Coronary and carotid artery occlusive disease: single center experience.

BACKGROUND AND OBJECTIVE: Due to increased life expectancy, the risk profile of the patients undergoing cardiac surgery changed dramatically. This is especially important in case of concomitant coronary artery disease and carotid artery stenosis (CAS). Careful decision making and appropriate surgical strategy in these patients is critical for the success of the operation. Controversy about relationship between staged and concomitant carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) still exists. In the current study, we present our case lood in treating patients with concomitant carotid artery stenosis and coronary artery disease. PATIENTS AND METHODS: CABG with additional CEA due to neurologic symptoms or high grade (>80%) CAS has been performed in 835 patients in the period of 1982-2010. Results of evaluation of perioperative mortality and morbidity in regard to the surgical approach have been discussed. RESULTS: The average patient age was 62.6 +/- 8.7 years. Echocardiography revealed that 28% of the patients had poor left ventricle ejection fraction (<30%). Coronarography demonstrated that 21.4% of the operated patients had significant left main coronary artery stenosis (>60%). In terms of neurological status, majority of the patients (88.3%) were neurologically asymptomatic. The overall mortality regardless the sequence of procedures was 2.3% (19 patients). In the group of concomitantly treated patients 44.6% (50 patients) required triple coronary bypass while the mean number of coronary bypasses was 2.6. Postoperative neurologic complications were present in 102 patients (12.2%). Eighty-four patients (10.0%) have had TIA, while 18 patients (2.2%) have had permanent neurologic deficit while 4 patients (0.5%) died as a result of it. CONCLUSIONS: It is imperative that every patient being considered for CABG should undergo ultrasonic evaluation of the carotid arteries regardless the neurological symptomatology. Concomitant surgery on patients with severe CAS and coronary disease carries a slightly higher operative risk and, therefore, should be avoided. Concomitant surgical treatment should only be considered in patients with unstable angina and significant CAS in whom we may expect higher morbidity and mortality.

[Multiple aortic aneurysms in chronic atrophic polychondritis]. / Anévrysmes aortiques multiples au cours d'une polychondrite atrophiante.

BACKGROUND: Although rare, cardiovascular involvement is the second most frequent cause of mortality in chronic relapsing polychondritis behind tracheobronchial tree chondritis. The most frequent cardiovascular complications are valvulopathy and aortic aneurysm. CASE REPORT: We report a case of chronic relapsing polychondritis with multiple aortic aneurysms that were clinically silent but continued to progress despite systemic corticosteroids and immunosuppressive therapy. DISCUSSION: Progression of aortic aneurysms and extravascular disease do not appear to be correlated. Although the disease may appear to be in remission, vascular lesions can continue to progress independently. This case shows that medical treatment has little effect on the progression of these aneurysms. Consequently, it is necessary to opt for surgical therapy at the opportune moment.

[Evolution of the treatment of chronic post-traumatic aneurysms of the descending thoracic aorta: 30 years experience]. / Evolution du traitement des anévrismes post-traumatiques chroniques de l'aorte thoracique descendante: une expérience personnelle de 30 ans.

The authors present the early and late results of a series of 40 patients treated for chronic post-traumatic aneurysms of the descending thoracic aorta from 1975 to 2005. With the exception of a patient who died of an intra-pleural rupture before surgery, the patients were treated by aortotomy and prosthetic graft (N=17), aortotomy and direct suture (N=17) or endoprosthesis (N=5). The use of distal aortic perfusion in 22 patients enabled 17 direct sutures (77.3%) thanks to extensive mobilisation of the aortic arch. Endoprostheses have been used since 1997 in high surgical risk patients with severe comorbid conditions. There were no deaths, one transient paraparesia after simple aortic clamping, one reoperation for a haemothorax and four cases of dysphonia due to paralysis of the recurrent laryngeal nerve. Thirty-five patients (90%) were followed up for an average of 119.7 +/- 16.4 months. There were no clinical complications and the late morphological results were good in all cases with the exception of one type 1 endoprosthetic leak. The treatment of chronic post-traumatic aneurysms of the descending thoracic aorta gives excellent early and late results, justifying wide operative indications. The wish to avoid use of a prosthesis in young patients with a long life expectancy should give preference to conventional surgical techniques which, providing distal aortic perfusion is employed, allow direct suture of three quarters of cases. Endovascular treatment is reserved only for "poor surgical risks".

