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Biomedical subjects

J J Bergan

Publications and source records attributed to J J Bergan.

At least 19 recordsLinked to original sources
PubMed1992

Unexpected, late cardiovascular effects of surgery for peripheral artery disease. Veterans Affairs Cooperative Study 199.

In reviewing late morbidity of a multicenter clinical trial comparing balloon angioplasty (percutaneous transluminal angioplasty) with bypass surgery for lower-extremity ischemia, an unexpectedly high incidence of adverse systemic events in surgical patients was uncovered. The study was prospective and randomized, and included a total of 263 patients, with follow-up from 2 to 6 years. When end points of related deaths, amputations, and intervention failures were summed, surgery was favored over percutaneous transluminal angioplasty at 4 years. Progression of cardiac and renal dysfunction and mortality differed between groups. A total of 42 deaths were in the group who underwent surgery and 27 in those who underwent percutaneous transluminal angioplasty. The percentage difference in death rate between the two groups increased each year to reach 10% at 5 years. A significant difference in renal function was noted in nine patients who underwent surgery and zero who underwent percutaneous transluminal angioplasty. Myocardial infarctions were greater on follow-up of surgical patients. After 6 years, congestive heart failure had occurred in 19 patients who underwent surgery and eight who underwent percutaneous transluminal angioplasty. The trends in this study of patients with only moderately severe peripheral arterial disease suggest an increased rate of deterioration of cardiac and renal function in patients who have arterial operations. In surgical patients, mortality was 13.1% per year, whereas it was 8.4% for patients treated with percutaneous transluminal angioplasty. Future intervention studies should include long-term follow-up of such cardiovascular events.

Amputation, Surgical↗
PubMed1992

Cerebrovascular magnetic resonance angiography: a critical verification.

Because simultaneous noninvasive noncontrast imaging of cervical and cerebral vasculature and brain is possible with magnetic resonance angiography (MRA) and imaging (MRI), the following study was undertaken from July 1990 to January 1992. One hundred twenty-eight patients were examined with General Electric 1.5 Tesla MRI systems. Axially acquired volumetric three-dimensional time-of-flight MRA with 0.7 mm3 voxel size with regional maximum intensity projection after processing followed a two-dimensional time-of-flight localizing sequence. These two MRA sequences combined with spin-echo parenchymal brain MRI were compared with duplex scans, contrast angiograms, and surgical findings. Blinded readings by a radiologist and vascular surgeon allowed comparison of grades of luminal diameter narrowing (normal, mild, moderate, severe, and occluded) seen on MRA to be compared with those of Doppler and contrast angiography. Excluding 12 nondiagnostically imaged internal carotid arteries (10 MRA) and limiting duplex correlation to within 5 days of the MRA examination allowed critical appraisal of 182 internal carotid arteries. Exact correlation of grade of stenosis was obtained by the radiologist in 136 (74.7%) of 182 arteries and the surgeon in 138 (75.8%) of 182 arteries. Spearman rank correlation analysis found rank correlation coefficients of 0.88 (p < 0.001) and 0.83 (p < 0.001), respectively, for the radiologist and vascular surgeon. Disagreement one category apart was found by the radiologist in 35 studies (19.3%) and the surgeon in 28 studies (15.4%). Two or more grades of disagreement were found by the radiologist in 11 studies (6%) and the surgeon in 16 studies (8.8%). Contrast angiogram-MRA agreement was found in 86% of 36 internal carotid arteries. The degree of stenosis detected by MRA was concordant with surgical findings in 39 of 40 patients. Thus MRA emerges as a useful and accurate method of obtaining cerebrovascular evaluation in clinical practice.

Adult↗
PubMed1990

Popliteal vascular trauma. A community experience.

