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Biomedical subjects

A D Shepard

Publications and source records attributed to A D Shepard.

At least 19 recordsLinked to original sources
PubMed1996

Surgical complications of transaxillary arteriography: a case-control study.

PURPOSE: The purpose of this study was to review the complications of transaxillary arteriography (TRAX), determine clinical factors associated with their occurrence, and define optimal treatment methods. METHODS: A retrospective review of 842 consecutive TRAX studies performed in a large, urban, tertiary care, academic medical center was undertaken. Patients with complications were compared with a concurrent randomized control group without complications with the use of a multivariate analysis model. Results of operative therapy for nerve injury were compared with those of nonoperative therapy. RESULTS: Nineteen (2.3%) complications were identified including 14 nerve injuries, four expanding hematomas/pseudoaneurysms without neurologic deficit, and one puncture site thrombosis. Several statistically significant or suggestive findings associated with the occurrence of complications were identified: female sex (odds ratio [OR] = 4.7), systolic blood pressure > or = 150 mm Hg at the conclusion of TRAX (OR = 9.5), periprocedural systemic heparin anticoagulation (OR = 7.9), concomitant use of intraarterial thrombolysis or percutaneous angioplasty (OR = 12.0), and duration of procedure > or = 90 minutes (OR = 4.0). Patients who underwent prompt exploration (< or = 4 hours from symptom onset) for nerve injuries were more likely to have complete resolution of their neurologic deficits (five of six patients) than those who were observed or underwent delayed operation (three of eight patients) (OR = 8.3). CONCLUSIONS: Aggressive treatment of post-TRAX hypertension, limitation of TRAX duration, delay of postprocedure anticoagulation, and use of alternative sites for arterial puncture in female patients or patients undergoing catheter-based intervention may reduce the incidence of TRAX-related complications. In patients who have neurologic deficits prompt surgical exploration of the puncture site with decompression of the involved nerve(s) may reduce the incidence of prolonged deficits.

Aneurysm, False↗
PubMed1994

Acute aortic occlusion. A 40-year experience.

OBJECTIVE: To review a large experience with acute aortic occlusion (AAO) to better define the cause, clinical presentation, treatment, prognostic variables, and outcome. DESIGN: Retrospective review of 46 consecutive patients with AAO during a 40-year period. SETTING: A large urban tertiary care referral center in Detroit, Mich. PATIENTS: Adult patients with arteriographic and/or operative confirmation of acute occlusion of the abdominal aorta plus signs and symptoms of acute ischemia. INTERVENTION: Operative and nonoperative treatment of AAO. MAIN OUTCOME MEASURES: Mortality, morbidity, and long-term survival. Other variables measured included cause, risk factors, and effects of duration and severity of ischemia and treatment methods on outcome. RESULTS: Two primary causes were identified--embolism (65%) and thrombosis (35%). Heart disease and female gender were risk factors for embolism, while smoking and diabetes were risk factors for thrombosis. Severity of ischemia on presentation correlated better with outcome than duration of ischemia. The hospital mortality rate was 35% and morbidity, 74%, with no difference between the two groups. Recurrent arterial embolism occurred in 43% of patients with embolic AAO. Seventy-two percent of AAO survivors were alive 5 years after therapy. CONCLUSIONS: Acute aortic occlusion remains a serious vascular surgical emergency with significant morbidity and mortality, even when recognized promptly and treated appropriately. Nevertheless, survivors have a reasonable long-term outcome. Permanent anticoagulation is suggested in patients with embolic AAO to minimize a high incidence of recurrent arterial embolism.

Acute Disease↗
PubMed1994

Results of lower extremity amputations in patients with end-stage renal disease.

PURPOSE: The purpose of this study was to determine the impact of end-stage renal disease (ESRD) on the outcome of patients undergoing lower extremity (LE) amputation. METHODS: Hospital charts and vascular surgery registry data were reviewed for all patients who underwent LE amputation over a consecutive 56-month period. The results of 84 patients with ESRD (137 amputations) were compared with 375 patients (442 amputations) without ESRD. RESULTS: Hospital mortality rate was significantly greater in patients with ESRD than patients without ESRD, 24% versus 7% (p = 0.001). Patients with ESRD undergoing minor amputations had mortality rates three times greater than patients without ESRD undergoing major LE amputations. In patients with ESRD requiring bilateral or unilateral above-knee amputation hospital mortality rates were 43% and 38%, respectively. In addition, patients with ESRD were seven times more likely to undergo bilateral amputation than patients without ESRD over a mean follow-up period of 17 months. No kidney transplant patients died after amputation. CONCLUSION: ESRD has a profound negative impact on morbidity, mortality, and survival rates after LE amputation. Attempts at prevention of amputation with aggressive foot care and patient education in this high-risk group should be the focus of therapy.

