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W J McCarthy

Publications and source records attributed to W J McCarthy.

At least 37 records · Page 2Linked to original sources
PubMed1998

Carotid plaque morphology correlates with presenting symptomatology.

PURPOSE: In carotid artery disease, correlation of carotid plaque morphology with the patient's presenting symptoms has drawn conflicting conclusions. The purpose of this series was to correlate carotid plaque characteristics with the presenting symptoms from a large cohort of patients who underwent operation for carotid artery disease. METHODS: From a series of 1252 consecutive patients who underwent carotid endarterectomy, presenting symptoms were divided into three groups: transiently symptomatic (transient ischemic attack [TIA] or amaurosis fugax), prior stroke, and asymptomatic. Plaque characteristics, including ulceration, intraplaque hemorrhage, and degree of stenosis, were recorded prospectively for 1008 procedures. All endarterectomy specimens were inspected during the procedure, and plaque characteristics were recorded immediately after operation. RESULTS: There was a higher incidence of plaque ulceration in the transiently symptomatic and prior stroke groups (391 of 508 [77%] and 91 of 115 [79%]) than in the asymptomatic cohort (231 of 385 [60%]; p < 0.0001, chi2 test). There was no significant difference in the incidence of plaque hemorrhage between the transiently symptomatic and prior stroke patients compared with the asymptomatic patients. There was no statistical difference for ulcerated plaque or plaque hemorrhage between the transiently symptomatic and prior stroke group. Intraplaque hemorrhage occurred more frequently in patients with high-grade stenosis (90% to 99%) than in those with less than 90% stenosis (202 of 299 [68%] versus 97 of 299 [32%]; p = 0.01, chi2 test). CONCLUSIONS: On gross examination of the carotid specimen in the operating room, plaque ulceration correlates with an initial presentation of amaurosis fugax, TIA, or prior stroke compared with patients operated on for asymptomatic disease. The presence of intraplaque hemorrhage is associated with more advanced stenosis of the internal carotid artery. These findings suggest that plaque morphology does play an important role in the presentation of carotid artery disease.

Adult↗
PubMed1998

A classification tree analysis of selection for discretionary treatment.

OBJECTIVES: To study treatment bias in observational outcomes research, the authors present a nonlinear classification tree model of clinical and psychosocial factors influencing selection for interventional management (lower extremity bypass surgery or angioplasty) for patients with intermittent claudication. METHODS: The study sample includes 532 patients with mild to moderate lower extremity vascular disease, without prior peripheral revascularization procedures or symptoms of disease progression. All patients were enrolled in a prospective outcomes study at the time of an initial referral visit for claudication to one of the 16 Chicago-area vascular surgery offices or clinics in 1993-95. The influence of baseline sociodemographic, clinical, and patient self-reported health status data on subsequent treatment is analyzed. Study variables were derived from lower extremity blood flow records and patient questionnaires. Follow-up home health visits were used to ascertain the frequency of lower extremity revascularization procedures within 6 months of study enrollment. Hierarchically optimal classification tree analysis (CTA) was used to obtain a nonlinear model of treatment selection. The model retains attributes with the highest sensitivity at each node based on cutpoints that maximize classification accuracy. Experimentwise Type I error is ensured at P < 0.05 by the Bonferroni method and jackknife validity analysis is used to assess model stability. RESULTS: Seventy-one of 532 patients (13.3%) underwent interventional procedures within 6 months. Ten patient attributes were used in the CTA model, which had an overall classification accuracy of 89.5% (67.6% sensitive and 92.9% specific), achieving 57.7% of the theoretical possible improvement in classification accuracy beyond chance. Eleven model prediction endpoints reflected a 33-fold difference in odds of undergoing lower extremity revascularization. CONCLUSIONS: Initial ankle-brachial index (100%), leg symptom status over the previous six months (89%), self-reported community walking distance (74%) and prior willingness to undergo a lower extremity hospital procedure (39%) were used to classify most patients in the sample. These attributes are critical control variables for a valid observational study of treatment effectiveness.

Angioplasty↗
PubMed1997

Sarcoma arising from an abdominal aortic aneurysm.

