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Biomedical subjects

E S Crawford

Publications and source records attributed to E S Crawford.

At least 19 recordsLinked to original sources
PubMed1998

Primary aortic intimal sarcoma of the endothelial cell type with long-term survival.

Primary tumors of the aorta are rare and are difficult to diagnose preoperatively. These tumors are malignant and ultimately fatal. A patient had initial evidence of aortoiliac obstructive disease. Aortic endarterectomy produced an excellent postoperative clinical result until the pathology report from the endarterectomy specimen revealed aortic sarcoma. The patient refused a second operation for en bloc aortic resection. One year later with recurrent symptoms, the patient underwent en bloc resection of the aorta and common iliac vessels until clear margins were obtained. The tumor was found to be intimal aortic sarcoma of endothelial cell origin. The only metastasis was to bone, and it was controlled with radiation and chemotherapy. The patient lived a total of 8 years from the time of initial diagnosis. Abdominal aortic intimal sarcoma of the endothelial cell type is a rare variety of aortic sarcoma that can be managed successfully if diagnosed early. This specific type of tumor has a longer survival period and better prognosis than other types of aortic sarcoma when managed with aggressive surgical resection, radiation, and chemotherapy.

Aged↗
PubMed1998

Using the ACNP Proficiency Testing Program to develop critical thinking. American College of Nuclear Physicians.

UNLABELLED: Critical thinking is cited as one of the essential skills for clinical practice. Educators need to be aware of barriers that may hinder the development of this skill in students and cultivate strategies to encourage it. This article describes one strategy to develop critical thinking. METHODS: Students participated in a critical thinking exercise by imaging the American College of Nuclear Physicians (ACNP) Renal Imaging Proficiency Test Phantom, critiquing their results, and comparing their results to results collected nationally in other nuclear medicine facilities and the true values reported by the ACNP. Students were instructed to review pertinent imaging principles before discussing the imaging results. They also were supplied with a list of questions pertinent to the review. RESULTS: Students experienced the complexity of designing a SPECT imaging protocol and how the final results are affected by the choices made by the technologist. They learned the importance of and method for proper matrix selection, determination of pixel size and the necessity for quality control. CONCLUSION: The imaging exercise was a successful means of helping students connect clinical practice with theory through the use of critical thinking.

Computer Simulation↗
PubMed1995

Marfan syndrome. Long-term survival and complications after aortic aneurysm repair.

BACKGROUND: Development of surgical therapy for aortic aneurysms and dissections has led to treatment of the life-threatening cardiovascular complications associated with Marfan syndrome. The present study determines the effect of surgical therapy on the life expectancy of patients with Marfan syndrome and the clinical course of these patients after aortic aneurysm repair. METHODS AND RESULTS: Medical records were reviewed on 192 patients with Marfan syndrome who underwent aortic aneurysm repair during the past 26 years; 103 patients were interviewed, and complete preoperative and postoperative medical information was obtained. Survival curves were generated, and data were analyzed. The median cumulative probability of survival was 61 years, significantly increased compared with the median survival of 47 years for patients with Marfan syndrome determined 30 years ago (P < .0006). The majority of patients (53%) had second surgeries to repair subsequent aneurysms or dissections at other sites, the vast majority of which involved the aorta. The most common pattern of aneurysm repair was proximal ascending aortic aneurysm repair, followed by descending thoracic aneurysm surgery. The following variables predicted patients requiring second vascular surgeries: presence of acute or chronic dissection at the time of the first surgery, hypertension after the first surgery, and a history of smoking. CONCLUSIONS: The life expectancy of patients with Marfan syndrome undergoing surgical repair of aortic aneurysms has improved and is consistent with increased survival. After initial repair of an ascending aortic aneurysm, a significant number of patients have subsequent surgeries at other sites throughout the aorta, indicating Marfan syndrome is a disease involving the entire aorta. Patients who had a dissection at the time of the first aortic surgery were more likely to require subsequent aortic surgery than were patients who underwent prophylactic composite graft repair of an aortic aneurysm.

Aortic Dissection↗
PubMed1993

Deep hypothermia with circulatory arrest. Determinants of stroke and early mortality in 656 patients.

