Liposarcoma of the posterior mediastinum in a child.

Liposarcoma is rare in children and rarely occurs in the posterior mediastinum in any age group. A massive intrathoracic tumor in a 17-year-old young man was a diagnostic dilemma; preoperative radiographic evaluation and biopsy led us to believe it was a teratoma. At operation, a poorly differentiated myxoid liposarcoma originating from the posterior mediastinum was found and excised. To our knowledge, this is the first liposarcoma of the posterior mediastinum reported in a patient less than 18 years old.

Pulsed laser and thermal ablation of atherosclerotic plaque: morphometrically defined surface thrombogenicity in studies using an annular perfusion chamber.

Although clinical trials using laser and thermal angioplasty devices have been underway, the effects of pulsed laser and thermal ablation of atherosclerotic plaque on surface thrombogenicity are poorly understood. This study examined the changes in platelet adherence and thrombus formation on freshly harvested atherosclerotic aorta segments from Watanabe-heritable hyperlipidemic rabbits after ablation by two pulsed laser sources (308-nm xenon chloride excimer and 2,940-nm erbium:yttrium-aluminum-garnet [YAG] lasers) and a prototype catalytic hot-tip catheter. Specimens were placed in a modified Baumgartner annular chamber and perfused with citrated whole human blood, followed by quantitative morphometric analysis to determine the percent surface coverage by adherent platelets and thrombi in the treated and contiguous control areas. Pulsed excimer laser ablation of plaque did not change platelet adherence or thrombus formation in the treated versus control zones. However, photothermal plaque ablation with a pulsed erbium:YAG laser resulted in a 67% reduction in platelet adherence, compared with levels in control areas (from 16.7 +/- 2.2% to 5.5 +/- 1.8%; p less than 0.005). Similarly, after plaque ablation using a catalytic thermal angioplasty device, there was a 74% reduction in platelet adherence (from 29.2 +/- 5.1% to 7.7 +/- 1.6%; p less than 0.005) and a virtual absence of platelet thrombi (from 8.6 +/- 2.3% to 0.03 +/- 0.03%; p less than 0.005). This reduced surface thrombogenicity after plaque ablation with either an erbium:YAG laser or a catalytic hot-tip catheter suggests that thermal modifications in the arterial surface ultrastructure or thermal denaturation of surface proteins, or both, may be responsible for reduced platelet adherence. These in vitro findings indicate that controlled thermal plaque ablation by catheter-based techniques may elicit endovascular responses that can reduce early thrombus formation during angioplasty procedures.

In vivo human atherosclerotic plaque recognition by laser-excited fluorescence spectroscopy.

Arterial wall perforation and chronic restenosis represent important factors limiting the clinical application of laser angioplasty. Discrimination of normal and atherosclerotic vessels by laser-excited fluorescence spectroscopy may offer a means of targeting plaque ablation, thereby reducing the frequency of restenosis and transmural perforation. In this study, with use of a 325 nm low power helium-cadmium laser, in vivo endogenous surface fluorescence was excited through a flexible 200 microns optical fiber within a 0.018 in. (0.046 cm) guide wire in contact with the intima of 268 vascular interrogation sites from 48 patients either during open heart surgery or during percutaneous catheterization procedures. Fluorescence spectra could be recorded in all patients in bloodless and blood-filled arteries. Endogenous surface fluorescence was analyzed measuring peak intensity, peak position and shape index of the spectra. Compared with normal wall, noncalcified and calcified coronary atheroma showed a 42% (p less than 0.001) and a 58% (p less than 0.001) decrease of peak intensity, and higher shape index (p less than 0.001 and p less than 0.01, respectively). In addition, peak position was shifted to longer wavelengths for noncalcified coronary atheroma (p less than 0.001). Compared with normal aorta sites, aortic plaques demonstrated a 46% decrease of peak intensity, longer peak position wavelengths (p less than 0.05) and a higher shape index (p less than 0.001). Using an atheroma detection algorithm, prospective analysis of aorta and coronary spectra showed a specificity of 100% for identifying normal sites and a sensitivity of 73% for recognizing atherosclerotic sites.(ABSTRACT TRUNCATED AT 250 WORDS)

Balloon expandable stent implantation in stenotic right heart valved conduits.

