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Biomedical subjects

J P Boland

Publications and source records attributed to J P Boland.

At least 19 recordsLinked to original sources
PubMed1997

Comparison of saruplase and alteplase in acute myocardial infarction. SESAM Study Group. The Study in Europe with Saruplase and Alteplase in Myocardial Infarction.

Four hundred seventy-three patients with acute myocardial infarction (AMI) were treated with either saruplase (80 mg/hour, n = 236) or alteplase (100 mg every 3 hours, n = 237). Comedication included heparin and acetylsalicylic acid. Angiography was performed at 45 and 60 minutes after the start of thrombolytic therapy. When flow was insufficient, angiography was repeated at 90 minutes. Coronary angioplasty was then performed if Thrombolysis In Myocardial Infarction (TIMI) trial 0 to 1 flow was seen. Control angiography was at 24 to 40 hours. Baseline characteristics were similar. Angiography showed comparable and remarkably high early patency rates (TIMI 2 or 3 flow) in both treatment groups: at 45 minutes, 74.6% versus 68.9% (p = 0.22); and at 60 minutes 79.9% versus 75.3% (p = 0.26). Patency rates at 90 minutes before additional interventions were also comparable (79.9% and 81.4%). Angiographic reocclusion rates were not significantly different: 1.2% versus 2.4% (p = 0.68). After rescue angioplasty, angiographic reocclusion rates of 22.0% and 15.0% were observed. Safety data were similar for both groups. Thus, (1) early patency rates were high for saruplase and alteplase treatment, (2) reocclusion rates for both drugs were remarkably low, and (3) complication rates were similar. Thus, saruplase seems to be as safe and effective as alteplase.

Aged↗
PubMed1997

Role of venous duplex imaging of the lower extremities in patients with fever of unknown origin.

BACKGROUND: Although a fever of unknown origin (FUO) is most often due to other causes, the few caused by pulmonary emboli, pelvic thrombophlebitis, or lower extremity venous thrombosis (DVT) present a diagnostic challenge. The purpose of this study was to evaluate the role of venous duplex imaging of the lower extremity in evaluating a large series of patients with FUO. This has not been reported previously in the English-language literature. METHODS: Medical records were analyzed of patients with FUO who were referred to the vascular laboratory for venous duplex imaging of the lower extremities to rule out DVT as a cause of their fever. A FUO was defined as a temperature of greater than 38.3 degrees C on several occasions for at least 3 weeks' duration that defied 1 week of hospital evaluation. DVT was considered as a probable cause of FUO if the following criteria were met: (1) a positive venous duplex image for acute DVT, (2) subsequent fever resolution within 7 days of anticoagulation therapy, and (3) a fever that was resistant to prior treatment. RESULTS: A total of 114 duplex examinations, gathered during a 2-year period, were analyzed. The 89 patients had a mean age of 58 years. Infections were the most common cause of FUO (57 of 89, 64%), and unknown causes constituted 19%. There were seven cases of DVT (8%), five (6%) of whom met the criteria for probable cause of FUO. The overall cost of venous duplex imaging examinations was $51,300 ($450 x 114 tests), with an average cost of $10,260 for each case of DVT detected as probable cause of FUO. CONCLUSIONS: Consistent with the literature, infections remain the most common cause of FUO; however, DVT was found to be a more common cause of FUO in our present series (6%). The cost of venous duplex imaging of the lower extremities in establishing DVT as a probable cause of FUO should be borne in mind when the work-up of these patients is planned.

Adult↗
PubMed1996

Corotid endarterectomy for symptomatic carotid artery disease demonstrated by duplex ultrasound with minimal arteriographic findings.