We have retrospectively evaluated our results after aortic surgery in adults using deep hypothermia with circulatory arrest to determine the patient predictors of early death and postoperative stroke by logistic regression analysis. Of the 656 patients operated on between July 7, 1979, and January 30, 1991, 43% (n = 283) were female, the median age of the patients was 64 years (range 10 to 88 years), 12% (n = 77) had acute dissection, 26% (n = 173) had previously undergone either cardiac or ascending aortic operations, and 13% (n = 85) had a history of cerebrovascular disease. Eighty-four patients underwent elephant trunk procedures. The median circulatory arrest time was 31 minutes (range 7 to 120 minutes). The univariable predictors of transient or permanent stroke, defined as clinical evidence of neurologic injury, either global or hemiparetic, which occurred in 44 patients (7%), were as follows (p < 0.05): increased age; a history of cerebrovascular disease; circulatory arrest time (7 to 29 minutes = 12/298 [4%], 30 to 44 minutes = 15/201 [7.5%], 45 to 59 minutes 9/84 [10.7%], 60 to 120 minutes 7/48 [14.6%]; cardiopulmonary bypass time; and concurrent descending thoracic aorta repair. The multivariably determined predictors were as follows (p < 0.05): a history of cerebrovascular disease; previous aortic surgery distal to the left subclavian artery; and cardiopulmonary bypass time. A history of aortic valve incompetence, however, was associated with a lower risk of stroke (adjusted odds ratio 0.42, p = 0.015). The multivariably determined predictors for increased risk of early death (p < 0.05), which occurred in 66 (10%) patients, were as follows: increased age; Marfan syndrome; concurrent distal aortic aneurysm; previous ascending aortic operation; cardiopulmonary bypass time; cardiac complications; renal complications; and stroke. In this study, the occurrence of stroke was observed to increase after 40 minutes of circulatory arrest; furthermore, the mortality rate increased markedly after 65 minutes of circulatory arrest. Thus the "safe" period for strokes not developing appeared to be limited to approximately 40 minutes. We conclude that deep hypothermia with circulatory arrest is a safe technique for the repair of complex aortic problems provided both the circulatory arrest and the cardiopulmonary bypass times are not excessive. In addition, the clinical characteristics of the patients are important determinants of stroke and death.

Actuarial Analysis↗
PubMed1993

Experience with 1509 patients undergoing thoracoabdominal aortic operations.

PURPOSE: The purpose of this study was to retrospectively identify variables associated with early death and postoperative complications in patients undergoing thoracoabdominal aortic operations. METHODS: The data on 1509 patients who underwent 1679 thoracoabdominal aortic repairs between 1960 and 1991 were retrospectively reviewed. The median age was 66 years (range 1.5 years to 86 years), and aortic dissection was present in 276 (18%) patients. The extent of the first repair performed included 378 (25%) type I (proximal descending to upper abdominal aorta), 442 (29%) type II (proximal descending aorta to below the renal arteries), 343 (23%) type III (distal descending and abdominal aorta), and 346 (23%) type IV (most of the abdominal aorta). The median total aortic clamp time was 43 minutes. RESULTS: The 30-day survival rate was 92% (1386/1509) for the 30-year period. On multivariate analysis the preoperative and operative variables associated with death included (p < 0.05) increasing age, preoperative creatinine level, concurrent proximal aortic aneurysms, coronary artery disease, chronic lung disease, and total aortic clamp time. When the postoperative variables were also included in the stepwise logistic regression model, then in addition, cardiac complications, stroke, kidney failure, and gastrointestinal hemorrhage became significant (p < 0.05). The overall incidence of paraplegia or paraparesis was 16% (234/1509). By use of stepwise logistic regression analysis, the significant predictors (p < 0.05) of paraplegia or paraparesis developing were total aortic clamp time, extent of aorta repaired, aortic rupture, patient age, proximal aortic aneurysm, and history of renal dysfunction. Kidney failure (postoperative creatinine level > 3 mg/dl or dialysis) occurred in 18% (269/1509) of patients; dialysis was required in 9% (136/1509). Gastrointestinal complications manifested in 7% (101/1509) of patients. CONCLUSION: Although the survival rate has improved, paraplegia/paraparesis and kidney failure continue to be vexing problems that require further research.

Adolescent↗
PubMed1992

Composite valve graft replacement of the proximal aorta: comparison of techniques in 348 patients.

Composite valve graft replacement of the ascending aorta is being increasingly used, although it is not clear which technique, the Bentall, Cabrol, or button, is the best method for coronary artery ostial reattachment. We retrospectively analyzed our results with respect to these three techniques in 348 consecutive patients operated on between September 17, 1979, and January 29, 1991. Variables included aortic arch replacement in 88 patients (25%), need for deep hypothermia and circulatory arrest in 119 (34%), aortic dissection in 131 (38%), acute dissection in 34 (9.8%), reoperation in 79 (23%), and insertion of St. Jude prostheses in 270 (78%). The 30-day survival rate was 91% (316/348), the in-hospital survival rate was 90% (312/348), and the 30-day incidence of postoperative new transient (n = 6) and permanent (n = 6) stroke was 3% (12/348). The 30-day survival rates for each method were as follows: Cabrol, 92% (144/157); button, 91% (39/43); and Bentall, 91% (125/137). On stepwise multivariate logistic regression analysis with control for operative date and independent prognostic factors, operative technique was not an independent determinant of early mortality or stroke. On late follow-up, the Kaplan-Meier 5-year survival rate was 71% with no significant difference between the groups (3-year survival: Cabrol, 76%; Bentall, 79%; and button, 81%; p = 0.28). The 3-year freedom from reoperation was 95% (Cabrol, 97%; Bentall, 91%; and button, 100%; p = 0.17). We conclude that for patients undergoing reoperation or complicated repairs or when tension on the ostial anastomoses may occur, the Cabrol technique is preferable. If feasible, however, the button technique has better long-term results for both survival and rate of reoperation. An alternative technique is to use an interposition graft to reattach the left coronary artery and excise an aortic button for the right coronary artery reattachment. This has the advantages of technical ease in reattaching the left coronary artery, good results for reattachment of the right coronary artery, minimal tension on the anastomoses, and visualization of all anastomoses.

