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David L Gillespie

Publications and source records attributed to David L Gillespie.

15 recordsLinked to original sources
PubMed2006

Physiological changes in venous hemodynamics associated with elective fasciotomy.

It has been postulated that lower extremity fasciotomy may disrupt the calf musculovenous pump and predisposes to development of chronic venous insufficiency (CVI). However, studies based on trauma patients who undergo emergent fasciotomy are confounded by the possibility of concomitant vascular and soft tissue injury and use historical controls. This is a prospective study that evaluates venous hemodynamics in young patients undergoing elective fasciotomy for chronic exertional compartment syndrome (CECS), eliminating the problems associated with retrospective study of trauma patients. CECS was diagnosed by history and, when indicated, measurement of compartment pressures. Prior to elective two- or four-compartment fasciotomy, each patient underwent lower extremity air plethysmography (APG) and colorflow duplex ultrasonography. These studies were repeated a minimum of 6 weeks postoperatively. Fifteen patients who had fasciotomies for CECS were studied; two of these patients had bilateral fasciotomies for a total of 17 limbs. There were 13 male and two female patients (average age 31.2 years). APG and colorflow duplex were performed an average of 12 weeks after fasciotomy. Outflow fraction, venous volume, and ejection volume showed no significant changes postoperatively. However, the venous filling index (VFI) increased (0.9 +/- 0.1 vs. 1.1 +/- 0.1 mL/sec; p < 0.05, paired t-test), the ejection fraction tended to decrease (59 +/- 4% vs. 52 +/- 2%; p < 0.08, paired t-test), and the residual volume fraction (RVF) increased (26 +/- 3% vs. 36 +/- 5%; p < 0.05, paired t-test). There were no patients with evidence of deep venous reflux. Two extremities with preoperative greater saphenous vein (GSV) reflux did not worsen, and three extremities developed new GSV reflux following fasciotomy, although VFI remained normal in each extremity. Elective fasciotomy for CECS does not lead to significant venous reflux but likely does diminish calf muscle pump function and increases RVF moderately in young adult patients. With longer follow-up this diminished calf muscle pump function may increase the risk of CVI.

Adult↗
PubMed2006

Venous thromboembolism among United States soldiers deployed to Southwest Asia.

INTRODUCTION: Military operations may represent a high-risk environment for venous thromboembolism (VTE). We sought to identify and describe cases of venous thromboembolism among US military personnel serving in Southwest Asia, and estimate relative disease rates compared to non-deployed personnel. MATERIALS AND METHODS: Retrospective review of imaging archives, hospital discharge codes, case logs and autopsy records for the diagnosis of deep vein thrombosis or pulmonary embolism occurring from 1 March 2003 through 29 February 2004 among U.S. military personnel deployed to Southwest Asia. Rates of disease in deployed and non-deployed active-duty soldiers were estimated using personnel data and deployment experience obtained from automated rosters. RESULTS: Forty cases of venous thromboembolism were identified. The case-fatality rate was 16% (3/19) among those with pulmonary embolism. Antecedent trauma followed by prolonged air evacuation was present in 55% (22/40). Compared to trauma-associated cases, non-trauma cases were more commonly over 40 years old (44% vs. 5%; p<0.05), assigned to a transportation or quartermaster company (56% vs. 14%; p<0.05), or had a history of remote venous thromboembolism (31% vs. 0%; p<0.05). The overall incidence among deployed active-duty soldiers was 22.1/100,000 person-years. Compared to non-deployed active-duty soldiers, the age-adjusted incidence rate ratio was 1.06 (CI(0.95) 0.68-1.67). CONCLUSIONS: VTE rates among deployed soldiers are relatively low compared to the general population, and are comparable to non-deployed soldiers. Fatalities from PE are not uncommon, and vigilance among clinicians remains warranted. Trauma followed by prolonged air evacuation or ground transport during military operations may represent unique interactive risk factors for venous thromboembolism.

Adult↗
PubMed2005

The endovascular management of recurrent aortic hypoplasia and coarctation in a 15-year-old male.

