PubMed Health⌕ Search

Biomedical subjects

T J Bunt

Publications and source records attributed to T J Bunt.

At least 19 recordsLinked to original sources
PubMed1992

The role of a defined protocol for cardiac risk assessment in decreasing perioperative myocardial infarction in vascular surgery.

Major elective peripheral vascular surgery has historically carried a significant risk of perioperative myocardial infarction; this risk has been quantified further by its association with proved reduction in cardiac reserve/presence of coronary artery disease by stress testing or invasive monitoring. Recognition of this risk logically should lead to protocols that delineate coronary artery disease/cardiac reserve before surgery and correct for observed abnormalities during surgery. This study sought to show that a coherent algorithm of preoperative cardiac assessment combined with aggressive perioperative management could indeed reduce perioperative myocardial infarction rates. Six hundred thirty consecutive elective vascular operations were performed by the author during 6 years. All patients were entered into a prospective protocol for preoperative cardiac risk assessment, which then determined the choice of operation, type of anesthesia, and level of hemodynamic monitoring. Sixty-eight percent of the patients demonstrated clinical coronary artery disease, 15% had previously undergone coronary catheterization or surgery, and 9% had ejection fractions less than 35%. All patients underwent baseline detailed cardiac histories, radionuclide cardioangiography, and electrocardiograms. Patients with significant historic coronary artery disease or ejection fraction less than 50% underwent stress thallium testing; patients with positive fixed or redistribution defects then underwent catheterization, constituting 7% of the series. Risk stratification by age and cardiac assessment then dictated the perioperative care. The overall perioperative myocardial infarction rate was 0.7% (5/628), ranging from 0% for 156 aortic operations and 114 carotid endarterectomies to 0.6% for 159 femoropopliteal and 3.3% for 90 femorotibial revascularizations.(ABSTRACT TRUNCATED AT 250 WORDS)

Algorithms↗
PubMed1992

Management of small artery vascular trauma.

This 11-year retrospective study reviewed 99 arterial injuries distal to the brachial bifurcation or popliteal trifurcation in 89 extremities in 88 patients. Associated injuries occurred in 78 of 88 (89%) patients, including 10 fractures or dislocations, 66 nerve injuries, and 59 single or multiple tendon injuries. Fasciotomy was performed in 9 upper extremities and 11 lower extremities (23% of patients). The selection of operative treatment by arterial repair or ligation was by surgeon choice (52% repair and 48% ligation). Postoperative patency was found in 45 of 47 (96%) repaired arteries. In cases of isolated single arterial injuries (10), there were excellent results, and there was no difference in the results between repair and ligation. In cases of nonisolated single arterial injuries (69), there were 46% and 36% nonvascular complications in the repaired and ligated groups, respectively. In 10 patients with nonisolated multiple arterial injuries in the same extremity, the results of repair of one artery with ligation of the other artery versus repair of both arteries were identical, and there were no vascular complications. Operative exploration was the key to complete evaluation of vascular and neuro/musculoskeletal injuries. The data suggest that one functional artery distal to the elbow or knee is sufficient for limb viability and vascular function (follow-up range: 0 to 110 months; mean: 12 months). Nerve injury was the single most important factor of extremity injury in terms of the degree of functional loss.

Adolescent↗
PubMed1992

Major complications of angioaccess surgery.

Angioaccess procedures at one institution over a 4-year period were retrospectively reviewed to ascertain the frequency of major limb- or life-threatening complications. A total of 435 angioaccess procedures were performed, including 81 Cimino-Brescia fistulas, 166 polytetrafluoroethylene grafts, and 111 thrombectomy/revisions. There were 77 operations for major complications in 53 patients. In addition, five patients required major vascular repair or emergency thoracotomy for complications of central hemodialysis line placement. A significant portion (18% of this series) of the total angioaccess caseload of a vascular surgeon will be utilized in the repair of major complications. The in-hospital (6 patients, or 11%) and long-term (12 patients, or 23%) mortality rates are significant. Although most complications can be repaired without limb loss and with shunt salvage, a small percentage (in our study three patients, or 4%) will have debilitating long-term symptoms.

Adult↗
PubMed1992

Randomized prospective double-blind trial in healing chronic diabetic foot ulcers. CT-102 activated platelet supernatant, topical versus placebo.

