Biomedical subjects
Publications and source records attributed to A D Ammar.
The third reported case of aneurysm of the thyrocervical trunk is presented. The patient developed embolization to the fingers of the right hand. Diagnosis was confirmed by arteriogram. Treatment was by surgical resection and arterial reconstruction.
This study was undertaken to compare postoperative epidural analgesia (PEA) with patient-controlled analgesia (PCA) regarding complications, particularly pulmonary, death, intensive care unit and hospital stay, and hospital and physician charges. The elective consecutive infrarenal abdominal aortic procedures performed by two vascular surgeons over a 1 year period were retrospectively analyzed. Although nonrandomized, of the 80 patients reviewed, 40 received PEA and 40 received PCA. The following demographic data were obtained: age, sex, diabetes mellitus, hypertension, coronary artery disease, prior coronary revascularization, stroke, renal insufficiency, smoking, and chronic obstructive pulmonary disease. Epidural catheters were placed preoperatively and maintained for an average of 4 days postoperatively. All patients underwent routine aortic reconstruction via midline transperitoneal incisions. The demographics were similar in both groups. Likewise, surgical intensive care unit stay and complications were similar in both groups. The average length of stay in patients receiving PEA was 7.59 days, compared with 6.68 days for the PCA group. Following discharge from the hospital, no additional complications were encountered and no readmissions required during a 4-week follow-up. Average charge (hospital and physician) per patient for PEA was $2489.00 compared with $443.00 for patients receiving PCA (no physician charges generated for PCA). The results do not support the routine use of PEA following abdominal aortic operations. Savings are more than $2000.00 per patient for PCA compared with PEA.
PURPOSE: This study was performed to determine whether comprehensive cost-cutting strategies adversely affect the outcome in patients undergoing carotid endarterectomy. METHODS: From December 1994 to December 1995, 237 consecutive patients undergoing 260 carotid endarterectomies were prospectively studied. The following variables were assessed: carotid arteriography, preoperative laboratory tests, electrocardiograms and chest x-ray films, use of carotid shunts during operation, use of pathology department, intensive care, oxygen therapy, telemetry, and hospital stay. In addition, complications were tabulated. RESULTS: Previously, all variables evaluated were routinely ordered. Subsequent to initiating the cost-containment strategies, the following results were achieved: arteriography in 52 (22%) of 237 patients, preoperative complete blood cell count and SMA-7 in 161 (62%) of 260 cases, preoperative electrocardiograms in 185 (71%) of 260 cases, preoperative chest x-ray films in 190 (73%) of 260 cases, carotid shunts in 83 (32%) of 260 cases, disease in no cases (0%), intensive care in 29 (11%) of 260 cases, oxygen therapy in 34 (13%) of 260 cases, telemetry in 17 (7%) of 260 cases, and hospital stay was decreased from an average of 2.6 to 1.3 days. Total savings based on average hospital and physician charges was $2.3 million. Complications included four strokes, one myocardial infarction, and no deaths. No patient required readmission. No recurrent or new neurologic or cardiac findings were identified clinically in follow-up at 1 and 4 weeks after surgery. CONCLUSIONS: The results clearly demonstrate that comprehensive cost-cutting strategies can reduce charges significantly while maintaining patient safety.
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Stroke is an important source of morbidity and mortality in the USA. Carotid occlusive disease is associated with most cerebrovascular accidents, and carotid artery intraplaque hemorrhage is particularly important in the pathogenesis of cerebral ischemic symptoms. The authors' experience with intraplaque hemorrhage in patients undergoing bilateral carotid endarterectomy was reviewed to determine whether unilateral intraplaque hemorrhage is predictive of the condition occurring on the contralateral side. Forty-seven patients underwent staged bilateral carotid endarterectomy performed by one vascular surgeon. Each plaque was reviewed by a pathologist for the presence of intraplaque hemorrhage. Of these patients, 33 demonstrated intraplaque hemorrhage on the side of initial endarterectomy; 27 of these 33 (82%) had bilateral hemorrhage. It was concluded that intraplaque hemorrhage in the initially operated carotid atheroma is highly predictive of the condition occurring in the contralateral atheroma. Furthermore, aggressive follow-up in this patient population may be warranted.
