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Biomedical subjects

J J Ricotta

Publications and source records attributed to J J Ricotta.

At least 19 recordsLinked to original sources
PubMed1992

Surgical repair of a celiac axis aneurysm and renal oncocytoma: a single case report.

Visceral artery aneurysms are unusual lesions. However the frequency of diagnosis has increased in recent years as a result of increased utilization of arteriogram and computed tomographic (CT) scan. When diagnosed in conjunction with other syndromes, alternative treatment options can be utilized. The present case discusses a 67-year-old black male who presented with a right renal mass and celiac artery aneurysm. The renal mass was diagnosed as an oncocytoma. This unique anatomy enabled us to perform a right nephrectomy in conjunction with a celiac artery aneurysmectomy with primary anastomosis between the right renal artery and common hepatic artery. This case demonstrates our approach to an unusual problem.

Adenoma↗
PubMed1992

Donor iliac angioplasty and crossover femorofemoral bypass.

We reviewed our experience with 99 patients who had 111 femorofemoral bypass grafts placed over a 10-year period. Mean follow-up was 36 +/- 28 months (range: 1 to 120 months). Bypass alone was performed in 89 cases (group 1). Preoperative donor iliac angioplasty was utilized in 22 cases (group 2). Overall graft failure was 21 of 89 in group 1 and 2 of 22 in group 2 (difference was not significant by chi 2: p greater than 0.05). Clinical success as calculated by life-table analysis was 95%, 83%, 75%, and 67% at 1, 3, 5, and 7 years, respectively, for group 1. Clinical success was 100% and 91% at 1 and 3 years, respectively, and 91% at 42 months for group 2. The success rates were not different for the two groups when analyzed by the log-rank test at 42 months (p greater than 0.30). We conclude that donor iliac angioplasty and femorofemoral bypass is an excellent option for patients with severe occlusive disease of one iliac artery and contralateral disease amenable to angioplasty.

Anastomosis, Surgical↗
PubMed1992

Abnormalities in the biosynthesis of type III procollagen in cultured skin fibroblasts from two patients with multiple aneurysms.

We examined the synthesis of collagenous proteins by cultured skin fibroblasts taken from 14 patients with an abdominal aortic aneurysm and either an aneurysm at a second site (8 patients) or a first order relative with an abdominal aortic aneurysm (6 patients). Fibroblasts were labeled with [3H] proline and, following pepsin digestion of media proteins, the ratio of type I/III collagen was examined by denaturing polyacrylamide gel electrophoresis (SDS-PAGE). With the exception of two patients, the ratio of type I/III collagen in the media of fibroblasts from aneurysm patients was similar to control values (6 controls). In two of the patients, the type I/III collagen ratio was greater than 3 standard deviations from the mean of both control ratios and those of other aneurysm patients. mRNA levels coding for type III procollagen, however, were normal in both patients. Patient #1 (ME) showed reduced type III procollagen on SDS-PAGE analysis of intracellular proteins. Intracellular and media type III procollagen levels were normal in patient #2 (HR), but media type III collagen was reduced by over 50% after digestion with a combination of trypsin and alpha-chymotrypsin for 5 minutes at 36 degrees C. Control type III collagen was only reduced after digestion at 39 degrees C. These data suggest an altered thermal stability of the type III collagen trimer synthesized by this patient, probably due to a mutation in the amino acid sequence. The data presented in this paper suggest that some forms of common abdominal aortic aneurysms may be caused by mutations in the gene coding for type III procollagen.

Aged↗
PubMed1992

Natural history of recurrent and residual stenosis after carotid endarterectomy: implications for postoperative surveillance and surgical management.

BACKGROUND: Noninvasive surveillance of patients after carotid endarterectomy is practiced routinely to detect recurrent stenoses. Many authors advocate repair of asymptomatic severe stenoses so detected. The likelihood of these lesions causing neurologic symptoms is unknown. Our aims were to (1) define the incidence of lesions, (2) determine the frequency of associated neurologic symptoms, and (3) identify patient-dependent factors that might predict restenosis. METHODS: Data on the status of 449 carotid arteries after endarterectomy were reviewed. The number of recurrent and residual severe (greater than or equal to 80%) stenoses was identified. Interval to development of symptoms was determined by life-table analysis. Patient-dependent factors (age, gender, smoking, diabetes, and patch closure) were evaluated by univariate and multivariate analysis to identify possible associations with severe lesions. RESULTS: Severe (greater than or equal to 80%) stenoses were seen in 35 patients (7.9%). Residual lesions were seen in 17 cases (eight occlusions and nine stenoses); recurrent lesions were identified in 18 patients (3.9%). Symptoms developed in five cases (14%) (one residual and four recurrent) 35, 48, 68, 98, and 103 months after surgery. The likelihood of developing symptoms associated with stenosis at 5 years was 6%. No factors correlated with residual stenosis. Age less than 60 years, female gender, primary closure, and absence of diabetes were more common in patients with recurrent lesions. CONCLUSIONS: Severe lesions can be found after carotid endarterectomy in at least 8% of patients and consist of residual defects, as well as recurrent stenoses. Recurrent lesions are more common in specific patient subgroups. These lesions are stable for long periods and the majority remain asymptomatic. Operation is not indicated unless symptoms develop in these patients. Intraoperative completion evaluation may be indicated to reduce the incidence of residual disease. Early noninvasive evaluation is useful as a quality-control measure. Repeated surveillance may provide data on the course of restenosis or contralateral disease progression but is of limited clinical benefit.