A 15-year-old male complained of easy fatigability, leg weakness, and pain on exertion with episodes of syncope while playing baseball. His past medical history was significant for aortic coarctation associated with a congenital bovine hypoplastic aortic arch. A recent arteriogram revealed innominate and left common carotid artery stenosis as well as recurrent coarctation. He had previously undergone three Dacron patch aortoplasties. At the age of 7, he underwent a fourth operation for recurrent coarctation and because of extensive scar tissue in the region of his prior procedures, a left subclavian artery-to-descending aortic bypass was performed. An endovascular repair to deal with the recent recurrence was performed because of prior surgical difficulties. Percutaneous balloon-expandable stents were placed in the aortic coarctation, innominate, and the left common carotid arteries. Postprocedure, ankle brachial indices were >1 and the patient remains asymptomatic after 1 year.

Adolescent↗
PubMed2005

What imaging studies are necessary for abdominal aortic endograft sizing? A prospective blinded study using conventional computed tomography, aortography, and three-dimensional computed tomography.

OBJECTIVE: Preoperative imaging modalities for endovascular abdominal aortic aneurysm repair (EVAR) include conventional computed tomography (CT), aortography with a marking catheter, and three-dimensional computed tomography (3D CT). Although each technique has advantages, to date no study has compared in a prospective manner the reproducibility of measurements and impact on graft selection of all three modalities. The objective of this study was to determine the most useful imaging studies in planning EVAR. METHODS: Twenty patients being considered for EVAR were enrolled prospectively to undergo a conventional CT scan and aortography. The CT scans were then reconstructed into 3D images using Preview Treatment Planning Software (Medical Media Systems, West Lebanon, NH). Four measurements of diameter and six of length were made from each modality in determining the proper graft for EVAR. RESULTS: Measurements from all three modalities were reproducible with intraobserver correlation coefficients of 0.79 to 1.0 for aortography, 0.87 to 1.0 for CT, and 0.96 to 1.0 for 3D CT. Measurements between observers were also similar from each modality; interobserver correlations were 0.70 to 0.97 for aortography, 0.76 to 0.97 for CT, and 0.73 to 0.99 for 3D CT. Significant differences ( P < .01) in diameter measurements were noted at D2 with aortography compared with 3D CT, whereas differences in length measurements were found between CT and 3D CT at L4 (nonaneurysmal right iliac) ( P < .01). The correlation between CT and 3D CT for most length measurements was acceptable (0.63 to 1.0). Aortography for diameters correlated poorly (0.35 to 0.67) with 3D CT. When the endograft selected by aortography/CT or 3D CT alone was compared with the actual endograft used, there was agreement in 11 of 11 patients when adjusted for +/- one size in diameter or length. CONCLUSION: Reproducible and comparable measures of diameter and length can be obtained by each of three imaging modalities available for endograft sizing. As a single imaging modality, 3D CT appears to have the best correlation for both diameters and lengths; however, the difference is not sufficient enough to alter endograft selection. Three-dimensional CT may be reserved for challenging aortic anatomy where small differences in measurements would affect patient or graft selection for EVAR.

Aged↗
PubMed2005

Contemporary management of wartime vascular trauma.

OBJECTIVE: The treatment of wartime injuries has led to advances in the diagnosis and treatment of vascular trauma. Recent experience has stimulated a reappraisal of the management of such injuries, specifically assessing the effect of explosive devices on injury patterns and treatment strategies. The objective of this report is to provide a single-institution analysis of injury patterns and management strategies in the care of modern wartime vascular injuries. METHODS: From December 2001 through March 2004, all wartime evacuees evaluated at a single institution were prospectively entered into a database and retrospectively reviewed. Data collected included site, type, and mechanism of vascular injury; associated trauma; type of vascular repair; initial outcome; occult injury; amputation rate; and complication. Liberal application of arteriography was used to assess these injuries. The results of that diagnostic and therapeutic approach, particularly as it related to the care of the blast-injured patient, are reviewed. RESULTS: Of 3057 soldiers evacuated for medical evaluation, 1524 (50%) sustained battle injuries. Known or suspected vascular injuries occurred in 107 (7%) patients, and these patients comprised the study group. Sixty-eight (64%) patients were wounded by explosive devices, 27 (25%) were wounded by gunshots, and 12 (11%) experienced blunt traumatic injury. The majority of injuries (59/66 [88%]) occurred in the extremities. Nearly half (48/107) of the patients underwent vascular repair in a forward hospital in Iraq or Afghanistan. Twenty-eight (26%) required additional operative intervention on arrival in the United States. Vascular injuries were associated with bony fracture in 37% of soldiers. Twenty-one of the 107 had a primary amputation performed before evacuation. Amputation after vascular repair occurred in 8 patients. Of those, 5 had mangled extremities associated with contaminated wounds and infected grafts. Sixty-seven (63%) patients underwent diagnostic angiography. The most common indication was mechanism of injury (42%), followed by abnormal examination (33%), operative planning (18%), or evaluation of a repair (7%). CONCLUSIONS: This interim report represents the largest analysis of US military vascular injuries in more than 30 years. Wounding patterns reflect past experience with a high percentage of extremity injuries. Management of arterial repair with autologous vein graft remains the treatment of choice. Repairs in contaminated wound beds should be avoided. An increase in injuries from improvised explosive devices in modern conflict warrants the more liberal application of contrast arteriography. Endovascular techniques have advanced the contemporary management and proved valuable in the treatment of select wartime vascular injuries.

