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Purpose: The role of air plethysmography (APG) as a predictor of clinical outcome after surgery in venous disease is yet to be defined. The purpose of this study was to investigate the value of APG in predicting clinical outcome after venous surgery for chronic venous insufficiency (CVI)., Methods: Seventy-three extremities in 71 patients with Class 3 through 6 CVI were assessed preoperatively with CEAP (c linical, e tiologic, a natomic, p athophysiologic) criteria, standing reflux duplex ultrasound scan, and APG with measurements of preoperative venous filling index (VFI), venous volumes, ejection fraction, and residual volume fraction. After surgical treatment of the affected limbs, repeat APG studies were obtained within 6 weeks. Established venous reporting standards were used for follow-up to calculate clinical symptom scores (CSSs) in each patient., Results: Superficial venous reflux occurred alone in 24 limbs or in conjunction with perforator incompetence in 26 limbs. Deep and superficial reflux, with or without perforator incompetence, was found in 16 limbs, and seven limbs had isolated deep insufficiency. Follow-up was available in 60 of 71 patients (mean period, 44.3 months). Postoperative APG demonstrated significant hemodynamic changes after surgery as measured with VFI, venous volumes, ejection fraction, and residual volume fraction. Mean CSSs decreased from 7.35 +/- 0.56 preoperatively to 1.79 +/- 0.32 at late follow-up after surgery (P <.001). With the use of logistic regression, the parameter correlating most closely with clinical outcome was the VFI. A normal postoperative VFI ( more...

Purpose: Bypass grafts that originate from the descending thoracic aorta to the iliac or femoral arteries are well described but are not commonly used as primary procedures, and the long-term results remain unknown. A 15-year experience with 50 descending thoracic aorta to iliofemoral artery bypass grafts for aortoiliac occlusive disease is the basis of this report., Methods: From January 1983 to December 1997, patients who underwent bypass grafting procedures from the descending thoracic aorta to the iliac or femoral arteries were identified. Surgical indications, morbidity and mortality rates, primary and secondary patency rates, limb salvage rates, and survival rates were determined., Results: Fifty descending thoracic aorta to iliofemoral artery bypass grafting procedures were performed 24 (48%) for severe claudication, 22 (44%) for rest pain, and 4 (8%) for ischemic ulceration. A primary procedure was performed in 31 patients (62%) for complete occlusion (21 patients) and severe atherosclerotic disease (10 patients) of the infrarenal aorta. The indications for 19 secondary revascularizations (38%) were prior aortic or extra-anatomic graft failure in 17 cases and aortic graft infection in 2 cases. The follow-up periods ranged from 1 to 150 months (mean, 39 months). The cumulative life-table 5-year primary patency, secondary patency, limb salvage, and survival rates were 79%, 84%, 93%, and 67%, respectively. An improved patency trend was observed for patients who underwent operation for severe claudication as compared with limb-threatening ischemia (92% and 69%; P =.07). However, there was no difference between primary and secondary operations in primary patency rates (81% and 79%; P = NS) or survival rates (72% and 62%; P = NS)., Conclusion: Descending thoracic aorta to iliofemoral artery bypass grafting has excellent overall long-term results. These results support its more liberal use for primary revascularization, especially for patients with severe atherosclerotic disease or complete occlusion of the infrarenal aorta. more...

Purpose: The efficacy of color flow duplex imaging (CFDI) in detecting proximal upper extremity venous outflow obstruction in hemodialysis patients was compared with that of traditional contrast venography., Methods: From 1993 through 1997, all hemodialysis patients who were evaluated for upper extremity venous outflow obstruction of the axillary, subclavian, or brachiocephalic veins with both CFDI and venography were identified. Medical history, hemodialysis access procedures, and indications for imaging were reviewed. The diagnostic accuracy of CFDI was compared with that of venography for proximal venous outflow obstruction, including focal stricture, partial obstruction, or complete occlusion., Results: Sixty upper extremities in 42 hemodialysis patients were imaged with both CFDI and venography. Previous ipsilateral intravenous dialysis catheters had been present in 33 (55%) of the extremities imaged; current catheters were present in 16 (27%) of the extremities imaged; and 28 (67%) of the extremities imaged had a current ipsilateral arteriovenous (AV) shunt. Five (8%) of the 60 duplex scans were nondiagnostic because of artifact from intravenous dialysis catheters (3) or incomplete visualization of the subclavian or brachiocephalic veins (2) and were excluded from further analysis. In the remaining 55 duplex scans, proximal venous outflow obstruction was found in 18 (33%), compared with 21 (38%) identified by means of venography (P = not significant [NS]). Overall sensitivity, specificity, positive predictive value, and negative predictive value for CFDI were 81%, 97%, 94%, and 89%, respectively., Conclusion: CFDI is a reliable means of detecting proximal upper extremity venous outflow obstruction and should replace contrast venography as the initial imaging study in hemodialysis patients. more...

