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Biomedical subjects

T J Devine

Publications and source records attributed to T J Devine.

18 recordsLinked to original sources
PubMed1996

Clinical and vascular laboratory determinants for outcome after infrainguinal atherectomy.

Three surgeons performed 180 atherectomy procedures in 161 patients using the Transluminal Extraction Catheter in 144 and the Auth Rotablator in 36. The primary patency rate was 55% at 1 year and 46% at 2 years, and failure was caused by stenosis in 28 (15.6%) and occlusion in 61 (33.7%) limbs. Multivariate Cox regression analysis showed significantly better outcome if the indication was claudication, the lesion was short or there was associated stenting. Vascular laboratory surveillance was performed in 93 limbs in 83 patients. Cox regression analysis in this subgroup also showed a significant relationship between outcome and the maximum peak systolic velocity from a duplex scan at the last study performed. Receiver operating characteristics curves showed that a raised maximum peak systolic velocity best predicted late failure (sensitivity 84%, specificity 66% for > 200 cm/s; sensitivity 72%, specificity 84% for > 250 cm/s); the velocity ratio at the stenosis to that in the segment above or the resting ankle/brachial pressure index were less predictive. For 50 procedures studied in the vascular laboratory which remained successful to the end of the study, maximum peak systolic velocities were > 250 cm/s from the first postoperative study, suggesting residual stenosis in 6%, or increased to become > 250 cm/s by the last study, suggesting recurrent stenoses in 12%. For 43 procedures which were studied and later failed, velocities were > 250 cm/s from the first test in 26% or increased to > 250 cm/s by the last test before failure in 40%. Vascular laboratory surveillance helps to predict outcome after atherectomy. Failure may be a result of residual disease from the time of the procedure or from restenosis. The apparent high incidence of clinically manifest or developing stenoses raises doubts as to the benefit of atherectomy over balloon dilatation alone.

Adult↗
PubMed1994

Infrainguinal atherectomy using the transluminal endarterectomy catheter: patency rates and clinical success for 144 procedures.

PURPOSE: To determine if atherectomy using the transluminal endarterectomy catheter (TEC) is an effective endoluminal therapy for infrainguinal occlusive disease. METHODS: Three surgeons used the TEC for 144 infrainguinal atherectomy procedures in 133 patients. The indications were severe claudication in 83, critical ischemia in 56, and graft stenosis in 5 limbs. The pathology was stenosis in 36 and occlusion in 105 limbs. Balloon dilation was also performed in 109 and stenting in 17 limbs. RESULTS: There was initial technical and anatomic success in 124 (86%) procedures. There were 67 technically successful procedures at mean follow-up of 19 months, although 3 of these limbs with gangrene and extensive distal disease required major amputation. There were 26 failures due to stenosis leading to further intervention and 51 due to occlusion. Twenty of these cases were managed conservatively, 21 were treated with repeat endovascular intervention, 31 with bypass grafting, and 5 with amputation. Repeat intervention in 52 limbs resulted in 36 with patent arteries, 10 that are occluded, and 6 that required amputation. Thirteen of the 14 amputations were for limbs with critical ischemia, but 1 was in a patient with claudication. Life-table analysis showed that the primary patency rate was 51%, the assisted primary patency rate was 61%, and the secondary patency rate was 75% at 15 months. The clinical success rate was 49%, and the salvage rate for limbs with critical ischemia was 78% at 12 months. Univariate log-rank testing showing no significant differences according to the clinical presentation of pathology, but results were worse for lesions > 5 cm long due to more frequent immediate failures. However, multivariate Cox regression analysis showed that results were significantly worse for critical ischemia than for claudication, stenosis compared to occlusions, for limbs with poor runoff, for operations performed by percutaneous rather than an open approach, and for those performed more recently. CONCLUSIONS: TEC atherectomy may have a place in selected patients, but the optimal circumstances for its use and long-term efficacy require further study.

Adult↗
PubMed1994

Perioperative stroke after carotid endarterectomy. Etiological risk factors and management.

