Microembolic signal counts increase during hyperbaric exposure in patients with prosthetic heart valves.

BACKGROUND: Patients with prosthetic heart valves have an increased risk of thromboembolic events, and transcranial Doppler sonography reveals microembolic signals. Whereas microembolic signals were initially assumed to be of particulate matter, recent studies suggest that they are partially gaseous in origin. If this is true, alteration of environmental pressure should change microembolic signal counts. We undertook this study to evaluate the influence of hyperbaric exposure on microembolic signal counts in persons with prosthetic heart valves. METHODS AND RESULTS: Microembolic signal counts were monitored by transcranial Doppler sonography of both middle cerebral arteries under normobaria (normobaria 1), 2 subsequent periods of hyperbaria (2.5 and 1.75 bar), and a second period of normobaria (normobaria 2) in 15 patients with prosthetic heart valves. Each monitoring period lasted 30 minutes. Compression and decompression rates were 0.1 bar/min. Microembolic signal counts increased from 20 (12-78) at normobaria 1 to 79 (30-165) at 2.5 bar (P <.01 vs normobaria 1 and 2), decreased to 44 (18-128) at 1.75 bar (P <.01 vs normobaria 1 and 2.5 bar; P <.001 vs normobaria 2), and returned to 20 (8-96) at normobaria 2 (values are medians and 95% confidence intervals). CONCLUSIONS: Our results strongly suggest that gaseous bubbles are underlying material for part of the microembolic signals detected in patients with prosthetic heart valves.     

Plastic surgery of the deep femoral artery in the treatment of severe ischemia of the limbs

The article analyses the results of operative treatment of 21 patients with atherosclerotic stenosis of the deep femoral artery (DFA) and occlusions of the femoral, popliteal, and tibial arteries with IIB-IV degree ischemia. The age of the patients ranged from 50 to 80 (average age of 69 years). All patients suffered from serious concomitant somatic diseases which increased the risk of major reconstructive operations in the aorto-iliac and femoro-popliteal regions. Isolated DFA plastics was conducted in 17 patients; in 4 patients DFA plastics was carried out to supplement aorto-iliac-deep femoral shunting. The late-term results were studied in periods of one to three years. They were positive in 90.5% of cases. Amputation through the thigh was carried out in one patient 12 months after the operation due to a progressive occlusive process. One patients died one year after the operation from myocardial infarction.     

"Bay window" technique for the arterial switch operation of the transposition of the great arteries with complex coronary arteries

BACKGROUND: The success of arterial switch operations for transposition of the great arteries largely depends on faultless coronary translocation and subsequent sufficient myocardial perfusion. However, in patients with complex coronary artery anatomy, coronary translocation is often difficult to perform by conventional surgical techniques alone. Therefore we developed the "bay window" technique as a useful adjunct in patients with complex coronary arteries undergoing concomitant coronary translocation and arterial switch operation. Early and midterm results of this technique are described. METHODS: Between September 2001 and February 2002, 4 patients with transposition of the great arteries with complex coronary arteries underwent arterial switch operation. The ages of the patients at the time of operation ranged from 8 to 52 days. Great arterial relationships were anteroposterior in 2 patients, right-oblique in 1, and side-by-side in 1. One patient also had ventricular septal defect. Coronary arterial patterns were as follows: absent left main trunk in 1 patient, short left main trunk in 1, and short right main trunk in 1. Both coronary arterial orifices were resected as a tall U-shaped cuff. The inferior half of the coronary cuff was sewn into a J-shaped incision on the pulmonary stump. The superior half of the coronary cuff was folded down inside to form a bay window channel. RESULTS: No coronary events occurred (ie, inclusive of coronary stenosis, myocardial infarction, and coronary death). Postoperative echocardiogram demonstrated normal ventricular wall motions in all 4 patients. CONCLUSIONS: The bay window technique is an innovative and simple surgical adjunct for translocating complex coronary arteries.     

Is duplex follow-up cost-effective in the first year after carotid endarterectomy?

