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Biomedical subjects

J W Joyce

Publications and source records attributed to J W Joyce.

At least 19 recordsLinked to original sources
PubMed1994

Selection and preparation of high-risk patients for repair of abdominal aortic aneurysms.

OBJECTIVE: To discuss the most important risk factors in patients who undergo surgical repair of an abdominal aortic aneurysm (AAA). DESIGN: This update in vascular surgical repair highlights the criteria that identify high-risk patients, the useful preoperative tests, and the perioperative measures that can aid surgical recovery. MATERIAL AND METHODS: In elective repair of AAAs, high-risk patients are those with severe coronary or valvular heart disease, decompensated chronic obstructive pulmonary disease, severe cerebrovascular disease, chronic renal failure, hepatic cirrhosis with portal hypertension, and chronic hematologic disorders associated with bleeding dysfunction. Patients with unstable or severely symptomatic heart disease should undergo preoperative coronary angiography and ventriculography. Pharmacologic stress testing is recommended for patients with clinical markers of serious coronary artery disease and other medical or physical factors that prevent any type of standard exercise stress testing. RESULTS: Our experience with high-risk patients supports conventional repair of AAAs. Our preference for the midline abdominal incision in high-risk patients is substantiated by an operative mortality rate of 5.7% in comparison with a reported 7% mortality rate for nonresective therapy. Approximately one in three high-risk patients will have a serious postoperative complication, the most common of which is a cardiac event. Most patients recover after a slightly prolonged hospital stay. CONCLUSION: Despite an increased operative risk, patients with a stable medical condition and an AAA larger than 6 cm in diameter should be considered for elective repair. High-risk patients with smaller aneurysms (5 to 6 cm in diameter) should undergo efforts to stabilize or to improve their general medical condition before elective operation.

Aged↗
PubMed1994

Diagnosis of acute deep venous thrombosis of the lower extremities: prospective evaluation of color Doppler flow imaging versus venography.

PURPOSE: To determine the value of color Doppler flow imaging in identification of deep venous thrombosis (DVT) of the femoropopliteal system without use of venous compression. MATERIALS AND METHODS: Color Doppler flow imaging was compared with venography in 103 lower extremities in 101 patients. Results of each examination were recorded as positive or negative for acute DVT or consistent with chronic DVT. RESULTS: Color Doppler flow imaging in 97 of 103 cases had a sensitivity of 95%, specificity of 99%, positive and negative predictive values of 95% and 99%, respectively, and accuracy of 98% in detection of acute DVT and was also helpful in differentiation of chronic from acute DVT. Color Doppler flow imaging prospectively identified six of eight patients with chronic DVT and correctly identified acute DVT in two patients with underlying chronic DVT. No results were false-positive for acute DVT in a patient with chronic DVT. CONCLUSION: Color Doppler flow imaging is complementary to compression ultrasonography in evaluation of suspected acute DVT and may be helpful in evaluation of suspected DVT in patients with previous or chronic DVT.

Acute Disease↗
PubMed1993

Clinical features and differential diagnosis of aortic dissection: experience with 236 cases (1980 through 1990).

Acute aortic dissection is the most common fatal condition that involves the aorta; nevertheless, despite major advances in noninvasive diagnosis, the correct antemortem diagnosis is made in less than half the cases. To promote continued improvement in the prompt recognition of aortic dissection, we present a review of the Mayo Clinic experience with 235 patients who had 236 substantiated aortic dissections. At the time of initial assessment, 158 patients (67%) had acute and 78 patients (33%) had chronic aortic dissection. Hypertension was the most common predisposing factor (78% of patients overall). The acute onset of severe chest pain was the most common initial complaint (74%), but 33 patients (15%) had painless aortic dissection and abnormal chest roentgenographic findings. Less common manifestations included congestive heart failure, syncope, cerebrovascular accident, shock, paraplegia, and lower extremity ischemia. The initial clinical impression was aortic dissection in 62% of patients overall. In 17 patients (28%), the correct diagnosis was not made before postmortem examination. Although the clinical features of aortic dissection have gained wider appreciation, the diagnosis still remains unsuspected in a substantial number of patients. In a patient who has a catastrophic illness and unexplained symptoms that could be of vascular origin, especially in the presence of chest pain, aortic dissection should always be included in the differential diagnosis.

Acute Disease↗
PubMed1992

Occlusive arterial disease of the upper extremity.

Occlusive and aneurysmal diseases of the large vessels of the upper extremity are uncommon experiences in most practices. Yet, by utilizing basic principles learned in the lower extremity that emphasize proper historic and physical examination, and by the selective use of angiography, these problems can be delineated and effectively treated. Some of the variations in anatomic location and the natural histories of some conditions more prevalent in the upper extremity have been emphasized.

Arm↗
PubMed1990

Buerger's disease (thromboangiitis obliterans).

