Endovascular stenting.
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Aneurysm, Ruptured↗
Biomedical subjects
T M Sullivan
Publications and source records attributed to T M Sullivan.
Early outcome assessment for 2228 consecutive carotid endarterectomy procedures: the Cleveland Clinic experience from 1989 to 1995.
PURPOSE: Several randomized trials now have established guidelines regarding patient selection for carotid endarterectomy (CEA) that have been widely accepted but have little relevance unless they are considered in the context of perioperative risk. The purpose of this study was to demonstrate the feasibility of early outcome assessment using a computerized database. METHODS: Since 1989 demographic information and in-hospital results for all surgical procedures performed by the members of our department have been entered into a prospective registry. For the purpose of this report, we have analyzed the stroke and mortality rates for 2228 consecutive CEAs (2046 patients), including 1924 that were performed as isolated operations and 304 that were combined with simultaneous coronary artery bypass grafting (CABG). This series incidentally contains a total of 153 reoperations for recurrent carotid stenosis. RESULTS: The respective stroke and mortality rates were 0.5% and 1.8% for all isolated CEAs, 4.3% and 5.3% for all CEA-CABG procedures, and 4.6% and 2.0% for carotid reoperations. According to a multivariable statistical model, the composite stroke and mortality rate for isolated CEA was significantly influenced by female gender (p = 0.050), by the urgency of intervention (p = 0.026), and by carotid reoperations (p = 0.024). Gender (p = 0.030) and urgency (p = 0.040) also were associated with differences in the stroke rate alone; furthermore, the incidence of perioperative stroke was higher in conjunction with synthetic patching (odds ratio, 2.6; 95% confidence interval, 1.2 to 5.3) and was marginally higher with primary arteriotomy closure (odds ratio, 2.7; 95% confidence interval, 0.8 to 9.5) compared with vein patch angioplasty (1.3%). The method used to repair the arteriotomy was the only independent factor that qualified for the multivariable composite stroke and mortality models that were applied to the combined CEA-CABG procedures, but too few patients in this cohort had synthetic patches or primary closure to validate the perceived superiority of vein patching. CONCLUSIONS: Prospective outcome assessment is essential to reconcile the indications for CEA with its actual results, and it may lead incidentally to important observations concerning patient care.
Adult↗
Percutaneous transluminal angioplasty and primary stenting of the iliac arteries in 288 patients.
PURPOSE: This study reports the initial and late results of percutaneous transluminal angioplasty (PTA) and intravascular stenting for atherosclerotic occlusive disease of the iliac arteries. METHODS: The preprocedural and postprocedural clinical records, arteriograms, segmental limb pressure measurements (ankle-brachial [ABI] and thigh-brachial [TBI] indexes), and pulse volume recordings of 288 patients who underwent PTA and primary stenting of the common iliac (354, 69.4%) and external iliac (156, 30.6%) arteries were reviewed. Initial and late clinical, hemodynamic, and angiographic success were assessed by objective criteria. Data on patients who underwent unsuccessful attempts at iliac stent placement are unavailable; results are not reported on an intent-to-treat basis. RESULTS: Clinical follow-up data (mean, 11.9 months) are available for 268 of 288 patients (93.1%) and for 394 of 424 limbs (92.9%). The initial success rates, as determined by TBI, ABI, and clinical limb status, were 90.2%, 87.8%, and 74.6%, respectively. The Kaplan-Meier estimates of angiographic patency (101 arteries) were 96%, 81%, and 73% at 6, 12, and 24 months. Cumulative patency rates were 84%, 76%, and 57% on the basis of TBI, ABI, and clinical limb status at 24 months. Factors associated with initial success included the need for multiple stents (p = 0.0001), a higher degree of initial stenosis (p = 0.0001), lower severity of baseline ischemia (p = 0.007), younger age (p = 0.0015), and the preprocedural patency of the ipsilateral superficial femoral artery (p = 0.002). A higher degree of initial stenosis (p < 0.001) and superficial femoral artery patency (p = 0.004) were also associated with late success. CONCLUSIONS: PTA and stenting of the iliac arteries is associated with reasonable angiographic, hemodynamic, and clinical success. The outcome is favorably affected by higher initial severity of stenosis and greater extent of disease, lower severity of baseline ischemia, younger age, and by patency of the ipsilateral superficial femoral artery.