Adult↗
PubMed2005

Ubiquitous expression of cyclooxygenase-2 in meningiomas and decrease in cell growth following in vitro treatment with the inhibitor celecoxib: potential therapeutic application.

OBJECT: Meningiomas are the second most common symptomatic primary central nervous system tumor in adults. Findings of epidemiological studies link meningiomas with a history of head trauma, indicating a causal relationship between the inflammatory response and meningioma tumorigenesis. Cyclooxygenase-2 (COX-2), an inducible inflammatory enzyme, converts arachidonic acid to prostaglandins, which have angiogenic, cell-proliferative, and antiapoptotic effects. The authors investigated COX-2 expression in meningiomas and the effects of celecoxib, a COX-2 inhibitor, on meningioma cell growth in vitro. METHODS: Four meningioma surgical specimens were immunohistochemically stained and graded (0 to 4) for COX-2. In addition, a Western blot analysis was performed to detect the presence of COX-2. Human meningioma cells grown in cell culture were treated with vehicle or celecoxib (0.25-1 mM). An immunohistochemical analysis of COX-2, a methylthiotetrazole cell proliferation assay, a TUNEL apoptosis assay, and a Western blot analysis for the proapoptotic protein BAX were performed in vitro. One hundred eleven (87%) of 128 benign meningiomas and six (86%) of seven atypical meningiomas displayed a high COX-2 immunoreactivity (Grade 4 staining). In the Western blot analysis all four surgical specimens (100%) stained positive for a 70-kD band consistent with COX-2. Celecoxib inhibited cell growth in a dose-dependent fashion and induced apoptosis by Day 2, with no change noted in the expression of the BAX protein. CONCLUSIONS: The COX-2 enzyme is universally expressed in meningiomas. Celecoxib inhibits meningioma growth in vitro in a dose-dependent fashion, with evidence of apoptosis. Inhibitors of COX-2 may have a role in the treatment of recurrent meningiomas.

Adult↗
PubMed2003

Endovascular management of a peroneal artery injury due to a military fragment wound.

A healthy 29-year-old male suffered bilateral lower extremity fragment wounds resulting in a tense right calf shortly following a wound that required a four-compartment fasciotomy. During treatment of other injuries after medical evacuation he complained of increasing right calf pain. A peroneal pseudoaneurysm (PSA) with a concomitant arteriovenous fistula (AVF) was diagnosed. The distal one-third of the peroneal artery was not visualized, and the posterior tibial and anterior tibial arteries were normal. The patient underwent percutaneous coil embolization of the pseudoaneurysm. Completion arteriography demonstrated no evidence of the PSA and AVF. The patient's bruit and pain resolved.

Adult↗
PubMed2003

Aberrant right subclavian artery syndrome: a case of chronic cough.

A young, otherwise healthy man had chronic cough of 16 months' duration. Evaluation revealed an aberrant right subclavian artery. Kommerell's diverticulum without aneurysmal degeneration was present. Imaging studies showed compression of the esophagus but not the trachea. Results of methacholine challenge test were negative for evidence of reactive airway disease, but suggested mild variable intrathoracic obstruction. While aberrant right subclavian artery syndrome most commonly involves dysphagia, our patient's only symptom was cough. Right subclavian artery to right common carotid artery transposition was performed, with oversewing of the subclavian artery stump to the left of the esophagus through a right supraclavicular incision. This treatment was curative, with complete resolution of symptoms.

