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Biomedical subjects

A O Mansfield

Publications and source records attributed to A O Mansfield.

At least 19 recordsLinked to original sources
PubMed1999

Repair of ruptured thoracoabdominal aortic aneurysm is worthwhile in selected cases.

INTRODUCTION: The risks and benefits of operating on patients with ruptured thoracoabdominal aortic aneurysm (TAAA) have not been defined. The aim of the present study is to report this unit's experience with operations performed for ruptured TAAA over a 10-year period. METHODS: Interrogation of a prospectively gathered computerised database. PATIENTS: Between 1 January 1983 and 30 June 1996, 188 consecutive patients with TAAA were operated on, of whom 23 (12%) were operated for rupture. RESULTS: There were nine survivors (40%). Patients whose preoperative systolic blood pressure remained above 100 mmHg were significantly more likely to survive (4/8 vs. 13/15, p = 0.03 by Fisher's exact test). Survival was also related to Crawford type: type I (two of three survived); II (none of six); III (two of six); and IV (five of eight). All non-type II, non-shocked patients survived operation. Survivors spent a median of 28 (range 10-66) postoperative days in hospital, of which a median of 6 (range 2-24) days were spent in the intensive care unit. Survivor morbidity comprised prolonged ventilation (> 5 days) (n = 3); tracheostomy (n = 1); and temporary haemofiltration (n = 2). No survivor developed paraplegia or required permanent dialysis. CONCLUSIONS: Patients in shock with a Crawford type II aneurysm have such a poor prognosis that intervention has to be questioned except in the most favourable of circumstances. However, patients with types I, III and IV who are not shocked on presentation can be salvaged and, where possible, should be transferred to a unit where appropriate expertise and facilities are available.

Aged↗
PubMed1998

Deuterium oxide-based University of Wisconsin solution improves viability of hypothermically stored vascular tissue.

BACKGROUND: Preservation of vascular function largely determines the outcome of transplantation. We have investigated replacing the water (H2O) in University of Wisconsin (UW) solution with deuterium oxide (D2O) in an attempt to improve vascular function after hypothermic storage. METHODS: Rat aortic segments were stored in UW solutions based on 100% H2O, 25% D2O, 50% D2O, and 100% D2O at 4 degrees C for 24, 48, or 72 hr. Vascular function was measured via contraction and endothelium-dependent relaxation after stimulation with phenylephrine and acetylcholine. RESULTS: UW solution with 25% D2O gave a significant (P<0.05) improvement of contraction and relaxation in comparison with H2O-based UW solution and other concentrations of D2O. CONCLUSIONS: Low concentrations (25%) of D2O-UW solution are significantly superior to the H2O-based (i.e., commonly used) equivalent at up to 72 hr. These results suggest that low concentrations of D2O-UW solution can improve the quality of hypothermic storage.

Adenosine↗
PubMed1998

Visceral ischemia and neutrophil activation in sepsis and organ dysfunction.

BACKGROUND: It has previously been shown that a rise in intraoperative neutrophil CD11b expression during supracoeliac cross-clamping is a marker for subsequent development of postoperative organ dysfunction. Prolonged visceral ischemia and increased aneurysm extent are associated with higher risks of morbidity and mortality after TAAA repair. This study investigates the relationship between visceral ischemia and neutrophil activation in sepsis and organ dysfunction following visceral reperfusion. METHOD: Fifty-one patients undergoing supracoeliac cross-clamping, 5 patients undergoing suprarenal clamping, and 8 patients undergoing infrarenal clamping for repair of aortic aneurysms were studied. Perioperative neutrophil CD11b expression was measured by flow cytometry. RESULTS: There was significant correlation between visceral clamp time and intraoperative CD11b expression. More extensive aneurysms resulted in increased visceral clamp times and CD11b expression. There were no differences between bypass and non-bypass-assisted surgery with regard to neutrophil expression. There were increased clamp time in patients who developed severe sepsis and postoperative organ dysfunction. Differences in preoperative levels of CD11b expression were observed between groups and high levels of preoperative CD11b expression were observed in patients who died intraoperatively, in type II patients who went on to develop severe sepsis and organ failure, and in patients who developed multiple organ failure rather than single organ failure. CONCLUSION: Longer periods of visceral ischemia are associated with higher levels of intraoperative CD11b expression, severe sepsis, and organ failure. High preoperative levels of CD11b may identify an "at-risk" subset of patients.

