The use of Singapore flaps for vaginal reconstruction in women with vaginal stenosis with obstetric fistula: a surgical technique.

Gynecologic and plastic surgeons collaborate to improve vaginal reconstruction for women with vaginal stenosis and obstetric fistula. As these cases occur typically in low-resource settings, the Singapore flap is a useful technique given its reliability, safety, ease of dissection, and minimal need for additional supplies. The fasciocutaneous flap maintains cutaneous innervation and vasculature and does not require stenting. The surgical collaboration has made it possible to provide functional vaginal reconstruction as a part of the overall care of obstetric fistula patients. The technique shows promise for improving sexual function for women with obstetric fistula and may also enhance healing. TWEETABLE ABSTRACT: Gynecologic & plastic surgeons collaborate to improve vaginal reconstruction for women with obstetric fistula.

Comparing online and telephone survey results in the context of a skin cancer prevention campaign evaluation.

Background: A large proportion of health promotion campaign evaluation research has historically been conducted via telephone surveys. However, there are concerns about the continued viability of this form of surveying in providing relevant and representative data. Online surveys are an increasingly popular alternative, and as such there is a need to assess the comparability between data collected using the two different methods to determine the implications for longitudinal comparisons. The present study compared these survey modes in the context of health promotion evaluation research. Methods: Data were collected via computer-assisted telephone interviewing and an online panel. In total, 688 and 606 respondents aged between 14 and 45 years completed the online and telephone surveys, respectively. Results: Online respondents demonstrated higher awareness of the advertisement, rated the advertisement as more personally relevant and had better behavioural outcomes compared with the telephone respondents. Conclusion: The results indicate significant differences between the telephone and online surveys on most measures used to assess the effectiveness of a health promotion advertising campaign. Health promotion practitioners could consider the combination of both methods to overcome the deterioration in telephone survey response rates and the likely differences in respondent outcomes.

Third trimester antiviral prophylaxis for preventing maternal genital herpes simplex virus (HSV) recurrences and neonatal infection.

BACKGROUND: Genital herpes simplex virus (HSV) infection is one of the most common viral sexually transmitted infections. The majority of women with genital herpes will have a recurrence during pregnancy. Transmission of the virus from mother to fetus typically occurs by direct contact with virus in the genital tract during birth. OBJECTIVES: To assess the effectiveness of antenatal antiviral prophylaxis for recurrent genital herpes on neonatal herpes and maternal recurrences at delivery. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2007), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 4), MEDLINE (January 1966 to February 2007) and EMBASE (January 1974 to February 2007; handsearched conference proceedings; reviewed bibliographies of all relevant articles for further references; and contacted experts in the field. SELECTION CRITERIA: Randomized controlled trials which assessed the effectiveness of antivirals compared to placebo or no therapy, on neonatal herpes and maternal disease endpoints among pregnant women with genital herpes. DATA COLLECTION AND ANALYSIS: Two authors independently applied study selection criteria and extracted data. MAIN RESULTS: Seven randomized controlled trials (1249 participants) which met our inclusion criteria compared acyclovir to placebo or no treatment (five trials) and valacyclovir to placebo (two trials). The effect of antepartum antiviral prophylaxis on neonatal herpes could not be estimated. There were no cases of symptomatic neonatal herpes in the included studies in either the treatment or placebo groups. Women who received antiviral prophylaxis were significantly less likely to have a recurrence of genital herpes at delivery (relative risk (RR) 0.28, 95% confidence interval (CI) 0.18 to 0.43, I(2 )= 0%). Women who received antiviral prophylaxis were also significantly less likely to have a cesarean delivery for genital herpes (RR 0.30, 95% CI 0.20 to 0.45, I(2) = 27.3%). Women who received antiviral prophylaxis were significantly less likely to have HSV detected at delivery (RR 0.14, 95% CI 0.05 to 0.39, I(2) = 0%). AUTHORS' CONCLUSIONS: Women with recurrent genital herpes simplex virus should be informed that the risk of neonatal herpes is low. There is insufficient evidence to determine if antiviral prophylaxis reduces the incidence of neonatal herpes. Antenatal antiviral prophylaxis reduces viral shedding and recurrences at delivery and reduces the need for cesarean delivery for genital herpes. Limited information exists regarding the neonatal safety of prophylaxis. The risks, benefits, and alternatives to antenatal prophylaxis should be discussed with women who have a history and prophylaxis initiated for women who desire intervention.

