Biomedical subjects
Publications and source records attributed to R E Fry.
Traumatic injuries to the abdominal arteries require operative exposures that allow for flexible repair. Dividing the abdominal arterial tree into four zones, based on exposure, provides expedient and precise repair of all major abdominal arteries.
Thirty-eight hip disarticulations performed in 34 patients were retrospectively reviewed. The indications were ischemia secondary to atherosclerosis in 17 cases, femoral osteomyelitis in 10, and trauma in 11. Patient ages ranged from 20 to 95 years. The mortality was 60% in patients with ischemia with preoperative infection, 20% in patients with ischemia without preoperative infection, 22% in patients with femoral osteomyelitis, 100% in patients with trauma with preoperative infection, and 33% in patients with trauma without preoperative infection. The overall mortality was 44%. Postoperative wound infections were frequent (63%) and had poor correlation with the presence of a preoperative wound infection. No patient was able to use a prosthesis after hip disarticulation, but most were independent in wheelchairs.
Two cases of multiple inflammatory aneurysms in young patients without evidence of autoimmune disease or an aneurysmal syndrome are presented. Neither case showed any clinical or histologic characteristics typical of Ehlers-Danlos syndrome, Marfan's syndrome, Takayasu's arteritis, or other aneurysmal syndromes. Pathologic findings showed adventitial and medical destruction in both patients; although the first case displayed more adventitial involvement, the second showed greater destruction of the medial elastic laminae. The decision to repair an aneurysm should be tempered by its location, the amount of involvement of the artery with multiple lesions, and the risk to the end-organ if repair is unsuccessful.
To determine the efficacy of extending vascular reconstruction to the pedal vessels, the records of 115 in-situ saphenous vein bypasses to the infragenicular vessels were examined. Ninety-four percent were performed for limb-threatening ischemia and 6 percent for claudication. Ninety-one bypasses were to tibial vessels in the calf (Group 1), whereas severe disease of the tibial vessels in the calf necessitated bypass to arteries at the ankle and beyond in 24 (Group 2). Life-table analysis was used to calculate limb salvage, graft patency, and functional status for Group 1 and Group 2 36 months postoperatively; there were no statistical differences between groups with regard to these variables (p = 0.38). Diabetes had no impact on the success of reconstruction, and preoperative noninvasive testing was not predictive of graft failure in either group. Significantly, limb salvage closely paralleled graft patency and functional status, illustrating the severe disease in all patients. Patients with severe tibial-peroneal atherosclerosis may benefit from bypass grafting to the pedal arteries with a success rate equal to those done to more proximal sites.
During a 4-year period, 136 patients undergoing 152 carotid endarterectomies consented to be randomized to primary or saphenous vein patch closure of the arteriotomy. At operation, before randomization, careful assessment of arterial dimensions and anatomy was made. Patients who had an internal carotid artery (ICA) diameter less than 5 mm, arteriotomy extending more than 3 cm beyond the origin of the ICA, or tortuous or kinked ICAs were not randomized; they received obligatory vein patch closure (necessary in 20% cases). All patients were followed up every 3 months for 1 year and every 6 months thereafter with duplex scanning, ocular pneumoplethysmography, and neurologic assessment. The incidence of atherosclerotic risk factors was equal in the groups and all except one of the patients were male. Perioperative morbidity was not significantly different among those having primary closure (n = 60), saphenous vein patch closure (n = 62), and obligatory vein patch closure (n = 30). Operative time among patients having primary closure (122 +/- 4 minutes) was significantly less (p less than 0.001) than among those having saphenous vein patch closure (150 +/- 3 minutes). Three perioperative strokes were evenly distributed among the groups (2% for all procedures); no deaths and no acute postoperative occlusions occurred. Recurrent disease occurred in 12.9% of patients having saphenous vein patch closure compared with its occurrence in 1.7% of those having primary closure (p less than 0.05). However, most recurrences were moderate stenoses (25% to 50% diameter reduction), all were smooth-surfaced, and none required a second operation. All except one of the recurrences among those patients with saphenous vein patch closure were in the bulb and the origin of the ICA; two had evidence of regression. This finding suggested that thrombus layering in the dilated part of the saphenous vein patch reconstruction was the cause. This study demonstrates that in men with carotid arteries of predetermined minimal dimensions undergoing carotid endarterectomy routine saphenous vein patch closure does not produce superior results, is associated with a higher incidence of early recurrence, and increases operative time. In selected patients with anatomic risk factors for recurrent disease or acute postoperative occlusion, saphenous vein patch closure is appropriate.
