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Biomedical subjects

R James Valentine

Publications and source records attributed to R James Valentine.

At least 19 recordsLinked to original sources
PubMed2007

Surveillance of small aortic aneurysms does not alter anatomic suitability for endovascular repair.

OBJECTIVE: Small abdominal aortic aneurysms (AAAs; 4-5.4 cm) are more likely to be suitable for endovascular aneurysm repair (EVAR) than large aortic aneurysms (>5.5 cm). The purpose of this study was to determine whether small AAA growth is associated with the development of morphologic characteristics that decrease eligibility for EVAR. METHODS: We studied 54 patients who underwent 2 or more computed tomography scans with 3-dimensional reconstruction during surveillance of small AAAs. Morphologic aortic aneurysm features and changes were measured according to Society for Vascular Surgery reporting standards. Suitability for EVAR was determined by neck anatomy (diameter, length, and angulations), iliac artery morphology, and total aortic aneurysm angulation and tortuosity. RESULTS: The median age of the study cohort was 73 years (interquartile range [IQR], 65-77 years). The median follow-up period was 24 months (IQR, 15-36 months). The median small AAA diameter increased from 44.5 mm (IQR, 41-48 mm) to 48.9 mm (IQR, 45.7-52.0 mm). The median aortic neck diameter increased from 23.0 to 24.0 mm (P = .002), whereas median neck length decreased from 26.5 to 20.0 mm (P = .001). Aortic aneurysm median tortuosity index increased from 1.09 to 1.11 (P = .05). No significant changes in iliac artery morphology occurred. Overall, the anatomic suitability for endovascular repair did not significantly change during the study period (74% vs 69%; McNemar test; P = .25). CONCLUSIONS: Changes in aortic morphology are frequently associated with small AAA growth at mid-term follow-up, but such changes are minor and do not affect overall anatomic suitability for EVAR. These data reveal that continued surveillance of small AAAs does not threaten the window of opportunity for EVAR.

Aged↗
PubMed2006

Computed tomographic angiography has added value in patients with vascular disease.

OBJECTIVE: Computed tomographic angiography (CTA) has the potential to detect unsuspected extravascular pathology in patients with vascular disease. The purpose of this study was to determine the prevalence of unexpected findings, additional associated costs, and alterations in treatment in vascular patients undergoing CTA. METHODS: During a recent 15-month period, 350 subjects (207 men, 143 women; mean age of 66 +/- 14 years) underwent CTA for evaluation of aortic aneurysms (43%), lower extremity occlusive disease (33%), renal artery disease (17%), or aortic graft infection (7%). Unexpected CTA findings were categorized as incidental, clinically important but probably benign, or possibly serious. Medical records were reviewed to determine the outcome of additional testing and to identify alterations in treatment plans. RESULTS: Of the 163 subjects (47%) with positive findings, 95 (27%) were categorized as incidental, 27 (8%) as probably benign, and 41 (12%) as potentially serious. Additional tests were required in 57 subjects (15%) to confirm these results. Seventeen (5%) of the 350 original subjects were ultimately considered to have life-threatening pathology found on CTA, but 11 of these were lost to follow-up. Significant alterations in treatment plan occurred in the six patients with life-threatening pathology and in one other patient with benign disease. CONCLUSIONS: These data suggest that unexpected CTA findings are common in vascular patients. Although few prove to be serious, treatment delays associated with evaluation of benign lesions are modest. Of major concern, one fourth of patients with potentially serious lesions did not undergo further evaluation in this study. Vascular surgeons need to ensure adequate follow-up for their patients with potentially serious extravascular lesions.

Aged↗
PubMed2005

Do resident duty hour restrictions reduce technical complications of emergency laparoscopic cholecystectomy?

