Commentary on carotid endarterectomy.
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Canada↗
Biomedical subjects
B Satiani
Publications and source records attributed to B Satiani.
Extracavitary vascular trauma.
Extracavitary vascular injuries involving the cervical area and the extremities constitute about 50% of all vascular injuries. Initial evaluation and resuscitation of patients with vascular injuries should follow standard Advanced Trauma Life Support protocols. Diagnosis of the injury is heavily reliant on physical examination, supplemented by arteriography in specific instances. Intraoperative management utilizes all the basic principles of vascular surgery. Postoperative nursing care focuses on the entire patient including the detection of early complications of vascular repair. Recent advances in transportation, resuscitation and operative techniques have lead to a decrease in mortality and morbidity.
Angiography↗
Noninvasive diagnosis of deep venous thrombosis.
Deep venous thrombosis of the lower extremity poses a diagnostic challenge. Clinical signs and symptoms are often misleading, and sensitive and specific tests are essential for diagnosis. The cost, patient discomfort and risk of morbidity associated with contrast venography have led to the development of noninvasive diagnostic techniques such as Doppler ultrasound, impedance plethysmography and duplex ultrasound scanning. If noninvasive tests unequivocally indicate deep venous thrombosis, treatment may be started without the need for contrast venography.
Anthropometry↗
The influence of contralateral disease on the natural history of nonoperated significant carotid stenosis.
The influence of contralateral disease on the natural history of ipsilateral nonoperated carotid stenosis greater than 50% was analyzed in 90 carotid arteries imaged by contrast arteriography or duplex scanning with a mean follow-up of 23.6 months. Ipsilateral stenosis was greater than 80% in 24 arteries and 50-79% in 66 arteries. Contralateral disease was present in 30 (Group I) and absent in 60 (Group II) patients. In Group I, the contralateral disease consisted of total occlusion in nine (30%), greater than 80% stenosis in five (17%), 50-79% stenosis in 12 (40%) with a mean of 78.6%. No significant difference existed in the incidence of initially asymptomatic vessels (57% versus 67%), stroke (13% versus 2%), or transient ischemic attack (17% each) between Groups I and II on the ipsilateral side (p greater than .05). New ipsilateral neurologic events occurred significantly more often in arteries with greater than 80% ipsilateral stenosis than those with 50-79% stenosis (p less than .02). The incidence of subsequent ipsilateral neurologic events (37% versus 22%), strokes, or transient ischemic attacks (20% versus 13%) was no different in Groups I and II, respectively (p greater than .05). Combined ipsilateral and contralateral neurologic events occurred significantly more often in patients with contralateral disease (p less than .05). Whereas in Group I, new ipsilateral symptoms were significantly more common in initially symptomatic vessels compared to asymptomatic ones (61.5% versus 17.6%, p less than .04), no such difference existed in Group II.
Aged↗
A technique for repair of iatrogenic femoral artery pseudoaneurysm.
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Aneurysm↗
Rapid volume replacement with warmed blood and fluids.
A prospective clinical study was undertaken in 50 consecutive patients suffering from severe traumatic shock to evaluate the clinical efficacy of a set for rapid administration of solutions (RSAS), which allows for rapid infusion and simultaneous warming of blood and fluids. The mechanism of injury was blunt in 37 patients and penetrating in 13. Admission trauma score averaged 7.5, and the injury severity score averaged 46. Average preresuscitation systolic blood pressure was 71 mmHg, pulse was 105 beats/minute, and temperature was 34.3 degrees C. Initial resuscitation was with the RSAS, and total fluid infused in the first twenty-four hours averaged 4,632 mL of blood, 1,914 mL of blood products, and 11,248 mL of crystalloid. The average postresuscitation systolic blood pressure was 120 mmHg, pulse was 96 beats/minute, and temperature averaged 34.9 degrees C. Survival at twenty-four hours was 29/50 (58%). There were no local complications of RSAS use and no evidence of infusion-related coagulopathy. The RSAS provided an effective and safe way to infuse large volumes of blood and fluid at body temperature.
Adolescent↗
Aberrant right hepatic artery vena cava fistula: a case report.
An unusual case of visceral arterial venous fistula between an aberrant right hepatic artery and the inferior vena cava is presented. A critical review of the anatomic relationships in this location offers a plausible explanation to account for the rarity of this type of fistula. The second issue deals with the ligation of the hepatic artery. We caution against hepatic artery ligation, especially when dealing with an aberrant right hepatic artery.
Adult↗
Normothermic rapid volume replacement in vascular catastrophes using the Infuser 37.
