Biomedical subjects

L A Scher

Publications and source records attributed to L A Scher.

47 records · Page 3Linked to original sources

PubMed1981

Progress in limb salvage by reconstructive arterial surgery combined with new or improved adjunctive procedures.

In the past nine years, 1196 patients whose lower extremity was threatened because of infrainguinal arteriosclerosis have been treated at Montefiore Hospital. In the last six years, limb salvage was attempted in 679 or 90% of 755 patients. Femoropopliteal (318), small vessel (204) and axillopopliteal (29) bypasses were used along with transluminal angioplasty (128) and aggressive local operations to obtain a healed foot. Immediate (one month) limb salvage was achieved in 583 or 86% of the 679 patients in whom revascularization was possible. The 30-day mortality rate was 3%. The cumulative life table (LT) survival rate of all the patients undergoing reconstructive arterial operations was 48% at five years. The cumulative LT limb salvage rate after all reconstructive arterial operations was 66% at five years. The cumulative LT patency rate of femoropopliteal bypasses was not influenced by angiographic outflow characteristics of the popliteal artery but was increased 15% by appropriate reoperations to 67% at five years. Cumulative LT patency and limb salvage rates of small vessel and axillopopliteal bypasses were more than 50% at two years. Of patients undergoing arterial reconstruction, 88% of those who died within five years did so without losing their limbs. Of all the patients in whom limb salvage was attempted, 68% lived more than one year with a viable, useable extremity, and 54% lived over two years with an intact limb. We believe this aggressive approach to limb salvage is justified, and can be undertaken with a low cost in mortality, knee loss and morbidity.

Aged↗

PubMed1981

Superficial femoral and popliteal arteries as inflow sites for distal bypasses.

In a series of limb salvage bypass to the popliteal and infrapopliteal arteries, the superficial femoral and popliteal arteries were used preferentially to provide inflow if these vessels were no more than minimally diseased proximal to the site of bypass origin. Cumulative life-table patency rate at 6 years for popliteal bypasses was 66% for 290 cases originating from the common femoral and 81% for 60 cases originating from the superficial femoral and popliteal arteries (P greater than 0.1). Infrapopliteal bypass patency rate at 5 years was 50% for 129 cases originating from the common femoral artery and 58% for 79 cases originating more distally (P greater than 0.25). When vein grafts alone were considered, patency rates were still not influenced by the site of origin of popliteal and infrapopliteal bypasses. Only 1 of 32 failures of a bypass with a distal origin could have been caused by proximal progression of disease. Because of these findings and multiple advantages that result from using arteries distal to the common femoral for bypass inflow, preferential use of the superficial femoral and popliteal arteries for this purpose is recommended in appropriately selected patients.

Adult↗

PubMed1980

Infected aneurysms of the abdominal aorta.

Infected aneurysms of the abdominal aorta are relatively uncommon, but potentially lethal if improperly managed. Two case reports emphasize the importance of the preoperative aortogram for accurate diagnosis. We stress the principles of total excision of infected tissue and revascularization in uninfected tissue planes. A useful vascular reconstructive technique consisting of unilateral axillofemoral bypass and an ilioiliac anastomosis was used in both patients.

Aged↗

PubMed1980

Phlegmonous gastritis: clinical presentation and surgical management.

Phlegmonous gastritis is an acute inflammatory process of the stomach clinically characterized by acute localized noncolicky epigastric pain, purulent vomiting, fever, and leukocytosis. The disease often occurs in patients with preexisting gastric abnormalities or in the elderly and is easily confused radiologically with infiltrating gastric carcinoma. The mortality exceeds that of any other nonmalignant gastric affliction. Intensive antibiotic therapy followed by early gastric resection is the recommended treatment.

Aged↗

PubMed1979

KMA-Greenfield filter placement for chronic pulmonary hypertension.

