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Biomedical subjects

T J Bunt

Publications and source records attributed to T J Bunt.

At least 55 records · Page 3Linked to original sources
PubMed1986

The clinical significance of the asymptomatic Hollenhorst plaque.

Sixty consecutive patients with visual complaints as the primary symptom of cerebrovascular insufficiency were evaluated with complete cerebral angiography (CCA). Eighteen patients referred for evaluation of asymptomatic Hollenhorst plaques had a 50% incidence of ipsilateral carotid bifurcation disease, but only 16% of these were considered surgically remediable; five of these patients eventually required carotid endarterectomy (CEA). Nine of the 18 patients with asymptomatic Hollenhorst plaques were further evaluated with serial ocular fundus photography: the plaque persisted in all nine patients--in four for more than 6 months and in five for more than 1 year. No patient had transient or fixed retinal or cerebral symptoms. Twenty-six patients with amaurosis fugax showed a 70% incidence of significant bifurcation disease and three had significant intracranial disease; 50% eventually required CEA. Twelve patients with fixed visual deficits (four patients had homonymous hemianopsia, four had retinal artery occlusions, and four had ischemic retinopathies) demonstrated a 100% incidence of bifurcation disease, but in addition 85% had significant intracranial disease; only one of this group had surgically amenable disease. Amaurosis fugax preceded blindness in two patients. Hollenhorst plaque as an isolated phenomenon appears to be a retinal embolic event of uncertain age, with poor predictive power for further embolic events, and not as highly correlated with significant or surgically amenabe carotid bifurcation disease.

Arterial Occlusive Diseases↗
PubMed1986

Non-directed relaparotomy for intra-abdominal sepsis. A futile procedure.

Over a 50-month period, 2,657 primary laparotomies were performed; 192 patients underwent urgent relaparotomy for complications of primary laparotomy. Forty-seven relaparotomies were performed for Type I intra-abdominal sepsis (IAS-1) with a 12.8 per cent mortality, and 46 for Type 2 IAS with a 82.6 per cent mortality (P less than 0.001). Of the 46 IAS-2 patients, 31 relaparotomies were "directed" by positive peritoneal signs (CAT/ultrasound/PIPIDA examinations) with 94 per cent (29/31) yielding positive findings. Fifteen were "non-directed" in an effort to uncover an occult source of continuing sepsis of MOSF and yielded a 13 per cent (2/15) positive rate (P less than 0.001), and a 93 per cent (14/15) mortality. Relaparotomy for sepsis directed by positive radiologic or clinical findings can be reliably expected to demonstrate a surgical focus whose correction may yield patient survival; non-directed relaparotomy, however, seldom demonstrates a focus and does not contribute to survival.

Abdomen↗
PubMed1986

Sources of Staphylococcus epidermidis at the inguinal incision during peripheral revascularization.

Staphylococcus epidermidis has been implicated as a major etiologic agent of delayed synthetic vascular graft infection and/or pseudoaneurysm formation at the femoral anastomosis. The source of possible operative graft contamination is debated. Forty-five inguinal incisions in consecutive patients undergoing elective peripheral revascularization were studied. No opening cultures were positive: 30 per cent showed positive nodal cultures; 25 per cent showed positive arterial wall cultures; and 20 per cent showed positive closing cultures, 95 per cent of which were S. epidermidis. There was no correlation with preoperative transfemoral angiography. This high incidence in the tissues of the inguinal incision may be related to the delayed development of S. epidermidis graft infections.

Extremities↗
PubMed1985

Gangrene of the immediate postoperative above-knee amputation stump: role of emergency revascularization in preventing death.

