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At least 1,387 records · Page 77Linked to original sources
PubMed2003

Primary tumors of the thoracoabdominal aorta: surgical treatment of 5 patients and review of the literature.

The objectives of this study were to describe five cases involving primary tumors of the thoracoabdominal aorta and to review the pertinent literature. Between April 1990 and April 2000, we performed surgery on five patients with primary tumors of the aorta (PTA). There were three men and two women ranging in age from 37 to 65 years (mean, 49.8 years). The presenting manifestations were renovascular hypertension in four cases, including three associated with abdominal angina and lower extremity embolism in one case. In all patients aortograms identified atherosclerotic-like occlusive lesions in the thoracoabdominal aorta extending to the descending thoracic aorta in three cases, visceral arteries in four cases, and infrarenal aorta in one case. Preoperative histological diagnosis of PTA was achieved in two patients following open repair with placement of an aortoaortic graft in one case and peripheral embolectomy in one case. In two cases, diagnosis of PTA was strongly suspected before or during the procedure. In the remaining case, diagnosis was not achieved until the definitive histological report. In two patients surgical treatment was carried out with curative intent (aortic resection with graft replacement). In two cases surgical treatment was incomplete (endarterectomy of the aorta and visceral arteries). In the remaining case surgical treatment was purely palliative (aortic and superior mesenteric artery bypass). Histological findings demonstrated intimal-type sarcoma in two cases, leiomyosarcoma in one case, and angiosarcoma in one case. In the remaining case, histological analysis was unfeasible for technical reasons. One patient died due to massive cerebral embolism 2 days after surgical treatment involving revascularization of the aortic arch carried out with hypothermic circulatory arrest. One patient developed secondary paraplegia. All four patients who survived the immediate postoperative period died of tumor-related complications and cachexia at 5, 7, 16, and 24 months after the initial surgical procedure. The results of this small series as well as those of 130 previously reported cases confirm the extremely dismal prognosis of PTA. Mean overall survival for patients presenting PTA was less than 16 months. Survival at 5 years was 8%. Survival rates appear to be higher after surgical treatment and were significantly improved by adjuvant chemotherapy. The main factors correlated with poor prognosis were intimal type, involvement of the ascending aorta, aortic arch, or visceral aorta, and incomplete resection.

Adult↗
PubMed2003

Surgical management of popliteal artery embolism at the turn of the millennium.

Popliteal artery embolism has been a focus of study at the Massachusetts General Hospital for over 60 years. It is a formidable vascular problem with significant limb loss and mortality. To assess the impact of advances in cardiac and vascular therapies, we reviewed our outcomes over 12 years. A retrospective review from our databases identified 66 patients with 72 popliteal artery emboli between January 1989 and October 2000. Patients undergoing nonsurgical therapy or with in situ atherosclerotic thrombosis were excluded. Demographics, comorbidities, presentation, duration, etiology, treatment, and outcomes were analyzed. Patients were classified into those with acute (AP; symptoms <7 days; 59 of 72, 82%) or delayed (DP; symptoms >7 days; 13 of 72, 18%) presentation. The presentation was typically acute ischemia (85%) in the AP group and claudication (69%), rest pain (15.5%), or gangrene (15.5%) in the DP group. The most common etiology was embolism secondary to atrial fibrillation (17 of 72, 24%). Femoral artery access (15 of 72, 21%) was more prevalent than in our prior experience. In the AP group, 9 of 59 (15%) were treated with a femoral artery approach, 44 of 59 (75%) with a popliteal artery approach, and 6 of 59 (10%) with bypass. In the DP group, 11 of 13 (85%) were treated with a popliteal approach and 2 of 13 (15%) with bypass. Completion angiography was done in 17 cases (24%). Limb salvage rate was 88% (88% AP, 85% DP); the rate was 94% with angiography and 85% without it (p > 0.1). There were seven deaths (10%). The mortality rate was 33% after amputation and 7% after limb salvage (p < 0.05). Except for a greater prevalence of femoral artery access as an etiology, the demographics of patients with popliteal embolism were similar to those of prior reports. Although a femoral approach may be appropriate in select AP cases, a popliteal approach is preferred in most patients and is necessary in DP cases. Completion angiography should be performed to ensure adequacy of the embolectomy. Outcomes are unchanged. Future therapies should aim to improve limb salvage and mortality rates.