A rare case of retroperitoneal sarcoma arising from an aneurysm sac is diagnosed in a patient following tube graft repair of the abdominal aortic aneurysm. The radiographic studies illustrate the characteristics of malignancy which are distinguishable from more common vascular complications. Malignancy should be considered in the differential diagnosis of retroperitoneal masses during radiographic follow-up of patients after aortic surgery. Sarcoma is optimally treated with complete excision, sometimes requiring concomitant vascular reconstruction. Radical en bloc resection was not attempted in this case due to extensive involvement of the aorta and inferior vena cava.

Aged↗
PubMed1997

Cytolytic activity of Bacillus thuringiensis CryIC and CryIAc toxins to Spodoptera sp. midgut epithelial cells in vitro.

A sensitive lactate dehydrogenase (LDH) assay was modified to determine the cytolytic activity of Bacillus thuringiensis CryIC and CryIAc delta endotoxins to viable collagenase-dissociated midgut epithelial cells (MEC) from larvae of Spodoptera frugiperda and Spodoptera exigua. The MEC preparations from these Spodoptera sp. consisted predominantly of columnar cells (65-75%) and goblet cells (25-35%). Time course microscopy experiments indicated that only the columnar cells became swollen during CryIC toxin incubation. Also, comparative cytotoxicity studies were run with cell lines of nonmidgut origin established from S. frugiperda (SF21AE) and S. exigua (SEUCR1A). Optimum conditions for the cytotoxicity assay were similar for MEC and cell lines of both species, and were met in an assay in which 0.1-ml cell concentrations (8.5 +/- 0.5 x 10(4) cells) were incubated with toxin dilutions (0.01-20 micrograms) for 1 h at 24 degrees C at a final pH of 7.8. The Spodoptera sp. MEC were twofold more sensitive to CryIC (68% lysis) than CryIAc (32% lysis) at optimum toxin levels (2.5-5 micrograms). Also, the SEUCR1A cells were more sensitive (2.3-fold) to CryIC (70% lysis) than CryIAc (30% lysis) at optimum toxin levels of 5-10 micrograms. The SF21AE cells, however, were twofold less sensitive to CryIC (30% lysis) than SEUCR1A cells and response to CryIAc and CryIC was similar. Immunoblot analysis of either Spodoptera sp. MEC or brush border membrane vesicles (BBMV) identified seven CryIC binding proteins with molecular mass of 137, 120, 115, 68, 65, 63, and 45 kDa. Occasionally, a 148-kDa protein band was observed. The CryIAc toxin bound to two proteins on MEC and BBMV with molecular mass of 137 and 120 kDa.

Animals↗
PubMed1997

Treatment of venous malformations by direct injection with ethanol.

PURPOSE: Venous malformations (VMs) may be discrete or extensive, and larger lesions may be difficult to remove with surgery. Incompletely removed lesions have a tendency to recur. We report our experience with ethanol ablation of VMs. METHODS: All 12 patients (seven women; mean age, 37 years) were evaluated with magnetic resonance imaging before treatment. A total of 19 prior surgical excisions had been performed for seven of the patients. Symptoms were present in all 12 patients and included bleeding, pain, swelling, and limitation of exercise. The VMs were present in the lower extremities of seven patients, in the upper extremities of three patients, and in the flank and buttocks in two patients. RESULTS: The 12 patients have undergone 30 injection procedures, with six patients requiring one, three patients requiring two, two patients requiring three, and one patient having undergone 12 treatments. General anesthesia was used in 11 patients. Blood loss was minimal for all procedures, and 28 of the 30 procedures were technically successful. Skin ulceration was seen in approximately half of the treated VMs, all of which healed with local wound care. Focal VMs were injected in six patients and resolved with a single treatment in five patients. Patients were free of symptoms at a mean follow-up of 10 months. Extensive VMs were injected for discrete, symptomatic areas in five patients. These lesions all regressed and were asymptomatic at a mean follow-up of 23 months in all but one patient. However, these lesions required multiple treatments as additional areas became problematic. CONCLUSIONS: Ethanol sclerosis is a well-tolerated, safe, and effective adjunct to the management of VMs. Advantages of ethanol injection include the ability to treat a very localized area without an incision. Conversely, extensive lesions may be palliated as symptoms occur.

Adult↗
PubMed1997

Perioperative low molecular weight heparin for infrageniculate bypass.

