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Biomedical subjects

I Franco

Publications and source records attributed to I Franco.

At least 19 recordsLinked to original sources
PubMed1997

Intravascular ultrasound assessment of the prevalence and causes of angiographic "haziness" following high-pressure coronary stenting.

Haziness at sites of balloon angioplasty is believed to represent plaque fractures or platelet deposition. The etiology of haziness adjacent to coronary stents remains uncertain. This study examines the prevalence and etiology of "peri-stent" haziness following high-pressure deployment. Consecutive patients undergoing coronary stenting and intravascular ultrasound imaging were included. Haziness was defined as nonhomogeneous contrast density and/or indistinct vessel borders by consensus of 2 observers. Patients were excluded if angiography revealed an obvious cause of haziness (thrombus, dissection). Matched control segments without haziness were selected for comparison. The most diseased site within the reference segment was identified by ultrasound. Lumen and plaque areas, percent plaque area, and plaque echo density were assessed. Haziness was identified within 31 segments in 30 patients (15% of 201 angiograms examined). At hazy sites, ultrasound revealed a large percent plaque area in 15, dissections in 14, and near-normal findings in 2 segments. In the absence of dissection, percent plaque area and lumen area step-down from the stent to the diseased reference were greater than controls (percent plaque area 64 +/- 12% vs 56 +/- 10%, p = 0.04 and lumen step-down 35 +/- 20% vs 13 +/- 25%, p = 0.006). With dissections, percent plaque area and lumen step-down were not different from controls (p = 0.13 and 0.30, respectively), but underlying plaques were more frequently echolucent (64% vs 23%, p = 0.02). Thus, in this study, peri-stent haziness was evident in 15% of patients after high-pressure coronary stent deployment. Etiologies identified by intravascular ultrasound included unrecognized reference plaque and angiographically occult dissections.

Aged↗
PubMed1996

The dilemma of diagnosing coronary calcification: angiography versus intravascular ultrasound.

OBJECTIVES: We sought to determine whether careful examination of angiograms in conjunction with other clinical information could reliably detect, quantitate and localize target lesion calcification before a coronary intervention. BACKGROUND: The presence, extent and location of calcium in coronary artery lesions are important determinants of outcome after coronary intervention. Intravascular ultrasound is proposed as a superior technique for identifying patients with coronary artery calcification. However, the precise role of this costly and invasive method has not yet been established. METHODS: Target lesion calcification was assessed in 183 patients (155 men; mean [+/-SD] age 58 +/- 10 years) by angiography and intravascular ultrasound before a planned percutaneous coronary intervention. RESULTS: Ultrasound detected calcium in 138 patients (>90 degrees in 56, 91 degrees to 180 degrees in 52, 181 degrees to 270 degrees in 22 and > 270 degrees in 8), whereas angiography showed calcification in 63 (1+ in 32, 2+ in 27 and 3+ in 4). The two techniques agreed in 92 patients and disagreed in 91. Sensitivity and specificity of angiography were 40% and 82%, respectively. The arc of calcium by ultrasound was greater in patients with angiographically visible calcification (175 degrees +/- 85 degrees vs. 108 degrees +/- 71 degrees, p=0.0001). The depth of calcification by ultrasound was superficial in 61 patients (44%), deep in 68 (49%) and mixed in 8 (7%). The sensitivity of angiography in identifying superficial calcium was 35%. Of 120 patients without angiographically visible calcium at the target lesion site, 83 showed calcium by ultrasound. The only predictor of ultrasound calcium in these 120 patients was angiographic calcification elsewhere in the coronary tree (p=0.0001). The probability of any calcium and superficial >90 degrees calcium were 60% and 12%, respectively, in the 90 patients without angiographic calcifications anywhere in the coronary tree. CONCLUSIONS: Despite poor sensitivity, angiography may help identify patients requiring intravascular ultrasound. When it is angiographically visible, the arc of calcium is likely to be large and superficial. Angiographic calcification at a remote site is a predictor of angiographically undetected target lesion calcium. Patients without angiographic calcification in the coronary tree may not need routine ultrasound examination, as the likelihood of >90 degrees superficial calcium is low.