291 patients were subjected to carotid endarterectomy from January 1985 to June 1992 in two Australian medical institutions. Of the 291 patients, perioperative stroke occurred in 22 (6.3%) after 347 operations (moderate 17 and severe 5). The 22 patients were studied with Doppler scan, angiography, reexploration and CT. Reexploration showed that 12 of 14 patients had thrombosis in the internal carotid artery at operation. The etiological factors for perioperative strokes included thrombosis at the operative sites in 14 patients (64%), cerebral embolism after operation in 4, clamping ischemia in 2, intracerebral hemorrhage in 1 and unknown cause in 1. Six patients (27%) recovered completely in 4 weeks, 10 (45%) had mild residual neurological deficits, 5 (23%) had moderate neurological deficits and 1 died 3 days after operation. Only 6 patients had permanent neurological deficits (6/347, 17%).

Aged↗
PubMed1993

Multivariate Cox regression analysis of covariates for patency rates after femorodistal vein bypass grafting.

Multivariate Cox regression analysis of patency rates for 750 consecutive femorodistal autogenous vein graftings for chronic lower limb ischemia showed that significant independent prognostic covariates were the type of graft (long saphenous or arm vein), presence of diabetes, and absence of a past history of myocardial ischemia. Analysis assumes that patients withdrawn with patent grafts due to death or loss to follow-up would have followed the same course as those who remain, and the degree to which this could distort results was studied. Patients who died with patent grafts were more likely to have had past myocardial ischemia and critical lower limb ischemia. Cox regression analysis for 600 operations after excluding patients who died with patent grafts then showed that significant independent covariates were the type of graft (long saphenous or arm vein) and indication (claudication or critical ischemia); then age, sex, hypertension, diabetes, myocardial ischemia, date of operation, surgeon, site of distal anastomosis, or first compared to repeat operations had no significant influence. Cox regression analysis helps determine which covariates influence graft patency rates, but results are affected by censored data, particularly from patients who die with patent grafts.

Adult↗
PubMed1988

Extraperitoneal unilateral iliac artery bypass for chronic lower limb ischaemia.

Extraperitoneal unilateral iliac artery bypass was used to treat chronic lower limb ischaemia in 105 patients (110 operations). This represented 20% of all operations for aorto-iliac disease. Unilateral iliac bypass was the preferred primary procedure for 99 operations, and was used to correct complications in one limb of a prior aortic bifurcation graft in the other 11. Ipsilateral femoropopliteal vein grafts were also performed in 45 legs (43%), prior to the iliac bypass in 18, as a synchronous operation in nine, and at a later date in 18 legs. This was a much higher proportion of combined operations than for patients by aortic bifurcation grafts (12%). Only 5 patients later required further proximal surgery, one for a blocked graft and four for contralateral iliac disease. The cumulative patency rate in surviving patients was 91% at 3 years. For the claudicants and for iliofemoral bypass operations, only one graft occluded, within 5 years, and no grafts occluded for operations where the superficial femoral artery was patent. The cumulative patency rates at 3 years were 85% for patients with critical ischaemia, 82% for ilioprofunda bypass operations, and 88% for operations where the superficial femoral artery was occluded. The cumulative foot-salvage rate in surviving patients initially treated for critical ischaemia was 77% at 3 years. The cumulative survival rate was 90% at 3 years. Extraperitoneal unilateral iliac bypass is now preferred as the primary operation for patients with apparent unilateral iliac disease causing severe ischaemia, if balloon dilatation is not appropriate or has failed.

Aorta, Abdominal↗
PubMed1987

Palpation of the femoral and popliteal pulses: a study of the accuracy as assessed by agreement between multiple observers.