Purpose: The role of air plethysmography (APG) in the diagnosis of venous disease is not well defined. We conducted this study to investigate the value of APG in the diagnosis of chronic venous insufficiency and to determine its correlation with the clinical severity of disease and the anatomic distribution of reflux., Methods: We studied 186 lower extremities with duplex scanning and venography and measured the venous volume, venous filling index (VFI), ejection fraction, and residual volume fraction with APG. Limbs were categorized according to the Society for Vascular Surgery and International Society for Cardiovascular Surgery classification of clinical severity of disease and according to the anatomic distribution of valvular incompetence., Results: Sixty-one limbs had no evidence of disease (class 0), 60 limbs had mild disease (classes 1, 2, and 3), and 65 limbs had severe disease (classes 4, 5, and 6). According to the results of duplex scanning and venography, there was no evidence of reflux in 56 limbs. Isolated superficial venous reflux occurred in 52 limbs, and perforator reflux, alone or in conjunction with superficial reflux, occurred in 30. Deep reflux, with or without superficial reflux, was found in 25 limbs. Deep and perforator reflux, with or without superficial reflux, was found in 19 limbs. The VFI had a sensitivity of 80% and 99% positive predictive value for any type of reflux. The VFI was significantly different between groups of limbs with different clinical severities of disease or different types of reflux. The incidence of deep or perforator reflux in limbs with a normal VFI value was 7%, and it was 82% in limbs with a VFI of more than 5. Among 86 limbs with VFI values not corrected with use of a thigh tourniquet, 28% did not have evidence of deep or perforator reflux, and among 15 limbs with VFI values corrected with the use of a tourniquet, 33% had perforator reflux, deep reflux, or both. All APG parameters had low positive predictive values for severe disease or ulceration. The ejection fraction and residual volume fraction did not influence the clinical severity of disease, did not discriminate between types of reflux, and in combination with the VFI did not improve the predictive value of APG., Conclusions: The VFI measured by APG is an excellent predictor of venous reflux, provides an estimate of the clinical severity of disease, and at high levels predicts deep reflux, perforator reflux, or both. Correction of an abnormal VFI with a thigh tourniquet is an unreliable predictor of the absence of deep or perforator incompetence. The predictive value of APG for severe disease or ulceration is poor. The ejection fraction and residual volume fraction, individually or in combination with the VFI, add little to the diagnostic value of APG, and their routine performance may not be clinically justified. more...

Breastfeeding is being abandoned as the preferred feeding method in the early months of baby's life, and many early failures take place among the few mothers who attempt to breastfeed their babies. For that reason, sanitation professionals must encourage breastfeeding and convince mothers to keep it up, at least, for 4-6 months after giving birth. Analysis of pregnancy, delivery and after delivery sociocultural and sanitary conditions may help sanitation workers to elaborate an educational strategy that considers breastfeeding as healthy behavior that should he encouraged. The support of sanitation professionals is considered fundamental for breastfeeding maintenance, and a more profound training of these professionals about every aspect of breastfeeding is necessary. More active sanitary policies supporting this healthy behavior should also be established. more...

Purpose: Salvage of thrombosed prosthetic dialysis shunts can be performed using surgical or endovascular techniques. A prospective randomized trial was designed to compare the efficacy of these two methods in restoring dialysis access function., Methods: One hundred fifteen patients with thrombosed dialysis shunts were randomized prospectively to surgical (n = 56) or endovascular (n = 59) therapy. In the surgical group, salvage was attempted with thrombectomy alone in 22% and with thrombectomy plus graft revision in 78%. In the endovascular group, graft function was restored with mechanical (82%) or thrombolytic (18%) graft thrombectomy followed by percutaneous angioplasty., Results: Stenosis limited to the venous anastomotic area was the cause of shunt thrombosis in 55% of patients, and long-segment venous outflow stenosis or occlusion was the cause in 30%. In 83% of the surgical group and in 72% of the endovascular group, graft function was immediately restored (p = NS). The postoperative graft function rate was significantly better in the surgical group (p < 0.05). Thirty-six percent of grafts managed surgically remained functional at 6 months and 25% at 12 months. In the endovascular group, 11% were functional at 6 months and 9% by 12 months. Patients with long-segment venous outflow stenosis or occlusion had a significantly worse patency rate than those with venous anastomotic stenosis (p < 0.05)., Conclusions: Neither surgical nor endovascular management resulted in long-term function for the majority of shunts after thrombosis. However, surgical management resulted in significantly longer primary patency in this patient population, supporting its use as the primary method of management in most patients in whom shunt thrombosis develops. more...

Background: The widespread use of ultrasonography for the diagnosis of deep vein thrombosis (DVT) has led to the overuse of ultrasonography with low diagnostic yield. We conducted this study to investigate the predictive value of clinical features in the diagnosis of DVT and their potential value as clinical guidelines for the use of ultrasonographic testing in the diagnosis of DVT., Methods: The results of lower-extremity duplex ultrasonographic studies and clinical surveys prospectively obtained in 1526 patients suspected of having DVT were analyzed., Results: There were 916 inpatients and 610 outpatients. Acute DVT was found in 16% of the inpatient duplex scans, and in 12% of the outpatient studies (p < 0.05). The incidence of acute DVT was not different between men and women in inpatient or outpatient populations. Acute DVT was found in the left leg in 60% of the outpatient studies, significantly more often (p < 0.001) than in the inpatients (35%). Bilateral DVT was more common (p < 0.05) in the inpatient population (35%) compared with the outpatient population (20%). No difference in the anatomic distribution of thrombosis was found between inpatients and outpatients. The presence of leg symptoms was associated with a significantly higher rate (p < 0.05) of positive studies compared with those patients without leg symptoms in both the inpatient and the outpatient populations. Individual symptoms, risk factors, and physical findings had low positive predictive value and sensitivity for the presence of acute DVT on duplex scan. A calf circumference discrepancy of less than 2 cm predicted the absence of DVT in 93% of inpatients and 85% of outpatients. The combination of a calf circumference discrepancy of less than 2 cm with the absence of recent operation, trauma, malignancy, previous history of DVT, or hypercoagulable state predicted the absence of DVT in 92% of the inpatients and 97% of the outpatients., Conclusions: Clinical symptoms, risk factors, and physical findings are poor predictors of the presence of acute DVT on duplex scan. However, the absence of a combination of objective clinical factors has high predictive value for the absence of acute DVT on duplex scan. These criteria may be used to establish clinical guidelines to reduce the use of duplex scanning for the diagnosis of DVT. more...