PURPOSE: Recent studies suggest that subcutaneous low molecular weight heparin (LMWH) is a safe, effective alternative to intravenous heparin (IVH) for deep venous thrombosis. LMWH may also be a safe, effective alternative to IVH when necessary for lower extremity bypass procedures performed with polytetrafluoroethylene (PTFE) grafts. The purpose of this study was to compare subcutaneous LMWH with IVH for perioperative anticoagulation in patients who underwent infrageniculate bypass procedures with PTFE grafts. METHODS: Of 361 lower extremity bypass operations performed at a single center over a 32-month period, 76 were to the tibial or below-knee levels using PTFE grafts for limb salvage. Seven patients were excluded because of absolute indications for perioperative IVH (ventricular thrombus in 1 patient, prosthetic valve in 2, cardiac dysrhythmia in 2, and documented hypercoagulable syndrome in 2), leaving 68 patients (35 women; mean age, 69.8 years) with 69 bypass procedures for study. Grafts completed in the past 16 months were treated with LMWH (28 grafts; Oct. 1994 to Jan. 1996) and were compared with 41 consecutive control grafts from the previous 16-month interval (Apr. 1993 to Oct. 1994) who received IVH. There were similar percentages of composite bypasses (IVH, 50%; LMWH, 46%), patients with tissue loss or gangrene (IVH, 56%; LMWH, 61%), and patients with prior ipsilateral bypass (IVH, 57%; LMWH, 56%) in each group. Age, sex, and atherosclerotic risk factors were also similar between the two groups. RESULTS: Morbidity rates (IVH, 19%; LMWH, 11%) and mortality rates (IVH, 2.5%; LMWH, 4%) were not significantly different. There were no significant differences in the number of grafts that failed before discharge (IVH, 1; LMWH, 0) or percentage of hemorrhagic complications (IVH, 15%; LMWH, 7%). The mean number of postoperative hospital days (IVH, 9.5; LMWH, 7.2; p < 0.009) and coagulation monitoring studies (IVH, 22; LMWH, 8.4; p < 0.0001) were significantly decreased in patients who were anticoagulated with LMWH. The mean number of days before conversion to oral anticoagulation (IVH, 7.3; LMWH, 8.0) did not differ significantly. CONCLUSIONS: When perioperative anticoagulation is deemed necessary, LMWH provides a safe, effective alternative to IVH for infrageniculate PTFE bypass grafting procedures. LMWH may reduce the number of postoperative hospital days and coagulation studies by allowing discharge before therapeutic anticoagulation with warfarin.

Aged↗
PubMed1997

Reduction in aortic aneurysm size: early results after endovascular graft placement. EVT Investigators.

PURPOSE: Previous reports demonstrate initial technical success with transluminally placed endovascular grafts (TPEG) for the treatment of abdominal aortic aneurysms. However, long-term changes in the size of the aorta and aneurysmal segments are unknown. The purpose of this study was to determine aortic dimensions at several levels by computed tomographic (CT) scans 1 year after TPEG. METHODS: Thirty-four patients underwent TPEG with 1-year CT scans. Patients were divided into three groups: group I, no perigraft leak; group II, early perigraft leak that sealed during the first year; and group III, persistent perigraft leak. Aortic minor and major diameters, perimeter, and area were measured at four locations: the celiac aorta, proximal neck, maximal aneurysm size, and distal neck. RESULTS: There were 32 men and two women, with a mean age of 73 +/- 8 years. In group I there were 20 patients (58%), and groups II and III had seven patients (21%) each. The overall mean aneurysm minor diameter decreased from 4.79 +/- 0.68 cm at implantation to 4.39 +/- 0.86 cm at 1 year (p < 0.0001). The aneurysm sac decreased by 0.63 +/- 0.58 cm in group I, and by 0.34 +/- 0.24 cm in group II. In group III, however, the aneurysm sac increased by 0.19 +/- 0.21 cm. Aneurysm size change did not correlate with inferior mesenteric or lumbar artery patency. The dimensions of the celiac aorta and proximal neck did not change significantly. However, diameter of the distal neck enlarged by 0.12 +/- 0.27 cm (p < 0.01). CONCLUSIONS: TPEG exclusion is associated with reduction of aneurysm size 1 year after implantation. Expansion of the aneurysms occurred with persistent perigraft leak. The aortic size at the celiac artery and proximal neck did not change. Dilation of the distal neck was minor but requires further long-term follow-up to determine clinical significance.