Two hundred seventy-five lower extremity amputations were performed over a 4-year interval for end-stage peripheral vascular disease. Fourteen patients (8.5%) of a total of 165 patients undergoing above-knee amputation (AKA) either suffered acute gangrenous ischemia of the AKA stump postoperatively, or were thought to be at high risk for same, and therefore underwent prophylactic inflow revascularization prior to or concomitant with AKA. The overall operative mortality rate was 28.5% in these 14 patients and was related either to inability to revascularize (two of three patients) or to the attempt to revascularize in the presence of a frankly necrotic amputation stump (three of five patients). Lower extremity amputation may be performed with an overall acceptably low mortality rate, which for our series is 0.9% for 113 below-knee amputation (BKA) and 2.8% for 140 AKA levels. Acute postoperative gangrene of the stump carries a high mortality rate and may be prevented by inflow revascularization prior to amputation. Three situations were identified as carrying a high risk for the subsequent development of gangrene: acute thrombosis of a prior combined inflow/outflow procedure, occlusion of the superficial femoral artery with an occluded/stenotic deep femoral artery and no palpable femoral pulse, and flat pulse volume recordings at the high thigh level. Patients who present for AKA with one of these indications should be considered as a candidate for prophylactic inflow revascularization prior to AKA to prevent ascending gangrene.

Acute Disease↗
PubMed1985

Infected abdominal aortic aneurysm.

In the surgical literature, 37 survivors of infected abdominal aortic aneurysmorrhaphy have been reported. The diagnosis is suspected if a patient with fever, leukocytosis, and abdominal pain is noted on physical examination to have a pulsatile abdominal mass. Confirmation is best obtained with computerized tomography and angiography. We used a protocol for surgical diagnosis and management to successfully treat two patients who are added to the list of known survivors of infection of an abdominal aortic aneurysm.

Aged↗
PubMed1985

Urgent relaparotomy: the high-risk, no-choice operation.

Two thousand six hundred fifty-seven primary laparotomies were performed during a 50-month period; 192 (7%) of these were relaparotomies within 21 days for complications of primary laparotomy. The overall mortality rate was 36% (69/192). Relaparotomy for dehiscence (0/15) or obstruction (5%-1/21) carried little risk and for abscess a moderate risk (13%-6/47). Relaparotomy for gastrointestinal or intraperitoneal hemorrhage entailed higher risks at 44% (4/9) and 27% (6/22), respectively. Age was a significant determinant of mortality, being 16% (13/82) for less than 50 years of age but 50% (56/110) for greater than 50 years (p less than 0.001). The major determinant at all age groups was sepsis, varying from 50% (4/8) for patients less than 50 years to 89% (34/38) for patients greater than 50 years (p less than 0.01). Differentiation was made between localized intra-abdominal infection (IAS-1) and nonlocalized/systemic infection (IAS-2): the mortality rate for 47 patients with IAS-1 was 13% and for IAS-2 83% (p less than 0.001). Urgent relaparotomy is necessary and may be performed safely for incisional dehiscence, obstruction, or IAS-1, with low mortality and high patient salvage rates. Directed relaparotomy for IAS-2 carries a high mortality rate but is the only means of patient salvage. Nondirected relaparotomy for multiple system and organ failure alone without supportive clinical or radiologic findings was futile, with a 13% (2/15) rate of positive exploration (p less than 0.001) and no patient salvage.

Abdomen, Acute↗
PubMed1985

Iatrogenic vascular injury during peripheral revascularization.

Iatrogenic vascular injury may occur during peripheral revascularization procedures secondary to the application of vascular occlusive devices. This review summarizes the known mechanical causes of such injury, relates this to clamp design, and suggests methods to minimize such injury by appropriate selection and handling of vascular occlusive clamps.

Animals↗
PubMed1985

Carotid endarterectomy. One solution to the stroke problem.

Stroke is most often the result of extracranial cerebral artery disease; stroke carries a high initial mortality and morbidity and portends an increased risk of subsequent stroke or myocardial infarction. Stroke is also a preventable disease in more than one half of patients, either by approximate treatment of premonitory transient ischemic attacks or by appropriate evaluation of otherwise asymptomatic carotid bruits. Combined patient education and referring physician awareness should result in a declining incidence of stroke in this country. Two hundred carotid endarterectomies were performed over a 4-year period by senior residents under the direct supervision of the authors. Operative mortality was 1.5 per cent; perioperative stroke, 1.5 per cent; temporary neurologic deficit, 1 per cent; and temporary cranial nerve injury, 1 per cent. Analysis of these patients and of the literature supports an aggressive approach to carotid endarterectomy for patients with focal transient ischemic attacks and a more cautious approach for patients with prior stroke or asymptomatic stenoses.