Ulcerated or irregular heterogeneous carotid plaque as seen by duplex ultrasound can cause hemispheric transient ischemic attacks (TIAs) and/or a cerebrovascular accident, even if only associated with nonsignificant carotid stenosis on arteriography. The purpose of this study was to review our experience in patients who underwent a carotid endarterectomy after medical treatment had failed, based on pathologic findings detected by carotid duplex ultrasound with minimal disease on arteriography. The medical records of 14 patients who underwent carotid endarterectomy for TIA symptoms related to ulcerated or irregular heterogeneous plaques were analyzed. All had had preoperative carotid duplex ultrasound, arteriography, and cardiac and neurologic workups to rule out other causes for their TIAs. Medical treatment had failed in all of them. There were 10 men and four women whose median age was 68 years. Carotid duplex ultrasound showed irregular heterogeneous carotid plaque in all patients associated with 20% to 50% stenosis in 12 and approximately 50% to 60% stenosis in two. All had normal to < 20% stenosis on arteriograms. The duplex ultrasound findings were all confirmed at operation. All had an uneventful postoperative course with relief of symptoms. Carotid duplex ultrasound is superior to carotid arteriography in detecting irregular or ulcerative heterogeneous plaque associated with nonsignificant stenosis. Carotid duplex ultrasound can be used to determine the desirability of carotid endarterectomy after failed medical treatment in patients with classical and persistent TIA symptoms despite normal or minimal disease on arteriograms. A successful endarterectomy appears to predict an asymptomatic postoperative course.

Aged↗
PubMed1996

Prospective randomized trial of carotid endarterectomy with primary closure and patch angioplasty with saphenous vein, jugular vein, and polytetrafluoroethylene: perioperative (30-day) results.

PURPOSE: The early outcomes of carotid endarterectomy (CEA) with primary closure (PC) versus vein patch closure (saphenous vein [SVP] and jugular vein [JVP]) and polytetrafluoroethylene patch closure (PTFE-PC) were compared. METHODS: Three hundred ninety-nine CEAs were randomized into the following groups: 135 PC, 134 PTFE-PC, and 130 vein patch closure (SVP alternating with JVP). Surviving patients underwent a carotid color duplex ultrasonographic scan 1 month after surgery. Demographic characteristics were similar in all groups. RESULTS: The incidence of perioperative cerebrovascular accidents (CVAs) was 4.4% for PC, 0.8% for PTFE-PC, and 0% for vein patch closure (PC vs vein patch, p = 0.0165; PC vs all patching [vein and PTFE], p = 0.007). The perioperative CVA and reversible ischemic neurologic deficit (RIND) combined rates for all patching were superior to PC (1.5% vs 5.2%; p = 0.04). These combined rates were also superior for vein patch closure when compared with PC (0.8% vs 5.2%; p = 0.037). The mean diameter of the internal carotid artery was similar in patients who had perioperative neurologic deficits and those who did not. After 1 month of follow-up, 11.9% of the PC arteries were narrowed 50% or more in contrast to 2.3% for PTFE-PC, 3.1% for SVP, and 10.3% for JVP.

Aged↗
PubMed1996

Treatment alternatives for axillary-subclavian vein thrombosis: long-term follow-up.

Spontaneous axillary-subclavian vein thrombosis in young patients produces long-term disability. Patients with secondary axillary-subclavian vein thrombosis usually require prolonged venous catheterization for chemotherapy or pacemaking. This study aimed to compare the early and late results of lytic versus anticoagulant therapy in the treatment of axillary-subclavian vein thrombosis, both spontaneous and secondary to central venous cannulation. Nine patients underwent conventional treatment (heparin and warfarin) (group 1), and 10 had initial lytic therapy followed by heparin and warfarin (group 2). Three patients had cervical or first rib resection. Thirteen patients had spontaneous thrombosis and six were secondary to central venous catheterization. The mean follow-up was 36 months. Two of nine patients (22%) in group 1 and eight of 10 patients (80%) in group 2 had total venous recanalization and symptom resolution (P = 0.018). In the spontaneous axillary-subclavian vein thrombosis subset, one of six patients (17%) in group 1 and five of seven patients (71%) in group 2 had total venous recanalization and symptom resolution (P = 0.078). The average difference in cost per patient between groups 1 and 2 was $19,039. In conclusion, lytic therapy appears superior to anticoagulation in the treatment of axillary-subclavian vein thrombosis. However, such treatment is more expensive and its benefits should be carefully weighed against the cost in each case.

