Laparoscopically assisted total daVinci aorto bifemoral graft bypass with a unique system of graft delivery.

We report the first known example of a fully robotic aortobifemoral graft and aortic endarterectomy using the daVinci Surgical System and a unique method for graft delivery using the Endo-Vein Harvester.

Clinical experience with the Greenfield filter in 193 patients and description of a new technique for operative insertion.

Transvenous inferior vena cava (IVC) interruption using the Greenfield filter was performed upon 193 patients from January 1982 to December 1988. Placement of a filter in the IVC was indicated for prophylaxis (23.8 percent), contraindication to anticoagulation (22.8 percent), pulmonary embolism despite anticoagulation (18.7 percent), complications of anticoagulation (26.9 percent) and free-floating thrombus (7.8 percent). Filters were placed in an infrarenal location in 92 percent of the patients. The remaining 8 percent of patients had placement of a suprarenal filter for specific indications, without complication. Most (97.4 percent) of the patients had filters placed through internal jugular or femoral vein cutdown. Five patients required filter placement through a retroperitoneal approach to the right common iliac vein and IVC junction. This new technique of filter insertion is described. The operative morbidity rate was 4.7 percent, with an additional 8.8 percent having postoperative thrombotic complications. The 30 day operative mortality rate (6.7 percent) was related to preexisting associated disease. Nonfatal, late, recurrent pulmonary embolism occurred in 2.6 percent of the patients despite filter placement. Caval patency remains at 97.9 percent in long term follow-up evaluation. The Greenfield filter is an effective and safe adjunct in the treatment of venous thromboembolic disease and a satisfactory prophylactic measure in specific high-risk patients.

Influence of distal arterial occlusive disease on prognosis following aortobifemoral bypass.

Arteriographic criteria were used to classify 376 consecutive patients who underwent aortobifemoral bypass for aortoiliac occlusive arterial disease between 1967 and 1977. Group A (126 patients, 34%) had isolated aortoiliofemoral disease, group B (156 patients, 41%) had associated femoropopliteal disease, and group C (94 patients, 25%) had associated femoropopliteal and tibioperoneal disease. Ischemic rest pain or tissue necrosis was the indication for operation in 13% of patients in group A, 30% of those in group B (P < 0.01), and 45% of those in group C (P < 0.001). The overall operative mortality rate was 5.6%, and differences in operative mortality among the three groups had no statistical significance. Fatal postoperative myocardial infarctions occurred in 4.5% of the entire series and accounted for 17 (81%) of 21 postoperative deaths. Late follow-up information for 3 to 13 postoperative years (mean, 6.3 years) was available for 337 (95%) of 355 operative survivors. Subsequent femoropopliteal or femorotibial bypass was necessary for 8% of patients in group A, 13% of those in group B, and 19% of those in group C (P < 0.05), but the presence of distal occlusive disease was not associated with meaningful differences in cumulative aortofemoral limb patency or major amputation. The late mortality rate was 28% for group A, 33% for group B, and 41% for group C. Myocardial infarctions were responsible for 46% of all late deaths and occurred in 11% of patients in group A, 15% of those in group B, and 20% of those in group C. The mortality rate (P < 0.01) and the incidence of fatal myocardial infarction (P < 0.02) within five postoperative years were statistically significant in group C.

Recurrent stenosis after carotid endarterectomy.

Thirteen of 1,250 patients required a second operation for recurrent stenosis following carotid endarterectomy performed at the Cleveland Clinic between 1958 and 1978. Two other patients underwent reoperation because of recurrent stenosis following primary operations at other institutions. Thirteen of the 15 patients experienced neurologic symptoms caused by recurent stenosis, while two patients remained asymptomatic. Atherosclerosis was responsible for recurrent stenosis in 12 patients and appeared to be related to hypercholesterolemia. Three of the patients had myointimal fibroplasia. Eleven of the 16 reoperations for recurrent stenosis of the carotid artery consisted of carotid endarterectomy with vein patch angioplasty. Three patients had carotid endarterectomy with closure of the primary arteriotomy. One patient with occlusion of the internal carotid artery underwent endarterectomy of the external carotid artery because of amaurosis fugax, and a saphenous vein interposition graft was used to replace a previous Dacron graft in one patient with anastomotic stenosis. One patient had a stroke during reoperation manifest as multiple retinal emboli. Fourteen patients have remained asymptomatic from one to 70 months following reoperation. One patient with occlusion of the contralateral internal carotid artery has experienced persistent vertebrobasilar symptoms.

Delayed appearance of traumatic ventral hernia: a case report.

An unusual traumatic ventral hernia is reported, observed 6 months after its presumed cause. The delay in diagnosis, the benign appearance of the abdomen in the supine position, and the necessity for marlex mesh prosthetic repair in a large traumatic defect are all unusual features. Following repair the patient has remained asymptomatic.