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Iliac vein stent placement is an increasingly common procedure in the treatment of chronic proximal venous outflow obstruction (PVOO), but secondary interventions after vein stent placement remain poorly characterized. Our goal was to identify the incidence, indications, operative findings, and outcomes of secondary interventions after the primary iliac vein stent procedure at a single institution.

Establishment and maintenance of vascular access for hemodialysis is life-sustaining for patients needing renal-replacement therapy. Arteriovenous fistulas (AVFs) are the preferred type of access, but the costs associated with creation and maintenance are poorly characterized, especially with respect to patient characteristics.

Arteriovenous access ischaemic steal (AVAIS) is a serious and not infrequent complication of vascular access. Pathophysiology is key to diagnosis, investigation and management. Ischaemia distal to an AV access is due to multiple factors. Clinical steal is not simply blood diversion but pressure changes within the adapted vasculature with distal hypoperfusion and resultant poor perfusion pressures in the distal extremity. Reversal of flow within the artery distal to the AV access may be seen but this is not associated with ischaemia in most cases.Terminology is varied and it is suggested that arteriovenous access ischemic steal (AVAIS) is the preferred term. In all cases AVAIS should be carefully classified on clinical symptoms as these determine management options and allow standardisation for studies.Diabetes and peripheral arterial occlusive disease are risk factors but a ‘high risk patient’ profile is not clear and definitive vascular access should not be automatically avoided in these patient groups.Multiple treatment modalities have been described and their use should be directed by appropriate assessment, investigation and treatment of the underlying pathophysiology. Comparison of treatment options is difficult as published studies are heavily biased. Whilst no single technique is suitable for all cases of AVAIS there are some that suit particular scenarios and mild AVAIS may benefit from observation whilst more severe steal mandates surgical intervention.

Objective To determine how frequent inflow stenosis is a contributing factor in the etiology of arteriovenous access-induced steal (AVAIS).Methods A retrospective review of hemodialysis patients who underwent interventions from October 1998 to December 2011 for AVAIS was conducted at Mount Sinai Hospital. Patients with grade 3 AVAIS and complete arch and upper extremity vascular imaging were included. Demographics, access history, time to AVAIS, pre-operative angiographic imaging and interventions performed were analyzed.Results A total of 52 patients were diagnosed with grade 3 (severe) AVAIS requiring intervention over the study period. Forty-seven percent of the patients were male, average age was 62 years, 47% were of African American race and 88% were diabetic. Seventeen consecutive patients, with imaging, were included in this study. The average time to presentation of steal symptoms was 147±228 days. All of the accesses were proximal, and 65.7% were autogenous. Imaging studies consisted of angiography (14) and computed tomography angiography (3). Five patients had imaging evidence of >50% luminal inflow stenosis (29.4%). The location of stenosis was the subclavian (3 cases) and brachial (2 cases) arteries. Patients underwent distal revascularization and interval ligation (3), ligation (1) and angioplasty/stenting (1).Conclusion In our population, nearly one-third of the patients with severe AVAIS had a significant subclavian or brachial artery stenosis. The implications of this finding suggest the importance of complete pre-operative imaging. The treatment of the inflow stenosis by itself may not be curative, but the correction may serve as an adjunct and contribute to the success of other therapeutic procedures.

We attempted cessation of prednisone therapy in 16 pediatric renal allograft recipients who were between the ages of 3/2and 16 years at the time of transplantation. Fourteen had primary grafts and 2 had second grafts. Nine had cadaver and 7 had living-related donor grafts. At the time of cessation of prednisone, cyclosporine was the only other immunosuppressive therapy for 15 of the patients and 1 patient was receiving CsA and azathioprine. All the patients had stable serum creatinines at the time prednisone was stopped, between 7 months and 5 years posttransplantation.

Purpose:The North American Subfascial Endoscopic Perforator Surgery (NASEPS) Registry was established to evaluate the safety, feasibility, and efficacy of minimally invasive endoscopic Linton operations for treatment of chronic venous insufficiency.