Endothelium-dependent responses in autogenous femoral veins grafted into the arterial circulation of the dog.

Endothelium-dependent responses differ in arteries and veins of the dog. Experiments were performed to determine whether chronic grafting of veins into the arterial circulation would alter the endothelium-dependent responses of the veins. Segments of femoral veins were grafted to the femoral artery of the dog. 6 wk after surgery the venous grafts were removed from the dog, cut into rings, and suspended in organ chambers for isometric tension recording. In some rings the endothelial cells were removed. Acetylcholine and alpha 2-adrenergic agonists did not cause endothelium-dependent relaxations in venous grafts. The calcium ionophore (A23187) initiated such relaxations which were not mediated by prostanoids. Endothelium-dependent relaxations were also observed in venous grafts to ADP, thrombin, and arachidonic acid. In segments of graft where myo-intimal hyperplasia was prominent, relaxations to ADP, thrombin, and A23187 were blunted and in some segments contractions were observed. These results demonstrate the ability of the endothelium of venous grafts to initiate changes in tone of the smooth muscle.

Viral infections in pregnancy.

Viral infections are a common complication of pregnancy and in some cases, can have profound effects for the unborn fetus. The human herpesvirus family is composed of large, enveloped DNA viruses that have close structural similarity. The family includes the herpes simplex viruses types 1 and 2, varicella zoster virus, Epstein Barr virus, cytomegalovirus (CMV), and human herpes viruses types 6, 7 and 8. These viruses all share the ability to establish latency and reactivate at a later time. Structural fetal abnormalities can result from intrauterine infection and transmission of the infection during the pregnancy or at the time of delivery can result in important neonatal disease. Human parvovirus B19 is a DNA virus with strong tropism for erythroid precursors and infection during pregnancy can result in fetal hydrops and stillbirth. The causative agents of hepatitis are hepatotropic viruses termed hepatitis A, B, C, D (deltavirus) and E. All except hepatitis B virus are RNA viruses. Vertical transmission of maternal infection with hepatitis B and C can result in significant long term sequelae.

Lymphoscintigraphy in lymphedema: an aid to microsurgery.

The role of lymphoscintigraphy, performed with 99mTc-labeled antimony sulfur colloid, in the diagnosis of lymphedema and as a test for selection of patients for microvascular operation was evaluated in 32 patients with primary and secondary lymphedema and four patients with other causes of leg edema. Lymphoscintigraphy clearly demonstrated if edema was of lymphatic origin. Five different image patterns were identified; abnormal image patterns could not be predicted from clinical history or physical findings. Quantitative evaluation of removal of the radioactive colloid from the injection site and appearance in lymph node sites and liver was of limited usefulness. Nine patients underwent various surgical procedures before or after lymphoscintigraphy. Lympho-venous anastomoses were possible only in patients who had patent lymph channels visible on lymphoscintigrams. Based on initial experience, lymphoscintigraphy seems to be useful to select patients for microvascular operation.

In vivo quantitation of platelet deposition on human peripheral arterial bypass grafts using indium-111-labeled platelets. Effect of dipyridamole and aspirin.

