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Biomedical subjects

T F O'Donnell

Publications and source records attributed to T F O'Donnell.

At least 19 recordsLinked to original sources
PubMed1992

The effect of suprarenal cross-clamping on abdominal aortic aneurysm repair.

Two hundred five patients who underwent elective abdominal aortic aneurysm repair were divided into two groups: those who underwent infrarenal cross-clamping alone (n = 166) and those who underwent suprarenal cross-clamping alone or combined with infrarenal cross-clamping (n = 39). Mortality was comparable between groups (1.2% for infrarenal cross-clamping vs 2.6% for suprarenal cross-clamping). Transient renal insufficiency was more frequent in the suprarenal group than in the infrarenal group (28% vs 10%), but dialysis rates (3% for suprarenal vs 2% for infrarenal) were similar. Cardiac morbidity was comparable between groups as well. Operating room data reflected the technical challenge of complex aneurysm repairs. The retroperitoneal approach was the preferred exposure in the suprarenal group since better access to the suprarenal aorta may be achieved with this technique. While abdominal aortic aneurysm repairs requiring suprarenal cross-clamping remain a technical challenge, the risks are not formidable and suprarenal cross-clamping should be considered when confronted with difficult periaortic dissection.

Academic Medical Centers↗
PubMed1992

Clinical and hemodynamic results of bypass to isolated tibial artery segments for ischemic ulceration of the foot.

Patients with ischemic ulceration of the foot and no continuous tibial or inframalleolar vessels acceptable for bypass are often treated with primary amputation. We have performed autogenous vein bypass to isolated tibial artery segments (ITAS) in nine patients with ischemic foot ulcers and no other outflow options. We reviewed the clinical and hemodynamic results of these bypasses to assess the efficacy of this approach. Hemodynamic comparisons of these ITAS bypasses were made to a concurrent series of 26 bypasses to intact tibial arteries and 24 inframalleolar artery bypasses assessed during routine follow-up. Eight of the bypasses originated from the above-knee popliteal artery and one from the profunda femoris artery. Recipient vessels were the anterior tibial (seven), peroneal (one), and posterior tibial (one) arteries. Although mean ankle brachial indices (ABI) increased significantly from 0.26 +/- 0.06 preoperatively to 0.75 +/- 0.04 postoperatively (p = 0.0015), ITAS bypass patients had lower mean postoperative ABIs than patients with bypasses to intact tibial (ABI = 0.98 +/- 0.03, p = 0.0001) or pedal arteries (ABI = 1.02 +/- 0.04, p = 0.0005). Similarly, duplex scan-derived peak systolic flow velocities of the ITAS bypasses (mean: 52.9 +/- 5.8 cm/sec) were lower than those of intact tibial artery bypasses (mean: 80.1 +/- 6.1 cm/sec, p = 0.02) but did not differ from those of pedal bypasses (mean: 59.5 +/- 3.5 cm/sec, p = 0.34). No ITAS bypass grafts have failed during a mean follow-up of 12.3 +/- 2.7 months. Although wound healing was prolonged (mean: 3.1 +/- 0.6 months), the wounds of eight of nine patients eventually healed, with three patients requiring minor amputations (one digital amputation and two transmetatarsal amputations). Although the hemodynamic results of ITAS bypass are inferior to those of more conventional bypasses, the early patency rates and successful healing of ischemic wounds confirm that it is a valid alternative in the threatened limb with no other outflow options.

Aged↗
PubMed1992

The variation in vein graft flow velocity with luminal diameter and outflow level.