Preventing amputation continues to be a significant challenge when popliteal vascular injuries occur. A retrospective review of cases from the San Diego County (California) Trauma System identified 108 patients with 76 blunt and 32 penetrating arterial injuries. The limb preservation rate was 88%; there were 13 amputations. The fracture-dislocated knee injury and close-range shotgun blasts were particularly limb threatening. In general, the trauma system achieved rapid evaluation of injuries and early operative intervention. All 13 patients who underwent amputations presented with signs of severe ischemia. Concomitant injuries to the popliteal vein, tibial nerves, and soft tissue were significantly more frequent in patients who underwent amputations. The importance of complete fasciotomy for compartment hypertension, early reconstructive management of soft-tissue injuries, and expeditious arterial repair, frequently without preoperative roentgenographic suite arteriography, is emphasized. An aggressive, multidisciplinary approach is required to achieve a functional extremity when popliteal vascular trauma occurs.

Adolescent↗
PubMed1989

Mesenteric venous thrombosis.

Sixteen patients with mesenteric venous thrombosis were reviewed retrospectively during a period from 1983 to 1987. Twelve patients had progressive abdominal pain, three had gastrointestinal bleeding, and one had general malaise. Seven of these 16 patients had previous deep-vein thrombosis. After negative routine gastrointestinal and hepatobiliary evaluation, 11 patients underwent an infusion computerized tomographic scan. Of these, 10 had superior mesenteric vein thrombosis; three of these 10 patients had portal vein thrombosis. Selective arteriography was done in two patients because of gastrointestinal bleeding, and a diagnosis of mesenteric vein thrombosis was made on the venous phase of the examination. The remaining four patients developed acute abdominal symptoms requiring surgical exploration, at which time mesenteric venous thrombosis was discovered. An identifiable coagulopathy was detected in nine patients (protein C deficiency in six, protein S deficiency in two, and factor IX deficiency treated with factor IX concentrate in one). No case of congenital antithrombin-III deficiency was identified. Six of these nine patients had a past history of deep venous thrombosis. Of five patients who underwent surgical exploration, all required bowel resection. In follow-up, two patients died of intestinal necrosis and a third died of associated pancreatic cancer. Thirteen patients were discharged from the hospital. Treatment of coagulopathy was by heparin in three patients and sodium warfarin (Coumadin) in four patients. Long-term anticoagulation was not instituted because of gastrointestinal bleeding in three and cirrhosis in three patients. Mesenteric venous thrombosis can occur without gangrenous bowel. Diagnosis should be suspected when acute abdominal symptoms develop in patients with prior thrombotic episodes and a coagulopathy.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1988

Multiple aneurysms in Behçet's disease.

Behçet's disease is characterized by recurrent ulcers of the mouth and genitalia and relapsing iritis. It is now recognized as a chronic multisystem disease affecting the skin, mucous membranes, eye, joints, central nervous system, and blood vessels. One of the known vascular complications of Behçet's disease is aneurysm formation or venous thrombosis. The two patients with Behçet's disease in this report developed multiple aneurysms over a short time span. Vascular surgeons dealing with young adults with peripheral aneurysms must be aware of this uncommon yet challenging clinical entity.

Adult↗
PubMed1988

The demise of primary profundaplasty.

Although the importance of the profunda femoris artery in maintenance of lower extremity integrity was recognized in the earliest days of modern vascular surgery, disappointment with the performance of primary profundaplasty has emerged fully only in recent years. During the 10 year period from 1977 to 1987, only 17 patients were subjected to this procedure at Northwestern Memorial Hospital. The nine men and eight women averaged 65.6 years in age and exhibited the usual precursors of arterial insufficiency: a history of smoking in 12 patients (71 percent), clinical coronary artery disease in 8 patients (47 percent), hypertension in 7 patients, diabetes mellitus in 6 patients, hyperlipidemia in 2 patients, and uremia in 1 patient. Four patients exhibited hemodynamic improvement after profundaplasty (ankle-brachial index increase of greater than 0.15). Four required amputation postoperatively, and a fifth exhibited hemodynamic failure 9 months postoperatively and required amputation. Two patients required subsequent femoral-to-peroneal bypass to improve distal arterial perfusion. One patient died after the procedure, for a 5.9 percent mortality rate. Thus, the fact that profundaplasty has proved disappointing in the treatment of severe arterial insufficiency deserves emphasis at this time.