Explore the source record for details and available documents.
To assess the need for routine preoperative computerized tomography scanning to discern patients with rupture among those presenting with acutely symptomatic abdominal aortic aneurysms, a retrospective review was performed. During a 5-year period, all patients presenting with symptomatic aneurysm underwent emergency operation without preoperative computerized tomography. The mortality rate was not significantly different among patients with symptomatic, intact aneurysms undergoing emergency operation (3 percent) and those without symptoms having elective operation (5 percent). The mortality rate of patients with ruptured aneurysms was 68 percent. We concluded that the addition of preoperative computerized tomography to the clinical evaluation would not have improved these results. Furthermore, since it is expensive and delays emergency operation in patients with ruptured aneurysms, computerized tomography seems rarely indicated in symptomatic patients with obvious aneurysms.
We evaluated the accuracy of duplex ultrasound in the postoperative follow-up of patients after renal revascularization. Between May 1976 and December 1987, 125 adult patients underwent 153 renal reconstructive procedures for renovascular occlusive disease. Technically satisfactory duplex scans were obtained in 49 of 59 patients (84%) at an average follow-up of 32 months (maximum 11 years). Arteriograms were available for correlation in 51 arteries or bypasses in 36 patients. Duplex scans accurately classified 8 of 10 stenotic (greater than 60% diameter reduction) or occluded vessels and 36 of 41 patent vessels. The overall diagnostic accuracy was 86%, sensitivity was 80%, and specificity was 87%. We confirmed previous reports that decreased diastolic flow correlated with advanced renal parenchymal dysfunction. We conclude that a normal duplex scan makes it highly unlikely that arteriography will reveal significant recurrent disease. An abnormal duplex scan, particularly in the presence of hypertension or deteriorating renal function, warrants arteriography.
Although the two-stage amputation technique entails an additional operation, several authors have advocated this approach to deal with wet gangrene because it allows primary wound closure with a reduced chance of wound infection. To examine this issue, 47 patients with necrotizing wet gangrene of the foot were randomized prospectively to receive either a one-stage amputation (definitive below- or above-knee amputation with delayed secondary skin closure in 3 to 5 days) or a two-stage amputation (open ankle guillotine amputation followed by definitive, closed below- or above-knee amputation). Antibiotic coverage was standardized with clindamycin and gentamicin used in all patients. Preoperative blood cultures and intraoperative foot cultures were obtained, as well as cultures from the deep muscle and lymphatic area along the saphenous vein to determine the presence of bacteria at the level of initial amputation. Twenty-four patients (11 diabetic and 13 nondiabetic) were randomized to the one-stage procedure. Twenty-three patients (14 diabetic and nine nondiabetic) were randomized to the two-stage procedure. Five of 24 patients in the one-stage group (21%) had positive muscle cultures vs 10 of 23 patients in the two-stage group (43%). Two of 24 patients in the one-stage group (8%) had positive lymphatic cultures vs 7 of 23 patients in the two-stage group (30%). Five of 24 patients in the one-stage group (21%) had wound complications attributable to the amputation technique vs none of 23 patients in the two-stage group (p = 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
Explore the source record for details and available documents.
Arterial injuries pose the greatest early threat to the patient with penetrating neck trauma and esophageal injuries, the greatest late threat. Clinical evaluation reliably identifies 80 percent of esophageal injuries, which, in our opinion, is not adequate. In 118 minimally symptomatic or asymptomatic patients with penetrating neck trauma, the combination of esophagography with esophagoscopy identified all 10 esophageal injuries in 118 patients with penetrating neck trauma. These data suggest that patients with penetrating neck trauma and minimal clinical findings should be initially evaluated with arteriography and esophagography. If the results of arteriography or esophagography are positive, then neck exploration should be performed. If the results of esophagography are equivocal, then rigid esophagoscopy should be performed. If all test results are negative, then observation is justified.