Indium-111-labeled autologous platelets, injected 48 hours after operation, were used to evaluate the thrombogenicity of prosthetic material and the effect of platelet inhibitor therapy in vivo. Dacron double-velour (Microvel) aortofemoral artery bifurcation grafts were placed in 16 patients and unilateral polytetrafluoroethylene femoropopliteal grafts were placed in 10 patients. Half the patients in each group received platelet inhibitors before operation (dipyridamole, 100 mg 4 times a day) and after operation (dipyridamole, 75 mg, and acetylsalicylic acid, 325 mg 3 times a day); the rest of the patients served as control subjects. Five-minute scintigrams of the graft region were taken with a gamma camera interfaced with a computer 48, 72, and 96 hours after injection of the labeled platelets. Platelet deposition was estimated from the radioactivities of the grafts and expressed as counts per 100 pixels per microcurie injected. Dipyridamole and aspirin therapy significantly reduced the number of platelets deposited on Dacron grafts and prevented platelet accumulation over 3 days. With the small amount of platelet deposition on polytetrafluoroethylene femoropopliteal artery grafts even in control patients, platelet inhibitor therapy had no demonstrable effect on platelet deposition on these grafts. It is concluded that (1) platelet deposition on vascular grafts in vivo can be quantitated by noninvasive methods, and (2) dipyridamole and aspirin therapy reduced platelet deposition on Dacron aortofemoral artery grafts.

Treatment of aortic graft infection with providone-iodine irrigation.

Considerable morbidity and mortality are associated with infections of vascular prosthetic grafts. Most vascular surgeons believe that once vascular prosthetic graft infections occur, any form of therapy short of removal of the prosthesis will fail. Although recent reports have noted the successful conservative treatment of vascular prosthetic graft infections in the groin, most surgeons have been hesitant to use such therapy for aortic prosthetic graft infections. We describe an 88-year-old woman with an aortic graft infection 2 months after abdominal aortic aneurysmectomy who was treated successfully with local debridement and continuous irrigation of the graft bed with providone-iodine solution. Such local therapy is an alternative and sometimes effective method of managing patients with infected aortic grafts in whom the risk of resection of the prosthesis and revascularization would be prohibitive.

Intra-aortic balloon counterpulsation as adjunct to aneurysmectomy in high-risk patients.

Patients with severe coronary artery disease that is not amenable to coronary artery bypass surgery face formidable risks when major aortic surgery becomes necessary. In this report we present such a patient, who successfully underwent abdominal aortic aneurysm resection and graft replacement with the prophylactic use of intra-aortic balloon counterpulsation. The use of intra-aortic balloon counterpulsation at the time of surgery has the potential of improving cardiac function in patients with left ventricular dysfunction and favorably influencing the perioperative and postoperative mortality in these patients. Its use also appears worthy of trial in patients with ruptured abdominal aortic aneurysm and shock, in the hope that it will result in improved survival in these patients.

Renovascular hypertension: a rare cardiovascular manifestation of the Ehlers-Danlos syndrome.

The association of the Ehlers-Danlos syndrome with many cardiovascular abnormalities is well known. To our knowledge, however, renovascular hypertension due to renal arterial aneurysms has not previously been reported in patients with this disease. We describe a patient with type IV Ehlers-Danlos syndrome who had multiple systemic and bilateral renal arterial aneurysms and hypertension. The hypertension could have been related to compression of renal tissue or arteries (or both) by the large aneurysms, associated stenoses, or small peripheral renal infarctions. A review of all patients in whom the Ehlers-Danlos syndrome had been diagnosed at our institution between 1967 and 1985 revealed that 4 of the 200 patients had hypertension. Three of these patients, and probably all four, had secondary causes of hypertension: Cushing's syndrome, renal insufficiency, or renovascular hypertension (in the present case). We conclude that hypertension is rare in patients with the Ehlers-Danlos syndrome and that, if present, it most likely is secondary hypertension. A thorough search for secondary causes of hypertension should be undertaken in these patients.

Percutaneous transluminal angioplasty in the lower extremities: a 5-year experience.