Aged↗
PubMed1996

Is contralateral exploration of the kidney necessary in patients with Wilms tumor?

PURPOSE: Surgical exploration of the contralateral kidney in patients with Wilms tumor is standard practice. The introduction of modern imaging techniques (ultrasound, computerized tomography and magnetic resonance imaging) in place of excretory urography has led to a more accurate definition of intrarenal pathology. Is contralateral kidney exploration still necessary in patients with Wilms tumor? MATERIALS AND METHODS: We reviewed the records of 75 patients from 3 medical centers who were evaluated and treated for Wilms tumor in the last 14 years. All children underwent preoperative excretory urography, computerized tomography, ultrasound and/or magnetic resonance imaging. RESULTS: Seven bilateral Wilms tumors were diagnosed preoperatively and confirmed surgically, whereas extensive operative exploration of the contralateral kidney in the other 69 patients revealed no additional pathological condition. This concurred with preoperative radiological findings with 100% sensitivity and specificity. Furthermore, 1 month to 12 years of followup (mean 4.3 years) revealed no tumor in the contralateral kidney. The major postoperative complication was small bowel obstruction in 5 patients 15 to 180 days (mean 77.2) after explorative laparotomy. CONCLUSIONS: In all patients preoperative radiological investigation was accurate in excluding bilaterality. With modern imaging techniques and effective chemotherapy extensive contralateral renal exploration may no longer be mandatory for managing Wilms tumor.

Adolescent↗
PubMed1995

Early and 1-year survival rates in acute myocardial infarction complicated by cardiogenic shock: a retrospective study comparing coronary angioplasty with medical treatment.

Cardiogenic shock remains a frequently lethal complication of acute myocardial infarction. Early revascularization of the infarct-related artery by coronary angioplasty has been suggested to significantly improve patient survival. In-hospital and 1-year survival was assessed in 50 patients hospitalized for acute myocardial infarction complicated by cardiogenic shock. All patients received medical treatment and intraaortic balloon pump support. Thirty-three patients underwent coronary angioplasty (PTCA group), while 17 patients remained on conventional therapy (no PTCA group). The two groups were comparable for all baseline characteristics. Survival was significantly better in the PTCA group than in the no PTCA group: 64% versus 24% in-hospital survival (p = 0.007) and 52% versus 12% at 1 year (p = 0.006). When angioplasty was successful in achieving reperfusion, survival was further enhanced: in-hospital survival rate was 76% versus 25% in patients with unsuccessful angioplasty and 60% versus 25% at 1 year.

Aged↗
PubMed1995

Percutaneous revascularization of ostial saphenous vein graft stenoses.

OBJECTIVES: This study sought to evaluate the short-term results and long-term outcome of percutaneous revascularization of ostial saphenous vein graft stenoses in a large patient series. BACKGROUND: Previous studies have demonstrated that the results of balloon angioplasty for native coronary ostial stenoses are significantly worse than those for nonostial lesions. However, it is controversial whether interventions in patients with ostial saphenous vein grafts carry a similar prognosis. METHODS: We identified 68 consecutive patients with ostial (group I) and 72 consecutive patients with proximal, nonostial (group II) saphenous vein graft stenoses who underwent percutaneous angioplasty or directional atherectomy for a single new stenosis at the Cleveland Clinic between 1986 and 1992. RESULTS: Success was achieved in 61 patients (89.7%) in group I and 64 (88.9%) in group II (p = 0.88). There were no differences in major procedural complications (death, Q wave infarction and bypass surgery) between the two groups. At a mean (+/- SD) follow-up of 23 +/- 17 months, 36 patients (64%) in group I had one or more adverse events (death, infarction, repeat coronary revascularization or cardiac-related hospital admission) compared with 34 patients (58%) in group II (p = 0.87). Twenty-eight patients (50%) were angina free in group I compared with 33 (56%) in group II (p = 0.65). During the follow-up period in group I, 7 patients died (13%), 10 had a myocardial infarction (18%), 11 had repeat bypass surgery (20%), 8 had repeat percutaneous interventions (14%), and 30 had one or more cardiac-related hospital admissions (54%). The incidence of these events was similar in group II except for a slightly higher incidence of myocardial infarction: 6 patients died (10%), 3 had a myocardial infarction (5%), 12 had repeat bypass surgery (20%), 12 had repeat percutaneous interventions (20%), and 26 had one or more cardiac-related hospital admissions (44%). CONCLUSIONS: Unlike ostial native coronary disease, the clinical, procedural and follow-up profile of ostial saphenous vein graft revascularization is not significantly worse than proximal nonostial disease. This finding may be related to the overall suboptimal results of percutaneous revascularization in saphenous vein grafts compared with native coronary arteries or to the unfavorable intrinsic properties of ostial native coronary arteries compared with ostial vein grafts.

