Biomedical subjects

R J Feldhaus

Publications and source records attributed to R J Feldhaus.

At least 37 records · Page 2Linked to original sources

PubMed1990

Sealed rupture of abdominal aortic aneurysms.

Sealed rupture of abdominal aortic aneurysms, even if uncommon, deserves particular attention for the possibility of misdiagnosis and for the deleterious effects of such a misdiagnosis. Sixteen patients (mean age 72 years; range 65 to 84 years) with chronic sealed rupture of abdominal aortic aneurysms are reported. Two patients had acute rupture of the aneurysm, and at operation chronic contained rupture was found along with the recent hemorrhage. One patient died after surgery. The remaining patients underwent successful resection with long-term survival and regression of symptoms. Consideration of sealed abdominal aortic aneurysm rupture should be included when examining elderly patients with history of unexplained back pain or femoral neuropathy. Computed tomography is a useful aid in the diagnosis of sealed rupture. Ultrasonography is less accurate; in three patients ultrasonography failed to diagnose the presence of the rupture.

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PubMed1989

Percutaneous transluminal angioplasty versus surgery for subclavian artery occlusive disease.

Twenty-one patients who underwent percutaneous transluminal angioplasty (PTA) for proximal stenosis of the subclavian artery were compared with 15 patients who underwent carotid subclavian reconstruction. This represents the first attempt to directly compare the two procedures. All patients had routine Doppler examination during follow-up. Mean follow-up was 30 +/- 24 months after PTA and 40 +/- 25 months after surgery. The incidences of procedural complications were similar (PTA one complication, surgery two complications). Although better early results were achieved in patients who underwent PTA (actuarial patency: PTA 91 percent, surgery 87 percent), after dilatation, we observed a continuous deterioration of the hemodynamic status of the artery, which led to a high rate of late restenosis (actuarial patency: PTA 54 percent, surgery 87 percent). There were no significant changes postoperatively. The specific role of each procedure is analyzed in view of the new acknowledgment of the clinical importance of proximal subclavian artery disease.

Angioplasty, Balloon↗

PubMed1989

Extrathoracic and transthoracic management of vascular disease of the aortic arch branches: a 16-year experience.

To determine factors influencing results of operation for proximal brachiocephalic arterial disease, a 16-year review of 74 consecutive patients was undertaken. A total of 62 subclavian, 14 common carotid, 6 innominate, and 2 vertebral arteries were revascularized during 79 procedures. The approach was transthoracic in 12 operations and extrathoracic in 67. Mean follow-up was 57 +/- 45 months. Two patients (2.5%) died of stroke after extrathoracic revascularization of the common carotid artery. Cumulative 5-year and 10-year freedom from neurological events was 81% and 75%, respectively. The best results were obtained with transthoracic procedures, with revascularization of the subclavian artery rather than the common carotid artery, and in operations performed in patients without associated distal carotid disease. In view of the recent progress in operative techniques and postoperative surgical care, the choice between the transthoracic approach and the extrathoracic approach should not be biased; rather, they should remain equal and viable alternatives based on anatomical and clinical features of the individual patients.

Adult↗

PubMed1989

Inflammatory aneurysms of the abdominal aorta: incidence, pathologic, and etiologic considerations.

Among 486 patients undergoing repair for abdominal aortic aneurysm (AAA) during a 12-year period, 30 (6.2%) had evidence of "inflammatory" AAA. One patient (3%) had acute rupture, and six patients (20%) had chronic contained rupture. Ureteral obstruction was evident in 20% of the patients. In the early period of the study there were two postoperative deaths and operative time and blood loss were significantly increased. In the last period of the study, no attempt was made to separate the duodenum and the ureters from the aneurysm; there was no operative mortality, and operative time and blood loss were similar to that of patients with atherosclerotic aneurysms. In 23 of 100 specimens of atherosclerotic AAA, microscopic findings resembling inflammatory AAA were found. On the basis of our study we conclude the following: (1) Inflammatory AAAs are simply atherosclerotic aneurysms that show an unusual accentuation of the chronic inflammation observed in relation to atherosclerotic aneurysms. (2) Operative technique should be modified to avoid excessive dissection and lysis of ureters and duodenum. (3) Excellent early and late results can be expected with proper surgical technique. (4) The causes of AAA are multiple, and chronic contained rupture of the aneurysm and reactive lymphatic hyperplasia might play a role of greater significance than previously thought.

