EVAR deployment in anatomically challenging necks outside the IFU.

OBJECTIVE: Treatment of abdominal aortic aneurysms with high-risk anatomy (neck length <10-15 mm, neck angle >60°) using commercially available devices has become increasingly common with expanding institutional experience. We examined whether placement of approved devices in short angled necks provides acceptable durability at early and intermediate time points. METHODS: A total of 218 patients (197 men, 21 women) at a single academic center underwent endovascular aneurysm repair (EVAR) with a commercially available device between January 2004 and December 2007. Available medical records, pre- and postoperative imaging, and clinical follow-up were retrospectively reviewed. Patients were divided into those with suitable anatomy (instructions for use, IFU) for EVAR and those with high-risk anatomic aneurysm characteristics (non-IFU). RESULTS: IFU (n = 143) patients underwent repair with Excluder (40%), AneuRx (34%), and Zenith (26%) devices, whereas non-IFU (n = 75) were preferentially treated with Zenith (57%) over Excluder (25%) and AneuRx (17%). Demographics and medical comorbidities between the groups were similar. Operative mortality was 1.4% (2.1% IFU, 0% non-IFU) with mean follow-up of 35 months (range 12-72). Non-IFU patients tended to have larger sac diameters (46.7% ≥60 mm) with shorter (30.7% ≤10 mm), conical (49.3%), and more angled (68% >60°) necks (all p < .05 compared with IFU patients). Operative characteristics revealed that the non-IFU patients were more likely to be treated utilizing suprarenal fixation devices, to require placement of proximal cuffs (13.3% vs. 2.1%, p = .003), and needed increased fluoroscopy time (31 vs. 25 minutes, p = .02). Contrast dose was similar between groups (IFU = 118 mL, non-IFU = 119 mL, p = .95). There were no early or late surgical conversions. Rates of migration, endoleak, need for reintervention, sac regression, and freedom from aneurysm-related death were similar between the groups (p > .05). CONCLUSIONS: EVAR may be performed safely in high-risk patients with unfavorable neck anatomy using particular commercially available endografts. In our experience, the preferential use of active suprarenal fixation and aggressive use of proximal cuffs is associated with optimal results in these settings. Mid-term outcomes are comparable with those achieved in patients with suitable anatomy using a similar range of EVAR devices. Careful and mandatory long-term follow-up will be necessary to confirm the benefit of treating these high-risk anatomic patients.

Impact of endovascular repair on open aortic aneurysm surgical training.

PURPOSE: The purpose of this study was to determine the impact of an endovascular stent-graft program on vascular training in open aortic aneurysm surgery. METHODS: The institutional and vascular surgery fellow experience in aortic aneurysm repair during a 6-year period was reviewed. The 3-year period before introduction of endovascular repair was compared with the 3-year period after introduction of endovascular repair. All patients undergoing abdominal aortic aneurysm (AAA) or thoracoabdominal aortic aneurysm repairs were entered prospectively into a vascular registry and retrospectively analyzed to evaluate the changing patterns in aortic aneurysm treatment and surgical training. RESULTS: Between July 1994 and June 2000, a total of 588 patients with AAA or thoracoabdominal aneurysms were treated at Stanford University Medical Center. There were 296 (50%) open infrarenal AAA repairs, 87 (15%) suprarenal AAA repairs, 47 (8%) thoracoabdominal aneurysm repairs, and 153 (26%) endovascular stent-grafts. The total number of aneurysms repaired per year by vascular fellows before the endovascular program was 71.3 +/- 4.9 (range, 68-77) and increased to 124.7 +/- 35.6 (range, 91-162) after introduction of endovascular repair (P <.05). This increase was primarily caused by the addition of endovascular stent-graft repairs by vascular fellows (51.0 +/- 29.0/year [range, 23-81]). There was no change in the number of open infrarenal aortic aneurysm repairs per year, 53.0 +/- 6.6 (range, 48-56) before endovascular repair versus 47.0 +/- 1.7 (range, 46-49) after (P = not significant). There was a significant increase in the number of suprarenal AAA repairs per year by vascular fellows, 10.0 +/- 1.0 (range, 9-11) before endovascular repair compared with 19.0 +/- 6.5 (range, 13-26) after (P <.05). There was no change in the number of thoracoabdominal aneurysm repairs per year between the two groups, 8.0 +/- 3.0 (range, 4-11) before endovascular repair compared with 7.6 +/- 2.3 (range, 5-9) after. CONCLUSIONS: Introduction of an endovascular aneurysm stent-graft program significantly increased the total number of aneurysms treated. Although the number of open aneurysm repairs has remained the same, the complexity of the open aneurysm experience has increased significantly for vascular fellows in training.

