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Protected stent-assisted carotid angioplasty in the management of late post-endarterectomy restenosis.

OBJECTIVES: The high complication rate associated with the surgical treatment of post-carotid endarterectomy restenosis has led several investigators to propose stent-assisted angioplasty as the treatment of choice for this condition. Late restenosis is very infrequent and mainly due to atherosclerotic progression. The aim of this study is to evaluate the potential risk of intraprocedural embolic stroke during stent-assisted angioplasty with cerebral protection devices in these patients. METHODS: We describe our recent experience in the endovascular treatment of 10 patients presenting late carotid restenosis by means of stent-assisted angioplasty with the aid of a filter cerebral protection device. Mean elapsed time from surgery to angioplasty was 92+/-31 months (range 48-144 months). RESULTS: Procedural success was obtained in all the cases. Pre-dilation was performed in six cases, post-dilation in all the cases. The mean percentage stenosis was reduced from mean 77+/-12% (range 60-95%) to 6.3+/-6.7% (range 0-17%). Bradycardia while inflating the balloon was mild-to-moderate in seven cases and severe in two. No patient sustained stroke or transient ischemic attack (TIA) during the procedure or during hospital stay. On follow-up, two patients presented with moderate asymptomatic restenosis and were managed conservatively. DISCUSSION: Carotid angioplasty with cerebral protection can be performed safely in late carotid restenosis with a high technical success rate. No clinical embolic complications occurred in this subset of patients. With recent innovations and improvements in angioplasty technique, previous indications for angioplasty in these patients will have to be redefined. Carotid angioplasty seems to be a valuable treatment alternative to conventional surgery in this subset of patients.

Aged↗

[Response of ventricular late potentials after surgical therapy of ventricular tachycardia].

19 patients with either previously documented sustained ventricular tachycardia (VT) (n = 16) or only inducible VT (n = 3, one of whom had recurrent syncope), due to previous myocardial infarction were studied pre- and postoperatively. Mean age was 53 +/- 6 years, 16 were male, 3 female. In all but one, VT could be induced preoperatively by programmed right ventricular stimulation. Late potentials (LP) were recorded at the end of or after the QRS-complex from the body surface using high-gain amplification and the signal averaging technique (RC-filter settings 100 to 300 Hz). Indication for surgery was either intractable VT or bypass grafting and/or aneurysmectomy. Preoperatively, mean duration of late potentials was 54 +/- 37.7 ms, mean amplitude was 12 +/- 14.0 mean V. Surgery was guided by epi- and endocardial mapping. In 14 cases endomyocardial encircling ventriculotomy was the main procedure, whereas in 5 patients only aneurysmectomy and bypass grafting were performed. Postoperatively, late potentials were no longer detectable in 12 cases, whereas in 6 of 7 cases there was a decrease in duration, but no essential change in amplitude. A postoperative electrophysiological study was performed in 18 cases. In those 12 patients with abolition of LPs, the maximal number of inducible ventricular echo beats using an extended stimulation program from three right ventricular sites, ranged between 1 and 5 in 9 cases, between 10 and 11 VE in 2 cases, whereas VT was induced in only 1 case. In 6 patients in whom LPs were still detectable, ventricular tachycardia could still be induced in 2 cases and a maximal response of ten echo beats was observed in another patient. Abolition of LP by surgery is closely related to the disappearance of the propensity to stimulus-induced VT. Thus the averaging technique may provide a non-invasive procedure to assess the successful outcome after operation for ventricular tachycardia. If, however, LPs are still present, this does not exclude successful surgical abolition of the propensity to ventricular tachycardia.

Cardiac Pacing, Artificial↗

[A combined method of autologous bone grafts and collagen allografts for the prevention of bone pockets].