From January 1979 to March 1984, percutaneous transluminal angioplasty (PTA) was used to treat 148 limbs of 135 Mayo Clinic patients with occlusive arterial disease of the lower extremities. The procedure was technically successful in more than 95% of the attempts. The outcome was clinical improvement in 89 limbs and no improvement in 40 limbs; in 19 limbs, PTA was technically successful but the patient was dismissed from the hospital and lost to follow-up before the extent of improvement could be determined. Mean ankle/brachial pressure indices increased after PTA in those with clinical improvement but not in those without improvement. Clinical improvement was less likely to follow PTA in patients with advanced age, diabetes, severe initial symptoms, low ankle/brachial indices, or distal occlusive disease. In patients with improvement after PTA, the mean follow-up period was 33 months; during that time, failure (defined as recurrence of the original symptoms or the need for repeat PTA or operation) occurred at a rate of 6.4% per year. Serious complications occurred after three procedures (2.0%). We conclude that PTA is technically feasible and generally safe for many patients with occlusive arterial disease of the lower limbs.

Arterial fibromuscular dysplasia.

Fibromuscular dysplasia is a nonatherosclerotic, noninflammatory vascular disease that involves primarily the renal and internal carotid arteries and less often the vertebral, iliac, subclavian, and visceral arteries. Although its pathogenesis is not completely understood, humoral, mechanical, and genetic factors as well as mural ischemia may play a role. The natural history is relatively benign, with progression occurring in only a minority of the patients. Typical clinical manifestations are renovascular hypertension, stroke, subarachnoid hemorrhage, abdominal angina, or claudication of the legs or arms. In patients with symptoms, percutaneous transluminal angioplasty has emerged as the treatment of choice in most involved vascular beds.

The effect of preclotting on surface thrombogenicity and thromboembolic complications of Dacron grafts in the canine thoracic aorta.

Previous reports have advocated preclotting and autoclaving of Dacron grafts to prevent graft hemorrhage, yet no data delineate possible changes in surface thrombogenicity or thromboembolic risks. To assess these factors, preclotted and preclotted-autoclaved woven Dacron prostheses were implanted in the thoracic aorta of 31 dogs. Grafts were harvested 1 week to 1 month following implantation, and the thrombus-free surface of each graft was calculated by computerized morphometry. Values for thrombus-free surface were lowest in autoclaved grafts preclotted in nonheparinized blood (72%) or in heparinized blood (78%). Grafts preclotted in platelet-rich plasma and autoclaved had a thrombus-free surface value of 85%. Regular preclotted grafts or grafts without preclotting had the greatest thrombus-free surface value (97% and 99%). Distal embolization to the kidneys was detected in seven of 31 animals (23%). No emboli were found in animals with grafts that were not preclotted or if grafts were preclotted with platelet-rich plasma and autoclaved. Thrombus-free surface values were lower (p less than 0.01) in grafts with embolic complications (71% versus 91%). These data suggest that, if the risk of severe bleeding in fully heparinized patients precludes the use of a woven Dacron graft without preclotting, autoclaving a graft preclotted with platelet-rich plasma appears to be the method of choice.

Metachronous bilateral nonfunctional intercarotid paraganglioma (carotid body tumor) and functional retroperitoneal paraganglioma: report of a case and review of the literature.

BACKGROUND: The occurrence of an intercarotid paraganglioma and a paraganglioma in an anatomic distribution away from the head and neck in the same patient is rare. We have treated a patient with this combination of tumors and report this unusual case with the purpose of reviewing the paraganglion system. We endeavor to clarify the confusion that exists by use of the terms chemodectoma, glomus tumors, nonchromaffin paragangliomas, and pheochromocytoma and to present a rational nomenclature based on their ontogeny. METHODS: A computer-generated list of articles on this subject was obtained, and all articles relative to this rare combination of tumors were reviewed. RESULTS: We found 31 other cases. Functional intercarotid paragangliomas are extremely rare, with only five cases having been reported. CONCLUSIONS: All hypertensive patients who are found to have an intercarotid paraganglioma should be investigated for a functional tumor. Family members should also be made aware of their probabilities of having these tumors because a familial trend has been documented in certain cases.

Advocates in vascular controversies.