Vascular complications in high-performance athletes.

PURPOSE: The purpose of this study was to evaluate our experience with the diagnosis and management of vascular injuries in a group of high-performance athletes. METHODS: Between June 1994 and June 2000, we treated 26 patients who sustained vascular complications as a result of athletic competition. Clinical presentation, type of athletic competition, location of injury, type of therapy, and degree of rehabilitation were analyzed retrospectively. RESULTS: The mean age of the patients was 23.8 years (range, 17-40). Twenty-one (81%) patients were men, and five (19%) were women. Athletes included 8 major-league baseball players, 7 football players, 2 world-class cyclists, 2 rock climbers, 2 wind surfers, 1 swimmer, 1 kayaker, 1 weight lifter, 1 marksman, and 1 volleyball player. There were 14 (54%) arterial and 12 (46%) venous complications. Arterial injuries included 7 (50%) axillary/subclavian artery or branch artery aneurysms with secondary embolization, 6 (43%) popliteal artery injuries, and 1 (7%) case of intimal hyperplasia and stenosis involving the external iliac artery. Subclavian vein thrombosis (SVT) accounted for all venous complications. Five of the seven patients with axillary/subclavian branch artery aneurysms required lytic therapy for distal emboli, and six required operative intervention. All popliteal artery injuries were treated by femoropopliteal bypass graft with autogenous saphenous vein. The external iliac artery lesion, which occurred in a cyclist, was repaired with limited resection and vein patch angioplasty. All 12 patients with SVT were treated initially with lytic therapy and anticoagulation. Eight patients required thoracic outlet decompression and venolysis of the subclavian vein. Thirteen arterial reconstructions have remained patent at an average follow-up of 31.9 months (range, 2-74). One patient with a popliteal artery injury required reoperation at 2 months for occlusion of his bypass graft. Eleven of the patients with an arterial injury were able to return to their prior level of competition. All of the patients with SVT have remained stable without further venous thrombosis and have returned to their usual level of activity. CONCLUSIONS: Athletes are susceptible to a variety of vascular injuries that may not be easily recognized. A high level of suspicion, a thorough workup including noninvasive studies and arteriography/venography, and prompt treatment are important for a successful outcome.

Lymphoscintigraphy in the diagnosis of lymphatic leak after surgical repair of femoral artery injury.

PURPOSE: Technetium-99m-labeled sulfur colloid lymphoscintigraphy is useful to evaluate lower extremity lymphatic circulation in cases of possible lymphedema and to reveal abnormal lymphatic collections. Groin lymphatic fistulas and lymphoceles are known complications of peripheral vascular surgical procedures. The authors describe a patient with ascites that developed into right lower extremity swelling after surgical repair of a femoral artery injury. Even after surgical ligation of multiple lymphatic channels, the patient continued to have lymphorrhea. It was unclear whether this was attributable to a persistent lymphatic leak or an ascitic leak from a postsurgical defect resulting in an abnormal connection with the peritoneal cavity. METHODS: Lymphoscintigraphy of the lower extremities was performed using Tc-99m sulfur colloid. Images were obtained at several intervals after injection of the radiotracer. Images were also acquired after the wound packing was removed. RESULTS: The images revealed an accumulation of radiotracer in the right groin, confirming the lower extremity lymphatic origin of the collection. CONCLUSIONS: Lymphoscintigraphy is useful to evaluate the origin of serous collections in the groin, a region in which lymphatic complications of vascular surgery are not uncommon.

