New mechanism for disruption of axillofemoral bypass.
Explore the source record for details and available documents.
Anastomosis, Surgical↗
Biomedical subjects
E R Jewell
Publications and source records attributed to E R Jewell.
Avoiding complications in arterial surgery.
Our approach to vascular surgery is to recognize and contemplate perioperative complications and devise strategies to avoid them. These strategies are detailed in several of the major areas of arterial surgery. It is far easier to avoid complications than to deal with them when they occur. This is especially true for some complications in vascular surgery, such as intraoperative or postoperative cerebrovascular accident, atheroembolic complications, or distal thrombosis in lower-extremity reconstruction, that may result in either irreversible morbidity or death.
Aortic Aneurysm↗
Abdominal aortic aneurysms.
Modern surgical techniques permit repair of abdominal aortic aneurysms and prevent eventual rupture, with a mortality rate of only a few percent. Coronary heart disease is the chief cause of death, depriving the patient of an assumed improved life expectancy after successful operation for aneurysm. Therefore, aggressive preoperative cardiac evaluation, including coronary arteriography and perhaps more protective myocardial revascularization procedures, is indicated.
Aorta, Abdominal↗
Peripheral aneurysms.
Peripheral atherosclerotic aneurysms occur primarily in elderly men. Major complications are arterial thromboembolism with ischemia of the limb and, rarely, rupture of the aneurysm. Vascular reconstruction is associated with a low mortality, and operation is recommended. These aneurysms are often associated with arterial ectasia at other locations. The presence of peripheral atherosclerotic aneurysms always requires a search for other peripheral aneurysms, particularly in the abdominal aorta.
Age Factors↗
Use of the triplex scanner in diagnosis of deep venous thrombosis.
We report our experience with 264 patients who underwent triplex scans for venous occlusive disease over a 10-month period. Venography was obtained in 30 of these patients. Correlation between the two procedures was 100%. The anatomic location of thrombosis and the extent of disease were identical in both studies. The presence of intraluminal clot by angiodynography is detected by looking for changes in the venous color-flow patterns and in the B-mode image. Newer clots have low echogenicity and are seen as large black areas in the gray-scale image. Older clots are more echogenic. The presence of enlarged venous collateral veins as well as absence of color flow and inability to compress the veins confirm the diagnosis of acute deep venous thrombosis. The results of angiodynography alone can be used safely in diagnosing acute deep venous thrombosis in patients. Equally important, treatment can be withheld safety in a patient with normal results.
Arm↗
The role of thrombolytic therapy in surgical practice.
The ability of streptokinase and urokinase to lyse intravascular fibrin-based clots is firmly established. However, there is a lack of enthusiasm for these agents because of serious haemorrhagic complications and a lack of controlled randomized studies indicating their efficacy. Thrombolytic therapy is suitable in only 15 per cent of patients with acute deep venous thrombosis. It restores the venous circulation to normal in up to 95 per cent of these patients if therapy is instituted within 5 days of the onset of symptoms. These patients have significantly fewer symptoms on follow-up than patients treated with heparin although the ability of thrombolytic therapy to preserve venous valvular function and to prevent the post-phlebitic syndrome is now in question. Thrombolytic therapy is as effective as heparin in preventing pulmonary embolism and may be superior in its treatment. Pulmonary haemodynamics are rapidly improved, diffusion capacity is restored and, although the evidence is inconclusive, long-term pulmonary hypertension may be prevented. Although the mortality rate is not decreased, controlled studies show that thrombolytic therapy may be beneficial in massive pulmonary embolism with clinical shock. Thrombolytic therapy is indicated for acute arterial and acute bypass graft occlusion when the surgical alternative is associated with a higher morbidity and mortality. Partial thrombolysis is achieved in up to 90 per cent of cases and the need for further therapeutic intervention is eliminated in one-third of the patients treated. New thrombolytic agents with greater specificity and potentially greater efficacy and fewer complications are being developed. Tissue plasminogen activator has been successfully used. Prourokinase, fibrin-seeking urokinase and acetylated streptokinase-plasminogen complex may expand the role of thrombolytic therapy in surgical practice.
Arterial Occlusive Diseases↗
Chronic rupture of abdominal aortic aneurysms.
Chronic rupture of the aorta is a rare condition. In this report, the presentation, diagnosis, and management of two patients with this complication is described. Chronic rupture may occur without hypotension and may mimic several other conditions. CT scans are superior to ultrasound in diagnosis and evaluation. Emergency repair is not necessary in clinically stable patients and careful preoperative planning may diminish morbidity and mortality.
Aged↗
Local antiseptic treatment of infected prosthetic vascular grafts in the groin.
Explore the source record for details and available documents.
Aged↗
Arm ischemia secondary to giant cell arteritis.
Patients with severe ischemic symptoms that fail to respond to steroid therapy, despite a dramatic and continuous drop in the erythrocyte sedimentation rate, may require arterial bypass surgery to overcome arterial ischemia caused by arteritis. We report the case of a patient with bilateral subclavian artery occlusion secondary to giant cell arteritis who responded well to steroid therapy and arterial reconstructive surgery. The patient has remained well for five years.
Arm↗
Intraaortic balloon pump placement through dacron aortofemoral grafts.
Occasionally, severe coronary insufficiency necessitates the placement of an intraaortic balloon pump in a patient with a preexisting synthetic aortofemoral bypass graft. Our experience with two such patients suggests that insertion of the intraaortic balloon through a limb of the aortofemoral graft is a safe and effective technique.
Aged↗
Long-term brachial artery catheterization: ischemic complications.