Adult↗
PubMed1994

Groin lymphatic complications after arterial reconstruction.

PURPOSE: The purpose of this study was to better define the associated risks and optimal management of groin lymphatic complications (GLC) after femoral artery reconstructive operations. METHODS: Retrospective review of a vascular surgery registry for the last 15 years identified 2679 arterial operations requiring a groin incision. Forty-one GLC were recognized, 28 lymphocutaneous fistulas (LF) and 13 lymphoceles. RESULTS: The incidence of GLC was 1.5% per patient or 1.2% per incision. The highest incidence of GLC was in patients having an aortobifemoral bypass for aneurysmal disease in a previously operated groin (8.1% per patient) and in those undergoing an isolated femoral procedure in a previously operated groin (5.3%). The lowest frequency of GLC was after femoropopliteal/tibial bypasses (0.5%). Twenty-nine patients (71%) were treated without operation with bedrest, intravenous antibiotics, and aggressive local wound care. Operative therapy with wound reexploration attempted identification and control of the leak site, and meticulous wound closure was used in 12 patients (29%). Lymph fistulas in patients undergoing reoperation (10/28) resolved sooner than in patients treated without operation (18/28) (9 +/- 3 days vs 24 +/- 3 days). Infectious wound complications with one resultant graft infection developed in five of 18 patients with LF who did not undergo reoperation. There were no wound or graft infections in the patients in the LF group treated with operation. Operative exploration of lymphoceles did not reduce hospital stay or infectious wound complications. Repetitive lymphocele aspiration did not affect rapidity of resolution or increase the infectious complications. CONCLUSION: GLC remain a troublesome complication of femoral arterial reconstruction. Early reoperation should be performed once a LF is diagnosed. Treatment for lymphoceles should be individualized, with neither operative nor nonoperative management showing clear superiority.

Aged↗
PubMed1993

Repair of pararenal abdominal aortic aneurysms. An analysis of operative management.

OBJECTIVE: To analyze different operative approaches for repair of pararenal abdominal aortic aneurysm, to define factors associated with perioperative morbidity, particularly renal insufficiency, and to compare the results of pararenal abdominal aortic aneurysm repair with standard infrarenal repair. DESIGN: Case series review of all patients undergoing repair of nonruptured pararenal abdominal aortic aneurysms over 7 consecutive years at a tertiary care teaching hospital. PATIENTS: Fifty-three consecutive patients with nonruptured atherosclerotic pararenal abdominal aortic aneurysms undergoing operative repair. A comparison group of 65 patients randomly selected from a pool of 384 patients undergoing concurrent infrarenal abdominal aortic aneurysm repair. MAIN OUTCOME MEASURES: Operative morbidity and mortality, postoperative renal insufficiency, estimated blood loss, perioperative blood and fluid requirements, and length of hospital stay. RESULTS: Postoperative renal insufficiency was more likely when concomitant renal revascularization was performed (P = .007) or when any major intraoperative complication occurred (P = .008). Retroperitoneal abdominal aortic aneurysm repair was associated with lower estimated blood loss (P = .05) and less fluid requirement within the first 24 hours following operation than transperitoneal repair (P = .03). No differences in outcome measures were identified with regard to site of proximal aortic clamping (supraceliac vs suprarenal). Pararenal abdominal aortic aneurysms were larger and their repair was associated with greater estimated blood loss (P = .007), intraoperative blood replacement (P < .001), and a longer hospital stay (P = .02) than infrarenal abdominal aortic aneurysms. CONCLUSIONS: Pararenal abdominal aortic aneurysm repair is a technically challenging operation associated with significant morbidity. A retroperitoneal approach facilitates repair. The site of proximal aortic cross-clamping should be dictated by technical factors and not by any perceived outcome advantages.

Acute Kidney Injury↗
PubMed1993

Supraceliac aortic cross-clamping: determinants of outcome in elective abdominal aortic reconstruction.