Angioplasty, Balloon↗
Factors affecting the growth of Fusarium proliferatum and the production of fumonisin B1: oxygen and pH.
Fumonisins are mycotoxins produced primarily by Fusarium moniliforme and Fusarium proliferatum in corn. In liquid culture, production of fumonisin B1 (FB1), the most common moiety of the family of fumonisins, can be obtained using a defined medium that is nitrogen-limited. Under nitrogen-limited conditions both growth and the production of FB1 were greatly influenced by pH and aeration. At pH above 5.0, F. proliferatum grew normally but produced little FB1 (< 100 micrograms m-1). At pH below 5.0, there was less growth but substantially more FB1. Below a pH of 2.5, both growth and metabolism were slower with very little FB1 produced. When the optimal pH range of between 3.0 and 4.0 under well-aerated conditions was used, both growth and FB1 production were high. However, under oxygen-limited conditions, less growth occurred, glucose consumption was increased, and no FB1 was produced.
Bioreactors↗
Assignment of SAFB encoding Hsp27 ERE-TATA binding protein (HET)/scaffold attachment factor B (SAF-B) to human chromosome 19 band p13.
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Chromosome Mapping↗
Vascular claudication: how to individualize treatment.
The development of angioplasty and stenting, along with the improvement of surgical procedures, have given physicians more options for treating claudication. However, most patients with intermittent claudication do not need a revascularization procedure, or even angiography. They do need an assessment of their coronary and carotid arteries. We present a treatment approach based on risk factor modification, symptom severity, and the risks and benefits of various procedures.
Adult↗
High incidence of restenosis/reocclusion of stents in the percutaneous treatment of long-segment superficial femoral artery disease after suboptimal angioplasty.
PURPOSE: To evaluate the efficacy of intravascular stents used to treat long-segment stenoses and occlusions of the superficial femoral artery (SFA) after suboptimal angioplasty. METHODS: Fifty-eight limbs in 55 patients who underwent stenting of the SFA were identified from a vascular registry. Indications for stent placement after suboptimal PTA included flow-limiting dissection, residual pressure gradient (>15 mm Hg) or stenosis (>30%), or failure to establish initial patency. Lesion length ranged from 6 to 35 cm (mean, 16.5 cm). Endpoints for primary patency were: restenosis of >50%, reocclusion, or diminution of the postprocedure ankle-brachial index greater than 0.15. RESULTS: The mean ankle-brachial index improved from 0.48 +/- 0.19 to 0.71 +/- 0.23 (p = 0.001). Primary patency rates by Kaplan-Meier estimates at 1 month, 6 months, and 1 year were 88%, 47%, and 22%, respectively. Secondary patency rates were 94% at 1 month, 59% at 6 months, and 46% at 1 year. The median time to reaching an endpoint of restenosis or reocclusion was 6 months primarily and 9 months secondarily. Clinical improvement at the time of latest follow-up occurred in 56% of patients (mean, 13.8 months). Periprocedural complications occurred in 24.5% of patients with the first intervention. The only factor that favorably influenced outcome was improvement in clinical category after the procedure (p = 0.001). CONCLUSIONS: There was a high incidence of restenosis and reocclusion with long-segment SFA disease that required stents to achieve initial success. Despite close surveillance and reintervention, anatomic patency at 1 year was poor. However, clinical benefit was maintained in the majority of patients. The outcome was similar in the claudication population compared with those who had limb-threatening ischemia. Percutaneous revascularization of long-segment SFA disease requiring stents should be reserved for patients with critical limb ischemia for which no reasonable surgical alternative exists.