The use of autogenous bone for elimination of intrabony pockets is a well established procedure. With the use of "fill-in-techniques" three problems still remain: 1. the limited amount of bone that can be obtained, 2. the additional surgical intervention to obtain the bone graft, 3. the associated gingival recession, which especially in the front region challenges every intervention. A rather simple combined technique is described to eliminate these difficulties. The use of an allogenic filler compensates efficiently for the limited amount of bone material available. Lyophilized dura mater is a suitable allograft. Lyophilized dura mater is commercially available and the extended and prolonged use in general surgery has confirmed it as a very reliable substitute. Its adaptation to the complex morphology of intrabondy defects and surrounding structures is easily obtained by cutting it to the desired shape and compressing it with a gauze pad. The additional surgical intervention and trauma can often be eliminated by the autogenous osseous material which is obtained from an intra-oral source, usually from the area where hte surgery is being performed. By incorporation of a filter in the existing suction device the osseous coagulum can be collected permitting the utilization of a coolant. The use of several layers of the allogenic graftmaterial reduces the gingival recession to a minimum and restores the interdental papilla. The small differences between this surgical technique and the classical one do not constitute a major problem. The case must be carefully selected and prescribed technique followed in every detail. The present results are substantiated only by clinical evaluation on a restricted number of patients and during a limited period of time.

Bone Transplantation↗

Transforming growth factor beta 2 levels in the aqueous humor in different types of glaucoma and the relation to filtering bleb development.

PURPOSE: To investigate the transforming growth factor beta 2 (TGF-beta 2) levels and total protein levels in the aqueous humor of eyes with different types of glaucoma [primary open-angle glaucoma (POAG), pseudoexfoliation glaucoma (PSX), juvenile glaucoma (JG)], and the relation to filtering bleb development after trabeculectomy. METHODS: Aqueous humor was collected at the beginning of surgery from 52 eyes with glaucoma (29 POAG eyes, 17 PSX eyes, 6 JG eyes) and from 29 control eyes that underwent cataract operation. TGF-beta 2 levels (intrinsically activated and total TGF-beta 2) using ELISA methods as well as total protein concentrations of the aqueous humor were determined. All preoperative clinical data of the glaucoma eyes (age, gender, IOP, previous treatment, type of surgery) were compared with the TGF-beta 2 levels. In 40 of these eyes, the postoperative follow-up (filtering bleb development, need for intervention, IOP) was correlated to the preoperatively determined TGF-beta 2 levels. RESULTS: TGF-beta 2 levels were increased in nearly half of the eyes with POAG and in most of the eyes with JG, but in eyes with PSX, TGF-beta 2 levels were within the normal range. No correlation between TGF-beta 2 levels and age, gender, IOP, previous treatment, or type of surgery, or between TGF-beta 2 levels and protein levels in aqueous humor, was found. Correlation between bleb formation and TGF-beta 2 levels revealed that all but two of the POAG eyes with good clinical outcome (type 1 bleb) had normal levels of activated TGF-beta 2. Of the 13 eyes that needed postoperative intervention (type 2 and type 3 bleb), 8 had high and 5 had normal TGF-beta 2 levels. CONCLUSIONS: PSX eyes differ from POAG and JG eyes not only by their clinical or biomicroscopic appearance, but also by their normal TGF-beta 2 levels in aqueous humor. The fact that most of the POAG eyes with favorable bleb development had normal TGF-beta 2 levels indicated that there might be some relationship between bleb formation and TGF-beta 2 levels. On the other hand, the fact that eyes with less favorable bleb development had both low and high TGF-beta 2 levels indicated that other factors are also involved in the scarring of the filtration bleb.

Adolescent↗

Right ventricular migration of a recovery IVC filter's fractured wire with subsequent pericardial tamponade.

A Recovery filter (C.R. Bard, Tempe, AZ, USA) is a device for pulmonary embolism prophylaxis. There have been few case reports involving the migration of this particular filter or of a broken wire migrating to the heart. We report a case of right ventricular migration of a fractured wire from this filter in a patient who subsequently developed pericardial tamponade and required open heart surgery to extract the fractured wire. We discuss the current US Food and Drug Administration (FDA)-approved nonpermanent inferior vena cava filters and their reported complications. These complications can be life-threatening and may require immediate surgical intervention.

Aged↗

Microrheology of filtered autotransfusion drain blood with and without leukocyte reduction.

