The impact of HPV cervical screening on negative large loop excision of the transformation zone (LLETZ): A comparative cohort study.

OBJECTIVE: To determine the incidence and predictors of negative large loop excision of the transformation zone (LLETZ) following the introduction of Human Papillomavirus (HPV) cervical screening. METHOD: A retrospective cohort study. Two independent cohorts, who attended for a LLETZ procedure, before and after the introduction of HPV cervical screening were compared. For each cohort, 401 individuals were randomly selected from a colposcopy database. Clinical and colposcopic variables were extracted. The incidence of negative LLETZ was estimated in each cohort. Regression analysis was used to adjust for potential confounders and explore predictors of negative LLETZ. RESULTS: Eighty women (19.9%) from the pre-HPV testing cohort and 54 women (13.4%) from the post-HPV cohort were negative for cervical intraepithelial neoplasia (RR 0.75, CI: 0.55 to 0.93). In the post-HPV testing cohort, independent predictors of negative LLETZ were low grade cytology (RR 3.60, CI: 2.18-5.97) and a type 3 transformation zone (TZ) (RR 2.88, CI: 1.76-4.72). Women with both low grade cytology and a TZ type 3 were 10.4 times more likely to have a negative LLETZ (absolute risk 40%, 95% CI: 27-54%). CONCLUSIONS: Despite a 25% reduction in negative LLETZ following the introduction of HPV cervical screening, the incidence is still high. These results highlight the importance of continuing to improve the specificity of cervical intraepithelial neoplasia screening; this should include the use of biomarkers that detect HPV-transforming infections and techniques that sample an entirely endocervical transformation zone.

The St. Jude valve prosthesis: analysis of the clinical results in 815 implants and the need for systemic anticoagulation.

Between July 1979 and December 1984, 785 patients received 815 St. Jude Medical valve prostheses. Valve-related mortality in the follow-up period was due to thromboembolism in seven cases, anticoagulant-related hemorrhage in three and perivalvular leak in two. Freedom from valve-related death or reoperation at 3 years was 96.4% for aortic valve replacement and 98.3% for mitral valve replacement. The overall rate of thromboembolism was 2.6%/patient-year with warfarin, 9.2%/patient-year with antiplatelet medication and 15.6%/patient-year in patients with no anticoagulant therapy. One episode of thrombotic obstruction of a mitral valve, in a patient receiving no anticoagulant therapy, resulted in an occurrence rate of such obstruction of 0.22%/patient-year. Valve replacement with the St. Jude valve produced excellent clinical results, but long-term anticoagulation with warfarin was required to minimize thromboembolic complications. The use of antiplatelet agents alone provided inadequate protection.

Renovascular reconstruction: factors affecting long-term prognosis in 919 patients followed up to 31 years.

During the 31-year period from May 3, 1955, to May 12, 1986, renovascular reconstructions were performed on 919 patients. The mean age of the 529 men was 54 +/- 0.58 (SE) years and, of the 390 women, 48 +/- 0.7 years. Mean preoperative diastolic blood pressure was 110 +/- 0.6 mm Hg. The most common causes of renal artery stenosis were atherosclerosis in 647 patients, fibromuscular disease in 161 patients, and renal artery aneurysm in 51 patients. In the remaining 60 patients, other causes were present, including kinks and fibrous bands. The most common surgical procedures were Dacron bypass graft (780 arteries) and endarterectomy with or without a patch graft (329 arteries). Four hundred sixty-nine patients had associated operations, the most common of which were abdominal aortic aneurysmectomy in 231 and aortoiliofemoral reconstruction in 141 patients. The perioperative mortality rate was 5.5% (51 of 919 overall); for renal procedures alone, it was 1.7% (8 of 450) and for combined surgical procedures, 9.2% (43 of 469). The overall graft patency rate at a follow-up of 18.8 +/- 1.9 months was 88.6% (381 of 430) and at a second follow-up of 50 +/- 4.3 months, 86.7% (111 of 128). Analysis of long-term blood pressure response and factors affecting late survival indicated that patients with preoperative diastolic pressures of greater than 100 mm Hg and renal artery stenosis of greater than 70% had the best blood pressure responses and that male sex, increasing age, bilateral renal stenosis, and associated vascular operations lowered the survival rate whereas fibromuscular disease enhanced the duration of survival.(ABSTRACT TRUNCATED AT 250 WORDS)

Vein graft patency and intimal proliferation after aortocoronary bypass: early and long-term angiopathologic correlations.

