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Biomedical subjects

K D Calligaro

Publications and source records attributed to K D Calligaro.

At least 55 records · Page 3Linked to original sources
PubMed1995

Recommendations for initial antibiotic treatment of extracavitary arterial graft infections.

BACKGROUND: Initial antibiotic treatment of extracavitary arterial graft infections is usually empiric or based on Gram's stain findings. Increasing virulence of bacteria causing extracavitary arterial graft infections may render previous choices of antibiotics obsolete. The purposes of this study were to correlate Gram's stain findings of gram-positive bacteria and gram-negative bacteria with wound cultures and provide a microbiologic basis for appropriate initial antibiotic therapy. METHODS: Between July 1, 1979 and June 30, 1994, specimens obtained on the day of admission from purulent wounds involving 113 extracavitary arterial graft infections were retrospectively reviewed for Gram's stain and culture and sensitivity results. RESULTS: Gram's stain findings correlated with final cultures on only 28 of 113 cases (25%), including 20 of 48 pure gram-positive, 2 of 24 pure gram-negative, and 6 of 41 mixed bacterial cultures. Staphylococcus aureus was the most common gram-positive bacteria cultured (43 isolates) and Pseudomonas species was the most common gram-negative bacteria (25 isolates). Bacteria were sensitive to a first-generation cephalosporin in only 32% (36 of 113) of infections. A combination of vancomycin and either ticarcillin-clavulanic acid or ceftazidime, which have minimal toxicity and provide excellent coverage against staphylococci, Pseudomonas, and other gram-negative bacteria, would have covered 96% (109) and 95% (107) of cultured organisms, respectively. CONCLUSIONS: Regardless of Gram's stain findings, current recommendations for initial treatment of extracavitary arterial graft infections should include vancomycin and ceftazidime or ticarcillin-clavulanic acid until final culture and sensitivity results dictate the use of more selective antibiotics.

Anti-Bacterial Agents↗
PubMed1995

Venous aneurysms: surgical indications and review of the literature.

BACKGROUND: During the last 20 years we diagnosed five cases of venous aneurysm of the jugular (n = 4) and basilic (n = 1) veins. The purpose of this report was to determine the natural history and indications for surgery of venous aneurysms. METHODS: Our five cases were included in an English-language literature review performed through August 1993. RESULTS: In our series two aneurysms (one external jugular vein, one basilic vein) were excised for cosmetic reasons. Three internal jugular vein aneurysms were followed up for up to 4 years without complications with serial color duplex ultrasonography. Of 32 patients with abdominal venous aneurysms (18 portal, seven inferior vena cava, four superior mesenteric, two splenic, one internal iliac), 13 (41%) had major complications including five deaths. Of 31 patients with deep venous aneurysms of the extremity (29 popliteal, two common femoral), 22 (71%) had deep vein thrombosis or pulmonary embolism and in 17 recurrent deep vein thrombosis or pulmonary embolism developed when patients were treated with anticoagulation alone. CONCLUSIONS: Prophylactic surgery is cautiously recommended for low-risk patients with venous aneurysms of the abdomen and strongly recommended for most patients with lower extremity deep venous aneurysms. Other venous aneurysms should be excised only if they are symptomatic, enlarging, or disfiguring.

Abdomen↗
PubMed1995

Impact of clinical pathways on hospital costs and early outcome after major vascular surgery.