Adult↗
Dose-response relationship of dexrazoxane for prevention of doxorubicin-induced cardiotoxicity in mice, rats, and dogs.
Dexrazoxane [(DZR), ADR 529, ICRF-187] ameliorates doxorubicin (DOX)-induced cardiotoxicity in animals, and is recommended as a cardioprotectant in patients receiving cumulative doses of DOX above 300 mg/m2. A DZR:DOX dose ratio of 10:1 is recommended based on studies in patients receiving 50 mg/m2. Since DOX may be used at much higher doses in certain clinical settings, we evaluated the ability of DZR to protect against cardiomyopathy in animals given bolus doses of DOX at varying dose levels. The severity and extent of the cardiomyopathy were evaluated histologically and expressed as the mean total score (MTS). Mice were given 10 doses of DOX (2 or 4 mg/kg) over a 7-week period. Without DZR, the MTS 4 weeks after the last treatment was 3.7 with 4 mg/kg DOX and 1.3 with 2 mg/kg DOX. DZR at 5:1, 10:1, and 20:1 dose ratios caused a dose-dependent decrease in the MTS but was less efficacious with the higher, more cardiotoxic dose of DOX. Rats were given DOX at 0.2, 0.4, and 0.8 mg/kg with a 20:1 ratio of DZR weekly for 13 weeks. Cardiomyopathy was most severe with the highest dose of DOX in the absence of DZR, especially in males, and progressed during the 6 weeks following the last treatment. DZR reduced the MTS in both sexes but in the males given the highest dose of DOX, there was still a significant amount of cardiac damage compared to vehicle-treated controls. Dogs were given 0.1, 0.3, and 0.8 mg/kg DOX with 20:1 DZR for 13 weeks. DZR reduced the MTS significantly (P < 0.05) in males and females but cardiac lesions were still present in each of the DZR-treated dogs. The results indicate that although DZR is highly effective in attenuating the cardiomyopathy caused by DOX, dose ratios of DZR:DOX capable of providing total or nearly complete cardioprotection at low doses of DOX are less efficacious at higher doses of DOX. One possible explanation for this effect is the marked pharmacokinetic difference between DZR and DOX, with DZR undergoing a much more rapid rate of elimination from the body compared to DOX. These findings point to the need for further studies to optimize the dose scheduling of DZR before using it clinically with bolus doses of DOX above those currently recommended.
Animals↗
Liquid culture methods for the production of fumonisin.
Currently, fumonisin B1 is obtained primarily by using solid culture methods. Although fumonisin B1 concentrations obtained in solid culture are typically quite high, subsequent extraction and purification present problems. In addition, current methods utilize complex media which makes analysis of biosynthetic pathways and control mechanisms difficult. Liquid culture methods of production could eliminate many problems associated with production in solid culture. However, in the past, concentrations obtained in liquid culture have been relatively low. In this work, factors affecting the production of fumonisin B1 from a shake flask scale of 100 ml to a fermenter scale of 100 liters were examined. Best results were obtained by using a fed batch method that is nitrogen limited, with pH control. With this method, concentrations in excess of 1000 ppm can be obtained.
Culture Media↗
Subclavian-carotid bypass to an "isolated" carotid bifurcation: a retrospective analysis.