Adult↗
PubMed1995

Cross-filling of circle of Willis and carotid stenosis by angiography, duplex ultrasound, and oculopneumoplethysmography.

PURPOSE: To evaluate the filling of the Circle of Willis on preoperative arteriograms and to correlate this observation with the results of oculopneumoplethysmography (OPG) and severity of carotid stenosis as determined by duplex ultrasonography and angiography. PATIENTS AND METHODS: Ninety-five patients underwent OPG, duplex ultrasonography, and selective carotid and vertebral arteriography. RESULTS: In all, 45 (88%) patients with a positive OPG had interhemispheric cross-filling of the middle cerebral artery and anterior cerebral artery from a contralateral carotid injection in contrast with 10 (23%) patients with a negative OPG (P < 0.001). Of patients with carotid stenosis > or = 80% on duplex ultrasound, 39 (91%) had cross-filling from a contralateral carotid injection in contrast with 16 (31%) patients with < 80% stenosis (P < 0.001). Of patients with carotid stenosis > or = 80% on arteriogram, 37 (90%) had cross-filling from a contralateral carotid injection in contrast with 18 (33%) patients with < 80% stenosis (P < 0.001). CONCLUSION: These data suggest that the Circle of Willis is frequently incompetent as a collateral pathway and that arteriographic cross-filling is not a reliable index of this pathway. Patients with a positive OPG and corresponding carotid stenosis are likely to have a physiologically incompetent collateral pathway. Perhaps these patients should undergo surgery, even if the stenosis is less than 80%.

Adult↗
PubMed1995

A case study of abdominal angina secondary to celiac compression syndrome.

Celiac compression syndrome occurs when the median arcuate ligament of the diaphragm and/or periarterial neural tissue causes extrinsic compression of the celiac axis. In rare cases, this syndrome can cause upper abdominal angina. The classic triad of celiac compression syndrome consists of abdominal pain, an epigastric bruit, and angiographic evidence of celiac compression. Operative therapy consists of thorough exploration, transection of the median arcuate ligament, and either celiac dilatation or a bypass. This article describes a case of celiac compression syndrome which was treated successfully by transection of the median arcuate ligament and aortosplenic bypass.

Abdominal Pain↗
PubMed1995

Hand-assisted laparoscopic splenectomy.

A method of performing a laparoscopic splenectomy with the aide of intraabdominal manipulation is described. We believe that this is a versatile technique that compares quite favorably with a pure cannula approach. It is likely that this approach is safer because vascular control can readily be assured by the intraabdominal operator. It is also less costly because it is more rapid than a procedure done solely by cannula techniques. Moreover, it is reproducible by an experienced general surgeon. The results appear equal in terms of access morbidity and hospitalization time to those seen with a purely laparoscopic approach. Experience with 21 splenectomies is described and compared with 20 others performed by the traditional open approach.

Adult↗
PubMed1994

Sympathectomy for reflex sympathetic dystrophy: factors affecting outcome.

This study includes our 12-year experience with chemical sympathetic blocks and surgical sympathectomies for causalgic pain of reflex sympathetic dystrophy (RSD) with emphasis on factors affecting clinical outcome. Medical records of patients undergoing sympathectomies for causalgic pain were analyzed. The patients were classified according to Drucker et al. as stage I, II, or III. Results of chemical and surgical sympathectomies were analyzed using both univariate and multivariate methods. Twenty-one patients had lumbar and seven had cervicodorsal sympathectomies for RSD. The mean duration between initial injury and chemical sympathetic block was 10 months with a mean of 11.4 months to surgical sympathectomy. Ten patients (36%) had overt extremity trauma as the precipitating event. Ten patients (36%) had a lumbar laminectomy, three of whom developed the syndrome bilaterally. There was no operative mortality; however, 25% had transient postoperative sympathetic neuralgia. The early and late (> 6 months) satisfactory outcomes after surgical sympathectomy were 82% and 71%, respectively. Patients with stage II presentations were significantly more likely to have satisfactory early (92%) and late (79%) outcomes than stage III patients, 0% and 0% (p = 0.019). Patients with an excellent response to chemical sympathetic block were more likely to have satisfactory early and late surgical outcomes. The time between injury and chemical block and surgical sympathectomy was significantly shorter in patients who had satisfactory early and late surgical outcomes (p < 0.0001). Multivariate analyses demonstrated that the most important independent factor in determining early and late satisfactory outcomes of sympathectomy was the time between injury and sympathectomy (p = 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1994

Laparoscopic staging laparotomy with intra-abdominal manipulation.