Impact of maternal nativity on the prevalence of diabetes during pregnancy among U.S. ethnic groups.

OBJECTIVE: This study examines the impact of maternal nativity (birthplace) on the overall prevalence of diabetes during pregnancy and among 15 racial and ethnic groups in the U.S. RESEARCH DESIGN AND METHODS: Birth certificate data for all resident single live births in the U.S. from 1994 to 1996 were used to calculate reported diabetes prevalence during pregnancy and to assess the impact of maternal birthplace outside of the 50 states and Washington, DC, on the risk of diabetes before and after adjustment for differences in maternal age, other sociodemographic characteristics, and late or no initiation of prenatal care overall and for each racial and ethnic group. RESULTS: Mothers born outside of the U.S. are significantly more likely to have diabetes during pregnancy. The impact of maternal nativity on diabetes prevalence is largely explained by the older childbearing age of immigrant mothers. However, adjusted diabetes risk remains elevated for Asian-Indian, non-Hispanic black, Filipino, Puerto Rican, and Central and South American mothers who were born outside the U.S. Conversely, birthplace outside the U.S. significantly reduces diabetes risk for Japanese, Mexican, and Native American women. CONCLUSIONS: Identification, treatment, and follow-up of immigrant mothers with diabetes during pregnancy may require special attention to language and sociocultural barriers to effective care. Systematic surveillance of the prevalence and impact of diabetes during pregnancy for immigrant and nonimmigrant women, particularly in racial and ethnic minority groups, and more detailed studies on the impact of acculturation on diabetes may increase understanding of the epidemiology of diabetes during pregnancy in our increasingly diverse society.

Leiomyosarcoma of the inferior vena cava. Experience with 7 patients and literature review.

Leiomyosarcoma of the inferior vena cava (IVC) is a rare malignant tumor originating in the smooth muscle of the media. Although rare, it is the most common malignancy in the IVC. One hundred and six cases have been reported thus far in the world literature, usually as isolated case reports. Clinical, radiologic, and therapeutic management and follow-up, including 7 additional cases, have been reviewed and summarized. Clinical manifestations are dependent upon the location of the tumor. The main symptom was a palpable mass for a tumor in segment I, abdominal pain for segment II, the presence of Budd-Chiari syndrome for segment III. Segment II was the most frequent site of leiomyosarcoma of the IVC, alone (n = 41) or with other segments (n = 39). Before laparotomy, clinical recognition was difficult or impossible. Recently, however, newer imaging modalities including ultrasound and CT scan have permitted earlier diagnosis. Metastases, when diagnosed, were either present at diagnosis (n = 20) or appeared as the disease progressed (n = 18). Metastatic disease frequently involved the liver, lung, lymph nodes, or bone. The small number of patients alive without metastases (16/113) must be analyzed all the more carefully because these patients were followed for less than 2 years. When prolonged follow-up is possible, the number of patients alive without neoplastic disease is significantly reduced. We found the prognosis of patients with LMS of the IVC to be poor. Diagnosis was made at autopsy for 27 patients. Among the 86 patients with follow-up information, 59 died within a mean of 16 months, and 26 were alive 25 months after the diagnosis. The main prognostic factor is topography, particularly the highest level of extension of the tumor. The upper-segment tumors have the poorest prognosis. The best therapeutic management is difficult to recommend because most of the cases in the literature did not include a sufficient follow-up. Given the very small number of patients completely free of neoplastic disease after sufficient follow-up, it seems unlikely that leiomyosarcoma of the IVC can now be cured. Patients who received a combination of surgery, radiotherapy and chemotherapy remained free of disease for longer periods. The unanswered question is: what is the best timing for each of these treatments? We recommend diagnosis of leiomyosarcoma of the IVC through biopsy guided by ultrasonography or computed tomographic scan. Therapeutic management should include large doses of chemotherapy preoperatively with or without radiotherapy to reduce tumor size.(ABSTRACT TRUNCATED AT 250 WORDS)

Glucose tolerance during pregnancy and birth weight in a Hispanic population.