To determine the clinical significance of intimal proliferation as a cause of aortocoronary bypass vein graft obstruction, 492 vein grafts from 281 patients were studied 0 to 75 months postoperatively. All grafts had been inserted between 1968 and 1975 by one surgeon using one technique. The graft patency rate was 92 percent (55 to 60) in the first month; 91 percent (49 of 54) at 1 to 3 months; 84 percent (37 to 44) at 4 to 6 months; 77 percent (33 of 43) at 7 to 12 months; 81 percent (113 of 140) at 13 to 24 months; 82 percent (59 of 72) at 25 to 36 months; and 84 percent (66 of 79) at 37 to 75 months. Vein graft samples were obtained from 41 patients: In 27 patients with 51 grafts (early group), they were obtained 0 to 30 days (mean 14 days) postoperatively; in 14 patients with 27 grafts (late group) they were obtained 7 to 75 months (mean 34 months) postoperatively. Intimal proliferation was graded 1 to 4 corresponding to an intima/media thickness ratio of 1,2,3 or 4, respectively. In the early group, all 51 vein grafts howed grade 1 to 2 intimal proliferation; 5 of these grafts were occluded, all as a result of recent thrombosis. In the late group, 17 of the 27 grafts were studied histologically. All patent vein grafts showed grade 2 to 3 intimal prolferation. Four vein grafts were occluded but only one as a result of grade 4 intimal proliferation. In 14 patients in the late group, angiograms performed shortly before vein graft samples were obtained revealed 14 patent and 4 occluded vein grafts. Ten of the 14 patent vein grafts showed grade 2 to 3 intimal proliferation but were of uniformly good caliber angiographically (graft/artery ratio more than 1.5).

Fortuitous rupture of aortic aneurysm: a catastrophic event affording time for surgical cure.

The rupture of an aortic aneurysm is generally a fatal event, but occasionally the rupture will occur into an adjacent vascular structure, thereby preventing exsanguination and affording temporary survival. Three cases are presented illustrating the fortuitous nature of the rupture of an aortic aneurysm into a vascular structure. The first patient had an atherosclerotic abdominal aortic aneurysm that ruptured into the inferior vena cava and was successfully repaired. The second case demonstrates the formation of a fistula from the aorta to the left pulmonary artery in a patient with a syphilitic thoracic aortic aneurysm. In the third patient a dissecting aneurysm of the aortic root that communicated with the right ventricle after coronary bypass surgery was successfully repaired. Rarely, aortic aneurysms will rupture fortuitously into vascular capacitance structures. These three cases emphasize the need for early accurate diagnosis and the institution of appropriate surgical measures.

Patterns of patency of 596 vein grafts up to seven years after aorta-coronary bypass.

The long-term behavior of vein grafts and their effect on the native circulation were studied by examining 596 vein grafts in 343 patients at a mean follow-up of 15.4 months, range zero to 84 months. Serial studies were performed on 27 patients with 38 grafts. The over-all graft patency rate was 84 per cent, and the rate after more than 5 years was 89 per cent. The patency rate in asymptomatic patients was 91 per cent compared with 81 per cent in the remainder. The patency of grafts attached distal to total occlusions was 82 per cent (78/82). The angle of origin of the grafts from the aorta did not appear to influence patency or the severity of intimal proliferative changes. In 76 patients with 126 grafts, pre- and postoperative cineangiograms were compared, and changes in the graft and underlying coronary artery classified as Groups 1 to to 6: Group 1, patent graft, bidirectional flow in the grafted vessel, proximal lesion unchanged; Group 2, patent graft, bidirectional flow, proximal lesion progressed to occlusion locally; Group 3; patent graft, distal flow only, occlusion of lesion and segment between graft and lesion; Group 4, graft occluded, native artery unaltered; Group 5, graft occluded, native artery now occluded at lesion and region of anastomosis; Group 6, new distal lesion. Results were as follows; Group 1, 58 per cent; Group 2, 21.2 per cent; Group 3, 5 per cent, Group 4, 12.5 per cent; Group 5, 2.5 per cent; and Group 6, 0.8 per cent. Native coronary arteries undergoing closure (Group 2) had lesions 95 per cent or greater in 93 per cent of patients. The rate of closure of ungrafted lesions was 2 per cent. We believe these results encourage the continued used of vein bypass grafts.

Long-term results of treatment of the totally occluded renal artery in forty patients with renovascular hypertension.

