large AAA (mean diameter 9.2 cm), with frank rupture in only three; in 17 of 19 patients (89%) the ALRVF was associated with a retroaortic left renal vein anomaly. The patient presented here had a large juxtarenal AAA with rupture into the left retroperitoneal space. The wide aneurysm neck and expanding hematoma created an avulsion of the second left lumbar vein from its junction with an anatomically normal (preaortic) left renal vein; the resulting renal vein tear allowed development of an arteriovenous communication that was responsible for the clinical presentation of ALRVF syndrome. The disease found here demonstrates a novel mechanism for the production of ALRVF syndrome in patients with juxtarenal AAA and otherwise normal pararenal venous anatomy.

Aged↗
PubMed1993

Acute mesenteric ischemia.

Acute mesenteric ischemia resulting from specific etiologies is a treatable vascular emergency. It requires a high index of suspicion and prompt, aggressive resuscitation and diagnostic maneuvers to determine the specific underlying cause. This will allow specific directed surgical revascularization, optimization of cardiac performance, or correction of a hypercoagulable state, all directed at maximizing the amount of functional bowel that is salvageable. These strategies are the cornerstones for a successful outcome in this life-threatening vascular catastrophe.

Acute Disease↗
PubMed1993

Extra-anatomic bypass: a new look (opposing view).

The criteria by which revascularizations are measured ultimately is patency, since cessation of blood flow equates with a failed graft and usually signals a return to the preoperative limb perfusion or less. An uncommonly analyzed criterion for graft function is blood flow capacity through the reconstruction which is critically important when increased blood flow demands are required with exercise. This is particularly true in the aortoiliac segment when the bypass must meet large blood flow requirements. When the extra-anatomic bypass is evaluated in this manner, it is often inadequate to meet the blood flow demands required with activity. The source of blood flow is the subclavian artery and not the aorta. The graft diameter is almost one half that used to bypass or substitute for the aorta and four times as long. It is not surprising, therefore, that increases in blood flow are limited in this remote subcutaneous bypass circuit. The axillofemoral and, to some extent, the femorfemoral bypass grafts produce hemodynamic gradients to blood flow increases above basal rates. Thus, graft patency alone does not realistically measure the functional capacity of an aortoiliac reconstruction. The conceptual design of an extra-anatomic bypass results in hemodynamic liabilities that produce an inferior performance to that observed with in-line direct aortofemoral bypass. This observation further supports our contention that extra-anatomic bypass of the aortoiliac segment should be restricted to circumvent a prosthetic graft infection in the aortoiliac segment to maintain limb perfusion following graft removal. Whether it has a role in selected patients with a short life span and critical ischemia who appear to be a prohibited risk for in-line aortofemoral reconstruction will always be debatable. Current experience does not justify expanded indications for extra-anatomic bypass in symptomatic patients with aortoiliac disease. The proven effective and durable intervention is aortofemoral revascularization.

Aorta, Abdominal↗
PubMed1992

Surgical recanalization of occluded peripheral arteries.

This article, reflecting on the surgical recanalization of occluded peripheral arteries, has exposed the very essence of vascular surgery. Only the pioneering cardiac anomalies repaired by Gross (patent duct arteriosus, 1938), Blalock and Taussig (tetralogy of Fallot, 1944), and Crafoord and Nylin (coarctation, 1945) and the legendary aortic grafting operations of Oudot (occlusion, 1950) and Dubost and coworkers (aneurysm, 1951) are not a part of this article. The contributions to surgical recanalization of the occluded peripheral arteries are numerous. Some are well conceived, and others are innovative. Perhaps the most significant technique of all, endarterectomy itself, began purely as a serendipitous event. The startling impact of dos Santos' revolutionaly "disobliteration" was realized at once. Intimal injury during the operation did not cause inevitable thrombosis, as historically taught. Thus, all vascular interventions, either endarterectomy, graft repair, or the newer endovascular techniques discussed in this issue, would not have been developed without the understanding of the tolerance of the human intima to injury. Thromboendarterectomy, the basis of surgical recanalization of occluded arteries, unlocked the mystery of arterial rethrombosis after intervention. Recognizing these crucial facts, it will have a lasting place in the expanded discipline of vascular disease and its treatment. Dos Santos, the European founder of endarterectomy, and Wylie, the American pioneer and proponent of endarterectomy, were great friends in life (Fig. 4) and would certainly be pleased to see the further development of technology aimed at the treatment of atherosclerotic obstruction of the peripheral arteries.

Arterial Occlusive Diseases↗
PubMed1992

Circumferential venolysis and paraclavicular thoracic outlet decompression for "effort thrombosis" of the subclavian vein.

Effort thrombosis of the subclavian vein (Paget-Schroetter syndrome) has long been considered a primary thrombotic process, but recent experience suggests that it may commonly result from repeated mechanical compression. Increased awareness of the pathophysiology of this syndrome can allow timely, improved diagnostic screening and the use of specific surgical intervention to relieve the venous consequences. During the past 15 years we have treated six patients with mechanical compression in the thoracic outlet causing surgically correctable venous occlusive problems. There were four men and two women with an average age of 38 years (range 26 to 53 years). All patients exhibited pain, swelling, and cyanosis of the upper extremity, with worsening venous congestion on abduction of the arm. Five of six patients were originally treated for effort thrombosis of the subclavian vein with arm elevation and anticoagulation; two also underwent immediate thrombolytic therapy with urokinase. Venography was prompted in each case by positional symptoms during follow-up and showed irregular stenosis of the subclavian vein adjacent to the first rib. All patients underwent extended first rib resection and circumferential venolysis (one patient underwent bilateral procedures); one was performed through a transaxillary approach, two through a supraclavicular approach, and four through a new, "paraclavicular" approach. All subclavian veins appeared normal after venolysis. Five of six patients also underwent complete scalenectomy and brachial plexus neurolysis. In each patient, venous and neurogenic symptoms resolved and venography confirmed a patent subclavian vein, with follow-up ranging from 11 months to 13 years (mean 3.8 years).

Adult↗