Angioplasty, Balloon, Coronary↗
PubMed1995

Selective sacral rhizotomy for the management of neurogenic bladders in spina bifida patients: long-term followup.

Selective sacral rhizotomy was introduced for the management of high pressure neurogenic bladders commonly encountered in myelodysplastic patients. In 1992, 2 of us (I.F. and W.K.) first reported results with selective sacral rhizotomy and cord untethering in 8 spina bifida patients. We report long-term followup of our original 8 patients and 3 additional patients. This followup demonstrates remarkable success in maintaining bladder volume and low pressures after rhizotomy and cord untethering. Uninhibited contractions resolved in all patients postoperatively. A more favorable response occurred in the patients younger than 9 years, supporting early intervention with selective sacral rhizotomy.

Adolescent↗
PubMed1995

Intraoperative spermatic venography reconsidered.

We review our most recent experience with varicocelectomy and post-ligation venography in 58 adolescents as followup to our previously reported series. A single injection venogram confirmed the completeness of varicocele ligation in 82% of cases while 2 or more injections were required in the remainder. Venography was not performed in 8 cases because of technical difficulties in 5 or surgeon choice in 3. The recurrence rate was 8.6% and was not statistically significant whether or not venography was performed (p = 0.86). Although intraoperative spermatic venography is technically simple and safe, in our series its efficacy in diminishing the recurrence rate after varicocelectomy was unproved.

Adolescent↗
PubMed1994

Comparison of costs of new atherectomy devices and balloon angioplasty for coronary artery disease.

The in-hospital cost for 126 consecutive patients undergoing 1-vessel, single-lesion coronary atherectomy (atherectomy group) beginning January 1, 1991, was reviewed (65 directional, 44 rotational, and 17 extractional atherectomies), and compared with the cost for 126 consecutive patients matched by sex and age who underwent 1-vessel, single-lesion standard balloon coronary angioplasty (angioplasty group). The in-hospital cost for each patient was determined using charges divided by a correction factor for each hospital department involved. Six different cost fields were created. The overall cost/charge ratio was 0.72. Angiographic and clinical success was 91% and 90% in the angioplasty group and 93% and 90% in the atherectomy group, respectively. Patients who underwent angioplasty required 1.3 +/- 0.6 devices/procedure, as compared with those who underwent atherectomy (2.4 +/- 1 devices/procedure) (p < 0.0001). The mean cost of angioplasty was $7,301 +/- $4,637 and of atherectomy devices $9,345 +/- $8,856 (28% increase). The difference was principally related to an increase in cost of supplies: angioplasty $2,028 +/- $1,196 versus atherectomy $3,632 +/- $1,525 (79% increase). There were no significant differences in hospitalization cost, procedure-room cost, and pharmacy and laboratory costs. Thus, higher risk morphologic lesions can be approached with new atherectomy devices with clinical and complication rates similar to coronary angioplasty. However, these results were obtained at a 28% increase in cost.

Angioplasty, Balloon, Coronary↗
PubMed1994

Late results of coronary angioplasty in patients with left ventricular ejection fractions < or = 40%.