Six vascular surgeons independently examined 44 legs in patients with suspected peripheral arterial disease. Each surgeon recorded whether the femoral and popliteal pulses were present or absent, and if thought to be present, whether they were normal or reduced in amplitude. Interobserver agreement was determined by calculating both observed agreement (Po) and agreement after correction for chance (kappa-k). The results were calculated both for each possible pair of surgeons and as an overall value for all possible pairs combined. Agreement as to whether pulses were present or absent was significantly better than expected by chance but was only moderately good (overall kappa for femoral pulse = 0.53, and overall kappa for popliteal pulse = 0.52). More often than not, agreement as to whether the pulses were normal or reduced was no better than expected by chance (overall kappa for femoral pulse = 0.15, and overall kappa for popliteal pulse = 0.01). For each assessment, agreement was no better for the more experienced than the less experienced pairs of surgeons. The results indicate that more objective methods than pulse palpation are required to determine whether there is significant disease in the aorto-iliac and femoro-popliteal arterial segments.

Arterial Occlusive Diseases↗
PubMed1982

Aorto-iliac reconstructions for intermittent claudication.

Over a 12-year period, 290 aortofemoral reconstructions were performed for intermittent claudication involving 449 legs in 262 patients. The accumulative patency rate in surviving patients was 79 per cent at 5 years. The patency rate was significantly better in patients who stopped smoking after operation, and in men compared with women. Dacron grafts were significantly more successful than endarterectomy in men. If there was no associated superficial femoral artery occlusion, endarterectomy and Dacron bypass grafts were equally successful, but Dacron bypass grafts were significantly superior to endarterectomy if the superficial femoral artery was severely stenosed or occluded. The success rates for improving the patients' intermittent claudication were 90 per cent at 3 months and 72 per cent at 3 years. The success rate at 3 years was 80 per cent if the superficial femoral artery was patent but only 62 per cent if the superficial femoral artery was severely stenosed or occluded. Mortality and morbidity rates fell markedly in the last 6 years of the study.

Aorta↗
PubMed1980

Severe leg ischaemia caused by anterior resection of the rectum.

A 45-year-old man developed severe leg ischaemia following anterior resection for rectal carcinoma. A previously unrecognized infrarenal aortic occlusion was also present. Division of important collateral arterial pathways during the anterior resection was the cause of ischaemia which contributed to the patient's death. Patients having rectal or colonic resection should be carefully assessed for aortoiliac occlusive disease. Extra-anatomical arterial reconstruction before the bowel resection would avoid this complication.

Aorta, Abdominal↗
PubMed1980

Femoropopliteal vein grafts for intermittent claudication.

Femoropopliteal vein grafts were performed for intermittent claudication in 160 patients (182 legs) over a 12-year period. The accumulative patency rate was 67 per cent at 5 years. However, patency rates improved significantly in the latter 6 years of the study, to 75 per cent at 5 years. Early postoperative occlusion and morbidity rates also markedly declined in this latter period. Patency rates were significantly better in males than in females, in patients who were able to stop smoking after operation and in legs with a three-vessel run-off compared with those with a two- or one-vessel run-off. The patients' age did not influence graft patency rates.

Adult↗
PubMed1980

Massive haemorrhage caused by left renal vein ligation.

It is common practice to ligate the left renal vein during aortic surgery. Although this does not usually lead to complications we report 2 patients in whom left renal vein ligation caused massive venous congestion of the kidney and major retroperitoneal haemorrhage. Nephrectomy was necessary to control the haemorrhage. In 1 patient immediate autotransplantation preserved renal function.

Aged↗
PubMed1980

Femoropopliteal bypass using polytetrafluoroethylene.

Reinforced expanded polytetrafluoroethylene (PTFE) was used as a femoropopliteal bypass graft in 31 patients (37 operations). The indications were intermittent claudication (13 operations), severe ischaemia with rest pain or gangrene (20 operations), and prophylactic treatment of popliteal aneurysms (4 operations). The one-year accumulative patency rates were 75% for patients with intermittent claudication and 20% for patients with severe ischaemia. In three patients with claudication, graft thrombosis led to amputation in spite of attempted graft thrombectomy. These results compare unfavourably with our experience using autogenous vein, in which the one-year accumulative patency rates were 80% for claudication and 70% for severe ischaemia, and in which failure of the bypass graft for claudication rarely made the patient worse.

Aged↗
PubMed1979

Axillofemoral arterial bypass grafts.