Thromboangiitis obliterans is a progressive, often relentless and devastating, vasculitis causing significant loss of digits and limbs in a youthful population of tobacco users. Whereas the specific pathogenetic mechanism has not been defined, tobacco use is clearly a trigger for what appears to be an autoimmune mechanism in a given group of patients. Its cessation almost always prevents further tissue damage. Medical and surgical therapy palliate accrued damage, but only complete abstinence from tobacco use allows stabilization of the process. An appreciation of the characteristic clinical, angiographic, and histopathologic features allows specific diagnosis and differentiation from premature atherosclerosis and other mechanisms of distal and microcirculatory deficits. There is a pressing need for the evaluation of agents that might interrupt this process in the face of continued tobacco use; such an agent would be helpful in combating proliferative arterial change in other types of vasculitis.

Adult↗
PubMed1986

Penetrating atherosclerotic ulcers of the thoracic aorta: natural history and clinicopathologic correlations.

Clinically, penetrating atheromatous ulceration of the aortic wall may be confused with either symptomatic thoracic aneurysm or classic spontaneous aortic dissection. Aortography and computed tomographic (CT) scanning of the thoracic aorta provide specific diagnostic information which permits one to distinguish this lesion from atherosclerotic aneurysm and classic dissection. Hallmarks of findings on aortography and CT scan include the presence of the ulcer and an intramural hematoma. Since the findings may be disarmingly subtle, the potentially progressive and serious nature of this condition may remain unappreciated. Recognition of the penetrating atheromatous ulcer and distinguishing it from aortic dissection arising just distal to the origin of the left subclavian artery is mandatory. Resection of only a conservative segment of the proximal descending aorta suffices for classic dissection in the upper descending thoracic aorta, but the penetrating aortic ulcer requires graft replacement in the area of the ulcer and intramural hematoma.

Aged↗
PubMed1985

Inflammatory abdominal aortic aneurysms: a thirty-year review.

The operative records of 2816 patients undergoing repair for abdominal aortic aneurysm (AAA) from 1955 to 1985 were reviewed. Inflammatory aortic or iliac aneurysms were present in 127 patients (4.5%), 123 men and four women. Most patients were heavy smokers (92.1%). Clinical evidence of peripheral arterial occlusive disease and coronary artery disease was found in 26.6% and 39.4%, respectively. Additional aneurysms occurred in half of the patients; iliac aneurysms were the most common (55 patients), followed by thoracic or thoracoabdominal (17 patients), femoral (16 patients), and popliteal aneurysms (10 patients). Ultrasound and computed tomography suggested the diagnosis in 13.5% and 50%, respectively; angiography was not helpful. Excretory urographic findings of medial ureteral displacement or obstruction suggested the diagnosis in 31.4%. The aneurysm was repaired in 126 patients. Only one patient experienced acute aneurysm rupture, but eight patients had chronic contained leakage. When compared with patients who have ordinary atherosclerotic aneurysms, patients with inflammatory aneurysms are significantly more likely to have an elevated erythrocyte sedimentation rate (ESR, 73% vs. 33%, p less than 0.0001); weight loss (20.5% vs. 10%, p less than 0.05); symptoms (66% vs. 20%, p less than 0.0001); and an increased operative mortality rate (7.9% vs. 2.4%, p less than 0.002). The triad of chronic abdominal pain, weight loss, and elevated ESR in a patient with an abdominal aortic aneurysm is highly suggestive of an inflammatory aneurysm and may be beneficial in the preoperative preparation of the patient for aneurysm repair.

Aged↗
PubMed1984

Lower limb ischemia in young adults: prognostic implications.

Fifty patients (41 men and nine women) less than 36 years of age were evaluated for lower limb ischemia. Claudication was the presenting symptom in 30 patients (60%) and distal ulceration in 20 (40%). The mean age was 28.3 years. Premature atherosclerosis was present in 24 patients (48%) and thromboangiitis obliterans in 12 (24%). Other causes included a variety of unusual etiologies. Risk factors were analyzed. Twenty-two patients with claudication underwent arterial reconstruction; three had sympathectomy. Arterial reconstruction was possible in only three patients with ulceration; 17 had sympathectomy. No operative deaths or early amputations occurred. Follow-up averaged 13.5 years. Twenty-four patients with claudication were improved, three were unchanged, one developed ulceration, one required late amputation, and one was lost to follow-up. Four patients with ulceration were improved, one was unchanged, 14 required late amputation, and one was lost to follow-up. Ten patients, all with atherosclerosis obliterans, developed coronary artery disease; five died of myocardial infarction. No patient developed cerebrovascular disease. We conclude that reconstructive arterial surgery for claudication can be performed with low risk and a strong likelihood of long-term improvement. Most patients presenting with ulceration, however, will ultimately require amputation. Patients with atherosclerosis obliterans are at risk for coronary artery disease and death of myocardial infarction.

Adult↗
PubMed1983

Doppler-determined segmental pressures and wound-healing in amputations for vascular disease.