PURPOSE: A 7-year experience in which 43 patients underwent supraceliac aortic cross-clamping (SC-AXC) during elective abdominal aortic reconstruction was reviewed. METHODS: Operation was performed for abdominal aortic aneurysm (AAA) in 29 (68%) patients, aortoiliac occlusive disease in seven (16%), proximal anastomotic AAA in three (7%), "shaggy" aorta syndrome in three (7%), and in situ grafting of a previously ligated aorta in one (2%) patient. The indications for supraceliac control included pararenal AAA origin (25), pararenal aortic atherosclerosis (18), inflammatory AAA (2), and a short infrarenal aortic stump (1). Vital organ ischemic complications (VOICs) were defined as any major ischemic complication involving the liver, kidneys, bowel, or spinal cord. RESULTS: The incidence of VOICs was significantly increased when concomitant renal or visceral revascularization (CRVR) was required (p = 0.002) and correlated with an increasing SC-AXC time (p = 0.015). In patients undergoing CRVR (n = 16) the perioperative mortality rate was 25%; VOICs developed in six patients and included renal failure (3), mesenteric/colonic ischemia (3), hepatic ischemia with coagulopathy (2), and spinal cord ischemia (1). In contrast, in those not requiring CRVR (n = 27), SC-AXC was well tolerated. There were no VOICs and no deaths; morbidity rate was 33%. CONCLUSIONS: The incidence of VOICs associated with the use of SC-AXC is primarily related to the level of preoperative renal or mesenteric insufficiency, the severity of pararenal aortic atherosclerosis, the extent of the operative procedure, and the duration of proximal aortic cross-clamping. In complex abdominal aortic reconstruction in which infrarenal aortic control is either not possible or deemed hazardous, SC-AXC is a safe and valuable technique for achieving proximal control.

Aged↗
PubMed1993

Outpatient duplex scanning for deep vein thrombosis: parameters predictive of a negative study result.

PURPOSE: Although clinical examination has been reported to be unreliable in the diagnosis of deep vein thrombosis (DVT), this conclusion has often been derived from hospitalized patients (HP) and may not be applicable in an outpatient setting. This study was undertaken to define clinical parameters that might predict the diagnostic value of emergency venous duplex scanning (VDS). METHODS: Venous duplex scans performed over a 9-month period (interval I) in 154 outpatients (154 limbs) and 145 HP (145 limbs) with suspected DVT were reviewed. RESULTS: Eighteen percent of scans of outpatients and 31% of scans of HP were interpreted as positive for lower extremity DVT. With stepwise logistic regression analysis, criteria predictive of a negative result of outpatient VDS included (1) duration of symptoms greater than 7 days (p = 0.003), (2) thigh circumference difference relative to the uninvolved side of less than 3 cm (p = 0.001), and (3) no history of neoplasia (p = 0.03). This model, when applied prospectively to 68 outpatients (68 limbs) over the next 5 months (interval II), yielded a negative predictive value (NPV) of 96.7% (sensitivity 90.9%, specificity 50.9%, positive predictive value 26.3%). Of the 222 outpatients examined during intervals I and II, 98 (44%) met these three clinical criteria. Three of these 98 outpatients had DVT on VDS and thus would have been misclassified as having a negative result. With a similar logistic regression analysis for HP, clinical criteria achieved an NPV of only 75% (sensitivity 36%, specificity 90%, positive predictive value 62%). CONCLUSION: Clinical assessment is unreliable in the diagnostic evaluation of HP with suspected DVT. In an outpatient population, however, clinical evaluation with the above criteria achieved an NPV of 96.7% in the diagnosis of DVT. These parameters may be useful as guidelines in determining the appropriateness of emergency outpatient VDS.

Ambulatory Care↗
PubMed1991

Management of infected aortoiliac aneurysms.

A 30-year retrospective review identified 13 patients treated for infected aneurysms of the abdominal aorta or iliac arteries, for an overall incidence of 0.65%. A constellation of clinical findings led to the correct preoperative diagnosis in 11 (85%) of 13 patients. Treatment methods included resection and in situ replacement grafting in seven patients, resection and extra-anatomic bypass in five patients, and resection-ligation in one patient. Four (31%) of 13 patients died within 30 days of operation, three of whom died of rupture. Overall, good results were achieved in five patients (38%), while poor results were noted in the remaining eight patients (62%). The determinants of outcome were aneurysm location or rupture, the presence of established infection, and the virulence of the infecting organism. In 10 (77%) of the 13 aneurysms, Salmonella species, Bacteroides fragilis, Staphylococcus aureus, and Pseudomonas aeruginosa accounted for all deaths, ruptures, and suprarenal aneurysm infections. These data suggest that patients with primary infections of the abdominal aorta or iliac arteries continue to present with advanced infections or aneurysm rupture that result in a high mortality.

Adult↗
PubMed1991

Left flank retroperitoneal exposure: a technical aid to complex aortic reconstruction.

