Lower extremity percutaneous transluminal angioplasty: multifactorial analysis of morbidity and mortality.
Explore the source record for details and available documents.
Retraction Notice↗
Biomedical subjects
J E Hasson
Publications and source records attributed to J E Hasson.
Lower extremity percutaneous transluminal angioplasty: multifactorial analysis of morbidity and mortality.
We analyzed the outcome of 202 percutaneous transluminal angioplasty (PTA) procedures performed between 1983 and 1989 to quantitate procedural risks and define factors associated with suboptimal results or immediate clinical failure. Premorbid factors studied included age, sex, treatment of single versus multiple lesions, stenoses versus occlusions, premorbid status of the limb (claudication vs limb threat), and most distal level of PTA. Adverse outcomes included complications (hematoma, acute occlusion, or thrombosis of PTA site, distal embolization, failure to dilate or cross, arterial dissection, rupture, and significant systemic derangement), major amputations (below knee and above knee), and deaths. There were 66 complications (32.7%), 22 amputations (10.9%), and 12 deaths (5.9%) in our series. Logistic regression analysis revealed that the major predictive variable for the occurrence of a complication (p = 0.002), and the only predictive variable for the outcomes of amputation and death (p = 0.0001 and p = 0.0139, respectively), was the premorbid clinical status of the limb. Lower extremity PTA is not an intrinsically benign procedure and is associated with a significant risk of complication, amputation, and procedure-associated death. These adverse outcomes cluster in patients with limb threat. Therefore it may be reasonable to restrict the use of PTA to patients with claudication and strictly selected cases of limb threat.
Adult↗
Fatal gastric artery dissection and rupture occurring as a paraesophageal mass: a case report and literature review.
Gastric artery aneurysms are rare, and the majority occur as life-threatening hemorrhage with few premonitory signs or symptoms. We report an unusual hemorrhagic manifestation of a ruptured gastric artery aneurysm, occurring as a pleural effusion and an apparent paraesophageal mass. Acute intraperitoneal and mediastinal bleeding from the extravisceral portion of the left gastric artery resulted in hemorrhagic shock, prompting an emergency laparotomy. Extensive medial degeneration in the gastric artery probably contributed to dissection and rupture.
Aged↗
Adult human vascular endothelial cell attachment and migration on novel bioabsorbable polymers.
We studied the ability of polymers from which vascular prostheses (VPs) are or could be fabricated to support attachment and migration of adult human vascular endothelial cells (AHVECs) in an in vitro system. Polymers included Mylar, Teflon, two novel bioabsorbable polymers with different biologic half-lives (BR1 and BR2), and an elastic nonabsorbable biocompatible polymer (EBN). Both BR1, BR2, and EBN supported AHVEC attachment well (56%, 62%, and 71%, respectively, of plated cells at one hour, respectively) but differed in their ability to support AHVEC migration. The AHVECs attached less well to Mylar and Teflon (39% and 21%), and in no case were AHVECs observed to grow or migrate on either of these polymers. This finding correlates with the clinical observation that VPs fabricated from Mylar and Teflon uniformly fail to develop an endothelial cell lining after implantation in vivo. Future VPs, fabricated from materials chosen for their ability to support AHVEC attachment, growth, and migration in vitro, might better support a spontaneous endothelial cell lining after implantation in humans.
Adult↗
Effect of compliance mismatch on vascular graft patency.
The hypothesis that a mismatch in compliance between a vascular graft and its host artery is detrimental to graft patency was tested by implanting paired arterial autografts, prepared with differential glutaraldehyde fixation of carotid arteries in the femoral arteries of dogs. These grafts differed only in circumferential compliance: they were 100% (compliant) vs. 40% (stiff) as compliant as the host artery. Their flow surfaces were equivalent, as determined by physicochemical measurements and scanning electron microscopy; both lacked viable cells, as determined by in vitro cell culture. In 14 dogs, eight stiff and two compliant grafts became occluded within 3 months, the latter doing so within 24 hours after their contralateral counterparts. Cumulative patencies were 85% and 37% for compliant and stiff grafts, respectively (p less than 0.05) and 100% and 43%, excluding the two dogs with bilateral graft failures (p less than 0.01). We conclude that even with near optimal flow surfaces, compliance mismatch is deleterious to graft patency.
Animals↗
Compliance changes in glutaraldehyde-treated arteries.