Distal emboli as an unusual late complication of a thrombosed arteriovenous hemodialysis graft.

The creation of an arteriovenous fistula for long-term hemodialysis access is one of the most commonly performed procedures in vascular and transplantation surgery. Prosthetic conduits are frequently prone to failure within their first year of construction, and after one or two revisions, they are left in their thrombosed state as permanent subcutaneous foreign bodies in the extremities. Conventional teaching has regarded these chronically thrombosed grafts to have a benign natural history, and their removal has been considered unnecessary. We describe an unusual late complication of distal thromboemboli from a chronically occluded arteriovenous graft that was implanted 10 years before and appeared as acute hand ischemia.

Will endovascular repair replace open surgery for abdominal aortic aneurysm repair?

OBJECTIVE: To evaluate of the impact of endovascular aneurysm repair on the rate of open surgical repair and on the overall treatment of abdominal aortic aneurysms (AAAs). METHODS: All patients with AAA who were treated during two consecutive 40-month periods were reviewed. During the first period, only open surgical repair was performed; during the subsequent 40 months, endovascular repair and open surgical repair were treatment options. RESULTS: A total of 727 patients with AAA were treated during the entire period. During the initial 40 months, 268 patients were treated with open surgical repair, including 216 infrarenal (81%), 43 complex (16%), and 9 ruptured (3%) aortic aneurysms. During the subsequent 40 months, 459 patients with AAA were treated (71% increase). There was no significant change in the number of patients undergoing open surgical repair and no significant difference in the rate of infrarenal (238 [77%]) and complex (51 [16%]) repairs. A total of 353 patients were referred for endovascular repair. Of these, 190 (54%) were considered candidates for endovascular repair based on computed tomography or arteriographic morphologic criteria. Analyzing a subgroup of 123 patients, the most common primary reasons for ineligibility for endovascular repair were related to morphology of the neck in 80 patients (65%) and of the iliac arteries in 35 patients (28%). A total of 149 patients underwent endovascular repair. Of these, the procedure was successful in 147 (99%), and 2 (1%) patients underwent surgical conversion. The hospital death rate was 0%, and the 30-day death rate was 1%. During a follow-up period of 1 to 39 months (mean 12 +/- 9), 21 secondary procedures to treat endoleak (20) or to maintain graft limb patency (1) were performed in 17 patients (11%). There were no aneurysm ruptures or aneurysm-related deaths. CONCLUSIONS: Endovascular repair appears to have augmented treatment options rather than replaced open surgical repair for patients with AAA. Patients who previously were not candidates for repair because of medical comorbidity may now be safely treated with endovascular repair.

Endovascular repair of abdominal aortic aneurysms: eligibility rate and impact on the rate of open repair.

OBJECTIVE: The purpose of this study was to determine the rate of eligibility among patients with abdominal aortic aneurysms (AAAs) considered for endovascular repair and to examine the effect of an endovascular program on the institutional pattern of AAA repair. METHODS: All patients evaluated for endovascular AAA repair since the inception of an endovascular program were reviewed for determination of eligibility rates and eventual treatment. Open AAA repairs were categorized as simple (uncomplicated infrarenal), complex (juxtarenal, suprarenal, thoracoabdominal, infected), or ruptured, and their rates before and after initiation of an endovascular program were compared. RESULTS: Over 3 years, 324 patients were considered for endovascular AAA repair; 176 (54%) were candidates, 138 (43%) were not candidates, and 10 (3%) did not complete the evaluation. The rate of eligibility increased significantly from 45% (66/148 patients) during the first half of this period to 63% (110/176 patients) during the second half (P <. 001). Candidates were significantly younger (74.4 +/- 7.6 years) than noncandidates (78.3 +/- 6.7 years) (P <.01), and their aneurysm diameter tended to be smaller (57.6 +/- 9.2 mm compared with 60.8 +/- 12.3 mm; P =.06). The most common reason for ineligibility was an inadequate proximal aortic neck. Of 176 candidates, 78% underwent endovascular repair, and 6% underwent open repair. Of 138 noncandidates, 56% underwent surgical repair. Over a period of 6 years, 542 patients with AAAs (429 simple, 86 complex, 27 ruptured) underwent open repair. The total number and ratio of simple to complex open repairs for nonruptured aneurysms during the 3 years before the initiation of the endovascular program (213 simple, 44 complex) were not significantly different from the repairs over the subsequent 3-year period (216 simple, 42 complex). Similarly, no difference in the total number and the ratio of simple to complex open repairs was found between the first and the second 18-month periods since the initiation of the endovascular program. CONCLUSIONS: The rate of eligibility of patients with AAA for endovascular repair appears to be higher than previously reported. The presence of an active endovascular program has not decreased the number or shifted the distribution of open AAA repair.