PURPOSE: The purpose of this study was to determine whether major vascular surgery could be performed safely and with significant hospital cost savings by decreasing length of stay and implementation of vascular clinical pathways. METHODS: Morbidity, mortality, readmission rates, same-day admissions, length of stay, and hospital costs were compared between patients who were electively admitted between September 1, 1992, and August 30, 1993 (group 1), and January 1 to December 31, 1994 (group 2), for extracranial, infrarenal abdominal aortic, and lower extremity arterial surgery. For group 2 patients, vascular critical pathways were instituted, a dedicated vascular ward was established, and outpatient preoperative arteriography and anesthesiology-cardiology evaluations were performed. Length-of-stay goals were 1 day for extracranial, 5 days for aortic, and 2 to 5 days for lower extremity surgery. Emergency admissions, inpatients referred for vascular surgery, patients transferred from other hospitals, and patients who required prolonged preoperative treatment were excluded. RESULTS: With this strategy same-day admissions were significantly increased (80% [145/177] vs 6.2% [9/145]) (p < 0.0001), and average length of stay was significantly decreased (3.8 vs 8.8 days) (p < 0.0001) in group 2 versus group 1, respectively. There were no significant differences between group 1 and group 2 in terms of overall mortality rate (2.1% [3/145] vs 2.3% [4/177]), cardiac (3.4% [5/145] vs 4.0% [7/177]), pulmonary (4.1% [6/145] vs 1.7% [3/177]), or neurologic (1.4% [2/145] vs 0% [0/177]) complications, or readmission within 30 days (11.3% [16/142] vs 9.2% [16/173]) (p > 0.05). There were also no differences in morbidity or mortality rates when each type of surgery was compared. Annual hospital cost savings totalled $1,267,445. CONCLUSION: Same-day admission and early hospital discharge for patients undergoing elective major vascular surgery can result in significant hospital cost savings without apparent increase in morbidity or mortality rates.

Aged↗
PubMed1995

Differences in early versus late extracavitary arterial graft infections.

PURPOSE: The purpose of this report was to determine differences in presentation, bacteriology, management, and outcome of early (EGIs) versus late extracavitary arterial graft infections (LGIs). METHODS: Between July 1, 1979, and June 30, 1994, we treated 141 patients with infected extracavitary arterial grafts (112 prosthetic, 29 vein) with selective partial or complete graft preservation. RESULTS: A total of 99 (70%) EGIs (< 2 months) and 42 (30%) LGIs (4 to 96 months) were involved. The hospital mortality rate was 14% (20 of 141), and the amputation rate in survivors was 13% (16 of 121). No significant difference in mortality (16% [16 of 99] vs 10% (4 of 42]) or limb loss (16% [13 of 83] vs 8% [3 of 38]) was seen between EGIs and LGIs, respectively (p > 0.05). Patients with EGIs were as likely to have a disrupted anastomosis (17% [17 of 99] vs 21% [9 of 42]) or systemic sepsis (4% [4 of 99] vs 4% [2 of 42]) as patients with LGIs, respectively (p > 0.05). Patients with EGIs were more likely to have patent, intact grafts and to be treated by complete graft preservation (61% [61 of 99] vs 26% [11 of 42]) (p = 0.0001). In comparison, patients with LGIs were more likely to have occluded grafts and to require subtotal graft excision (48% [20 of 42] vs 18% [18 of 99]) (p = 0.0001). Surviving patients with EGIs treated by complete graft preservation were more likely to have successful healing of their wounds after long-term follow-up (average 3 years) than patients with LGIs (79% [41 of 52] vs 40% [4 of 10], respectively) (p = 0.03). The pathogens cultured from wounds of EGIs versus LGIs were pure gram-positive bacteria in 49 (49%) versus 19 (46%), pure gram-negatives in 18 (18%) versus 11 (26%), and both types in 33 (33%) versus 12 (28%) (p > 0.05). CONCLUSION: Complete graft preservation can be attempted more frequently and is more likely to be successful in EGIs than in LGIs. No difference in bacteriology was seen between the two groups. Graft-preserving treatment can be successful but should only be cautiously attempted in patients with late extracavitary arterial graft infections.

Amputation, Surgical↗
PubMed1995

Atherosclerotic aneurysm of the intrathoracic subclavian artery: a case report and review of the literature.