Aortic Aneurysm, Abdominal↗
PubMed1997

Elevations of tissue-type plasminogen activator and differential expression of urokinase-type plasminogen activator in diseased aorta.

PURPOSE: Elevations of plasmin have been implicated in the pathogenesis of abdominal aortic aneurysms (AAA) because of its ability to digest extracellular matrix proteins. Plasminogen activators regulate the conversion of plasminogen to plasmin. Tissue-type plasminogen activator (tPA) is more important in modulation of fibrinolysis, and urokinase-type plasminogen activator (uPA) is predominant in tissue remodeling. The purpose of this study was to determine the levels of plasminogen activators in diseased aorta because they may be responsible for the increased plasmin levels previously described in AAA. METHODS: Levels of tPA and uPA in AAA, occlusive, and normal (organ donor) aorta were studied in tissue explant supernatants. Supernatant tPA and uPA levels were measured with an enzyme-linked immunosorbent assay. Northern analysis was used to quantitate uPA messenger RNA (mRNA) levels in aortic tissue. RESULTS: Levels of tPA in the supernatants were similar in occlusive (20 +/- 4 ng/ml) and AAA (23 +/- 8) aorta, but threefold higher than in normal aorta (7 +/- 5; p < 0.005 for normal vs occlusive and p < 0.001 for normal vs AAA). In contrast, uPA supernatant levels were differentially expressed, with the highest level existing in AAA (9.7 +/- 2.7 ng/ml), followed by occlusive (4.9 +/- 3.5), and the lowest levels in normal aorta (1.2 +/- 0.7; p < 0.05 for normal vs occlusive, p < 0.001 for normal vs AAA, and p < 0.005 for occlusive vs AAA). Inhibition of protein or RNA synthesis by addition of cyclohexamide or actinomycin D, respectively, revealed no significant difference between treated and control supernatants, suggesting that the increases were caused by protein release rather than active synthesis. Levels of uPA mRNA followed the same trend as the supernatant uPA levels (AAA 1.07 +/- 0.54, occlusive 0.54 +/- 0.08, and normal aorta 0.01 +/- 0.01). CONCLUSIONS: Levels of tPA were similar in aneurysmal and occlusive aorta, but exhibited a threefold increase over normal aorta, suggesting that the elevations of tPA are associated with the arteriosclerosis present in both aneurysmal and occlusive disease. Differences in uPA levels were significant between all three groups, with the highest levels in AAA and the lowest levels in normal specimens. Northern analysis of uPA mRNA followed the same trend, suggesting that the increase in uPA may be regulated at the level of transcription. As uPA plays an important role in tissue remodeling, our findings may also reflect the relative tissue repair activities in these three types of specimens and may explain the previously reported increased levels of plasmin seen in AAA.

Adult↗
PubMed1996

Current management of visceral artery aneurysms.

BACKGROUND: Visceral artery aneurysms are an uncommon but important form of abdominal vascular disease. This study reviews a contemporary experience with special emphasis on newer methods of diagnosis and treatment. METHODS: From 1980 to 1994, 37 patients were diagnosed with 46 visceral artery aneurysms. These consisted of 22 splenic, 10 hepatic, 4 superior mesenteric, 2 gastroduodenal, 3 celiac, 2 left gastric, 1 pancreatoduodenal, 1 jejunal-ileal, and 1 inferior mesenteric artery aneurysms. Follow-up was complete for 28 patients, average of 37.7 months. There were 17 asymptomatic and 29 symptomatic aneurysms, including 11 presenting with rupture. RESULTS: Seventeen patients were treated surgically, with no surgical deaths. Surgical complications included splenic abscess (two) and failure to thrombose (one). Transcatheter embolization was used in 12 patients. Complications included splenic infarction (one) and recurrence (two), successfully treated with repeat embolization. Nine patients were treated with observation. Eight experienced no complications during follow-up; one died of a ruptured splenic artery aneurysm before treatment was initiated. CONCLUSIONS: The widespread use of computed tomography has led to increased detection of asymptomatic visceral artery aneurysms. Although surgery remains necessary in many patients, transcatheter embolization is effective in the treatment of selected visceral artery aneurysms with few complications and low recurrence.