Adolescent↗
PubMed1992

Spinal oxygenation, blood supply localization, cooling, and function with aortic clamping.

Similar to other methods of organ preservation, "spinoplegia" may protect the spinal cord from the effects of oxygen desaturation during aortic cross-clamping. In porcine experiments, spinal cord O2 saturation was studied during intraoperative localization of the blood supply to the spinal cord using hydrogen; division of arteries not supplying the spinal cord; aortic cross-clamping for 60 minutes; and 60 minutes after unclamping. In 5 animals, 120 mL of cold saline solution with lidocaine (100 mg/dL) was infused into the aorta during aortic cross-clamping. During sequential localization, O2 saturation dropped by 40.02% (standard deviation, 20.16%) for T-14 artery testing versus a decrease of 17.27% (standard deviation, 11.88%; p = 0.0075) for L-5 artery segment testing in the control animals and returned to baseline thereafter. During aortic cross-clamping maximal O2 desaturation was 5% of baseline (15.7%; p less than 0.0001), which improved slightly by 30 minutes after clamping (48% of baseline +/- 37.37%; p = 0.048 versus maximum) and then returned to baseline (97.1% of baseline +/- 41%) with unclamping; 5 minutes later, hyperoxygenation occurred with a progressive decline thereafter (68% of baseline +/- 29.3%; p = 0.025, 45 minutes after unclamping versus baseline). The decrease in spinal motor evoked potentials was significantly less (p less than 0.02) in the treated group. Intraoperative hydrogen testing in 8 patients was demonstrated to be safe. It accurately localized reattached arteries, and O2 saturation of the spinal cord fell by 56% (standard deviation, 29%; p = 0.0025) with aortic cross-clamping. We conclude that spinal cord ischemia occurs with aortic cross-clamping in both animals and humans.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1992

Doppler echocardiographic evaluation of pseudoaneurysms complicating composite grafts of the ascending aorta.

BACKGROUND: Pseudoaneurysms of the ascending aorta is a rare and serious complication after composite graft surgery for combined disorders of the aortic valve and ascending aorta. METHODS AND RESULTS: Echocardiographic and Doppler findings are described in eight patients (seven men, one woman; mean age, 45 +/- 12 years) with documented pseudoaneurysm of the ascending aorta and are compared with those by aortography and at surgery. The diameter of the ascending aorta ranged from 6 to 14 cm. Pseudoaneurysm was diagnosed by echocardiography in seven cases (six transthoracic, one transesophageal), by aortography in five, and by both methods in all patients. All three patients not diagnosed by aortography had a single dehiscence at the aortic annulus anastomosis. Five patients had more than one site of origin of the pseudoaneurysm. Periannular dehiscence (n = 7) was identified by color flow Doppler in six cases and by aortography in only one, and coronary artery dehiscence (n = 6) was detected by echocardiography in three and by aortography in two arteries. Of the three patients with distal graft dehiscence, one was identified by aortography and none by echocardiography. In cases of dehiscence at the aortic annulus, continuous wave Doppler further supported the diagnosis by demonstrating two distinct jets, one through the prosthetic valve and another with higher velocity through the communication. CONCLUSIONS: Echocardiography with Doppler can diagnose the presence of pseudoaneurysms complicating composite grafts and identify their proximal sites of origin. Furthermore, it complements aortography in the overall evaluation of patients with suspected pseudoaneurysm, particularly in those with single dehiscence of the graft at the aortic annulus anastomosis.

Adult↗
PubMed1992

Marfan syndrome: defective synthesis, secretion, and extracellular matrix formation of fibrillin by cultured dermal fibroblasts.