True aneurysm of the subclavian artery is extremely rare. Excluding the more common aneurysms of an aberrant right subclavian artery, those associated with thoracic outlet syndrome, and posttraumatic "aneurysms," atherosclerosis is the most common cause. Syphilis, tuberculosis, and cystic medial necrosis are less often the cause. These aneurysms can rupture, thrombose, embolize, or cause symptoms by local compression. Surgical treatment is generally indicated, and has evolved from ligation procedures to extirpation or endoaneurysmorrhaphy to the present practice of resection with revascularization. A case of a surgically treated, asymptomatic, atherosclerotic aneurysm of the intrathoracic left subclavian artery is presented, with a review of the English-language literature on the subject.

Adolescent↗
PubMed1994

Successful preservation of an infected common femoral vein to common femoral vein crossover prosthetic graft.

We used selective graft preservation to treat an infected anastomosis of a functioning common femoral vein to common femoral vein crossover PTFE bypass performed for iliac vein occlusion. The graft was successfully salvaged by operative debridement and placement of a rectus abdominis muscle flap. With the growing interest in venous reconstructive surgery, bypass infections may be seen more frequently. This case illustrates that selective preservation of infected prosthetic grafts anastomosed to a peripheral vein may be a simple and improved method to treat these complications.

Abdominal Muscles↗
PubMed1994

Comparison of muscle flaps and delayed secondary intention wound healing for infected lower extremity arterial grafts.

Selective preservation of infected arterial grafts is an alternative to graft excision. The purpose of this study was to compare the outcome and cost of treating infected lower extremity arterial grafts with either muscle flaps (MFs) or delayed secondary intention (DSI) wound healing. Between 1985 and 1991 we treated 28 graft infections by graft preservation. All grafts (19 polytetrafluoroethylene, 8 autologous vein, and 1 Dacron) were patent with intact anastomoses and showed no signs of sepsis. Wounds in 18 patients were treated by repeated, aggressive operative debridement and allowed to heal by DSI. Wounds in 10 patients were treated with MFs (4 sartorius, 3 gracilis, 1 rectus abdominis, 1 semimembranous, and 1 gastrocnemius). Costs included anesthesiologists' and surgeons' fees, operating room charges, and daily semiprivate and ICU bed charges. Four (14%) patients died from cardiac complications (1 DSI and 1 MF), sepsis (1 MF), and anastomotic hemorrhage (1 DSI). Of the 24 survivors, 4 patients treated by DSI required graft excision for nonhealing wounds (2), graft thrombosis (1), and recurrent infection (1). However, 3 of these 4 patients were not candidates for MFs because the wounds were not considered acceptable for a flap. Twenty (83%) grafts in survivors were successfully preserved after long-term follow-up (mean 26 mo). No survivors required an amputation. Twenty patients who did not require graft removal were compared for treatment by MF (n = 8) or DSI (n = 12). Two MFs (both sartorius) in survivors necrosed and a new flap was required to successfully preserve the graft.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1994

Acute arterial thrombosis associated with total knee arthroplasty.

PURPOSE: Acute arterial thrombosis associated with total knee arthroplasty (TKA) is a rare but limb-threatening complication. The purpose of this report was to determine the incidence and optimal management of these complications by reviewing our extensive orthopedic experience and the English-language literature. METHODS: Between April 1989 and March 1994 seven (0.17%) patients had development of acute limb-threatening ischemia after 4097 TKAs that were performed at our hospital. Management of these complications included (1) emergency arteriography to define inflow and outflow arteries, (2) use of autologous vein from the contralateral leg when arterial bypasses were necessary (because TKAs are associated with a high incidence of deep vein thrombosis), and (3) early, aggressive revascularization that often required difficult distal bypasses to achieve limb salvage. Management of our cases are compared with treatment of 13 patients described in the literature. RESULTS: Ten patients treated at other hospitals by arterial thrombectomy alone (six cases), sympathectomy alone (two cases), fasciotomy alone (one case) or delayed arterial bypass resulted in seven major amputations and one death. All seven of our patients and three patients treated elsewhere underwent emergency femorodistal bypasses (six tibial, three below-knee popliteal, one pedal). All 10 patients had limb salvage after long-term follow-up (average 18 months; range 1 to 58). CONCLUSION: Thrombectomy alone for acute arterial thrombosis associated with TKA generally is unsuccessful and associated with unacceptably high amputation rates. Dismal results without emergency bypass is due to underlying chronic occlusive atherosclerotic disease found in these patients and intimal plaque disruption that can occur with knee manipulation or tourniquet compression. Acute arterial occlusion after TKA is best managed by emergency arteriography and a femoroinfrageniculate bypass.