BACKGROUND: The impact of resident duty hour restrictions on patient care has not been assessed. STUDY DESIGN: We studied 275 patients undergoing emergency cholecystectomy before and after duty hour regulations instituted by the Accreditation Council for Graduate Medical Education. Operations were stratified into 6-hour intervals from the time in-hospital call began. Procedure-related complications (bile duct injury, cystic duct leak, abdominal hemorrhage, trocar injury, intraabdominal/wound infection, unrecognized retained stone) were the primary outcomes variables. RESULTS: Complications occurred after 7 of 107 (6.5%) operations performed before duty hour restrictions, which was not different from 15 of 168 (8.9%) after duty hour restrictions. In both periods, all complications followed operations that began within the first 18 hours of duty. Patients with complications had longer operative times (p = 0.038) and a higher proportion of operations lasting 120 minutes or longer (p = 0.006). Comparing patients with and without complications, there were no significant differences in patient demographics, operative complexity, or PGY level of the surgeon. Only operative time of 120 minutes or longer retained significance in the multivariable model (p = 0.0023; odds ratio, 4.05; 95% CI, 1.65-9.97). CONCLUSIONS: There was no correlation between imposition of duty hour restrictions and technical complication rates in this study. Duration of operative time of 120 minutes or longer was the only independent marker, suggesting that technical complications are a function of operative complexity, not duration of duty. These data suggest that duty hour restrictions might not have a measurable influence on the surgical complication rate after emergency cholecystectomy.

Adult↗
PubMed2005

Hand ischemia after radial artery cannulation.

BACKGROUND: Hand ischemia is a rare but potentially devastating complication of radial artery cannulation for arterial monitoring. The causes and ultimate outcomes of hand ischemia after radial artery cannulation are unclear. STUDY DESIGN: My colleagues and I reviewed the clinical course of radial cannula-induced arterial thrombosis in eight patients during a recent 5-year period. RESULTS: Mean (+/- SD) duration of radial artery ischemia was 3 +/- 2 days. Injuries were associated with advanced (grade IIb) ischemia that affected the entire hand in four patients and first three digits in the other four patients. Radial artery thrombosis was documented using noninvasive tests or arteriography in all patients. Five injuries were initially treated with thrombectomy and patch angioplasty (n = 4) or vein graft interposition (n = 1); two others were treated nonoperatively with vasodilators, and one was observed without treatment. Three of the four patch angioplasty repairs occluded within 24 hours. Regardless of patency, all patients who survived arterial repairs had continuing ischemia that resulted in digital gangrene or amputation. In contrast, gangrene developed in only one patient treated nonoperatively. CONCLUSIONS: These data show that hand ischemia after radial artery cannulation is associated with high risk of tissue loss or amputation. Operative repair offered no advantage over nonoperative therapy in prevention of digital gangrene in this series. We hypothesize that digital gangrene results from distal embolization from the site of the initial arterial thrombosis, producing ischemia that is not remediated by radial artery revascularization. Nonoperative therapy with vasodilators can be equally effective in treating cannula-induced radial artery injuries in some patients.

Amputation, Surgical↗
PubMed2005

Arterial reconstruction of infected femoral artery pseudoaneurysms using superficial femoral-popliteal vein.

BACKGROUND: Infected femoral artery pseudoaneurysms (IFAPs) secondary to percutaneous arterial access, injection of illegal substances, and from infected synthetic grafts, appear to be increasing in incidence. Ligation of IFAPs without revascularization offers control of infection but may risk limb ischemia. Revascularization with extraanatomic synthetic grafts may risk reinfection and abrupt thrombosis. Excision of IFAPs with revascularization using superficial femoral popliteal vein (SFPV) provides both control of infection and excellent limb perfusion. STUDY DESIGN: A retrospective review was conducted of patients diagnosed with IFAP who underwent resection and revascularization with SFPV at a single medical center. Outcomes measured included reinfection and amputation rate. These were compared with other series using various methods to treat IFAPs. RESULTS: Eleven patients with IFAP were encountered from 1992 to 2004. Mean age was 64 years (+/-10 SD). Five patients developed IFAP secondary to percutaneous arterial access procedures. Four patients developed infected femoral artery pseudoaneurysms secondary to synthetic graft infection. Two patients developed IFAP secondary to injection of illegal substances in the femoral region. All patients had positive wound cultures initially. Staphylococcus was the most common organism found in wound cultures. All patients underwent resection of IFAP with lower extremity revascularization using SFPV. There was no incidence of limb ischemia and no perioperative deaths in this series. CONCLUSIONS: Excision of IFAP with revascularization can be successfully achieved using SFPV. This method may prove to be superior to other methods with apparent higher patency rates and resistance to reinfection.