Twenty patients (Group 1) with a mean age of 38.5 +/- 16 years and an admission Trauma Score of 7.26 +/- 5.9, suffered 27 vascular injuries and were resuscitated with the Infuser 37 (IN-37) with an integral heat exchanger. Admission systolic BP averaged 46.47 mmHg (seven with absent vital signs). A mean of 7,030 ml of blood, 3,313 ml of colloid and 13,630 ml of crystalloid per patient was given in less than 24 hours, mostly through the IN-37. Twelve thoracotomies, nine laparotomies, and one extremity exploration were performed. Twelve patients, seven with a Trauma Score less than 3, died in less than 24 hours of exsanguination. The survival rate was 40% at 24 hours and 25% at 30 days. Six patients (Group 2) with a mean age of 70.33 +/- 8.3 years underwent operation for ruptured aortic aneurysm (5 pts), and elective aortic aneurysm (1 pt) with a 66% survival at 24 hours. Admission systolic blood pressure averaged 84 mmHg. A mean of 3,895 ml of blood, 1,900 ml of colloid and 7,733 ml of crystalloid per patient was administered in less than 24 hours, mostly through the IN-37. The IN-37 provides a safe and simple means of normothermic, rapid volume replacement in hemorrhagic shock. Its use in critically ill but potentially salvageable patients with vascular injuries and aortic aneurysm may avoid the consequences of prolonged hypoperfusion and hypothermia.
Adolescent↗
Natural history of nonoperated, significant carotid stenosis.
One-hundred sixty-seven patients with 190 carotid arteries (109 asymptomatic) demonstrating 50-99% stenosis by arteriography (80), duplex scanning, or other noninvasive techniques were followed from 1-84 months (mean 24.2) for evidence of brain infarct, transient ischemic attacks, or vertebrobasilar symptoms. Thirty-nine arteries (20.5%) were symptomatic at last follow-up, including 13 (6.8%) producing ipsilateral strokes. Twenty-eight sides underwent carotid endarterectomy, 16 for symptomatic lesions at a mean interval of 14.5 months after the initial diagnostic study, with no neurologic deficit. Twenty-seven patients (16.2%) died, eight from stroke (30%), and 12 from cardiac causes (44%). In initially symptomatic sides, the incidence of any subsequent neurologic event (28.7%) or stroke/transient ischemic attack (25%) was significantly greater than in asymptomatic arteries (14.6% and 12%, respectively) (p less than .05). Carotid arteries with greater than 80% stenosis by arteriography and duplex scanning had a 46% incidence of further symptoms and 41.6% stroke/transient ischemic attack rate compared to 19.6% and 15%, respectively, in arteries with less than 80% stenosis (p less than .01). Cumulative life table analysis at 12, 24 and 36 months showed greater than 80% stenosed arteries to have stroke/transient ischemic attack free rates of 69%, 50.5%, and 21.6% compared to 91%, 83.7%, and 76% for arteries with less than 80% stenosis (p less than .05). At a mean follow-up of over two years, nonoperated carotid stenosis (greater than 50%) carries a 20.5% risk of neurologic symptoms and a 6.8% risk of stroke, 61.5% of strokes being fatal. Symptomatic carotid stenosis had a significantly greater incidence of ensuing neurologic events than asymptomatic arteries.(ABSTRACT TRUNCATED AT 250 WORDS)
Arterial Occlusive Diseases↗
Normothermic rapid volume replacement in traumatic hypovolemia. A prospective analysis using a new device.
Inadequate infusion flow rates and hypothermia are significant problems encountered in managing traumatic hemorrhagic shock. The Rapid Solution Administration Set (RSAS) allows normothermic volume restoration at flow rates of up to 2200 mL/min via a single peripheral venipuncture. The RSAS was utilized in 33 consecutive multiple-trauma patients with a mean trauma score (TS) of 6.8. Admission systolic blood pressure averaged 66.9 mm Hg. A mean of 5692 mL of packed red blood cells, 5515 mL of blood products, and 12,052 mL of crystalloid solution per patient was infused within 24 hours of admission mostly via the RSAS. Mortality was 45% at 24 hours following arrival and 61% overall. The mortality was 93.8% (15/16) in patients with a TS of 5 or less and 29.4% (5/17) in patients with a TS over 5. The initial postinfusion patient temperatures averaged 35.2 degrees C. All abnormal preinfusion coagulation values normalized within 24 hours in the survivors, and no significant complications occurred with the use of the RSAS. The RSAS seems to provide an uncomplicated means of normothermic volume replacement. The 24-hour survival in potentially salvageable patients may be improved. Its use in patients with lethal injuries (TS less than or equal to 3) requires further evaluation.
Adolescent↗
Reconstruction of the external carotid artery.
