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Objectives: Recombinant thrombin (rThrombin) is a potential hemostatic alternative to bovine and human plasma-derived thrombin. This report examines the clinical results for the vascular surgery subgroup of patients enrolled in a larger double-blind, randomized, multicenter trial, which evaluated the comparative safety and efficacy of rThrombin and bovine plasma-derived thrombin (bThrombin) when used as adjuncts to surgical hemostasis., Methods: Data from the 164 vascular patients who underwent either a peripheral arterial bypass (PAB) or arteriovenous graft (AV) procedure are included in this analysis. Time to hemostasis at proximal and distal anastomotic sites at 1.5-, 3-, 6-, and 10-minute intervals was determined by procedure (PAB or AV) and overall (PAB + AV). Baseline and day 29 immunologic sera were analyzed. The incidences of postoperative adverse events were compared between treatment groups. Categorical adverse events were evaluated in relation to thrombin product antibody formation., Results: Patients were randomized to either bThrombin (n = 82) or rThrombin (n = 82). Procedures included PAB (n = 88) and AV (n = 76). The bThrombin and rThrombin groups were well matched for demographics and baseline characteristics. A comparable incidence of anastomotic hemostasis was observed in both treatment groups at 10 minutes (94% bThrombin, 91% rThrombin). The incidence of hemostasis was lower at all time points for PAB procedures compared with AV procedures. In the PAB group, a significantly greater proportion of patients receiving rThrombin (55%) achieved hemostasis at 3 minutes compared with bThrombin (39%; P < .05). Adverse event profiles and laboratory findings were similar between groups. No patients in the rThrombin group developed anti-rThrombin product antibodies at day 29, whereas 27% of patients in the bThrombin group developed antibodies to bThrombin product (P < .0001)., Conclusions: rThrombin or bThrombin used as a hemostatic ancillary for anastomotic bleeding was equally effective at 10 minutes; however, rThrombin compared with bThrombin may provide a more rapid onset of hemostasis at 3 minutes in PAB procedures. Adverse events were similar between the two thrombins. In patients undergoing vascular surgery, both treatments were similarly well tolerated, although rThrombin demonstrated a superior immunogenicity profile.

Background: The efficacy of carotid endarterectomy (CEA) in octogenarians is controversial. Recent reports have examined this question in the general population, but little data exist on veterans. With the emergence of carotid artery stenting, we need to evaluate the role of CEA in treating elderly veterans with carotid stenosis., Methods: Retrospective chart review of all CEAs performed between January 1995 and December 2004., Results: A total of 286 procedures were performed in 239 patients; 39 procedures were performed in 33 octogenarians, and 247 procedures were performed in 206 younger veterans. Both groups had similar preoperative comorbidities. There were no statistically significant differences between octogenarians and younger veterans for postoperative stroke (2% vs. 1%), death (0% vs. 1%), myocardial infarction (5% vs. 2%), length of stay (7 +/- 19 vs. 3 +/- 8 days), or 4-year survival (53% vs. 57%)., Conclusions: CEA can be safely performed in octogenarian veterans with outcomes similar to younger veterans.

Background: Patients with metastatic neck disease from upper aerodigestive tract carcinomas have an extensive history of tobacco and alcohol abuse. These patients are predisposed to develop atherosclerotic vascular disease., Objective: An increased incidence and severity of carotid stenosis in patients receiving radiotherapy for head and neck cancers is known. Management of patients with severe carotid stenosis who require surgical treatment of their neck disease has not been described. The authors describe our experience with simultaneous carotid endarterectomy and neck dissection., Study Design: Prospective data collection., Methods: From 1991 to 1997 at West Virginia University Hospitals, Morgantown, West Virginia, and State University of New York (SUNY) at Buffalo, three patients with severe carotid stenosis required surgery for metastatic neck disease. Preoperative evaluation revealed a bilateral carotid stenosis greater than 90% in all patients. All patients underwent modified radical neck dissections and simultaneous carotid endarterectomies with saphenous vein grafting. Two patients, one undergoing partial pharyngectomy and laryngectomy and the other a laryngectomy and neck dissection, had coverage of the carotid artery with the myogenous component of a pectoral major graft. One patient had only a neck dissection., Results: Two patients healed with no local morbidity, no neck recurrence, and a patent carotid artery by Doppler. No strokes were encountered. One patient died of a myocardial infarction., Conclusion: Severe carotid stenosis that requires revascularization may have endarterectomy performed simultaneously with treatment of head and neck primary with no increase in morbidity.