Glutaraldehyde tanning of carotid arteries was used to develop a model for studying the effects of compliance on arterial graft performance, independent of other graft parameters. Canine carotid segments were filled with dilute phosphate-buffered glutaraldehyde (0-0.5%, pH 7.4), maintained at physiological pressure, and then immersed in either saline or 10.0% glutaraldehyde for up to 1 hr. After rinsing with saline, compliance was measured in vitro. All vessels which were immersed in 10% glutaraldehyde exhibited a significant reduction in compliance compared to native artery control [C = 11.8 +/- 1.3 (mean +/- SEM), % radial change/mm Hg X 10(-2), measured at 100 mm Hg], but maximum stiffness (C = 1.1 +/- 0.3) required that the lumen be specifically exposed to at least 0.025% glutaraldehyde in addition to simple immersion of the vessel segment in 10% fixative. Exposing the artery to 0.5% glutaraldehyde internally, without immersion of the entire structure, caused a decrease in compliance similar to that obtained after immersion in 10% glutaraldehyde, with only saline present in the lumen. Matched pairs of stiff and compliant grafts were generated by exposing the lumen to 0.025% glutaraldehyde and immersing the vessels in 10% fixative or saline, respectively. Light and scanning electron microscopy, internal reflection spectroscopy, and measurements of critical surface tension revealed nearly identical wall morphology and lumenal surface chemistry for these matched pairs. Differential tanning of the internal and external surfaces of carotid arteries thus provides a good model of arterial prostheses, wherein a substantial compliance mismatch can be studied without the complicating influences of varying diameter or differing flow surface properties.
Aldehydes↗
Suture technique and para-anastomotic compliance.
We previously described a para-anastomotic hypercompliant zone (PHZ), located 3 to 4 mm from end-to-end continuous anastomoses in canine femoral arteries, in which arterial compliance first increases approximately 50% above adjacent reference values before falling to a minimum at the anastomosis. To determine if PHZ is affected by suture technique, 16 interrupted and 21 continuous end-to-end anastomoses were studied. Pulsed ultrasound was used to obtain detailed longitudinal profiles of compliance and diameter vs. distance, at 1 mm intervals within a 2 cm region centered at the anastomoses. Both compliance and diameter at the anastomosis were lower in continuous compared with interrupted anastomoses (p less than 0.003). The PHZ was present in 86% of continuous but in only 50% of interrupted anastomoses (p less than 0.03). The site of peak compliance averaged 3.8 +/- 1.2 mm from the anastomosis and was independent of suture technique. The increase in peak compliance at the PHZ, when normalized to adjacent references values, was the same in continuous and interrupted anastomoses. PHZ augments any preexisting compliance mismatch between artery and graft, which may contribute to the development of para-anastomotic subintimal hyperplasia. Interrupted anastomoses, which create a smaller compliance mismatch than do continuous and have a lower incidence of PHZ, may be preferred in certain settings.
Animals↗
Noninvasive measurements of nonlinear arterial elasticity.
To describe fully the compliance characteristics of an artery with nonlinear elastic properties, measurements must be obtained over a wide range of pressures. Furthermore, repeated measurements, as required in temporal studies of arterial implants, require that the measuring technique be noninvasive. The application of a pulsed ultrasound echo-tracking device is described, which fulfills both criteria. Nonlinear compliance-pressure (CP) curves were obtained from the femoral arteries of dogs, with the use of halothane anesthesia to vary systemic pressure, and were used to compare the gross elastic properties of different vessels. Studies using controlled hemorrhage or the vasoactive drugs, nitroprusside and levarterenol (norepinephrine), were used to verify that the CP curves obtained during halothane anesthesia did not reflect varying degrees of smooth muscle activation. However, surgical exposure did temporarily reduce arterial compliance at pressures between 60 and 140 mmHg. The effect of vasoactive intervention and of postsurgical changes in arterial or graft compliance can thus be quantitated by use of CP curves or by comparing incremental elastic moduli, which can also be estimated from the noninvasively derived measurements.
Animals↗
Mural degeneration in the glutaraldehyde-tanned umbilical vein graft: incidence and implications.
After discovering an aneurysm in a glutaraldehyde-tanned umbilical vein (GTUV) graft that resulted in graft thrombosis, we reevaluated all patients from our institution who had GTUV grafts implanted for more than 2 years. Of 60 patients identified, 14 of 15 patients with patent grafts were recalled and had either digital subtraction or standard angiographic studies. Angiographic changes in the grafts were graded on a scale of 0 to 3, from normal (grade 0) to frank aneurysmal degeneration (grade 3). Eight grafts (57%) had frank aneurysmal (grade 3) changes, and three other grafts (21%) had preaneurysmal (grade 2) changes. Only one graft was angiographically normal. GTUV grafts undergo aneurysmal degeneration in a significant percentage of implants. Symptomatic aneurysms have presented with thrombosis and limb-threatening ischemia as well as rupture. GTUV aneurysms should be treated by complete graft resection, as segmental resection of diseased portions of grafts resulted in metachronous aneurysm recurrence. Because of the high incidence of GTUV degeneration, the clinical indications for the use of GTUV grafts should be seriously reevaluated, and we recommend that all patients with patent GTUV grafts for more than 2 years be evaluated for the presence of aneurysmal degeneration.
Aldehydes↗
Migration of adult human vascular endothelial cells: effect of extracellular matrix proteins.