Adult↗
PubMed1996

Plasminogen activator levels are influenced by location and varicosity in greater saphenous vein.

PURPOSE: The plasminogen system, which includes tissue type plasminogen activator (tPA), urokinase type plasminogen activator (uPA), and their main inhibitor, plasminogen activator inhibitor type 1 (PAI-1), plays a major role in both fibrinolysis and tissue remodeling. This study compares the levels of tPA, uPA, and PAI-1 at the groin and ankle in normal and varicose greater saphenous vein (GSV). METHODS: GSV was collected from patients undergoing varicose vein (VV) removal and from normal vein (NV) from arterial bypass procedures. Portions of the GSV at the groin and the ankle were minced and placed in serum-free media for 48 hours. Assays of the supernatants were obtained for tPA, uPA, and PAI-1 protein by enzyme-linked immunosorbent assay. Cyclohexamide and actinomycin D were also added to the media of the VV tissue explant supernatants to inhibit protein and RNA synthesis, respectively. RESULTS: Levels of tPA were significantly higher at the groin (11 +/- 2) than the ankle (5 +/- 1) in the VV (p < 0.005), and this trend was also seen in the NV (groin 10 +/- 2 and ankle 7 +/- 3). Levels of uPA were significantly higher in the groin VV (14 +/- 4.3) than in NV (3.0 +/- 0.8, p < 0.05). This difference, although not statistically significant, applied to the ankle as well (VV 14.5 +/- 6.3 and NV 5.3 +/- 2.7). No significant difference was seen between NV and VV for PAI-1 (NV, groin 155 +/- 73 and ankle 113 +/- 53, VV, groin 161 +/- 20 and ankle 142 +/- 38) or tPA. Inhibitor studies revealed no significant difference among control, cyclohexamide, and actinomycin D supernatants for tPA, suggesting release of protein rather than active synthesis. In contrast, inhibitor supernatants were significantly lower for uPA and PAI-1 than control supernatants (p < 0.05), suggesting that uPA and PAI-1 were actively synthesized. CONCLUSIONS: In the tissue explant supernatant model uPA and PAI-1 are actively synthesized, but tPA is not. Levels of PAI-1 were comparable in all four groups. Levels of uPA in the varicose GSV were higher than in NV, suggesting a role for uPA in the pathologic makeup of VV. Levels of tPA were higher at the groin versus the ankle position, potentially explaining the previously described increased fibrinolytic activity seen at the groin.

Aged↗
PubMed1996

Effect of lower extremity blood pressure on physical functioning in patients who have intermittent claudication. The Chicago Claudication Outcomes Research Group.

PURPOSE: Claudication patients' perceptions of walking impairment often influence recommendations for peripheral bypass and angioplasty. The actual relationship between lower extremity blood flow and physical functioning, however, has rarely been explicitly studied. METHODS: Patients were enrolled at a visit to one of 16 vascular surgery offices and clinics that participated in a prospective outcomes study. A total of 555 patients (445 men and 110 women) with an abnormal ankle-brachial index (ABI), none of whom had had previous leg revascularization or symptoms of rest pain, skin ulcers, or gangrene, completed the SF36 Health Survey and the Peripheral Arterial Disease Walking Impairment Questionnaire (WIQ). Stepwise multiple regression analysis was used to test the statistical significance and strength of association between patients' ABI level and SF36 physical functioning (PF) and WIQ community walking distance scores, controlled for sociodemographic characteristics and the presence and severity of comorbid conditions. RESULTS: Univariate correlations with ABI were modest but significant (PF score, r = 0.12, p = 0.004; WIQ distance score, r = 0.18, p < 0.001). ABI was a very significant predictor of both PF (b = 18.8; p = 0.001) and WIQ scores (b = 0.33; p < 0.0001) in the multiple regression analysis. Other positive predictors of PF scores were high-school graduation and male sex. Negative predictors of PF scores were heart, lung, and cerebrovascular disease; knee arthritis and chronic back pain; and enrollment at a Veterans Administration clinic rather than a private community or academic office. CONCLUSION: Cross-sectional findings indicate that a 0.3 improvement in ABI is associated with an average improvement of 5.6% in PF or 10.3% in WIQ distance score. However, proper selection of individual candidates for interventional therapy, that is, those patients who have lower ABIs, lower initial functioning, and fewer disabling comorbidities would be predicted to produce a much greater functional benefit. Surgeons should make a rigorous functional evaluation when recommending interventional management of claudication.