Aged↗
PubMed2005

Graft-associated hemorrhage from femoropopliteal vein grafts.

OBJECTIVE: The femoropopliteal vein (FPV) graft has been used extensively for large-caliber vascular reconstructions. To date, there have been no reports of anastomotic dehiscence or rupture leading to graft-associated hemorrhage (GAH). In the present report, we review our experience with GAH from FPV grafts to determine the incidence of this problem, to better understand the etiology, and to determine potential methods to prevent this complication. METHODS: All patients undergoing arterial reconstructions with FPV grafts were entered into a registry that included demographics, operative details, complications, and follow-up information. Episodes of GAH that occurred during the period from 1990 to 2004 were studied to determine etiologic factors and outcomes. RESULTS: During the study period, 574 FPV grafts were used for arterial reconstructions in 364 patients. GAH occurred in 11 patients (3%). Onset of GAH ranged from 1 hour to 180 days after operation. The mean blood transfusion requirement for GAH was 10 +/- 4 units. In three patients, the etiology of GAH was purely technical, resulting in a slipped or "popped" tie from a large side branch. In eight patients, the etiology was due to graft disruption secondary to uncontrolled infection and failure of anastomotic healing. Most of these patients were being treated for aortic graft infection. Special risk factors for this complication included malnutrition, ongoing polymicrobial and fungal infections, immunocompromised state, active cancer, steroid treatment, and ongoing graft contamination from gastrointestinal or pharyngeal leaks. Outcomes included four deaths and one stroke. CONCLUSIONS: GAH is a serious complication with high morbidity, mortality, and transfusion requirements. Although technical problems are preventable, FPV grafts, like all biologic grafts, can develop disruption with GAH from ongoing infection, especially in severely immunocompromised patients who are malnourished and have poor healing ability. Strategies for prevention and alternative treatment modalities are appropriate in patients at high risk for GAH.

Aged↗
PubMed2004

Family history is a major determinant of subclinical peripheral arterial disease in young adults.

BACKGROUND: Cardiovascular disease is prevalent in first-degree relatives of young adults with premature-onset peripheral arterial occlusive disease (premature PAD), but it is not known whether the genetic influence is independent of other risk factors, the most prevalent of which is smoking. This study was performed to determine the relative contributions of family history and smoking to the development of occult PAD in siblings of patients with premature PAD. METHODS: The prevalence of occult PAD was determined with carotid, abdominal, and lower extremity duplex ultrasound scanning in 50 asymptomatic siblings (25 men, 25 women) of patients with premature PAD (onset 20 cigarettes/day) and 50 nonsmokers. RESULTS: Duplex ultrasound scans demonstrated raised arterial lesions in 20 asymptomatic siblings (40%), 20 heavy smokers (40%), and 2 nonsmoking control subjects (4%), resulting in 42 affected and 108 unaffected subjects. As expected, smokers were far more likely to have arterial lesions than were nonsmokers (odds ratio [OR], 11.19; 95% confidence interval [CI], 4.1-30.7; P <.0001). Individuals with a family history of premature PAD were almost three times more likely to have arterial lesions than those with no family history of cardiovascular disease (OR, 2.76; 95% CI, 1.3-5.8; P =.006). Stratified and multivariable logistic regression indicated no interaction between smoking and family history, indicating simple additive effects on PAD. CONCLUSIONS: Family history is a major determinant of occult PAD in young adults, and is at least as important as standard atherosclerotic risk factors. A high proportion of heavy smokers have clearly detectable lesions even though asymptomatic. Smoking and family history act additively to increase the risk for premature PAD.