Duplex scanning has recently been used to monitor the patency of infrainguinal vein grafts. Empirically derived criteria that have been used for identifying the failing graft have never accounted for the effect of vein graft diameter or varying outflow resistance, despite the fact that they are major determinants of flow. We prospectively examined the variation in graft peak systolic flow velocity with graft diameter and outflow level in a consecutive series of 68 patients with 72 normally functioning vein grafts returning for routine follow-up. Images were obtained of vein grafts with a duplex scanner throughout their lengths, and the distal peak systolic flow velocity and intraluminal diameters were recorded. There were 15 popliteal, 26 tibial, and 21 inframalleolar grafts. The mean ankle-brachial index of inframalleolar grafts was 1.01 +/- 0.04 and did not differ significantly from tibial (0.96 +/- 0.03) or popliteal (0.93 +/- 0.06) grafts (p = 0.32). Grafts to the three outflow levels differed significantly in diameter, with inframalleolar grafts measuring 3.95 +/- 0.17 mm, tibial grafts 4.78 +/- 0.21 mm, and popliteal grafts 5.65 +/- 0.38 mm (p = 0.0001). In a similar manner inframalleolar grafts had significantly lower peak systolic flow velocities (59.1 +/- 3.4 cm/sec) than tibial (77.2 +/- 5.6 cm/sec) or popliteal (71.0 +/- 7.6 cm/sec) grafts (p = 0.04). Inframalleolar grafts did not demonstrate a significant correlation (r = -0.21, p = 0.29) between peak systolic flow velocity and graft diameter. Conversely, both tibial (r = -0.49, p = 0.005) and popliteal (r = -0.73, p = 0.002) grafts demonstrated significant inverse correlations.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1992

Late stroke after carotid endarterectomy: the role of recurrent stenosis.

Perioperative stroke after carotid endarterectomy has been well studied, although little information is available regarding later strokes. We determined the etiology of late stroke after carotid endarterectomy by examining the records of those patients in our carotid registry who had a stroke more than 30 days after surgery. Thirty-five (5.1%) of the 688 patients in our registry had a stroke more than 30 days after surgery (mean follow-up, 59.3 months; standard error, 1.8 months; range, 1 to 292 months). The cause of late stroke was established by input from consulting neurologists, CT scanning of the head, magnetic resonance imaging results, angiograms, noninvasive studies, and postmortem examinations. Eight of the 11 strokes of unknown origin were massive fatal events for which no further evaluation was undertaken. Restenosis or occlusion accounted for fewer strokes (3 of 20, 15%) in the 1- to 36-month postoperative interval than in the greater than 36-month interval (8 of 15, 53.7%) (p less than 0.02 by Fisher's Exact Test). These data support the hypothesis that the early pseudointimal hyperplastic lesion is less likely to result in stroke than is later recurrent stenosis, which is usually related to atherosclerosis.

Arteriosclerosis↗
PubMed1992

Long-term results of compression treatment for lymphedema.

Although numerous operations have been devised for lymphedema, most surgeons manage this vexing condition by nonsurgical means. Previous studies by us showed that high-pressure (90 to 100 torr) sequential external pneumatic compression (SEP) reduced both limb girth and volume in a lymphedematous extremity. To assess the long-term effects of a program entailing (1) SEP, (2) elastic compression stockings to maintain the post-SEP girth, and (3) daily skin care, we reviewed the long-term courses of 49 patients managed by one surgeon. Limb girths measured at nine levels on the limb were obtained serially in follow-up (mean 25 months) by an independent observer to provide an objective response to therapy. The relative reduction in lymphedematous tissue was determined by the difference between the pretreatment, postacute treatment, and long-term treatment girths at nine points in the limb. In long-term follow-up, 26 of the patients maintained a full response (reduction at > 3 levels), whereas 10 maintained a partial response (reduction at < or = 3 levels). At late follow-up, calf and ankle girths were reduced by an absolute value of 5.37 +/- 1.01 and 4.63 +/- 0.88 cm in the full-response group and 5.43 +/- 1.58 and 3.98 +/- 1.18 cm in the partial-response group over pretreatment measurements. The degree of subcutaneous fibrosis in relationship to the duration of the edema appeared to influence results greatly. The treatment of lymphedema with SEP and compression stockings is associated with long-term maintenance of reduced limb girth in 90% of patients.

Adult↗
PubMed1992

Routine postendarterectomy duplex surveillance: does it prevent late stroke?