Background: The purpose of this study was to review our experience with central vascular reconstruction for innominate artery occlusive disease. Eighteen patients underwent central reconstruction for innominate artery (IA) occlusive disease during an 8-year period (1986 to 1994). Mean age was 59 years (range, 36 to 77 years). Women outnumbered men 12 to 6. All patients had symptoms including amaurosis fugax 55%, transient ischemic attacks 44%, vertebrobasilar insufficiency 44%, and arm claudication 33%. The IA was occluded in three patients and stenotic in 15. Three patients underwent previous extrathoracic bypass procedures for IA lesions that failed., Methods: Operations performed through a median sternotomy included aortocarotid bypass with reimplantation of the subclavian (n = 10) and aortoinnominate bypass (n = 7). Transection and oversewing of the IA was performed in all but one patient, in whom ligation of the IA was performed. One patient with severe chronic obstructive pulmonary disease and previous coronary artery bypass grafting underwent retrograde-transluminal IA angioplasty with endovascular stent placement via a carotid approach. Four patients underwent concomitant carotid endarterectomy). Two patients underwent concomitant coronary artery bypass grafting at the time of IA reconstruction., Results: There was one operative death from myocardial infarction. Perioperative morbidity included dysrrhythmia (three), respiratory insufficiency (three), subendocardial myocardial infarction (two), cerebrovascular accident with complete recovery (two), hemorrhage (one), and acute graft occlusion (one). All grafts remained patient at a mean follow-up of 21 months (range, 8 to 60 months). The only patient who underwent ligation of the IA required a subsequent revision of the IA to transection and oversewing for an embolic event at 4 months status-post aortocarotid bypass. The patient who underwent angioplasty remained asymptomatic with a patient IA at 12 months. Average length of stay for transthoracic repair was 14 days and for transluminal angioplasty 2 days., Conclusions: Innominate artery bypass based on the ascending aorta is effective in providing relief of symptoms and has a high patency rate. Because of the significant morbidity, these procedures should be reserved for patients with symptoms. The IA should be transected and oversewn to prevent recurrent embolism. Transcarotid, retrograde angioplasty provides an alternative approach to stenotic lesions located in the IA or proximal common carotid artery. An aggressive approach directed at defining coronary artery disease is an invaluable adjunct to the proper treatment of this patient population. more...

Endovascular repair of peripheral arterial lesions was performed in 10 patients including two iliac aneurysms, two iliac anastomotic pseudoaneurysms, one subclavian pseudoaneurysm, one axillary anastomotic disruption, two prosthetic pseudoaneurysms, and two posttraumatic arteriovenous (AV) fistulas. The indications for repair were aneurysm size in five cases, massive hematoma in one, threatened prosthetic dialysis graft in two, venous hypertension with non-healing ulcer in one, and arm pain in one. Vascular access was obtained through surgical cutdown in all cases, via the femoral artery in five patients, the proximal brachial artery in three and a prosthetic graft in two. Stented prosthetic grafts were used in five cases (1 polyester and polytetrafluoroethylene 4 [PTFE]), and PTFE-covered stents in five cases. Concomitant procedures were done in four patients including two open repairs of a common femoral artery aneurysm, a transluminal dilatation of a proximal aortic anastomotic stenosis, and an iliac artery transluminal angioplasty. Eight of 10 cases were technically successful. Completion arteriography revealed complete exclusion of all lesions, except for one minimal proximal stented graft leak in a pseudoaneurysm, and an incomplete obliteration of an AV fistula. No complications occurred. Operative time ranged from 45 min to 5 hours. Postoperative hospital stay was 1 day in five patients, 2 days in three patients, and 4 days in two patients. Follow-up contrast CT scan, arteriography, or duplex scanning demonstrated complete exclusion of all lesions except an AV fistula, and decrease in size in three aneurysms. The proximal leak initially present in a stented graft resolved. All grafts and covered stents remained patent at 2-19 months of followup. Endovascular exclusion of peripheral arterial aneurysms, pseudoaneurysms, and AV fistulas can be done with a high degree of technical success, low morbidity, and short hospital stay. Short-term follow up is encouraging, however, long term follow up of these procedures is warranted to assess durability of the repair and absence of complications. more...

Current surgical options for the treatment of unilateral iliac artery occlusive disease are quite varied and include aortic-based procedures, femorofemoral bypass ileofemoral bypass, and transluminal angioplasty and stenting. Patients with unilateral iliac disease present with a variety of anatomic, physiological and clinical situations. As a result, the surgical options are complementary rather than competitive, and their use needs to be tailored on an individual basis. Femorofemoral bypass, despite its relatively lower patency rate compared with aortic-based inflow procedures, is a useful operation for the treatment of unilateral limb ischemia. It is best suited for patients with limited life-expectancy and/or for those with contraindications for transabdominal or more extensive surgery, or as a remedial procedure for unilateral limb failure of aortofemoral grafts. The purpose of this article is to analyze the results of femorofemoral bypass, and to discuss the factors that may influence its outcome in the treatment of unilateral iliac artery occlusive disease. more...

This study was conducted to assess the mechanical characteristics of dilated polytetraflouroethylene (PTFE) for use in transluminally placed endovascular grafts (TPEGs). Ten-centimeter lengths of 3- and 4-mm thinwalled PTFE were dilated to 8, 10, 12, and 15 mm diameters (3 mm) and 10-, 14-, 16-, and 20-mm diameters (4 mm), respectively (n = 6 for each size). The dilated PTFE segments were evaluated for leakage, further dilation, structural changes (with electron microscopy), and changes in wall thickness occurring after 24 hours of perfusion at pressures of 300-350 mmHg. Both 3- and 4-mm thinwalled PTFE could be dilated to five times their initial diameter before rupture occurred. Three-millimeter grafts dilated to 12- and 4-mm grafts dilated to 14 mm remained resistant to leakage at perfusion pressures up to 350 mmHg. When 3-mm grafts were dilated to 15 mm, the PTFE leaked saline at a rate of 20.3 +/- 9.3 cc per hour at 300 mmHg. pressure. Four-millimeter grafts dilated to 16- and 20-mm diameters leaked saline at 8.4 +/- 7.8 and 52.8 +/- 22 cc per minute, respectively, at the same pressure. No grafts were found to increase in diameter after 24 hours of pressure perfusion. Electron microscopy revealed that PTFE node size was significantly smaller in dilated grafts than in undilated grafts, but there was no significant change in internodal distance. This data suggests that thinwalled PTFE can be dilated to large diameters and retain sufficient strength to resist supraphysiologic pressures. Long-term studies are needed to determine the late structural integrity of dilated PTFE. more...