Arteriosclerosis↗
PubMed2004

Deep vein harvest: predicting need for fasciotomy.

OBJECTIVE: Deep thigh veins, including the superficial femoral, superficial femoropopliteal, and profunda femoris veins, are versatile autogenous conduits for arterial reconstruction. Although late venous complications are unusual, deep vein harvest may induce severe venous hypertension and predispose the limb to acute compartment syndrome. The purpose of this study was to define the frequency of fasciotomy in patients undergoing deep vein harvest and to identify clinical predictors of the need for fasciotomy after deep vein harvest. METHODS: Over 9 years, 162 patients underwent arterial reconstruction with deep vein harvested from 264 limbs. Indications for deep vein harvest included aortofemoral reconstruction in 127 patients, brachiocephalic arterial reconstruction in 22 patients, and visceral arterial reconstruction in 13 patients. RESULTS: Fasciotomy was performed in 47 of 264 limbs (17.8%) after deep vein harvest. The prevalence of fasciotomy after deep vein harvest was 20.6% for patients requiring aortofemoral reconstruction, whereas no patients underwent fasciotomy after deep vein harvest for mesenteric or brachiocephalic arterial reconstruction (P =.0068). Fasciotomy was performed in 20.7% of limbs after complete deep vein harvest to a level below the adductor hiatus, but no fasciotomies were performed in patients undergoing subtotal deep vein harvest, ending above the adductor hiatus (P =.0023). The mean preoperative ankle-brachial index (ABI) was significantly lower in limbs requiring fasciotomy (ABI, 0.39 +/- 0.05), compared with patients who did not require fasciotomy (ABI, 0.79 +/- 0.02; P <.0001). Fasciotomy was performed in 76.0% of limbs undergoing concurrent ipsilateral greater saphenous vein (GSV) and deep vein harvest, compared with 11.7% of patients undergoing deep vein harvest alone (P <.0001). The mean volume of intraoperative fluid administered to patients requiring fasciotomy was almost 50% higher than the fluid resuscitation received by patients who did not require fasciotomy (9.6 +/- 1.2 L vs 6.5 +/- 0.6 L; P <.0001). Logistic regression analysis determined that lower preoperative ABI (odds ratio [OR], 60.1; 95% confidence interval [CI], 12.5-289.3; P <.0001) and concurrent harvest of the ipsilateral GSV (OR, 9.9; 95% CI, 3.1-31.3; P <.0001) were predictors of the need for fasciotomy. CONCLUSIONS: One in four patients undergoing deep vein harvest for aortofemoral reconstruction may be expected to develop acute compartment syndrome and require fasciotomy. The risk appears to be greatest in patients with severe lower extremity ischemia and in patients undergoing simultaneous GSV and deep vein harvest. Prophylactic fasciotomy may be appropriate in patients with both risk factors, but vigilance for the development of compartment syndrome after deep vein harvest is required in all patients undergoing deep vein harvest for aortofemoral reconstruction.

Compartment Syndromes↗
PubMed2004

Aortofemoral bypass in young patients with premature atherosclerosis: is superficial femoral vein superior to Dacron?