A study of 40 patients with renovascular hypertension and a totally occluded renal artery was made to determine the optimal management of such lesions. There were 20 men and 20 women, ranging in age from 9 to 73 years (mean age, 51.4 years). Associated contralateral renal artery stenosis was present in 31 patients. Twenty-one patients underwent reconstruction of the occluded renal artery; 15 of the 21 experienced long-term success (up to 223 months) and six experienced failure. Sixteen patients underwent follow-up arteriography. The 14 patients who were treated by primary nephrectomy and reconstruction of a contralateral stenotic kidney had excellent results. In five patients, only a contralateral reconstruction was performed. Factors that were analyzed to determine the best predictors of success included age, sex, total renal function, contralateral reconstruction, associated vascular procedure, surgical technique, nephrogram or excretion of dye on intravenous pyelography, visualization of the distal renal artery on aortography, length of the kidney, and weight and pathology of the nephrectomy specimens. Only the size and weight of the kidney were consistent predictors of outcome. The preoperative demonstration of function in the kidney supplied by a totally occluded renal artery was unimportant. As a result of this study, we recommend reconstruction only for kidneys > 9.5 cm in length and nephrectomy or no treatment for smaller kidneys supplied by totally occluded renal arteries except when preservation of renal tissue is important. In such cases, revascularization of a small kidney can be accomplished but is associated with a significant risk of subsequent nephrectomy.

Resection of abdominal aortic aneurysm in the presence of horseshoe kidney.

We report four cases of abdominal aortic aneurysm associated with horseshoe kidney. These cases illustrate the factors that determine the ease of resection in this situation: whether the isthmus of the kidney is parenchymatous or thin and fibrous; the presence or absence of anomalous renal arteries; and the origin of the arterial supply of the renal isthmus. Although the technical challenges involved in aneurysm resection in the presence of horseshoe kidney are significant, these cases illustrate that standard resection and replacement of the aneurysm with a prosthetic graft usually should be possible.

Celiac axis, superior mesenteric artery, and inferior mesenteric artery occlusion: surgical considerations.

Occlusion of the celiac, superior mesenteric, and inferior mesenteric artery has been studied in 46 patients treated by operation. The condition was acute and was caused by embolic obstruction of the superior mesenteric artery in four cardiac patients and detachment of the inferior mesenteric artery in two patients during removal of infrarenal abdominal aortic aneurysms. The condition was chronic and involved two or all three of the vessels in 40 patient. Embolic obstruction caused severe abdominal pain but few physical signs early in the process,, but the picture of an acute abdomen indicating bowel gangrene developed in a few hours. Ischemia from inferior mesenteric detachment was observed at operation. Patients with chronic obstruction had abdominal pain, weight loss, and diarrhea. Patients with embolic obstruction were treated successfully by embolectomy, and patients developing intraoperative sigmoid ischemia were treated by reattachment of inferior mesenteric arteries to aortic graft. Various procedures were employed in patients with chronic multiple obstruction. However, graft bypass using Dacron tubing was preferable because of its simplicity and because the frequently (48%) associated occlusive disease and aneurysm of the distal aorta were treated at the same time. Confining operation to the abdomen significantly reduced the magnitude of operation and eliminated risks in this age group. Of the 46 patients, 91% survived and were relieved of their symptoms despite associated disease. The 5-year survival rate in this group of patients was 62%.

Improved results of operation for ruptured abdominal aortic aneurysms.

Of 1,393 consecutive patients operated on for aneurysm of the abdominal aorta between 1964 and 1978, 61 consecutive patients had undergone emergency operation for ruptured abdominal aortic aneurysm, for an incidence of 4.4% (61 of 1,393). There were 57 men and four women; their mean age was 77.5 years, with a range of 49 to 93 years. In 21 patients the diagnosis of aneurysm had been known from 1 day to 5 years prior to rupture. Hypotension (less than 100 mm Hg systolic) was present in 27.9% of patients (17 of 61) on admission to hospital and prior to operation in a total of 44.3% patients (27 of 61). Operation was begun in eight patients with an initially unrecordable blood pressure. The perioperative mortality rate (30 day) was 14.8% (nine of 61). The two factors most influencing survival were age [no patient younger than 60 years died vs. 40% of patients (four of 10) older than 80 years] and the magnitude of blood loss (survivors lost a total of 4,513 ml vs. 8,500 ml in those who died). Thus the most common cause of death was myocardial infarction (six of eight) in elderly patients, secondary to poorly tolerated severe hypovolemia. The results of this study suggest the need for avoidance of technical problems during operations, earlier referral of patients with known abdominal aortic aneurysms, especially the elderly, and early diagnosis with immediate operation for ruptured aneurysms.

Surgical treatment of renovascular hypertension. Long-term follow-up of 216 patients up to 20 years.