Purpose: To evaluate the management and outcome of chronic atherosclerotic infrarenal aortic occlusion (IRAO), a review of 48 patients who were treated for angiographically documented IRAO between January 1980 and December 1994 was undertaken. Mean follow-up was 45 months. Mean age was 57 years (range, 33 to 88 years). Forty-seven patients were heavy smokers. Symptoms included claudication in 81%, rest pain in 25%, and tissue loss in 15%. Impotence was documented in 73% of men. Associated arterial disease included inferior mesenteric artery occlusion in 31 patients, renal artery stenosis or occlusion in 12, superior mesenteric artery stenosis in two, and celiac artery stenosis in one., Methods: Forty inflow procedures were performed, including 17 thoracobifemoral bypass (TBF) procedures, 15 aortobifemoral/iliac bypass (ABFI) procedures, and eight axillobifemoral bypass (AXBF) procedures. Eight patients were managed without surgery. The thoracic aorta was chosen as the inflow source in 17 patients because of previous abdominal aortic surgery in eight, poor status of the abdominal aorta in eight, and horseshoe kidney in one., Results: The overall operative mortality rate was 5%, and the perioperative morbidity rate was 18%. There was no statistical difference in perioperative mortality and morbidity rates among the operative groups. The five-year survival rate (life-table) for all IRAO patients was 67%. TBF and ABFI revascularization procedures yielded 5-year patency rates of 71% and 79%, respectively (p < 0.05). All eight patients who underwent AXBF died or had occluded grafts at 3 years after surgery. Two-year patency rates (life-table) for TBF, ABFI, and AXBF were 92%, 92%, and 44%, respectively. The AXBF patency rate was significantly inferior to those of TBF and ABFI (p < 0.05). Changes in ankle-brachial indexes after TBF or ABFI were similar, but were significantly greater than changes after AXBF (p < 0.05). Three patients in the nonoperative group died, and two underwent major amputation. Acute renal failure did not occur in our study population. Follow-up creatinine levels > 2.0 mg/dl were documented in three operative patients and in one nonoperative patient, and none required dialysis., Conclusions: In patients who have IRAO, aorta-based inflow procedures are superior to AXBF both in hemodynamic outcome and in patency rates. Treatment of IRAO with TBF or ABFI yields similar long-term results; the descending thoracic aorta represents an excellent inflow alternative to the abdominal aorta. Clinically significant renal impairment is rarely associated with IRAO. Nonoperative management of IRAO is associated with an increased mortality rate and a high rate of limb loss. more...

A canine model was designed to evaluate the changes in abdominal aortic aneurysm (AAA) pressure and wall stress after endovascular repair. Eight canines underwent laparotomy and creation of an AAA. The aneurysm was then excluded with a transluminally placed endovascular graft (TPEG) inserted through the right femoral artery and deployed across the AAA to exclude the infrarenal aortic branches from aortic perfusion. Blood pressure and flow data were recorded for 6 hours. The AAA blood pressure decreased from 135 +/- 9.3 mm Hg before exclusion to 45 +/- 17.6 mm Hg at 10 minutes after exclusion (p < 0.001). At 6 hours, AAA blood pressure had declined further to 26 +/- 12.5 mm Hg. Blood flow in the excluded iliac artery decreased from a baseline of 242 +/- 58 ml/min to 41 +/- 29 ml/min 10 minutes after TPEG placement (p < 0.001). At 6 hours, flow was reduced to 12 +/- 3.5 ml/min (p < 0.05 compared with that at 10 minutes). Aortic wall stress was significantly reduced by TPEG placement but was only slightly lower than baseline aortic wall stress before AAA creation. The lumbar arteries were patent with retrograde flow in all cases and were found to be the major contributors to postexclusion aneurysm pressure. Endovascular AAA exclusion results in an immediate decrease in blood pressure and wall stress within the excluded aneurysm, but the aneurysm remains perfused by retrograde flow through the lumbar arteries, which resulted in near-baseline levels of aneurysm wall stress in this canine model. Embolization of patient lumbar vessels at prosthesis placement may further reduce the risk of late rupture. more...