Over the last 5 years an extended left flank retroperitoneal approach was used in 85 of 531 (16%) aortic reconstructions deemed technically complex. Abdominal aortic aneurysm repair was performed in 70 patients (82%), bypass of aortoiliac occlusive disease was performed in 11 (13%), and aortic endarterectomy for mesenteric and/or renovascular disease was performed in 4 (5%). Indications for use of this approach included a "hostile" abdomen (43 patients), juxta/suprarenal abdominal aortic aneurysm (35), large (greater than 10 cm) abdominal aortic aneurysm (12), extreme obesity (10), associated renal and/or visceral artery stenosis requiring endarterectomy (9), inflammatory abdominal aortic aneurysm (2), and horseshoe kidney (2). Suprarenal or supraceliac aortic clamping, averaging 31 minutes, was required in 43 patients (50%). Postoperative recovery was rapid (average length of stay, 10.2 days), and morbidity was minimal despite the complex nature of these reconstructions. The perioperative mortality rate in elective operations was 1.2%. This approach facilitated proximal abdominal aortic exposure and anastomosis, especially in large, pararenal aneurysms or in situations unfavorable to a transabdominal approach. Whereas a left flank retroperitoneal approach can be used in most aortic reconstructions, it seems especially suited to those that pose significant technical challenges.

Abdomen↗
PubMed1990

Intraoperative autotransfusion in vascular surgery.

To determine the impact of intraoperative autotransfusion on vascular surgical care, data related to 304 major vascular surgical operations performed over a 42-month period were retrospectively analyzed. Procedures included abdominal aortic aneurysmectomy (N = 152), aortobilateral femoral bypass (N = 60), thoracoabdominal aortic aneurysmectomy (N = 20), and other vascular procedures (N = 68). Fifty percent of the transfusion requirement was met by autotransfusion for the average patient. The per patient average volumes (liters) autotransfused were as follows: elective abdominal aortic aneurysmectomy, 0.87 L and nonelective, 1.45 L; elective aortobilateral femoral bypass, 0.63 L; elective thoracoabdominal aortic aneurysmectomy, 2.47 L, and nonelective, 2.15 L; and elective other, 0.53 L and nonelective, 1.30 L. Results of immediate postoperative and hospital discharge hemoglobin, hematocrit, and coagulation studies (prothrombin time, partial thromboplastin time, and platelets) did not differ from results of preoperative studies in any group. Neither mortality nor morbidity was related to intraoperative autotransfusion. These data suggest that intraoperative autotransfusion is a safe blood replacement method during major vascular surgical operations.

Adult↗
PubMed1990

Pitfalls in lower extremity venous duplex scanning.

Results of scans performed on 1074 patients over an 18-month period were evaluated to define the limitations of lower extremity venous duplex scanning. Eighty-four patients had confirmatory phlebography performed within 24 hours of their venous duplex scanning. In 71 patients scans were considered diagnostic (sensitivity 91%, specificity 95%). Eighteen studies (13 equivocal, 5 misinterpretations) were scrutinized to determine the limitations of venous duplex scanning compared to phlebography and are the focus of this analysis. Seven patients had phlebograms documenting only infrapopliteal thrombus, seven had normal phlebographic findings, and four had findings consistent with chronic thrombosis. In the seven patients with infrapopliteal thrombus, four had normal imaging outcomes but abnormal Doppler flow patterns, whereas three had both normal imaging results and flow patterns. All four patients with chronic thrombosis had identifiable thrombus and abnormal flow patterns by venous duplex scanning, but in each case thrombus age was indeterminate. Of the seven patients with normal phlebographic results, five had incompressible segments of the superficial femoral vein on imaging, one had abnormal Doppler flow without visualized thrombus and without apparent reason, one had venous duplex scanning visualized thrombus with a normal outcome on phlebography. These data suggest that the diagnostic yield of lower extremity venous duplex scanning may be improved by (1) meticulous infrapopliteal vein examination, (2) better estimation of the age of the thrombotic process, and (3) recognizing segmental incompressibility of the superficial femoral vein within the adductor canal as a normal finding especially in the absence of abnormal Doppler flow or imaged thrombus.

Chronic Disease↗
PubMed1990

Ureteral complications and aortoiliac reconstruction.