Adult↗
PubMed1988

Improved long-term patency of infragenicular polytetrafluoroethylene grafts.

This article reviews late graft patency and the incidence of postoperative complications in 75 infragenicular polytetrafluoroethylene bypass grafts (20 posterior tibial, 26 anterior tibial, and 29 peroneal). All patients received a heparin infusion after operation and were switched to warfarin before discharge to maintain coagulation parameters (prothrombin time and partial thromboplastin time) approximately twice that of control subjects. Primary procedures were done in 14 patients (19%), and the remaining patients had one or more previous procedures. Ninety-seven percent of patients had limb-threatening ischemia. Graft patency was confirmed by interval examinations and Doppler ankle pressure measurements. The mean follow-up was 36 months, and long-term graft patency (4 years) was determined by life-table analysis. The 2-year cumulative patency rate for this group was 45% and the 4-year patency rate was 37%. The latter is significantly better than the patency rates of 12% reported for similar untreated randomized grafts. Anticoagulation was subtherapeutic in 15 patients at the time of graft thrombosis, and if these were excluded, the 2- and 4-year patency rates were 58% and 50%, respectively. Hematomas requiring drainage occurred in 10 patients (13.3%) and six patients (8%) developed wound infections, but graft infection occurred in only two patients. Two patients (2.6%) developed late bleeding complications necessitating cessation of the warfarin. There was one fatal perioperative myocardial infarction (1.3%) and four late deaths, none of which were related to the warfarin therapy. Although the incidence of postoperative hematoma and wound infection was increased, late complications occurred infrequently.(ABSTRACT TRUNCATED AT 250 WORDS)

Amputation, Surgical↗
PubMed1988

The effect of distal arterial anatomy on the success of popliteal aneurysm repair.

The success of bypass grafting for popliteal aneurysms may be compromised by the natural history of these lesions. During a 9-year period 35 patients had repair of 48 popliteal aneurysms. Elective repair was performed in 26 limbs and the remaining 22 limbs required urgent or emergent treatment after aneurysm thrombosis (16) or embolic digital ischemia (six). Retrospective review of preoperative and intraoperative arteriograms and CT or ultrasound scans was done to define the relationship of distal runoff anatomy to initial symptoms and long-term grafting success during a mean follow-up of 48 months. Only five of 48 limbs (10%) had three continuous tibial vessels and a patent pedal arch. Twenty-six limbs (55%) had one or no named calf vessels and 11 limbs had incomplete pedal arches. When thrombosis or symptomatic embolism occurred, the anatomy was significantly worse; 15 of 22 such limbs (68%) had one or no patent tibial vessels and seven had incomplete pedal arches. Nineteen of 28 aneurysms examined by CT or ultrasound scanning showed intraluminal thrombus. Eight of 13 patent aneurysms with intraluminal thrombus had one or no patent tibial vessels. The 5-year graft patency rate was 74% for the entire study group. Bypass for repair of asymptomatic aneurysms had a patency rate of 91% at 5 years vs 54% for symptomatic patients (p less than 0.05). Patients with popliteal aneurysms often have advanced tibial disease that appears worse in those with symptoms. The occurrence of a patent popliteal aneurysm with intraluminal thrombus and advanced runoff disease suggests that chronic microembolism may be an etiologic factor in the tibial disease observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1987

Technical defects as a cause of early graft failure after femorodistal bypass.

Technical defects threaten the early patency of infrainguinal bypass grafts. We reviewed 849 cases of femorodistal bypass to determine the incidence of technical graft failure, as well as other causes of early graft occlusion. The efficacy of adjunctive intraoperative arteriography was assessed. Early graft failure occurred in 62 (7.3%) cases and was due to technical defects in nine (14.5%) cases. Embolization caused early failure in six (9.7%) cases, coagulation disorders caused occlusion in ten (16.1%) cases, and failure was due to inadequate runoff in seven (11.3%) cases. No identifiable cause of graft thrombosis was found in 30 (48%) cases, but thrombectomy and empiric anticoagulation therapy salvaged 25 of these grafts. Intraoperative arteriography was very specific (98%) and moderately sensitive (76%) for the detection of technical defects in this series. Technical defects appear not to be the most common cause of early infrainguinal bypass graft failure and were found in only 1% of all cases reviewed. Critical attention must be given to other causes, such as emboli, and particularly to disorders of the host coagulation system that may threaten the success of the procedure.