OBJECTIVE: To assess the efficacy of topically applied CT-102 APST for treating diabetic neurotrophic foot ulcers. RESEARCH DESIGN AND METHODS: Thirteen patients entered a randomized, double-blind trial of topically applied CT-102 APST vs. placebo (normal saline) gauze dressings for the treatment of nonhealing diabetic neurotrophic foot ulcers. CT-102 APST (Curative Technologies, Setauket, NY) was prepared from homologous platelets and contained multiple growth factors including PDGF, PDAF, EGF, PF-4, TGF-beta, aFGF, and bFGF. Inclusion criteria for subjects included diabetes, ulcer of > 8 wk duration, peri-wound transcutaneous oxygen tension > 30 mmHg, platelet count > 100,000/mm3, and no wound infection. Wounds were excised before entry and were > 700 mm3 but < 50,000 mm3 in volume, < 100 cm2 in area, and involved subcutaneous tissue. RESULTS: In the CT-102 group, 5 of 7 ulcers were healed (100% epithelialized) by 15 wk, but only 1 of 6 ulcers was healed by 20 wk with placebo (P < 0.05). Average percent reduction in ulcer area at 20 wk was 94% for CT-102 vs. 73% for placebo. Daily reduction in ulcer volume was 73.8 +/- 42.4 mm3/day (mean +/- SE) for CT-102 vs. 21.8 +/- 8.1 mm3/day for placebo (P < 0.05). Daily reduction in ulcer area was 6.2 +/- 1.8 mm2/day for CT-102 vs. 1.8 +/- 0.4 mm2/day for placebo (P < 0.05). CONCLUSIONS: CT-102 significantly accelerated wound closure in diabetic leg ulcers when administered as part of a comprehensive program for the healing of chronic ulcers.

Chronic Disease↗
PubMed1992

The influence of vascular certification on lower extremity revascularization at one institution.

The potential impact of vascular certification on the practice of vascular surgery at Maricopa Medical Center (Phoenix, AZ) was analyzed by comparison of lower extremity revascularization results over consecutive 2-year periods before (Period I) and after (Period II) institution of vascular surgery service. The overall setting (county hospital, surgical residency) and ancillary services (Anesthesia, Intensive Care Unit, Radiology) were unchanged, except for the authors' use of invasive hemodynamic support. In Period I, there were 49 cases (30 inflow, 19 outflow) with 14 per cent (7/49) mortality, 32 per cent (21/67) limb thrombosis or embolus, and 10 per cent (5/49) graft infection; 80 per cent (39/49) of operations were done for claudication; 20 per cent (10/49) were done for inappropriate indications (P less than 0.005). In Period II, there were 110 cases (47 inflow, 63 outflow). The increase in cases was predominantly due to increased use of extra-anatomic inflow and complex infrapopliteal outflow reconstructions. Seventy per cent (77/110) of operations were done for limb salvage; of 17 aortic cases, 3 were "re-do's" and 5 underwent simultaneous renal revascularization. There was a 3 per cent (4/110) mortality (P less than 0.025), 11 per cent (13/137) limb thrombosis or embolus (P less than 0.005), and no graft infections (P less than 0.001). Lower extremity revascularization delivered by certified vascular surgeons was offered to more patients with lower overall mortality and morbidity rates after more thorough diagnostic work-up and for more appropriate indications, with concomitant use of more refined vascular techniques/procedures.(ABSTRACT TRUNCATED AT 250 WORDS)

Age Factors↗
PubMed1992

Bilateral traumatic internal carotid artery dissections: case report.

Bilateral internal carotid artery dissections after blunt cervicofacial trauma are rare, with 16 cases being previously published. Management is presumed to be an extension of the dominant therapy for unilateral dissection, that being anticoagulant therapy; however, bilateral stenoses engender questions of threat to total cerebral blood flow. We herein present a patient who suffered bilateral type B dissections and who then had progression of the process on anticoagulant therapy, resulting in an unusual carotid reconstruction.

Adult↗
PubMed1990

Frequency of vascular injury with blunt trauma-induced extremity injury.

