Predictors of health after revascularization for extremity ischemia.

BACKGROUND: To assess the impact of surgical revascularization for lower extremity ischemia, we determined (with the use of the SF-36 health survey) the functional health status of patients who underwent either inflow or outflow procedures. METHODS: The SF-36 survey was given prospectively to 104 patients before operation and at intervals ranging from 10 days to 1 year after operation from January 1998 to July 1999. To determine whether revascularization was associated with improved patient health status, mean scores were compared before and after operation by univariate and multivariate analysis. To identify the factors that influenced patient health status, we performed multiple regression analysis to test the hypothesis that outcome is affected by age, gender, time since procedure, diabetes, indication, and inflow versus outflow procedure. RESULTS: There was a significant decrease in the general health score of patients before outflow bypass as compared with inflow procedure (45.3 +/- 5.3 versus 32.1 +/- 3.3 [mean +/- SEM]; P <.05). After the procedure, only those patients who had undergone inflow procedures had improved outcome scores. Diabetes, outflow procedures, limb salvage as indication, and time since operation were determined by multiple regression affecting outcome scores to be significant factors. CONCLUSIONS: The SF-36 health survey demonstrated that diabetes, procedure type, indication, and time after procedure significantly affected the functional outcome for patients who were treated surgically for lower extremity ischemia. Despite successful revascularization, significant deficits in functional health remain in patients with lower extremity ischemia.

Endovascular management of ureteroarterial fistula.

Ureteroarterial fistulas, although rare, appear to be increasing in frequency. Because open surgical repair may be difficult and associated with significant risk for complications, endovascular intervention may provide an attractive treatment alternative. We review the diagnosis and management of a ureteroarterial fistula and iliac pseudoaneurysm that presented with massive hematuria during ureteral stent removal. The patient was treated by means of the percutaneous embolization of the right hypogastric artery and placement of an expanded polytetrafluoroethylene stent-graft. Endovascular stent-graft placement may serve as a safe and practical alternative in the treatment of these patients, whose cases are challenging.

Endovascular stent graft for management of ureteroarterial fistula after orthotopic bladder substitution.

We describe the first case of an ureteroarterial fistula developing after orthotopic neobladder substitution and its minimally invasive management using endovascular stent grafting. We outline the risk factors for the development of ureteroarterial fistulae and trace the evolution of diagnostic and therapeutic modalities used in the management of these life-threatening complications. Minimally invasive management with endovascular stent grafting and exclusion of two pseudoaneurysms in the iliac artery system was performed successfully. After successful endovascular exclusion of two pseudoaneurysms, the patient's hematuria resolved and he recovered fully. Three-dimensional computed tomography performed 3 months later documented a patent aortoiliac arterial system without evidence of pseudoaneurysm or endovascular leak. Ureteroarterial fistula after orthotopic bladder substitution was managed with an endovascular stent graft without the need for extra-anatomical vascular bypass. Early recognition, stabilization, and angiographic evaluation followed by this minimally invasive technique may avoid open operative repair and attendant morbidity.

Adenocarcinoma arising within a testicular metastasis.

Teratoma with malignant transformation is defined as the emergence of a non-germ cell tumor from a teratoma. Although extremely rare in extraovarian sites, cases have been reported that involve primary extragonadal germ cell tumors with transformation to variants of sarcoma. We report a 54-year-old man who was found to have adenocarcinoma arising within a mature teratomatous retroperitoneal metastasis 15 years after treatment of a nonseminomatous testicular germ cell tumor. The tumor was successfully excised and he remains without evidence of disease.

Elective aortic surgery with minimal banked blood.

It has been a historical supposition that aortic surgery, even in an elective setting, has been associated with the transfusion of large amounts of blood products. We feel that this assumption is now dated, and in fact far fewer patients now receive allogenic blood products. To assess this assumption, we carried out a retrospective chart review of all patients who underwent elective aortic surgery over an 18-month period from April 1994 to October 1995. Factors analyzed included type of procedure, blood loss, amount of Cell Saver blood replaced, need for autologous blood transfusion, and need for allogenic blood transfusion. Sixty-seven patients underwent elective aortic surgery with either an aortic tube graft (23), an aortobiiliac graft (25), or an aortobifemoral graft (19). The male:female ratio was 48:19, with a mean age of 67 years (range, 42-85 years). Mortality and morbidity were 4.4 per cent and 8.9 per cent, respectively. The average blood loss per patient was 770 cc. Cell saver was used in 65 patients, with the average amount of blood returned being 542 cc. Overall, 73 per cent of patients did not require allogenic blood transfusion, and 58 per cent did not need any type of transfusion. Of those who stored autologous blood prior to operation, none required allogenic blood perioperatively. With the new advances in autologous blood transfusion both by predeposit and salvage transfusion, we have greatly reduced the need for transfusion of allogenic blood products in patients undergoing major aortic surgery. This is reassuring, and although increasing short-term cost, will reduce the morbidity-infectious, noninfectious, and immunologic-associated in prior decades with allogenic blood transfusions. We strongly recommend the use of Cell Saver techniques, and also, where possible, patients should be encouraged to donate their own blood prior to major aortic procedures for future transfusion.