Left ventricular (LV) function is the most important independent predictor of long-term survival in patients with coronary artery disease, and results of bypass surgery improving survival in the setting of depressed LV function are well documented. Data regarding long-term outcome in patients undergoing coronary angioplasty are limited. From 1983 through 1989, 343 consecutive patients with an ejection fraction (EF) < or = 40% (mean 34% +/- 5%) undergoing elective coronary angioplasty were evaluated, retrospectively. The mean age was 61 +/- 10 years and 80% were men. Angiographic success (469 of 496 narrowings) was 95%. Major complications occurred in 26 patients (7.6%): emergency bypass surgery (n = 11), nonfatal myocardial infarction (n = 8), and death (n = 9). Follow-up was available for 99% of patients with clinical success (mean = 36 +/- 22 months). Fourteen patients (4.5%) developed nonfatal myocardial infarction and 72 patients (23%) had symptomatic restenosis, 32 patients requiring repeat angioplasty or atherectomy and 29 bypass surgery. Fifty-six patients (18.2%) died. Three-year survival was 84%. EF was a significant predictor of death: 3-year survival was 69%, 83% and 92%, respectively, in patients with EF < or = 30%, 31% to 35%, and 36% to 40% (p = 0.0001). A high angiographic success rate and an acceptable procedural risk were encountered in patients with depressed LV function undergoing angioplasty. The 3-year mortality rate, however, is substantial and directly related to the degree of LV dysfunction.

Adult↗
PubMed1994

Directional coronary atherectomy in unstable angina.

OBJECTIVES: To determine whether excision of complex, ulcerated plaque improves the risk of patients with unstable angina to the level of those with stable angina, the results of directional coronary atherectomy were compared in patients with these two syndromes. BACKGROUND: The procedural results of angioplasty in the setting of unstable angina are not as favorable as those observed for chronic stable angina, presumably because thrombus-associated plaque augments the risk of abrupt closure. METHODS: Two hundred eighty-seven consecutive patients who had undergone directional atherectomy for a single new stenosis were studied. Seventy-seven patients had stable angina (Group I); 110 patients had progressively worsening angina in the absence of rest or postinfarction angina (Group II); and 100 patients had rest or postinfarction angina, or both (Group III). RESULTS: Major ischemic complications (death, Q wave infarction, emergency bypass surgery) occurred more frequently in Group III (1.3% [Group I] vs. 0.9% [Group II] vs. 7% [Group III], p = 0.036). This difference was largely due to a higher incidence of emergency surgery in Group III (1.3% [Group I] vs. 0% [Group II] vs. 5% [Group III], p = 0.05). Clinical follow-up was obtained in 97% of successful procedures for a mean follow-up period of 22 months (range 9 to 52) and revealed a higher incidence of hospital admission for angina (p = 0.05) and a trend toward more bypass surgery (p = 0.09) and myocardial infarction (p = 0.16) in Group III. There was no difference in repeat percutaneous interventions among the three groups (range 19% to 24%, p = 0.75). CONCLUSIONS: These results show that the definition of unstable angina is important in determining the immediate outcome of directional atherectomy. In the absence of rest or postinfarction angina, the immediate results are not significantly different from those obtained in stable angina. Our results also suggest that both the immediate and short-term outcome in unstable angina are not greatly influenced by atherectomy but more so by the pathophysiology of unstable angina, which increases the complications of percutaneous interventions.

Analysis of Variance↗
PubMed1994

The importance of catheter size in the achievement of urinary continence in patients undergoing a Young-Dees-Leadbetter procedure.

During the last 8 years 49 patients have undergone urinary tract reconstruction at our institution to manage urinary incontinence. Of these patients 25 underwent a Young-Dees-Leadbetter procedure, of whom 13 boys and 6 girls were available for followup. Average patient age was 12.2 years and mean followup is 30.2 months. Augmentation cystoplasty was required in 14 cases. All 12 patients (100%) undergoing tubularization over an 8F catheter attained diurnal continence, and 92% are completely continent day and night. Furthermore, the 6 patients in whom augment capacities attained were less than the expected volume for age were also completely continent when tubularization was performed over an 8F catheter. We conclude that creation of a narrow (8F) Young-Dees-Leadbetter bladder neck tubularization leads to an increased likelihood of diurnal and nocturnal continence but precludes spontaneous unaided voiding to completion. Furthermore, achievement of urinary continence appears to be less dependent on bladder capacity when it is coupled with a narrow Young-Dees-Leadbetter tubularization.

Adolescent↗
PubMed1994

Endoscopic management of bladder calculi following augmentation cystoplasty.

