PubMed Health⌕ Search

Biomedical subjects

K D Calligaro

Publications and source records attributed to K D Calligaro.

At least 37 records · Page 2Linked to original sources
PubMed1998

Revision of failing lower extremity bypass grafts.

BACKGROUND: Color-duplex ultrasound (CDU) surveillance of arterial bypass grafts has been validated, but the natural history of "failing" grafts remains poorly defined. Our purpose was to compare failing grafts having prophylactic revision with those that did not. METHODS: Postoperative duplex surveillance was performed in an accredited vascular laboratory for all lower extremity bypass grafts performed at a single institution. Eighty-five infrainguinal grafts (57 vein, 21 polytetrafluoroethylene (PTFE), and 7 composite grafts) in 83 patients were identified as failing by accepted criteria. Twenty-five grafts were revised early (early), 20 grafts revised more than 2 months after the initial CDU-abnormality (late), and 40 grafts were not prophylactically revised (no revision) at any time. RESULTS: The three groups were not different (P > 0.10) with regard to gender, age, level of bypass, type of conduit, location of stenoses, or timing of abnormality after surgery. No revision patients more frequently had diffuse low peak systolic flow velocity (PSV) as the CDU abnormality (P = 0.013). Cumulative primary patency was significantly better at 12 months (P = 0.028) in the no revision group (78.9%) compared with early grafts (43.1%) or late grafts (63.8%), and this difference remained significant when low PSV grafts were excluded from analysis. However, assisted primary patency, secondary patency, and limb salvage rates did not differ between the three groups (P > 0.10). CONCLUSIONS: Our experience in this retrospective study contradicts other reports supporting the efficacy of prophylactic graft revision for grafts identified as failing by currently accepted CDU criteria. Refinement of CDU criteria to more accurately predict graft thrombosis is needed.

Adult↗
PubMed1998

Selective use of duplex ultrasound to replace preoperative arteriography for failing arterial vein grafts.

PURPOSE: In an effort to minimize costs and patient discomfort, we determined whether duplex ultrasound (DU) could selectively replace preoperative arteriography performed in the radiology suite to diagnose failing arterial bypass grafts (FABs) constructed of autogenous vein. METHODS: Between January 1, 1994, and December 31, 1996, we treated 106 FABs. Graft revision solely on the basis of DU was performed only if a focal stenosis was clearly identified in the graft (peak systolic velocity [PSV] > 300 cm/sec, ratio of adjacent PSVs > 3.0) or in inflow or outflow arteries (resulting in uniform graft PSVs < 45 cm/sec). Intraoperative arteriograms were frequently obtained to confirm DU findings. Preoperative arteriograms were obtained if DU revealed multiple or ill-defined stenoses, diffuse inflow or outflow arterial disease, uniformly low PSVs without an identifiable lesion, or equivocal stenosis despite clinical evidence of an FAB. RESULTS: Seventy-three (69%) FABs with 81 lesions were revised on the basis of DU only. Of 76 stenotic lesions, an intraoperative arteriogram or surgical findings confirmed a diameter stenosis of 75% to 99% in 69 grafts (91%) and stenosis of 50% to 74% in three grafts (4%). DU incorrectly identified the site of stenosis or underdiagnosed the extent of disease in four grafts (5%). DU correctly identified the site of missed arteriovenous fistulas in five grafts. The 73 FABs were treated with intraoperative balloon angioplasty (30 grafts), patch angioplasty (20), interposition or jump grafts (12), ligation of arteriovenous fistula (3), a new bypass graft (1), or a combination of these interventions (7). A significant change in intraoperative strategy potentially could have been avoided if a preoperative arteriogram had been obtained in three of the 73 FABs (4.1%). CONCLUSIONS: DU can reliably be used to revise FABs and avoid the morbidity, discomfort, and cost of confirmatory arteriography in two thirds of cases.

Adult↗
PubMed1997

Use of arm and lesser saphenous vein compared with prosthetic grafts for infrapopliteal arterial bypass: are they worth the effort?