Purpose: The purpose of this study was to develop an aortic aneurysm (AA) model with a predictable tendency for rupture for the evaluation of the efficacy of endovascular prostheses in preventing rupture and their long-term outcome after implantation., Methods: An infrarenal AA measuring two to three times the diameter of the proximal aorta was created in 18 dogs with a full-thickness patch of jejunum. Seven dogs were allowed to survive without aneurysm exclusion. In 11 dogs the aneurysm was immediately excluded with a stented 8 mm Dacron graft mounted in a 14F delivery system introduced through the femoral artery with aortographic guidance. The pressure differential between the aorta and the excluded aneurysm was measured, and angiography, necropsy, and histologic examination were performed at 3- and 6-month survival., Results: All animals survived aneurysm implantation. Without aneurysm exclusion, six dogs died of rupture within 1 to 6 days of surgery. In three dogs the exclusion failed because of graft-to-aorta size mismatch or misplacement demonstrated on angiography and by a low pressure differential between the aorta and the aneurysm (< 5 mm Hg); all three dogs died of rupture within 4 days. In eight dogs the aneurysm was successfully excluded on the basis of angiography results, with a mean aorta-to-aneurysm pressure differential of 51 mm Hg. Two dogs were killed at 1 and 6 days after surgery because of paraplegia produced by graft thrombosis because of kinking but without evidence of aneurysm rupture. Six dogs survived on a long-term basis, and angiography and necropsy performed at 3 and 6 months revealed patent grafts without migration, reduction in aneurysm size, no flow in the excluded lumbar arteries in five of six animals, and complete incorporation of Dacron graft and stents. No evidence of graft infection was found in any animal. The survival rate was significantly better (p < 0.023) in dogs with successfully excluded aneurysms (n = 6) compared with that in dogs without exclusion or with failed aneurysm exclusion (n = 7)., Conclusion: This aneurysm model demonstrates that without effective aneurysm exclusion all animals die of rupture and that successfully placed endovascular prostheses can prevent AA rupture with long-term graft patency and stability. Endovascular aortic Dacron grafts in dogs undergo complete incorporation at 3 months from implantation. This aneurysm model is useful for the evaluation of endovascular devices designed for the treatment of AAs. more...

Purpose: The purpose of this study was to review the various extrathoracic reconstruction options in patients with occlusive disease of the supraaortic trunks and to define the efficacy of these procedures in maintaining graft patency and relieving symptoms., Methods: Forty-four consecutive patients underwent 47 extrathoracic bypass procedures of the supraaortic trunks for correction of symptomatic subclavian (SCA), common carotid (CCA) or innominate (INA) artery occlusive disease between July 1975 and May 1994. SCA stenosis (n = 27) was associated with upper extremity claudication (55%), vertebrobasilar insufficiency (15%), or both (30%). CCA stenosis (n = 14) was accompanied by hemispheric symptoms in 86% and global ischemia in 14%, whereas INA stenosis (n = 3) was associated with transient ischemic attacks (67%) and right arm ischemia (33%)., Results: SCA revascularization included carotid-subclavian or carotid-axillary bypass (n = 19), axilloaxillary bypass (n = 8), and subclavian-carotid transposition (n = 3). CCA reconstructions included subclavian-carotid (SC) bypass (n = 13) and carotid-carotid bypass (n = 1). INA procedures included three axilloaxillary bypasses. Six patients had an associated carotid endarterectomy, and three underwent concomitant vertebral artery transpositions. Intraluminal shunts were not routinely used. Vein was used as a conduit in five procedures, and a prosthetic graft (23 Dacron, 16 polytetrafluoroethlyene) was used in the remainder. The average postoperative intensive care unit and hospital and hospital stay were 1 and 5 days, respectively. Follow-up was available in 43 of 44 patients (mean = 26.2 months). The perioperative mortality rate was 2.2% (one axilloaxillary). There were five graft occlusions in procedures involving the axillary artery (3 of 11 axilloaxillary, 2 of 7 carotid-axillary) as compared with one of 29 thromboses when the operation was confined to the supraclavicular fossa (p < 0.05) Relief of symptoms was achieved in all patients with patent grafts. There were no perioperative strokes in the series. Other complications included one brachial plexus neuropraxia (axilloaxillary) and four patients with phrenic nerve neuropraxia., Conclusion: Extrathoracic revascularization of the supraaortic trunks is well tolerated and durable when operations are confined to the supraclavicular fossa and do not involve the axillary artery. more...

Purpose: Endovascular exclusion of arterial injuries associated with arteriovenous fistulas and pseudoaneurysms has only recently been described using various stent-graft prostheses. This report details a transbrachial technique used to exclude an axillary artery pseudoaneurysm developing at the axillary anastomosis of an axillofemoral graft., Methods and Results: Thin-walled polytetrafluoroethylene was expanded with an angioplasty balloon catheter and used to cover standard Palmaz stents. Two covered stents were delivered under fluoroscopic guidance via open brachial artery access to the site, resulting in complete exclusion of the pseudoaneurysm. Follow-up duplex scanning confirmed aneurysm exclusion 3 months postprocedure., Conclusions: This technique can be applied in arteries of different sizes and lengths, using currently available materials. However, the long-term behavior of these devices in the arterial tree must be determined before their widespread use can be recommended for most indications. more...

We conducted this study to investigate the physiologic variations in venous valvular function and calf muscle pump function that occur in normal limbs after prolonged stationary standing. Twenty-two limbs from 11 healthy volunteers were studied after a brief period of activity and after 4 to 6 hours of stationary standing. Vein diameter, peak reflux flow velocity (PRFV), and valve closure time (VCT) were measured with duplex scanning in the standing position in the common femoral vein (CFV), superficial femoral vein (SFV), popliteal vein (POP), proximal greater saphenous vein (GSV), and greater saphenous vein at the knee (kGSV). Pneumatic rapid inflation-deflation cuffs were used to elicit reflux. Vein cross-sectional area (VA) and peak reflux volume (PRVol) were calculated. Venous volume (VV), venous filling index (VFI), ejection fraction (EF), residual volume fraction (RVF), and outflow fraction (OF) were measured with air plethysmography in all limbs. After stationary standing, there was no significant change or trend toward an increase in diameter or VA in any of the deep veins and there was no change in the PRFV or VCT. In the proximal GSV there was a significant increase in diameter (p = 0.0001) and VCT (p = 0.048) without a change in PRFV. No significant changes were noted in the kGSV. In the GSV the PRFV was significantly lower (p < 0.05) and the VCT significantly shorter (p < 0.05) compared with the SFV and POP but values were no different from those in the CFV. The PRFV was significantly higher in the SFV (p < 0.0001) and the POP (p < 0.002) compared with that in the CFV.(ABSTRACT TRUNCATED AT 250 WORDS) more...