We describe a method for performing laparoscopic staging laparotomy. We believe this minimally invasive approach can ease the transition between purely open and laparoscopic surgery, and it is applicable to a variety of intra-abdominal problems. The results are comparable to those of a standard staging laparotomy, with improvement in access morbidity and decreased hospitalization time.

Abdomen↗
PubMed1993

Polytetrafluoroethylene grafts in infrainguinal arterial revascularization. Factors affecting outcome.

One hundred thirty-seven polytetrafluoroethylene infrainguinal bypass grafts were performed over 2 years. The results were analyzed using univariate and multivariate analyses. Our operative mortality was 3.2% and the post-operative amputation rate was 5.8%. Forty-eight reconstructions were done for claudication, with a 5-year secondary patency rate of 64%, no early amputations, and a 2.9% (one limb) late amputation rate. Sixty-six reconstructions were done for rest pain with a 5-year secondary patency rate of 58% and a 3-year limb salvage rate of 77%. The 5-year secondary patency rate for 23 patients with trophic changes was 30%, and the 3-year limb salvage rate was 71%. Multivariate analysis identified the ankle-brachial index as the most important independent factor predicting both primary and secondary graft patency. The cumulative primary and secondary patency rates for patients with an ankle-brachial index of less than 0.5 at 78 months was 37% and 46%, respectively; and 57% and 68%, respectively for patients with an ankle-brachial index of 0.5 or more.

Adult↗
PubMed1993

Therapeutic and prophylactic vena caval interruption for pulmonary embolism: caval and venous insertion site patency.

Although anticoagulation remains the treatment of choice for acute pulmonary embolism, vena caval interruption represents an alternative for patients with contraindications and complications or in whom anticoagulation fails. The purpose of this study was to evaluate the effectiveness and safety of two types of caval interruption devices: the original stainless steel Greenfield filter and the Adams-DeWeese clip. Emphasis has been placed on maintaining caval patency with filters and clips and the patency of the femoral vein vs. the jugular vein after filter insertion. We retrospectively reviewed 161 patients who underwent caval interruption (92 filters and 69 clips) for both therapeutic and prophylactic reasons. The operative mortality and morbidity rates were 0% and 3.3% for filter patients and 8.7% and 2.9% for clip patients; no procedure-related mortalities occurred. The late caval patency rate as documented by duplex ultrasonography/venography was 100% for filter patients and 88% for clip patients (p = 0.011). Seven percent of the filter patients and 20% of the clip patients experienced late limb swelling postoperatively (p = 0.05). The incidence of recurrent late pulmonary embolism was 2.5% in the filter group and 1.9% in the clip group. In the filter group, 10% of patients experienced postoperative thrombosis at the femoral vein insertion site and 0% at the jugular vein insertion site. We found that both devices were effective in preventing pulmonary embolism, the filter provided better caval patency than the clip, and the jugular vein had a better patency than the femoral vein after filter insertion.

Adult↗
PubMed1993

Complications of arteriography in a recent series of 707 cases: factors affecting outcome.