Our recent finding that less than 50% of late postendarterectomy strokes are related to recurrent carotid stenosis led us to question the utility of routine postendarterectomy duplex surveillance (RpCEADS) in the prevention of late stroke. To evaluate our RpCEADS program, we reviewed our postoperative duplex studies and correlated their results with clinical data. A total of 1053 postendarterectomy scans was carried out on 348 carotid arteries (258 patients) (3.0 +/- 0.1 studies/artery) during an average follow-up of 52.6 (+/- 2.3) months. Less than 50% of recurrent carotid stenosis was documented throughout follow-up in 292 (83.9%) of 348 arteries. Recurrent carotid stenosis of greater than 50% or occlusion of either the common or internal carotid artery was noted in the remaining 56 arteries (16.1%). Of the 56 duplex-detected recurrent stenoses, only two (3.6%) resulted directly in an unheralded stroke, whereas eight (14.3%) underwent prophylactic reoperation, eight (14.3%) resulted in transient ischemia requiring reoperation, eight (14.3%) occluded without causing stroke, and 29 (51.8%) remained asymptomatic and did not progress to occlusion. Assuming that each of our eight patients who underwent prophylactic reoperation would have had a stroke if operation had not been carried out and our two unheralded strokes could have been prevented with more rigorous follow-up, RpCEADS might have prevented late stroke related to 10 (2.9%) of 348 arteries in 10 (3.9%) of 258 patients after surgery. All other cases of duplex-detected recurrent carotid stenosis or occlusion were asymptomatic or manifest by transient cerebral ischemia. Therefore RpCEADS cannot be justified as a means of preventing late strokes related to recurrent stenosis.

Carotid Stenosis↗
PubMed1992

Femoral vein valvuloplasty: intraoperative angioscopic evaluation and hemodynamic improvement.

Femoral vein valvuloplasty (FVV) is the operation of choice for primary valvular incompetence, but this procedure is highly operator dependent for judging the competence of the valve repair during surgery. We have reviewed our experience with FVV, focusing on the utility of angioscopic-guided valve repair and hemodynamic results. Nine limbs in six patients underwent superficial FVV. There were four men and two women; the average age was 49 years (range 32 to 62 years). All limbs were Society for Vascular Surgery/International Society for Cardiovascular Surgery clinical stage III (venous ulcer), and descending phlebography showed grade 4 reflux in six limbs, grade 3 reflux in one limb, and grade 2 reflux in two limbs. In addition to FVV, five limbs underwent subfascial ligation of incompetent perforators and three limbs underwent ligation and stripping of superficial varicosities. Two limbs underwent polytetrafluoroethylene wrapping of the valvuloplasty. The last five valvuloplasties underwent angioscopic evaluation of the repair, and the last two procedures were closed valvuloplasties (without venotomy). Follow-up averaged 20.3 months (range 2 to 51 months). In all patients ulcers healed without recurrence. There were two perioperative deep vein thromboses in the polytetrafluoroethylene wrapped repairs. All superficial femoral veins were patent by duplex scanning at the time of follow-up. Venous refill time measured by light reflection rheography did not improve after surgery. Venous filling index measured by air plethysmography showed near normalization (3.83 +/- 0.82) after angioscopically guided FVV.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1992

Comparison of descending phlebography with quantitative photoplethysmography, air plethysmography, and duplex quantitative valve closure time in assessing deep venous reflux.

To assess the role of noninvasive tests--quantitative photoplethysmography, air plethysmography, and quantitative duplex scanning, we compared a group of normal (group N, eight limbs) volunteers to patients with severe chronic venous insufficiency who were stratified according to the degree of reflux seen on the current "gold standard," descending phlebography. Group M (10 limbs) had mild (grades 0 to 2) reflux, and group S (10 limbs) had severe (grades 3 to 4) reflux as determined by phlebography. Quantitative photoplethysmography could identify normal from abnormal limbs but could not distinguish the severity of reflux. Air plethysmography was used to calculate venous filling index, ejection fraction, and residual volume fraction. Ejection fraction was the same in all groups. Venous filling index could not significantly distinguish the degree of reflux (group M vs group S) but increased as reflux increased. Residual volume fraction was considerably higher in group S. Quantitative duplex valve closure time was measured in the superficial femoral and popliteal veins, with the values added together in each limb to give a total valve closure time (TVCT). A TVCT value greater than or equal to 4 seconds correlated best with severe phlebographic reflux, with a sensitivity of 90%, a specificity of 94%, and an accuracy of 93%. This value was confirmed as the best test for venous reflux by receiver operating characteristic curve analysis. Thus in the evaluation of patients with severe chronic venous insufficiency who are candidates for phlebography and surgery, quantitative duplex measurement of TVCT gives the best noninvasive assessment of the severity of deep venous reflux.