OBJECTIVES: We sought to evaluate the effectiveness and utility of an endoscopic approach to calculi that develop in the bladders of children following augmentation cystoplasty. In addition, we aimed to determine the indications for open vesicolithotomy. METHODS: We reviewed our experience between 1981 and 1993 with 26 children who formed bladder calculi following augmentation cystoplasty. Data were retrieved retrospectively with respect to management approach and outcome. RESULTS: Nineteen cases were managed cystoscopically using simple extraction and/or electrohydraulic lithotripsy; 3 cases required open vesicolithotomy and four calculi passed spontaneously. Complete stone extraction was achieved after a single endoscopic treatment in every case approached in this fashion. Every patient resumed preoperative voiding patterns and there were no infections, strictures, or other complications. Calculi reformed in 4 patients and were successfully managed endoscopically. CONCLUSIONS: An endoscopic approach to bladder calculi is a safe and effective method of managing this increasingly prevalent problem in children following augmentation cystoplasty even in the presence of a reconstructed bladder neck. Open vesicolithotomy should be reserved for the very large stone burden.

Adolescent↗
PubMed1994

Optimal renal preservation with timely percutaneous intervention: a changing concept in the management of blunt renal trauma in children in the 1990s.

OBJECTIVE: To report the results of treatment of 132 children with blunt renal trauma and indicate our treatment recommendations. RESULTS: Between 1971 and 1991 132 children presented with blunt renal trauma. Grade I injuries (renal contusion) were seen in 97 children, grade II injuries (renal laceration) in 32 and grade III (shattered kidney and pedicle injury) in three. Twenty-six children with grade II injuries were treated non-surgically. Urinomas developed in three, which were drained percutaneously with complete resolution. Prior to 1985 six patients with grade II injuries underwent total or partial nephrectomy for major renal lacerations. Repair of shattered kidneys resulted in significant morbidity. Conservative management of major blunt injuries with judicious percutaneous intervention resulted in no renal loss. CONCLUSION: We believe that conservative therapy with timely percutaneous drainage of urinomas in children with major blunt renal injury, other than shattered kidney or pedicle injuries, optimizes renal preservation and minimizes secondary complications.

Adolescent↗
PubMed1994

Relation of clinical presentation, stenosis morphology, and operator technique to the procedural results of rotational atherectomy and rotational atherectomy-facilitated angioplasty.

BACKGROUND: Rotational atherectomy using the Rotablator has recently become available to treat coronary stenoses. This study was performed to determine the relation of patient characteristics, stenosis morphology, and operator technique to procedural outcome to gain insight into which patients might be best treated with this device. METHODS AND RESULTS: Four hundred stenoses from 316 patients randomly selected from the initial Rotablator experience at three major referral institutions were analyzed. Angiographic data were assessed at a central angiographic laboratory using standardized morphological criteria and caliper measurement. Patients were somewhat more elderly than most percutaneous transluminal coronary angioplasty (PTCA)-treated groups (mean age, 64 +/- 11 years), 74% were men, and the lesions treated were often complex (modified American College of Cardiology/American Heart Association lesion type A, 24%; B1, 40%; B2, 30%; and C, 6%). Elective adjunctive PTCA was used for 82% of stenoses treated. Procedural success was achieved in 89.8% of stenoses (93.5% if results with creatine kinase two to three times normal are not counted as failures), and major ischemic complications (death, 0.3%; non-Q-wave myocardial infarction, 5.7%; Q-wave myocardial infarction, 2.2%; or emergency bypass surgery, 0.9%) occurred in 8.9% of patients. Complications were due to epicardial coronary obstruction in 3.8% of patients and to delayed coronary runoff ("slow reflow") in 5.1% of patients. Procedural failure was correlated independently with outflow obstruction (success rate, 64%; odds ratio for failure, 5.4; multivariate P = .002), lesion irregularity (76%; odds ratio, 3.3; P = .003), stenosis bend > or = 60 degrees (73%; odds ratio, 3.7; P = .03), and female sex (84%; odds ratio, 2.4; P = .03). Ischemic complications were correlated independently with lesion length (> or = 50% narrowing) > or = 4 mm (complication rate, 12%; odds ratio, 3.6; multivariate P = .005), right coronary artery stenosis (13%; odds ratio, 2.4; P = .02), stenosis bend > or = 60 degrees (27%; odds ratio, 6.1; P = .03), and female sex (13%; odds ratio, 3.0; P = .04). Slow reflow was correlated with total burring duration (odds ratio, 1.005/s; multivariate P = .001), right coronary artery stenosis (incidence, 17%; odds ratio, 4.5; P = .009), and to a lesser extent with recent myocardial infarction in the treated territory (44%; odds ratio, 4.3; P = .08). CONCLUSIONS: The procedural outcome of rotational atherectomy is highly correlated with stenosis morphology and location and sex of the patient. After stratification for these parameters, overall outcome with the Rotablator appears to be similar to that with balloon angioplasty and other competing techniques. Short-term outcome with specific subsets of patients may be superior with the Rotablator (calcified stenoses), but this technique might best be avoided in some patients (those with irregular or possibly thrombus-containing stenoses, highly angulated stenoses, and possible right coronary artery stenoses or those associated with impaired distal runoff caused by a recent myocardial infarction or manifest by a fixed thallium defect).