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PubMed1989

A rare endobronchial neurilemmoma (Schwannoma).

Primary neurogenic tumors of the lung are rare. Often, their histologic behavior presents a treatment dilemma. We present a case of benign endobronchial neurilemmoma managed by means of YAG laser resection together with a brief discussion of the management options available for these tumors.

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PubMed1989

Natural history of recurrent carotid artery disease.

Controversy exists as to whether early and late recurrent stenosis of the carotid artery represents two distinct types of recurrence or whether it is the same type of lesion detected at different times. Eleven specimens from patients whose carotid arteries were reoperated upon were examined. A temporal sequence was noted: with increasing intervals, the relative presence of areas of myointimal hyperplasia tended to decrease, whereas the relative presence of features of atherosclerosis tended to increase. The clinical data and B-mode ultrasound studies performed from one to 190 months after 210 carotid endarterectomies were reviewed. Twenty-seven carotid arteries (12.9 per cent) exhibited hemodynamically significant restenosis. Three ultrasonographic patterns were described: homogenous soft plaque, homogenous hard plaque and heterogenous plaque. A previous correlation between ultrasonographic and pathologic findings showed the three ultrasound patterns to correlate with myointimal hyperplasia, fibrous atherosclerotic plaque and complex atherosclerotic plaque, respectively. Soft plaques were detected earlier than heterogenous plaques (p less than 0.001). Results from serial studies showed progression of soft plaque to hard or heterogenous plaque, or both. Early and late recurrent lesions are the same type of lesion detected at different intervals. Symptoms of cerebral ischemia are more common at the stage of heterogenous plaque (p = 0.02).

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PubMed1989

Operative strategies in patients with symptomatic internal carotid artery occlusion.

A 15-year experience with 98 patients who underwent extracranial artery reconstruction for symptomatic internal carotid artery occlusion is reviewed. Thromboendarterectomy of the occluded carotid artery resulted in unacceptably high mortality and morbidity rates, and long-term patency of the internal carotid artery was rarely achieved. Carotid endarterectomy on the side opposite the occlusion proved to be successful in relieving nonlateralizing symptoms of cerebral ischemia, whereas results were less encouraging in patients with focal symptoms in the hemisphere ipsilateral to the occlusion. External carotid artery reconstruction on the side of the occlusion was successful in relieving focal symptoms. Surgical treatment in patients with symptomatic internal carotid artery occlusion should be planned in each patient on the basis of symptoms and anatomic pattern.

Actuarial Analysis↗

PubMed1989

Popliteal aneurysms.

A 15 year experience with 50 popliteal aneurysms in 36 patients is reviewed. Forty-seven popliteal aneurysms were atherosclerotic while three were related to entrapment of the popliteal artery. Fourteen asymptomatic popliteal aneurysms were observed preoperatively during a mean period of 26 months. Ischemic complications developed in five of these. At admission, 16 limbs were asymptomatic (group 1) while the other 34 limbs presented with ischemic symptoms (group 2). No operation was performed upon three limbs, and another two were surgically explored and amputated. No operative deaths resulted from 45 vascular reconstructions. Results from follow-up study of one to 176 months (a mean of 57 months) revealed a late patency rate of 62 per cent. The late patency rate of autologous saphenous vein (ASV) was 100 per cent; polytetrafluoroethylene (PTFE) and Dacron (polyester fiber) grafts had a patency rate of 74 and 34 per cent, respectively (ASV versus PTFE, p = N.S.; ASV versus Dacron, p less than 0.002). The rate of late salvage of limbs was 88 per cent. The bypass grafts of group 1 and those performed upon limbs with good runoff fared significantly better than others (p less than 0.05 and p less than 0.001). The risk of natural complications of popliteal aneurysms and the good results from surgical treatment suggested that a revascularization procedure in the asymptomatic stage is always recommended. The use of PTFE grafts for repair of popliteal aneurysms is justified when the ASV is not available. The use of Dacron grafts is no longer indicated.