PURPOSE: Previous studies have documented poor patency rates in "young" patients (age 55 years or younger) with premature atherosclerosis undergoing aortofemoral bypass (AFB) to treat aortoiliac occlusive disease. Given the high reported graft patency rates with superficial femoral vein (SFV) grafts performed because of aortic graft infection, we evaluated the role of SFV grafts for AFB as primary therapy for premature atherosclerosis in a case-control study. METHODS: Over 10 years 31 patients aged 55 year or younger underwent AFB with use of SFV (V-AFB). Case controls consisted of all patients 55 years of age or younger who underwent AFB with use of Dacron (D-AFB) during the same period (n = 80). In all cases this was the initial therapy (no repeat operations). The two groups were well matched for age, sex, weight, preoperative ankle-brachial index, and the comorbid conditions of smoking, coronary artery disease, chronic obstructive pulmonary disease, hyperlipidemia, hypertension, and renal insufficiency. There were more patients with diabetes in the V-AFB group (34% vs 16%; P =.05). Patients in the V-AFB group had more advanced disease, and the surgical indication was more frequently critical ischemia compared with the D-AFB group (90% vs 46%; P <.001). RESULTS: There was only one perioperative death in each group. There were no differences in cardiac, pulmonary, or gastrointestinal complications. However, fasciotomy occurred more frequently with V-AFB (44% vs 1%; P <.001). Surgery time was longer with V-AFB (7.3 vs 4.5 hours; P <.001). Despite these short-term drawbacks, V-AFB proved superior at long-term follow-up. The 5-year primary patency rate was significantly higher with V-AFB than with D-AFB (100% vs 56%; P =.013). There was also a trend for higher limb salvage at 5 years (90% vs 62%). Four graft infections occurred with D-AFB, and none with V-AFB (P =.32). CONCLUSIONS: AFB performed with SFV grafts is a far more durable operation than standard D-AFB in young patients with aortoiliac occlusive disease. However, V-AFB is far more likely to require lower extremity fasciotomy, and takes almost twice as long to perform.

Age Factors↗
PubMed2003

Emerging role of endovascular grafts in complex aortoiliac occlusive disease.

BACKGROUND: Aortobifemoral bypass is the standard therapy for complex aortoiliac occlusive disease. The purpose of this study was to examine the use of endovascular grafts as an alternative to aortobifemoral bypass in patients with advanced aortoiliac occlusive disease at high risk. METHODS: Endovascular grafts were placed in 23 limbs in 22 patients with TransAtlantic Inter-Society Consensus document (TASC) type C and D lesions. All procedures were performed in the operating room, and images were obtained with portable digital fluoroscopy. Surgical exposure of the ipsilateral common femoral artery was performed to enable safe closure of 9F to 12F sheath sites and to facilitate ipsilateral interventions in the distal external iliac artery. Concomitant infrainguinal outflow procedures were performed in 6 patients. RESULTS: Twenty of 22 patients were men; mean patient age was 63.2 +/- 3.2 years. Indications for intervention were rest pain in 12 of 23 limbs and tissue loss in 9 of 22 limbs. Risk factors included hostile abdomen or pelvis in 8 patients, coronary artery disease in 11 patients, end-stage renal disease in 3 patients, and severe chronic obstructive pulmonary disease in 3 patients. Each patient received a mean of 1.6 grafts. Initial technical success was 95.2%, with one technical failure. There was no 30-day mortality. All patients experienced at least one grade improvement per Society for Vascular Surgery reporting standards. Primary patency at 24 months was 84.2% +/- 8.0%, with a limb salvage rate of 95.3% +/- 5.0%. Mean (+/- SD) ankle brachial index improved from 0.49 +/- 0.22 to 0.87 +/- 0.26 (P <.001). CONCLUSION: Endovascular grafting to treat advanced aortoiliac occlusive disease can be accomplished with good clinical outcome and acceptable short-term patency. This endovascular technique can be a viable alternative to conventional surgical revascularization in patients with advanced aortoiliac occlusive disease at high risk.

Aged↗
PubMed2003

Surgical mortality in patients with infected aortic aneurysms.