We studied the synthesis, secretion, and aggregation into the extracellular matrix of fibrillin by dermal fibroblasts from 26 probands with the Marfan syndrome. Cells from seven probands synthesized approximately half the normal amount of fibrillin when compared with intrafamilial or unrelated controls. Cells from an additional seven probands synthesized a normal amount of fibrillin but secreted the protein less efficiently than control cells. Cells from a further eight probands synthesized and secreted normal amounts of fibrillin but the protein was poorly incorporated into extracellular matrix. Cells from the remaining four probands were indistinguishable from control cells in their synthesis and processing of fibrillin. Cells from 18 family members of 10 of the probands were also studied. Cells from affected individuals in the same family had the same biochemical defect and those from unaffected family members were indistinguishable from controls. These results indicate that mutations in the gene that encodes fibrillin are responsible for the Marfan syndrome in the majority of individuals (confirming recent immunohistochemical and genetic linkage studies) and that a variety of mutations can produce the phenotype associated with the syndrome.

Adolescent↗
PubMed1992

Thoracoabdominal aortic aneurysms associated with celiac, superior mesenteric, and renal artery occlusive disease: methods and analysis of results in 271 patients.

Two hundred seventy-one of 1509 patients who underwent thoracoabdominal aortic repairs had either celiac or superior mesenteric or renal artery occlusive disease. These latter patients were treated by endarterectomy or bypass between June 20, 1960 and Jan. 10, 1991. After 1987, the 30-day survival rate was 93% (79 of 85) compared with 90% (245 of 271) before 1988. Multivariate predictors of death were age, postoperative reoperation for bleeding, and cardiac complications (p less than 0.05). Renal complications (13% dialysis, 35 of 271) were associated with preoperative renal dysfunction, elevated preoperative serum creatinine level, urine clearance time of dye, extent of the aorta replaced, coagulopathy, and paraplegia or paraparesis (p less than 0.05). The incidence of postoperative renal dysfunction was reduced by renal artery endarterectomy (p less than 0.05). On univariate analysis the risk of renal failure was reduced by renal artery perfusion with cold Ringer's lactate solution (p less than 0.05). Gastrointestinal complications (9%, 25 of 271) were associated with a history of peptic ulcer disease on multivariate analysis (p less than 0.05). The Kaplan-Meier 5-year survival rates for patients with and without occlusive disease were 53% and 60%, respectively, and at 10 years 37% and 30%, respectively (p = 0.08). We conclude that endarterectomy or bypass of occlusive visceral disease reduces the risk of renal failure after thoracoabdominal aortic aneurysm repairs, does not decrease early or late survival, and does not increase the risk of gastrointestinal complications.

Aged↗
PubMed1992

Surgery for acute dissection of ascending aorta. Should the arch be included?

Thirty-day and 1-, 5-, 10-, and 20-year overall survivorships among 82 patients undergoing replacement of the ascending aorta with or without the arch for acute aortic dissection between 1968 and May 1989 were 79%, 66%, 56%, 46%, and 30%, respectively. The multivariably determined risk factors for death were the inclusion of the arch in the replacement, the year of the operation, the predissection New York Heart Association functional class, diabetes, and concomitant coronary artery bypass grafting. The current 30-day survivorship predicted by the multivariable equation when the operation involves only the ascending aorta is 97%, and the 10- and 20-year predicted survivorships are 61% and 39%, respectively. When the current era the replacement involves the arch as well as the ascending aorta, the predicted 30-day survivorship is 84%, and the 10- and 20-year ones are 48% and 31%. In 1990 sixteen additional patients (one hospital death) underwent ascending aortic replacement, and six (no hospital deaths) ascending aorta and arch replacement. The predictions for 1990 from the multivariable equation were similar to these actual experiences (Ps for differences were 0.6 and 0.4). Seventy percent of surviving patients with DeBakey type I dissection were free of a second aortic operation for aneurysmal dilation of the distal false channel, but this occurred in none of nine patients in whom an intimal tear in the transverse arch was included in the resection.

Acute Disease↗
PubMed1992

Thoracoabdominal aortic aneurysm associated with umbilical artery catheterization: case report and review of the literature.

Aneurysms in infants and children are rare and are usually associated with cardiovascular malformations or connective tissue disorders. A new subgroup of patients has become recognized over the past two decades--those with aneurysms associated with umbilical artery catheterization. Critically ill newborns who have required umbilical artery catheterization and have developed sepsis, usually staphylococcal, are at risk for the development of mycotic aneurysm disease of the aorta or its major branches or both. Since first described in 1970, 34 cases have been reported in the literature, 14 involving the descending thoracic aorta, 10 the abdominal aorta, 6 the iliac arteries, and 4 either the thoracoabdominal aorta or multiple aneurysms involving both the thoracic and abdominal aorta. This report presents a case we recently treated of a 15-month-old-boy with a large thoracoabdominal aortic aneurysm and aneurysms of the infrarenal abdominal aorta and proximal right common iliac artery. It includes a review of the recent literature to analyze pathogenesis, clinical manifestations, and to formulate methods of treatment.

Aorta, Abdominal↗