PURPOSE: Arm and lesser saphenous veins (ALSVs) are generally considered to be the best alternative for infrapopliteal arterial bypass grafts when greater saphenous vein is not available. The need for additional incisions and repositioning of the patient, along with occasional use of general anesthesia for arm vein harvesting, led to our perception that the use of ALSVs increased operative time and possibly patient discomfort. Therefore, we compared the outcome of ALSVs with that of prosthetic infrapopliteal arterial bypass procedures performed at our hospital. METHODS: Between July 1, 1991, and Dec. 31, 1996, we performed 96 infrapopliteal arterial bypass procedures using 45 ALSVs (28 arm vein, 17 lesser saphenous) and 51 polytetrafluoroethylene (PTFE) grafts. Seventy grafts were single-length ALSV or PTFE bypass grafts, and 26 grafts were placed as the distal segment of a sequential or composite bypass graft. Every attempt was made to use ALSV and avoid the use of PTFE, even if a short segment of the vein graft measured less than 4.0 mm in diameter. There were no significant differences between patients with ALSV compared with PTFE grafts in terms of age, sex, indication for surgery, or number of previous revascularization procedures (2.1 vs 1.7), respectively (p > 0.05). However, ALSV grafts had more factors associated with an expected worse outcome: they were more commonly anastomosed to pedal arteries (17% [8 of 45] vs 0%; p = 0.0009), less commonly single-segment grafts (62% [28 of 45] vs 82% [42 of 51]; p = 0.03), had higher average runoff resistance values (2.3 vs 1.5; p = 0.001), and were less frequently treated with lifelong warfarin (65% [29 of 45] vs 95% [48 of 51]; p = 0.0001). RESULTS: The hospital mortality rate was 3.1% (3 of 96; 3 PTFE). All deaths were cardiac-related. Despite the potential factors associated with worse patency rates for ALSVs, 2-year assisted primary patency rates tended to be higher for arm veins (46%) than for lesser saphenous veins (23%) and PTFE grafts (26%), although this difference was not statistically significant. Limb salvage rates were similar between ALSV and PTFE grafts (76% vs 71%, respectively). The average operative time was significantly longer for ALSV bypass procedures (mean, 6.2 hours) than for PTFE bypass procedures (mean, 4.9 hours; p = 0.003), and for single-length conduits when revision of previously placed grafts was not attempted, the operative time was 4.0 hours for ALSV grafts and 2.5 hours for PTFE grafts. CONCLUSION: In our experience ALSV bypass grafts to infrapopliteal arteries do not function as well as reported by some others. In spite of the extra effort involved, arm vein grafts are preferred over PTFE grafts for their likely higher assisted primary patency rates and equivalent, if not better, limb salvage rates.

Aged↗
PubMed1997

Safety, feasibility, and early efficacy of subfascial endoscopic perforator surgery: a preliminary report from the North American registry.

PURPOSE: The North American Subfascial Endoscopic Perforator Surgery (NASEPS) Registry was established to evaluate the safety, feasibility, and efficacy of minimally invasive endoscopic Linton operations for treatment of chronic venous insufficiency. METHODS: Retrospective analysis was performed on the clinical data of 151 patients who underwent attempt at 158 SEPS in 17 medical centers in the United States and Canada between June 1993 and February 1996. RESULTS: SEPS was completed on 155 limbs of 148 patients, 81 male and 67 female (mean age, 56 years; range, 27 to 87 years). Three procedures were aborted. Seven patients had bilateral procedures (data from one limb were analyzed). One hundred four limbs (70%) had active ulcers, and 22 (15%) had healed ulcers. A single endoscopic port without insufflation was used in 66 procedures (45%) and laparoscopic instrumentation, with two or three ports, in 82 (55%), with CO2 insufflation in 78 (53%). A tourniquet was used on 112 patients (76%). Concomitant venous procedures were performed in 106 patients (72%; saphenous stripping in 71, high ligation in 17, varicosity avulsion in 85). No early deaths or thromboembolism occurred. Complications included wound infections (9), superficial thrombophlebitis (5), cellulitis (4), and saphenous neuralgia (10). Seven patients with wound infection had open ulcers; nine of 10 with neuralgia had concomitant procedures. A roll-on tourniquet caused skin necrosis in one patient. The clinical score improved from 9.4 to 2.9 after surgery (p < 0.0001). Mean follow-up was 5.4 months; 31 patients had > or = 6 months follow-up. Ulcers healed in 88% (75 of 85); recurrence or new ulcer was reported in 3% (4 of 120). CONCLUSIONS: The SEPS modified Linton operation appears safe, with no postoperative deaths or early thromboembolism. Wound infection after SEPS remains important. Early results indicate rapid ulcer healing. Prospective evaluation of long-term results is warranted.