OBJECTIVE: To assess the effect of screening glucose values and gestational diabetes mellitus (GDM) on birth weight in a community-based population of pregnant Hispanic women and infants in Detroit, Michigan. METHODS: In a prospective cohort study of 372 mother-infant pairs, analysis of variance and multiple linear and logistic regression were used to examine the effects of maternal screening glucose and GDM status on mean birth weight and the risk of large for gestational age (LGA) and small for gestational age (SGA) births. RESULTS: Screening glucose values of at least 135 mg/dL were found in 26.6% of the mothers and GDM in 5.1%. There was a significant relation between increasing maternal screening glucose level and adjusted mean birth weight (P < .005). As glucose level increased, there was a significant trend toward an increasing percentage of LGA infants and a decreasing percentage of SGA infants (Cochran-Armitage test for trend, P = .001 and P = .009, respectively). Among nondiabetic women, a 10-mg/dL increase in glucose value was associated with an adjusted 30.5-g increase in birth weight (standard error 9.0; P < .001), increased adjusted odds of LGA (adjusted odds ratio [OR] 1.17; 95% confidence interval [CI] 1.02, 1.34), and decreased adjusted odds of SGA (adjusted OR 0.69; 95% CI 0.52, 0.93). CONCLUSION: Our findings showed a high prevalence of glucose abnormality and an independent effect of maternal glucose level on birth weight in our Hispanic population. Maternal glucose level should be included in studies of factors that affect birth weight, and appropriate prenatal care provided to Hispanic women with abnormal and borderline metabolic status.

Determinants of prenatal care use in Hawaii: implications for health promotion.

This study examines the association between maternal sociodemographic characteristics and the receipt of different levels of prenatal care use (no care, inadequate, intermediate, adequate) in order to determine different patterns in the relationships between maternal characteristics and these distinct categories of prenatal care use. Using the 1979-1992 Hawaii live birth vital record file, single live births to Hawaii resident mothers of white, Hawaiian/part-Hawaiian, Filipino, or Japanese ethnicity, who did not indicate on the birth certificate that either parent was active duty military, were selected. Over one quarter of this study population did not initiate prenatal care in the first trimester. Given the high level of insurance coverage found in Hawaii, this finding is disconcerting, particularly in relation to the U.S. Year 2000 Objective of 90% initiation in the first trimester. Overall, the factors that predicted receipt of any prenatal care predicted more adequate use of prenatal care as well. Noteworthy exceptions were maternal age and ethnicity. Identifying these exceptions is important for the development of a more detailed understanding of risk factors related to use of prenatal care to better target program responses aimed at improving prenatal care use. In addition, these data suggest that removing financial barriers to access to care does not guarantee universal use of disease prevention and health promotion services.

Health of infant is the main reason for breast-feeding in a WIC population in Hawaii.

OBJECTIVE: To determine factors influencing infant feeding method choices among women who received services from the Special Supplemental Food Program for Women, Infants, and Children (WIC) during pregnancy in Hawaii. DESIGN: A retrospective survey mailed to all resident mothers who had live births in Hawaii between January 1, 1989, and March 31, 1989, and who received WIC services during pregnancy. SETTING: The state of Hawaii. SUBJECTS: The subjects were 322 mothers who received WIC services during pregnancy for whom data were complete, taken from a sample of 2,013 women who had live births in the state of Hawaii (51% response rate) between January 1, 1989, and March 31, 1989, of whom 324 participated in WIC during pregnancy. MAIN OUTCOME MEASURES: Infant feeding method (exclusive breast, exclusive formula or mixed) at hospital discharge. STATISTICAL ANALYSES PERFORMED: The chi 2 analysis for differences among feeding method groups and multiple logistic regression to calculate odds ratios for independent effects of maternal characteristics and other influences on feeding method choice. RESULTS: Reasons for infant feeding choice, timing of the choice, maternal age, parity, and place of residence were the main factor influencing infant method choice. Health of the infant was the primary reason for choice of feeding method and was the strongest determinant of exclusive breast-feeding (odds ratio = 23.99; confidence interval = 9.75-59.02; P < .0001) and was negatively related to the choice to formula-feed (odds ratio = 0.03; confidence interval = 0.01-0.08; P < .0001). APPLICATIONS: Relationship between WIC and hospital lactation consultants could enhance follow up in the hospital and after returning home with WIC mothers who prenatally state an intention to breast-feed. Convenience and bonding are aspects of breast-feeding enjoyed by WIC mothers in Hawaii that could be used in breast-feeding promotion efforts.