Adolescent↗
PubMed1997

Clostridium difficile colitis after aortic surgery.

OBJECTIVE: To determine the incidence and outcome of Clostridium difficile colitis (CDC) following aortic surgery. DESIGN: Retrospective clinical study, and case-note review. PATIENTS: Of 180 patients undergoing aortic surgery for either aneurysmal or occlusive disease between 1 September 1994 and 31 August 1996 (24 months), 15 (8.4%) developed CDC. There were 12 male and three female patients of median age 65 (range 46-84). RESULTS: Two patients died from multiple organ failure in association with CDC, one of whom underwent negative relaparotomy for suspected ischaemic bowel because the diagnosis of CDC had not been entertained. Previously identified risk factors for CDC comprised: age > 65 (eight); renal impairment (four); chronic obstructive airways disease (seven); coexistent malignancy (three); admission from another hospital (four); H2 antagonist therapy (13); ITU (nine); and/or HDU care (14). Diarrhoea commenced a median of 9 (range 5-26) days, and CDC, was diagnosed a median of 14 (range 10-26) days after operation. All patients received intravenous Cefuroxime, originally prescribed as prophylaxis, for a median of 6 (range 3-16) days prior to onset of CDC. Two patients received 1 additional antibiotic; one received 2; two received 3; and one received 4 prior to onset of CDC. CONCLUSIONS: CDC is a common and potentially serious complication of vascular, and in particular, aortic surgery. Although such patients often possess several risk factors for CDC, colitis frequently follows prolonged 'prophylactic' cephalosporin administration, which should therefore be avoided.

Aged↗
PubMed1997

Endotoxin related early neutrophil activation is associated with outcome after thoracoabdominal aortic aneurysm repair.

BACKGROUND: Thoracoabdominal aortic aneurysm (TAAA) repair is associated with high mortality rates, especially in patients who develop postoperative renal and pulmonary impairment. Organ damage during TAAA repair may be mediated by activated polymorphonuclear neutrophils (PMNs) during a systemic inflammatory response. The association between intraoperative neutrophil activation and postoperative outcome was studied after TAAA surgery. METHODS: Perioperative PMN activation (surface CD11b expression by flow cytometry), plasma endotoxin, plasma endotoxin core antibody, tumour necrosis factor (TNF), and interleukin 1 (IL-1) levels were measured in 21 patients undergoing TAAA repair. RESULTS: Intraoperative PMN CD11b expression was significantly greater in the 11 patients who developed pulmonary and renal complications than in those who made an uneventful recovery (P = 0.0009). In addition, CD11b expression during visceral reperfusion was preceded by a rise in plasma endotoxin level and a fall in antibody level (reflecting binding by absorbed endotoxin) which was significantly greater in patients who developed complications (P = 0.031 and P = 0.001 respectively). Plasma endotoxin level correlated with CD11b expression (r = 0.828, P = 0.001). There were no significant differences in intraoperative plasma levels of TNF and IL-1, or aortic cross-clamp times and blood transfusion volumes between the complicated and uncomplicated repairs. CONCLUSION: Intraoperative neutrophil activation is a marker for the development of postoperative complications after TAAA reconstruction and is associated with endotoxin absorption.

Acute-Phase Reaction↗
PubMed1996

Aortic prosthetic infection: 50 patients treated by radical or local surgery.

Fifty patients with aortic prosthetic infection were managed in a period of 10 years from 1983 to 1993. Twenty-five patients had recurrent sepsis after local surgery (group 1) and 22 of these eventually required radical surgery. Twenty-five patients had radical graft excision as the first procedure (group 2). Group 1 contained an excess of patients with local groin symptoms (11 in group 1 versus five in group 2, P = 0.03) and in this group fewer radiological techniques were used to document the extent of graft infection. The perioperative mortality rate was similar in both groups (seven in group 1 versus five in group 2). The number of amputations was also similar (five in group 1 versus four in group 2). The triad of occlusive disease, aortobifemoral bypass and groin symptoms was associated with eight of nine amputations. While the authors would consider using local techniques if the anastomosis was intact, the graft remained patent and infection appeared to be confined to the groin, this combination is uncommon and radical graft excision remains the preferred treatment.