Institutional peer review can reduce the risk and cost of carotid endarterectomy.

HYPOTHESIS: Surgeon-directed institutional peer review, associated with positive physician feedback, can decrease the morbidity and mortality rates associated with carotid endarterectomy. DESIGN: Case series. SETTING: Tertiary care university teaching hospital. PATIENTS/INTERVENTIONS: All patients undergoing carotid endarterectomy at our institution during a 5-year period ending August 1998. RESULTS: Stroke rate decreased from 3.8% (1993-1994) to 0% (1997-1998). The mortality rate decreased from 2.8% (1993-1994) to 0% (1997-1998). Length of stay decreased from 4.7 days (1993-1994) to 2.6 days (1997-1998). The total cost decreased from $13,344 (1993-1994) to $9548 (1997-1998). CONCLUSIONS: An objective, confidential peer review process that provides ongoing feedback of performance to surgeons and documents that performance in relationship with that of peers seems to be effective in reducing the morbidity and mortality rate associated with carotid endarterectomy. In addition, the review process lowered the hospital cost of performing carotid endarterectomy.

Surgical intervention is not required for all patients with subclavian vein thrombosis.

PURPOSE: The role of thoracic outlet decompression in the treatment of primary axillary-subclavian vein thrombosis remains controversial. The timing and indications for surgery are not well defined, and thoracic outlet procedures may be associated with infrequent, but significant, morbidity. We examined the outcomes of patients treated with or without surgery after the results of initial thrombolytic therapy and a short period of outpatient anticoagulation. METHODS: Patients suspected of having a primary deep venous thrombosis underwent an urgent color-flow venous duplex ultrasound scan, followed by a venogram and catheter-directed thrombolysis. They were then converted from heparin to outpatient warfarin. Patients who remained asymptomatic received anticoagulants for 3 months. Patients who, at 4 weeks, had persistent symptoms of venous hypertension and positional obstruction of the subclavian vein, venous collaterals, or both demonstrated by means of venogram underwent thoracic outlet decompression and postoperative anticoagulation for 1 month. RESULTS: Twenty-two patients were treated between June 1996 and June 1999. Of the 18 patients who received catheter-directed thrombolysis, complete patency was achieved in eight patients (44%), and partial patency was achieved in the remaining 10 patients (56%). Nine of 22 patients (41%) did not require surgery, and the remaining 13 patients underwent thoracic outlet decompression through a supraclavicular approach with scalenectomy, first-rib resection, and venolysis. Recurrent thrombosis developed in only one patient during the immediate period of anticoagulation. Eleven of 13 patients (85%) treated with surgery and eight of nine patients (89%) treated without surgery sustained durable relief of their symptoms and a return to their baseline level of physical activity. All patients who underwent surgery maintained their venous patency on follow-up duplex scanning imaging. CONCLUSION: Not all patients with primary axillary-subclavian vein thrombosis require surgical intervention. A period of observation while patients are receiving oral anticoagulation for at least 1 month allows the selection of patients who will do well with nonoperative therapy. Patients with persistent symptoms and venous obstruction should be offered thoracic outlet decompression. Chronic anticoagulation is not required in these patients.