The utility of dobutamine echocardiography in preoperative evaluation for elective aortic surgery.

BACKGROUND: Preoperative cardiac evaluations have been advocated prior to major vascular procedures to reduce the incidence of postoperative cardiac complications. This study was undertaken to evaluate the efficacy and predictive value of routine dobutamine echocardiography (DE) in the screening of patients undergoing elective aortic surgery. METHODS: Dobutamine echocardiography was performed preoperatively on all patients having elective aortic procedures by our university surgical group from June 1995 to August 1996. The cardiac morbidity and mortality from this group were compared with that of a similar group undergoing elective aortic procedures from June 1993 to May 1995 with no dobutamine echocardiography (NDE). RESULTS: Although there was no statistically significant difference in either overall mortality (4.4% in NDE vs. 2.3% in DE) or cardiac mortality (2.9% in NDE vs. 0% in DE) between the two groups, cardiac events occurred only in those patients with previous coronary artery disease. In addition, dobutamine echocardiography had a negative predictive value of 97% CONCLUSIONS: Although routine screening is not necessary, selective screening of patients using dobutamine stress echocardiography is justified because of its high negative predictive value.

Efficacy of prophylactic vena cava filters in high-risk trauma patients.

Severely injured trauma patients are at increased risk of pulmonary embolism (PE). Certain injuries may preclude the use of standard prophylactic measures, and even when used, these measures may be ineffective in the trauma population. We defined a group of trauma patients who are at statistically elevated risk of venous thromboembolic events. We then adopted an aggressive approach to the placement of prophylactic inferior vena cava (IVC) filters in these high-risk patients. Between January 1994 and January 1996 we treated 250 trauma patients who met our high-risk criteria. Prophylactic IVC filters were placed in 99 of these patients, and 151 received deep venous thrombosis prophylaxis with either heparin, sequential compression stockings, or a combination of these modalities. High-risk patients did not receive filters if they were unlikely to survive or showed rapid clinical improvement and were felt to not remain at high risk. The incidence of pulmonary embolism in this high-risk population was 1.6%. This is a significant reduction (p = 0.045, Fisher exact test) from the 4.8% incidence of PE in high-risk historical control patients with similar injury profiles. No patient with a prophylactic IVC filter suffered a clinically evident PE and there were no complications associated with placement of these filters. We conclude that the placement of prophylactic IVC filters in high-risk trauma patients is a safe and effective method of reducing the incidence of pulmonary embolism.

Antiphospholipid antibodies lead to increased risk in cardiovascular surgery.

BACKGROUND: Antiphospholipid (APL) antibodies are a heterogenous group of antibodies that have been associated with an increase in bleeding complications and a marked increase in thrombotic events, both of which result in significant patient morbidity and mortality. PATIENTS AND METHODS: A retrospective analysis of patients identified to be positive for APL via a university thrombosis registry who had cardiovascular surgery between 1989 and 1994. RESULTS: Seventy-one patients positive for APL antibodies were identified. Of those patients, 19 had cardiovascular surgical procedures (11 women and 8 men, mean age 58.4 years, range 38 to 78). A total of 48 cardiovascular surgical procedures (mean 2.5 procedures/patient) were performed in the 19 patients. These procedures included 13 lower-extremity reconstructions, 11 upper-extremity reconstructions/fistulas, 8 cardiac valve replacements, 5 coronary artery bypass procedures, 5 major amputations, 4 infrarenal aortic reconstructions, and 2 carotid endarterectomies. Sixteen of the 19 patients (84.2%) suffered major postoperative complications. These included 16 thrombosed grafts, 5 strokes, 5 major bleeding events, 2 pulmonary emboli, and 2 myocardial infarctions. Ultimately, 12 of the 19 patients (63.2%) died of complications related to surgery. CONCLUSIONS: This series of patients confirms that patients with circulating APL antibodies are prone to excessive postoperative morbidity and mortality after cardiovascular surgical procedures. The presence of APL antibodies may be a maker of increased risk of complications after cardiovascular surgery.

Persistent sciatic artery in association with varicosities and limb length discrepancy: an unrecognized entity?