PURPOSE: The purpose of this study was to attempt to identify a group of patients undergoing infrarenal aortic bypass in whom blood loss is consistently less than 2 units, making the routine use of autotransfusion devices unnecessary. METHODS: Four groups of patients were prospectively studied as follows: abdominal aortic aneurysm (AAA) repair with tube graft (n = 21), AAA repair with bifemoral or biiliac bypass (n = 19), and aortobifemoral bypass (AFB) or biiliac bypass for occlusive disease either with Cell Saver Autotransfusion Device (Haemonetics Corp., Braintree, Mass.) (n = 18) or without Cell Saver (n = 18). The latter two groups were randomized on an alternating basis. RESULTS: The following parameters were obtained on all patients: preoperative hemoglobin values, estimated blood loss, Cell Saver return volumes, intraoperative and postoperative homologous blood transfused, postoperative hemoglobin values on the day of surgery and on postoperative days 1 and 4, complications, and length of hospital stay. In comparing the groups undergoing AFB with Cell Saver and AFB without Cell Saver by the above parameters, we found no statistically significant differences, except for a higher hemoglobin level on postoperative day 1 in the group undergoing AFB with Cell Saver (mean 11.86 vs 10.74, p = 0.02). The estimated blood loss and Cell Saver return volumes were less for those patients undergoing AFB for occlusive disease compared with those undergoing AFB for aneurysmal disease. Interestingly, estimated blood loss and Cell Saver return volumes for patients with AAA with tube graft and patients undergoing AFB with Cell Saver were similar. CONCLUSIONS: We conclude that routine setup and use of rapid autotransfusion devices may not be necessary in every patient undergoing routine aortofemoral bypass for occlusive disease. Furthermore, the possibility that some patients may undergo AAA repair with tube grafts without use of the Cell Saver may be deserving of further investigation.
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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.
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Seizures are uncommon after carotid endarterectomy. Patients at greatest risk for having this complication are those with high-grade carotid stenosis and possibly those with recent stroke or severe hypertension. The most favored theory regarding the pathophysiology is hyperperfusion caused by failure of cerebral autoregulation. This article describes our experience with the management of a patient suffering focal motor seizures after subclavian-carotid bypass performed to treat common carotid occlusion.
The optimum treatment of acute infrainguinal arterial thrombosis remains controversial. During the past year, our group has used combined intraoperative balloon thrombectomy with intraoperative balloon angioplasty in eight patients with acute arterial thrombosis. All patients experienced resolution of acute symptoms, and seven of eight patients had a palpable pedal pulse. There were no complications, and all patients were discharged by the second postoperative day. The above results have been maintained in a follow-up of 12 to 24 months (average, 16 months). This modality offers many advantages over other treatment modalities and is both therapeutically and cost-effective. We believe that intraoperative balloon thrombectomy with intraoperative balloon angioplasty is the initial treatment of choice in the management of suspected acute infrainguinal arterial thrombosis.
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Single carotid intraplaque hemorrhage has been related to the occurrence of cerebrovascular ischemic symptoms. We were unable to reproduce these findings; therefore, our patient population was reinvestigated to ascertain the importance of repeated plaque hemorrhages and their possible relationship to the production of neurologic symptoms. Eighty-five consecutive patients underwent 95 carotid endarterectomies. Plaques were separated into three groups: those from patients with lateralizing symptoms, nonlateralizing symptoms, and no symptoms. All the plaques were inspected microscopically for evidence of hemorrhage, specifically, repeated hemorrhages. Repeated hemorrhages were found in 29 of 44 plaques (66%) in the lateralizing symptom group, 6 of 19 (32%) in the nonlateralizing symptom group, and 12 of 32 (37%) in the no symptom group. We conclude that repeated rather than single intraplaque hemorrhage is the critical factor related to the production of specific cerebrovascular ischemic symptoms.
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The clinical significance of celiac artery compression by the median arcuate ligament of the diaphragm remains unsettled. The controversy stems from an undefined pathophysiologic mechanism and the existence of celiac compression in asymptomatic patients. This study was therefore conducted to evaluate the late results of operative therapy among our patients and possibly to identify parameters that might correlate with sustained symptom relief. Among 51 patients (12 men and 39 women) (mean age 47 years) who underwent operative treatment for symptomatic celiac artery compression, 44 (86%) were available for late follow-up. Their clinical status was determined between 1 and 18 years postoperatively (mean 9.0 years) by patient interview (36) or chart review (7). Operative treatment consisted of celiac axis decompression only (16 patients), celiac decompression and dilatation (17 patients), or celiac decompression and reconstruction by primary reanastomosis or interposition grafting (18 patients). Sustained symptom relief occurred more often with a postprandial pain pattern (81% cure), age between 40 and 60 years (77%), and weight loss of 20 pounds or more (67%). A negative correlation with clinical improvement was demonstrated for an atypical pain pattern with periods of remission (43% cure), a history of psychiatric disorder or alcohol abuse (40%), age greater than 60 years (40%), and weight loss of less than 20 pounds (53%). Eight of 15 patients (53%) treated by celiac decompression alone remained asymptomatic at late follow-up in contrast to 22 of 29 patients (76%) treated by celiac decompression plus some form of celiac revascularization. Late follow-up arteriograms (18 studies) showed a widely patent celiac artery in 70% of asymptomatic patients but a stenosed or occluded celiac axis in 75% of symptomatic patients. These findings suggest that persistent clinical improvement in patients with symptomatic celiac axis compression can be achieved by an operative technique that ensures celiac axis patency. Although some clinical features are identified that correlate with long-term benefit, reliable diagnosis of the symptomatic patient awaits definition of the pathophysiologic mechanisms involved in this syndrome.