Adult↗
PubMed1997

Same-day admissions and other cost-saving strategies for elective aortoiliac surgery.

PURPOSE: We retrospectively analyzed whether same-day admissions and other resource utilization methods for patients undergoing elective infrarenal aortoiliac surgery (AoIS) were safe and cost-effective. METHODS: Morbidity and mortality rates and costs were compared between 71 patients admitted before the day of surgery (group I) and 57 patients admitted the day of surgery (group II) who underwent elective AoIS between July 1, 1992, and December 31, 1995. After January 1, 1994, a concerted effort was made to decrease hospital costs by performing out-patient preoperative assessment, admitting patients the morning of surgery, and planning early discharge through implementation of clinical pathways. Patients were excluded (total, 33; 20%) from analysis if they were admitted before the day of surgery for intravenous hydration (5), optimizing cardiac function (4), or prolonged preoperative antibiotics (2), or if they required emergency surgery (10) or were transferred from another service or hospital (12). After exclusion, there were no significant differences (p > 0.05) between groups I and II in terms of age, sex, race, diabetes, hypertension, pulmonary disease, cardiac disease, renal insufficiency, type of incision (midline or retroperitoneal), indication for surgery (aneurysm or occlusive disease), or inflow site (aorta or common iliac artery). RESULTS: There were no significant differences between groups I and II in terms of mortality rate (0%); cardiac (1.4% [1/71] vs 0%), pulmonary (9.9% [7/71] vs 5.3% [3/57]), or renal (1.4% [1/71] vs 0%) complications; or readmission rates within 30 days (5.6% [4/71] vs 5.2% [3/57]), respectively (p > 0.05). There were significant decreases in length of hospital stay (mean, 6.4 vs 11.2 days; p < 0.0001) and hospital cost per patient ($34,198 vs $45,694; p = 0.001) for group II compared to group I, respectively. CONCLUSIONS: The majority of patients who require elective infrarenal aortoiliac surgery can be admitted the day of surgery and undergo early discharge with significant hospital cost savings and without apparent increase in morbidity or mortality rates.

Adult↗
PubMed1996

Safety and cost-efficiency of 24-hour hospitalization for carotid endarterectomy.

The safety and cost savings of carotid endarterectomy (CEA) were determined with guidelines developed after vascular "critical pathways" were implemented. Using these guidelines, our goal was to admit patients the day of surgery and to discharge them the next morning. Morbidity, mortality, readmission rates, same-day admissions, duration of stay, and hospital costs were compared between patients undergoing CEA who were electively admitted between September 1, 1992 and August 31, 1993 (group 1) and January 1, 1994 and March 31, 1995 (group 2). Between these two time periods, vascular critical pathways were instituted and all preoperative examinations were performed on an outpatient basis. The majority of CEAs were performed with the patient under general anesthesia. We found no significant differences between group 2 (n = 68) vs. group 1 (n = 40) in terms of mortality (1.5% [1 of 68] vs. 2.5% [1 of 40]), cardiac events (2.9% [2 of 68] vs. 2.5% [1 of 40]), neurologic events (2.9% [2 of 68] vs. 2.5% [1 of 40]), or readmission rate (1.5% [1 of 68] vs. 0% [0 of 40]). Same-day admissions were significantly higher (94% [64 of 68] vs. 5% [2 of 40]; p < 0.0001), and average duration of stay was significantly lower (1.3 vs. 5.1 days; p < 0.0001) in group 2 vs. group 1, respectively. Hospital charges were decreased by $5510 per patient in group 2. We conclude that hospital costs can be significantly reduced for most patients undergoing CEA when they are admitted on the day of surgery and discharged the following morning, with no negative impact on morbidity and mortality.