Aged↗
PubMed1996

Elevated levels of plasminogen-activator inhibitor type 1 in atherosclerotic aorta.

PURPOSE: Plasminogen activator inhibitor type I (PAI-1) inhibits the plasminogen activators that convert plasminogen to plasmin. In addition to initiating fibrinolysis, plasmin activates tissue matrix metalloproteinases, which cause degradation of the extracellular matrix (ECM) in the arterial wall. Elevated levels of PAI-1 ultimately decrease plasmin formation and may lead to an accumulation of ECM and arteriosclerosis. METHODS: PAI-1 was studied by four methods in atherosclerotic (aneurysmal and occlusive) and normal (organ donor) aorta: (1) PAI-1 secretion by tissue explant supernatants, including time course and inhibition studies; (2) tissue PAI-1 by protein extraction; (3) PAI-1 mRNA was quantitated by Northern analysis using glyceraldehyde-3-phosphate dehydrogenase to normalize for RNA loading; and (4) in situ hybridization was used to localize the cells that produced PAI-1 mRNA. RESULTS: Supernatant PAI-1 levels at 48 hours were 776 +/- 352, ng/ml in 11 atherosclerotic aortas and 248 +/- 98 ng/ml in 8 normal aortas (p < 0.005). Tissue PAI-1 levels per 100 mg of tissue were 99 +/- 58 ng in 11 atherosclerotic aortas and 38 +/- 20 ng in 5 normal aortas (p < 0.05). PAI-1 mRNA levels by Northern analysis were 0.91 +/- 0.49 in seven atherosclerotic aortas and 0.44 +/- 0.27 in five normal aortas. Supernatant time-course experiments revealed that PAI-1 increased over time. Inhibitor studies revealed that PAI-1 decreased to approximately one third of control values when cycloheximide or actinomycin D were added to the media, indicating that active synthesis of PAI-1 had occurred. In-situ hybridization localized PAI-1 mRNA predominately to endothelial cells and a few scattered vascular smooth muscle and inflammatory cells. Subgroup analysis revealed no statistically significant differences between aneurysmal and occlusive PAI-1 levels in any of the experiments. CONCLUSION: PAI-1 secretion, as measured by tissue explant supernatants, and total tissue PAI-1 in the protein extracts were significantly increased in atherosclerotic aorta. This elevation was also observed in the mRNA, which suggests that the increase is controlled at the level of transcription. PAI-1 mRNA was localized to endothelial, vascular smooth muscle, and inflammatory cells. We conclude that elevated levels of PAI-1 exist in diseased aorta. These elevated levels may lead to an accumulation of ECM, thereby contributing to the arteriosclerosis found in aortic occlusive and aneurysmal disease.

Adult↗
PubMed1996

Peripheral vascular disease in spinal cord injury patients: a difficult diagnosis.

The timely detection of peripheral vascular disease (PVD) in spinal cord injury (SCI) patients is difficult because the usual symptoms of claudication and rest pain are absent. In fact, the initial manifestation of PVD in SCI patients is often advanced gangrene, so that healing, primarily or following major amputation, is either difficult and prolonged or impossible. In addition, sacral and ischial pressure sores common among SCI patients may be exacerbated and reconstruction made more difficult by PVD. Five SCI patients presented with lower extremity gangrene as the initial recognized manifestation of PVD at our institution between January 1992 and January 1994. All 5 patients had risk factors for PVD. Four out of ten limbs in these patients required amputation, either above the knee or below the knee. Three patients required concurrent vascular reconstruction of the aortoiliac segments, including an aortobiprofunda femoral bypass, an iliac embolectomy with femoral-femoral bypass, and iliac angioplasty. Three patients had ischial and/or sacral pressure sores that had recurred following multiple musculocutaneous flap reconstructions before vascular disease was recognized. The timely diagnosis of PVD involving the iliac segment in the SCI patient is sometimes overlooked and is often necessary to optimize the treatment of both lower extremity ulcers and sacral/ ischial pressure sores common among these patients.