The results of 24 axillofemoral arterial bypass grafts performed over a five-year period are presented. This extraanatomical technique of arterial reconstruction is valuable following removal of an infected aortic Dacron graft and for limb salvage or severe intermittent claudication in selected poor-risk patients with aortoiliac occlusive disease. There were few early patency rate was excellent, but the long-term success of the operation is uncertain.

Aged↗
PubMed1979

Techniques of reconstruction for arterial insufficiency.

Arterial surgery has developed rapidly over the past thirty years, although the principles were well established at the start of the century. This article discusses the techniques currently used for arterial reconstruction of occlusive disease in the aorta, iliac and femoral arteries, and for embolectomy.

Aortic Diseases↗
PubMedDate not supplied

Surgical treatment of acute deep venous thrombosis.

In patients with venous thrombotic disease and in whom anticoagulation or thrombolytic therapy is inappropriate, ineffective, or even contraindicated, insertion of vena caval filters or venous thrombectomy must be considered. The primary indication for the placement of vena caval filters is in patients who have developed a pulmonary embolus and in whom anticoagulation is either contraindicated or in whom anticoagulation must be discontinued because of the development of bleeding complications. At the present time, either the Greenfield filter placed through a jugular, femoral, or axillary venotomy or the bird's nest filter are appropriate and appear to be the most effective and least fraught with complications. The use of venous thrombectomy has waxed and waned over the last several decades. At the present time, the procedure is advocated mainly for lower limb venous thrombosis which is extensive enough to threaten limb viability. On occasion, it may be appropriate to extend the indications for venous thrombectomy to include femoral thrombosis of less than 10 days duration or iliac thrombosis of less than 3 weeks duration with floating thrombi at the level. Technical modifications which improve the patency of the obliterated veins which are predisposed to rethrombosis include the creation of a temporary arteriovenous fistula and meticulous care in removing the entire clot. The patient should be treated with anticoagulants postoperatively to prevent a recurrence of the problem. The main theoretical advantage of venous thrombectomy is a reduced incidence of postthrombotic syndrome. Objective data to support this contention do not exist.

Hemodynamics↗
PubMedDate not supplied

In vivo heparin response and consumption in patients before and during arterial reconstructive surgery.

This study investigated the effects of heparin in patients with peripheral arterial disease, before and during operation. The relation between heparin dosage and heparin response and consumption were calculated from changes in the activated clotting time (ACT). Before operation, 38 patients were each given 10,000 units of heparin by intravenous injection and ACT was measured after 5, 10, 20, 30 and 60 minutes. Assuming a linear relation between heparin dosage and ACT, a dose of heparin was calculated which should double the normal ACT. This was given during operation in 21 patients while a standard dose of 7,500 units of heparin was given to another 10 patients. ACT was measured during operation at the same time intervals as before operation. ACT was always at its highest level at the 5 minute test and was always still raised at 60 minutes, both before and during operation. No significant correlation was found between ACT, heparin response or heparin consumption, and the patients' ages, sex, body weights and creatinine levels, either before or during operation. It was not possible to predict the intraoperative response from the preoperative test. It is concluded that the heparin effect should be monitored during operation in each patient if the best dose response is to be obtained.

Aged↗
PubMedDate not supplied

Femoropopliteal bypass using autogenous vein and modified human umbilical vein. A comparative study.

This study is based on 223 consecutive femoro-popliteal and femorotibial bypass grafts performed between January 1978 and June 1985 at the Western General Hospital. Autogenous vein grafts demonstrated better 5 year patency rates (54%) than modified human umbilical vein (32%). The superiority of autogenous vein was even more marked when anastomoses were to below knee vessels: 56% compared with 26% at 5 years. Grafts anastomosed to the superficial femoral artery had similar long term patency to those anastomosed to the common femoral artery. When grafts were required for severe ischaemia, similar 5 year patency rates were achieved with autogenous vein (35%) and modified human umbilical vein (30%). The 5 year limb salvage rate in severe ischaemia was 72% for autogenous vein and 63% for modified human umbilical vein. The findings confirm that modified human umbilical vein is a satisfactory alternative when autogenous vein is not available.

Aged↗