Adult↗
PubMed2003

Endovascular assisted in situ bypass grafting: a simplified technique for saphenous vein side branch occlusion.

The in situ bypass procedure for lower extremity limb salvage requires a long continuous incision or multiple interrupted incisions over the greater saphenous vein to ligate the saphenous vein side branches. This can result in wound complications that frequently prolong hospital stay and threaten the graft. In an effort to reduce the incidence of wound complications, alternate methods of occluding the vein side branches have been used. One method is to deliver coils under angioscopic vision into the saphenous vein side branches. This report details a simplified technique that uses widely available catheter-based equipment to perform saphenous vein side branch occlusion under fluoroscopic guidance.

Embolization, Therapeutic↗
PubMed2003

Microthrombectomy reduces postsclerotherapy pigmentation: multicenter randomized trial.

OBJECTIVE: Postsclerotherapy pigmentation occurs in nearly 30% of patients. Hemosiderin, from degradation of the venous thrombus, is the possible cause. The hypothesis that early removal of the thrombus may eliminate or decrease the incidence of pigmentation has not been proved or documented. The objective of this study was to investigate the effects of early microthrombectomy on incidence of postsclerotherapy pigmentation. MATERIAL AND METHODS: This multicenter, randomized, controlled study involved 101 patients with varicose veins (100 women, 1 man; mean age, 46 years [range, 25-68 years]). Patients were divided into two groups, with veins 1 mm or less in diameter (group 1, n = 50) or veins 3 mm or less in diameter (group 2, n = 51). Group 1 was treated with Sotradecol (STD) 0.25%, and group 2 with STD 0.50%. In each patient, an area of varicosities was selected and divided into halves. One half was randomized to microthrombectomy and the other half served as control. Microthrombectomy was performed 1 to 3 weeks after treatment in the randomized half. Standard photographs were obtained before and 16 weeks after treatment, and were evaluated by three independent reviewers who were blinded to treatment assignments. Each reviewer received an identical set of pretreatment and posttreatment 10 x 15-cm color photographs of the study area, and completed a scoring sheet. Average of the scores was used to evaluate primary (pigmentation) and secondary (overall clinical improvement) end points. The paired t test and chi-square test were used for statistical analysis. RESULTS: In group 1, microthrombectomized areas had statistically significant less pigmentation (P =.0047) and better overall clinical improvement scores (P =.0002) compared with the control side. In group 2 there was no significant difference between the two areas, but patients reported significant relief of pain and inflammation associated with postsclerotherapy thrombophlebitis. CONCLUSION: In veins 1 mm or smaller, microthrombectomy reduced pigmentation and improved overall clinical results. In veins 3 mm or smaller, statistical significance was not achieved, but thrombectomy resulted in faster resolution of the postsclerotherapy pain and inflammation. On the basis of these results, microthrombectomy after sclerotherapy is recommended.

Adult↗
PubMed2002

Preoperative risk stratification using electron beam computed tomography in elective vascular surgery: relationship to clinical risk prediction and postoperative complications.

We studied the utility of electron beam computed tomography as a screening test for the cardiovascular risk of elective vascular surgery. In 45 patients undergoing principally carotid and aortic surgical procedures, coronary artery calcification was prevalent and severe, and related to the clinically predicted cardiovascular risk of the procedure. However, only the clinically predicted surgical risk, and not coronary artery calcification, was related to the incidence of perioperative cardiovascular complications.

Aged↗
PubMed2002

Endovascular management of renal ischemia in a patient with acute aortic dissection and renovascular hypertension.

We report the endovascular management of a patient with a type B aortic dissection complicated by renal ischemia and resultant severe hypertension. A 69-year-old male presented with acute type B aortic dissection with proximal extension complicated by severe renovascular hypertension secondary to left renal ischemia. Endovascular management consisted of imaging with intravascular ultrasound and left renal artery stenting with balloon-expandable stents. His hypertension subsequently resolved and he was discharged on his baseline two-drug regimen. Management of the ischemic complications of type B aortic dissections may be primarily approached using endovascular methods in stable patients, with open surgery reserved for those patients refractory to these methods. Patients with evidence of decreased renal perfusion represent a select group with an increased risk of associated morbidity and mortality and should therefore be aggressively managed. Accurate information and assessment of anatomy can be obtained with intravascular ultrasound and is therefore an important adjunct to the armamentarium of endovascular specialists managing complications of aortic dissection.