Most patients with occlusion of the common carotid artery will have concomitant occlusion of the internal and external carotid arteries. A few, however, will maintain antegrade internal carotid flow via retrograde flow from the ipsilateral external carotid artery. These patients remain at risk for hemispheric transient ischemic attacks (TIAs), ischemic stroke, or vertebrobasilar insufficiency/global cerebral ischemia. Historically, diagnosis of this condition has relied on cerebral arteriography and/or blind exploration of the carotid bifurcation. More recently, color-enhanced duplex ultrasonography has been used to facilitate the diagnosis and has allowed focused, delayed arteriographic views of the appropriate carotid bifurcation, making blind exploration unnecessary. From 1985 to 1994, nine patients with TIAs (n = 5), completed stroke with minimal residual deficit (n = 2), or vertebrobasilar insufficiency (n = 2) were found to have occlusion of the common carotid artery with a patent carotid bifurcation on duplex ultrasound images. All nine had this particular anatomic condition confirmed by arteriography and were subsequently treated by subclavian-carotid bypass using autologous reversed saphenous vein (n = 5) or synthetic (n = 4) grafts. Five of nine patients required concomitant bifurcation endarterectomy. There were no perioperative strokes or TIAs and no operative deaths. Six of eight survivors remain asymptomatic at 1 to 92 months' follow-up (mean 37.1 months). Symptomatic patients with occluded common carotid arteries and patent bifurcations can be treated surgically with low operative morbidity and good long-term results.
Carotid Arteries↗
Influence of gender on cardiac risk and survival in patients with infrarenal aortic aneurysms.
PURPOSE: To determine whether gender distinction influence the cardiac risk or survival rates associated with surgical treatment of infrarenal abdominal aortic aneurysms (AAAs). METHODS: From 1983 to 1988, graft replacement of intact AAAs was performed in 490 men (84%) and in 92 women (16%) who had no history of myocardial revascularization before the discovery of their AAAs. Patients of both genders were comparable with respect to mean age (68 years) and the prevalence of coronary artery disease (CAD) by standard clinical criteria (men, 73%; women, 65%). Preoperative coronary angiography was obtained in 471 of the 582 patients (men, 81%; women, 80%) during this particular study period. Preliminary coronary bypass was warranted on the basis of existing indications in 111 (24%) of these 471 patients (men, 25%; women, 18%), including 104 (31%) of the 337 who had clinical indications of CAD (men, 32%; women, 26%) but only 7 (5.2%) of the 134 who did not (men, 6%; women, 4%). Follow-up data were collected during a mean interval of 53 months (men, 54 months; women, 48 months) and were analyzed by Kaplan-Meier survival analysis and Cox proportional hazards models. RESULTS: Twenty-nine perioperative deaths (5.0%) occurred in conjunction with AAA repair (men, 5.1%; women, 4.3%), and 126 early and late deaths have occurred (men, 22%; women, 22%). Survival rates for the series were found to correlate with age (p < 0.001), the serum creatinine level (p < 0.001), and the coronary angiographic classification (p < 0.001). No significant differences were identified between the gender cohorts. The cardiac mortality rate for AAA resection was only 1.8% in the 111 patients who had preliminary coronary bypass, but five additional perioperative deaths (4.5%) related to renal failure or sepsis occurred in this group. However, 5-year survival rates for patients receiving preliminary bypass (men, 82%; women, 75%) were closely comparable with those for patients found to have only mild to moderate CAD by angiography (men, 86%; women, 82%). CONCLUSION: We conclude that men and women with AAAs have similar cardiac risks and survival rates associated with surgical treatment. Our results also illustrate that the potential benefit of coronary intervention for severe CAD in patients of either gender must be considered in the context of long-term outcome and the early mortality rate of AAA repair.
Aged↗
Endovascular management of unusual aneurysms of the axillary and subclavian arteries.
PURPOSE: Aneurysms of the upper extremity arteries are uncommon and may be difficult to manage with standard surgical techniques. We report the exclusion of three axillary-subclavian aneurysms with covered stents. METHODS AND RESULTS: Palmaz stents were covered with either polytetrafluoroethylene (2 cases) or brachial vein and deployed to exclude pseudoaneurysms in 1 axillary (ruptured) and 2 left subclavian arteries. Two of the patients had advanced cancer and died within 52 days and 3 months of treatment, but their aneurysms were occluded at the time of their death. The repair in the third patient is patent at 9 months. CONCLUSIONS: Endovascular exclusion of axillary and subclavian aneurysms with covered stents may offer a useful alternative to operative repair, particularly in patients with significant comorbidities.