Although valved conduits have been used successfully in severe forms of right ventricular-pulmonary artery discontinuity, progressive valved conduit stenosis is an important clinical problem. To determine the feasibility of reducing right heart valved conduit stenosis with a balloon expandable stent, a baboon model was used, in which the pulmonary artery was ligated and a right ventricular to pulmonary artery 14 mm bioprosthetic Dacron valved conduit implanted. In five baboons, at an average of 40 months after valved conduit implantation, fibrointimal stenosis at the valve site resulted in narrowing and a mean transconduit pressure gradient of 49 mm Hg (range 33 to 65). A tubular slotted steel stent (1.2 cm long) was deployed within the valved conduit after inflation of an 8 to 15 mm diameter balloon catheter that was introduced through the femoral vein. A stent was delivered to all valved conduits; however, in two baboons, balloon undersizing resulted in stent dislodgment. In the remaining three baboons, the transconduit gradient was reduced by 59% (49 to 20 mm Hg) and right ventricular systolic pressure decreased acutely by 35% (77 to 50 mm Hg). It is concluded that stent deployment is feasible in right ventricular to pulmonary artery stenotic valved conduits and may result in significant hemodynamic improvement. However, successful stent delivery is critically dependent on the proper selection of stent length and balloon diameter.

Fluorescence-guided laser-assisted balloon angioplasty in patients with femoropopliteal occlusions.

In 12 patients (aged 64 +/- 10 years) with femoropopliteal occlusions (1-27 cm; average, 8.4 cm length) that could not be recanalized by standard guidewire-balloon angioplasty techniques, percutaneous laser-assisted balloon angioplasty was performed by use of a new fluorescence-guided dual-laser system. Plaque detection by 325-nm laser-excited fluorescence spectroscopy provided real-time feedback control to a 480-nm pulsed dye laser (2-microseconds pulses) for atheroma ablation. By means of a common 200-microns optical fiber, after diagnostic fluorescence sensing, computer algorithms directed a fire or no-fire signal (5 Hz) to the treatment laser for selective plaque removal. Laser recanalization (15-50 mJ/pulse) was successful in 10 of 12 patients; this procedure was followed by definitive balloon angioplasty in seven of 12 patients with increased ankle/arm indexes (from 0.60 +/- 0.12 at baseline to 0.84 +/- 0.11 after treatment, p = 0.0043). In laser and balloon angioplasty failures, all femoropopliteal occlusions were heavily calcified, and there were two mechanical guidewire perforations without clinical sequelae. Ablation of calcified lesions required higher pulse energies and greater total energy per centimeter of recanalized tissue (1,837 +/- 1,251 mJ/cm vs. 90 +/- 39 mJ/cm, p = 0.0036). Fluorescence spectroscopy (n = 219 sites) was helpful in flush occlusions and correctly identified plaque, underlying media, and thrombus by changes in fluorescence intensity, shape, and peak position. Thus, when fluorescence-guided laser angioplasty was used in a subgroup of patients refractory to standard angioplasty techniques, primary recanalization and subsequent balloon angioplasty of femoropopliteal occlusions was successful in 83% and 58% of the patients, respectively. Importantly, treatment of heavily calcified lesions accounted for all of the failures and will require modified delivery systems to create larger primary channels and to increase catheter-tip control, which should improve clinical results in the future.

A comparison of the open and closed methods in the initial treatment of sternal wound infections.

