The treatment of cerebral ischemia by external carotid artery revascularization.

Thirteen patients with internal carotid artery occlusion and symptomatic external carotid artery stenosis underwent external carotid artery revascularization by means of endarterectomy (n = 10) or subclavian artery--external carotid artery bypass (n = 3). All patients but one were followed up, for five to 46 months (mean, 20 months). There were no operative deaths or complications and no late strokes. One patient (7.7%) required early extracranial-intracranial (EC-IC) bypass for failure of the external carotid artery endarterectomy to relieve the initial symptoms. All remaining patients were completely (n = 9) or partially (n = 2) relieved of symptoms, and EC-IC bypass was not required. There were no criteria identified by either oculopneumoplethysmography or angiography that could reliably predict the need for subsequent EC-IC bypass. Ninety-two percent of the patients were adequately treated with external carotid artery revascularization alone, suggesting that subsequent EC-IC bypass is seldom required in patients with ipsilateral internal carotid artery occlusion and external carotid artery stenosis.

Diagnosis, treatment, and outcome of blunt carotid arterial injuries.

BACKGROUND: Blunt carotid injuries are rare, and present late with devastating strokes. A sizeable single-institution descriptive report could help characterize the injury and its diagnosis and treatment. METHOD: We performed a retrospective review of blunt carotid artery injuries from May 1988 to December 1997 at a level I trauma center. Chart review consisted of demographics, mechanism of injury, associated injuries, diagnostic modalities, initial neurologic status, treatment, and outcome. Discharge outcome was classified as "good" (normal-mild deficit), "fair" (needing daily assistance), "poor" (institutionalized), or "dead." RESULTS: During the study period 16 patients sustained a carotid artery injury. Mean age was 35 years and 63% were female. Vehicular trauma was the most common mechanism of injury (81%), followed by assaults (13%). Dissection was the most common injury (75%), with one quarter having an associated pseudoaneurysm. Initial neurologic presentation was normal in 31% and Glasgow Coma Score was < 13 in 31% (including 13% in coma). Eventual hemispheric symptoms developed in 81%. Associated injuries were present in 94%, commonly head (44%) and chest (50%). Duplex ultrasound accurately identified the injury in all patients (5 of 5) when used. Anticoagulation (88%) had no complications. Observation and therapeutic embolization each resulted in 1 fatal stroke. A third patient, with worsening deficits on heparin, died after carotid ligation, for an overall mortality of 19%. There were no deaths in the 13 patients treated by anticoagulation alone. Six patients (38%) had a "good" neurologic outcome, five (31%) "fair," and two (13%) "poor." Initial neurologic presentation, associated injuries, and mechanism of injury did not appear to correlate with these outcome categories. CONCLUSIONS: These uncommon injuries should be suspected in the presence of head and/or chest injuries, basilar skull fracture, or coma (particularly if the computed tomography scan is unremarkable). Presentation may be varied, but most patients eventually develop hemispheric symptoms. Duplex ultrasound detects many of these injuries, but this does not demonstrate its utility as a screening tool. Anticoagulant therapy appears to be associated with a better outcome than expectant or occlusive therapy.

An unusual case of heterotopic pancreas of the stomach.

A 56 year old man had an unusual case of heterotopic pancreas of the stomach. The patient had two lesions. One was at the gastroesophageal junction, representing the highest location in the stomach reported for this lesion. The second lesion was in the prepyloric antrum and consisted of heterotopic pancreatic tissue as well as tissue consistent with heterotopic ampulla of Vater. A general review of heterotopic pancreas is presented.

The historical development of prosthetics in hernia surgery.

Since the time of Bassini, surgeons have looked for techniques and applicable prostheses to improve the results of hernia surgery. This article records the historical parade of biomaterials used in this endeavor from the earliest use of sliver wire coils to the current popular prostheses in use today, each prosthesis is reviewed with respect to its introduction, popularization, clinical use, and ultimate failure. Current prosthetic biomaterials are compared in detail. The quest for the ideal material to reinforce or bridge abdominal wall defects is discussed.

Increased limb salvage. Distal tibial/peroneal artery thrombectomy/embolectomy in acute lower extremity ischemia.

