Reconstruction of the male external genitalia.

Congenital malformation, infection, lymphatic obstruction, trauma and carcinoma all have common denominator, the loss of tissue. This loss necessitates the surgeon's use of various techniques in reconstructing the male external genitalia. The stretching of remaining skin, split thickness grafts, flaps and pedicle tube grafts are used to cover the denuded area or reconstruct the penis and scrotum. These methods have been used recently in transsexual operations, combining the expertise of the plastic surgeon, urologist, endocrinologist and psychiatrist. Further improvement upon the preceding approaches is sought to maintain sensation, achieve acceptable cosmesis, create a sexual organ as well as a urinary conduit and prevent severe postoperative complications.     

Operative management of the kinked carotid artery

In instances in which coexistent significant carotid artery disease and internal carotid redundancy coexist, we have found that use of the resected autogenous internal carotid artery to be a convenient and satisfactory way of patching the frequently small distal internal carotid artery following resection of the redundant portion. There has been no morbidity associated with additional suture lines, and in follow-up care extending through 24 months, there have been no recurrent symptoms.     

Replacement of the carotid artery using nonreversed saphenous vein

Carotid artery replacement has been performed with a nonreversed saphenous vein in one patient who had carotid artery resection in association with resection of a squamous carcinoma at the carotid bifurcation. An excellent result was obtained. The technical aspects of this procedure are described herein.     

Natural history of recurrent carotid artery disease

Controversy exists as to whether early and late recurrent stenosis of the carotid artery represents two distinct types of recurrence or whether it is the same type of lesion detected at different times. Eleven specimens from patients whose carotid arteries were reoperated upon were examined. A temporal sequence was noted: with increasing intervals, the relative presence of areas of myointimal hyperplasia tended to decrease, whereas the relative presence of features of atherosclerosis tended to increase. The clinical data and B-mode ultrasound studies performed from one to 190 months after 210 carotid endarterectomies were reviewed. Twenty-seven carotid arteries (12.9 per cent) exhibited hemodynamically significant restenosis. Three ultrasonographic patterns were described: homogenous soft plaque, homogenous hard plaque and heterogenous plaque. A previous correlation between ultrasonographic and pathologic findings showed the three ultrasound patterns to correlate with myointimal hyperplasia, fibrous atherosclerotic plaque and complex atherosclerotic plaque, respectively. Soft plaques were detected earlier than heterogenous plaques (p less than 0.001). Results from serial studies showed progression of soft plaque to hard or heterogenous plaque, or both. Early and late recurrent lesions are the same type of lesion detected at different intervals. Symptoms of cerebral ischemia are more common at the stage of heterogenous plaque (p = 0.02).     

Comparison between carotid duplex sonography and angiography in the diagnosis of extracranial internal carotid artery occlusion.

To determine the diagnostic accuracy of extracranial internal carotid artery (ICA) occlusion by carotid duplex sonography and ophthalmic flow direction, we compared both carotid sonograms and angiograms in 82 cases of ischemic cerebrovascular disease. A total of 157 carotid arteries were available for comparison. The overall diagnostic accuracy of ICA occlusion by duplex scanning was 96% (sensitivity, 83%; specificity, 98%; positive predictive value, 91%), by ophthalmic flow examination, 95% (sensitivity, 79%; specificity, 98%; positive predictive value 86%), and by combined study, 98% (sensitivity, 96%; specificity, 98%; positive predictive value 92%). We recommend that the ophthalmic flow examination should be used in combination with other sonographic methods in detecting extracranial carotid artery disease. The combined study gives higher diagnostic accuracy than the single method. When an occlusion or a tight stenosis is uncertain on carotid sonograms, color Doppler or angiography is indicated for further confirmation.     

The importance of arteriographic interpretation in occlusion or pseudo-occlusion of the carotid artery

Carotid arteriography can be misleading in that roentgenographic occlusion of the internal carotid artery (ICA) may be suggested when the artery is actually anatomically patent. The distinction of occlusion versus pseudo-occlusion is crucial in recommending proper treatment. Aroused by the misinterpretation of two arteriograms by our radiology departments, a review of 780 arteriograms done on 780 patients during a three year period was begun. Of these, eight (1.0 per cent) symptomatic patients had conflicting arteriographic reports, with the radiologists reporting complete occlusion and the authors describing pseudo-occlusion. Established arteriographic criteria for pseudo-occlusion of the ICA are emphasized. These eight patients underwent carotid arterial exploration and all were found to have patent ICA. After successful carotid endarterectomy, seven of the eight patients have remained asymptomatic and have had no hemodynamically significant stenosis on noninvasive testing in the follow-up period, ranging from two to 38 months. Therefore, in evaluating patients with carotid territory symptoms, knowledge of the established arteriographic criteria for ICA pseudo-occlusion should alert the physician to the possibility of ICA patency. If this is suspected, the patient should undergo exploration of the carotid artery with subsequent endarterectomy if patency is demonstrated.     

Reduced baroreceptor sensitivity and elasticity of the carotid artery in a preeclamptic patient

Baroreflex sensitivity, distensibility coefficient, and intima-media thickness (IMT) of the common carotid artery were determined in a preeclamptic patient during 1st and 3rd trimesters as well as after childbirth. From the beginning of her pregnancy, baroreflex sensitivity and distensibility coefficient of the carotid artery exhibited a parallel decline, whereas the IMT increased as compared with normotensive pregnancies. The values of all parameters examined returned to their initial levels after 14 weeks of delivery. These results suggest that augmented IMT and carotid stiffness coupled to baroreceptor dysfunction may have contributed to the perturbation of blood pressure control in our preeclamptic patient.     

Decrease in pulsatile flow in the internal carotid artery in fetal hydrocephalus

Summary. The effect of ventriculomegaly on pulsatile flow in the internal carotid arteries has been studied by Doppler ultrasound in four hydrocephalic fetuses. The pulsatility index showed progressive elevation proportional to the developing ventriculomegaly and thus may be a valuable index for the study of the mechanism of brain injury and for the determination of optimal timing of intervention.     

Decrease in pulsatile flow in the internal carotid artery in fetal hydrocephalus

The effect of ventriculomegaly on pulsatile flow in the internal carotid arteries has been studied by Doppler ultrasound in four hydrocephalic fetuses. The pulsatility index showed progressive elevation proportional to the developing ventriculomegaly and thus may be a valuable index for the study of the mechanism of brain injury and for the determination of optimal timing of intervention.     

Fetal internal carotid artery flow velocity time waveforms in twin pregnancies

The fetal internal carotid artery and umbilical artery flow velocity time waveforms were studied in 17 consecutive twin pregnancies. The pulsatility index was calculated for each fetus in each artery as an index of vascular resistance. All studies were done within 14 days before delivery. In 8 pregnancies both fetuses were of birthweight appropriate for gestational age; whereas, in 9 patients one or both of the infants were small for gestational age (SGA). From ultrasound criteria and Doppler studies of the umbilical and fetal internal carotid arteries, decreased fetal internal carotid artery pulsatility index (cut off value less than or equal to 1.2) was found to be the best predictor of SGA (sensitivity 83%, specificity 95%, positive predictive value 91%, negative predictive value 91%).