Adult↗
PubMed1991

Femorofemoral artery bypass for blunt iliac artery occlusion in a child.

Vascular injuries from blunt trauma are rare in children. This report concerns traumatic occlusion of the common iliac artery with limb-threatening ischemia in a 6-year-old boy sustained while wearing a lap belt. Associated injuries included fracture of the third lumbar vertebra, perforation of the sigmoid colon, and disruption of the anterior abdominal wall musculature. Because of fecal contamination from the colon perforation, revascularization using a subcutaneous prosthetic femorofemoral artery bypass was performed and proved successful in limb salvage. As improved prosthetic vascular conduits of smaller caliber are developed, applications in small children with vascular injuries may increase.

Accidents, Traffic↗
PubMed1991

Long-term follow-up of patients operated on for recurrent carotid stenosis.

We reviewed our experience with 29 operations for recurrent carotid stenosis in 27 patients who underwent both their primary carotid endarterectomy and their reoperations at our institution. These 27 patients represent 4% of the 667 patients who underwent primary carotid endarterectomies at our institution and who are included in our carotid follow-up registry. Reoperation was prompted by recurrent symptoms in 19/29 (65.5%) cases. Comparison of long-term stroke prevention in those patients who did (84% at 5 years, 78.6% at 10 years) and did not (90.3% at 5 years, 83.6% at 10 years) develop recurrent stenosis requiring reoperation revealed no statistically significant difference (p = 0.48) when measured from the time of primary operation. The perioperative stroke and death rates for reoperation (3.4% and 0%) were acceptable. We conclude that with our acceptably low perioperative stroke morbidity (3.4%), surgery for recurrent carotid stenosis in symptomatic patients or in asymptomatic patients with high-grade (greater than or equal to 75%) stenosis maintains the durable stroke prevention offered by primary carotid endarterectomy.

Carotid Arteries↗
PubMed1991

The economic implications of high-risk abdominal aortic aneurysms.

Financial data of 102 patients undergoing elective and emergent abdominal aortic aneurysm repair over a 3-year period were evaluated in terms of postoperative length of stay, net revenue, total standard cost, and net margin. Cost reimbursement was based on diagnosis related group payments. Aneurysm repairs were classified as emergent, high-risk elective, or low-risk elective. A net loss of $409,459 was noted for the entire series. Emergent repairs, although only 12% of the population, accounted for 73% of total losses, with a mean loss of $24,655/patient. The mean net loss in the high-risk elective group was $3590/patient, and a net gain of $1132/patient was noted in the low-risk elective group. Length of stay outliers, defined as length of stay greater than 28 days, contributed to the bulk of the losses in the elective series and were predominant in the high-risk group. No preoperative comorbidity, other than high-risk classification, predicted outlier status. Length of stay correlated with total standard costs in all categories of aneurysm repair. Third party payment for length of stay outliers was inadequate; the diagnosis related group system warrants revision so that outlier reimbursement will be based on a tiered system derived from length of stay.

Aorta, Abdominal↗
PubMed1990

Chronic venous insufficiency.

Like the noninvasive assessment of arterial occlusive disease, the various methods for evaluation of chronic venous insufficiency (CVI) can be divided into those that provide hemodynamic information and those that provide anatomic detail. The majority of noninvasive methods for evaluation of CVI are directed toward assessing hemodynamic events in large vessels by detecting abnormally directed blood flow, elevated venous pressure, increased limb-volume changes, or valvular reflux. B-mode ultrasound, the principal non-invasive method for anatomic assessment of CVI, defines either valvular incompetence, obstruction, or recanalization changes.