A 42-year-old multiparous pregnant woman presented with swelling and pain of the left arm at 34 weeks gestation. She had no discoloration of her arm nor a loss of radial pulse. Duplex scanning demonstrated a thrombosis in the axillary vein. She was found to have a positive circulating lupus anticoagulant. Intravenous heparin was administered and resulted in resolution of discomfort and swelling on day four of therapy. The patient was maintained on therapeutic doses of subcutaneous heparin until vaginal delivery at 39 weeks. Prenatal course was complicated by a resolving infection believed to be due to cat-scratch disease which produced a five centimeter cystic lesion in the left axillae which was removed in the first trimester. Titers for cat-scratch disease were positive for mother and infant at delivery but infant titers were negative at six weeks. Axillary vein thrombosis in pregnancy can be complicated by pulmonary embolism and should be treated by heparin.

Background: Spontaneous rupture of abdominal aortic aneurysm into the inferior vena cava is rare. The clinical presentation is highly variable, and the diagnosis can be difficult, often being made only at operation. The aortocaval fistula results in a large left-to-right shunt, which can cause cardiac failure. Once the diagnosis is made, treatment is by surgical closure of the fistula and repair of the aneurysm with a graft., Methods: This is a retrospective review of a single surgeon's experience with aortocaval fistula complicating abdominal aortic aneurysms., Results: Over a 15-year period, we had five patients with spontaneous aortocaval fistula who were treated operatively. Preoperative diagnosis was made in two, suspected in one, and not made in two, one of whom died (the only perioperative death in the series)., Conclusions: Spontaneous aortocaval fistulas are uncommon, and their preoperative recognition is difficult. Hematuria in association with an abdominal aortic aneurysm should raise the suspicion of an aortocaval fistula. Surgical correction is possible, with survival rates comparable to those associated with rupture of aneurysms into the retroperitoneum. Early operative control of the fistula is important to optimize the preload to the heart.

The objective of this study was to determine the incidence of internal jugular vein thrombosis in patients undergoing free flap reconstruction and simultaneous neck dissection. Patients underwent Doppler ultrasound examination of their internal jugular veins on postoperative days 1 and 7 after functional neck dissection and free flap transfer. Long-term follow up was obtained at a minimum of 3 months. The incidence of internal jugular vein thrombosis in patients undergoing free flap reconstruction with simultaneous neck dissection is similar to that of patients undergoing just neck dissection. A significant number of these veins recanalize and have excellent long term patency. There does not seem to be a correlation between venous thrombosis and free flap survival.

Objective: To determine the incidence of internal jugular vein thrombosis after functional or selective neck dissection., Design: Patients underwent serial Doppler ultrasonographic examinations of their internal jugular veins, on postoperative days 1 and 7, following functional neck dissection. Long-term follow-up was conducted at a minimum of 3 months., Setting: Department of Otolaryngology, West Virginia University, Morgantown., Patients: Sixty-five patients (51 men and 14 women) underwent 100 functional neck dissections between 1993 and 1995. Thirty-five patients had N0, 10 had N1, and 20 had N2 node involvement, respectively. Thirty-five patients underwent bilateral neck dissection, 17 underwent left neck dissection, and 13 underwent right neck dissection., Main Outcome Measures: Thrombosis of the internal jugular veins was determined using duplex Doppler scanning. Correlation with the length of the procedure, intraoperative blood loss, preoperative radiation therapy, stage of neck disease, presence of extracapsular spread, wound infection, and pedicled musculocutaneous flap closure was determined., Results: Of the 100 internal jugular veins studied, 20 (24.7%) of 81 and 19 (26.4%) of 72 were found to have evidence of thrombosis on postoperative days 1 and 7, respectively. On long-term follow-up, the incidence of internal jugular vein thrombosis was significantly lower (5.8%; P < .001). None of the variables examined correlated significantly with the presence of thrombosis. Of the 20 veins that were thrombosed initially, on follow-up 13 had normal flow and 2 had persistent thrombosis. Five patients were unavailable for follow-up. No thrombosis developed as a late finding., Conclusions: Our results indicate that even though the incidence of internal jugular vein thrombosis is relatively high immediately following neck dissection, a significant number of these veins will undergo recanalization and have excellent long-term patency.

Vena cava filters are now widely used as a safe and effective means of reducing the risk of pulmonary embolus in patients hospitalized with acute stroke or trauma. We report a case of traumatic disruption of vena cava filter resulting from guidewire manipulation with migration of the main structure to the heart after successful initial placement of the filter.