Internal iliac artery embolization in the stent-graft treatment of aortoiliac aneurysms: analysis of outcomes and complications.

PURPOSE: To analyze the complications of internal iliac artery (IIA) embolization in conjunction with stent-graft treatment of aortoiliac aneurysms. MATERIALS AND METHODS: Seventy-one patients with aortoiliac (n = 47) or iliac (n = 24) aneurysms were treated with endoluminal placement of stent-grafts. Thirty-two patients (31 men, one woman; mean age, 73 years; range, 56-88 years) had embolization or occlusion of one (n = 27) or both (n = 5) IIAs. Status of the IIAs and the collateral circulation was assessed by retrospective review of angiographic images. Follow-up consisted of a standardized patient questionnaire and review of radiologic and medical records. RESULTS: The mean follow-up time was 35 months (range, 5-64 months). Eleven of the 47 patients with abdominal aortic aneurysms (AAA) (23%) and 19 of the 24 patients with iliac aneurysms (79%) required IIA embolization. One patient with AAA and another with iliac aneurysm had unintentional occlusion of an IIA by extension of the stent-graft over their origins. A total of seven patients had bilateral occlusion of the IIAs after the procedure. Additionally, the inferior mesenteric arteries (IMAs) of two other patients with AAA were also embolized. In six patients, all three vessels were occluded after placement of the stent-grafts. Symptoms were reported in nine of the 20 (45%) patients with iliac aneurysms and in three of the 12 (25%) patients with AAA. Symptoms consisted of buttock claudication (nine of 32, 28%), new sexual dysfunction (two of 16, 12%), and transient urinary retention (3%). Seven of the claudicants had resolution of symptoms after a mean interval of 14 months (range, 1-36 months). There were no instances of bowel ischemia, neurologic sequelae, or buttock necrosis related to these procedures. CONCLUSION: Embolization of the IIA is associated with symptoms in a significant number of patients. While symptoms are transient in most patients, they can be problematic. Efforts should be made to preserve the pelvic circulation if possible.

A comparison of 4 intraoperative methods to determine femoral component rotation during total knee arthroplasty.

A total of 100 consecutive posterior cruciate-retaining total knee arthroplastics were performed in 81 patients with an average age of 69 years by 1 surgeon. Diagnoses included osteoarthritis in 93 knees and rheumatoid arthritis in 7 knees. The femoral alignment necessary to create a rectangular flexion gap was determined and compared with Whiteside's line, the transepicondylar axis, and a line in 3 degrees of external rotation relative to the posterior condyles of the femur. The transepicondylar axis most consistently recreated a balanced flexion space, whereas 3 degrees of external rotation off the posterior condyles was least consistent, especially in valgus knees.

The Ranawat Award. Femoral component rotation during total knee arthroplasty.

One-hundred consecutive posterior cruciate retaining total knee arthroplasties were performed by one surgeon in 81 patients with an average age of 69 years. Diagnoses included osteoarthritis in 93 knees and rheumatoid arthritis in seven. The femoral alignment necessary to create a rectangular flexion gap was determined and compared with Whiteside's line, the transepicondylar axis, and a line in 3 degrees external rotation relative to the posterior condyles of the femur. The transepicondylar axis most consistently recreated a balanced flexion space whereas 3 degrees external rotation off the posterior condyles was least consistent especially in knees in valgus.

Reoperation for carotid stenosis is as safe as primary carotid endarterectomy.