Aged↗
PubMed2002

The pelvic venous syndromes: analysis of our experience with 57 patients.

BACKGROUND: The pelvic venous syndromes comprise a group of poorly understood disorders of the pelvic and gonadal venous circulation. The objective of this paper was to review our experience with the pelvic venous syndromes and, in the light of the current literature, make management recommendations. MATERIALS AND METHODS: Fifty-seven female patients (age range, 24 to 48 years; mean, 34 years) with symptoms of pelvic pain, dysuria, dysmenorrhea, dyspareunia, and the presence of vulval and pelvic varices were studied. Diagnosis included physical examination, Doppler scan, duplex ultrasound scan, computed tomography, magnetic resonance imaging, and retrograde cinevideoangiography. The symptoms were classified as: 1, mild (n = 15); 2, moderately severe (n = 19); and 3, severe (n = 23). Group 1 was treated with sclerotherapy/local excision of vulval varices. Group 2 had gonadal vein resection (GVR; n = 12) and sclerotherapy or gonadal vein coil embolization (GVE; n = 7) and sclerotherapy. Only the incompetent side was treated. Patients in group 3 with isolated hypogastric vein tributary reflux were treated either with hypogastric vein tributaries division (HVTD) or with embolization (HVTE) as the only procedure. Those with combined gonadal and hypogastric vein reflux were treated with HVTE followed by GVR. The follow-up period ranged from 2.5 to 24 years (mean GVR/HVTD, 12.4 years; mean GVE/HVTE, 2.3 years). Pain improvement was assessed with a visual analog scale and through mailed questionnaires (response rate, 100%). Patient results were classified as excellent (asymptomatic), moderate (mild discomfort), or no improvement. RESULTS: In group 1, 12 patients had excellent results and three had moderate results. In group 2, 10 patients treated with GVR had excellent results, one had moderate results, and one had no improvement. Three patients treated with GVE were asymptomatic, and four had no improvement. In group 3, three patients treated with HVTD were asymptomatic and two had no improvement. Five patients treated with HVTE were asymptomatic, and one had no improvement. Of the 12 patients treated with HVTE and GVR, 10 were asymptomatic, one had moderate results, and one had no improvement. CONCLUSION: Local excision of vulval varices and sclerotherapy were sufficient in patients with mild symptoms. Gonadal vein excision produced better results than GVE. In patients with isolated hypogastric vein reflux, embolization was a better option than surgical treatment. GVR preceded by embolization of the incompetent tributaries of the internal iliac vein was indicated in patients with combined reflux and severe symptoms. Supplemental sclerotherapy of vulval varices is recommended after control of the intrapelvic reflux.

Adult↗
PubMedDate not supplied

Review of standards for competence in catheter-based endovascular procedures: a resource and strategy for the interventional vascular surgeon.

The field of peripheral vascular disease management is evolving. As such, vascular surgeons can no longer be complacent and expect to be included in the rapidly expanding practice of endovascular intervention. If not engaged, vascular surgeons risk losing not only the patients who have largely driven this evolution but also their role as leaders in the management of vascular disease. Therefore vascular surgeons and vascular surgical training programs find themselves in an awkward and sometimes confrontational circumstance attempting to gain experience and training in catheter-based procedures. Individual societies, both surgical and nonsurgical, have put forth competence standards for catheter-based procedures. However these standards are not always consistent and the definition of competence is often a heated debate. In addition, combining the acquisition of endovascular skills with the multitude of available endovascular training experiences, didactic and "hands-on," is not well coordinated. The objectives of this review are to summarize the literature as it relates to catheter-based endovascular competence, including publications from nonsurgical catheter-based specialties, and to place the acquisition of basic endovascular skills in context with the available endovascular courses in a stepwise strategy. A final objective is to provide a literature-based resource that outlines specific phases in the development of interventional vascular surgeons and training programs as they advance into the arena of catheter-based endovascular therapies.

Catheterization↗