Aged↗
PubMed2005

Acute supramesenteric thrombosis of an abdominal aortic aneurysm with deleterious embolism: a case report.

A 55-year-old man was admitted with severe pain, paralysis of both legs and absent femoral pulses. Computed tomographic scan demonstrated a 6 cm juxtarenal abdominal aortic aneurysm (AAA) with thrombosis starting at the level of the celiac trunk. At immediate operation, thrombectomy of visceral arteries was performed and distal neovascularization was achieved with a bifurcated prosthesis. It was revealed that all major arteries were occluded with debris. Embolectomy did restore flow in major vessels, but organ perfusion was not achieved due to occlusion of smaller vessels. The patient died with multiorgan failure. This is the first description in the literature of an acutely thrombosed AAA at the supramesenteric level.

Acute Disease↗
PubMed2005

Cardiogenic embolism producing crescendo transient ischemic attacks.

Lateralizing, repetitive transient ischemic attacks are characteristic of symptomatic carotid bifurcation atherosclerotic plaques. We report a case in which a cardiogenic embolus, after lodging at the left carotid bifurcation, produced crescendo episodes of expressive aphasia and mild right upper extremity weakness. Complete neurological recovery was achieved following emergent carotid embolectomy and endarterectomy. This case demonstrates that the laminar nature of internal carotid blood flow may result in the localization of embolic events to a single region of the cerebral vasculature, regardless of the source lesion in the carotid artery. The role of endoluminal techniques in the diagnosis and management of such lesions is discussed.

Aged, 80 and over↗
PubMed2006

Neuronal nitric oxide synthase immunopositivity in motoneurons of the rabbit's spinal cord after transient ischemia/reperfusion injury.

1. Motoneurons in the spinal cord are especially vulnerable to ischemic injury and selectively destroyed after transient ischemia. To evaluate the role of nitric oxide (NO) in the pathophysiology of the spinal cord ischemia, the expression of neuronal nitric oxide synthase (nNOS) in the motoneurons of the lumbosacral spinal cord was examined in the rabbit model of transient abdominal aorta occlusion. 2. The aim of the present study was to find if there is any consensus between the duration of transient abdominal aorta occlusion, nNOS positivity of the motoneurons and neurological hind limb impairment. 3. According to the degree of neurological damage (i.e., from the group with almost no sign of damage to a group with fully developed paraplegia), the experimental animals were divided into three groups. The respective spinal cord segments of each experimental group were compared to the control group. 4. Spinal cord ischemia (15 min) was induced by Fogarty arterial embolectomy catheter occlusion of abdominal aorta with a reperfusion period of 7 days. On seventh day, the sections of lumbosacral segments were immunohistochemically treated and L1-L7, and S1-S2 segment sections were monitored using light microscopy.

Animals↗
PubMed2002

Neuroendovascular Rescue: Interventional Treatment of Acute Ischemic Stroke.

Stroke continues to be a major health problem for our society. Despite the proven effectiveness of intravenous tissue plasminogen activator (t-PA) for the treatment of acute ischemic stroke, only a minority of patients qualify for this type of therapy. Furthermore, the existing literature has demonstrated that t-PA is not as effective in the treatment of occlusion of large cerebral arteries. The benefit-to-risk assessment of this subpopulation of stroke patients makes them the best candidates for neuroendovascular rescue. This term refers to the intra-arterial application of techniques designed to promote arterial recanalization, and includes intra-arterial thrombolysis and antithrombotic agents, direct mechanical disruption, angioplasty, stenting, embolectomy, and vasoactive pharmacologic intervention. The timing and choice of these procedures, as well as the care of the patient prior to, during, and after the intervention, requires a highly focused and expert approach.

Journal Article↗
PubMed2001

Small Bowel Ischemia.