The external carotid artery (ECA) is an underestimated but important collateral to the cerebral hemisphere and eye in patients with severe disease of the internal carotid artery. Fifteen symptomatic patients with total occlusion of the internal carotid artery underwent ECA reconstruction. Ipsilateral ECA reconstruction was performed upon all patients with no mortality or neurologic deficits. Contralateral disease of the carotid artery was noted in 11 and required correction in seven patients. Follow-up study of the patients ranged from one to 68 months (a mean of 26.8 months) after operation. Vertebrobasilar symptoms persisted in two patients, both with contralateral disease. One of these patients successfully underwent extracranial-intracranial bypass. One ipsilateral and one contralateral stroke occurred during follow-up study, both in patients with contralateral disease. Eleven patients were alive and asymptomatic at last follow-up examination. Symptomatic selected patients with occlusion of the internal carotid artery and ECA stenosis or cul-de-sac formation should be considered for operation. ECA reconstruction is associated with little morbidity and three-fourths of the patients remain asymptomatic. A high incidence of contralateral disease of the carotid artery is present. Extracranial-intracranial bypass should only be considered when symptoms persist after correction of contralateral disease of the carotid artery and any ECA lesions.
Aged↗
The role of echocardiography in patients with acute peripheral arterial embolization.
Forty-seven patients with acute arterial embolism requiring urgent embolectomy had postoperative echocardiography (36 2-D, 11 M-mode) in an attempt to identify a cardiac source of emboli. On the basis of history, physical examination, electrocardiogram, and chest roentgenogram, 37 patients were believed to have an apparent cardiac source. All histories and physical examinations in this group reaffirmed significant underlying cardiac disease. Nine of the 47 patients had no discernible source based on clinical data, and one had an arterioarterial embolus. In the presence of a clinically obvious source, although echocardiography (26 2-D, 11 M-mode) helped to clearly define evident cardiac disease in these patients, it failed to demonstrate a cardiac embolic source in those without clinical evidence of cardiac disease or to influence subsequent management. The continued use of echocardiography for the sole purpose of identifying a potential cardiac embolic source should be reconsidered.
Adult↗
Normothermic rapid volume replacement for hypovolemic shock: an in vivo and in vitro study utilizing a new technique.
Hypovolemic shock secondary to intraoperative or traumatic hemorrhage requires urgent, aggressive resuscitation to achieve a successful outcome. Common difficulties encountered include the need for venous access, restoration of blood volume, and most important, maintenance of normothermia. The rapid solution administration set utilized in this study addresses the above limitations. Venous access is quickly accomplished by the percutaneous insertion of a large-bore catheter into the central venous system. The set requires only one central venous entry site for adequate fluid resuscitation. Expeditious restoration of blood volume is accomplished by gravity-induced infusion of crystalloids, colloids, and blood products at flow rates of up to 1,600 ml/minute. High flow rates are obtained by utilizing low-resistance filters and large-bore perfusion tubing. Avoidance of transfusion-induced hypothermia is addressed by incorporation of an extracorporeal heat exchanger into the administration set. The infusate temperature is maintained at 37 degrees C regardless of the administration rate or the initial fluid temperature. In vitro and canine in vivo testing demonstrated no significant hemolysis of the transfused blood and allowed maintenance of normothermia.
Animals↗
Predictors of success in bypass grafts to the isolated popliteal segment.
Of 130 infrainguinal bypasses, 25 grafts to an isolated popliteal segment (IPS) were examined for clinical, anatomic and hemodynamic predictors of success. Fourteen autogenous veins (AV) and 11 polytetrafluoroethylene (PTFE) grafts were performed, all for limb salvage. A discontinuous tibial vessel was present in 72 per cent but only 24 per cent were graftable. A mean of 1.7 named collaterals were seen in IPS. Mean preoperative ankle pressure (APR) was 26.29 and ankle to brachial index (ABI) was 0.17. Segmental pressure gradient indices were also measured. Mean follow-up time was 13.6 months (a range of two to 43 months). One hundred per cent immediate graft patency and patient survival rates were obtained. Postoperative APR improved to 86.3 millimeters of mercury and ABI to 0.63 (p less than 0.05). Crude late patency rate was 72 per cent and limb salvage rate was 76 per cent. Cumulative life table patency rate was 58.8 per cent and limb salvage was 68 per cent at 36 months. Patency rate for AV (84.1 per cent) was better than PTFE (41.7 per cent). In 39 concurrent tibial grafts, cumulative patency rate at 36 months was 68 per cent for simple bypass grafts. Success could not be predicted by the length of the IPS, number of collaterals, profunda disease, number of discontinuous or graftable tibial vessels, APR or ABI and profunda popliteal collateral index. The tibial gradient index reflecting poor runoff was significantly greater in failed grafts (p less than 0.05). Bypass grafts to the IPS are a safe and reliable alternative to tibial bypass grafts. The AV performed better than PTFE grafts. The tibial gradient index appears to be a promising indicator for predicting graft success.
Aged↗
Management of asymptomatic carotid disease.
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Aged↗