One hundred and two diabetic and non-diabetic patients with severe vascular disease of the lower extremities were studied in the vascular laboratory at the Mayo Clinic prior to amputation. The level of amputation was chosen on the basis of clinical findings alone. Sixty-seven of the amputations were the classic below-the-knee type. The tests performed included determinations of segmental systolic pressures of the arm, thigh, calf, and ankle determined with the Doppler ultrasonic velocity detector. Contrary to other reports, we found no demonstrable relationship between calf pressure or calf-arm pressure index and the degree of healing of below-the-knee amputations in diabetic or non-diabetic patients.

Adult↗
PubMed1983

Arteriomegaly: classification and morbid implications of diffuse aneurysmal disease.

Ninety-one patients with arteriomegaly and diffuse aneurysmal disease below the level of the renal arteries have been classified according to the extent and location of aneurysmal change. There exists a high incidence of thrombotic and embolic complications, and treatment entails increased rates of morbidity and mortality when compared to surgical treatment of simple abdominal aneurysms of peripheral artery aneurysms. Complete revascularization at the initial operation would appear to give the best result, but this approach must be tempered by the individual patient risk factors and the urgency of the mode of presentation of the patient.

Adult↗
PubMed1982

Splenic artery aneurysms.

The records of 100 patients with documented splenic artery aneurysms seen between January 1960 and January 1980 were reviewed. Eighty-seven were women and 13 men. Ages ranged from 16 to 81 years (mean 58.2 years). Eighty women (92%) had been pregnant. The number of pregnancies ranged from 1 to 16 (mean 4.5); 21 women (24.1%) had been pregnant six or more times. Aneurysm diameter ranged from 0.6 to 30 cm (mean 2.1 cm). The aneurysm was calcified in 72 patients. Most aneurysms (78%) were located in the distal third of the splenic artery and were saccular. Multiple aneurysm occurred in 29 patients. Seventeen patients were symptomatic at the time of diagnosis; all presented with abdominal pain. Rupture occurred in three patients, one of whom was pregnant; two survived. Atherosclerotic occlusive disease occurred in 21 patients. Other arterial aneurysms occurred in 12 patients. Eighty-one patients had surgical treatment. Aneurysmectomy with splenectomy was the most common procedure. The elective operative mortality rate was 1.3%. The 19 patients not undergoing surgery were followed from 1.0 to 19 years (mean 7.4 years). No ruptures or other complications of the aneurysm occurred in these patients. This study supports the view that patients who are pregnant or who present with a symptomatic splenic artery aneurysm should undergo surgical resection.

Adolescent↗
PubMed1982

Thoracic aortic aneurysms: a population-based study.

Thoracic aortic aneurysms were detected in 72 residents (44 women and 28 men) in a stable midwestern community over a 30-year period, for an age- and sex-adjusted incidence of 5.9 new aneurysms per 100,000 person-years. The incidence was equal in both sexes and decreased slightly over the 30 years. Ages ranged from 47 to 93 years (median 65 years for men and 77 years for women). The ascending aorta was involved in 37 patients, the aortic arch in 8, and the descending aorta in 27. Pathologic examination was performed in 51 patients. The cause was aortic dissection in 27 patients (53%), atherosclerosis in 15 (29%), aortitis in 4 (8%), cystic medial necrosis in 3 (6%), and syphilis in 2 (4%). All autopsied patients had pathologic evidence of significant hypertension. Eleven patients (25%) had concomitant abdominal aortic aneurysms. Rupture occurred in 53 patients (74%) and 50 died. Thirty-seven of these patients had no prior diagnosis of aneurysm. The median interval between diagnosis and rupture in the 16 remaining patients was 2 years (range 1 month to 16 years). Ninety-five percent of aortic dissections ruptured and 51% of nondissecting aneurysms ruptured. The actuarial 5-year survival for all 72 patients was 13%; for patients with aortic dissection, 7% and for patients without dissection, 19.2%.

Actuarial Analysis↗
PubMed1976

Chronic arterial insufficiency of the upper extremity.

When claudication or distal ischemia is significant, the treatment of choice for intrinsic arterial insufficiency of the upper extremity caused by atherosclerotic occlusive disease of the subclavian, axillary, or brachial artery with patent distal circulation is direct arterial surgery. Both endarterectomy and bypass procedures are utilized. In the 20 years from 1947 to 1967, 15 patients were operated on for such lesions and adequate circulation was restored in 12 patients treated by the direct method. Nine patients available for 1-year follow-up were cured of their symptoms; of the remaining three patients, one had amputation of an arm and two had sympathectomy with improvement. No hospital death occurred and morbidity was minimal. Although the diagnosis can be established on clinical grounds, arteriography is essential to ascertain the surgical procedure needed. Peripheral diseases involving the small arteries are clinically a more common cause of arterial insufficiency in the upper extremity; progress is slow and complications are infrequent. When ischemic complications exist, direct arterial surgery is not feasible and cervicodorsal sympathectomy is the usual form of treatment. Of 76 patients operated on for such disease, 74 underwent sympathetic neurectomy. The results were excellent, good, or satisfactory in 50 (78%) of the 64 traced patients. The remaining 14 patients had persistent or recurrent symptoms after operation. Removal of the stellate ganglion in addition to the second ganglion yielded better results and is indicated in recurrent or more cases.

Adult↗