Small bowel ischemia is a relatively uncommon disorder requiring prompt recognition and aggressive management if significant morbidity and mortality are to be averted. The pathophysiology of the ischemic event usually will determine the management approach used. Factors to be considered include whether the ischemia is the consequence of arterial or venous occlusive disease; the cause and nature of the ischemia (ie, a consequence of arterial spasm, inflammation, complete or incomplete occlusion); whether the occlusion is the result of an embolus or thrombosis; the preexistence and degree of development of arterial collateral channels; and the existence and extent of comorbid conditions. Established and experimental therapeutic interventions have varied in efficacy and include 1) correction of physiologic alterations predisposing to the ischemic event, 2) angiography with arterial infusion of vasodilators; 3) embolectomy or thrombectomy, and resection of necrotic bowel; 4) anticoagulation (veno-occlusive disease); and 5) selective application of thrombolytic agents. The overall success of any therapeutic intervention depends upon the early recognition and management of ischemia, as the incidence of morbidity and mortality rises after infarction occurs.

Journal Article↗
PubMed1987

Review of echocardiographically diagnosed right heart entrapment of pulmonary emboli-in-transit with emphasis on management.

2DE permits detection of thromboemboli transiently entrapped in the right heart chambers while en route to the pulmonary arteries. Review of the 49 cases recorded to date reveals that the supple elongated clot produces a 2DE picture--a mass of changing configuration and striking mobility--that is highly characteristic. Since emboli that become entrapped are large, when managed by medical measures alone they have an attendant mortality rate of 50%, usually soon after 2DE diagnosis, upon completion of pulmonary embolization. Death occurred in 8 of 16 patients treated with anticoagulants, thrombolytic agents, or antiaggregants and in 6 of 13 who received supportive measures only. Of 20 patients referred for surgery (cardiotomy and, in 17, pulmonary embolectomy), only three died, two of them failures of preceding anticoagulant treatment. These data indicate that thromboemboli entrapped in the right heart chambers are best handled as a surgical emergency.

Echocardiography↗
PubMed1989

Efficacy of treatment of patients with echocardiographically detected right-sided heart thrombi: a meta-analysis.

Although echocardiography detected right-sided heart thrombi are frequently associated with massive pulmonary embolism and death, there are conflicting recommendations in the literature about the optimal treatment of this condition. Our objective was to resolve this uncertainty by pooling all existing English language case reports in order to examine the relationship of treatment with survival. There were 71 published reports involving 119 subjects, of which 93% presented with abnormal cardiac signs and symptoms and 7% were asymptomatic but had risk factors for pulmonary embolism. The only factors that were significantly related to survival were whether pulmonary emboli were present, and the type of treatment actually received. Variables not significantly related to survival included cardiac symptoms and the echocardiographic appearance of the thrombus. The estimated probability of survival in patients with pulmonary emboli receiving heparin, thrombolytic agents, surgical embolectomy, or none of the above, was 0.70, 0.62, 0.62, and 0.19, respectively, while the estimated probability of survival in patients without pulmonary emboli for the same four treatment groups, was 0.92, 0.89, 0.89, and 0.53, respectively. We conclude that the efficacy of all three treatments are similar, and that they enhance the probability of survival. Because of the similar efficacy of drug therapy and surgery and the convenience of the former, drug therapy should probably be chosen. In addition, considering the small advantage of heparin with respect to the probability of survival, heparin may be the best choice if the illness is not characterized by a rapid downhill course.

Echocardiography↗
PubMed1990

Peripheral arterial occlusive disease of the extremities in the United States: hospitalization and mortality.