Recent reports have suggested that duplex scanning is an ideal method to noninvasively assess the incidence of recurrent carotid stenosis. However, the timing and frequency of the follow-up studies are controversial. In the present study, 150 patients underwent 173 carotid endarterectomy procedures over a 2 year period. In the postoperative period, a total of 210 duplex studies were carried out on 117 carotid arteries. 21.4 percent of the 117 arteries studied had recurrent stenosis of 16 percent or greater at a mean postoperative follow-up of 15.2 +/- 3 months. Recurrent stenoses were detected early after operation; 96 percent were detected at or before 15 months postoperatively. Patients with recurrent stenoses remained stable and had infrequent symptoms. Several risk factors placed the patient at increased risk for recurrent carotid stenosis: presence of contralateral disease (defined as stenosis of 50 percent or greater), use of tacking sutures, and continued smoking in the postoperative period. Although it remains important for researchers to thoroughly investigate the natural history of atherosclerosis of the extracranial carotid artery, including those changes that occur after carotid endarterectomy, our results indicate that frequent duplex scanning in the first postoperative year is unnecessary and is not cost-effective. Duplex follow-up studies 1 and 12 months after carotid endarterectomy are sufficient for assessing the problem of recurrent stenosis in the first postoperative year.     

Influence of segmental arteries,extent, and atriofemoral bypass on postoperative paraplegia after thoracoabdominal aortic operations

Purpose: The purpose of this article was to study the influence of either reattachment or oversewing of patent segmental intercostal or lumbar arteries, extent of aneurysm, and atriofemoral bypass on the incidence of postoperative paraplegia/paraparesis in patients at high risk with type I or II thoracoabdominal aneurysms.Methods: Data were prospectively collected on 99 patients undergoing type I or II thoracoabdominal aneurysm repairs, including exact extent of repair and whether atriofemoral bypass was used. Patency of intercostal arteries from T3 to T12 and lumbar arteries from L1 to L4 were checked by intraoperative inspection. If the arteries were patent, note was taken of whether they were reattached to the new aortic prosthesis. Postoperative neurologic motor function was graded daily for the first 5 days, and the worst score in the first 30 postoperative days (POD) was used for analysis.Results: Ninety-five of 99 (96%) patients were 30-day survivors. By POD 30, 31 of 98 (32%) patients had had a neurologic deficit. There was no difference in the incidence of deficits according to whether lumbar or intercostal arteries were reattached, ignoring the effect of patency of the arteries. Of greater importance, however, was whether patent segmental arteries were oversewn at specific levels. Thus, for patients who had one or more arteries at T11, T12, or L1 oversewn (often because they could not be reattached), a deficit developed in 11 of 23 (48%) patients versus 20 of 75 (27%) patients who did not have patent arteries or had all patent arteries reattached ( p = 0.05, odds ratio = 2.5). More specifically, if all arteries at this level were oversewn, a neurologic deficit developed in 63% of patients versus 23% if all their arteries were reattached ( p = 0.01). Reattachment of patent arteries at individual levels from T7 to L4 showed a trend toward a lower risk of deficits but did not reach statistical significance. On multivariate analysis, atriofemoral bypass was associated with a lower risk of paralysis ( p = 0.068), and significantly so when controlled for age ( p = 0.0329, odds ratio 0.287). Subgrouping of extent type I thoracoabdominal aneurysms resulted in an incidence of paralysis of 14% (3/22) for subgroup A and 23% (5 of 22) for subgroup B compared with 43% (23 of 55) for type II thoracoabdominal aneurysms (type I [8 of 44 18%], versus type II [p = 0.0097]).Conclusion: Patients with no or few patent segmental arteries in the aortic segment being replaced have a lower risk of neurologic deficits, compared with those with patent arteries. Every effort should be made to reattach all arteries at T11, T12, and L1 and, when possible within the constraints of technical feasibility and time, also those from T7 to L4. Preoperative angiography or intraoperative hydrogen testing may better identify the arteries that need to be reattached. When feasible, atriofemoral bypass appears to be protective, particularly when sequential clamping and segmental repairs can be performed. (J VASC SURG 1994;20:255-62.)     

The diagnosis and surgical treatment of ischemic heart disease in patients with occlusive arterial lesions of the lower extremities]

Concomitant ischemic heart disease was encountered in every 5 patients among 840 patients who underwent operation for occlusive lesions of the arteries of the lower limbs. Coronary cardiosclerosis increases the incidence of fatal myocardial infarction in the early and late-term postoperative periods. The presence of a clinical picture of ischemic heart disease and ECG changes require the performance of loading tests and, if their results are positive, the accomplishment of coronary ventriculography so as to solve the question of preventive revascularization of the myocardium. Preventive aortocoronary shunting excludes the risk of the development of cardiogenic complications in reconstruction of the great arteries of the lower limbs.     