The need for a vascular prosthesis that does not require preclotting is apparent. The use of biological biodegradable coatings may carry the potential disadvantages of undesirable healing, inflammatory or antigenic reactions, and increased thrombogenicity. A graft has been developed to minimize porosity by coating only the outer surface with a bioinert non-absorbable elastomer (mainly Silastic) so as to leave the inner surface unchanged. Thoracoabdominal aortic 8-mm grafts (ten knitted and five woven coated grafts, six uncoated Dacron grafts) 12 cm long were implanted in mongrel dogs for 6 months. Differences in patency and healing in coated and uncoated grafts were observed by angiography, and by scanning electron and light microscopy. Statistical analysis included Fisher's exact test and Student's unpaired t test. Clinically, no ill effects were noted in coated grafts, and the transinterstitial blood loss was similar to that in preclotted uncoated grafts. One graft in each group occluded for technical reasons. One knitted coated graft developed perigraft seroma. The woven coated grafts and control prostheses had similar handling properties; however, needles appeared to pass through the coated graft material more easily and with less suture drag. Scanning electron microscopy was used to demonstrate similar presence of endothelial-like cells in both groups. Comparisons between coated and control grafts using light microscopy were as follows: pseudoendothelium, 0.26 versus 0.31 mm (P not significant); inflammation, 0.21 versus 0.73 (P < 0.01); giant cell formation, 0.02 versus 0.80 (P < 0.01); fibrosis, 1.31 versus 1.80 (P < 0.03). Tissue ingrowth into and around the Dacron fibers from the outer surface was similar.(ABSTRACT TRUNCATED AT 250 WORDS)

A guiding catheter was used in seven patients who underwent balloon dilation of nine renal arteries. The advantages of using a guiding catheter for renal angioplasty are analogous to the benefits obtained with a coronary angioplasty guiding catheter used in coronary angioplasty. The guiding catheter provides back-up support to cross lesions and allows selective contrast visualization of the lesion before, during, and after dilation. It is also possible, when using a guiding catheter, to measure pressure gradients across lesions without having to recross the lesion which may help to ensure that adequate dilation of the stenosis has been accomplished.

It has been hoped that pharmacologic prophylaxis in thoracic aortic cross-clamping may avert the unpredictable complication of spinal cord paraplegia, may avoid the mechanical difficulties associated with shunts, partial bypass, or monitoring devices, and may serve as a substitute for or as an adjunct to cerebral spinal fluid drainage. Toward this end 21 mongrel dogs were studied in four groups and underwent 60 minutes of thoracic aortic cross-clamping: group I, five with thoracic aortic cross-clamping; group II, five with thoracic aortic cross-clamping and cerebral spinal fluid drainage; group III, five with thoracic aortic cross-clamping, cerebrospinal fluid drainage and intravenous administration of a single dose (5000 units/kg) of polyethylene glycol-conjugated superoxide dismutase (PEG-SOD) given 15 to 20 minutes before thoracic aortic cross-clamping; and group IV, six with thoracic aortic cross-clamping and PEG-SOD. Paraplegia was graded by the Tarlov method at 24 hours and up to 5 days after thoracic aortic cross-clamping. The carotid and femoral artery pressures, the central venous pressure, and core temperature, taken during the experiment and at the time the dogs were killed, were found to be similar between groups. At 24 hours all dogs in group I were paraplegic; groups II and III had no paraplegic dogs (p less than 0.01), and group IV had fewer paraplegic dogs (two of six) than group I (p less than 0.05). Paraplegia was averted in all dogs treated with cerebral spinal fluid drainage, even 5 days after thoracic aortic cross-clamping.(ABSTRACT TRUNCATED AT 250 WORDS)

An unusual complication following transhiatal esophagectomy for lower esophageal carcinoma is reported in which extrapericardial tamponade and profound shock occurred secondary to a herniated section of omentum in the immediate postoperative period. The two-dimensional echocardiogram was nondiagnostic, but the diagnosis was confirmed during reexploration of the abdomen. Anatomic and pathophysiologic considerations of this unusual but life-threatening complication are discussed. The literature suggests that computed tomography is the study of choice to confirm the clinical diagnosis of pericardial pathology, and this case report is yet another example to support routine closure of the esophageal aperture.