During a period of 20 years, 216 patients between the ages of 19 and 76 years underwent renal artery reconstruction for correction of renovascular hypertension. Reconstruction was bilateral in 18% of the patients. A transperitoneal approach was used in all cases. The most commonly used reconstructions were aortoneal bypass in 43% of the patients, thromboendarterectomy with primary closure or patch in 26%, and nephrectomy in 11%. There were 13 late nephrectomies. There was no operative mortality. Postoperatively, blood pressure was normal in 85% of the patients, improved in 11% and unchanged in 2%. Follow-up was one to 20 years. Actuarial survival at five years was 93%, at ten years 80%, and at 20 years 70%. Normal blood pressure was present at five years in 81% of the survivors, at ten years in 77%, and at 15 years in 74%. The results indicate the excellent long-term results of renovascular reconstruction for renovascular hypertension in appropriate patients.

Suture material as a factor in the occurrence of anastomotic false aneurysms. An analysis of 26 cases.

False aneurysm formation is a well-recognized late complication of prosthetic graft insertion. Despite the fact that other etiologic factors may be involved, the behavior of the suture material remains of central importance. In a retrospective review of 1,330 peripheral vascular cases, we found 26 cases involving a total of 39 false aneurysms, or an incidence of 2% (26/1,330). Twenty-four of these were directly attributable to failure of the monofilament plastic suture or silk suture material. Braided Dacron suture was used in the original anastomosis in another seven cases, and in these instances the false aneurysms were not related to suture failure but were association with such factors as previous endarterectomy, failure of arterial wall, and chronic hypertension. None of the 39 aneurysms was secondary to infection or trauma. These results emphasize the importance of using a braided, nonabsorbable suture material to ensure the continued integrity of an anastomosis involving prosthetic grafts.

Renal artery aneurysm. Long-term relief of renovascular hypertension by in situ operative correction.

Renal artery aneurysm is an uncommon cause of renovascular hypertension. Nephrectomy or, more recently ex vivo arterial reconstruction have been recommended as the treatment of choice. In contrast, we advocate in situ repair of the aneurysm and any associated lesions. Twenty-five hypertensive patients with 30 renal artery aneurysms were treated by tangential aneurysmectomy with primary arteriorrhaphy, saphenous vein patch angioplasty, or bypass graft. Nephrectomy was performed in two patients, one for a ruptured aneurysm. There was no operative mortality. Follow-up was obtained on all patients six months to 19 years after operation. Hypertension was relieved immediately and in the long-term in the majority of survivors. We believe these results indicate that despite the presence of severe renovascular disease, the affected kidney can be preserved and hypertension successfully relieved by a direct surgical approach without recourse to either nephrectomy or ex vivo reconstruction.

Late repair of coarctation of the descending thoracic aorta in 190 patients. Results up to 30 years after operation.

Over a 30-year period, 190 consecutive patients had repair of coarctation of the descending thoracic aorta at a mean age of 25 years (range, 1 to 60 years); 130 were male. Median preoperative blood pressure (BP) was as follows: systolic, 160 mm Hg (range, 94 to 300 mm Hg) and diastolic, 90 mm Hg (range, 50 to 160 mm Hg). Dacron grafts were used in 64.7% of patients. Follow-up was obtained at a mean interval of 84.9 months, range, one to 360 months. Survival status was established for 86.1% (163/190) of patients. Postoperatively, the median BP was 133 mm Hg systolic (range, 90 to 195 mm Hg) and 80 mm Hg diastolic (range, 50 to 120 mm Hg). Overall, 80% of patients were either normotensive or had mild hypertension after operation. The best BP response and late survival were in patients operated on under 13 years of age. This study further confirms that early operation (below 5 years of age) is desirable. However, contrary to some previous reports, patients operated on as adolescents, despite some mild residual hypertension, had an excellent long-term prognosis. Patients over 21 years of age at operation had a high rate of persistent hypertension and experienced other serious cardiovascular complications.

An improved introducer for the sutureless myocardial pacemaker lead.

Although the sutureless myocardial pacemaker lead has proved a useful advance, the introducer supplied with it has had the disadvantages of requiring bimanual operation, creating forces directed toward the myocardium, and producing release of the lead head in a rotating motion. An improved introducer, described here, has overcome these problems and has further simplified the application of this useful device.

Acute and chronic stimulation thresholds of intramyocardial screw-in pacemaker electrodes.