Analysis of Variance↗
PubMed1992

Aneurysmal change at or above the proximal anastomosis after infrarenal aortic grafting.

We conducted a retrospective review of all patients undergoing repair of abdominal aortic aneurysm at or above the proximal anastomosis of a previous infrarenal aortic graft between 1986 and 1991. Infected grafts and patients with suprarenal aneurysms present at the time of the original graft were excluded. Twenty-one patients, 19 men and two women, were included. The original indication for surgery was aneurysm in 14 patients and occlusive disease in seven; the mean interval from initial surgery to presentation was 10 years (range, 3 to 23 years). Twelve lesions were anastomotic false aneurysms, and nine were true aneurysms beginning in the proximal juxta-anastomotic aorta. Fourteen patients had an asymptomatic abdominal mass. Seven patients had symptoms of acute expansion (three), rupture (three), or thrombosis (one). True aneurysm and symptomatic presentation were correlated with aneurysm as the original indication for surgery. Repair was accomplished by an interpositional graft in 13 and graft replacement in eight. Seven patients required suprarenal anastomosis or renal and visceral reconstruction. Five operative deaths (24%) occurred, including two of three patients with rupture (67%) and two of seven patients (28%) in the suprarenal group. The mortality rate for elective repair with an infrarenal anastomosis was 11%. Two additional late deaths occurred during the follow-up period.

Aged↗
PubMed1992

Late complications of revascularization for radiation-induced arterial disease.

During a 14-year period 23 patients underwent 25 revascularizations for radiation-induced arterial obstructive disease. An average of 5000 rads was delivered, 3 to 24 (mean 9) years before arterial insufficiency, for malignancies of the following origin: gynecologic (n = 9), lymphoma (n = 7), head and neck (n = 5), testicular (n = 1), and lower extremity sarcoma (n = 1). Arterial occlusive disease occurred in the aortic arch vessels (n = 8), visceral aortic vessels (n = 1), and aortofemoral vessels (n = 16). Presenting symptoms were claudication (n = 8), rest pain or nonhealing ulcers (n = 7), transient ischemic attacks (n = 6), asymptomatic bruit (n = 1), and renal insufficiency (n = 1). Reconstructive operations included anatomic bypass (n = 10), extra-anatomic bypass (n = 4), patch angioplasty (n = 5), endarterectomy (n = 3), and resection with interposition graft (n = 1). In this group of patients there were no major perioperative wound complications or other major radiation-associated morbidity. Five patients had late graft infections that manifested from 2 to 5 years after surgery. All occurred in anatomic regions where the bypass graft passed through previously irradiated tissues. Presenting symptoms of infection included a draining groin sinus (n = 3) or soft tissue abscess (n = 2). In all cases the graft had not incorporated into the surrounding tissues when passing through the irradiated area. Treatment included graft excision and extra-anatomic bypass through nonirradiated tissue. One patient died of systemic sepsis. Vascular reconstructive surgery can safely be performed for radiation-induced arterial disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Arterial Occlusive Diseases↗
PubMed1991

Surgical treatment of primary aortoduodenal fistula.

Primary aortoduodenal fistula is a rare and potentially fatal condition. Awareness of its existence, precise diagnostic evaluation, and early surgical intervention are essential for the survival of the patient. Although early experience indicated that interruption of the fistula, repair of the enteric defect, oversewing of the aorta and extraanatomic bypass was the procedure of choice, in situ aortic replacement with a prosthetic graft seems to be a viable option. This article includes a case report of a primary aortoduodenal fistula and review of the literature.

Aged↗
PubMed1991

Total excision and extra-anatomic bypass for aortic graft infection.