Aged↗
Effect of external reinforcement on the patency of infrainguinal polytetrafluoroethylene arterial grafts.
BACKGROUND: Expanded polytetrafluoroethylene (PTFE) has been used for infrainguinal revascularization when the saphenous vein is unavailable or unsuitable. Patency rates are, however, decidedly inferior to those with autologous vein, especially when anastomosed distally to the infrageniculate popliteal or tibial arteries. Although there are theoretical advantages to the use of reinforced grafts, the issue of external support for infrainguinal grafts has not been addressed in large clinical trials. Despite the insufficiency of data to support their use, externally supported PTFE grafts are widely used in clinical practice. This study attempts to determine whether or not external reinforcement of PTFE grafts affects patency when the graft crosses a joint in a canine arterial model. STUDY DESIGN: Patency rates of standard PTFE prostheses were compared with those of externally supported PTFE across the hip joint in 19 mongrel dogs. In each animal, one limb was randomly assigned to receive standard PTFE and the other, externally supported PTFE. External iliac-superficial femoral artery grafts were constructed in a standardized fashion. At 12 to 16 weeks after implantation, graft patency was assessed by arteriography. RESULTS: Thirteen animals (26 grafts) underwent angiographic evaluatIon of patency. Overall patency was 42 percent at 84 to 113 days. There was no statistically significant difference in patency between the two graft materials. CONCLUSIONS: Intrinsic factors, rather than the presence or absence or external graft reinforcement, are the most important determinants of graft patency in this model. These data do not support the routine clinical use of externally reinforced PTFE grafts for infrainguinal revascularization.
Anastomosis, Surgical↗
Aortocaval fistula in ruptured inflammatory abdominal aortic aneurysm. A report of two cases and literature review.
Inflammatory abdominal aortic aneurysms (IAAA) occur infrequently in clinical practice. The reported incidence varies from 2.5-15% of all abdominal aortic aneurysms (AAA). Four percent of all AAA rupture into the vena cava. IAAA rupturing into the vena cava is exceedingly rare. To date, four such cases have been reported. IAAA are associated with a thick, rigid aortic wall which may be thin posteriorly and posterolaterally, where they are likely to rupture. A dense, fibrotic, desmoplastic reaction is found in the periaortic tissues often involving the duodenum, the inferior vena cava, the left renal vein, and ureters. IAAA may present with abdominal, back, or flank pain even in the absence of rupture. The diagnosis of IAAA can be made preoperatively by CT scan and at the time of laparotomy. Aortocaval fistula (ACF) can occur as a complication of AAA. The triad of low back pain, a palpable AAA, and a machinery murmur is diagnostic. ACF in association with IAAA is even more rare. It is amenable to surgical correction using a standard technique of fistula repair from within the aneurysm and prosthetic aortic graft replacement. Two cases of AAA with aortocaval fistula (ACF) are presented. In both, the diagnosis of ACF was made preoperatively. Repair of ACF was performed from within the aneurysm, with subsequent graft replacement. Despite complicated postoperative courses, both patients survived.
Aged↗
Intraoperative assessment of carotid endarterectomy: a comparison of techniques.