Geographic patterns of low birth weight in Hawaii.

This study examines areal variations in low birth weight, using the census tract as the unit of analysis. Reports from the 1980 U.S. census were used to develop summary indicators of environmental and socio-economic conditions, including poverty, employment, education and crowding, for 155 census tracts in the state of Hawaii. Maternal socio-demographic, prenatal care utilization, and medical risk indicators and low birth weight percentages for resident, single live births were extracted from the Hawaii 1979-1987 vital record live birth files and aggregated by census tract. Multiple regression analysis was used to develop a model that predicted 61% of the variation among census tracts in the percentage of low birth weight. Patterns of low birth weight were primarily associated with ethnic patterns of maternal residence and single marital status. There was no association between inadequate prenatal care and low birth weight at the census tract level.

Intravenous digital subtraction angiography in Takayasu's disease. A report of 32 cases.

IVDSA appears to be a reliable method and should therefore be considered as a first step examination when Takayasu's disease is suspected. The simplicity and safety of the method provide a rationale for the use of this technique in Takayasu's disease. Therapeutic decisions can usually be obtained without further radiological investigation, and conventional arteriography has to be performed only when data obtained with IVDSA are insufficient. In these rare cases, conventional arteriography aims at the investigation of a particular area. The site of arterial puncture can be precisely guided by IVDSA.

Area-level predictors of use of prenatal care in diverse populations.

Patterns and predictors of the use of prenatal care in Hawaii were examined by census tract, taking into account summary measures of socioeconomic status, environmental conditions, and aggregated indicators of pregnancy-related risk characteristics of mothers. The objectives of the study were to identify those census tracts with high levels of inadequate use of prenatal care services; to develop a model, based on census tract characteristics, to explain observed geographic variations in the use of prenatal care services; and to identify for further investigation specific localities with unanticipated patterns of use. Data were drawn from 1980 census reports and vital statistics live birth files for the period 1979-87. Regression analysis was used to develop a model that was able to predict 61 percent of the census tract variation in the percentages of inadequate use of prenatal care services. Increased proportions of mothers of Japanese and other Asian-descent and of adults with more than high school education were associated with low levels of inadequate use of prenatal care services. Increased proportions of high parity-for-age risk and Samoan mothers were associated with higher levels of inadequate use. Census tract maps of actual and predicted percentages and studentized residual values were used to identify areas with high and low rates of inadequate use of prenatal care services. The area-level methods used are believed applicable to health care planning in other areas with ethnically or socioculturally diverse populations.

Birth outcomes of Korean women in Hawaii.

Since the end of the Korean War, immigration of Koreans to the United States has increased rapidly. In 1990, 11.6 percent of all Asians in the United States were of Korean ethnicity, and it is projected that Koreans will outnumber all other Asian groups, except Filipinos, in the United States by the year 2030. Despite the growing size of this population, very little is known about their health status. This study, using 1979-89 Hawaii vital record data, investigates the relationship between maternal sociodemographic characteristics, prenatal care utilization factors, and birth outcomes among Koreans as compared with Caucasians. The ethnic term "Caucasian" is used in Hawaii's vital records and is synonymous with non-Hispanic whites. Korean mothers were more likely to be older and have lower educational attainment, and less likely to be adolescent, single, or to have received adequate prenatal care than Caucasian mothers. More than 80 percent of the Korean mothers were foreign born. Significantly higher risks for very preterm delivery (less than 33 weeks) and very low birth weight births were observed for Koreans as compared with Caucasians. Nativity had no effect on birth outcome in this population. The results of this study suggest that prevention of preterm birth is an important focus for improving pregnancy outcomes in this growing ethnic group.