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PubMed1989

Subclavian artery revascularization: a comparison between carotid-subclavian artery bypass and subclavian-carotid transposition.

Extrathoracic revascularization has become the most popular form of surgical treatment of symptomatic subclavian disease. Despite the many theoretical advantages, subclavian-carotid transposition (SCT) has not gained wide popularity. During a 15-year period, 46 patients underwent carotid-subclavian bypass (CSB) or SCT for symptoms referable to occlusion of the subclavian artery. Follow-up ranged from 2 to 148 months (mean, 46.9 months). Seven-year actuarial patency rate was 100% for SCT and 86% +/- 7% for CSB (p = NS). Mean operative time and intraoperative blood loss were significantly reduced for SCT (p less than 0.05). After CSB a continuous deterioration of the hemodynamic status of the reconstruction was noted, whereas there were no significant changes after SCT (p less than 0.05). Whenever feasible, SCT should be considered the operation of choice for patients with symptomatic severe subclavian artery disease.

Adult↗

PubMed1988

Combined aortofemoral and extended deep femoral artery reconstruction. Functional results and predictors of need for distal bypass.

In patients with combined aortoiliac and femoropopliteal occlusive disease, severe involvement of the deep femoral artery (DFA) has often been considered an indication for simultaneous aortofemoral and femorodistal bypass grafting. In 73 patients (87 limbs) with multilevel disease, extended DFA reconstruction was performed with aortofemoral bypass. Five-year actuarial patency of the reconstructions and overall five-year actuarial limb salvage were 62.2% and 60.2%, respectively. Of 20 variables tested, four were significantly associated with the functional outcome of the procedures. Multivariate analysis identified two factors as predictive of outcome independently from other variables: preoperative ankle-brachial pressure index and angiographic status of the below-knee popliteal artery. However, in case of reoperation for occluded aortofemoral graft, these factors lost their validity. Extended DFA reconstruction is a valuable and durable procedure able to provide an adequate outflow and distal perfusion. Careful judgment in each clinical situation will aid in selecting a small group of patients in which simultaneous femorodistal bypass is required.

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PubMed1988

Identification of abdominal aortic aneurysm patients with different clinical features and clinical outcomes.

To determine the clinical characteristics and factors influencing outcome in patients with atherosclerotic abdominal aortic aneurysms (AAA), 526 patients who underwent aneurysmal resection were retrospectively reviewed: Group I had clinical evidence of atherosclerotic occlusive disease; Group II had no evidence of atherosclerotic occlusive disease. The incidence of ruptured AAA, multiple aneurysms, and a family history of AAA was higher in Group II patients. We concluded that patients with AAA and without atherosclerotic occlusive disease in other areas represent a subgroup with peculiar clinical characteristics. In planning operative treatment and during the follow-up period, it should be kept in mind that Group II patients have a higher incidence of aneurysm rupture; the incidence of late pseudoaneurysm is higher; and there is a greater possibility of aneurysm in other arterial segments. It remains to be seen if the pathogenetic mechanism of AAA formation in Group II patients is different from that in Group I patients.

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PubMed1988

Early and late results in patients with carotid disease undergoing myocardial revascularization.

A ten-year review of 1,360 patients undergoing coronary artery bypass grafting (CABG) by the same surgeon was undertaken. Sixty-two patients with symptoms of coronary artery insufficiency underwent carotid endarterectomy prior to or at the time of CABG (Group I). Ninety-seven patients had asymptomatic carotid bruits but did not undergo carotid endarterectomy (Group II). Sixty of these patients were studied by ultrasonic duplex scanning or ocular pneumoplethysmography or both, and hemodynamically significant stenosis was detected in 50 (Group IIa). Group III included 80 patients without carotid artery disease matched with Group II for sex, age, and clinical status. Group IV consisted of 200 patients without carotid artery disease randomly selected from our series. Follow-up ranged from 3 to 120 months (median, 41 months). In patients with proven carotid artery disease (Groups I and IIa), operative mortality was greater than in the patients randomly selected (Group IV) (p less than 0.05) but similar to that in the matched Group III. Late neurological deficits were greater in patients with carotid disease not undergoing carotid endarterectomy (p less than 0.01). Patients with carotid artery disease had lower survival than Group IV patients (p less than 0.01) but similar survival to that in the matched Group III. This study suggests that (1) asymptomatic patients with carotid artery disease who undergo CABG are not at increased risk of perioperative stroke; (2) these same patients are at increased risk of late neurological deficit; and (3) carotid artery disease is an indirect sign of severe associated disease and therefore is associated with increased operative mortality and decreased life expectancy.