Adult↗
PubMed1996

Carotid endarterectomy. Lessons from intraoperative monitoring--a decade of experience.

OBJECTIVE: The authors analyzed a single institution's 10-year experience with intraoperative monitoring during 709 primary carotid endarterectomies and investigated the impact of contralateral internal carotid artery stenosis on carotid artery stump pressure (SP). SUMMARY BACKGROUND DATA: Stump pressure reflects the combination of contralateral carotid artery anatomy, collateral intracranial vasculature, and systemic blood pressure. By controlling for blood pressure with a stump index (SI) (SI = [SP/mean arterial pressure] x 100), a correlation between pressure and contralateral carotid artery anatomy can be demonstrated. Although the use of SP has long been advocated as an indicator of adequate cerebral perfusion, its correlation with perioperative complications while using an intraluminal shunt has not been evaluated completely. METHODS: From a series of 886 primary carotid endarterectomy cases, SP and mean arterial pressure were measured prospectively in 709 procedures. Temporary intraluminal shunts were used in cases with demonstrated contralateral carotid occlusion, prior cerebrovascular accident (CVA), or SPs less than 35 mmHg. Ipsilateral and contralateral angiographic degree of carotid stenosis was recorded at the time of the operation. Neurologic status was recorded prospectively for all 709 procedures. Operative electroencephalogram (EEG) changes and SP then were compared with the neurologic status of the patient in the perioperative period. RESULTS: The mean SP for the group (n = 709) was 46.7 +/- 15.3 mmHg (mean +/- standard deviation [SD]) with a mean SI of 54.9 +/- 22.6. The distribution for the SI is a more gaussian curve than that for SP. There were 19 ipsilateral CVAs (2.7%). The mean SP in the nonstroke group was 47.1 +/- 15.2 mmHg (mean SI = 54.7 +/- 16.5) compared with 31.9 +/- 13.2 mmHg (mean SI = 38.8 +/- 18.2) in the stroke group (P < 0.0001). Stroke rate for SP < or = 35 mmHg was 7% (13/185) versus 1.1% (6/524) for SP > 35 (p < 0.0001). Stump index and SP are related to contralateral carotid artery stenosis. The pattern of SI or SP versus contralateral stenosis is biphasic, with an increase at 75%. If SI is < or = 40, the mean contralateral stenosis is 55.1%; if SI is > 40, the mean contralateral stenosis is 35.1% (p < 0.05). Continuous EEG monitoring was completed for the 549 most recent operations. Patients who had a perioperative stroke had EEG changes observed during the procedure in only 6 of 12 cases (50% sensitivity), with 76% specificity. Using SP < or = 35 mmHg, sensitivity was 68% and specificity was 75%.

Aged↗
PubMed1995

Simultaneous abdominal aortic aneurysm repair and nephrectomy for neoplasm.

BACKGROUND: Abdominal aortic aneurysm and renal neoplasm are occasionally discovered concurrently. Simultaneous operative therapy may be an effective alternate management strategy to a staged procedure. PATIENTS AND METHODS: The medical records of 10 consecutive patients undergoing abdominal aortic aneurysm repair and nephrectomy for renal neoplasm were reviewed. Data collected included mode of presentation, preoperative evaluation, renal pathology, and in-hospital morbidity and mortality. Long-term follow-up was obtained through office records and telephone contact. RESULTS: In 7 patients, the renal mass was identified during evaluation of abdominal aortic aneurysm. The aneurysm was identified during evaluation of hematuria in 2 patients. One patient was discovered to have both conditions simultaneously. All patients underwent successful aneurysm repair and nephrectomy. Pathology revealed 6 renal cell carcinomas, 2 complex cysts, 1 hemangiopericytoma, and 1 oncocytoma. Four patients have died in the follow-up period: 1 of metastatic cancer and 3 of unrelated causes. There have been no cases of graft infection. CONCLUSION: Simultaneous abdominal aortic aneurysm repair and nephrectomy for neoplasm is an appropriate management strategy for selected patients.

Adenoma, Oxyphilic↗