Two screw-in intramyocardial electrodes were inserted in the left ventricle of each of 6 mongrel dogs, and the electrical characteristics were studied over a six-month period. The unipolar lead configuration had consistently better threshold and sensing values than the bipolar configuration during this period. Peaking between implantation and 3 weeks later, mean lead thresholds increased significantly (unipolar, 0.4 to 8.2 mu J; bipolar, 0.6 to 10.2 mu J) while R wave amplitude decreased (unipolar, 16.6 to 8.5 mv; bipolar, 10.6 to 5.8 mv). Mean chronic values for stimulation thresholds were as follows: unipolar, 2.6 mu J, and bipolar, 3.1 mu J. Mean values for the R wave amplitude were as follows: unipolar, 10.6 mv, and bipolar, 7.2 mv. Analysis of the results indicated that with certain exceptions, the optimum system has 2 intramyocardial electrodes, 1 in unipolar configuration and 1 "reserve." In general, adequate values at implantation are a stimulation threshold of 1.4 mu J (e.g., 1.1 v at 500 ohms and 0.6 msec pulse width) and an R wave amplitude of 5 mv.

Aortocoronary saphenous vein autograft accidentally attached to a coronary vein: follow-up angiography and surgical correction of the resultant arteriovenous fistula.

The fate of aortocoronary saphenous vein bypass graft to the left anterior descending (LAD) coronary vein is reported. The vein graft communicated with the coronary sinus through the proximal LAD vein, producing a functional coronary arteriovenous fistula. The LAD vein was totally occluded distally at follow-up four months after operation. The natural history of congenital fistulas between coronary arteries and the coronary sinus suggested that bacterial endocarditis, pulmonary hypertension, and cardiac failure were all possible future complications in this patient. Operation was performed to revascularize the LAD artery to relieve persistent angina, and to close the fistula. Postoperative angiography showed a patent graft to the LAD artery with complete obliteration of the fistula. The patient is asymptomatic ten months after operation.

Determinants of survival 10 to 14 years after coronary bypass: analysis of preoperative variables in 1,448 patients.

To determine which preoperative variables were most predictive of long-term survival after coronary bypass surgery, the status of 1,448 consecutive patients was determined 10 to 14 years after operation. All patients were operated on at least 10 years ago and follow-up at 10 years was 93.8% complete. The overall 14-year survival probabilities were: for one-vessel disease, 73.3%; for two-vessel disease, 45.9%; for three-vessel disease, 34.2%; and for left main coronary artery disease, 41.9%. Patients with good left ventricular function had an overall survival rate of 53.3%, and patients with poor ventricular function had a survival rate of 31.9%. Preoperative variables predictive of greater risk of total mortality were: digoxin usage, multivessel disease, poor quality of left ventricular function, age at operation, electrocardiographic evidence of myocardial infarction, previous stroke, diabetes, heart failure, diuretic usage, cigarette smoking, and residual ungrafted coronary artery disease. The major determinants of long-term survival were variables associated with preoperative left ventricular function. Diabetes was the only important metabolic risk factor identified. This study suggests that unfavorable preoperative conventional risk factors should not be considered a contraindication to operation in patients with adequate coronary anatomy and left ventricular function.

Clinical experience with the Smeloff-Cutter prosthesis: 1- to 12-year follow-up.

To determine the long-term results of aortic valve replacement with the Smeloff-Cutter prosthesis, the fate of 358 of 459 (78%) consecutive patients was determined 1 to 12 years postoperatively. There were 319 male patients (70%). Mean age at operation was 57 years (range, 15 to 84 years). Aortic stenosis was the dominant lesion in 267 patients (58%) and aortic regurgitation in 133 patients (29%). Fifty-nine patients (13%) had both aortic stenosis and regurgitation. In addition to aortic valve replacement, 93 patients (20%) had coronary artery bypass, 30 (6.5%) had mitral commissurotomy, 23 (5%) had mitral valve replacement, and 41 (9%) had other procedures. Preoperative status by New York Heart Association Functional Class was: Class I, 3 (1%); Class II, 39 (8%); Class III, 148 (32%); and Class IV, 269 (59%). Operative (30-day) mortality was 8.5% (39 out of 459). Functional improvement was obtained in all postoperative survivors: 345 (82%), Class I; 63 (15%), Class II; and 12 (3%), Class III. A perivalvular leak developed in 6 patients (1%) and subacute bacterial endocarditis in five (1%). Actuarial long-term survival was 80% at 5 years and 71% at 8 years. Thromboembolism occurred in 34 patients (9.5%). The incidence of thromboembolism per 100 patient-years for patients receiving no anticoagulants was 5.4; antiplatelet agents, 2.9; and Coumadin (sodium warfarin), 2.6. Major thromboembolism was uncommon in patients on a regimen of sodium warfarin but major morbidity from bleeding was significant.