Adult↗
PubMed1985

Differential endothelial injury caused by vascular clamps and vessel loops. I. Normal vessels.

Silicone rubber looped tourniquets were compared with standard crossmembered metallic peripheral vascular occlusive clamps in a canine aorto-iliac vessel model to compare the degree and severity of endothelial injury as demonstrated by scanning electron microscopy. The moderate-to-severe injury incurred by the standard clamps was not seen whatsoever with the looped tourniquets. Selective and preferential use of silastic rubber vessel tourniquet loops for vascular occlusion and control is thus advocated.

Animals↗
PubMed1985

Differential endothelial injury caused by vascular clamps and vessel loops. II. Atherosclerotic vessels.

Performance of a vascular anastomosis or repair requires meticulous, gentle technique and a bloodless operative field. Many vascular surgeons rely on commercial "atraumatic" vascular clamps for the latter; however, most experimental evidence incriminates clamps as agents of moderate to severe endothelial and medial injury. Our previous studies in normal canine aortoiliac vessels have demonstrated that silastic rubber vessel loops did not cause injury in that setting; this study examines in vivo atherosclerotic human femoropopliteal artery segments. Ten centimeter segments of perfused femoropopliteal arteries were exposed during performance of above-knee lower extremity amputation for endstage vascular insufficiency. DeBakey, Cooley, Fogarty, and bulldog vascular clamps, and double-looped silastic rubber vessel loops were applied at 3-centimeter intervals for 15 minutes. Each segment was then examined under scanning electron microscopy. All vascular clamps caused endothelial and presumed medial injury; no injury was seen with the vessel loops. Selective and preferential use of silastic rubber vessel loops is thus advocated to minimize iatrogenic complications.

Adult↗
PubMed1984

Endoscopic visualization of an intraluminal dacron graft: definitive diagnosis of aortoduodenal fistula.

The literature contains more than 250 cases of graft enteric fistula. The classic symptom complex involves antecedent bleeding followed by exsanguinating hemorrhage within hours to days. In patients with gastrointestinal hemorrhage and a history of aortic graft implantation, the role of endoscopy is crucial, first to delineate any coexistent disease and secondarily to view the fistula itself. Although only 20 cases have been so diagnosed, aggressive intubation of the distal duodenum in a patient fully prepared for surgical intervention may yield a definitive diagnosis of aortoduodenal fistula, thus facilitating appropriate aggressive surgical management.

Aged↗
PubMed1984

Incidence of positive inguinal lymph node cultures during peripheral revascularization.

Synthetic vascular graft infections occur more commonly at the inguinal incision, and there is contamination of the graft by transection of bacteria-laden lymphatics proximal to a distal extremity infection. In 45 consecutive peripheral revascularizations, significant positive inguinal lymph node cultures were not obtained in 30 normal extremities; two of 15 distally infected extremities demonstrated the same bacteria in the distal infection and the inguinal lymph node. Both patients subsequently developed graft infections. Inguinal lymph nodes proximal to a distal infection may harbor bacteria capable of causing a synthetic vascular graft infection. Consideration should be given to culture-directed rather than routine antibiotic prophylaxis under this circumstance.

Arterial Occlusive Diseases↗
PubMed1984

Lower extremity amputation for peripheral vascular disease. A low-risk operation.

Two hundred fifty-three consecutive major amputations of the lower extremity for peripheral vascular insufficiency were performed over a 3-year period. Operative mortality was 0.9 per cent for 113 below-knee and 2.8 per cent for 140 above-knee amputations. Although lower extremity amputation has a reputation for high mortality and morbidity, this is unwarranted; adherence to a protocol of aggressive medical management with timely surgical intervention allows a mortality that is appropriate to the age and general debility of this patient population.

Aged↗