Reports of high mortality and amputation rates following total excision and extra-anatomic bypass for aortic graft infection have prompted the use of alternate approaches including local antibiotics, partial resection, in situ revascularization, and graft excision without revascularization. Experience with aortic graft infection was reviewed to establish current morbidity and mortality rates and evaluate our bias in favor of total excision and extra-anatomic bypass. Aortic graft infection was identified in 32 patients, 8 with aortoenteric fistulas. The mean interval between graft placement and infection was 34 months. History of groin exposure (75%) or multiple prior vascular surgery (50%) was common. Clinical signs included fever and/or leukocytosis (23 patients), false aneurysm (9 patients), graft thrombosis (6 patients), groin infection (11 patients), and gastrointestinal hemorrhage (6 patients). Microbiologic data, available in 26 patients, demonstrated gram-positive organisms in 15 patients and gram-negative in 9. Multiple organisms were seen in 11 patients. Patients were treated by partial removal with (8 patients) or without (4 patients) revascularization or total removal with (18 patients) or without (2 patients) revascularization. Revascularization was by an extra-anatomic route, either simultaneous or staged. Overall morbidity/mortality was less in the revascularized groups (p = 0.01), while late complications were seen only after partial removal (p less than 0.01). The best results were found after total excision with revascularization. No patient in this group experienced late infection or amputation during a mean follow-up of 34 months (range: 1 to 168 months). Complications after total excision and extra-anatomic bypass for aortic graft infection are lower than generally appreciated. This approach should remain the standard to which other approaches are compared.

Aged↗
PubMed1991

Use of duplex imaging to assess suitability of the internal mammary artery for coronary artery surgery.

The internal mammary artery is the preferred conduit for coronary artery surgery. To determine the role, if any, of preoperative duplex imaging in assessing the suitability of this vessel, preoperative noninvasive measurements of internal mammary artery diameter and blood flow were performed in 243 patients. The left internal mammary artery was insonated through the third intercostal space by use of duplex scanner (5.0 MHz probe) before coronary artery surgery. Internal mammary artery diameter (millimeters), peak systolic velocity (centimeters/second), and mean velocity (centimeters/second) were measured, and internal mammary artery flow was calculated from velocity and cross-sectional area. In 45 of these patients the internal mammary artery diameter also was measured during surgery with a sterile caliper, and blood was collected for 30 seconds from the transected internal mammary artery to measure flow. These findings were compared to the preoperative values. In 243 patients the mean internal mammary artery diameter was 2.34 +/- 0.03 mm, and mean peak systolic blood flow was 226.7 +/- 6.3 ml/min. In the 45 patients in whom intraoperative measurements were obtained, preoperative mean internal mammary artery diameter was 2.39 +/- 0.05 mm and was not significantly different from the intraoperative mean internal mammary artery diameter of 2.36 +/- 0.04 mm. Preoperative peak systolic flow was 231.3 +/- 8.1 ml/min, and mean flow was 110.3 +/- 7.1 ml/min; intraoperative flow measured 136 +/- 3.6 ml/min. Noninvasive determinations correlated with operative findings for internal mammary artery diameter (r = 0.87) (p less than 0.05), peak systolic blood flow (r = 0.70) (p less than 0.05), and mean blood flow (r = 0.60) (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1991

Conserving resources after carotid endarterectomy: selective use of the intensive care unit.

A retrospective review was undertaken of a random sample (N = 73) comprising 50% of carotid endarterectomies performed during 1986 to evaluate the necessity of routine postoperative intensive care unit (ICU) admission after carotid endarterectomy. Severity of illness was determined with use of the Acute Physiology Score of the APACHE II system. The Therapeutic Index Scoring System was used to quantify postoperative services used. Postoperative morbidity was analyzed. Financial impact was extrapolated with use of 1990 billing data. Length of ICU stay was 24.5 hours. Only 13 of 73 patients (18%) required ICU services. In 10 (77%) of these patients therapy was initiated in the recovery room and discontinued in six patients within 3 hours of ICU admission. Only two patients required ICU services for 16 hours after surgery. The mean Acute Physiology Score was low (4.96) and could not identify patients who required unique ICU services. Neurologic deficits were seen in five patients (6.9%). In three cases deficits were recognized in the recovery room; deficits developed in two patients after discharge from the ICU. Observation in the recovery room with transfer of stable patients would have eliminated ICU admission in 60 patients (82%). In 1990 the incremental ICU charge was $720/patient day. This represents 12.5% of the hospital charges for carotid endarterectomy. The ICU is an expensive and highly used hospital resource. Only a few patients need unique ICU services after carotid endarterectomy, and this is usually apparent within 2 hours of surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1991

Ruptured abdominal aortic aneurysms: factors affecting mortality rates.