To evaluate the impact of central venous obstruction on upper extremity hemodialysis access failure, we retrospectively analyzed our recent experience in managing this problem. We reviewed 158 upper extremity hemodialysis access procedures performed in 122 patients during a 1-year period. Fourteen (11.5%) patients had central vein obstruction as the cause of severe arm swelling, graft thrombosis, or graft malfunction. All 14 patients had had bilateral temporary subclavian vein dialysis catheters and failed upper extremity arteriovenous access. Seventeen lesions were treated in 14 patients including eight subclavian vein occlusions, six subclavian vein stenoses, two internal jugular vein stenoses, and one superior vena cava stenosis. Twenty-one procedures were performed including 17 percutaneous transluminal balloon angioplasties (PTAs) with stent placement in 13, two axillary to innominate vein bypasses, and two axillary to internal jugular vein bypasses. All patients had resolution of symptoms. Thirteen (76%) PTAs were initially successful but in four (24%) cases it was impossible to recanalize the vein. Eight (47%) PTAs provided functional hemodialysis access for 2 to 9 months, two (12%) restenosed at 3 and 10 months and were successfully redilated, two occluded at 2 and 4 months and were unable to be recanalized, and one failed immediately after a successful PTA. Four PTA failures were followed by venous bypass, which remained patent and provided functional access 7 to 13 months after surgery. Of nine stenotic venous lesions six (67%) were successfully dilated without restenosis, whereas of eight occluded veins only two (25%) were successfully treated without recurrence. Temporary central hemodialysis catheters produce a significant number of symptomatic central vein obstructions in patients with upper extremity arteriovenous access.(ABSTRACT TRUNCATED AT 250 WORDS) more...

Purpose: The purpose of this study was to review the treatment of patients with failed or infected axillofemoral bypass grafts and to determine the efficacy of remedial procedures in maintaining graft patency and limb preservation., Methods: Thirty-four patients with 37 failed or infected axillofemoral grafts were retrospectively reviewed. In nine cases there was no attempt at revascularization, and in the remaining 28 cases, a total of 52 remedial procedures was performed. Nine were performed in patients with graft infection and 43 in patients with graft thrombosis. In patients with axillofemoral graft failure, 21 thrombectomies, 13 graft revisions, and 9 secondary reconstructions were performed. Eighty-eight percent of patients were monitored at least 2 years or until graft failure., Results: Eight of nine patients receiving no remedial procedure required major amputation. The limb salvage rate was 64% +/- 11% at 30 months in the 25 patients undergoing remedial procedures. Twenty-eight percent of failed axillofemoral grafts remained patent at 2 years after initial failure with single or multiple thrombectomies or revisions. Life-table primary patency after secondary reconstructions (81% +/- 10.9% at 24 months) was significantly better than after thrombectomy alone (10% +/- 4.2% at 24 months) or graft revision (16% +/- 10.6% at 24 months) by log-rank test (p < 0.001 and p < 0.005, respectively). Patients undergoing reconstruction with descending thoracic aorta to femoral artery bypass had an 89% +/- 11% patency rate at 24 months. Graft infection resulted in a perioperative mortality rate of 22% and amputation in 57% of survivors., Conclusion: Axillofemoral graft failure most often results in limb loss without remedial procedures. Thrombectomy and revision procedures had poor long-term patency rates and salvaged only a minority of grafts despite multiple procedures. Reconstruction by use of an alternate source of inflow such as the descending thoracic aorta resulted in better long-term patency rates in patients well enough to tolerate a major reoperative procedure. more...

Bypass grafting from the descending thoracic aorta to the iliac or femoral artery is an underutilized procedure; fewer than 200 cases were reported in the past 30 years. Over the last decade we performed 32 bypasses to the femoral iliac or popliteal arteries using the descending thoracic aorta as the inflow source. In 19 (59%) patients the procedure was a primary aortic reconstruction, whereas in 13 (41%) it was secondary. The 30-day in-hospital mortality rate was 6.2%. Primary graft patency was 86% (+/- 7.8) at 2 years. To obtain a meaningful long-term patency analysis, we combined our experience with that reported in the literature during the same period. Follow-up data were available in 146 patients in whom the mean follow-up time ranged from 15 to 53 months. The operation was a secondary aortic reconstruction in 84 (58%) patients and was a primary procedure in 62 (42%). Reasons for the selection of the descending thoracic aorta as the inflow source included previous abdominal aortic graft failure in 56 (38%) patients, abdominal aortic graft infection in 26 (18%), unfavorable abdominal conditions in 30 (21%), and miscellaneous causes in 34 (23%). The 30-day in-hospital mortality rate for the collective experience was 5.5%. Life-table analysis of the collective primary graft patency rate was 88.3% (+/- 2.9) at 1 year, 81% (+/- 4.3) at 3 years, and 72.7% (+/- 8.5) at 6 years. Secondary graft patency for the collective experience was 93.1% (+/- 2.3) at 1 year, 88.2% (+/- 3.7) at 3 years, 82.7% (+/- 7.3) at 6 years, and 82.7% (+/- 10) at 8 years. Patient survival was 67.5% (+/- 6.9) at 5 years and 55.4% (+/- 9.9) at 7 years. These data suggest that bypass from the descending thoracic aorta to the iliac or femoral arteries offers low mortality and excellent durability and should be considered as the procedure of choice for secondary or extra-anatomic aortoiliac reconstruction. more...