PURPOSE: Patients with recurrent carotid artery stenosis are sometimes referred for carotid angioplasty and stenting because of reports that carotid reoperation has a higher complication rate than primary carotid endarterectomy. The purpose of this study was to determine whether a difference exists between outcomes of primary carotid endarterectomy and reoperative carotid surgery. METHODS: Medical records were reviewed for all carotid operations performed from September 1993 through March 1998 by vascular surgery faculty at a single academic center. The results of primary carotid endarterectomy and operation for recurrent carotid stenosis were compared. RESULTS: A total of 390 operations were performed on 352 patients. Indications for primary carotid endarterectomy (n = 350) were asymptomatic high-grade stenosis in 42% of the cases, amaurosis fugax and transient ischemic symptoms in 35%, global symptoms in 14%, and previous stroke in 9%. Indications for reoperative carotid surgery (n = 40) were symptomatic recurrent lesions in 50% of the cases and progressive high-grade asymptomatic stenoses in 50%. The results of primary carotid endarterectomy were no postoperative deaths, an overall stroke rate of 1.1% (three postoperative strokes, one preoperative stroke after angiography), and no permanent cranial nerve deficits. The results of operations for recurrent carotid stenosis were no postoperative deaths, no postoperative strokes, and no permanent cranial nerve deficits. In the primary carotid endarterectomy group, the mean hospital length of stay was 2.6 +/- 1. 1 days and the mean hospital cost was $9700. In the reoperative group, the mean length of stay was 2.6 +/- 1.5 days and the mean cost was $13,700. The higher cost of redo surgery is accounted for by a higher preoperative cerebral angiography rate (90%) in redo cases as compared with primary endarterectomy (40%). CONCLUSION: In this series of 390 carotid operations, the procedure-related stroke/death rate was 0.8%. There were no differences between the stroke-death rates after primary carotid endarterectomy and operation for recurrent carotid stenosis. Operation for recurrent carotid stenosis is as safe and effective as primary carotid endarterectomy and should continue to be standard treatment.

Subclavian vein thrombosis: outcome analysis based on etiology and modality of treatment.

Therapeutic options for subclavian vein thrombosis (SVT) include anticoagulation, thrombolysis, endovascular repair, and direct surgical intervention. The most effective method of treatment remains undetermined. We reviewed our institutional experience over 7 years with SVT patients to compare the results of treatment based on etiology of thrombosis. Nineteen patients suffered SVT secondary to malignancy, catheter placement, radiation, or hypercoagulability. Thirteen were Paget-Schroetter (PSS), or primary effort-related SVT. Patients with dialysis access procedures were excluded. Thrombolysis was initiated in 31/32 patients. Success was defined as complete obliteration of clot. Adjunctive treatment to relieve external compression or improve lumenal contour was performed on 16/32 patients (eight PSS, eight secondary SVT). Success of adjunctive treatment was defined as return to baseline activity without symptoms. Objective follow up (venography or duplex scanning) was included when available. Adjunctive treatment included balloon angioplasty (6), stent placement (5), first rib resection and scalenectomy (4), and vein reconstruction (4). Initial treatment success with thrombolysis was achieved in 26/31 patients (84%). Angioplasty failed in three PSS and three secondary SVT patients. Stent placement was successful in 2/5 patients (both secondary SVT). Surgery was performed only on PSS patients: first rib resection and scalenectomy succeeded 4/4 times, vein reconstruction 2/4. Twenty-eight patients were given long-term therapy with oral anticoagulation with good long-term results. Seven patients experienced complications, including one death. Results of SVT therapy including thrombolysis and oral anticoagulation are very good. Angioplasty and stent placement in secondary SVT patients appears to add little long term benefit. Surgery may improve outcome in selected PSS patients, although the additional benefit could not be determined by the design of this study. Evaluation and treatment limited only to PSS excludes the majority of SVT patients.

Extension metacarpal osteotomy in the treatment of trapeziometacarpal osteoarthritis: a biomechanical study.

The biomechanical effects of extension metacarpal osteotomy on contact pressures in the trapeziometacarpal joint during lateral pinch were studied in 20 anatomic specimens using pressure-sensitive film. The gross appearance of joint surfaces was classified by severity of arthritic disease and correlated with specimen x-ray films taken before the osteotomy. Extension metacarpal osteotomy effectively unloaded the palmar contact area in nonarthritic and moderately arthritic specimens; primary contact areas and zones of peak pressure were shifted from the diseased palmar compartment to the normal dorsal compartment. In contrast, the pathologically congruent contact pattern seen in end-stage osteoarthritic joints was unaffected by osteotomy. The data demonstrate the efficacy of extension metacarpal osteotomy in unloading the palmar contact areas of normal and moderately arthritic joints but provide no biomechanical rationale for metacarpal osteotomy as originally described in treatment of advanced trapeziometacarpal osteoarthritis.