Aged↗
PubMed1996

Management and outcome of infrapopliteal arterial graft infections with distal graft involvement.

PURPOSE: The purpose of this study was to determine the outcome of patients with infrapopliteal artery graft infections (InfraPopGIs) who presented with graft infection distal to the popliteal artery. PATIENTS AND METHODS: Between July 1, 1979 and June 30, 1994, 27 patients presented with infrapopliteal artery graft infections (18 polytetrafluoroethylene [PTFE], 9 autologous vein). The infection involved the anastomosis in 22 cases (8 anterior tibial, 8 posterior tibial, 4 peroneal, 2 dorsalis pedis arteries) and was localized to the body of the graft in 5 cases (4 calf, 1 ankle). All bypasses were originally performed for limb salvage. Twelve patients with patent grafts and intact anastomoses were managed by complete graft preservation. Fifteen patients presented with occluded grafts (10), anastomotic hemorrhage (4), or systemic sepsis (1) and were treated by total or subtotal graft excision. RESULTS: The hospital mortality rate was 19% (5 of 27) and the amputation rate in survivors was 27% (6 of 22). These results were compared with a mortality rate of 13% (15 of 114; P > 0.05) and a limb loss rate of 10% (10 of 99)(P = 0.05) in 114 patients during this period who presented with infection proximal to the tibial arteries. Of 6 survivors with graft infections who required amputations, 5 lacked a suitable outflow artery for a secondary bypass and 1 developed progressive gangrene despite a patent secondary bypass. Among the other 16 survivors, 7 (44%) limbs remained viable without requiring a secondary bypass, 6 (37%) limbs were salvaged with successful preservation of patent grafts, and 3 (19%) required secondary bypasses to prevent limb loss. CONCLUSIONS: Patients presenting with infrapopliteal artery graft infections have higher amputation rates than patients with more proximal infected peripheral grafts. Selective graft preservation and selective revascularization when outflow arteries are available are essential adjuncts to minimize high rates of limb loss associated in patients with graft infections.

Amputation, Surgical↗
PubMed1996

Duplex ultrasonography to diagnose failing arterial prosthetic grafts.

BACKGROUND: Although several reports have documented the usefulness of a surveillance program with duplex ultrasonography (DU) to diagnose failing autologous vein bypasses, the effectiveness of DU to detect failing arterial prosthetic grafts has not been confirmed. We attempted to determine whether our program, which included DU and other noninvasive techniques (NonDU), was useful for this purpose. METHODS: Between July 1, 1991, and September 30, 1994, 85 prosthetic bypasses in 59 patients performed for lower extremity ischemia were entered into a graft surveillance protocol. There were 35 femoropopliteal, 16 femorotibial, 15 iliofemoral, 13 axillofemoral, and 6 femorofemoral bypasses. Both DU and NonDU were performed 1 week and every 3 months after the initial bypass or after graft revision. NonDU criteria of a failing graft included changes in symptoms or pulses, decreased ankle/brachial index greater than 0.15, or diminution of ankle pulse volume recordings greater than 50%. Normal grafts were bypasses that had less than 50% stenosis documented by arteriography or remained patent. Problem grafts were those that required revision or thrombosed before intervention. Follow-up of patient grafts ranged between 3 and 36 months (mean, 11 months). RESULTS: DU predicted 17 (81%) of 21 problem grafts versus only 5 (24%) diagnosed by NonDU (p = 0.001). Lesions associated with these 21 grafts were perianastomotic in 10 cases, in adjacent inflow or outflow arteries in 8 cases, and intrinsic to the graft in 3 cases. The likelihood of a graft thrombosing in the presence of a normal test was 7% (4 of 58) for DU compared with 21% (16 of 76) for NonDU (p = 0.04). CONCLUSIONS: DU is more sensitive than NonDU in predicting failure of prosthetic grafts. This study suggests that DU should routinely be performed as part of a surveillance program for peripheral arterial prosthetic bypasses.