A critical step in the performance of in-situ bypass is to produce incompetence of the venous valves. Currently, there are several commercially available valvulotomes designed to fulfill this task. The purpose of the present work was to evaluate, in an ex-vivo system simulating an in-situ bypass, the efficiency of valve cutting and the degree of luminal damage produced by four of the most commonly used instruments (Reusable LeMaitre, Expandable LeMaitre, Gore Eze-Sit, and Mills).Cryopreserved cadaveric veins (2.5-6 mm diameter) were mounted in a perfusion chamber and submerged in Ringer's lactate. The same buffer containing 0.6% papaverine was infused at a pressure of 100 mm Hg through a catheter inserted into the proximal end of the vein. The valvulotome to be evaluated was introduced through the distal end of the vein, advanced beyond the most proximal valve and withdrawn at a rate similar to that used clinically through the full length of the vein. The vein was opened longitudinally and the efficacy of valve cutting (expressed as percent of individual valve cut) and presence of luminal damage were carefully evaluated by means of a dissecting microscope.Thirty-three valves in seven segments of veins (mean size 4.35 ± 0.86 mm) were tested with the Reusable LeMaitre valvulotome. The percent of valvular cutting was 29.9 ± 33.4. The Expandable LeMaitre valvulotome was tested in 22 valves contained in five segments (vein diameter 4.07 ± 1.04 mm) and the percent of valvular cutting was 89.2 ± 15.7. The Gore Eze-Sit valvulotome produced a 80.6 ± 25.5% of cutting in the 32 valves contained in the seven venous segments tested (vein diameter 3.67 ± 0.42 mm). The Mills valvulotome was tested in five segments of vein containing 20 valves and there was a 82.1 ± 24.0% of valve cutting after valvulotomy (diameter 3.67 ± 0.57 mm). Statistical analysis demonstrated a significant difference with less cutting (p < 0.0001) when the results of the Reusable LeMaitre valvulotome were compared against each of the other three valvulotomes. Luminal damage was detected in one instance after use of the Mills valvulotome.The Expandable LeMaitre, Gore Eze-Sit, and Mills valvulotomes demonstrated consistent efficacy in valve cutting, the Mills valvulotome producing injury to the wall in one occasion. The Reusable LeMaitre valvulotome gave significantly poorer results, most likely related to failure of engagement of the circular blade. Because of the presently demonstrated safety and efficacy, and avoidance of need for long skin incisions, the Expandable LeMaitre and Gore Eze-Sit are the most promising of the four tested valvulotomes.

This is a case report of a successful popliteal-to-dorsalis pedis artery by pass. The patient had a previous fem oropopliteal bypass which remained patent but failed to halt the ischemic disease. Distal revascularization al lowed a transmetatarsal amputation, which preserved the limb. Bypass to the level of the ankle and foot should always be considered in patients with severe ischemic disease before ampu tation is performed.

Background: The purpose of this work was to study, in a theoretical electric model the effect that an adjunctive arterio–venous fistula (AVF) produces on the flow patterns of a distal infrapopliteal bypass. Method: A theoretical electric model that mimics a femoro–infrapopliteal bypass with an adjunctive AVF was designed. Based on Thevenin's Theorem, flows in different areas of the circuit (bypass, collaterals, AVF, segment of artery distal to bypass anastomosis, arteriolar system) were calculated at different resistance values for AVF, collaterals, and bypass. Results: This model demonstrated the following: (1) An adjunctive AVF with large resistance (smaller vein diameter) maintains distal flow, as opposed to a low-resistance AVF. (2) Good collateral flow, in addition to low-resistance AVF, can produce retrograde flow in the segment of the artery distal to the AVF. (3) True distal flow (arteriolar flow) in the presence of high collateral resistance can decrease with decreasing resistance of the AVF, but it will never become retrograde. Conclusion: The effect of an adjunctive AVF on the hemodynamics of a bypass and its distal runoff vessels depends on the resistance of the AVF and the collateral vessels. The presence of AVF always increases the bypass flow and in this respect it may promote graft patency. However, Bypass grafting in the face of a low collateral resistance is of dubious value and the addition of a fistula in this situation is detrimental.

• This report presents our experience using double-lumen, silicone rubber, indwelling central venous catheters with a subcutaneous Dacron cuff as access for hemodialysis. Twenty-seven catheters were placed in 27 patients through venous cutdowns. A 10-cm subcutaneous tunnel was created leaving the Dacron cuff 2 cm from the external exit. Sixteen Raaf catheters (lumen diameter [LD], 1 mm), three double-lumen Hickman catheters (LD, 1.6 mm) and eight HemoCath catheters (LD, 2 mm) were used. The tip of the catheter was positioned fluoroscopically in either the superior vena cava or the right atrium. One hundred fifty-nine treatments were done with the Raaf catheters (mean blood flow [MBF], 188.1±26.4 mL/min); two of these catheters became obstructed and could not be used further. Three double-lumen Hickman catheters were used in 12 hemodialysis treatments (MBF, 216.3±27.1 mL/min). One hundred fifty-five treatments were done using the HemoCath catheters (MBF, 236.7±5.5 mL/min). The degree of recirculation of these catheters was 8.56%±4.34%. The major advantages of this modality include simplicity of introduction, lack of serious complications, no sacrifice of major arteries, no need for venipuncture, and potential use in either short- or long-term hemodialysis.(Arch Surg 1986;121:229-232)

Vena cava interruption using the Greenfield filter has proved to be a safe and effective method. In a series of 156 patients receiving the filter, published by Greenfield, the patency rate was 98%, and there was no mortality secondary to the filter placement. The incidence of recurrent pulmonary embolism resulting from the proximal propagation of a thrombus has been reported to be 5%. The present work reports on a case of recurrent pulmonary embolism resulting from the proximal propagation of a thrombus originating in a Greenfield filter.