The cardiovascular surgeon may find bibliographic support for his or her particular therapeutic bias for almost any controversial clinical problem. Such management dilemmas are not unique to vascular surgery in particular or surgery in general but reflect much of the field of medicine. Therapeutic controversies usually represent our ignorance of the natural history of disease or the deficiencies in our knowledge of the efficacy of medical or surgical therapy. While prospective epidemiologic studies or randomized blind clinical trials should be the optimal basis for our therapeutic decisions, how much of medical practice can lay claim to such a foundation? This panel debate represents a programmatic attempt to accomplish what each of us should, but often fails to, do in reaching a clinical therapeutic decision in the face of controversial alternatives: namely, objectively search one's experience and the available literature, pro and con. This approach proved very popular to those attending the meeting of the Southern Association for Vascular Surgery. The audience was greeted with the fruits of labor of the panelists who had taken their charge seriously. As advocates of their particular position in the therapeutic arguments, each panelist had carefully reviewed the pertinent literature, much of which is subject to the deficiencies and bias that are reflected in our clinical approach to these problems. Indeed, some of the advocates used the same literature references to support their opposing sides of the argument. Nevertheless, the eloquence and intensity of each presentation heightened the interest and understanding of the audience to these controversies. The annotated bibliography left a tangible document of the effort that had been expended in this debate. One hopes that out of our increased recognition of the fallibility of some of our therapeutic approaches to vascular controversies will come future efforts to base our clinical decisions on the results of epidemiologic studies or properly designed clinical trials.

Superior vena cava and central venous reconstruction.

Partial or complete obstruction of the superior vena cava and its major tributaries occassionally results in incapacitating venous hypertension of the upper extremities and/or head and neck. Factors intrinsic and extrinsic to the central veins play a role in the pathogenesis. The more common causes include mechanically and chemically induced intimal injury with resultant fibrosis, sclerosis, or thrombosis and neoplastic masses with external compression or direct extension in the central venous structures. Medical therapy is indicated in the acute situation and generally allows the time necessary for development of collateral drainage routes. Persistent or progressive symptomatic venous hypertension develops in 5% to 40% of these patients, and approximately 10% of the patients will remain incapacitated. Presented here is a series of 10 patients who underwent reconstruction of the superior vena cava or central veins for incapacitating venous hypertension of the upper extremities and/or head and neck. Reconstruction was accomplished by venous transposition (three patients), externally reinforced ePTFE (six patients), and reversed saphenous vein graft (one patient). No perioperative deaths occurred; however, two late deaths occurred at 3 and 9 months after reconstruction from causes unrelated to the operative procedure. One patient experienced early postoperative graft thrombosis requiring thrombectomy, after which the graft remained patent. All patients had patent grafts and were asymptomatic with respect to their venous disease at the time of preparation of this manuscript, with a mean follow-up period of 30 months. Specific details concerning these 10 cases are discussed and integrated with a focused review of the literature and the historic development of the intraoperative techniques and postoperative care that facilitate the successful management of patients with symptomatic central venous occlusion.

Endothelial seeding of venous prostheses.

To evaluate the potential benefit of endothelial seeding of venous prostheses, 20 dogs were subjected to iliocaval reconstruction with expanded polytetrafluoroethylene grafts protected by an arteriovenous fistula. Grafts seeded with enzymatically derived endothelial cells were compared with control grafts that were sham seeded with culture medium and blood. Five seeded and seven sham-seeded grafts remained patient and were perfusion fixed in situ 4 to 6 weeks after operation. Specimens were examined by light, scanning, and transmission electron microscopy. No statistical difference in early patency was noted. The mean thrombus-free surface area was 80% in the seeded and 71% in the sham-seeded group. Light microscopy of these areas revealed a monocellular layer lining the lumen in all grafts. Scanning electron microscopy demonstrated a thin cellular lining covering 50% to 100% of the specimens' surface area in four of the five seeded and five of seven sham-seeded grafts. Transmission electron microscopy revealed these cells to exhibit characteristics typical of endothelial cells. The subcellular layer was equally thin in both groups. Early patency rates were not benefited by endothelial seeding of grafts placed in the venous system. Seeding of grafts with enzymatically derived endothelial cells provides a good endothelial cover with a thin subendothelial layer but not to a greater extent than does sham seeding of the venous prostheses.