Fractures of the clavicle and injuries of the sub-clavian artery. Report of 10 cases.

During four years, the authors have observed ten lesions of the sub-clavian artery associated with a fracture of the clavicle. The clinical picture in one case out of two was that of an acute ischemia of the upper limb. The surgical repair has been performed in 8 cases. The thoracic approach was necessary three times. The clavicle was resected in most cases. The prognosis of these lesions depends on the rapidity of their recognition, and of their treatment, and on the fact whether the brachial plexus is involved or not

"Redo" surgery for late aorto-femoral graft occlusive failures.

Experience of late failures of Dacron aortofemoral grafts is presented; about 70 cases observed during the past eight years on whom 105 subsequent operations were performed. One third of these patients were first operated upon by another surgical team. During the same period, 850 patients were submitted to reconstructive surgery of the abdominal aorta and iliac arteries either for atherosclerotic or for aneurysmal disease. It appears that conservative procedures like thrombectomy of the occluded limb are often insufficient, impossible, inappropriate or dangerous, even after restoration of a good deep femoral outflow. On the other hand, aggressive restoration of limbflow is generally necessary, with other various and ingenious direct or indirect reconstructive techniques for restitution of a good inflow and outflow. These techniques are usually successful (85%) and gain time against the major etiology of these late failures viz the development of atherosclerotic disease.

Arteriovenous fistulae of the internal iliac vessels.

Seven patients with arteriovenous fistulae of the internal iliac artery are reported. Ages varied from 6 to 50 years (mean 32 years). Cutaneous angiomata , leg oedema and pain was present in 4 cases each, bleeding in 2 cases whilst only one was asymptomatic. Only 1 patient had cardiac insufficiency. In six patients the lesion was a congenital malformation but in one it was posttraumatic. Arteriography both global and selective, intravenous pyelography and cardiac output are routine. Recently, pelvic computerised tomography has been most helpful. Embolization is recommended in all cases with surgery within 24 hours unless the lesion is very extensive and considered to be inoperable. Repeat embolization is used for recurrence or very extensive lesions. Results were good in five patients; in two patients the results were clinically good but control angiograms showed a recurrence.

A new study demonstrates the efficacy of naftidrofuryl in the treatment of intermittent claudication. Findings of the Naftidrofuryl Clinical Ischemia Study (NCIS).

BACKGROUND: The efficacy and safety of naftidrofuryl were assessed in a double blind, placebo controlled, parallel group study, in patients presenting with intermittent claudication, according to the latest European guidelines. METHODS: The outpatients selected were of both sexes, aged 35 to 85, with moderately severe chronic, stable intermittent claudication and a pain-free (PFWD) and maximum walking distance (MWD) on the treadmill of between 100 and 300 metres. They received naftidrofuryl 200 mg tid or placebo for six months and were then assessed during a six-month follow-up period without treatment. The primary outcome measures were the pain-free walking distance and maximum walking distance. RESULTS: Of the 221 selected patients, 196 were randomised and 181 entered the intention-to-treat analysis. The two groups were well matched for demographic variables, risk factors and history of vascular disease. After six months of treatment, patients who received naftidrofuryl had a 92% im-provement of geometric pain-free walking distance versus 17% in the placebo group (p < 0.001) and an 83% improvement of geometric maximum walking distance versus 14% in the placebo group (p < 0.001). During the follow-up period without treatment, the walking distances of the patients in the naftidrofuryl group significantly decreased. The incidence of adverse events was similar in the two groups. CONCLUSIONS: This study demonstrated the efficacy of naftidrofuryl versus placebo in patients with intermittent claudication with a highly significant and clinically relevant difference and confirmed its good safety profile.

Carotid artery surgery in patients over 70 years of age.