Amputation, Surgical↗
PubMed1996

Detection and widespread distribution of Chlamydia pneumoniae in the vascular system and its possible implications.

AIMS: To attempt to detect Chlamydia pneumoniae DNA in atheromatous vascular tissue. METHODS: A modification of an existing polymerase chain reaction (PCR) assay and immunofluorescence staining with a monoclonal antibody directed against C pneumoniae were used to detect C pneumoniae. Specimens from 32 patients undergoing abdominal aortic aneurysm repair were examined. Vascular tissue, ostensibly normal, from six liver transplant donors was also examined for comparison. Altogether, 43 vessels from these 38 subjects (age range 36-85 years) were examined. RESULTS: C pneumoniae was detected in 11 (44%) of 25 aortas, five (55%) of nine iliac arteries, two (40%) of five femoral arteries, and one of two iliac veins. Immunofluorescence staining supported positive PCR results in three of 12 cases in which it was used. Overall, C pneumoniae was detected in the arteries of 14 (44%) of the patients undergoing vascular surgery and three (50%) of the donors. CONCLUSIONS: This study is the first in the UK in which C pneumoniae organisms have been found in atherosclerotic vessels and the tendency for the organisms to be present most often in such vessels exhibiting chronic inflammatory changes suggests that a search for them in various forms of arteritis may also be rewarding.

Adult↗
PubMed1995

Surgical repair of thoracoabdominal aortic aneurysm: 10 years' experience.

Between 1983 and 1993, a total of 110 patients underwent elective repair of thoracoabdominal aortic aneurysm. Mortality rate varied with the extent of repair: 26 per cent (five of 19) after type I repair, 42 per cent (eight of 19) after type II repair, 24 per cent (four of 17) after type III repair and 15 per cent (eight of 55) after type IV repair. A further 20 patients underwent urgent operation for suspected rupture in nine and true rupture in 11. The mortality rate was 73 per cent for those with true rupture and 33 per cent for those with threatened or contained rupture. Death was most commonly due to coagulopathy and bleeding (39 per cent) or myocardial ischaemia (19 per cent). Preoperative risk factors for death included type II repair, urgent or emergency operation, aortic dissection, impaired renal function and abnormal spirometry (P < 0.05). Postoperative risk factors included reoperation, dialysis or prolonged ventilation (P < 0.05). Twenty patients required dialysis; ten died, five recovered normal renal function and five were discharged on dialysis. Eight patients developed paraplegia and four of them died. Thoracoabdominal aneurysm remains a formidable surgical challenge, but 90 per cent of survivors are free of major morbidity.

Adult↗
PubMed1995

Thrombolysis in arterial graft thrombosis.

OBJECTIVE: to assess the impact of peripheral arterial thrombolysis for vascular graft occlusion. DESIGN: Retrospective review. SETTING: University Hospital. MATERIALS: Thirty-one patients presented with 33 episodes of graft thrombosis. CHIEF OUTCOME MEASURES: Successful thrombolysis in terms of total clearance or sufficient clearance to reveal an underlying factor responsible for graft failure. MAIN RESULTS: Thrombolysis was successful in seven of 10 suprainguinal grafts (4 of 5 rtPA; 3 of 5 SK). One patient had failed lysis requiring an ilio-femoral graft. Of the seven patients with successful lysis, one required revision of a proximal anastomosis, two required distal anastomotic revisions, and one rethrombosed. Twenty-three thrombosed infrainguinal grafts were managed initially with intraarterial thrombolysis (9rtPA, 14 SK). Of 27 patients surviving at 30 days, seven required major amputation despite aggressive intervention. CONCLUSIONS: Thrombosed suprainguinal grafts are amenable to thrombolysis and adjunctive surgery when necessary, with no major haemorrhagic complications. The majority of patients with thrombosed infrainguinal grafts require surgical intervention in order to preserve, or establish long term patency. For polytetrafluoroethylene (PTFE) grafts, thrombolysis was associated with poor success, haemorrhagic complications and a high amputation rate.

Amputation, Surgical↗