Aged↗
PubMed1996

Congenitally absent inferior vena cava presenting in adulthood with venous stasis and ulceration: a surgically treated case.

Absence of the inferior vena cava (IVC) is an uncommon congenital abnormality. Symptoms of lower extremity venous insufficiency resulting from this anatomic abnormality have been reported only once in the English literature, and no experience with surgical treatment of this condition has been published. We report the case of an otherwise healthy 41-year-old man with an 18-month history of severe venous insufficiency involving the right leg manifested by extensive ulceration that did not respond to aggressive conservative treatment. Duplex findings were not suggestive of venous obstruction or reflux, but venography documented no filling of the common iliac vein or inferior vena cava, and outflow was via collaterals to the azygous and hemiazygous systems. Computed tomography demonstrated complete absence of the inferior vena cava with azygous continuation. A prosthetic bypass from the external iliac to the intrathoracic azygous vein was performed with complete symptomatic relief after a 30-month follow-up period. Venous bypass surgery may play a role in treatment of this rare cause of venous insufficiency.

Adult↗
PubMed1996

Thrombolytic and endovascular treatment of peripartum iliac vein thrombosis: a case report.

This case report details the multidisciplinary treatment of peripartum left iliac vein thrombosis using percutaneous catheter-directed urokinase thrombolysis and balloon thromboplasty. Enhanced chances for long-term patency and the normalization of venous function make these minimally invasive procedures accepted options for the treatment of iliofemoral deep venous thrombosis in selected peripartum patients.

Adult↗
PubMed1996

Role of nursing personnel in implementing clinical pathways and decreasing hospital costs for major vascular surgery.

Collaboration with key nursing personnel is essential to successfully implement clinical pathways, establish a dedicated vascular wing, and achieve significant hospital cost savings while still maintaining quality care with low morbidity and mortality rates. Key nursing personnel met once a month during a 1-year period with vascular surgeons, hospital administrators, and health care advisors to plan strategies to develop clinical pathways and establish a dedicated vascular ward. The pathways were then implemented. We compared morbidity, mortality, readmission rates, adn hospital costs among two groups of patients admitted for major vascular surgery. Nursing personnel, attending staff, and surgical residents found that treating patients who had undergone major vascular surgery was more straightforward and efficient after clinical pathways and a dedicated vascular wing were established. In addition, there were no significant differences between the groups in terms of overall mortality or pulmonary, neurologic, or cardiac complications despite shorter hospital stay and decreased hospital costs. Also there were no significant differences in readmission rates within 30 days.

Aged↗
PubMed1995

Thrombolysis to treat arterial thrombotic complications of heparin-induced thrombocytopenia.

An 80-year-old man with diabetes developed acute ischemia of the right leg secondary to heparin-induced thrombocytopenia while being treated for a pulmonary embolism. For fear of recurrent thrombosis at the operative site, he was treated with cessation of heparin, placement of a Greenfield filter, and intra-arterial infusion of urokinase into the popliteal artery for 36 hours. All arterial thrombus resolved with no complications. One week later he underwent a below-knee popliteal to anterior tibial artery translocated cephalic vein bypass and transmetatarsal amputation for progressive gangrene of the right toes. The graft remains patent 2 years later. This patient represents the eighth case reported in the world literature in which thrombolytic therapy was used to treat arterial thrombotic complications of heparin-induced thrombocytopenia. Five patients were successfully treated without complications, two others required major amputations, and one died of adrenal hemorrhage. Although thrombolytic therapy should be used cautiously for treatment of arterial thrombotic complications of heparin-induced thrombocytopenia, this adjunct may prove useful and safe in selected cases.

Aged↗
PubMed1995

Congenital aneurysm of the internal jugular vein in a pregnant woman.

A pregnant woman with a symptom-free congenital aneurysm of the internal jugular vein (IJV) is described. A color duplex scan revealed an aneurysm (2.4 cm in diameter) of the right IJV in the mid-neck without evidence of thrombus. To the authors' knowledge, this is the first reported case demonstrating that such a lesion in a pregnant woman can be safely managed without excision.

Adult↗