Autotransfusion of filtered knee drain blood (FKDB) is frequently practised in orthopaedic surgery, but questioned because it contains inflammatory cytokines, contaminants from lysed blood cells, debris and chemicals from the wound. We have studied the microrheology (5 microm pore filtration) of FKDB (n = 23) with versus without the addition of a leukocyte reducing filter (LRF) in line with the drain. As expected the whole blood clogging was reduced (p < 0.01) due to the lowered leukocyte number by the LRF. FKDB plasma contains clogging particles of unknown origin. With the LRF the increased plasma clogging was reduced (p approximately 0.05). With resuspended erythrocytes there was an increase in clogging rate in FKDB at 24 hours. This increase was abolished with the addition of the LRF, which may indicate that the erythrocyte trauma results from the incubation together with leukocytes in the drain container. There is a potential for further improvement of the filters in autotransfusion drains.

Aged↗

[Acute pulmonary thromboembolism during the surgery for bilateral lower extremity fracture].

A 50-year-old woman underwent open reduction and internal fixation for bilateral lower extremity fracture under general anesthesia. During the surgery, arterial oxygen saturation and expired CO2 concentration dropped suddenly when the left limb was fixed. Immediately, we performed aspiration of the pulmonary thrombus and inserted a temporary infra-vena cava filter followed by heparinization. Ten days later, we carried out the surgery on the right limb uneventfully. The major cause of APTE is deep vein thrombosis (DVT), which is extremely common during perioperative period. Therefore, we must perform antithrombotic therapy for the patient at high risk for DVT.

Acute Disease↗

Retinal function in Swedish ophthalmologists using argon lasers as reflected in colour contrast sensitivity. Normal thresholds in the great majority of the cases.

PURPOSE: To map the colour contrast sensitivity (CCS) and possible elevations of colour contrast thresholds in Swedish ophthalmologists operating argon lasers. MATERIAL AND METHODS: CCS was measured by a computer and colour monitor system developed by Arden and co-workers. CCS of 58 Swedish ophthalmologists, all users of argon laser, was compared to 26 age-matched controls. The ophthalmologists provided information on their professional use of lasers, whether the laser was equipped with a blue-absorbing filter, and the length of time spent in retinal surgery. RESULTS: There was no significant difference in colour vision comparing laser-users to controls (p>0.2). However, eight subjects showed elevated tritan thresholds (>1 SD above mean), in three of the cases an elevation >2 SD above mean. All these colleagues had an extensive exposure to blue-green laser and/ or a long time spent operating. Compared to others, they had performed more laser sessions prior to the lasers being equipped with protecting filters (p<0.01). CONCLUSION: Normal thresholds were found in a majority of the cases and no permanent impairment of retinal function was observed among these ophthalmologists. However, the laser-users with the greatest number of sessions seemed to show a certain decrease in retinal function as reflected in tritan thresholds.

Adult↗

Prevention of endophthalmitis by intraocular solution filtration and antibiotics.

Gentamicin sulfate was used in a millipore-filtered irrigating solution for 12,000 cases of anterior segment surgery (extracapsular cataract extraction with posterior chamber lens implantation) without one occurrence of endophthalmitis. One instance of endophthalmitis occurred in eight cases in which unfiltered gentamicin sulfate solution was used. No side effects have been associated with the use of the millipore-filtered irrigating solution.

Bacterial Infections↗

Deep venous thrombosis during neoadjuvant chemotherapy in a patient with osteosarcoma: a case report.

A 29-year-old man with an osteosarcoma of the left distal femur developed asymptomatic deep venous thrombosis (DVT) during neoadjuvant chemotherapy. The thrombotic event occurred in the left common iliac vein and was revealed by pelvic computed tomography (CT). We successfully performed a limb salvage operation with placement of a permanent inferior vena cava filter. The thrombus spontaneously regressed without thrombolytic therapy after surgery. We should consider DVT in patients with musculoskeletal sarcomas who are under long-term hospitalization and immobilization associated with not only surgery but also chemotherapy. To screen for both metastasis and DVT, we recommend contrast-enhanced whole-body CT, including scans of the pelvis.