Adult↗

PubMed1988

External carotid endarterectomy: indications, technique, and late results.

In the past 14 years, 22 patients (25 operated sides), with occlusion of the internal carotid artery (ICA), underwent ipsilateral external carotid artery (ECA) endarterectomy at our institution. Operative indications were amaurosis fugax in 13 sides and nonlateralizing transient ischemic attacks in the remaining 12. There were no operative deaths. One patient suffered a minor stroke after operation. Follow-up ranged from 6 to 110 months (median 36 months). In 16 cases, simple endarterectomy with or without vein patch closure was performed (type I). In two cases the ostium of the ICA was occluded with interrupted sutures after endarterectomy (type II). In the remaining seven cases the ICA was transposed as a patch over the endarterectomized ECA after endarterectomy (type III). All but six patients (six sides) underwent duplex scanning or angiography during follow-up. Four of nine patients with previous nonlateralizing symptoms had persistent symptoms after operation, whereas none of those with previous amaurosis fugax did. Recurrent occlusive disease was more common in type I reconstructions (p less than 0.05). Proper ECA reconstruction results in long-term patency. In the patient with ipsilateral ICA occlusion, transposition of the ICA as a patch over the endarterectomized ECA offers a valid hemodynamic solution. Objective parameters are needed to identify patients with nonlateralizing symptoms who will benefit from operation.

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PubMed1988

Asymptomatic carotid artery stenosis on the side contralateral to endarterectomy. A comparison between patients with and those without operation.

From May 1974 to October 1983, 82 patients with severe bilateral carotid disease had unilateral carotid endarterectomy (CE) on the symptomatic side (group I). The carotid artery contralateral to the endarterectomy was severely stenosed (lumen diameter reduction 51% up to 99%) and it was not repaired for different reasons. Group I patients were compared with 78 patients who had bilateral CE (group II), matched with group I for associated diseases, operative indication, and angiographic findings. In this analysis, only neurologic deficits referable to the contralateral hemisphere were considered. There was a higher incidence of later neurologic deficits in the group I patients; however, this difference was not statistically significant. In group I, the occurrence of late neurologic deficits was statistically correlated to (1) severity of stenosis, (2) presence of large compound ulceration, and (3) history of previous stroke. Stepwise logistic regression analysis identified two groups of patients at higher risk for late neurologic deficits (1) patients with stenosis 75% or greater and large ulceration and (2) patients with stenosis 75% or greater and previous stroke. CE on the asymptomatic contralateral side should be considered in selected patients at high risk for late neurologic events at a surgical center with an established low incidence of perioperative complications. A nonoperative policy with careful follow-up is warranted in the remaining cases.

Carotid Arteries↗

PubMed1988

Ultrasonographic features of carotid plaque and the risk of subsequent neurologic deficits.

In a prospective study, 214 consecutive patients considered not to be candidates for surgical intervention were evaluated by means of duplex scanning. Of the patients, 135 had no symptoms and 79 had a history of previous neurologic symptoms. In 139 sides duplex scanning demonstrated nonhemodynamic stenosis (lumen diameter reduction, less than 50%) and in 99 sides, hemodynamic stenosis (lumen diameter reduction, 50% or greater). Of the 238 carotid artery plaques examined, 167 were homogenous and 71 were heterogenous. During a mean follow-up of 34 months, 27 new focal neurologic deficits occurred. Patients with previous symptoms had a higher incidence of new deficits (18/79 vs 9/135) (p less than 0.01). The severity of the stenosis and the presence of a heterogenous plaque were statistically correlated with the occurrence of new deficits (p less than 0.001). Multivariate analysis showed that the ultrasonographic pattern and the severity of the stenosis were independent variables. We conclude that a heterogenous plaque should be considered an unstable plaque with the possibility of causing cerebral ischemia.