Purpose: To evaluate the results of femorofemoral bypass graft (FFBPG), we analyzed 110 consecutive FFBPGs performed at our institution during an 11-year period., Methods: In 62 (56%) patients the indication for surgery was claudication and in 48 (44%) patients rest pain or tissue loss. In 42 patients the superficial femoral artery (SFA) was occluded. A preoperative percutaneous transluminal balloon angioplasty (PTA) was performed in 24 (22%) patients to correct a significant donor iliac artery stenosis. In 48 (44%) patients a total of 54 arterial procedures were performed simultaneously with FFBPG., Results: After surgery 75 (68%) patients were moderately or markedly improved, whereas 20 (18%) were minimally improved, unchanged, or worse, including 7 (6%) with hemodynamic failures. The in-hospital mortality rate was 4.5%. Actuarial patient survival rate was 70% +/- 8.6% at 6 years. The actuarial primary graft patency rate was 83% +/- 4.2% at 1 year, 71% +/- 6.9% at 3 years, 60% +/- 8.3% at 5 years, and 51% +/- 9.6% at 6 years. Age, sex, and race of the patient did not influence graft patency. Grafts placed for limb-threatening ischemia or in patients with SFA occlusion had a similar patency rate compared with those placed for claudication or in patients with patient SFA. The overall limb preservation rate was 83% +/- 7.3% at 5 years but was only 64% for patients who underwent operation for limb-threatening ischemia., Conclusions: In conclusion, FFBPG offers moderately low long-term patency in a population with limited survival. Outflow procedures performed concomitantly with FFBPG seemed to compensate for the negative impact on graft patency rate of ipsilateral SFA occlusion and limb-threatening ischemia. Limb-threatening ischemia, however, carried a significantly higher (p < 0.05) amputation rate. The influence of preoperative donor iliac artery percutaneous transluminal balloon angioplasty on FFBPG patency remains unclear. more...

Progression of distal disease is considered the most common cause of femorofemoral artery crossover bypass graft (FFBPG) failure. Twenty-seven patients with patient grafts (mean 53 months) were evaluated with segmental Doppler and duplex scan arterial studies for evidence of disease progression. In the early postoperative period (compared with preoperative levels), 26 patients (95.3%) showed a significant improvement (> 0.1) in the recipient limb ankle-brachial index (ABI) (mean increase of 0.38; SD = 0.24) and/or ankle spectral arterial waveform. However, there was a statistically significant decrease (p = 0.0001) in the donor limb ABI, and 12 patients (44.4%) had a > 0.1 deterioration. On long-term follow-up (compared with preoperative levels) this difference was no longer significant (p = 0.49); only seven donor limbs remained with a > 0.1 decrease in ABI. The recipient limbs maintained a significant improvement (> 0.1) in the ABI compared to preoperative levels (p < 0.0001; mean of 0.39; SD = 0.16) except for three limbs that had decreased by 0.1. However, eight patients (29.6%) developed an increase in their donor common femoral artery acceleration time > 133 msec and/or increased blood flow velocity without a simultaneous significant decrease in their recipient limb ABI. In the latter group the preoperative donor limb common femoral artery acceleration time and ABI and the immediate postoperative change in donor limb ABI were not significantly different (p > 0.05) than in the remaining patients.(ABSTRACT TRUNCATED AT 250 WORDS) more...

Lower hindgut duplications, although very rare, usually present as a cystic mass located posterior to the rectum and confined to the pelvis. Hindgut duplications are often associated with genitourinary or spinal anomalies. We describe a neonate with a previously unreported heterotopic colonic duplication presenting as an exophytic perineal mass associated with classic bladder exstrophy. The embryonic significance of these anomalies is discussed. more...

Percutaneous catheter drainage (PCD) has become an established and often preferred alternative to surgical treatment in the management of pancreatic pseudocysts. However, the long term results of percutaneous drainage of pancreatic pseudocysts remain uncertain. In an effort to determine the long term outcome of this therapy, 42 patients undergoing PCD of a pancreatic pseudocyst were analyzed retrospectively. Forty-two pancreatic pseudocysts were drained percutaneously in 42 patients. Sixty-seven percutaneous drainage procedures were performed--22 patients underwent one, 15 had two and five patients required three procedures. Percutaneous drainage was considered not to be effective when the pseudocyst persisted or when it recurred after initial resolution. Twenty-three pseudocysts were infected at the time of drainage and 19 were not infected. In 30 patients, the cause of the pseudocyst was alcoholic pancreatitis. There were no deaths related to the procedures and seven complications occurred, including hemorrhage, pancreatic fistula and empyema. Mean follow-up evaluation time of the patients was ten months. In nine patients, the pseudocyst was successfully drained and resolved. There were 33 treatment failures, among which 26 pseudocysts failed to resolve and seven recurred after initial resolution. Eventually, 25 patients underwent a surgical procedure, 20 for persistent pseudocyst and five for recurrence. Using contingency table analysis, the size of the pseudocyst, amount of fluid drained, amylase concentration in the aspirate, presence of infection, number of drainage procedures performed and duration of catheter drainage had no influence on the likelihood of success in long term pseudocyst resolution after PCD. Pseudocysts not related to alcoholic pancreatitis seemed to be less likely (p < 0.05) to resolve with percutaneous drainage than those caused by alcohol. PCD is a safe and valuable procedure in the acute management of patients with pancreatic pseudocyst. However, the current data suggest that despite early success with percutaneous drainage, the lack of resolution and recurrence rate of pancreatic pseudocyst is high. Therefore, it should not be considered as the definitive form of therapy in most patients. Close surveillance of patients undergoing percutaneous drainage and communication between surgeons and radiologists are critical in the management of pancreatic pseudocysts. more...