Between 1965 and 1979, 934 patients underwent 1,057 operations for extracranial carotid stenosis at this institute, and over a recent 30-month period 463 patients underwent 511 operations of this type. This number is equal to the total of operations performed during the years 1965-1976. The increase in the frequency of carotid artery surgery has been more marked in patients of over 70 years. The percentage of elderly patients has increased from 17.5% to 27% in the recent period. In the latter group of 511 operations, results were good in 93.17% of cases, while there was a mortality rate of 1.95% (1% of which were directly related to the surgery), in 1.95% the neurologic condition deteriorated and in 3.13% there was no change. In the first period the mortality rate for patients over 70 years of age was 7.69%. In the second it was 3.27% (1.63% of which were due to non-neurologic causes), 4.09% deteriorated, in 2.18% there was no change and good results were obtained in 90.46%.

[Aortic dissections: recent endovascular therapeutic advances and current indications]. / Dissections aortiques: apports thérapeutiques endovasculaires récents et indications actuelles.

Dissection is one of the most serious diseases of the aorta if only because of its potential for rupture, but also for other complications which may be fatal. Replacement with a prosthesis remains the treatment of reference as an emergency for proximal dissection and as an elective procedure for selected cases of distal dissection with complications. Despite steady progress in ancillary management (distal perfusion, circulatory arrest, cardiac, neurological and visceral protection) the operation remains a very invasive procedure. Aortic endoprostheses represent the therapeutic innovation of the decade for the treatment of aortic aneurysms and their use could be extended to dissections, at least for the most distal forms and to patients at very high surgical risk.

[Inflammatory aneurysms of the thoracic aorta. Surgical aspects]. / Anévrysmes inflammatoires de l'aorte thoracique. Aspects chirurgicaux.

In the Western world, inflammatory aneurysms account for only 1 to 5%, of all operated thoracic aorta aneurysms. Takayasu's disease is by far the commonest cause although all forms of aortitis may result in aneurysm formation. Usually observed in young patients, these aneurysms are suitable for often major surgery with results that are globally better than in degenerative or dissecting aneurysms. However, they pose, two specific problems: the progression of the inflammatory disease which may require pre- and/or post-operative steroid therapy and that of the risk, at least in theory, of a late pseudo-aneurysm, which justifies regular long-term follow-up after surgery.

[Coronary involvement in Takayasu's disease. Apropos of 3 cases, of which 2 were surgically treated, and review of the literature]. / AL'atteinte coronarienne dans la maladie de Takayasu. A propos de 3 cas dont 2 opérés et revue de la littérature.

Coronary arteries like other branches of the aorta may be involved in Takayasu's disease. This complication is not rare (7% of cases) but appears to be relatively unappreciated. Three new cases are reported of main coronary artery disease, two of which were treated by coronary bypass surgery. A review of the literature of 1 130 cases of Takayasu's disease revealed 86 cases with coronary involvement, 33 of which were confirmed anatomically and 15 by coronary arteriography. The clinical manifestations, angina and/or myocardial infarction, were present in 5% and 3% respectively, of patients with Takayasu's disease. They may be the first sign of the disease and, in some cases, the only symptomatic arterial localisation. The coronary lesions are either ostial, a direct complication of the aortic disease, or on a main vessel, usually proximal. Histological studies show typical changes of stenosing inflammatory panarteritis involving mainly the media and adventitia. Thrombosis and secondary atheromatous plaques may be observed. Aneurysms are rare. Apart from cases with typical ostial lesions, the coronary angiographic appearances are not specific, but some features are suggestive of the diagnosis; the occurrence in young women; the presence of associated peripheral arterial lesions, their localisation and grouping; their radiological and/or histological characteristics. The spontaneous prognosis of these proximal lesions is usually poor and justifies surgical revascularisation by coronary bypass. Six patients, including two in this series, have been treated surgically. The associated aortic lesions may pose special technical problems which we discussed. The relatively high incidence of coronary involvement in Takayasu's disease and its often unexpected revelation by myocardial infarction or sudden death, suggest that coronary arteriography should be undertaken more often during investigation of the arterial lesions of these patients. Takayasu's disease should figure prominently amongst the causes of coronary artery disease in young women.