Overcoming failure of venous vascular prostheses.

Thrombogenicity of graft material, low velocity of blood flow, and wall collapsibility have been cited as the main factors responsible for the high occlusion rate of vascular prostheses placed in the venous system. This study was performed to analyze the effects of measures taken to overcome each of these factors. The thrombogenicity of expanded polytetrafluoroethylene (ePTFE) was evaluated by determination of the 3-hour deposition of radionuclide-labeled platelets and fibrin on grafts placed in the infrarenal vena cava of 18 dogs. Wetting the prosthesis with heparin before implantation significantly decreased platelet deposition at the cranial anastomosis (p less than 0.025) and on the graft surface (p less than 0.01), whereas the decrease of fibrin deposition was not statistically significant. The effects of flow velocity and graft support were studied in 44 dogs subjected to iliocaval bypass. The results of these studies demonstrated that a flow-increasing arteriovenous fistula was necessary to maintain patency of ePTFE grafts (p less than 0.01) but did not enhance patency of autogenous vein grafts. External ring support of ePTFE grafts did not significantly improve early patency. Decreasing thrombogenicity by wetting the grafts with heparin and increasing the blood flow by constructing an arteriovenous fistula helps in overcoming failure of venous vascular prostheses.

Subclavian-axillary artery aneurysms.

The records of all patients with aneurysm of the subclavian-axillary artery who were seen between January, 1960, and January, 1980, were reviewed. There were 31 patients (21 male and 10 female) with a mean age of 47 years. The aneurysm (mean size, 3.0 cm) was located on the right in 20 patients and on the left in 10; one patient had bilateral aneurysms. Mural thrombus was present in 25 patients. Eight patients were asymptomatic and 23 presented with upper extremity pain. Thromboembolism occurred in five patients, one presenting with impending loss of tissue. Two patients had the aneurysm rupture and one of them died. A pulsating mass was palpable in 20 patients, including the eight who were asymptomatic. Vocal cord paralysis occurred in two patients. The cause of the aneurysm was atherosclerosis in 12 patients, trauma in 10, poststenotic dilation secondary in thoracic outlet obstruction in 6, mycotic aneurysm in 2, and Ehlers-Danlos syndrome in one patient. Seven patients had nine aneurysms in other areas. Surgical treatment consisted of thoracic outlet decompression in 4 patients, graft interposition in 11, tangential aneurysmorrhaphy in 8, ligation in 4, and exploratory surgery only in one. One forearm amputation was subsequently performed. Three patients did not undergo surgery. Average length of follow-up was 9.2 years. Except for the patient who underwent amputation, all treated patients had adequate circulation in the extremities. No aneurysm recurred and no complication of the repair developed. We conclude that aneurysms of the subclavian-axillary artery, although rare, are both life- and limb-threatening. Resection and arterial reconstruction are recommended.

Surgical management of chronic intestinal ischemia: a reappraisal.

Fifty-six patients with chronic intestinal ischemia underwent surgical revascularization. All patients had abdominal pain, 98% experienced significant weight loss, and 75% had an abdominal bruit. Visceral artery occlusive disease was documented by angiography in all patients; 77% of our patients had multiple-vessel occlusive disease, and 23% had single-vessel involvement of either the celiac or the superior mesenteric artery. The mortality rate was 8.9%. Ninety-six percent of the survivors were completely relief of symptoms, but an overall late recurrence rate was noted in 26.5%. Fifty-nine percent of our patients underwent revascularization of all stenotic vessels. Complete revascularization in multiple-vessel disease resulted in a late recurrence rate of 11%. When two of three stenotic vessels were revascularized, there was a 29% recurrence rate, and when one of three stenotic vessels was revascularized, there was a 50% recurrence rate. These findings suggest that although single-vessel revascularization may relieve symptoms, the optimal long-term result can be obtained by complete revascularization of all stenotic vessels.