Rheolytic thrombectomy using the "Angiojet" complex in treating arterial thrombosis]

Results of roentgenendovascular treatment of arterial thrombosis by rheolytic thrombectomy with "Angiojet" are presented. 18 patients (1 woman, 17 men) underwent 19 rheolytic thrombectomies from peripheral arteries. Mean age of patients was 53.3 +/- 3.0 years, time of thrombosis--from 20-30 min to 60 days (mean 121 +/- 17 hours). Thrombectomy was performed from superficial femoral, popliteal or tibial arteries, or from all these vessels simultaneously. In one case thrombus was removed from femoro-popliteal graft. Rheolytic thrombectomy was combined with balloon angioplasty of hemodynamicaly important stenosis, 5 patients underwent implantation of 9 stents. Good and satisfactory results were achieved in 77.8% patients; thrombectomy as the stage of operation was ineffective in one case only. Rheolytic thrombectomy from coronary arteries was performed 3 times, with complete effect in 1 and with partial--also in 1 patient.     

The accuracy of the supraorbital Doppler examination in the diagnosis of hemodynamically significant carotid occlusive disease.

The supraorbital Doppler technique was used to study 102 carotid arteries prior to arteriography. A carotid stenosis was defined as being hemodynamically significant if the diameter of the lumen were reduced by more than 50 percent. The Doppler examination gave a false-positive result in only two of the 61 arteries which did not demonstrate significant stenoses. False-negative Doppler results occurred in 22 percent of the 41 significant carotid lesions. The presence or absence of significant carotid lesions were predicted in 96 percent of 67 arteries for which the results of the supraorbital examination and carotid auscultation were in agreement. False-negative results occurred in association with significant ipsilateral external and common carotid stenoses and in the presence of unusually efficient collateral circulation via the circle of Willis. The supraorbital Doppler examination is a valuable technique for the identification of patients with hemodynamically significant carotid stenoses.     

The early results of treatment of simple transposition in the current era

A total of 187 neonates with simple transposition of the great arteries (TGA) have been entered into a twenty institution cooperative study between Jan. 1, 1985, and June 1, 1986. Eighty-two percent entered within the first 2 days of life. Seventy-six of the 187 patients were initially entered into a treatment protocol leading to an arterial switch repair, 45 into one leading to an atrial switch (Mustard) repair, and 49 into one leading to a Senning repair. Five (7%) of the patients entered initially into an arterial switch protocol later were crossed over to an atrial switch protocol, and 7% of those entered into an atrial switch (Mustard) protocol were crossed over to an arterial switch protocol. Formal follow-up information is available on all patients. Only 5% of patients entered into an arterial switch protocol were without repair 2 weeks after entry, whereas 96% and 100%, respectively, of those entered into a Mustard or Senning atrial switch protocol were without repair at that time. Ninety-seven percent of the first group had no preliminary procedures other than balloon atrial septostomy, which was true of only 76% and 90%, respectively, of the last two groups. No deaths before repair occurred in the first group, whereas five occurred in the latter two groups (P = 0.06). Overall survival rate among the 187 patients was 81% at 1 year. The only risk factors for death were birth weight, date of entry into the study, and an arterial switch protocol in the group of institutions at high risk for arterial switch repair; neither an arterial nor an atrial switch protocol was a risk factor per se. According to the multivariate equation, the 12-month predicted survival rate of a patient with a birth weight of 3.4 kg, entered currently into atrial or arterial switch protocols (except in the high risk for arterial switch group of institutions) is 92%.     