Infection of the foot is a limb threatening condition for patients with diabetes mellitus. Identification of patients with diabetes and severe infection of the foot most likely to benefit from early revascularization or major amputation would improve the results of a treatment policy to prevent limb loss and avoid futile delays in amputation. During a nine year period, 79 diabetic patients underwent emergency procedures for severe infection of the foot during the initial hospitalization period. None of the patients underwent arterial reconstruction. Eventually, 21 of the patients required a major amputation, eight during the initial hospitalization and 13 on a subsequent admission. Stepwise discriminant analysis of clinical independent variables revealed that the patients most likely to require a major amputation during the initial hospitalization were those with an absent dorsalis pedis pulse and a polymicrobial infection (p = 0.018). The overall amputation rate (immediate or subsequent amputation) was higher for patients of either sex with nonpalpable pedal pulses when compared with those with at least one palpable pulse (p less than 0.05). Males who were not dependent on insulin had the highest risk of overall limb loss (p = 0.01). Patients undergoing delayed amputation required a significantly higher number (p = 0.01) of readmissions to the hospital for recurrent infection of the foot than those who did not undergo amputation. Data in the current study suggest that early major amputation in a subset of patients would prevent delay in the rehabilitation process of the amputee, decrease long term morbidity and reduce health care cost. An aggressive policy of early revascularization in patients with a pulse deficit may reduce the amputation rate in those with diabetes with severe infection of the foot. more...

The natural history of intermittent claudication is generally benign. Clear indications for revascularization in patients with intermittent claudication are rest pain and necrotic tissue. Disabling claudication in patients who are at low operative risk is another acceptable indication for surgical treatment. Young patients with intermittent claudication from aortoiliac occlusion constitute a subset of patients in whom a more aggressive approach is justified. Nevertheless, in most patients, the management of intermittent claudication should be conservative. more...

A unique case of an infarcted carcinoid of the appendix is presented in which the computed tomography (CT) and clinical findings mimicked an appendiceal abscess. Though unusual, this possibility and appearance should be familiar to the radiologist particularly if percutaneous drainage is considered. more...

1. Although varicose veins are the most prevalent form of venous insufficiency, obstruction or valvular incompetence of the deep system produces the most severe forms of lower extremity venous insufficiency and is responsible for most cases of leg ulceration of venous etiology. 2. With careful patient selection, surgery for varicose veins can be successful. Deep venous surgery, however, has limited indications and still carries a high failure rate; it should only be indicated in selected patients after conservative therapy has failed. 3. The main causes for failure of deep venous surgery are the low pressure and low velocity flow characteristics of the venous system that favor thrombosis. more...

The absence of neurologic deficit does not preclude the diagnosis of stab wound injury of the spinal cord. Adequate radiologic examination is fundamental in detecting retained foreign bodies. Surgical extraction of foreign bodies is indicated to avoid infection and myelopathy. more...

The feasibility of measuring pulmonary blood flow (PAQ) continuously using a removable, extraluminal 20 MHz pulsed Doppler probe, which has been used successfully to measure aortic blood flow, was assessed in seven anesthetized mongrel dogs. Simultaneous recordings were made from the Doppler probe (range-gated 5-6 mm from the anterior wall of the main pulmonary artery) and an electromagnetic flow probe (encircling the aorta) over cardiac outputs (CO) ranging from 0.2 to 5.5 L/min. Assuming a flat velocity profile and a fixed cross-sectional area, PAQ was initially calculated as the product of area and mean velocity. Regression analyses (PAQ = a + b X CO) indicated good intraanimal linear correlations in six animals (r greater than or equal to 0.84) and no correlation in one animal (r = 0.003); however, PAQ was consistently higher than CO and interanimal variability was marked, as suggested by large deviations in mean intercept and slope values (a = 1.67 +/- 1.09 L/min and b = 0.70 +/- 0.33). Results improved (r greater than or equal to 0.79 in all animals, a = 0.47 +/- 0.52 L/min, and b = 0.77 +/- 0.21) when the method to estimate PAQ was altered to assume that the starting cross-sectional area was the area that would make baseline PAQ and CO agree, and that the area during each subsequent CO level changed as a function of pulmonary artery pressure and an estimate of pulmonary artery compliance. Results of this study imply that it will be more difficult to use this Doppler probe to monitor CO from the pulmonary artery than it was from the aorta due to the elliptical, more compliant pulmonary vessel walls and the irregular pulmonary artery velocity profile. more...

Pulmonary artery blood flow velocity was measured in 15 dogs by a recently developed direct intraluminal pulsed Doppler technique. Changes in velocity characteristics under conditions of experimentally induced hypoxic pulmonary hypertension were observed. Experimental conditions (fractional inspired oxygen concentration = 0.10) produced significant increases in mean pulmonary artery pressure and pulmonary vascular resistance. Overall and maximal negative velocity increased with pulmonary hypertension. Negative velocity occurred predominantly in the posterior half of the pulmonary artery during both control and experimental conditions. With pulmonary hypertension, diastolic negative velocity increased only in the posterior half of the pulmonary artery and systolic negative velocity decreased only in the anterior half. More basic knowledge of pulmonary artery blood flow characteristics may facilitate an informed approach to noninvasive detection of pulmonary hypertension. Direct measurements by this recently developed intraluminal technique will be useful in studying various conditions with altered pulmonary blood flow. more...

A fistula between the trachea and the innominate artery, a potentially fatal complication of tracheostomy, can be managed successfully. We have derived several guidelines from our experience with one such case and from a review of the 36 cases reported in the literature over the last decade. Diagnosis must be established before exsanguination occurs. Bronchoscopy and angiography are often nondiagnostic. Control of hemorrhage and a patent airway are the initial goals of treatment. Interruption of the innominate artery is the definitive treatment, with a low rebleeding rate (7%, 1/14 cases) and good long-term survival (64%, 9/14 cases). Maintenance of continuity of the innominate artery is contraindicated, because of a high rebleeding rate (60%, 6/10 cases) and poor long-term survival (10%, 1/10 cases). There is no convincing evidence that interruption of the innominate artery causes significant neurologic or vascular compromise. more...