Child-Pugh versus MELD score in predicting survival in patients undergoing transjugular intrahepatic portosystemic shunt.

BACKGROUND: In patients undergoing transjugular intrahepatic portosystemic shunt (TIPS), prognostic scores may identify those with a poor prognosis or even those with a clear survival benefit. The Child-Pugh score (CPS) is well established but several drawbacks have led to development of the model of end stage liver disease (MELD). AIM: The aim of the study was to compare the predictive power of CPS and MELD, to validate the original MELD formula, and to assess the predictive value of the determinants used in the two prognostic scores outside of a study setting. PATIENTS: A total of 501 patients underwent elective TIPS placement and 475 patients fulfilled the inclusion criteria. METHODS: Data of all patients undergoing elective TIPS in one university hospital and four community hospitals in Vienna, Austria, between 1991 and 2001, were analysed retrospectively. The main statistical tests were Cox proportional hazards regression model, the log rank test, Kaplan-Meier analysis, and concordance c statistics. RESULTS: Median follow up was 5.2 years and median survival was 4.6 years. During follow up, 230 patients died, 75 within three months after TIPS placement. In stepwise proportional hazards analyses, independent predictors of death were creatinine level, bilirubin level, age, and refractory ascites. MELD was better in predicting survival in a stepwise Cox model but both scores were equally predictive in c statistics for one month, three month, and one year survival. Renal function was the strongest independent predictor of survival. CONCLUSIONS: Although MELD was the primary predictor of overall survival in multivariate analysis, c statistics showed that both scores can be used for patients undergoing TIPS with equal accuracy. For assessing prognosis in patients undergoing TIPS implantation, there seems little reason to replace the well established Child-Pugh score.

The bridge graft: a new concept for infrapopliteal surgery.

BACKGROUND: The long-term results of ePTFE grafts are particularly poor in crural reconstructions. We report on a novel surgical technique, whereby both run-off and anastomotic mismatches are concomitantly addressed. PATIENTS AND METHODS: Short segments of vein grafts (5-15 cm in length) were used to bridge two crural artery segments. Subsequently, a femoro-distal ePTFE graft was anastomosed to the bridge graft. Venous valves were made incompetent to allow bi-directional flow. In a retrospective series of 45 patients with crural bridge grafts, 12 patients were in stage III and 33 in stage IV. In 18 patients the reconstruction was the first procedure and in the remaining 28 patients it was the first or second re-operation. RESULTS: The primary patency rate at 1, 2, 3 and 4 years was 53, 44, 35 and 26% respectively. The secondary patency rate was 67, 53, 49 and 39% respectively. The corresponding limb salvage rate was 70, 61, 56 and 45%. In a small subgroup of patients, in which the crural bridge was the first reconstructive procedure, the primary patency was 76 at 1 year and 64 at 4 years. CONCLUSION: convincing long-term crural bridge grafts should be considered in those patients who have more than one crural or pedal artery available for grafting and an insufficient length of saphenous vein.

Redo surgery for carotid artery stenosis: when and how?

PURPOSE: We analyzed operations performed at our institution retrospectively for recurrent carotid artery stenosis to assess the indication for surgery. We also assessed the techniques used for these operations. PATIENTS AND METHODS: From January 1992 to December 1998 1210 carotid endarterectomies were performed. Forty two (3.4%) of these were for recurrent stenosis. A new vein patch was implanted in 27 cases, PTFE patches were used in nine cases. In six cases an interposition with the great saphenous vein was performed. RESULTS: The mean interval between primary and secondary procedure was 60. 2months (3months to 23yr). Twenty five of our 41 patients had had ipsilateral neurologic symptoms before redo surgery, the remainder were free of symptoms. The grade of stenosis was over 90% in 22 cases, between 75 and 90% in 11 cases and below 75% in nine cases, two cases had aneurysmatic lesions. None of the patients died in the 30day observation period. One patient had a stroke with a permanent neurological deficit. In two cases postoperative bleeding occurred requiring reexploration. Two patients developed hypoglossal neurapraxia and in four patients the recurrent laryngeal nerve was injured. One patient had an apneic episode in the recovery room. CONCLUSION: The reported incidence of recurrent carotid artery stenosis surgery ranges from 3 to 36% and our incidence is at the lower end of this range. The surgical results of reoperating are acceptable with a low incidence of complications.

Endoluminal treatment of infrarenal aortic aneurysms: clinical experience with the Talent stent-graft system.