Vascular injury associated with select blunt trauma-induced orthopedic injuries is thought to occur frequently enough to require angiography in most cases. We sought to establish the actual frequency of such vascular injuries by reviewing all orthopedic and vascular patients seen during 4 years at one institution. A total of 569 at-risk parajoint fractures or dislocations were seen with a 1.5% incidence of vascular injury; all were recognized on clinical examination and vascular consultation then obtained. Vascular injury in this setting is uncommon, associated with particular clinical presentations, and recognized by the orthopedic surgeon, without need for routine angiography or vascular consultation.

Arm Injuries↗
PubMed1990

Porta hepatis disruption from blunt trauma.

Extrahepatic porta hepatis injuries from blunt abdominal trauma are exceedingly rare; all recently reported cases involve disruption of the common bile duct at its intrapancreatic portion. We herein report a patient with lacerations of the proper hepatic artery and bile duct occurring from deceleration/torsion of the porta hepatis after high speed vehicular collision.

Accidents, Traffic↗
PubMed1990

Physiologic amputation for acute pedal sepsis.

There are three options for management of pedal sepsis requiring lower extremity amputation: one-stage emergency, two-stage guillotine, or physiologic amputation. The excessive mortality usually ascribed to amputation surgery is basically derived from the selection of one of these options in emergency situations, with published mortalities of 10 per cent to 40 per cent being the norm. We have performed 465 lower-extremity amputations for vascular insufficiency for seven years, with overall 30-day operative mortalities of 0.5 per cent for below-knee amputations and 2.7 per cent for above-knee amputations. One hundred sixteen of these patients presented with acute pedal sepsis superimposed on significant medical disability, and were managed initially with physiologic amputation and intensive hemodynamic monitoring; the overall mortality for this select group was 5.1 per cent. An algorithm of management of patients presenting with acute pedal sepsis has thereby been derived, and is herein presented.

Acute Disease↗
PubMed1990

Iatrogenic tibial pseudoaneurysm following below-knee amputation.

Tibial vessel injury during lower extremity amputation has not been reported, despite the obvious proximity of these vessels to the fibula and tibia. We present a case of acute pseudoaneurysm with arteriovenous fistula of the posterior tibial vessels following amputation, due to (unrecognized) arterial and venous injury due to fibular periosteal elevation.

Adult↗
PubMed1989

Prevention of amputation by diabetic education.

This prospective randomized study evaluated the influence of a simple education program on the incidence of lower extremity amputation in diabetic patients. Two hundred three patients were randomized into two groups: Group 1, education (103 patients, 203 limbs) and Group 2, no education (100 patients, 193 limbs). There were no significant differences in medical management or clinical risk factors between the two groups. The amputation rate was three times higher in Group 2 (21 of 177 limbs versus 7 of 177 limbs; p less than or equal to 0.025), the ulceration rate was three times higher in Group 2 (26 of 177 limbs versus 8 of 177 limbs; p less than or equal to 0.005), and there was no difference in the overall incidence of infection (2 of 177 limbs). Overall success in Group 1 was highly significantly different from Group 2 (160 of 177 limbs versus 128 of 177 limbs; p less than or equal to 0.0005). This study demonstrated that a simple education program significantly reduced the incidence of ulcer or foot and limb amputation in diabetic patients.

Amputation, Surgical↗
PubMed1988

Complete cerebral angiography in the evaluation of patients with cerebrovascular insufficiency.

Three hundred and twenty-eight consecutive patients presenting with symptoms of cerebrovascular insufficiency were evaluated with complete cerebral angiography (CCA) under a prospective protocol evaluating the necessity and the utility of CCA over diagnostic modalities confined in their scope to the carotid bifurcation. Procedure mortality was 0.3 per cent (one fatal stroke), major morbidity 0.6 per cent (one non-fatal stroke and one stroke with resolution), and minor morbidity 2.1 percent. Eighteen per cent (60/328) of the CCAs demonstrated highly significant intracerebral pathology that materially affected choice of therapy. CCA was as valuable in evaluating patients with transient ischemic attack, 22 per cent (27/121), as prior stroke, 23 per cent (22/98). CCA is highly useful for the accurate evaluation of associated disease outside the carotid bifurcation, and is therefore essential for accurate delineation of intracerebral anatomy, pathology, and flow patterns. It may be performed with reasonable patient risk, provides information not available from, or of better quality than, real time ultrasound or intravenous digital subtraction angiography, and therefore is essential for the proper selection of procedures, if any is necessary, and the proper order of those procedures.