Outcome of 113 operations for ruptured abdominal aortic aneurysms were reviewed to determine the contribution of perioperative events to mortality rates. Preoperative, intraoperative, and postoperative factors were examined with regard to their influence on early and late deaths. A mortality rate of 64% (72/113) was unrelated to age, gender, and preexistent medical conditions. Death within 48 hours occurred in 42 of 72 patients (58%). Preoperative status, including cardiac arrest, loss of consciousness, and acidosis influenced early deaths (less than 48 hours) but not late deaths. Early deaths were also influenced by severe operative hypotension and excessive transfusion requirements. Late deaths (greater than 48 hours) occurred in 30/72 cases (42%) at a mean of 24.6 +/- 22.9 days. Late death was related to postoperative organ system failure, specifically renal and respiratory failure, and the need for reoperation. The overall mortality rate was influenced by preoperative, intraoperative, and postoperative factors. Postoperative renal failure was the strongest predictor of overall deaths. Survival after ruptured abdominal aortic aneurysm depends on intraoperative and postoperative complications as well as preoperative conditions. Late death, the greatest strain on resources, is independent of preoperative status. The thesis that some patients with ruptured abdominal aortic aneurysm should be denied operation to conserve resources is not supported by these data. Efforts to improve survival should focus on reducing intraoperative complications and improving management of postoperative organ failure.

Aged↗
PubMed1990

Seizures following carotid endarterectomy.

Cerebral infarction, headache, and hypertension are well-known complications of carotid endarectomy (CEA). Seizures are a less frequent, but important complication. We describe eight patients with focal and generalized seizures following CEA. Seizures occurred 6 to 13 days after CEA. All began as focal motor seizures contralateral to the side of the CEA, and six patients developed generalized tonoclonic seizures. Lorazepam and phenytoin sodium controlled the seizures. Five patients without evidence of stroke on computed tomographic scan were normal in follow-up and had no further seizures. The other three patients had mild deficits. One developed a chronic seizure disorder. The pathogenesis of this syndrome following CEA remains unclear, but may involve cerebral hyperperfusion, cerebral embolization, or both.

Aged↗
PubMed1990

Plaque characterization by B-mode scan.

High-resolution ultrasound technology provides anatomic information on the nature of the vessel wall. As such, it is a complementary modality to both frequency analysis, which provides flow data, and angiography, which describes vessel lumen. At present, the technology is most effectively applied to superficial vessels such as the carotid, common femoral, and popliteal arteries. Measurement can be compromised by heavy vessel calcification, and the technique is most useful in mild to moderate disease. Prospective blinded trials have shown that HRUS can be used to determine lumen diameter and per cent stenosis, although its accuracy is improved by adding frequency analysis. The technique is most useful for interrogating the atherosclerotic plaque itself; as such, it appears superior to angiographic techniques. Several investigators have documented the ability of HRUS to characterize plaque and particularly to identify intraplaque hemorrhage and ulceration. Criteria for diagnosis remain difficult to standardize and, for the moment, must be developed for each center involved in these studies. The future of HRUS appears to lie in development of more detailed analyses of plaque morphology and the study of atherosclerotic disease in large populations over time.

Arteriosclerosis↗
PubMed1990

The role of carotid screening before coronary artery bypass.

Five hundred thirty-nine patients with no symptoms of cerebral ischemia undergoing coronary artery bypass were preoperatively evaluated for presence of carotid stenosis by noninvasive methods (duplex scanning and ocular pneumoplethysmography-Gee). Overall prevalence of carotid stenosis greater than 75% was higher (8.7%) than that generally reported. Age greater than 60 years was significantly related to presence of carotid stenosis greater than 75% (11.3% vs 3.8%, p = 0.003). Risk factors such as hypercholesterolemia, hypertension, diabetes mellitus, and smoking were not predictive for carotid stenosis, postoperative stroke, or death. Carotid stenosis greater than 75% (odds ratio 9.87, p less than 0.005) and coronary artery bypass redo (odds ratio 5.26, p less than 0.05) were both independent predictors of stroke risk. Patients were divided into four groups: group 1, minimal or mild degree of carotid stenosis (less than 50%), not submitted to prophylactic carotid endarterectomy (432 patients, 80.1%); group 2, moderate degree of stenosis (50% to 75%), no prophylactic carotid endarterectomy (60 patients, 11.2%); group 3, severe carotid stenosis; (greater than 75%), submitted to prophylactic carotid endarterectomy (19 patients, 3.5%), group 4, severe carotid stenosis (greater than 75%) no prophylactic carotid endarterectomy (28 patients, 5.2%). Patients in group 4 had significantly higher stroke rate (14.3%) compared to the other three groups (1.1%) (p = 0.0019). The finding of carotid stenosis greater than 75% in patients over 60 years of age was associated with occurrence of stroke in 15% of cases. Carotid screening is helpful to determine patients at increased risk of stroke and should be performed in patients greater than 60 years.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1989

Influence of cadaveric organ source on delayed renal allograft function.