Acute Disease↗
PubMed1994

Selective preservation of infected prosthetic arterial grafts. Analysis of a 20-year experience with 120 extracavitary-infected grafts.

OBJECTIVE: The authors report on their 20-year experience with 120 patients with infected extracavitary prosthetic arterial grafts (95 polytetraflouroethylene, 25 Dacron). Throughout this experience, an effort was made, when appropriate, to salvage all or a portion of these infected grafts. METHODS: When patients had arterial bleeding (20 cases) or systemic sepsis (6 cases), immediate graft excision was performed. When the infected graft was occluded (43 cases), subtotal graft excision was performed, leaving an oversewn 2- to 3-mm graft remnant to maintain patency of the artery. Complete graft preservation was attempted in 51 cases in which the graft was patent, the patient was not septic, and the anastomoses were intact. Aggressive operative wound debridement was repeated, as necessary, to achieve wound healing. The preferred method of revascularization, when necessary, included secondary bypasses tunneled through uninfected (often lateral) routes. Follow-up averaged 3 years (range, 1 month-20 years). RESULTS: This strategy resulted in a hospital mortality of 12% (14/120) and a hospital amputation rate in survivors of 13% (14/106 threatened limbs). Of the surviving patients treated by complete graft preservation, the hospital amputation rate was only 4% (2/45) and long-term complete graft preservation was successful in 71% (32/45) of cases. Partial graft preservation also proved successful in 85% (35/41) of surviving patients who had occluded grafts. Successful complete graft preservation was as likely when gram-negative or gram-positive bacteria were cultured from the wound, with the exception of Pseudomonas (successful graft preservation in only 40% [4/10] of cases). CONCLUSION: Based on this 20-year experience, the authors conclude that selective partial or complete graft preservation represents a simpler and better method of managing infected extracavitary prosthetic grafts than routine total graft excision.

Aged↗
PubMed1994

Reoperative approaches to failed procedures confined entirely to the abdominal aorta.

Options do exist when the vascular surgeon is faced with failed procedures confined to the abdominal aorta. Knowledge of the various techniques outlined previously allows an orderly and minimal-risk approach in these patients. Use of the original graft is often the first choice to revascularize ischemic lower extremities in low-risk patients. Extra-anatomic bypasses are generally reserved for high-risk patients. The exception is hepatorenal and splenorenal bypasses that are the revascularization method of choice in most patients with failed unilateral aortorenal bypasses.

Acute Disease↗
PubMed1993

Carotid stump pressure, stump pulse, and retrograde flow.

In order to obtain a more comprehensive intraoperative hemodynamic profile and to predict hypoperfusion during carotid endarterectomy, stump pressure, stump pulse, and retrograde internal carotid flow were measured in 261 patients. Our results show a significant correlation between stump pressure and retrograde flow (p < 0.001), stump pressure and the presence of a stump pulse (p < 0.001), and retrograde flow and the presence of a stump pulse (p < 0.001). We also demonstrated a significant correlation between stump pressure (lower), retrograde flow (less), and the absence of a stump pulse in patients with contralateral carotid artery occlusion. There was no correlation between the indication for carotid endarterectomy and any hemodynamic measurement. The triad of stump pulse, stump pressure, and retrograde flow accurately reflects collateral blood flow when the carotid is cross-clamped. These determinations can be obtained at low cost and are easily and rapidly performed. A protocol for selective shunting in patients undergoing carotid endarterectomy with general anesthesia is suggested.

Adult↗
PubMed1993

Deep femoral artery pseudoaneurysm caused by acute trunk and hip torsion.