Fifty-five acutely ischemic lower extremities, in 35 patients, which remained ischemic after standard thrombectomy/embolectomy techniques were further treated with distal tibial/peroneal thrombectomy/embolectomy by ankle level arteriotomy to increase limb salvage. A total of 84 infrapopliteal arteries were explored and thromboembolectomy performed in 79. The precipitating ischemic event was arterial embolus in 38 per cent, arterial thrombus in 60 per cent, and trauma in 2 per cent of the cases. There were 16 female and 19 male patients. Additional bypass grafting was used in 18 per cent of extremities. The limb salvage rate was 91 per cent in this select "tibial/peroneal" group. This technique salvaged 50 limbs that otherwise would have required major amputation. The addition of this technique changed the potential limb salvage rate from 76 per cent of the entire 199 lower extremities treated during this period to an actual limb salvage rate of 97 per cent. Operative mortality was 16 per cent in this selected group with an overall mortality of 6 per cent for all patients with acutely ischemic lower limbs. A mean patient follow-up of 32 months (range 12 to 72 months) identified only three late amputations, demonstrating that distal tibial/peroneal thrombectomy/embolectomy is a durable procedure. It is a technically easy means of promoting limb salvage in the acutely ischemic limb which either 1) remains ischemic after standard transinguinal iliofemoral thromboembolectomy, or 2) is secondary to infrapopliteal artery occlusion. It allows successful thromboembolectomy of acutely occluded infrapopliteal arteries without distal popliteal arteriotomy. These techniques should be within the armamentarium of all surgeons dealing with acute lower extremity ischemia.

Carotid endarterectomy in a community hospital surgical practice.

Three hundred twenty-four carotid endarterectomies (CEAs) were performed on 303 patients over 5 years. Sixty per cent of the patients were symptomatic with completed stroke (36.4%), amaurosis fugax (35.4%) or transient ischemic attack (TIA) (50.5%). Some patients had multiple symptoms. Perioperative stroke occurred in four patients (1.2%) and 30-day mortality in five (1.5%). The combined stroke-mortality rate was 2.8 per cent. Other postoperative complications included TIA (1.9%), cranial nerve injury (3.1%), wound hematoma (6.5%), and hypertensive reperfusion syndrome (9.6%). Ten early reoperations were performed for wound hematoma (7) or technical problems (3). Follow-up of 284 CEAs (88%) at a means of 31 months revealed 33 late deaths, with two due to stroke. Late strokes occurred in 11 patients (3.9%). Five late strokes were ipsilateral (1.8%) and six were contralateral (2.1%) to the operated carotid artery. Ninety-seven carotid arteries were evaluated by duplex ultrasound scanning at a mean postoperative interval of 27.2 months. Ninety-two per cent had 0-30 per cent restenosis, 5 per cent had 40 per cent to 60 per cent restenosis and 3 per cent had 70 per cent or greater restenosis. The authors conclude that CEA can be performed with acceptable morbidity and mortality rates and that it is a durable operation that reduces the risk of late stroke.

Five-year experience with the "four-before" laparoscopic ventral hernia repair.

Between 1993 and 1998, we performed a linear study of laparoscopic ventral hernia repair performed in a standard fashion using expanded polytetrafluoroethylene on 49 patients. Eighteen patients had recurrent hernias and 30 patients were morbidly obese with a body mass index >30. Conversion to open procedure was required in two patients. Patients were observed a mean of 27 months. Three patients died of unrelated causes during the observation period. Three patients developed recurrent hernias. By a follow-up survey, we found that 90 per cent of patients were "satisfied" with their operation and results. Because of decreased complications, postoperative pain, hospital stay, and hernia recurrence, the "four-before" laparoscopic repair is our preference for ventral hernias. It has been particularly useful for obese patients and patients with recurrent ventral hernias.

Perioperative factors as predictors of operative mortality and morbidity in pneumonectomy.

Pneumonectomy for lung cancer is associated with significant morbidity and mortality. Risk factors for the morbidity and mortality have been reported, but consistent conclusive data are undetermined. Current accepted 30-day mortality rates for pneumonectomy range from 7 to 11 per cent. The objective of this study is to determine whether various perioperative factors can serve as predictors of morbidity and mortality in pneumonectomy patients and to review outcome data on patients undergoing pneumonectomy for lung cancer. A total of 105 patients undergoing pneumonectomy for lung cancer from 1988 through 1998 are studied in a retrospective chart review. The main outcome measure is the 30-day operative mortality and morbidity. Complications occurring in 10 per cent or more of the patients included atrial fibrillation (33.3%), respiratory failure (23.8%), pneumonia (21.9%), and bronchopleural fistula (12.4%). The 30-day mortality rate was 10.5 per cent (11 deaths). By Fisher's exact test for Chi-square only three statistically significant mortality factors were identified: respiratory failure (P < 0.021), sepsis (P < 0.008), and male sex (P < 0.031); respiratory failure, sepsis, and sex were predictors of death. Significant correlation could not be made to predict postoperative morbidity. Overall long-term clinical outcome for pneumonectomy as lung cancer treatment was poor. Clinical judgment remains an essential factor when considering pneumonectomy as an option for lung cancer treatment.