To determine the optimal initial treatment method for sternal wound infections, a retrospective review of 3,229 consecutive adult open heart operations was performed. There were 40 deep sternal wound infections (1.2%). All types of open heart procedures had approximately the same rate of infection except for left ventricular aneurysm repair plus coronary artery bypass grafting, which had a sternal wound infection rate of 5.8% (p less than 0.01). The use of single and double internal mammary artery grafts did not increase the rate of sternal wound infections. Treatment outcome was available for 39 patients. Twenty-eight patients were initially treated with debridement and closed mediastinal irrigation, which had a failure rate of 42% and a mortality rate of 35%. Six patients were initially treated with debridement, open packing, and muscle flap closure of the sternal wound. No deaths or treatment failures occurred in this group. The mortality and failure rates for the open treatment method were significantly better than for the closed treatment method in the initial treatment of sternal wound infections (p less than 0.05). These data, as well as a review of the literature, suggest that the open method is superior to the closed method in the initial treatment of deep sternal wound infections.

Platelet adherence and thrombus formation with flowing human blood on atherosclerotic plaque: reduced thrombogenicity of Watanabe-heritable hyperlipidemic rabbit aortic subendothelium.

Platelet adherence and aggregation are important in the development of ischemic sequelae in atherosclerosis. To directly examine platelet interaction with plaque, everted, deendothelialized aortic fibrous plaques from Watanabe-heritable hyperlipidemic rabbits were exposed to flowing human blood in an annular perfusion chamber. Morphometry was used to compare platelet adherence and thrombi on this surface with that observed when blood was perfused over normal New Zealand White (NZW) rabbit aortic subendothelium. Platelet spreading, adherence, and thrombi on the atherosclerotic surface were approximately half that observed on NZW aorta. When surface proteins of NZW aorta were denatured by a hot-tip catheter, these parameters were reduced by 89-96%. The reduced thrombogenicity of uncomplicated plaques may help keep these narrowed vessels patent, while fissure, rupture, or hemorrhagic dissection of plaque may precipitate occlusive thrombosis.

Early and late healing responses of normal canine artery to excimer laser irradiation.

Acute in vitro histologic studies have shown that the pulsed xenon chloride excimer laser causes precise microablation without the surrounding thermal tissue injury associated with frequently used continuous-wave lasers such as the argon, carbon dioxide, and neodymium:yttrium aluminum garnet lasers. However, the in vivo healing response of artery wall to excimer laser injury is not known. Accordingly, a xenon chloride excimer laser (308 nm, 40 nsec pulse width, 39 mJ/mm2/pulse) was transmitted via a 600 micron fused silica fiber to create 420 craters of varying depths (30 to 270 micron) in 21 normal canine femoral and carotid arteries. At 2 hours, 2 days, 10 days, and 42 days after excimer laser ablation, the artery segments were perfusion fixed in situ and analyzed by light, scanning, and transmission electron microscopy. At 2 hours, craters were covered by a carpet of platelets and entrapped red blood cells. Fibrin and exposed collagen fibers were seen at the crater base. There was a sharp demarcation of the crater-artery wall interface without lateral laser tissue injury. At 2 days, adherent platelets persisted with thrombus covering the base of the craters. Early healing responses were present, consisting of polymorphonucleated leukocytes and new endothelial cells, which extended over the crater rims. At 10 days, no thrombi were seen, and healing continued with almost complete reendothelialization. Macrophages, fibroblasts, fibrin, and entrapped red blood cells were present below the reendothelialized surface. At 42 days, healing was complete with obliteration of the craters by fibrointimal ingrowth. The surface was completely covered by a smooth monolayer of axially aligned endothelial cells. There were no aneurysms or surface hyperplastic responses. These favorable healing responses in normal canine arteries suggest that pulsed lasers with high tissue absorption coefficients, such as the xenon chloride excimer laser, may be suitable energy sources for clinical laser angioplasty procedures. However, further studies in atherosclerotic animals are required before human clinical responses can be accurately predicted.

Human arterial surface fluorescence: atherosclerotic plaque identification and effects of laser atheroma ablation.