An ideal vascular prosthetic graft should support rapid endothelial coverage and allow maximal rates of endothelial cell migration on its surface. To study this we modified and developed a method to measure rates of migration of adult human vascular endothelial cells (AHVECs) on test surfaces using an O-ring fence technique. We measured the rates of AHVEC migration on a variety of extracellular matrix proteins of interest because of their ability to support cell attachment. AHVECs, initially constrained in rings with an area of 0.62 cm2 (day 0), were allowed to migrate radially, and area coverage was measured after 7 days. The greatest areas of migration were seen on fibronectin (1.20 cm2) and gelatin (1.29 cm2) when compared with control (polystyrene [0.97 cm2]), p less than 0.01, p less than 0.05. Migration on laminin and prepared extracellular matrix from AHVEC was not statistically different from that of controls. Of extracellular matrix proteins studied in our system, a gelatin substrate in the presence of serum resulted in maximal rates of AHVEC migration.
Blood Vessel Prosthesis↗
Use of tritiated thymidine as a marker to compare the effects of matrix proteins on adult human vascular endothelial cell attachment: implications for seeding of vascular prostheses.
We have developed a technique to measure attachment of adult human vascular endothelial cells to test surfaces with tritiated thymidine used as a marker. With this technique, we measured attachment of adult human vascular endothelial cells to a series of extracellular matrix proteins, including fibronectin-coated (10 micrograms/cm2), laminin-coated (10 micrograms/cm2), and collagen-coated (1% gelatin) surfaces because of the role of these proteins in promoting cell attachment and growth. For a typical experiment, in the presence of serum, initial attachment (at 1 hour) was greatest on fibronectin-coated (63%) and gelatin-coated (60%) tissue culture plastic (polystyrene) and was least on laminin-coated (28%) or untreated polystyrene (18%). The data suggest that fibronectin, either alone, or with a more complex combination of extracellular components may need to be present on prosthetic surfaces to produce maximal cell attachment and subsequent growth to confluence in vivo. The described method of measuring attachment is independent of surface properties, ensures complete recovery of cells, and will allow systematic exploration of those properties that best support human endothelial cell attachment to vascular prosthetic surfaces.
Blood Vessel Prosthesis↗
Increased compliance near vascular anastomoses.
Mismatch in mechanical properties (compliance mismatch) between host artery and prosthetic graft has been suggested as a cause of graft failure, but no mechanism linking the two has been identified. With the use of a simplified model based on isocompliant arterial grafts, pulsed ultrasound was used to generate detailed longitudinal profiles of diameter and compliance near the anastomoses. These longitudinal profiles revealed that although arterial diameter decreases monotonically to a minimal level at an anastomosis, arterial compliance first increases by approximately 50% before decreasing to 60% of the control value. This para-anastomotic hypercompliant zone (PHZ) is centered 3.6 mm from the anastomosis. PHZ also occurs in the artery adjacent to compliant or stiff grafts and is probably caused by transmitted effects of the suture line on the arterial wall. PHZ adds to any mismatch in compliance that already exists between artery and graft and can produce a compliance mismatch even between an artery and a nominally isocompliant prosthetic graft. It is hypothesized that PHZ, a region of increased cyclic stretch, promotes subintimal hyperplasia near anastomoses and may thus be a link between the mechanical properties of arteries and the failure of bypass grafts.
Animals↗
Postsurgical changes in arterial compliance.
Mismatch in elasticity between artery and graft, a possible contributing factor to graft failure, has traditionally been believed to be caused by the graft. Compliance of the artery and/or graft may change after surgery, resulting in a different compliance mismatch. To study the arterial contribution to compliance mismatch, we measured compliance-pressure (CP) curves noninvasively in the femoral arteries of five dogs. One femoral artery was then simply exposed, and the incision was closed. Repeated CP curves were obtained after 24 hours, and after 1, 2, 3, and 4 weeks. Compliance remained normal after 24 hours, but by one week compliance of the dissected arteries had dropped significantly at all pressures between 70 and 120 mm Hg. Compliance reached a minimum after two weeks and remained low until after four weeks. Postsurgical arterial stiffening causes a significant decrease of arterial-graft compliance mismatch and may suggest an upper limit for synthetic graft compliance.
Animals↗
Penetrating duodenal trauma.
Ten cases of penetrating injuries to the duodenum are presented. Six injuries were treated with primary repair, retrograde decompressing jejunostomy, and feeding jejunostomy. There was no postoperative duodenal leak in any patient treated with primary repair and retrograde decompressing jejunostomy. In a review of 563 cases of penetrating duodenal trauma, the superiority of primary repair of duodenal injuries with decompression of the suture line by a tube inserted in a remote site of the bowel (stomach or jejunum) was demonstrated. This technique afforded the lowest mortality and incidence of postoperative duodenal fistulae. When applicable, primary repair with retrograde decompressing jejunostomy and feeding jejunostomy is a rapid, simple, and safe method for the treatment of penetrating duodenal injuries.
Adolescent↗