The brachial artery is not used for long-term catheterization and routine hemodynamic monitoring because a high incidence of ischemic complications is anticipated. However, in a review of 157 patients who had 225 percutaneous transbrachial hepatic artery catheters placed for infusion of chemotherapeutic agents, catheters remained in situ from 1 day to 14 months (median 68 days). One hundred seventy-three catheters (77%) were removed electively and 52 catheters (23%) were removed because of complications. Diminution or loss of the radial pulses occurred on insertion of 88 catheters (39.1%) and 16 of these (8%) were removed after 24 hours because ischemic symptoms developed. Subsequently, 25 other catheters (11.1%) were removed because of complications such as paresthesia, eight (3.5%); brachial artery thrombosis, four (1.7%); microembolization, three (1.3%); claudication, two (0.8%); and pseudoaneurysm, one (0.4%). Seven catheters (3.1%) were removed because of a combination of pallor, diminished pulses, and muscle weakness. Hemorrhage from the arteriotomy site necessitated the removal of 11 other catheters (4.9%). Amputation, ischemic ulceration, major neuromuscular sequelae, and peripheral embolization to the head or lower limbs did not occur. This study suggests that long-term brachial artery catheterization is associated with a low incidence of permanent ischemic complications.
Antineoplastic Agents↗
Natural history of subclavian steal syndrome.
Eighty-two patients presenting with subclavian steal syndrome (36 men, 46 women; median age, 66.5 years) were studied. All patients underwent clinical and noninvasive evaluation. Diagnosis was based on both a 20 mmHg difference in blood pressure between arms and reversed blood flow in the vertebral artery. Twenty-one patients (25.6%) had a transient ischemic attack or cerebrovascular accident before the study. In 16 patients (19.5%), the anterior circulation was involved and the vertebrobasilar circulation was effected in 5 patients (4.8%). Fifty-five patients were followed for one to six years (mean 4.1 years). During this period three patients died. Noninvasive studies showed that 39 patients (70.9%) had progression of disease in the carotid arteries and that 10 of these 39 (12.1%) exhibited a transient ischemic attack or cerebrovascular accident, and eight patients (9.7%) required carotid endarterectomy. No patient had a stroke involving the vertebrobasilar circulation, but four patients (4.8%) had a transient ischemic attack. Three other patients had revascularization procedures performed for arm ischemia. Patients with subclavian steal syndrome are more likely to experience a transient ischemic attack or cerebrovascular accident involving the carotid circulation than the vertebrobasilar circulation. Noninvasive evaluation of the carotid arteries and the posterior circulation should be included in the long-term follow-up of these patients.
Aged↗
Preoperative evaluation of the high-risk patient.
The benefits of surgery are usually clear and easy to define. The risk to which a particular patient is subjected during a specific operation, however, is a multifactorial and complex question related to preoperative condition, the complexity of the surgery proposed, and the skill and experience of the surgeon. We have concentrated our discussion only on preoperative evaluation of the patient's condition. By our system of evaluation of preoperative cardiac, pulmonary, carotid artery, nutritional, and general medical status some estimation of the risk of postoperative complication can be formulated. In some of our discussion we reported studies of other investigators, in which the likelihood of postoperative complications was expressed in percentages. An approach derived by study of groups of patients may or may not apply to a particular patient. Although such an approach may not be entirely accurate, it can assist in the estimation of the chance of serious postoperative complications. Obviously the most ideal situation would be to define precisely the risks and benefits of each operative procedure we recommend to a patient. Because this is not possible, we should state the benefits and estimate the risks of surgery preoperatively. We should also delay operation until the patient's preoperative condition is optimal, thereby decreasing the risks of complications. With a systematic preoperative evaluation these goals can be approximated. A critical part of the benefit-to-risk equation is the surgeon's judgment of whether the patient is a good operative risk. This opinion should not be ignored and should be part of any system of preoperative evaluation of risk of postoperative complications.
Adult↗
Chronic intestinal ischemia. The Lahey Clinic approach to management.
Recognizing decreased mesenteric arterial blood supply in symptomatic and asymptomatic patients is essential to successful treatment of the ischemic bowel. The vascular disease can be documented by using standard arteriography, including a lateral projection. We favor revascularization by bypass in the celiac and superior mesenteric systems and by reimplantation or bypass in the inferior mesenteric system. Externally supported ringed PTFE is our conduit of choice. The chances of late recurrence can be lessened by complete revascularization. For the patient with no symptoms of mesenteric insufficiency who undergoes revascularization for other abdominal arteries, it is important to avoid restricting the mesenteric flow when disease is present, and it may be necessary to revascularize the superior mesenteric artery simultaneously as a prophylactic measure. Avoidance of the major problems of bowel infarction can be achieved by these maneuvers.
Arterial Occlusive Diseases↗
Clinically active carotid artery disease. Role of intraplaque hemorrhage.
Explore the source record for details and available documents.
Carotid Artery Diseases↗
Aneurysm formation in distal saphenous vein bypass grafts as a cause of graft failure.
Aneurysms of a reversed saphenous vein femoropopliteal bypass graft developed in two patients. In both patients, the aneurysm led to thrombosis and occlusion of the graft. One graft was reopened by intraarterial thrombolysis followed by local graft revision; the other required complete regrafting. This uncommon cause of graft occlusion should be considered before thrombolysis.
Aged↗
Vagal body tumor: paraganglioma of the head and neck.
Vagal body tumors (VBTs) are rare tumors of the paraganglion cells of the vagus nerve, usually occurring near the ganglion nodosum. They can be familial, multicentric, malignant, and sometimes hormonally active. The most accurate diagnosis is made by angiography. Primary treatment is surgical excision. Radiation therapy may play a role in preoperative preparation or in palliation. The prognosis is good when the tumor is found early and completely resected. Lifelong follow-up of patients and their family members is recommended.
Cranial Nerve Neoplasms↗