Polytetrafluoroethylene grafts in infrainguinal arterial revascularization. Factors affecting outcome.

One hundred thirty-seven polytetrafluoroethylene infrainguinal bypass grafts were performed over 2 years. The results were analyzed using univariate and multivariate analyses. Our operative mortality was 3.2% and the post-operative amputation rate was 5.8%. Forty-eight reconstructions were done for claudication, with a 5-year secondary patency rate of 64%, no early amputations, and a 2.9% (one limb) late amputation rate. Sixty-six reconstructions were done for rest pain with a 5-year secondary patency rate of 58% and a 3-year limb salvage rate of 77%. The 5-year secondary patency rate for 23 patients with trophic changes was 30%, and the 3-year limb salvage rate was 71%. Multivariate analysis identified the ankle-brachial index as the most important independent factor predicting both primary and secondary graft patency. The cumulative primary and secondary patency rates for patients with an ankle-brachial index of less than 0.5 at 78 months was 37% and 46%, respectively; and 57% and 68%, respectively for patients with an ankle-brachial index of 0.5 or more.

Treatment of giant intracranial aneurysm with carotid ligation, saphenous vein bypass graft.

Giant intracranial aneurysms pose difficult problems for neurosurgeons. This article describes the technique of extracranial-intracranial saphenous vein bypass graft and carotid artery ligation as treatment to remove a giant intracranial aneurysm.

Diagnosing giant cell temporal arteritis.

Arteritis is a complex and totally underestimated clinical entity that may present in several ways. Due to the diversity of clinical features and the frequent overlapping of clinical syndromes, many different classifications are available for arteritides, but the simplest classification for the practicing physician is the broad division of arteritis into giant cell arteritis and non-giant cell arteritis. Giant cell arteritis encompasses two distinct clinical entities that are pathologically indistinguishable from each other; but both involve arteritis of median and large-sized arteries characterized by an infiltration of giant cells. These include temporal arteritis and Takayasu's arteritis. The non-giant cell arteritis encompasses a greater variety of uncommon diseases that are often associated with other systemic processes such as systemic lupus erythematosus or periarteritis nodosa, and it generally results in ischemic organ dysfunction that is amenable only to medical treatment. Less commonly, however, non-giant cell arteritis may become manifested as acute arterial occlusion caused by circulating anticoagulants, abdominal apoplexy as intra-abdominal bleeding from rupture of micro aneurysms of artery branches, gastrointestinal bleeding from local necrosis of the gastrointestinal tract, or deep-vein thrombosis secondary to hypercoagulable states. Although temporal arteritis has generated a voluminous body of literature, its precise etiology remains elusive. This study summarizes our experience in 15 cases of temporal arteritis and one case is presented to increase knowledge about this disease entity.

Laparoscopic cholecystectomy.

In recent months, the technique of Laparoscopic Laser Cholecystectomy (LLC) was introduced at our institution. A small series is presented here involving 14 patients, seven of whom underwent LLC and seven in which a "mini-lap" cholecystectomy was performed. Symptomatic cholelithiasis was the indication for surgery in all cases, and operative cholangiograms were employed in 12 patients. Comparisons are made regarding length of hospitalization, recovery time and operative time. An improved recovery period is indeed demonstrated with LLC allowing return to normal activities and employment much sooner than with an open cholecystectomy. We suggest that, though some prudence and caution is advised, this appears to be a safe and feasible adjunct in the treatment of cholelithiasis.

Therapeutic and prophylactic vena caval interruption for pulmonary embolism: caval and venous insertion site patency.

Although anticoagulation remains the treatment of choice for acute pulmonary embolism, vena caval interruption represents an alternative for patients with contraindications and complications or in whom anticoagulation fails. The purpose of this study was to evaluate the effectiveness and safety of two types of caval interruption devices: the original stainless steel Greenfield filter and the Adams-DeWeese clip. Emphasis has been placed on maintaining caval patency with filters and clips and the patency of the femoral vein vs. the jugular vein after filter insertion. We retrospectively reviewed 161 patients who underwent caval interruption (92 filters and 69 clips) for both therapeutic and prophylactic reasons. The operative mortality and morbidity rates were 0% and 3.3% for filter patients and 8.7% and 2.9% for clip patients; no procedure-related mortalities occurred. The late caval patency rate as documented by duplex ultrasonography/venography was 100% for filter patients and 88% for clip patients (p = 0.011). Seven percent of the filter patients and 20% of the clip patients experienced late limb swelling postoperatively (p = 0.05). The incidence of recurrent late pulmonary embolism was 2.5% in the filter group and 1.9% in the clip group. In the filter group, 10% of patients experienced postoperative thrombosis at the femoral vein insertion site and 0% at the jugular vein insertion site. We found that both devices were effective in preventing pulmonary embolism, the filter provided better caval patency than the clip, and the jugular vein had a better patency than the femoral vein after filter insertion.