Adult↗

Leucocyte filtration during cardiopulmonary reperfusion in coronary artery bypass surgery.

Postoperative organ dysfunction after cardiac operations has been related to the damaging effects of cardiopulmonary bypass (CPB). These complications are considered to be mediated partly by complement activation and subsequent activation of leucocytes due to the contact between blood and the large nonendothelial surfaces in the bypass circuit. Removal of leucocytes by filtration during the reperfusion period may potentially reduce the postoperative morbidity after CPB. Forty patients undergoing elective, primary coronary artery bypass grafting were randomized to initial identical bypass circuits until the aortic crossclamp was released. Then, the ordinary arterial line filter was closed and either a leucocyte depletion filter (n = 20), or a control filter (n = 20) was incorporated in the circuits during the reperfusion period of CPB. Blood samples were drawn at fixed intervals and analysed for white blood cell and platelet counts, plasma concentration of myeloperoxidase, C3-complement activation products, the terminal complement complex, and interleukins (IL)-6 and -8. The numbers of circulating white blood cells in the leucocyte-depleted group decreased during the reperfusion period from 5.5 (4.8-6.8) to 5.3 (4.4-6.2) x 10(9)/l, and increased in the control group from 6.5 (5.1-8.0) to 7.4 (5.7-9.0) x 10(9)/l. Two hours postoperatively the total white blood cell count in the leucocyte-depleted group was 14.7 (12.1-17.2) x 10(9)/l, and in the control group 17.6 (14.5-20.7) x 10(9)/l. The differences between the groups were statistical significant (p = 0.05). There were no statistically significant differences between the groups with regard to other test parameters or clinical data. We conclude that the use of leucocyte filters during the reperfusion period in elective coronary artery bypass surgery significantly reduced the number of circulating leucocytes, whereas no effects were seen for granulocyte activation measured as myeloperoxidase release, platelet counts, complement activation, or IL-6 and -8 release. The clinical benefit of leucocyte filters in routine or high risk patients remains to be demonstrated and is suggested to be dependent on both the efficacy and the biocompatibility of the filters.

Aged↗

Correlation between the early morphological appearance of filtering blebs and outcome of trabeculectomy with mitomycin C.

PURPOSE: To correlate the morphologic appearance of filtering blebs in the early postoperative period with the outcome of trabeculectomy with mitomycin C (MMC) during the first postoperative year. PATIENTS AND METHODS: In a prospective study, the morphologic appearance of filtering blebs after primary trabeculectomy with adjunctive MMC (0.1 mg/ml for 5 minutes intra-operatively) was classified; 49 eyes of 49 patients were examined preoperatively, 1 and 3 days, 1 and 2 weeks, 1, 3, 6, and 12 months postoperatively. Status of filtering bleb, intraocular pressure (IOP), and number of medications were recorded. RESULTS: One year after surgery all patients had IOP < or = 21; 6 patients received antiglaucoma medication. One eye required needling of the filtering bleb because of encapsulation. During the first postoperative year, eyes with conjunctival subepithelial micro cysts, observed in the first and the second postoperative week, had significantly lower mean IOP, than eyes without (11.1 mm Hg vs. 13.9 mm Hg; p:0.0043, ANOVA). Eyes with corkscrew vessels, observed in the first and the second postoperative week, had significantly higher mean IOP, than eyes without during the first postoperative year (13.4 mm Hg vs. 11.7 mm Hg; p:0.0141, ANOVA). CONCLUSION: Classification of filtering blebs after trabeculectomy with MMC may help to disclose patients with an increased failure risk.

Aged↗

Phacoemulsification in filtered chronic angle closure glaucoma eyes.

PURPOSE: To report the results of phacoemulsification in eyes with chronic angle closure glaucoma having a functional filtering bleb. METHODS: A prospective and non-comparative study was undertaken in 60 consecutive eyes of 44 patients having a functional filtering bleb for chronic angle closure glaucoma and undergoing cataract surgery. Only those cases who had intraocular pressure 0.05 using paired t-test). The central anterior chamber depth was statistically significant (P = 0.002) when preoperative (1.90 +/- 1.27 mm) was compared to postoperative at 6 months (2.11 +/- 1.27 mm). CONCLUSION: Phacoemulsification in eyes with a functional filtering bleb for chronic angle closure glaucoma is challenging. However, with slight modifications in technique, it can be accomplished without compromising the functioning of the bleb.