A true pancreaticoduodenal artery (PDA) aneurysm (ie, one not associated with pancreatitis) is the second least common splanchnic artery aneurysm; it is usually situated in or near an area that is hard to dissect, and it has a distinct propensity to rupture. We reviewed a total of 36 cases of PDA aneurysm, including three from our institution, and we analyzed them in two time periods with relation to age, sex, method of diagnosis, morbidity, and mortality. Cases reported before 1970 were compared with those reported during or after 1970. The male-female ratio was 4:1 before 1970 and 1:1 after 1970, yet the mean age has stayed significantly lower for female populations (P less than .02). The use of angiography has increased significantly recently (P = .004). The overall mortality has not improved significantly (P = .08); however, if the initial diagnosis was made by angiography, the survival was significantly better (P less than .025). Surgical intervention remains the standard treatment, but preoperative angiography significantly improves operative results. Anecdotal reports suggest that selected high-risk cases may be successfully managed by therapeutic angiography with embolization.

The internal mammary artery is used with increasing frequency for myocardial revascularization. However, preoperative coronary angiography does not always provide adequate visualization of subclavian arteries. If a proximal subclavian artery stenosis exists or develops in a patient who has myocardial revascularization with the internal mammary artery, graft malfunction can occur resulting in myocardial ischemia. We have identified four cases of internal mammary artery graft malfunction at our own institution and identified an additional 12 cases from the literature. These 16 cases are analyzed for age, sex, time of onset of symptoms, clinical findings, method of revascularization, and long-term follow-up. Sixty-three percent of the patients were men, and the mean age was 52.9 +/- 9.0 years. Onset of symptoms occurred after a mean interval of 25.1 months from the time of myocardial revascularization. Three patients had asymptomatic reversal of flow in the internal mammary artery as diagnosed by coronary arteriography during routine follow-up examination before 1980. One death after internal mammary artery-coronary bypass grafting was related to immediate malfunction. In the remaining 12 patients with symptomatic malfunction, all but one were treated by placement of a carotid-subclavian bypass graft with no mortality. Relief of myocardial ischemia was complete in 93% of the patients with a mean follow-up of 29.3 months. Carotid-subclavian bypass grafting appears to be the treatment of choice for the usual management of internal mammary artery graft dysfunction. Careful preoperative evaluation and postoperative follow-up of the subclavian arteries, even by simple comparison of bilateral arm blood pressure should help reduce the incidence of this syndrome.

High mortality rates reported with common bile duct exploration (CBDE), 3.4 per cent to as high as 30 per cent in re-exploration of those over 70 years of age, prompted review of endoscopic papillotomy (EP) for stone extraction in a community hospital as well as an attempt to assess its impact on the treatment of common duct stones. Endoscopic papillotomy in 237 patients had a 1.3 per cent mortality. Successful extraction of the stone occurred in 91.6 per cent of 108 patients followed for at least 2 years with no further treatment required. Morbidity and mortality was uneffected by previous biliary surgery, repeat attempts at stone extraction or EP performed prior to cholecystectomy (P greater than 0.1). The results of treatment for choledocholithiasis in 111 consecutive patients was then retrospectively reviewed to assess the impact of endoscopic papillotomy. CBDE was used initially in 79 and EP in 32 patients. Previous cholecystectomy and age biased the selection for endoscopic papillotomy (P less than 0.01). The mean ages were 57.8 years and 70.6 years (P less than 0.01), for CBDE and EP pts respectively. Age adjusted hospital stay was significantly longer for common bile duct exploration (P = 0.002). Overall, morbidity was not different between the treatment modalities (P = 0.50) and each group had one death (P = 0.23). In this community hospital, endoscopic papillotomy is safe, effective, and was reserved mainly for older patients or those with prior cholecystectomy and choledocholithiasis.(ABSTRACT TRUNCATED AT 250 WORDS)

To reassess the role and timing of operative intervention for spontaneous pneumothorax, 119 patients were retrospectively reviewed to compare recurrences, complications, and hospital stay between a nonoperative group (Group 1) and an operative group (Group 2). Total hospital days were greater in Group 2, but excluding the length of preoperative stay, the number of hospital days were similar in both groups. Group 1 patients more than 40 years old had a longer postoperative hospitalization, but not a higher rate of complication. Overall, morbidity was not different between the two groups, and there were no immediate or perioperative deaths in either group. There were no recurrences in Group 2. At least 11 of the 49 patients in Group 1 had a recurrence (p = .012). Considering the excellent results achieved with operative pleurodesis and the total hospital days accrued with nonoperative therapy, operative pleurodesis should be considered if an active leak persists more than three days after the initial episode of spontaneous pneumothorax or at the time of the first recurrence in the hospitalized patient.