• Twenty-seven patients (40 extremities) with chronic venous insufficiency and 30 controls (60 extremities) were studied using noninvasive measurements of foot volume (foot mercury strain-gauge plethysmography [FMSGP]). Tests were performed with exercise (sitting) and with elevation (Trendelenburg), with and without tourniquets, to evaluate muscle pump efficiency and valvular competence. Empiric venous sufficiency indexes were calculated for exercise and for Trendelenburg's test. Test results were compared with invasive ambulatory venous pressure (AVP) data (13) and with ascending and retrograde venography (25). Distinctive plethysmographic patterns revealed the insufficiency was saphenous (four), calf perforators (14), saphenous plus perforators (seven), and deep venous (15), including occlusion (four). Correlation with AVP and venography was good but FMSGP was more discriminating, providing precise anatomical information, better reproducibility, and distinguishing poor muscle pump function from regurgitation. Patients accept FMSGP well. Repeated postoperative data are readily obtained for evaluation of surgical procedures.(Arch Surg 1984;119:1013-1017)

Chronic venous stasis is an extremely complex clinical syndrome of pain and changes in the skin that can involve the superficial, deep, and perforating veins. This syndrome is commonly referred to as "the postphlebitic syndrome," implying that thrombophlebitis is its sole etiology. To test this hypothesis, we performed ascending venography on 51 limbs of patients with the chronic venous stasis syndrome and demonstrated that 32 had no radiological evidence of recent or old thrombophlebitis. Instead, they had normal-appearing veins, suggesting primary incompetence of the deep and/or perforating venous valves rather than thrombophlebitis as the etiology. Since various operations have recently been proposed to correct or bypass malfunctioning valves, precise demonstration of pathological change is required to choose the appropriate procedure and to evaluate results. Descending venograms were combined with the ascending studies in 42 limbs for this purpose. In addition to outlining the abnormalities responsible for chronic venous stasis syndrome in individual cases, interesting conclusions regarding the syndrome itself were reached.(JAMA 1987;258:941-944)

Thirty-seven diabetic men selected to exclude the confounding effects of other medical illnesses and nondiabetic medications and 53 healthy controls underwent extensive psychosexual and medical evaluations and penile blood pressure assessments by ultrasonic Doppler measurement and mercury strain-gauge plethysmography. There was a significant negative correlation between age and the penile-brachial index (PBI) in the diabetic but not in the control group. The impotent diabetic group had significantly lower PBI than nondysfunctional diabetic and healthy control subjects. Diabetic type, complications, and adequacy of metabolic control were not statistically related to PBI. Although the PBI may not have diagnostic utility for individual patients, it may provide a valuable noninvasive physiologic measure of penile vascular changes in studies on the aged and the medically ill. The processes that mediate the interaction of diabetes and aging on penile blood pressure and erectile capacity deserve further investigation.

The Eichwald-Silmser phenomenon (rejection of male skin graft by isogenic females of certain strains) and the sexual dimorphism in the anti-A antibody production are demonstrated to be unrelated. These studies show no A-like antigenic activity on tissues of C57BL/10 males. While anti-B production is induced in both males and females with one injection, males require a large dose in primary immunization or secondary immunization to produce anti-A antibody and the titers are always lower than in the females. It is proposed that the difference between males and females in the spontaneous production of anti-A-like agglutinins is attributable to genetic control of this immunological response.

WHEN administered by the intraarterial route, many drugs induce lesions in the small arterioles, resulting in thrombosis and ischemic damage to tissues supplied by them.1-7 Intra-arterial injection of penicillin has been reported to induce damage by this same mechanism.8-11This communication refers to two cases of accidental intra-arterial injection of penicillin.Report of CasesCase 1.—A 10-month-old infant was brought to the emergency room of Mt Sinai Hospital, New York, with a two-day history of fever and pain in the right ear. On examination, a purulent right otitis media was found and a mixture of penicillin G benzathine and penicillin G procaine (Bicillin C-R), 1,200,000 units, was administered in the upper third of the external aspect of the left thigh. Immediately after injection, the child became very irritable; four hours later, the mother noticed marked swelling of the left inferior extremity. In the emergency room, the swelling

• This report describes a new double gastroenterostomy tube. It has been used in patients where delayed oral feedings are anticipated, ie, a perforated duodenal ulcer, suture-plicated, with stenosis of the duodenum; a duodenal ulcer with outlet obstruction treated with vagotomy and gastroenterostomy; and patients with chronic lung disease undergoing gastric surgery and requiring postoperative respiratory assistance. Its use has proved to be beneficial, and it is cheap and allows early enteric feeding.(Arch Surg 112:1260-1261, 1977)