Angioplasty of the distal anastomosis und runoff arteries of occluded infrainguinal bypasses

BACKGROUND: We investigated the clinical results of transluminal angioplasty performed through infrainguinal bypass grafts for stenotic or occlusive lesions at the distal anastomosis and/or in the runoff arteries in high risk patients and the influence of different parameters on limb salvage, primary and secondary patency rate. PATIENTS AND METHODS: Between January 2001 and March 2005 we performed 49 transluminal angioplasties on stenotic or occlusive lesions at the distal anastomosis and/or in the runoff arteries in 49 (16 female, 23 male, mean age 71.1 years) patients with occluded infrainguinal bypass. 20 angioplasties occurred in the runoff arteries, 5 at the distal anastomosis and 24 at both locations at a median of 11.3 months (range 2-85 months) after infrainguinal bypass grafting). 20 procedures were on popliteal artery above the knee, 21 below the knee and 8 on crural arteries. RESULTS: Kaplan-Meier analysis showed a cumulative limb salvage of 87.6 and 76.4 % after 6 months and two years, respectively. Patients with gangrenous lesions had a 5 times higher risk of amputation (Cox-regression model). Primary and secondary patency rates were at 6 months 85.1 and 91.1 % respectively and were at one year 73.3 and 78.8 % respectively. Patients with end stage renal disease were in 4 times hazard to primary occlusion and patients with gangrenous lesions 5 times to secondary occlusion (Cox-regression model). CONCLUSION: Even if the long-term results of angioplasty on stenotic or occluded lesions at the distal anastomosis and/or in the runoff arteries are inferior to the results of surgical revisions reported in literature, angioplasty in high risk patients with absence af a vein may be the first line alternative intervention for limb salvage.     

Comparison of expanded PTFE and vein grafts in lower extremity arterial reconstructions

Polytetrafluoroethylene (PTFE) bypasses were used in a series of arterial reconstructions to the popliteal artery (45) and to arteries below that level (11). These were performed in high-risk situations in patients who lacked a suitable saphenous vein. Vein bypasses were performed in a comparable series of high-risk situations in patients having a suitable autologous saphenous vein (45 to the level of the popliteal artery and 11 to an artery below that level). PTFE patency rates at 4-14 months were 43 to 45 (96%) for the femoro-popliteal reconstructions (with a limb salvage rate of 39 to 45 or 87%) and 5 of 11 (45%) for the distal bypasses. Saphenous vein bypass patency rates at 8-14 months were 39 of 45 (87%) for the femoropopliteal reconstructions (with a limb salvage rate of 36 of 45 or 80%) and 5 of 11 (45%) for the distal bypasses. These results justify continued use of PTFE grafts in patients without saphenous veins who require lower extremity arterial reconstructions for limb salvage. The exact place of PTFE grafts in arterial reconstructive surgery of the lower extremity definition based on longer periods of observation.     

"Resection of parietal cells" in the treatment of duodenal ulcer

Resection of the parietal cells, a modification of the generally known Wangensteen's tubular resection, was carried out in 8 patients with duodenal ulcer. The greater curvature of the stomach was removed to the left of the line joining the prepyloric part and the His angle. The operation was not devoid of technical difficulties, especially in well-nourished patients with high position of the cardia. The immediate postoperative course was uneventful. The ulcer was not found in any of the patients by endoscopy conducted in periods of 16 to 36 months, all of them noted subjective improvement after the operation. The results allow the operation to be recommended for the treatment of duodenal ulcer complicated by penetration and hemorrhages, when distal resection is a considerable risk.     

Regional hemodynamics and its surgical correction in combined arteriosclerotic lesions of the iliac and femoral arteries

The authors analyse the regional hemodynamics and the results of surgical treatment of 81 patients with coexistent atherosclerotic affections of the iliac and femoral arteries. Radiocontrast angiography and ultrasonic dopplerometry were conducted by elaborated methods for morphofunctional characteristics of arterial circulation. Inclusion of the internal iliac and deep femoral arteries in the main blood flow was the principal method of surgical correction. A differentiated choice of the reconstructive operation allowed a positive result of treatment to be produced in 80.25% of patients in the immediate and in 76.31% of patients in the late-term postoperative periods.     