BACKGROUND: Mortality in patients with infected aortic aneurysms remains high. A number of patient- and infection-specific risk factors for death have been proposed, but none is consistently predictive of poor outcomes. The purpose of this study was to examine the possible contribution of infection-related risk factors and the systemic inflammatory response syndrome (SIRS) to outcomes of patients with infected aortic aneurysms. STUDY DESIGN: Ten patients with infected aortic aneurysms presenting to our institution over a recent 6-year period were studied. Collected data included aneurysm location, culture results, preoperative indicators of SIRS, operative details, and outcomes. RESULTS: Common presenting symptoms included abdominal or back pain and fevers. Aneurysms involved the thoracoabdominal aorta in four patients, the suprarenal aorta in one, the juxtarenal aorta in one, and the infrarenal aorta in four. Seven patients met criteria for SIRS. Repairs included in situ replacement of the infected aneurysm using rifampin-soaked, gel-impregnated Dacron in four patients with thoracoabdominal aneurysms and using autogenous superficial femoral-popliteal vein in five patients with infrarenal aneurysms. Four patients died of sepsis, and six patients survived to discharge after a mean of 23 +/- 12 days in the hospital, followed by extensive rehabilitation. The combination of SIRS and suprarenal extension was present in all four patients who died. CONCLUSIONS: Although rare, infected aortic aneurysms are associated with marked morbidity and mortality. Sepsis is the leading cause of death. A combination of host- and infection-specific variables may be more predictive of outcomes than any single risk factor. Prolonged hospitalization and extended rehabilitation are frequently required in survivors, but longterm outlook is good after successful treatment.

Adult↗
PubMed2003

Comparison of superficial femoral vein and saphenous vein as conduits for mesenteric arterial bypass.

PURPOSE: Gangrenous bowel, intraabdominal sepsis, and previous failed mesenteric bypass are indications for use of an autogenous conduit for mesenteric arterial reconstruction. Saphenous vein (SV) is often used as the autogenous conduit of choice, but it may be prone to graft stenosis or occlusion. Recent experience with superficial femoral vein (SFV) suggests that it is an excellent alternative conduit for major arterial reconstruction. The purpose of this study was to compare the outcomes of SV and SFV for mesenteric arterial bypass. METHODS: During a 7-year period, 26 patients underwent 43 mesenteric arterial bypass procedures with autogenous conduit. SV was used for 23 bypasses (53%), and SFV was used for 20 bypasses (47%). Indications for revascularization included chronic mesenteric ischemia (n = 15; 58%), acute mesenteric ischemia (n = 9; 35%), and mycotic aneurysm of the paravisceral aorta (n = 2; 7%). Three patients (11%) underwent revascularization with SV grafts and two patients (8%) with SFV grafts after previous failed mesenteric bypass. RESULTS: The 30-day mortality rate was 15%. Three deaths occurred after SV bypass for acute mesenteric ischemia, and one death occurred after a SFV bypass for a ruptured paravisceral mycotic aneurysm. Twenty-two surviving patients were followed for a mean of 31 +/- 6 months. Three of 11 patients (27%) who survived after SV bypass had recurrent mesenteric ischemia develop (acute, n = 1; chronic, n = 2) from graft thrombosis at a mean interval of 32 +/- 22 months after surgery. No patient had recurrent symptoms develop after SFV bypass. One of the three patients with SV graft failure died of acute mesenteric ischemia, and the other two patients underwent successful bypass with SFV. Symptomatic graft failure was significantly more likely to occur in patients receiving SV grafts compared with SFV grafts (P <.05). CONCLUSION: SFV yields acceptable clinical outcomes for mesenteric arterial bypass compared with SV. SFV is a viable alternative to SV when autogenous conduit is indicated for mesenteric arterial reconstruction.

Adult↗
PubMed2002

Superficial femoral-popliteal vein as a conduit for brachiocephalic arterial reconstructions.