Blood Flow Velocity↗
PubMed1990

Cardiac risk in patients undergoing carotid endarterectomy: impact on perioperative and long-term mortality.

To identify patients undergoing carotid endarterectomy who are at high risk for cardiac events and death, we studied the course of 614 patients with known risk factors who were entered into our carotid follow-up registry. Patients were divided into two groups, group I with overt coronary disease (prior myocardial infarction, angina, significant electrocardiographic abnormalities) (N = 324) and group II without overt coronary disease (N = 290). Group II patients were subdivided into groups with (IIA) (N = 206) and without (IIB) (N = 84) coronary risk factors (cigarettes, diabetes, or hyperlipidemias). Thirty-day, 5-, 10-, and 15-year life-table survival for the groups was: I = 98.5%, 68.6%, 44.9%, 36.4%, respectively; II = 100%, 86.4%, 72.3%, 54.3%, respectively; IIA = 100%, 84.8%, 66.9%, 41.5%, respectively; IIB = 100%, 90.5%, 87.9%, 87.9%, respectively. Overt coronary disease was associated with diminished 30-day (p = 0.03) and late (p less than 0.0001) survival. Risk factors in the absence of overt disease were not associated with diminished 30-day survival. Late survival up to 3 years from endarterectomy was similar in groups IIA and IIB, but later survival was diminished in group IIA. Myocardial infarction was the most frequent cause of death in all groups. Patients with overt coronary disease are at high risk for late cardiac events and death. Patients without overt disease are at less risk than those with overt disease, and in the absence of overt disease, those without are at less risk than those with risk factors.(ABSTRACT TRUNCATED AT 250 WORDS)

Age Factors↗
PubMed1990

Comparison of ejection fraction and Goldman risk factor analysis to dipyridamole-thallium 201 studies in the evaluation of cardiac morbidity after aortic aneurysm surgery.

Associated coronary artery disease is the critical factor that influences early and late mortality after abdominal aortic aneurysm surgery. Dipyridamole-thallium 201 scintigraphy, left ventricular ejection fraction, and Goldman risk factor analysis have been suggested as preoperative noninvasive screening methods to detect significant coronary artery disease. In this series of 95 elective abdominal aortic aneurysm repairs dipyridamole-thallium 201 scintigraphy was highly predictive of the absence of perioperative cardiac morbidity (96% specificity, 44/46 normal scans, no cardiac morbidity), whereas ejection fraction (73% specificity, 31/42 normal ejection fraction, no cardiac morbidity) and Goldman risk factor analysis (84% specificity, 44/51 class I, no cardiac morbidity) were less. Furthermore, thallium redistribution on dipyridamole-thallium 201 scintigraphy leading to coronary angiography identified a significant number of patients with occult coronary artery disease who required preoperative coronary revascularization (8%, 8/95) and might have remained undetected on the basis of left ventricular ejection fraction or Goldman risk factor analysis. Finally, fixed thallium deficit, which some investigators have interpreted as a low probability finding for cardiac morbidity, was associated with a higher than expected incidence of cardiac complications. Forty-six percent (7/15) of all postoperative cardiac complications (three myocardial infarctions, three ischemic events, one death) occurred in patients with abdominal aortic aneurysms with fixed deficits. This suggests that patients with fixed deficits on dipyridamole-thallium 201 scintigraphy should be considered for later "delayed" (4 hours) thallium images or coronary angiography or both.

Aged↗
PubMed1990

Carotid endarterectomy contralateral to an occluded carotid artery: perioperative risk and late results.