Thirteen patients with internal carotid occlusion underwent 14 primary external carotid revascularization procedures over a 31 month period. Ten patients had obliteration of their internal carotid stump combined with patch angioplasty of the external carotid artery, and 3 had vein bypasses from the common carotid artery to the external carotid artery. Eleven patients were symptomatic with either amaurosis fugax or hemispheric transient ischemic attacks. Two patients were asymptomatic. All patients had serial carotid noninvasive tests (B-mode ultrasonography, spectral analysis, and oculoplethysmography). The mean follow-up was 22 months. Recurrent amaurosis fugax secondary to recurrent stenoses developed in two patients. These were correctly predicted by B-mode imaging and altered flow characteristics on spectral analysis. Both patients were successfully treated with reoperative procedures to prevent failure of the primary reconstruction. External carotid revascularization is a safe and durable procedure, but careful periodic follow-up is necessary to detect stenoses developing at or remote from the initial operative site. Carotid noninvasive tests appear to be helpful in detecting recurrent disease. Carotid revascularization is superior to other forms of therapy in patients who have development of neurologic symptoms ipsilateral to a chronically occluded internal carotid artery.
The histopathologic characteristics of primary plaques and recurrent carotid disease were studied in 32 patients. These data were related to symptoms, recurrence interval (6 to 176 months), arteriographic anatomy, and in situ operative findings. A striking predilection was noted for recurrent lesions to be located in the internal carotid artery near the origin, but still within the confines, of the original endarterectomy site and suture line. Although recurrence was frequently associated with a long primary arteriotomy, evidence of technical faults or periarterial fibrosis was rare. Early recurrent lesions (recurrence interval less than 36 months, n = 13) had significantly more smooth muscle cells and proteoglycans (p less than 0.001) than late recurrent lesions (recurrence interval greater than 36 months, n = 19). As previously reported, features of atherosclerosis (abundant collagen, calcium deposits, and foam cells) were more pronounced in late recurrences (p less than 0.001). However, the histopathologic differentiation between early and late recurrent carotid disease was indistinct. A continuum was noted whereby characteristics of late recurrent lesions increased in proportion to recurrence interval. All recurrent lesions were easily distinguished from primary plaques in that recurrences had a less orderly arrangement of all elements and lacked the classic topographic features of advanced atherosclerosis. An important feature that differentiated primary and recurrent lesions was the presence of surface and intraplaque thrombus in 90% of recurrent lesions (p less than 0.001). In early recurrent disease, luminal surface thrombus was striking; this was frequently platelet-rich and showed organization devoid of neovascularity. Intraplaque thrombus was more common in late recurrent disease, consisted almost entirely of fibrin, and was often contiguous with luminal surface thrombus. No discernible relationships were noted between thrombus associated with recurrent lesions and the presence or absence of symptoms, treatment with antiplatelet agents, and hypertension. This finding suggests that thrombus was a continuous and intrinsic component of recurrent disease rather than a secondary, complicating feature. Recurrent carotid disease is a progressive lesion that stems from ongoing thrombogenesis occurring at the endarterectomy site. Organized thrombus and smooth muscle cell proliferation comprise the bulk of the lesion, which undergoes atherosclerotic change with time.
From 1976 to 1983, 682 patients have undergone aortic reconstruction at Parkland Memorial Hospital and the Veterans Administration Hospital in Dallas, Texas. Thirty-five patients (5.1%) had a biliary tract operation performed before, during, or after their aortic procedure. Fourteen percent of patients had bacteria in the bile and 11.4% needed common bile duct exploration. Twelve patients had their aortic reconstruction first. Biliary pancreatitis developed postoperatively in one patient. Two patients who had infected prostheses removed had acalculous cholecystitis after operation and one had jaundice and fever 3 years after operation, but no biliary disease was found. Twenty-one patients had the biliary procedure first. Four patients were operated on for suspected aneurysm rupture an average of 18 months after operation. There was one true rupture; this patient had no gallstones. One patient had acute aortic thrombosis 10 days after emergency operation for acute cholecystitis. Only two patients underwent combined operative procedures; both were patients with acute aortic problems in whom chronic and subacute biliary disease was found. Eight operative deaths occurred, all in the patients undergoing aortic procedures. There were no ruptured aneurysms or acute biliary problems needing emergency operation in any patient with cholelithiasis. On the basis of our experience, we believe that concomitant cholecystectomy and aortic reconstructions rarely need to be performed and then only in those patients in whom the risk of not treating both biliary and aortic conditions is greater than the operative risks. In these circumstances, cholecystostomy should be considered to decrease operative time and the risk of graft contamination.