Phlegmasia complicating prophylactic percutaneous inferior vena caval interruption: a word of caution.

PURPOSE: The purpose of this study was to evaluate the incidence of thrombotic complications in patients with deep vein thrombosis (DVT) who were treated with percutaneous inferior vena caval interruption in place of anticoagulation. METHODS: A retrospective review of all percutaneously placed inferior vena cava filters for 1 year, August 1993 through July 1994, was performed. RESULTS: Thirty-three percutaneous inferior vena cava filters were placed in 32 patients. The underlying disease was pulmonary embolism in 15 (47%) and DVT in 17 (53%) patients. Of patients with pulmonary embolism, 11 had a documented DVT, and four were not evaluated for DVT. There were 14 men and 18 women, with a mean age of 63.5 years (range 24 to 93 years). Indications for vena caval interruption were recurrent pulmonary embolism with therapeutic anticoagulation (n = 2 [6%]), prophylactic insertion with documented pulmonary embolism and therapeutic anticoagulation (n = 8 [25%]), documented pulmonary embolism and absolute contraindication to anticoagulation (n = 5 [16%]), documented DVT and absolute contraindication to anticoagulation (n = 2 [6%]), prophylactic insertion with documented DVT and therapeutic anticoagulation (n = 5 [16%]), and documented DVT with relative contraindication to anticoagulation (n = 10 [31%]). Of the 32 patients with inferior vena cava filters, 17 were not given anticoagulants (7 absolute contraindications, 10 relative contraindications), and 15 were given anticoagulants. Insertion of a percutaneous inferior vena cava filter in patients who were not given anticoagulants was followed by the development of phlegmasia cerulea dolens in four patients (24%), which was bilateral in two patients; one patient eventually died. No patients treated with inferior vena cava filter and anticoagulation had development of phlegmasia. CONCLUSIONS: Percutaneous inferior vena caval interruption effectively prevents pulmonary embolism in patients with DVT but does not impact the underlying thrombotic process and in fact may contribute to progressive thrombosis in patients who are not given anticoagulants. Anticoagulation with intravenous heparin in safe and effective therapy for DVT in most patients. We believe that percutaneous insertion of vena cava filters should not replace anticoagulation in routine proximal DVT, and those patients who require an inferior vena cava filter for failure of anticoagulation should continue to receive heparin to treat the primary thrombotic process. We caution that relative contraindications to anticoagulation should be carefully scrutinized before recommending vena cava interruption as a primary therapy for DVT.

Contact patterns in the trapeziometacarpal joint: the role of the palmar beak ligament.

Twenty-three cadaver forearm specimens were mounted on a Plexiglas acrylic plastic base for study of the trapeziometacarpal joint. Extrinsic and intrinsic motors were loaded to simulate lateral pinch, and pressure-sensitive film was used to record joint contact patterns in various functional positions. The palmar compartment of the trapeziometacarpal joint was the primary contact area during flexion adduction of the thumb ray in lateral pinch. Simulation of dynamic pinch and release produced dorsal enlargement of the contact pattern, suggesting physiologic translation of the metacarpal on the trapezium. Detachment of the palmar beak ligament resulted in dorsal translation of the contact area, producing a pattern similar to that of cartilage degeneration seen in the osteoarthritic joint. End-stage osteoarthritic specimens had a nonfunctional beak ligament and demonstrated a pathologic total contact pattern of joint congruity that was unaffected by further manipulations of the beak ligament. This work defines the contact patterns in the normal and diseased trapeziometacarpal joint and establishes the important influence of the palmar beak ligament on those contact areas.