To define better the short-term risk and long-term benefit of carotid endarterectomy opposite an occluded carotid artery, we reviewed our experience since 1961. Angiographic data are available for 598 of 670 (89.3%) patients in our carotid registry. In 63 (10.5%) patients the internal or common carotid artery on the side opposite the endarterectomy was occluded. All operations were carried out under general anesthesia with selective shunting based on electroencephalographic criteria. Shunting was required in 29 of 63 (46.0%) patients with contralateral occlusion and 72 of 535 (13.5%) control subjects (p less than 0.0001). Perioperative strokes occurred in 3 of 63 (4.8%) patients with contralateral occlusion and 14 of 535 control subjects (2.6%) (p = 0.23). Perioperative death occurred in 0 of 63 patients with contralateral occlusion and 6 of 535 (1.1%) control subjects (p = 0.40). Life-table cumulative stroke-free rates at 1, 5, and 10 years were 95.2%, 91.0%, and 76.2% in the group with contralateral occlusion and 96.0%, 89.4%, and 84.1% in control subjects (p = 0.25). Life-table cumulative survival rates at 1, 5, and 10 years were 93.1%, 80.8%, and 75.4% in the group with contralateral occlusion and 94.8%, 77.0%, and 57.9% in control subjects (p = 0.58). Carotid endarterectomy contralateral to an occluded carotid artery may be carried out with acceptable risk and late stroke-free and survival rates comparable to those seen in other patients who have undergone carotid endarterectomy.

Arterial Occlusive Diseases↗
PubMed1990

Long-term results with the above-knee popliteal expanded polytetrafluoroethylene graft.

Since approximately 30% to 40% of autogenous vein bypass grafts to the femoropopliteal level may occlude within 5 years of implantation, additional vein will be required for subsequent revisions. We undertook a study to determine whether the preferential use of an above-knee expanded polytetrafluoroethylene bypass graft to save vein is an appropriate option. We reviewed our experience with 114 above-knee expanded polytetrafluoroethylene bypass reconstructions. Life-table analysis of primary and secondary graft patency was carried out by the method of Peto and statistically analyzed for the influence of clinical indication, runoff as determined by both preoperative and intraoperative completion arteriography, smoking, and diabetes. The 5-year primary patency rate of 57% for patients with claudication was comparable to contemporary randomized or retrospective series with below-knee autogenous vein for that indication, and it was superior to the patency rate for limb salvage. The status of the runoff vessels was an important determinant of outcome. The 59 limbs with good arteriographic runoff (2 to 3 vessels) had a markedly higher 5-year patency rate (70%) than the poor arteriographic runoff (0 to 1 vessels) group (30%). Continued cigarette smoking and diabetes mellitus also appeared to affect adversely primary graft patency in our hands. Our data support the use of preferential above-knee expanded polytetrafluoroethylene grafts in patients with good angiographic runoff. This approach does not appear to prejudice the limb against secondary revisionary procedures or the use of a new autogenous graft, if required.

Adult↗
PubMed1989

Carotid endarterectomy in patients with intracranial vascular disease: short-term risk and long-term outcome.

To determine the influence of angiographically identifiable intracranial vascular lesions on the outcome of carotid endarterectomy, 597 patients from our carotid surgery registry who had had complete angiographic evaluation were divided into two groups: (1) significant intracranial disease identified by angiography (N = 134) and no significant intracranial disease identified by angiography (N = 463). The short- and long-term outcomes of carotid endarterectomy in the two groups were compared. Perioperative stroke morbidity (intracranial disease 1.9%, no intracranial disease 1.8%) and mortality (intracranial disease 0.5%, no intracranial disease 0.7%) were acceptable and not statistically different (p greater than 0.7). Late stroke prevention was nearly identical in the two groups, with 3-, 5-, and 10-year life-table of stroke-free rates of 93%, 87%, and 79%, respectively, versus 92%, 90%, and 85%, respectively, in the intracranial disease and no intracranial disease groups (p = 0.75). The incidence of recurrent transient ischemic attack was 9.7% in the intracranial disease group and 6.5% in the no intracranial disease group (p = 0.22). In the clinical population studied in the described method, angiographically identifiable intracranial vascular disease did not appear to have a statistically demonstrable influence on the short-term or long-term prognosis after carotid endarterectomy.

Brain Ischemia↗