Late onset azotemia from RAAS blockade in CKD patients with normal renal arteries and no precipitating risk factors

Despite proven renoprotection from RAAS blockade and its increased application since the early 1990s, we have experienced an increasing CKD/ESRD epidemic, especially among U.S. diabetics. Consequently, some concerns regarding iatrogenic azotemia from RAAS blockade have surfaced. We hypothesized that susceptible CKD patients with normal renal arteries on conventional angiography, including MRA, but who have microvascular arteriolar narrowing in the renal circulation - mimicking large vessel renal artery stenosis, even without precipitating risk factors - could experience worsening azotemia after periods of time exceeding three months on stable doses of RAAS blockade. Between September 2002 and February 2005, as part of a larger prospective study of renal failure in CKD patients on RAAS blockade, we studied five patients with >25% higher serum creatinine and normal MRA without precipitating factors. RAAS blockade was discontinued. eGFR by MDRD was monitored. Five Caucasians (M:F = 1:4; age 68 years) were enrolled and followed-up at 29.6 months. The duration of RAAS blockade at enrollment was 34.6 months. The baseline eGFR had decreased from 28.4 +/- 7.1 to 17.0 +/- 7.4 ml/min/1.73 m(2) BSA (p < 0.001) at enrollment. One required temporary hemodialysis; no deaths occurred. eGFR increased from 17.0 +/- 7.4 to 24.6 +/- 9.5 ml/min/1.73 m(2) BSA (p = 0.009), 29.6 (20-43) months after stopping the RAAS blockade. We conclude that worsening azotemia occurs in susceptible CKD patients on stable doses of RAAS blockade after long periods of time, despite normal renal arteries without precipitating risk factors. We submit that microvascular renal arteriolar narrowing is the pathophysiologic mechanism. These observations call for further study.     

Carotid intima-media thickness and plaques in hemodialysis patients

Atherosclerosis is accelerated in hemodialysis patients. Using B-mode ultrasonography, we compared intima-media thickness (IMT) and the prevalence of plaques in the common carotid and internal carotid arteries in 28 randomly selected hemodialysis patients with that in 28 age- and sex-matched normal controls. The IMT values of the common carotid and internal carotid arteries were higher in hemodialysis patients than in controls with more hemodialysis patients having plaques. In hemodialysis patients, there was a relationship between age and IMT in the common carotid arteries, in the area of bifurcation, and in the internal carotid arteries. We found no relationship between IMT and atherosclerotic risk factors or duration of hemodialysis treatment. IMT at all sites correlated with the number of plaques. Age was the only significant determinant for number of plaques. The results indicate that hemodialysis patients showed advanced atherosclerosis in the carotid arteries compared with age- and sex-matched normal subjects.     

Higher Non-fasting Serum Triglyceride Preceding the Carotid Stenosis Progression

The present study was conducted to investigate whether non-fasting serum triglyceride (TG) levels can be used to assess a risk for the progression of carotid artery stenosis. This was a single- center retrospective study. Consecutive 96 patients with ≥50% stenosis of at least unilateral cervical internal carotid artery and normal fasting serum low-density lipoprotein cholesterol (LDL-C) levels of ≤140 mg/dL were followed up for at least 1 year (mean, 3.1 years), and clinical variables were compared between patients with and without carotid stenosis progression (≥10% increases in the degree on ultrasonography). Carotid stenosis progression was shown in 21 patients, associated with less frequent treatment with calcium channel blockers (CCBs), higher non-fasting TG and glucose levels. In carotid artery-based analyses including <50% stenosis side, stenosis progression was shown in 23 of 121 arteries except for those with complete occlusion and less than 1-year follow-up period because of carotid artery stenting (CAS) or carotid endarterectomy (CEA). Stenosis progression was more frequently observed in symptomatic and/or radiation-induced lesions, and was also accompanied with less frequent treatment with CCBs, higher non-fasting TG and glucose levels in carotid artery-based analyses. The receiver operating characteristic (ROC) curve analyses revealed that a cutoff value of non-fasting TG to discriminate carotid stenosis progression was 169.5 mg/dL for carotid arteries with the baseline stenosis of <50%, and 154.5mg/dL for those of ≥50%. Non-fasting TG level was an independent risk factor of carotid stenosis progression, and more strict control of non-fasting TG may be necessary for higher degree of carotid artery stenosis.     

Color Doppler sonography in the detection of parathyroid adenomas.