Angiography↗
PubMed1987

The reoperative potential of infrainguinal bypass: long-term limb and patient survival.

The present study reviews the fate of patients undergoing reoperation after failure of infrainguinal bypass grafts. During a 10-year period, 202 patients with failed distal bypass grafts had 389 infrainguinal reoperative procedures, an average of 1.9 reoperations per patient. Including the initial procedure and subsequent reoperations, a total of 591 operations were performed in this group. Secondary bypass was performed in 101 patients, a tertiary procedure in 51, a fourth bypass in 30, and more than four operations were required in 20 patients. Reoperation was performed to treat severe ischemia (rest pain, ulceration, or gangrene) in 377 of 389 cases (97%). Repetitive bypass was performed with autogenous vein in 21 cases (7.4%), composite grafts in 16 patients (5.6%), and polytetrafluoroethylene in 247 cases (87%). The remaining 105 reoperations were thrombectomy in 77 cases, thrombectomy plus distal angioplasty in 20 cases, and profundaplasty in eight cases. The distal anastomosis was to the popliteal artery in 14% of reoperative cases and to the tibial or peroneal artery in 59%. Mean follow-up for all patients was 70 months. Four operative deaths occurred in 389 reoperations (1.0%), and there were 35 late deaths. The cumulative life-table 5-year survival rate for all patients was 80%. The operative morbidity rate was 12.3%, including wound infection in 3.1% and hematoma in 6.4%. Sixty-seven cases required major amputation, below-knee in 48 (72%) and above-knee in 19 (28%). The 5-year limb salvage rate was 59%. Cumulative graft patency was 37% at 5 years. The 80% 5-year survival rate may reflect aggressive management of associated carotid and coronary artery disease. The demonstrated long survival indicates that recurrent ischemia after distal bypass failure requires attention. In this study, re-operation provided long-term limb salvage in most cases without significant compromise in patient safety or amputation level if amputation was required.

Amputation, Surgical↗
PubMed1986

Descending thoracic aorta-to-femoral artery bypass.

Descending thoracic aorta-to-femoral artery grafts were placed in 13 patients who had abdominal aortas deemed undesirable for surgical treatment. These included seven patients in whom an infected aortic graft had been removed for primary graft infection (three) or aortoduodenal fistula (four). These patients had been treated initially with axillary-femoral grafts. In five other patients, this approach was used following failure of at least two previous aortofemoral grafts. The remaining patient was so treated following multiple complex abdominal operations. The surgical technique involves a posterolateral, seventh interspace thoracoabdominal incision with a transdiaphragmatic retroperitoneal tunnel to the left groin. There was no operative mortality. The mean follow-up of all patients was 22 months (range, one to 44 months). All grafts remained patent except one, which was removed because of ascending groin infection. Three patients died, at 24, 29, and 44 months postoperatively, respectively. Reasonable perioperative morbidity and reliable patency make this an attractive technique for the conversion of axillofemoral bypasses and, when reentry of the abdominal cavity is undesirable, laparotomy is avoided.

Aorta, Thoracic↗
PubMed1986

Popliteal aneurysm: a celebration of the bicentennial of John Hunter's operation.

Analysis of the original documents on Hunter's operation revealed that Hunter himself never realized the theoretical implications of his operation, particularly that collateral circulation could develop following ligation of the main arterial trunk of a limb. This operation, however, marks a monumental step in the history of vascular surgery. Even though supplanted only one century later by Matas' obliterating endoaneurysmorraphy, this technique became the first efficient means of managing popliteal aneurysms, the prognosis of which had been absolutely disastrous until that time, leading to either amputation or death in most cases.

Aneurysm↗