In vivo plaque recognition may be important for safe and precise intra-arterial atheroma ablation during laser coronary angioplasty. This study examined the feasibility and sensitivity of utilizing quantitative fluorescence spectroscopy and video-enhanced fluorescence imaging for plaque identification in atherosclerotic human necropsy arterial wall before and after laser atheroma ablation. With wide-band (450 to 490 nm) blue light excitation, the 540 nm fluorescence intensity ratio of normal to diseased sites (n = 13) was 2.09 +/- 0.82 (p less than 0.001) and video fluorescence imaging provided enhanced delineation of atheroma surface characteristics. Continuous argon and pulsed excimer (308 nm) laser ablation of atheroma decreased fluorescence intensity ratios by 42 and 20% (p less than 0.001), respectively (that is, from abnormal to nearly normal). Low power 325 nm laser-excited fluorescence spectroscopy from normal (n = 115) and abnormal (n = 146) necropsy sites revealed an average 45% decrease in atheroma fluorescence intensity (p less than 0.0001) and changes in fluorescence spectra appearance that corresponded to plaque morphologic subtypes. Studies using a dual laser system combining 325 nm laser-excited fluorescence plaque recognition and a 480 nm pulsed dye laser for tissue ablation with common optical fibers demonstrated normalization of both fluorescence intensity and spectra appearance after laser atheroma ablation. Thus, in vitro analysis of surface arterial fluorescence by quantitative spectroscopy and video fluorescence imaging reliably differentiate plaque from normal tissue and may provide the feedback signal needed to activate a laser source for selective plaque removal.

Laser-induced fluorescence detection of atherosclerotic plaque with hematoporphyrin derivative used as an exogenous probe.

Clinical use of laser angioplasty is limited by the lack of an adequate guidance system. As a first step toward developing a reliable guidance system, laser-induced surface fluorescence and a fluorescent probe were used to differentiate plaque from normal arterial wall. The aortas from four normal New Zealand white rabbits and six atherosclerotic rabbits were studied in vitro. Rabbits from each group received 2.5 mg/kg of hematoporphyrin derivative intravenously 24 hours before death. Segments of the aortas were irradiated with a helium-cadmium laser, and the tissue surface fluorescence spectra were recorded with an optical multichannel analyzer. A plaque index, based on the resulting spectra, was calculated for each specimen of aorta. The spectra from normal aorta without hematoporphyrin derivative, normal aorta with hematoporphyrin derivative, and from plaque of atherosclerotic rabbits without hematoporphyrin derivative showed the same wavelength dependence. The plaque index values were not significantly different from one another. However, in plaque from atherosclerotic rabbits given hematoporphyrin derivative, the spectrum was markedly different, showing a broad spectral peak at 632 nm. This spectral peak corresponds to the spectral peak of hematoporphyrin derivative and was only seen in the plaque of atherosclerotic rabbits given hematoporphyrin derivative. The plaque index for these specimens was significantly different from all other specimens (p less than 0.001). This difference in fluorescence spectra and plaque index could be incorporated into a guidance system for laser angioplasty.

Early detection and treatment of spinal epidural metastases: the role of myelography.

Spinal epidural metastases were detected in 75 of 140 cancer patients with back pain who were evaluated prospectively by clinical criteria, spine roentgenography, and bone scan. Fifty-five of the 75 patients with epidural metastases had no evidence of myelopathy when diagnosed. Of the patients diagnosed and treated while still ambulatory, more than 90% remained so. Myelograms were performed in 127 patients to diagnose the 75 with epidural disease. To try to reduce the number of myelograms needed, we attempted to design radiotherapy ports based on clinical symptoms and the plain spine films alone. A port could not be designed for 64 of the 127 patients, either because of diffuse vertebral metastases or a normal plain roentgenogram. A port could be designed for 63 patients, and all epidural disease would have been encompassed in 50 of the 54 patients who had spinal epidural metastases (93%). Most patients with cancer and back pain require myelography for accurate treatment planning. There are, however, situations in which treatment can be determined based on symptoms and plain films alone, with a low risk of missing epidural cancer.