Seven hundred and seven consecutive arteriograms were analyzed regarding the effects of various factors on clinical outcome. Complication rates were assessed regarding age, inpatient or outpatient procedures, operator caseload, clinical indication, preoperative renal disease, approach site, graft puncture, selective injection of arteries, amount of contrast, and catheterization time. The major complication rate for arteriography was 7% and the mortality rate was 0.7%. The complication rates for femoral and axillary approaches, respectively, were local, 9% and 27%; nervous system, 1.4% and 11%; and major, 6% and 24% (p = 0.0075, p < 0.0001, and p < 0.0001, respectively). Brachial plexus injury was noted in 13% of the patients undergoing the axillary approach. There was a trend toward a higher overall complication rate in four-vessel arch aortograms with selective vs. nonselective carotid injections, but both had similar neurologic complications. More contrast was used in patients with post-arteriogram renal failure, 224 ml vs. 168 ml. The complication rates were directly related to catheterization time, amount of contrast, and number of vessels punctured. There was a trend toward a higher complication rate in physicians with a lower caseload. In conclusion, arteriography is still associated with significant morbidity and mortality. The transfemoral approach is safer than the transaxillary route, even in patients with femoral graft punctures.

Aged↗
PubMed1993

Management of deep vein thrombosis of the lower extremity in pregnancy.

Deep vein thrombosis (DVT) of the lower extremity during pregnancy is infrequent, but its complication, pulmonary embolism, remains an important cause of maternal mortality. To evaluate the best method of caring for patients with DVT, we reviewed the records of patients at the Charleston Area Medical Center from 1987-1992 who were treated for this condition. Twelve patients were treated with conventional continuous intravenous heparin for 7 days-10 days followed by subcutaneous heparin until 6 weeks-8 weeks after delivery. The other group consisted of nine patients who were treated with lower dose subcutaneous heparin for 7 days-10 days and maintained as the first group, but a Greenfield filter was inserted for patients with iliofemoral DVT. The patients who received low-dose heparin and Greenfield filters tended to do better than those who received high-dose conventional heparin treatment. However, since there were so few patients evaluated, further verification is needed.

Adult↗
PubMed1993

Feeding gastrostomy: a critical review of its indications and mortality rate.

Gastrostomy can be a valuable adjunct to patient care, and percutaneous endoscopic gastrostomy is often considered the method of choice for gastrostomy placement. As with all surgical procedures, however, patient selection is important no matter how the gastrostomy is placed. In a retrospective review of 125 randomly selected patients having gastrostomy tube placement, there were certain groups of patients who received virtually no benefit from gastrostomy and may even have died sooner due to gastrostomy placement. The leading indication for gastrostomy placement was neurologic debilitation; the procedural mortality rate for these patients was 28%. However, patients with pulmonary cachexia or metastatic cachexia had much higher mortality rates: 90% and 37%, respectively. We believe patient selection has been imperfect and that certain patients should not have a gastrostomy tube. These patients suffer the moral indignation of persistent intervention and often die without receiving any real benefit.

Adolescent↗
PubMed1992

Adjunctive intraoperative linear extrusion (Fogarty-Chin) balloon angioplasty.

Eighty-nine patients with 94 stenotic segments (mostly iliac or femoral) underwent balloon angioplasty with the first-generation (no guidewire) linear extrusion (Fogarty-Chin) system, in an adjunctive mode, and the overall long-term patency rate (mean follow-up: 21 months) was 81%. Patients were grouped into those having iliac or superficial femoral artery (SFA) lesions and subdivided according to the length of lesions. The overall primary and late success rates for iliac lesions were 95% and 86%, respectively, and for SFA lesions 91% and 76%, respectively. The primary and late success rates for iliac lesions less than 2 cm were 100% and 96%, respectively, and for iliac lesions 2 cm to less than 5 cm 92% and 80%, respectively. The primary and late success rates for SFA lesions less than 2 cm were 100% and 100%, respectively; for lesions 2 cm to less than 5 cm 100% and 83%, respectively; and for lesions 5 to 10 cm 83% and 67%, respectively. A stratified analysis by vessel and segment length reveals that, in SFA lesions with a segment length greater than 5 cm, there is a significantly lower patency rate (67%) when compared with the combined results of the Fogarty-Chin balloon angioplasty system in iliac and femoral artery lesions less than 5 cm (92%). In comparing the composite results presented in a recent text on endovascular surgery by Moore and Ahn as the base data for the standard coaxial (Gruntzig) balloon system, our results (short and long term) are similar.

Aged↗