PAODE is an important cause of morbidity and health care expenditures among the elderly. Data from the NHDS and National Vital Statistics System were used to assess its impact in the U.S. In 1985 to 1987, an estimated 229 thousand men and 184 thousand women per year were discharged with any diagnosis of chronic PAODE. Discharge rates were much higher in men and increased sharply with age. Lower extremity arteriography was performed during 88 thousand hospitalizations and aorta-iliac-femoral bypass procedures were done during 31 thousand hospitalizations per year. Numbers of procedures increased markedly since 1979. An estimated 60 thousand men and 50 thousand women per year were discharged with any diagnosis of acute PAODE. Embolectomy or thrombectomy of lower limb arteries was listed for 28 thousand discharges per year. Few deaths were attributed to PAODE. Although these data are limited by likely incomplete reporting and by the nonspecificity of diagnostic codes, they provide an indication of the magnitude of the problem. An aging population and advances in surgical techniques suggest continued monitoring using multiple data sources. Vigorous primary prevention programs are needed to lessen the impact of all atherosclerotic diseases.

Acute Disease↗
PubMed1995

Right ventricular dysfunction after acute pulmonary embolism: pathophysiologic factors, detection, and therapeutic implications.

Acute PE may lead to right ventricular dilatation and failure. Through ventricular interdependence and decreased left ventricular filling, cardiac output and systemic circulation also may be compromised. The associated decrease in coronary perfusion pressure to the acutely overloaded right ventricle may produce ischemia and worsening right heart failure. This downward cycle of right ventricular failure and ischemia may ultimately progress to right ventricular infarction, circulatory arrest, and death. Certain clinical findings, hemodynamic values, and, particularly, echocardiographic signs can identify right ventricular dysfunction after PE. Detection of right ventricular hypokinesis helps to stratify patients' risk, because right ventricular dysfunction confers a worse prognosis than does normal right ventricular function after PE. The concept of "hemodynamic instability" after PE should be expanded to include right ventricular dilatation and wall motion abnormalities, even among normotensive patients. Aggressive intervention with thrombolytic therapy, vasoactive agents, or mechanical embolectomy may improve right ventricular function and clinical outcome.

Electrocardiography↗
PubMed1980

Pulmonary hypertension as a presentation of hepatocarcinoma. Report of a case and brief review of the literature.

A case, unique in the literature, is reported in which a primary carcinoma of the liver presented a right-sided heart failure and pulmonary hypertension. The diagnosis of hepatocarcinoma was established by needle biopsy of the liver. Later, postmortem examination demonstrated that the pulmonary arterial tree was severely compromised by multiple tumor microemboli, despite the persistent lack of characteristic roentgenographic abnormality in our patient. In reviewing the literature, we found rare cases of occult renal cell carcinoma, choriocarcinoma and one of occult hepatocarcinoma, which presented as pulmonary embolism. These were diagnosed by pulmonary embolectomy, human chorionic gonadotrophin levels or autopsy, respectively. In another small group of reported cases of known carcinoma (gastric, breast, colonic) the patients had a clinical picture of "idiopathic" pulmonary hypertension or of pulmonary hypertension with pulmonary metastases. Pulmonary hypertension in these cases resulted from carcinomatous lymphangitis and/or tumor microembolization, as in our case. We report this case to emphasize the necessity of including occult carcinoma in the differential diagnosis of pulmonary hypertension and right ventricular failure.

Carcinoma, Hepatocellular↗
PubMed1985

Echocardiographic demonstration of pulmonary embolism as it evolves through the right heart chambers.

In three patients with pulmonary embolism, two-dimensional echocardiography demonstrated thrombi within the right heart chambers. These thrombi, suspected of embolizing into the pulmonary circulation, showed varied morphology and mobility. Of the two patients undergoing embolectomy, only one survived. The third patient improved with anticoagulation therapy. Two-dimensional echocardiography is useful in evaluating patients suspected of having pulmonary thromboembolism because it may demonstrate evolution of the thrombus.

Adult↗
PubMed1977

Ischemia of the upper extremity due to noncardiac emboli.

Nine cases of microemboli of arterial origin to the upper extremity are reported. The source of emboli in five of these cases was in the subclavian artery compressed by osseous anomalies in the thoracic outlet. Three aneurysms, one in a subclavian vein graft and two traumatic false aneurysms in the hand, were also noted to be the sources of distal emboli. One unproved case of emboli from an atherosclerotic plaque of the subclavian artery is also reported. Chronicity of symptoms and delay in operation are often noted and lead to difficulties in surgical management. The compressing osseous structures causing the vascular lesion in the thoracic outlet syndrome must be resected, along with removal of the source of emboli. Cervicodorsal sympathectomy is often needed in cases of extensive thrombosis and/or long-standing ischemia. Embolectomy is usually a futile procedure when the main arterial trunk contains old, organized thrombus. Differential diagnostic problems between collagen vascular disease, vasculitis, vasospastic disease, and microembolic disease in cases of unilateral Raynaud's phenomenon are pointed out.