The persistence of the sciatic artery is an unusual occurrence, with an angiographically demonstrated incidence of 0.06%. There have been 71 cases previously reported. We report an additional case in a 14-year-old boy who presented with a chief complaint of unsightly varices. The involved right limb was notably shorter than the uninvolved left lower extremity. Work-up included physical examination, duplex studies, venography, and angiography. Our patient was found to have a patent deep venous anatomy with valvular incompetency associated with complete persistence of the sciatic artery and a foreshortened right leg. He has done well with conservative treatment. The persistence of a sciatic artery has occasionally been associated with other anomalies including Mullerian and left renal agenesis, A-V fistula formation, hypertrophy or hypotrophy, multiple hemangiomata, neurofibromatosis, or anomalies of leg arteries. The literature describes three previous case reports in which patients presented with gross varicosities and were incidentally found to have persistent sciatic arteries as well as limb length discrepancies. Our patient is a fourth example of this syndrome. This pattern of physical attributes has not been previously described as a distinct entity. The association of venous incompetency, limb discrepancies, and persistence of the sciatic artery may be an incidental finding or may represent a related embryologic event. This relationship merits consideration in a young patient presenting with severe venous varicosities.

Symptomatic subclavian steal syndrome four decades after operation for dysphagia lusoria.

Congenital abnormalities of the aortic arch may lead to signs and symptoms of tracheal and esophageal obstruction secondary to a restrictive vascular ring. There are many case reports and monographs concerning the surgical management of dysphagia lusoria. This case provides the first example of long-term follow-up of surgical intervention for relief of dysphagia lusoria. A 45-year-old laborer presented with a several year history of episodic bilateral blindness and a more recent onset of "drop attacks." Notably this patient had presented at the age of 18 months with difficulty breathing and eating since birth. The patient also had frequent upper respiratory infections and episodes of pneumonia. Workup revealed a right-sided aortic arch with a left ligamentum arteriosum. When he was first seen in our clinic, history and physical examination revealed claudication and diminished pulses in the left upper extremity. Arteriography and duplex studies confirmed reversal of flow in the patient's left vertebral artery. The arteriogram demonstrated the presence of a right-sided aortic arch and descending aorta along with the proximal stump of the previously ligated left subclavian artery. He underwent left carotid to left axillary artery bypass for the treatment of symptomatic subclavian steal syndrome. His symptoms have resolved with return of antegrade vertebral flow and the presence of normal pulses in the left arm. Congenital aortic abnormalities that lead to tracheal and esophageal compromise are numerous and varied. Surgical management requires a thorough understanding of the person's anatomy and preoperative planning. The life expectancy of patients with dysphagia lusoria necessitates consideration of the long-term consequences of surgical intervention.

Fibromuscular dysplasia of the brachial artery: an endovascular approach.

Fibromuscular dysplasia (FMD) is a nonatherosclerotic segmental disease of unknown etiology primarily affecting muscular arteries of intermediate size. The pathology affects the renal arteries in the majority of cases, followed by the carotid, vertebral, and ilio-femoral arteries. There have been only six reported cases of FMD involving the brachial artery. This case report describes the seventh case and illustrates an endovascular approach to this clinical entity. A 63-year-old female with a history of hypertension presented to vascular surgery clinic with a 4-day history of numbness, pain, and coolness of her left hand. On physical exam, the patient had a normal axillary and brachial pulse, but had only a Doppler signal of the left ulnar artery. There was no Doppler signal of the radial artery. Segmental pressures and PVR waveforms were normal in the upper arm, but there was a significant blunting of the waveform and decrease in pressure at the level of the wrist. An arteriogram revealed significant narrowing and irregularity of the brachial artery with a characteristic "string-of-beads" appearance. There was complete thrombosis of the radial artery and evidence of fresh thrombus in the distal brachial artery. The patient was treated with intra-arterial infusion of urokinase with restoration of the radial pulse and resolution of her symptoms. Subsequently, the patient had a percutaneous transluminal balloon angioplasty of the involved segment of brachial artery, with normal PVR's and segmental pressures upon completion. FMD of the brachial artery and its sequelae are extremely rare, and therefore, there is no consensus on proper management.(ABSTRACT TRUNCATED AT 250 WORDS)

Increased oxygen extraction as adaptation to acute renal ischemia.

Acute renal ischemia is an infrequently encountered clinical entity with occasionally devastating consequences. The renal compensation to acute ischemia is unknown and is the purpose of this report. Eight pigs were anesthetized and ventilated. Left atrial, aortic, CVP, left renal venous, and ureteral catheters were inserted. Renal blood flow (RBF) reduction was accomplished by the graded constriction of the left renal artery using a balloon occluder. Renal oxygen extraction ratio (RER, %), renal oxygen delivery (RO2D, cc/min per 100 gm), renal oxygen consumption (RVO2, cc/min/100 gm), creatinine clearance (CrCl, ml/min), and renal lactate production (delta [L], mg/min per hgm) were measured at baseline and following sequential 90-minute intervals of moderate and then severe left renal flow reduction. Significant increases in renal oxygen extraction were observed when RBF was severely limited (.30 +/- .05 vs .64 +/- .06, p < .01). CrCl decreased precipitously (16.5 +/- 4.6 vs 0.2 +/- 0.07, p < .05). Lactate production by the ischemic organs correlated with blood flow reduction (r = .546, p = .0034). In severe ischemia, healthy kidneys increase oxygen extraction to preserve oxygen consumption.