A 33-year experience with 58 ureteral complications in 50 of 3580 patients undergoing aortoiliac reconstruction was analyzed. Ureteral obstruction was treated before or in conjunction with aneurysm repair in six patients with aneurysmal disease. The remaining 44 patients had 46 ureteral complications after aortic reconstruction; complications included hydronephrosis (42), ureteral leak (3), and ureteral necrosis (1). A high incidence of associated graft complications was noted. Graft thrombosis developed in one of the six patients undergoing prior or simultaneous ureteral procedures, and graft infection developed in another. Thirty-six graft complications developed in 24 (55%) of the 44 patients with postoperative ureteral complications. The complications included 19 anastomotic aneurysms, eight graft limb thromboses, six graft infections, and three aortoenteric fistulas. Twenty-nine of the 44 patients with postoperative ureteral complications underwent ureteral or graft operations or both. These included five patients having ureteral operations alone, seven with a ureteral procedure and subsequent graft operation, eight requiring simultaneous ureteral and graft procedures, and nine undergoing a graft operation with ureteral observation. Six of these 29 patients (21%) died after operation, all from graft complications including aortoenteric fistulas (three), ruptured anastomotic aneurysms (two), and graft infection (one). Graft complications affected 55% of 44 patients with postoperative ureteral complications, compared to 12% of 3536 patients without ureteral complications (p less than 0.0001). Patients with postoperative ureteral complications were 4.4 times as likely to have graft complications compared to those without ureteral complications (p less than 0.0001). These data suggest that such urologic complications may be markers for recognition of or harbingers for graft complications.

Adult↗
PubMed1990

Distal internal carotid exposure: a simplified technique for temporary mandibular subluxation.

Distal internal carotid artery exposure can be technically demanding even for experienced vascular surgeons. Although a variety of techniques have been described to facilitate such exposure, temporary mandibular subluxation has emerged as the simplest and least debilitating approach. Current techniques for maintaining temporary mandibular subluxation during distal internal carotid artery procedures, including maxillomandibular arch bar fixation and circummandibular/transnasal wiring, have been time consuming and associated with complications. Over the last 4 years a new simplified technique of temporary mandibular subluxation fixation has been used in 14 patients requiring distal internal carotid exposure. Indications for operation included extended carotid endarterectomy (8), carotid body tumor excision (2), repair of distal internal carotid artery trauma (2), and repair of postendarterectomy pseudoaneurysm (2). Among patients with healthy teeth, unilateral temporary mandibular subluxation was maintained by interdental wiring from the ipsilateral mandibular bicuspids to the contralateral maxillary bicuspids. In edentulous patients or those with chronic periodontal disease, temporary mandibular subluxation was maintained with diagonal wiring between maxillary and mandibular Steinmann pins. No instances of malocclusion, dental injury, or local infection were observed. Transient postoperative cranial nerve dysfunction was observed in three patients. Transient ipsilateral temporomandibular joint pain occurred in three patients. Two patients developed permanent cranial nerve injuries unrelated to temporary mandibular subluxation. These data suggest that temporary mandibular subluxation by diagonal interdental/Steinmann pin wiring is safe, expeditious, and effective in facilitating exposure of the distal internal carotid artery.

Bone Nails↗
PubMed1987

Clinical, hemodynamic, and anatomic follow-up of direct venous reconstruction.

Conventional therapy for the advanced clinical stages of the postthrombotic syndrome is associated with recurrence of symptoms and ulcer. Direct venous reconstruction may relieve the symptoms of patients with either iliac vein obstruction or valvular incompetence, but there are few reports detailing late hemodynamic and anatomic findings. We summarized the clinical, hemodynamic, and anatomic follow-up of six patients with saphenofemoral bypass (SFB) and ten patients with axillary vein valve-to-popliteal vein transplants (PVTs) who were followed up for a minimum of two years. All ten ulcers in the PVT group healed and symptoms of venous claudication, limb swelling, and all ulcers healed in the SFB group. Late (greater than 2 years) anatomic and functional assessment showed that the SFB bypasses were patent and the PVTs were both patent and functional.

Adult↗
PubMed1986

Retroperitoneal approach to high-risk abdominal aortic aneurysms.

During a 14-month period we used a left-flank, retroperitoneal, retrorenal approach in 23 high-risk patients with abdominal aortic aneurysm (AAA). Fourteen patients underwent suprarenal/celiac cross clamp for juxtarenal/suprarenal AAA and/or associated occlusive disease. Other indications for this approach included diminished cardiac and/or pulmonary reserve, previous extensive abdominal surgery, obesity, and inflammatory AAA. There was only one death (4%) in this high-risk group and minimal operative morbidity. The flexibility afforded by this approach for high aortic exposure allowed expeditious proximal anastomoses with minimal postoperative renal dysfunction. Pulmonary complications, ileus, and pain were reduced and patient mobilization was rapid despite the complex nature of the operative procedures. We believe that this approach offers significant advantages for all cases of AAA but particularly for anatomically complex lesions and medically high-risk patients.

Aged↗