Revascularization of brachiocephalic arteries with prosthetic graft offers excellent patency for most reconstructions. For complex brachiocephalic reconstructions, such as redo operations or reconstructions for infection, autogenous conduit may be preferable. Occasionally saphenous vein is inadequate or absent. The purpose of this study was to evaluate the indications and intermediate-term outcomes of superficial femoral-popliteal vein (SFPV) as an alternative conduit for brachiocephalic reconstructions. Over a 6-year period, 71 patients underwent carotid, subclavian, or axillary artery bypass. In 18 (25%) of these reconstruction SFPV was used as the conduit. Ten bypasses (55%) were redo operations. Three bypasses (17%) were performed after failed prosthetic grafts. Three grafts (17%) were required in infected patients. Indications for the use of SFPV included inadequate saphenous vein (n = 13), infection (n = 3), and failed prosthetic bypass (n = 3). Thirty-day mortality was 5.5%. The neurologic event rate was 5.5%. During a mean follow-up of 26 +/- 5 months, there were no graft thromboses or graft infections. Revision-free primary patency was 92% at 48 months. Assisted primary patency was 100%. These data suggest that SFPV is a safe, durable conduit for brachiocephalic reconstructions. SFPV yielded excellent results for a disadvantaged patient population.

Adult↗
PubMed2002

Inferior mesenteric artery reimplantation does not guarantee colon viability in aortic surgery.

Reimplantation of the inferior mesenteric artery (IMA) at the time of aortic surgery has been advocated to prevent colon ischemia in patients deemed to have inadequate perfusion of the left colon. The purpose of this study was to determine whether IMA reimplantation is globally protective against colon necrosis. We reviewed the medical records of all patients who were diagnosed with colon ischemia after aortic surgery during a 10-year period. Cases were indexed from the institution's operative database and from the vascular morbidity and mortality registry. Ten patients (eight men, two women; mean age 71 +/- 9 years) were identified during the study period. Five patients (50%) underwent successful IMA reimplantation for inadequate Doppler signals on the antimesenteric border of the sigmoid colon. Five other patients (50%) did not undergo IMA reimplantation because they were deemed to have adequate colon perfusion. Transmural colon necrosis occurred in 6 of the 10 study patients, 4 of whom had IMA reimplantation. Five of the six patients had intraoperative hypotension. Three of the four patients with colon ischemia presenting less than 24 hours after aortic revascularization survived (mortality 25%), but both patients with late colon ischemia died of multisystem organ failure (mortality 100%). Four patients developed mucosal ischemia and did not undergo colectomy. Only one of these had IMA reimplantation. Colon ischemia was detected more than 1 week postoperatively in three patients. All four patients were treated with supportive therapy and antibiotics, and all four survived to discharge after a mean length of stay of 14 +/- 10 days. These data show that IMA reimplantation does not ensure colon viability in aortic surgery. Transmural colon necrosis tends to present sooner than mucosal ischemia and may be attributable to nonanatomic variables such as intraoperative hypotension. Although transmural necrosis is a highly morbid complication after aortic surgery, timely colectomy may lead to survival in some patients.

Aged↗
PubMed2002

Transient advanced mental impairment: an underappreciated morbidity after aortic surgery.