Capsulorhexis↗

Tissue fragments recovered at cardiac surgery masquerading as tumoral proliferations. Evidence suggesting iatrogenic or artefactual origin and common occurrence.

The entity described in the literature as a "distinctive cardiovascular lesion" resembling histiocytoid hemangioma and more recently referred to as "mesothelial/monocytic incidental cardiac excrescence" may not be a true proliferative lesion. Rather, it may represent an artefact produced by suctioning of the pericardial cavity during cardiac surgery. This hypothesis was explored by comparing two index cases of cardiac histiocytoid hemangioma-like lesions (HLLL) to (a) the contents of extracorporeal bypass pump (ECBP) filters in 22 random cardiac surgical cases, and (b) material adherent to mediastinal and pericardial drains in 15 random post-cardiac surgery cases. In 18 of the 22 ECBP filter cases (82%) and two of the 15 postsurgery cases (13%), tissue fragments indistinguishable from the HHLL index cases were identified. These filter and drain fragments had light microscopic, immunohistochemical, and ultrastructural features identical to those of the index cases, as well as to the HHLLs described in the literature. In neither index case, nor in the study patients, were any proliferative lesions identified at surgery. Three study cases subsequently came to autopsy, and no proliferative lesions were found. This and other evidence strongly suggest that these lesions not only are artefactual, but also are a common occurrence. They are likely produced during cardiac surgery by the cardiotomy suction, with compaction of friable mesothelial strips, other tissue debris, and fibrin into tumor-like fragments that may be transported around the operative site on the suction tip.

Adult↗

[Effect of hygrophobic filter or heated humidifier on peroperative hypothermia].

A study was carried out to find out whether the use of a hygrophobic filter (Pall, Ultipor) or of a heated humidifier (Dräger, Aquapor) during surgery had any effect on a patient's intraoperative core temperature and thermal balance. Seventy-five ASA I or II patients scheduled for gynaecological surgery were randomly assigned to three groups: group A (n = 25), where no warming device was used; and two groups (n = 25 for each) where inhaled gases were humidified and heated with either a hygrophobic filter set up between the endotracheal tube and the Y-piece (group B) or a heated humidifier set to 100% saturation at a temperature of 41.5 degrees C (group C). The patients were all anaesthetised with the same technique (thiopentone 5 mg.kg-1, dextromoramide 0.03 mg.kg-1 and 0.1 mg.kg-1 of either pancuronium or vecuronium, followed by enflurane with nitrous oxide in oxygen); the perfused fluids were not heated. Room, tympanic, rectal, oesophageal and four skin (thorax, arm, leg, thigh) temperatures were measured with calibrated Exacon thermistances, on arrival in the operating theatre, during induction, every ten minutes for two hours, and then every twenty minutes for two hours more. Ramanathan's and Burton's formulae were used to calculate mean skin temperature and heat loss respectively. In the recovery room, patients were warmed up with an electric blanket. Shivering was ranked from "0" to "+ +". There were no differences between groups as far as age, drug doses, perfusion volumes and room temperature were concerned.(ABSTRACT TRUNCATED AT 250 WORDS)

Anesthesia, Inhalation↗

[Filter efficiency of commercial face masks in capturing particles and airborne bacteria].

The filter efficiency of seven kinds of commercial face mask for particles and airborne bacteria was tested in the wash room of a laboratory animal facility. The filter efficiency of the masks was 19 to 50%, as measured by the weight of particles with diameters below 10 micron, 22 to 71% for particles of the 0.3 micron level, 47 to 90% for the 1 micron level, and 90 to 99.6% for the 5 micron level. The filter efficiency for airborne bacteria was 35 to 81%. Among these even masks tested, glasswool surgery masks, three-sheet synthetic fiber masks with and without charcoal, and 28-sheet gauze masks with glass filter showed generally high efficiency, and single-sheet synthetic fiber masks, 18-sheet of gauze masks and gas masks showed low efficiency.