Six patients with unilateral blue toe syndrome presented a diagnostic dilemma with regard to the source of embolization: central aortic versus peripheral. Two patients had moderately severe aortoiliac atherosclerosis associated with focal stenoses in the superficial femoral arteries, and four patients had mild aortoiliac disease associated with localized plaques confined to either the superficial femoral or popliteal arteries. In all patients, it was elected to explore the peripheral lesions first. At operation, ulcerated plaques or focal stenoses were found, and all lesions had adherent white thrombi on their surfaces. All patients were treated either by localized thromboendarterectomy or short reversed saphenous vein grafting. There was no morbidity or mortality. Recurrent embolization did not occur during a follow-up of 8 to 24 months. Distal atherosclerotic lesions should be sought to explain distal embolization before more complex aortoiliac disease is incriminated. In the presence of concomitant aortoiliac disease, it is mandatory to directly explore the peripheral lesion, open the artery, and carefully examine the lesion in situ. Thrombus adherent to the surface of an ulcerated plaque is evidence of an embolizing source. This approach is associated with minimal morbidity and may be curative. If these findings are not present, it would be appropriate to proceed with staged correction of aortoiliac disease.
Colonic ischemia has been reported to occur in 1% to 13% of all cases of aortic reconstruction. To examine intestinal blood flow in aortic occlusion, three groups of dogs were subjected to measurement of hemodynamic parameters and mesenteric blood flow. Group I served as a control group, while group II underwent balloon catheter occlusion of the infrarenal aorta. Group III received intravenous nitroglycerin infusion during and after aortic occlusion. There was no statistically significant change in intestinal blood flow in group I. Small bowel mucosal blood flow fell in group II. Small bowel serosal blood flow was preserved but total small bowel and small bowel mucosal values fell sharply in group III. Ascending and descending colonic blood flow was unaltered in group I but fell significantly in groups II and III. After restoration of normal aortic circulation, small bowel mucosal flow remained significantly below baseline in groups II and III. Ascending and descending colonic blood flow also remained depressed in groups II and III. Both mucosal and serosal blood flow fell and serosal values remained constant in group III. Both groups exhibited decreased total, mucosal, and serosal blood flow in the descending colon after release of the aortic occlusion. These data show that temporary infrarenal aortic occlusion causes significant changes in intestinal blood flow. The mechanism is due to persistent autoregulatory vasoconstriction. Nitroglycerin used for afterload reduction in aortic reconstruction does not ameliorate decreases in intestinal blood flow and may actually shunt blood away from the distal colon and the distal intestinal mucosa during aortic occlusion.
Twenty-four patients with internal carotid artery lesions extending above the second cervical vertebra underwent mandibular subluxation for additional exposure. The original technique of bilateral arch bar wiring requiring 90 minutes for application has evolved into a circummandibular/transnasal wiring technique requiring approximately 10 minutes. Subluxation of the mandibular condyle 10 to 15 mm anteriorly results in displacement of the mandibular ramus 20 to 30 mm anteriorly. This technique provides a marked increase in exposure of the internal carotid artery up to the base of the skull by transforming a triangular operating field into a rectangular field. The technique is quick, easy to perform, and not associated with objective or subjective temporomandibular joint dysfunction.
From 1976 to 1981, 22 patients were treated for atherosclerotic renovascular disease and with widespread atherosclerosis. The average age was 56 years. Preoperatively, the average blood pressure (BP) was 211/123 mm Hg. The standard operation was aortorenal bypass, associated with resection of an abdominal aortic aneurysm in three cases. Four patients had nephrectomy. Most patients were referred after failure of a previous renal revascularization procedure. In three patients, most of the renal arterial system was thrombotic. All patients had preoperative Swan-Ganz catheter placement for monitoring of fluid balance, filling pressure, and cardiac output. Intravenous vasodilators were used to control BP and to reduce the afterload on the left ventricle. There were no operative deaths. The average postoperative BP was 136/81 mm Hg. Three patients had improvement in renal function, and one was able to stop hemodialysis after operation. Because of a low mortality and overall satisfactory results, patients with atherosclerotic renovascular hypertension should be considered for vascular reconstruction.