Over a period of four years, 23 patients had the diagnosis of chronic pulmonary hypertension made on the basis of elevated resting pulmonary arterial pressures above 30 mmHg mean. Clinical features included dyspnea (100%), previous thromboembolism (43%), congestive failure (39%), venous thrombosis (35%), syncope (30%), lung disease (22%), recent trauma (22%), hemoptysis (17%) and precordial pain (17%). Pulmonary angiograms showed embolic occlusion in all but four patients, who were considered to have primary pulmonary hypertension. KimRay-Greenfield((R)) vena caval filters were inserted in 18 patients. Three of them were in refractory shock at the time, and only the one who had successful intraluminal catheter embolectomy survived. These patients have been followed an average of 23 months with two embolic deaths, one from the right atrium and one bypassing a filter misplaced in the right iliac vein (overall mortality 22%). There has been no other known recurrent embolism, but one patient developed hematuria from the filter. The five patients who did not receive a filter have all died after intervals up to 18 months. Recurrent thromboembolism was documented in three and suspected in one patient with known embolic disease who died suddenly. Regardless of etiologic factors, pulmonary hypertension with cor pulmonale is associated with a high incidence of fatal thromboembolism. In our experience, maximal protection is afforded by long-term anticoagulation therapy and the placement of a venacaval filter.

Adolescent↗

PubMed1979

Surgical implications of acid ingestion.

Ingestion of mineral acid may be accidental or intentional. This form of corrosive usually sears the esophageal mucosa only to produce major injury to the stomach. The prepyloric antrum is almost always injured, but the fundus and cardia may be involved if the stomach is empty at the time of ingestion. Clinically, significant esophageal injury occurs in less than 20 per cent. Initial treatment is supportive, with early operation reserved for patients with severe ingestion in whom gastric necrosis rapidly ensues. In the more typical patient, however, late gastric outlet obstruction still makes surgical therapy mandatory. Subtotal gastrectomy with Billroth I reconstruction is usually possible and is the treatment of choice. Total parenteral nutrition is a useful adjunct.

Adult↗

PubMed1978

Emergency management and sequelae of acid ingestion.

Because it causes immediate pain when taken into the mouth, strong mineral acid is less often swallowed than corrosive alkali, but psychotic, inebriated or determined individuals may consume lethal amounts. Burns of the oropharynx and glottis may lead to asphyxial death. Acid has only superficial effects upon the esophagus but, upon reaching the stomach, flows along the lesser curvature, induces pylorospasm, and pools in the distal antrum. Pyloric stricture is the most common late complication among survivors. Due to the rapidity with which acid acts, local and systemic therapy must be expeditious. Neutralization and demulcification are recommended but no time should be lost if weak alkali is not readily available. Lavage has limited applicability and induced emesis is strictly contraindicated. Aggressive intravenous fluid therapy, antibiotics, and opiates for pain are needed in most instances. Immediate gastrectomy and steroids are controversial but operative intervention is eventually required following most significant ingestions.

Acids↗

PubMedDate not supplied

Utilization patterns with inferior vena cava filters: surgical versus percutaneous placement.

PURPOSE: To determine whether more inferior vena cava (IVC) filters were used after interventional radiologic placement methods became available, and if so, whether this increase could be due to expansion of indications. PATIENTS AND METHODS: A retrospective analysis of the number of filters placed, the method of placement used, the indications for placement, and patient survival was performed during the 3 years before and the 3 years after 1989, the first year filters were placed percutaneously at the authors' institution. RESULTS: From 1986 through 1988, 35 filters were all placed by surgeons in the operating room. From 1990 through 1992, 201 filters were all placed by radiologists in the special procedures suite. In the surgery group, 13 of 35 filters (37%) were placed for contraindications to anticoagulation therapy, 12 (34%) were placed for complications of anticoagulation, and nine (26%) were placed for recurrent thromboembolic disease despite anticoagulation. One filter was placed because of a free-floating thrombus in the IVC. In the radiology group, 98 of 161 patients (60%) underwent placement for contraindications to anticoagulation, 25 (16%) experienced complications of anticoagulation, 28 (17%) experienced recurrent thromboembolic disease, and nine (6%) had a free-floating thrombus. The 6-month survival in patients treated before 1989 was 80% versus 43% after 1989. CONCLUSION: At the authors' institution, filters are now placed exclusively by interventional radiologists. The overall indications for placement remain unchanged. The increase in utilization appears primarily related to more frequent placement in severely ill patients who may not experience considerably improved survival but may benefit from a substantial reduction in the risk of hemorrhagic complications.