Animal Husbandry↗

Speech recognition impairments in patients with intractable right temporal lobe epilepsy.

PURPOSE: To evaluate speech recognition in patients with focal intractable epilepsy and surgical resections in the nondominant (right) hemisphere. METHODS: Speech recognition was tested prospectively, under different listening conditions, in 22 patients with right temporal lobe (11 patients) or extra-temporal lobe epilepsy. All were left-hemisphere dominant for language on preoperative intracarotid sodium amobarbital testing. RESULTS: All patients demonstrated normal auditory recognition of words and environmental sounds before and after surgery. However, when real-world listening conditions were simulated by using acoustically degraded (filtered) words, patients with temporal lobe epilepsy performed significantly worse than patients with frontal or parietooccipital lobe epilepsy before and after surgery (p<0.0001). CONCLUSIONS: Patients with intractable right temporal lobe epilepsy are at risk for speech recognition impairments in real-world listening environments, independent of surgery. The impact of speech recognition difficulties on verbal communication, coupled with the prevalence of adverse listening environments, underscores the importance of testing speech recognition under different listening conditions in patients with intractable right temporal lobe epilepsy.

Adolescent↗

Regulation of testicular inhibin subunit messenger ribonucleic acid levels in vivo: effects of hypophysectomy and selective follicle-stimulating hormone replacement.

To examine the pretranslational regulation of inhibin subunits in the rat testis by FSH, we studied the effects of hypophysectomy with or without selective FSH replacement on testicular inhibin subunit mRNA levels in immature and adult animals. In the first experiment (Exp I), sexually immature (20-23 days old) intact and hypophysectomized male rats were killed 1, 3, and 7 days after surgery, and the testicular content of inhibin subunit mRNAs was determined by filter hybridization. A second group of immature, intact, or hypophysectomized rats was treated with saline or FSH for 7 days as follows: I) intact, saline; II) hypophysectomized, saline; III) hypophysectomized, FSH [0.05 microgram/100 g BW, sc, twice daily (BID)]; IV) hypophysectomized, FSH (0.50 microgram/100 g BW, sc, BID); V) hypophysectomized, FSH (5.0 micrograms/100 g BW, sc, BID); and VI) hypophysectomized, FSH (50.0 micrograms/100 g BW, sc, BID). In the second experiment (Exp II), adult (60 days old) intact or hypophysectomized animals were treated with saline, FSH, and/or testosterone for 7 days as follows: I) intact, saline; II) hypophysectomized; saline; III) hypophysectomized, 22-mm testosterone implant; IV) hypophysectomized, FSH (50.0 micrograms/100 g BW, sc, BID; and V) hypophysectomized, 22-mm testosterone implant plus FSH (50.0 micrograms/100 g BW, sc, BID. The effects of FSH and testosterone on testicular inhibin subunit mRNA levels were measured by filter hybridization. In Exp I, the level of inhibin alpha-subunit mRNA per testis was significantly lower in hypophysectomized rats than in intact controls at all time points after surgery. Replacement of FSH to hypophysectomized immature rats led to a dose-dependent increase in alpha-subunit mRNA per testis. However, hypophysectomy and FSH replacement had no significant effect on beta-B-subunit mRNA. In adult rats (Exp II), hypophysectomy significantly lowered and FSH replacement increased testicular inhibin alpha-subunit mRNA levels. Replacement of testosterone to adult animals, either alone or in combination with FSH, had no effect on expression of inhibin alpha-subunit mRNA. beta-B mRNA levels in adult testis were not significantly altered by any of the treatments. beta-A-Subunit mRNA levels were below the detection threshold of filter hybridization in both Exp I and II. Collectively, these data demonstrate that FSH regulates alpha- but not beta-B-subunit mRNA in the testis of both immature and adult rats in vivo. Differential regulation of inhibin subunits may provide a mechanism for creation and regulation of functional diversity of inhibin-related peptides in the testis.

Animals↗