BACKGROUND: Various diagnostic modalities have been utilized to aid in the detection of abnormal parathyroid tissue; however, its localization is not always easy. The purpose of this study was to determine whether the evaluation of potential hemodynamic changes in thyroid arteries could aid in the detection of parathyroid adenomas. METHODS: Twenty-eight patients with laboratory evidence of hyperparathyroidism were examined with color Doppler sonography. Data were collected for the superior and inferior thyroid arteries separately. These findings were compared with data for a control group of 14 healthy subjects. RESULTS: Retrospective analysis of the data indicated that peak systolic velocities in the inferior thyroid arteries ipsilateral with the parathyroid adenomas were significantly higher than in normal controls (p <.001). Peak velocity values in the superior thyroid arteries ipsilateral with parathyroid adenomas located in the upper position were also significantly increased compared with those in control subjects (p <. 02). Conversely, peak velocities in the inferior and superior thyroid arteries contralateral with the adenomas, as well as velocities in the superior thyroid arteries ipsilateral with lower position adenomas, did not differ significantly from those in control subjects. The localization of both side and level site of the adenomas presented an accuracy of 86.6%, sensitivity reached 96. 5%, and specificity 83.1%. CONCLUSION: Our results suggest that color Doppler sonography can be used to improve diagnostic accuracy in detecting parathyroid adenomas.     

Feasibility of multi-slice computed tomography in the diagnosis of arteriogenic erectile dysfunction

OBJECTIVE: To compare computed tomography (CT) angiography (CTA) obtained by multi-slice CT (a new minimally invasive method) with the current standard of arterial imaging, digital subtraction angiography (DSA), in diagnosing arteriogenic erectile dysfunction (ED). PATIENTS AND METHODS: Twenty-one patients with suspected arteriogenic ED underwent DSA and CTA after providing informed consent. Prostaglandin E1 was injected into the penile cavernosal body and then non-ionic contrast medium was rapidly infused into the antecubital vein. The DSA and CTA images were diagnosed as showing a normal or abnormal status by three reviewers independently. CTA was undertaken on an outpatient basis but DSA required hospitalization. RESULTS: In the 42 internal pudendal arteries, DSA showed 28 normal and 14 impaired arteries; CTA showed 21 normal arteries and 21 occlusions. The CTA image correlated closely with the diagnosis of stenosis or occlusion in internal pudendal arteries, with a sensitivity of 93%, a specificity of 71% and an accuracy of 79%. In the cavernosal arteries, DSA depicted 14 normal and 28 impaired arteries; CTA showed seven normal arteries and 35 occlusions. The CTA image agreed closely with the diagnosis of stenosis or occlusion in cavernosal arteries, with a sensitivity of 96%, a specificity of 43% and an accuracy of 79%. Of the 42 inferior epigastric arteries, DSA could not depict 11 arteries but CTA showed all 42 inferior epigastric arteries. CONCLUSIONS: CTA images correlated with DSA images; at present DSA is better than CTA in visualizing stenosis in fine arteries. However, CTA is less invasive and relatively inexpensive, and in future will probably provide even greater improvements in graphic quality. CTA would be an adequate replacement for DSA in evaluating internal pudendal arterial stenosis.     

"High" arcuate osteotomy of the tibia in the treatment of arthrosis deformans of the knee joint]

The article shows the urgency of the problem of treatment of genu varus deformity consequent upon Stage III arthrosis deformans; nonoperative treatment of this contingent of patients was ineffective. The authors show the results of an operative method for valgoid osteotomy conducted in 52 cases; the patients' ages ranged from 42 to 78 years. The work discusses the clinical picture, techniques, and postoperative management of the patients. The late-term results were studied in follow-up periods of up to 7 years. The results were good in 92% and satisfactory in 8% of patients.     

Myocardial revascularization with three native in situ arteries. Gastroepiploic and bilateral internal mammary artery grafting

Three native arteries were used for coronary artery bypass grafting in six patients in whom complete revascularization was not feasible because of varices or previous venous stripping. The right gastroepiploic and both internal mammary arteries were placed as pedicled conduits, and four patients additionally received a total of six vein grafts available from the greater or lesser saphenous system. Surgical complications were minimal and complete relief from angina was obtained in all patients, even in maximal stress testing. All 24 grafts were angiographically checked: 23 (96%) were patent and one gastroepiploic artery was occluded. All patients had at least three patent grafts. These native arteries are excellent conduits when suitable veins are not available. They should also be used on individual indications to replace occluded grafts.