Intestinal injury after lumbar discectomy.

In a review of 5,200 lumbar discectomies performed from 1974 to 1989, two patients sustained a ventral perforation of the disc space followed by isolated small intestinal injury. Both patients underwent lumbar discectomy at the lumbosacral junction and presented with signs and symptoms of acute abdominal distress within three days after the operation. At surgical laparotomy, small tears were noted in the ileum, which were closed primarily. The patients had an uneventful recovery. The results of a review of 11 instances reported in the literature suggest that isolated intestinal injuries usually occur postoperatively at the lumbosacral junction and involve the small intestine. Factors, such as body habitus, surgical experience, patient positioning and types of instruments, as well as the use of a surgical microscope, do not appear to modify the risk of intestinal injury. After discectomy, patients may present with acute abdominal signs and symptoms or chronic wound infections. Work-up studies include evaluation of vascular structures and ureters either roentgenographically or at abdominal exploration. A high index of suspicion and adequate disc space visualization during discectomy may reduce the incidence of this complication.

Increased limb salvage with intraoperative and postoperative ankle level urokinase infusion in acute lower extremity ischemia.

Over a 30-month period (May 1988 to November 1990) 143 acutely ischemic lower extremities (126 patients) were treated with an aggressive surgical approach that included ankle level tibial-peroneal artery thromboembolectomy. Twelve lower extremities in 10 patients that remained ischemic were further treated with adjuvant ankle level urokinase infusion. Sixteen ankle level arteries in 12 extremities were infused with an intraoperative bolus (1 to 2) of urokinase (50,000 to 100,000 units). Continuous postoperative urokinase (25,000 to 50,000 units per catheter per hour x 1 to 5 days) was infused through ankle level arteriotomies in 10 extremities (14 arteries) that did not improve with the initial intraoperative bolus. Concomitant bypass grafting was necessary in four extremities. With adequate inflow established, adjuvant ankle level urokinase salvaged all 12 extremities. The mean increase in ankle/brachial pressure index was 0.84. During continuous postoperative urokinase infusion, lower extremity bleeding requiring blood transfusion occurred in four patients (50%). No deaths occurred in the operative period. Although rhabdomyolysis occurred in 90% of patients, no patients had renal insufficiency. The addition of ankle level urokinase delivery increased the potential limb salvage from 90% of the entire 143 extremities treated during this period to an actual limb salvage of 98%. A mean follow up of 13 months (6 to 36 months) identified one late amputation. Despite the demanding postoperative management required in these patients and the frequent need for early reoperation, the limb salvage obtained justifies this aggressive adjuvant technique in the management of the acutely ischemic lower extremity.

Comparison of three mechanical thrombus removal devices in thrombosed canine iliac arteries.

PURPOSE: To assess and compare intimal and medial vascular damage caused by three mechanical wall-contact thrombectomy devices: Fogarty embolectomy catheter, Arrow-Trerotola peripheral thrombectomy device, and MTI-Castañeda over-the-wire brush. MATERIALS AND METHODS: Bilateral external iliac arteries of 15 canines were thrombosed before mechanical thrombolysis. Ten thrombosed arteries were randomly assigned to receive each device. Animals were sacrificed immediately, and histologic assessment of endothelial and medial damage in the vessels was performed. RESULTS: The vascular damage found with all devices extended into the tunica media. The Fogarty embolectomy catheter and the Arrow-Trerotola device caused significantly more damage than the Castañeda brush. CONCLUSION: All devices caused lesions extending into the media. Previous research has shown that the extent and depth of the vascular lesion may be contributing factors in promoting early atherosclerotic and accelerated hyperplastic intimal and medial changes. These findings warrant further study of these devices in an atherosclerotic model with longer follow-up.

Subclavian steal despite ipsilateral vertebral occlusion.

In the classic subclavian steal syndrome, vertebrobasilar insufficiency is caused by reverse flow in the vertebral artery ipsilateral to a subclavian stenosis or occlusion. We present two patients with vertebrobasilar insufficiency and ipsilateral vertebral and subclavian occlusive disease. The postulated mechanism of vertebrobasilar insufficiency is reverse flow in collateral neck vessels. In both patients, symptoms were relieved by carotid subclavian bypass. Thus, vertebral occlusion ipsilateral to a subclavian stenosis does not preclude subclavian steal syndrome.