Cerebral Angiography↗
PubMed1988

Nitroglycerine-induced volume loading.

Fifty-five patients who underwent elective aortic aneurysmorrhaphy were studied intraoperatively to assess ventricular function responses to volume loading and nitroglycerine/inotrope mini-infusions. Assessments of preoperative cardiac reserve and risk of perioperative myocardial infarction were based on ejection fraction (EF); an algorithm was developed to direct differential preanesthetic loading to maximize ventricular performance in normal (EF, greater than 60%), moderate-risk (EF, 35% to 60%), and high-risk (EF, less than 35%) patients. Sixty percent of the patients in the series were at significant risk of myocardial infarction, including 25 with an EF from 35% to 60% and seven with an EF less than 35%; the perioperative myocardial infarction rate was zero. Nitroglycerine-induced volume loading in this series allowed aortic aneurysmorrhaphy without any decrease in ventricular function at the critical points of anesthetic induction, aortic cross clamping, or declamping; such optimization of myocardial performance appears to prevent perioperative myocardial infarction, even in high-risk patients.

Aorta, Abdominal↗
PubMed1988

Assessment of transmural force during application of vascular occlusive devices.

An in vivo system was established whereby the transmural forces exerted across the arterial wall during vascular occlusion were directly measured. Evaluation of various currently available vascular occlusive devices was conducted and transmural force transmission data were recorded. The clamps were classified according to their mechanical design characteristics. The magnitude of force required to obtain cessation of distal flow varied significantly among devices of differing mechanical design but correlated well when compared with clamps of similar design. This information was then compared with graded analysis of the degree of intimal injury created by these specific devices as assessed with scanning electron microscopy. The amount of transmural force exerted by each individual device correlated with the grade of intimal injury created by that device. We conclude that fundamental clamp design dictates the magnitude of applied transmural force, that force and the vectors of the application of that force are directly responsible for the degree of resultant intimal injury, and that the intima appears to possess an injury threshold of approximately 5 x 10(4) dynes/cm2. Intimal injury may determine success or failure of vascular surgical procedures; therefore it is prudent to seek the least traumatic means of vascular occlusion.

Animals↗
PubMed1987

Continuous epidural anesthesia for aortic surgery: thoughts on peer review and safety.

Continuous epidural anesthesia (CEPA) has been recommended on the basis of limited reported experience as being safe to use during elective peripheral revascularization. This study surveyed peer acceptance and safety by means of a questionnaire that was mailed to the 190 members of the Southern Association for Vascular Surgery (52% rate of response). Of the respondents, 42% used CEPA and 54% considered it safe; 895 cases were compiled without complication. Twenty-five consecutive patients undergoing abdominal aortic reconstruction were then studied under a prospective protocol, which measured left ventricular function perioperatively. Preanesthetic, nitroglycerin-induced volume loading averaged 3570 ml in 15 general anesthesia (GA) cases and 3463 ml in 10 CEPA cases. Intraoperative volumes averaged 4341 ml GA and 6350 ml CEPA; after correction for blood loss per administration, patients in whom CEPA was used received an average 3080 ml excess volume. Eighteen-hour postoperative volumes averaged 1750 ml GA and 3156 ml CEPA. In the GA cohort, cardiac index fell from 3.57 to 2.80 L/min-m2 and rebounded to 3.07 L/min-m2 after unclamping. Left ventricular stroke work index fell from 56 to 46 gm-m/m2 (p less than 0.05), remained greater than 45 throughout clamping, and rebounded to 51 after unclamping. In the CEPA cohort, cardiac index fell from 3.50 to 2.85 L/min-m2 after supplemental GA administration, fell to a low of 2.30 L/min-m2 and remained at that range throughout the study; left ventricular stroke work index fell from 50 to 35 gm-m/m2 and remained depressed throughout. All intraoperative values were significantly (p less than 0.001 to p less than 0.05) depressed from baseline values, and from before unclamping and onward they were significantly (p less than 0.01) depressed as compared with those of the GA cohort. The use of CEPA has moderate peer group acceptance and apparently few major technique-related complications in elective revascularization cases. In aortic surgical procedures, and when combined with GA, the use of CEPA results in greater total perioperative fluid volume administration and has the potential for subtle left ventricular dysfunction.

Anesthesia, Epidural↗