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PubMed1988

Carotid endarterectomy in octogenarians and nonagenarians.

Experience with carotid endarterectomy (CE) in patients 80 years of age and older is analyzed by reviewing results in terms of patient survival, quality of life and recurrence of symptoms of cerebral ischemia. During a 12 year period, 90 octogenarians underwent CE. Ages ranged from 80 to 93 years with a mean of 83 years. Two groups of patients younger than 80 years of age were selected from the series for comparison. There were no differences between age groups with respect to operative mortality and morbidity, with two deaths and one stroke in the elderly group. Follow-up periods ranged from one to 120 months with a mean of 39 months. There were two late strokes in patients older than 80 years of age. At late follow-up study, 87 per cent of patients operated upon for hemispheric symptoms were free of neurologic deficits; in contrast, only 67 per cent of those operated upon for nonhemispheric symptoms were symptom-free (p less than 0.05). The incidence of occlusive disease of the intracranial portion of the internal carotid artery was higher in the elderly group (p less than 0.01). The presence of intracranial occlusive disease represented an unfavorable factor in regard to the results of CE in patients with nonhemispheric symptoms. The over-all five year survival rate was 60 per cent. These data indicate that advanced age alone should not be considered a contraindication to CE. Excellent results should be expected in instances of operations performed for hemispheric symptoms. In instances of nonhemispheric symptoms, results are less encouraging because of the high incidence of intracranial carotid occlusive disease.

Actuarial Analysis↗

PubMed1987

Factors influencing enlargement rate of small abdominal aortic aneurysms.

The purpose of this study was to determine the factors influencing enlargement rate of small abdominal aortic aneurysms. Fifty-seven high-risk patients with asymptomatic abdominal aortic aneurysms initially measuring 3.5 to 5.9 cm in the largest transverse diameter were followed with serial echographic measurements for 6 to 78 months (mean 24). The mean enlargement rate (MER) and the occurrence of sudden change in size (SCS) for each aneurysm were correlated to 23 variables. MER ranged from 0 to 1.8 cm/year (mean 0.48). During the study period 17 aneurysms showed SCS. The results of univariate analysis indicated that 8 variables were statistically correlated to the degree of MER and 5 to the occurrence of SCS. A multiple regression model was generated by stepwise regression analysis and demonstrated that 2 variables were independent predictors of the degree of MER: (1) the absence of distal arterial occlusive disease and (2) the ratio of the diameter of the aneurysm to that of the aorta (RD). The overall model P value was less than 0.001. A statistically valid multiple regression model to predict the occurrence of SCS was not feasible (P = 1.0). We conclude that the occurrence of SCS of small abdominal aortic aneurysms is often unpredictable and that the RD rather than the value of the aneurysmal diameter per se must be considered in selecting high-risk patients for echographic follow-up.

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PubMed1987

Reoperation for femoral anastomotic false aneurysm. A 15-year experience.

An experience on the surgical treatment of anastomotic false aneurysms during the last 15 years was reviewed. Fifty-nine were femoral anastomoses complicated by false aneurysm appearance requiring surgical excision. They represented 2.9% of all femoral anastomoses performed, whereas they represented 3.3% when considering reconstruction in which the femoral artery was the distal anastomosis. Reconstructions with distal anastomosis performed on the femoral artery were primarily involved (58 of 59), whereas grafts with "take off" from the femoral artery were rarely affected (p less than 0.05). A higher incidence of false aneurysm formation was demonstrated in hypertensive patients (p less than 0.05) as well as those who previously had femoral thromboendarterectomy (p less than 0.01). Infection was considered a causative factor even if it developed before (6-14 months) false aneurysm appearance. When a false aneurysm was resected, the best hemodynamic reconstruction, to avoid recurrence, was considered a bypass with distal anastomosis performed end-to-end on the femoral artery (p less than 0.05). The surgical treatment of choice was false aneurysm resection and graft interposition. However, a reanastomosis in the presence of small false aneurysms, when technically possible, has been successfully performed. Both treatments allowed good long-term results.

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