Adult↗

PubMedDate not supplied

Five year experience with axillopopliteal bypasses for limb salvage.

Over the last 5 years, we have performed 34 axillopopliteal bypasses to salvage threatened limbs of patients in whom standard anatomic or extra-anatomic bypasses had either failed or were not feasible. The indications for these axillopopliteal bypasses, all of which were performed with 6 mm polytetrafluoroethylene grafts, were: (1) severe atherosclerotic disease of the common, superficial and deep femoral arteries which precluded use of these vessels for inflow or outflow for a standard vascular procedure (15 cases); (2) failed aortofemoral bypass with sufficient fibrosis or disease progression in the profunda femoris artery to prevent its use in a reoperation (7 cases); (3) insufficient hemodynamic improvement and failure to heal a foot lesion after an axillofemoral bypass (9 cases); and (4) sepsis in the groin from a previously infected bypass (3 cases). Graft patency was determined by objective measures. Cumulative life table graft patency rates were 77% at 1 year, 51% at 3 years, and 45% at 5 years. Although these rates are not as good as those for our axillofemoral bypasses (75% at 5 years), 22 limbs revascularized by axillopopliteal bypasses were salvaged with function for 1 year and 9 were salvaged with function for 2 years or longer in situations in which no option other than amputation was available. This justifies the continuing use of axillopopliteal bypass in an effort to salvage those limbs imminently threatened with amputation and in which no standard reconstruction is feasible because of disease or infection.

Aged↗

PubMedDate not supplied

Six year experience with expanded polytetrafluoroethylene arterial grafts for limb salvage.

We have used 822 polytetrafluoroethylene (PTFE) grafts in arterial reconstructions for limb salvage over the last 6 years at Montefiore Medical Center-Albert Einstein College of Medicine, Four hundred and twenty-seven femoropopliteal reconstructions with PTFE had a 6 year cumulative life table patency rate of 55% with follow-up of 76 grafts for more than 3 years and 28 grafts for more than 4 years. Seventy-nine bypasses to the isolated popliteal segment had a 6 year cumulative patency rate of 72%. There were 207 bypasses performed to the tibial, peroneal or dorsalis pedis arteries. Life table patency rates were 55% at 1 year, 40% at 2 years and 37% at 4 years. Ninety-two PTFE femorofemoral and 62 axillofemoral bypasses had 5 1/2 year cumulative life table patency rates of 83% and 75%, respectively. Axillopopliteal PTFE bypasses can salvage otherwise doomed limbs. Thirty-four such grafts had 74% 1 year and 45% 5 year patency rates. The overall infection rate in all 822 PTFE grafts was only 0.5%. Thus, PTFE is a promising vascular prosthetic material which facilitates otherwise difficult or impossible limb salvage procedures.

Adult↗

PubMedDate not supplied

Diagnosis and management of failing lower extremity arterial reconstructions prior to graft occlusion.

In 191 instances, infrainguinal graft occlusion was presumed because of a rethreatened foot, diminished pulses and/or decreased ankle pressure. Routine urgent arteriography revealed 38 instances where the graft was patent (22 vein, 16 PTFE). Ten of these grafts were to the femoral artery, 18 to the popliteal artery and 10 were to infrapopliteal arteries. The deterioration despite a patent graft was due to development of inflow stenosis (15), vein graft lesions (13) or distal disease progression (10). All were treated successfully by percutaneous transluminal angioplasty (30) or simple local operative revisions (8). Cumulative life table patency rates 2 years after reintervention were 89% for failing reconstructions to the femoral artery, 94% for those to the popliteal artery and 89% for infrapopliteal procedures. Comparable rates for limb salvage were 90%, 100% and 100%, respectively. These findings underscore the importance of urgent angiography in suspected lower extremity graft failure. Defects may be detected before real graft occlusion occurs and appropriate interventional treatment can provide important additional periods of limb salvage.

Angioplasty, Balloon↗