Spontaneous pseudoaneurysm is extremely uncommon. Apparently the first case of a deep femoral artery pseudoaneurysm, caused by acute trunk and hip torsion during a golf swing, is reported. The lesion was documented by computed tomography, arteriography and surgical investigation. The present report is aimed at making known the possibility of such a complication following this and similar types of physical activity in order to enable prompt assessment and treatment of the lesion.

Aged↗
PubMed1993

Pulmonary risk factors of elective abdominal aortic surgery.

PURPOSE: The purpose of this study was to retrospectively identify risk factors for postoperative pulmonary complications in patients undergoing elective abdominal aortic surgery via a midline incision. METHODS: We reviewed 181 consecutive patients who underwent operation between July 1986 to December 1992. Preoperative factors analyzed included age, sex, diabetes mellitus, history of smoking, chronic obstructive pulmonary disease, obesity, indication for surgery (aneurysm [126] or aortoiliac occlusive disease [AIOD] [55]), history of coronary artery disease, length of preoperative hospital stay, American Society of Anaesthesiologists class, and pulmonary function tests. Intraoperative factors analyzed included endotracheal tube diameter, percent of inspired oxygen, blood loss, blood and crystalloid replacement, total operative time, epidural analgesia, and stress ulcer prophylaxis. RESULTS: Although the operative mortality rate was only 1.7% (3 of 181), major pulmonary complications occurred in 29 (16%) patients, including two lung-related deaths. Pneumonia occurred in 17 (9%) patients, prolonged intubation greater than 24 hours occurred in nine (5%), and reintubation caused by pulmonary insufficiency occurred in three (2%). On univariate analysis, the following were associated with major pulmonary complications (p < 00.05): American Society of Anaesthesiologists class IV, age greater than 70 years, ideal body weight greater than 150%, forced vital capacity of 80% or less predicted, forced expiratory flow rate (25 to 75) of 60% or less predicted, crystalloid replacement greater than 6 L, and total operative time greater than 5 hours. CONCLUSIONS: The presence of these pulmonary risk factors, notably increased age and weight, decreased forced vital capacity and forced expiratory flow rate (25 to 75), and expected prolonged operative time, influences our decision not to proceed with surgery for small aortic aneurysms or for AIOD causing claudication. Patients at high pulmonary risk with AIOD who require revascularization for limb salvage would be more likely to undergo extraanatomic bypass. Pulmonary risk factors may play as important a role as cardiac factors in elective aortic surgery.

Age Factors↗
PubMed1993

Management of arterial injuries produced by percutaneous femoral procedures.

BACKGROUND: A significant number of vascular injuries occur with the use of percutaneous diagnostic and therapeutic procedures. This study was done to indicate the types of these injuries and their management. METHODS: Over a 30-month period, 55 patients required operation for vascular complications after percutaneous femoral procedures including infrarenal arteriography (six patients) and angioplasty (22 patients), coronary angiography (16 patients) and angioplasty (five patients), and aortic balloon pump insertion (six patients). RESULTS: The 14 iliac and 41 femoral artery injuries included 29 pseudoaneurysms, six lacerations with persistent bleeding, seven dissections, six occlusions, three ruptures, two arteriovenous fistulas, and two large hematomas. Control for all femoral and distal external iliac artery lesions was obtained solely through a groin incision in 45 (82%) patients. Our technique for exposure of the external iliac artery through the groin is described. A separate retroperitoneal incision was necessary in 10 patients because of proximal injury, massive pseudoaneurysm, morbid obesity, or heavily scarred groins. In this series 34 lateral suture repairs, 11 interposition or bypass grafts, four patch angioplasties, one endarterectomy, three thrombectomies, and two hematoma evacuations were performed. Although no limb loss occurred, we encountered nine wound complications, five myocardial infarctions, and two deaths. CONCLUSIONS: This experience shows the wide variety of vascular complications caused by percutaneous procedures and the different techniques necessary for their management.

Adolescent↗
PubMed1992

Risk of prophylactic contralateral carotid endarterectomy.