OBJECTIVES: To determine the incidence, risk factors, and associated morbidity of transient advanced mental impairment (TAMI) after aortic surgery. METHODS: We retrospectively studied the charts of 188 consecutive patients undergoing elective aortic reconstruction during a recent 6-year period at a university hospital. All patients were lucid on admission and nonintubated at the time of evaluation at least 2 days after operation. TAMI was defined as disorientation or confusion on 2 or more postoperative days. Preoperative, intraoperative, and postoperative clinical variables were examined statistically for associations with TAMI. RESULTS: Fifty-three patients (28%) had development of TAMI 3.9 plus minus 2.8 days after operation. Stepwise logistic regression analysis selected the following independent predictors for TAMI: age >65 years (odds ratio [OR], 7.9; 95% confidence interval [CI], 2.7 to 23.7), American Society of Anesthesiology physical status classification >3 (OR, 2.8; 95% CI, 1.3 to 5.9), diabetes mellitus (OR, 3.4; 95% CI, 1.2 to 9.8), old myocardial infarction (OR, 2.4; 95% CI, 1.1 to 5.3), and hypertension (OR, 2.3; 95% CI, 1.0 to 5.3). Alcohol consumption was not significantly associated with TAMI. In the postoperative period, patients with TAMI were more likely to have hypoxia (P <.001), a need for reintubation (P <.001), pneumonia (P <.001), congestive heart failure (P =.003), and kidney failure (P =.05). In addition, patients with TAMI had a longer duration of endotracheal intubation (3.7 plus minus 7.8 vs 0.6 plus minus 1.2 days, P <.001), stay in the intensive care unit (8.9 plus minus 9 vs 3.9 plus minus 2 days, P <.001), and postoperative hospital stay (14.8 plus minus 11 vs 9.2 plus minus 5 days, P <.001) than patients without TAMI. Twenty (38%) patients with TAMI were discharged to intermediate-care facilities, compared with 11 (8%) patients without TAMI (P <.001). Postoperative variables conferring the largest relative risks for development of TAMI included oxygen saturation less than 92% (5.4), the need for reintubation (3.3), congestive heart failure (3.3), and pneumonia (3.2). TAMI, conversely, conferred the largest relative risks for development of postoperative congestive heart failure (15.3), the need for reintubation (9.3), pneumonia (7.1), and the need for ICU readmission (3.8). CONCLUSIONS: These data show that TAMI is prevalent among patients undergoing aortic reconstruction and is associated with dramatically increased morbidity and postoperative hospitalization rates.

Adult↗
PubMed2002

The effect of anticoagulation therapy and graft selection on the ischemic consequences of femoropopliteal bypass graft occlusion: results from a multicenter randomized clinical trial.

OBJECTIVE: A recent retrospective study showed that the ischemic consequences of femoropopliteal bypass graft occlusion were more severe with polytetrafluoroethylene (PTFE) than with vein. This study examines this conclusion and whether oral anticoagulation therapy reduces the degree of ischemia after occlusion of PTFE and vein femoropopliteal bypass grafts. METHODS: Four hundred two patients who underwent femoropopliteal bypass grafting (233 PTFE and 169 vein) were randomized to a postoperative regimen of either warfarin (international normalized ratio, 1.4 to 2.8) and aspirin (WASA; 325 mg daily) therapy or aspirin alone (ASA) therapy. The grade of acute ischemia at the time of graft occlusion was assessed with the Society of Vascular Surgery recommended reporting standards (I, viable; II, threatened). Early graft occlusions (<30 days) were excluded. RESULTS: There were 100 graft occlusions (67 PTFE and 33 vein) during a mean follow-up period of 36 months (PTFE) and 39 months (vein). Forty-eight patients were randomized to WASA therapy, and 52 were randomized to ASA therapy. The patients were well matched for age, atherosclerotic risk factors, operative indication, and preoperative ankle-brachial index. Overall, a greater percentage of the PTFE occlusions caused grade II ischemia than did the vein graft occlusions (48% versus 18%; P =.005). The ankle-brachial index at the time of graft occlusion was significantly lower in the PTFE grafts than in the vein grafts (0.28 versus 0.45; P =.001). The patients with PTFE who were undergoing WASA therapy at the time of graft occlusion had less grade II ischemia than did those patients who were undergoing ASA therapy (28% versus 55%; P =.057). However, the incidence rate of severe ischemia after graft occlusion remained greater with PTFE grafts and WASA therapy as compared with all the vein grafts (28% versus 18%). The vein graft occlusions had the same incidence rate of grade II ischemia with WASA therapy as with ASA therapy (20% versus 17%; P = 1.0). CONCLUSION: The ischemic consequences of femoropopliteal bypass graft occlusion are worse with PTFE than with vein. Treatment with WASA therapy lessens the severity of acute ischemia after the occlusion of PTFE graft as compared with ASA therapy but not to the degree seen with vein graft occlusion. Occlusion of femoropopliteal vein grafts is seldom accompanied by severe ischemia and is not improved with WASA therapy.

Aged↗