Routine intraoperative imaging of the carotid artery following carotid endarterectomy can detect defects at the site of endarterectomy that may lead to neurologic morbidity. A number of methods have been used to evaluate the completed endarterectomy. In this prospective study we compared subjective methods of assessment (hand-held, continuous-wave Doppler imaging with audible interpretation of signals) and objective methods of assessment (duplex ultrasonography with color flow and digital subtraction arteriography) with respect to their ability to detect operative abnormalities. Fifty-three carotid endarterectomies were evaluated by means of all methods of assessment. Six patients had significant abnormalities in which the vessel was reopened and the abnormality confirmed. The sensitivity and specificity for detecting abnormalities for each method are, respectively: duplex ultrasonography with color flow, 100% and 100%; digital subtraction arteriography, 66% and 95.7%; and continuous-wave Doppler imaging with audible interpretation of signals, 16% and 97.8%. There was one (1.8%) operative carotid neurologic complication during the postoperative period and follow-up (stroke due to vein patch rupture on postoperative day 2). These data suggest that an objective rather than a subjective method of assessing carotid endarterectomy is more useful in detecting operative abnormalities and that duplex ultrasonography with color flow is as useful as digital subtraction arteriography.
Angiography, Digital Subtraction↗
Subclavian-carotid transposition: an option for repair of traumatic subclavian artery dissection: case report.
An extremely rare injury, dissection of the subclavian artery from blunt trauma, is reported. Arterial flow to the upper extremity was restored by subclavian-carotid transposition, obviating the need for prosthetic graft repair. Subclavian-carotid transposition is a useful technique in the repair of selected subclavian artery injuries.
Carotid Artery, Common↗
Clinical experience with the Greenfield filter in 193 patients and description of a new technique for operative insertion.
Transvenous inferior vena cava (IVC) interruption using the Greenfield filter was performed upon 193 patients from January 1982 to December 1988. Placement of a filter in the IVC was indicated for prophylaxis (23.8 percent), contraindication to anticoagulation (22.8 percent), pulmonary embolism despite anticoagulation (18.7 percent), complications of anticoagulation (26.9 percent) and free-floating thrombus (7.8 percent). Filters were placed in an infrarenal location in 92 percent of the patients. The remaining 8 percent of patients had placement of a suprarenal filter for specific indications, without complication. Most (97.4 percent) of the patients had filters placed through internal jugular or femoral vein cutdown. Five patients required filter placement through a retroperitoneal approach to the right common iliac vein and IVC junction. This new technique of filter insertion is described. The operative morbidity rate was 4.7 percent, with an additional 8.8 percent having postoperative thrombotic complications. The 30 day operative mortality rate (6.7 percent) was related to preexisting associated disease. Nonfatal, late, recurrent pulmonary embolism occurred in 2.6 percent of the patients despite filter placement. Caval patency remains at 97.9 percent in long term follow-up evaluation. The Greenfield filter is an effective and safe adjunct in the treatment of venous thromboembolic disease and a satisfactory prophylactic measure in specific high-risk patients.
Adolescent↗
Cephalic vein grafts for lower extremity revascularization.
From 1980 to 1989 infrainguinal revascularization was performed with cephalic vein grafts in a consecutive series of 34 patients (35 limbs) whose saphenous veins were either inadequate or already had been harvested for previous coronary (N = 16, 47%) or ipsilateral lower extremity bypass (N = 19, 56%). Surgical indications included ischemic rest pain or focal tissue necrosis in 25 limbs (71%), disabling claudication in six (17%), and popliteal aneurysms or prosthetic femoropopliteal graft infections each in two (6%). Preliminary arteriovenous fistulas were constructed in the arms of 23 patients (68%) to enhance the diameter of their cephalic veins, and 24 (69%) of the 35 infrainguinal procedures in this series were performed with use of cephalic vein alone. The distal popliteal artery was used for the outflow anastomosis in 10 limbs (29%), a tibial vessel was used in 12 (34%), and the peroneal artery was used in 13 (37%). Fourteen graft occlusions (40%) and six amputations (17%) have occurred during follow-up intervals of 1 to 107 months (mean, 28 months; median, 27 months). At 3 years the cumulative primary patency rate is 40%, the secondary patency rate is 46%, and the limb salvage rate is 82%. Despite their relative inconvenience, cephalic vein grafts appear to be preferable to prosthetic materials for infrainguinal revascularization below the knee.
Adult↗