Fifty-eight patients underwent a prophylactic contralateral carotid endarterectomy following an initial endarterectomy for symptomatic (38 patients) or asymptomatic (20 patients) carotid stenosis. No deaths occurred after either operation. Two (3.4%) minor neurologic deficits occurred after the initial operation and two (3.4%) major and two (3.4%) minor deficits occurred after the prophylactic contralateral carotid endarterectomy. Sixteen (28%) of the initial endarterectomies were associated with perioperative hyper- or hypotensive episodes compared to 35 (60%) of the prophylactic contralateral carotid endarterectomies (p less than 0.001). We did not document an increased risk of surgery in patients undergoing prophylactic contralateral carotid endarterectomy soon after the initial operation. All four neurologic events following a prophylactic contralateral carotid endarterectomy occurred when the operation was performed more than five weeks after the initial endarterectomy. The incidence of perioperative hyper- or hypotension was similar in patients undergoing prophylactic contralateral carotid endarterectomy less than or greater than five weeks after the first operation. Our results suggest that a prophylactic contralateral carotid endarterectomy may be associated with a higher incidence of neurologic complications and hyper- and hypotensive episodes than the initial carotid endarterectomy. Waiting more than five weeks to repair a contralateral asymptomatic carotid stenosis may not enhance the safety of the operation.

Adult↗
PubMed1992

Arterial and ischemic aspects of total knee arthroplasty.

Prospective and retrospective analyses of 1,182 consecutive patients undergoing primary total knee arthroplasty (TKA) were performed to determine (1) the incidence of chronic lower extremity ischemia (CLEI); (2) the effect of tourniquet occlusion; and (3) guidelines that will allow TKA to be performed safely. Despite the appropriately advanced age of our patients, the incidence of CLEI was only 2%. All ischemic complications occurred in six patients with CLEI (25%), but none resulted in death or amputation. The ischemic complications consisted of pressure-induced necrosis of toes, heel, or foot, atheroembolism, femoral-popliteal graft occlusion, and asymptomatic popliteal occlusion. Tourniquet compression in the 1,158 patients without CLEI produced no untoward effects. Patients with mild CLEI can have a TKA performed safely with a tourniquet if there is no femoropopliteal calcification. When the ischemia is severe or there is a femoropopliteal aneurysm, arterial reconstruction should precede the TKA. In patients with patent femoral-popliteal bypasses or calcification without ischemia, TKA should be performed without a tourniquet. Ischemic pressure necrosis is an additional mechanism of injury.

Adult↗
PubMed1992

Management of infected lower extremity autologous vein grafts by selective graft preservation.

Between 1975 and 1991, we treated 16 patients with infected lower extremity autologous vein grafts performed for limb salvage by complete graft preservation. Traditional treatment of these infections includes immediate graft excision and complex revascularization procedures to prevent limb loss. The infection involved an intact anastomosis in 12 patients or the body of a patent graft in 4 patients. None of the patients was systemically septic. All patients were treated with appropriate intravenous antibiotics. Six patients were treated by placement of autologous tissue on the exposed graft (4 rotational muscle flaps, 2 skin grafts), and 10 were treated with antibiotic-soaked dressing changes and repeated operative débridements to achieve delayed secondary wound healing. This treatment resulted in a 19% (3 of 16) mortality rate and an 8% (1 of 13) amputation rate in survivors. Of the six patients managed by autologous tissue placement onto the infected graft, five patients had wounds that healed without complications, and one died of a myocardial infarction. Of the 10 patients treated by delayed secondary wound healing, 2 developed anastomotic hemorrhage, which resulted in death in 1 patient and above-knee amputation in the other, 1 died of a myocardial infarction, 1 developed graft thrombosis, and 6 had wounds that healed. Placement of autologous tissue to cover an exposed, infected patent vein graft with intact anastomoses may prevent graft dessication, disruption, and thrombosis, which renders graft preservation an easier, safer method of treatment compared with routine graft excision.

Aged↗