Aged↗
PubMed1993

Indications for directional coronary atherectomy: 1993.

New coronary devices are being developed in attempts to solve the limitations of balloon angioplasty. Directional coronary atherectomy was the first of these devices to gain Food and Drug Administration approval. Theoretically, directional atherectomy improves coronary stenoses by an entirely different mechanism than balloon angioplasty, removing atherosclerotic plaque and leaving a smooth surface with less elastic recoil. Nonrandomized experience has shown that directional atherectomy is most useful in proximal to mid-segment, noncalcified, large (> 2.5 mm) coronary arterial segments, yielding minimal residual stenosis and larger lumen diameters than are generally achieved with angioplasty. Experience suggests that directional atherectomy is most useful in ostial coronary lesions, bifurcation stenoses, proximal left anterior descending lesions, discrete saphenous vein graft stenoses, complex or thrombus-containing lesions, highly eccentric lesions, and lesions failing PTCA secondary to elastic recoil, recurrent thrombosis, or limited dissection. Dissection and out-of-catheterization-laboratory acute closure are infrequent and appear to be improved over balloon angioplasty. However, intimal hyperplasia leading to restenosis is not solved by directional atherectomy. Randomized studies such as the Coronary Angioplasty Versus Excisional Atherectomy Trial (CAVEAT) will help to clarify further the overall utility of directional atherectomy compared with balloon angioplasty in the future, but due to the limited power of subgroup analyses, CAVEAT may not have fully defined all the specific lesion characteristics that may be improved by atherectomy over PTCA. Review of the data presented may help the clinician identify specific areas in which atherectomy appears to offer an advantage over angioplasty, although definitive answers await specifically targeted randomized trials.

Angioplasty, Balloon, Coronary↗
PubMed1993

Is aggressive heparinization necessary for elective PTCA?

The optimal level of heparin anticoagulation for elective PTCA is unknown. To determine if PTCA complications are related to the level of anticoagulation, serial ACT values were prospectively measured in 189 patients undergoing 201 elective PTCA procedures. The mean heparin dose before balloon inflation (pre-inflation) was 10,100 units, and the mean dose per procedure was 13,200 units. The mean pre-inflation ACT was 295 sec, but was < 300 sec in more than 50% of patients. Acute complications were not related to any ACT parameter and the development of new intracoronary thrombus was not observed. In elective PTCA procedures, the routine monitoring of ACT values is unnecessary when standard heparin doses are used.

Angioplasty, Balloon, Coronary↗
PubMed1993

Urolithiasis in children following augmentation cystoplasty.

Until recently urolithiasis in children following augmentation cystoplasty was an infrequently noted problem. We examined our 10-year experience and found urinary calculi to form in 52% of children and young adults undergoing augmentation cystoplasty. Calculi formed at a median interval of 24.5 months after surgery, predominantly in the lower tract. Urinary tract infection was a statistically significant risk factor, while the use of absorbable staples, intestinal mucus and hypocitraturia were also implicated. Calculus composition was primarily a mixture of apatite, struvite and ammonium urate. Bladder calculi were effectively managed endoscopically in the majority of cases without complication. Upper tract calculi presented an endourological challenge.

Adolescent↗