From 1984 to 1987, 110 locally retrieved cadaveric kidneys were transplanted into 108 local recipients, including 50 kidneys from multiple-organ retrieval (MOR) procedures and 60 from kidney-only (KO) donors. Conventional multiple organ retrieval technique, iced Euro-Collins storage, and cyclosporine-prednisone immunosuppression were employed. Delayed graft function (DGF), defined as dialysis dependence after transplantation, was twice as high in the MOR allografts as in the KO allografts, 46% vs. 22%, P less than 0.01. DGF was associated with longer hospitalization postoperatively and reduced eventual allograft function. The greater concordance of DGF in allograft pairs from the MOR group (25% vs. 7% in the KO group) and the increased incidence of DGF when more complex forms of MOR were used (40% with liver or heart retrieval, 55% with liver and heart retrieval) suggested that retrieval-related factors influenced allograft function. DGF in the MOR allografts was unrelated to other differences in donor, preservation, or recipient characteristics in the comparative groups. Unrecognized warm ischemia during conventional MOR is a plausible cause of DGF in kidneys from multiple-organ donors.

Adult↗
PubMed1989

Risk factors in a community experience with carotid endarterectomy.

Experience with 1035 carotid endarterectomies in a single community over a 2-year period was analyzed. Twenty-two surgeons working in six hospitals were involved. All surgeons had full-time or part-time appointments at the University of Rochester, 18 had special interest in vascular surgery, and eight had obtained a certificate of qualification in vascular surgery. Mortality rate was 1.4% (14 deaths), with additional permanent, nonfatal, neurologic morbidity of 3.4%. Mortality and morbidity were independent of surgeon, caseload, or hospital. Age and prior history of myocardial infarction influenced the incidence of postoperative myocardial infarction but not the incidence of death or neurologic morbidity. Factors that increased the risk of postoperative death or neurologic complication included hypertension; contralateral carotid disease as manifested by stroke, endarterectomy, or occlusion; whether the patient was a woman; and symptoms of crescendo ischemia. Lack of preoperative neurologic symptoms was correlated with decreased risk of myocardial infarction and neurologic complications. Overall mortality and neurologic morbidity associated with operation for "asymptomatic stenosis" was 3.1% (seven of 222 cases). However, the incidence of contralateral carotid disease was high in the patients in the asymptomatic group (60%), and all complications in this group occurred in patients with prior contralateral carotid endarterectomy or occlusion (p less than 0.05).

Adult↗
PubMed1989

Reexploration for thrombosis in carotid endarterectomy.

We reviewed the records of patients undergoing carotid endarterectomy and manifesting either postoperative stroke or thrombosis by oculopneumoplethysmography (OPG-Gee) to analyze the etiology of stroke and to determine the indications for reexploration. Of 900 consecutive elective endarterectomies performed during an 8-year period, 41 patients experienced a perioperative stroke, carotid thrombosis, or both. These patients were subdivided into three groups: group 1, 22 patients with perioperative stroke and carotid thrombosis; group 2, six patients with carotid thrombosis but without symptoms; and group 3, 13 patients with postoperative stroke but no thrombosis. In group 1, 17 patients were reexplored (group 1a), and five were observed without reexploration (group 1b). In group 2, three of the patients were reexplored (group 2a), and the remaining three were observed (group 2b). None of the group 3 patients were reexplored. In group 1a, four (23%) patients awoke from anesthesia with neurological deficits, whereas in group 3, nine (69%) patients awoke with such deficits. Follow-up at 30 days revealed that 76% of group 1a patients demonstrated improvement in symptoms, whereas similar results were seen in only 20% of group 1b patients and 23% of group 3 patients. These trends were maintained throughout the follow-up period of 1-5 years. Those patients who were asymptomatic, group 2, with thrombosis were more likely to have been operated on for asymptomatic carotid stenosis. with thrombosis were more likely to have been operated on for asymptomatic carotid stenosis. Thrombosis was the most common cause of postoperative stroke (63%) in patients after carotid endarterectomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