Adult↗
PubMed1978

Management of the upper extremity with absent pulses after cardiac catheterization.

Thirty-one patients had a delayed loss of brachial artery and radial artery pulse after cardiac catheterization; eleven of the patients had early embolectomy or a vein patch graft and 82% of these had immediate restoration of pulse and remained asymptomatic. Early surgery failed in two patients, requiring late vein bypass grafting for claudication. Twenty patients did not have early surgery, eleven (55%) remaining asymptomatic and nine (45%) developing ischemic symptoms. Five of these nine patients (25%) required late vein bypass grafting for severe claudication. Of the fifteen patients who lost their pulse and did not undergo surgery, the average Doppler forearm pressure immediately following the occlusion was 50 mm Hg (pressure index=0.46). The average Doppler pressure measured at the time of follow-up was 80 mm Hg (pressure index = 0.61). Early local surgery is highly successful in patients who lose their radial artery pulse after cardiac catheterization. Conservative nonoperative therapy may be successful but often results in late ischemic symptoms that may require late vein bypass grafting.

Arm↗
PubMed1982

Arterial embolism: a 44 year perspective.

Forty-four years of experience with arterial embolism is reviewed. Patients presenting with this problem are increasingly older, more frequently female, and usually have atherosclerotic coronary artery disease. Atrial fibrillation is found in a high percentage of these patients. Mortality after embolism is decreasing but remains high (25 percent). Limb salvage is usually achieved (87 percent) but has improved little since the balloon embolectomy catheter became available. Prompt treatment, careful patient selection for operation, and anticoagulation remain the keys to successful outcome in the management of patients with arterial embolism.

Age Factors↗
PubMed1983

Management of acute ischemia of the upper extremity.

Records of 76 patients who presented with ischemia of the upper extremity from 1966 to 1981 were reviewed. Patients were divided into three groups according to cause: Group 1, emboli from the artery; Group 2, ischemia after catheter injury; and Group 3, ischemia due to lesions of the axillary and subclavian arteries. Management varied among the three groups. Long-term anticoagulation therapy was helpful in Group 1 patients in preventing reembolization. Forty percent of patients with catheter-related trauma required angioplasty of some sort in addition to embolectomy. Management of Group 3 patients was most difficult and the results least acceptable (three patients required amputation). Management of this type of ischemia must be individualized; it should vary according to the underlying disorder.

Acute Disease↗
PubMed1991

Origin of cells that line damaged native blood vessels following endothelial cell transplantation.

Endothelial cell (EC) transplantation has been proposed as a method to reduce the thrombogenicity of both vascular grafts as well as injured native blood vessels. While techniques have been developed to establish EC monolayers on these surfaces, a major question that remains is whether the cells that exist on the blood flow surface are the same cells placed on the surface at the time of transplantation. We have developed an intravital fluorescent staining technique that permits isolated, autologous, fat-derived microvascular endothelial cells (MVEC) to be labeled and subsequently detected following their transplantation. In our study, rat abdominal aortas (AA) were injured with a 3F embolectomy catheter, and the injured surfaces were immediately treated with fluorescently labeled MVEC. Five days after transplantation, AA were evaluated by both scanning electron and fluorescence microscopy. Results of scanning electron microscopy showed the existence of nonthrombogenic regions in the areas of injury, and fluorescence microscopy of the identical areas established that these cells contained fluorescent dye. Our results indicate that the cells that line these injured areas of native vessels are the same cells that were originally transplanted. Our intravital fluorescence technique provides a method to trace the origin and disposition of transplanted cells on the vascular surfaces.

Adipose Tissue↗