PURPOSE: To evaluate the safety and efficacy of the Talent stent-graft (TSG) system in the endoluminal treatment of infrarenal abdominal aortic aneurysms (AAAs). PATIENTS AND METHODS: Endoluminal treatment of an AAA was attempted in 30 men with a mean age of 70.5 years (range, 51-83 years). Seven patients had AAAs suitable for treatment with a tube graft. In the other patients, treatment with a bifurcated TSG was planned. All procedures were performed as a combined surgical-radiologic procedure in an angiographic room. RESULTS: Primary technical success was achieved in 25 of 30 patients (83%). Technical failures were due to misplacement of the TSG (n = 2) with proximal leakage as a consequence, inability to gain access via the iliac arteries (n = 1), and a distal leakage (n = 2). Secondary interventions (n = 2) and spontaneous thrombosis of a distal leak (n = 1) increased the secondary technical success rate to 93% (28 of 30). Two procedures were converted to open surgery (conversion rate = 6%). One patient died during the first 30 days after uncomplicated stent-graft insertion because of myocardial infarction (30-day mortality = 5%). No complications occurred during a mean follow-up of 15.4 months (range, 6-19 months). The maximum diameter of the AAA decreased in eight patients and remained unchanged in the remaining patients. No increase in diameter was observed. No late endoleak or migration of the TSG was observed. CONCLUSION: The TSG-system revealed satisfactory initial and early follow-up results. Treatment of AAAs with this stent-graft system is feasible. The technical success rate in carefully selected patients should be 90% or more. However, long-term observations are necessary to determine if the encouraging early results of this type of therapy can be preserved during long-term follow-up.

The safety and efficacy of oral transmucosal fentanyl citrate for preoperative sedation in young children.

Oral transmucosal fentanyl citrate (OTFC) is a labeled preoperative pediatric sedative. Doses greater than 15 micrograms/kg are associated with a high incidence of post-operative nausea and vomiting and occasional respiratory depression. We studied the safety and efficacy of OTFC in children 6 yr old and younger at a dose of 15 micrograms/kg. Nineteen patients undergoing surgery associated with postoperative pain were randomized to receive OTFC/intravenous (IV) saline or placebo lozenge/IV fentanyl. After 45 min, patients receiving OTFC became more sedated than the placebo group, but there were no differences in cooperation, apprehension, parental separation, or induction cooperation scores. Preoperatively, neither respiratory depression nor oxygen desaturation occurred. Nine of 10 OTFC patients developed mild pruritus, and three of 10 OTFC patients vomited preoperatively; neither complication occurred in the placebo group. (The high incidence of preoperative vomiting led to the termination of the protocol before the anticipated enrollment of 40 patients.) General anesthesia was induced via a mask, followed by a propofol infusion. Spo2 and respiratory rate were monitored, and sedation, apprehension, cooperation, ease of parental separation, and induction cooperation were scored. One OTFC patient developed rigidity during induction. Emergence and recovery were not delayed by OTFC despite a 50% incidence of postoperative vomiting. We do not recommend the use of OTFC in a 15 micrograms/kg dose as a routine preoperative sedative in children 6 yr old and younger.

The effects of ketorolac and fentanyl on postoperative vomiting and analgesic requirements in children undergoing strabismus surgery.

Fifty-four ASA I and II children 1 to 10 yr of age undergoing strabismus surgery were randomized to receive in a double-blind fashion intravenous ketorolac (0.9 mg/kg), fentanyl (1 microgram/kg), or saline placebo (2 mL) during a standardized general anesthetic. Patients received no analgesic or antiemetics intraoperatively except for the study drug. Patients receiving ketorolac or placebo compared to fentanyl had a significantly lower incidence of postoperative vomiting in the day surgery unit (DSU) (P = 0.03) and overall (DSU plus home) (P = 0.005). The severity (number of episodes) of post-operative vomiting was significantly lower in the DSU, at home (first 24 h after hospital discharge), and overall for patients receiving ketorolac or placebo compared to fentanyl (P < 0.01). Postoperative pain scores and frequency of acetaminophen administration did not differ among the study groups, suggesting that the intraoperative use of ketorolac or fentanyl during pediatric strabismus surgery is unnecessary. No patients required fentanyl postoperatively, indicating that rectal acetaminophen administered in the postanesthesia recovery room provides sufficient analgesia for pediatric strabismus surgery. In conclusion, neither ketorolac nor fentanyl was associated with less postoperative vomiting or analgesic requirements compared to saline placebo administered during pediatric strabismus surgery. Fentanyl should be avoided, as it was associated with a significantly greater incidence of postoperative vomiting compared to ketorolac or placebo.

Sevoflurane versus halothane for general anesthesia in pediatric patients: a comparative study of vital signs, induction, and emergence.

STUDY OBJECTIVE: To compare vital signs and the speed of induction and emergence with sevoflurane versus halothane in pediatric patients. DESIGN: Prospective, randomized, open study. SETTING: Thomas Jefferson University Hospital. PATIENTS: 40 unpremedicated ASA Physical Status I and II children age 9 months to 16 years undergoing elective inpatient otorhinolaryngologic or orthopedic surgery. INTERVENTIONS: Standardized induction of anesthesia with sevoflurane (start: 1%, maximum: 7%) or halothane (start: 0.5%, maximum: 5%) in nitrous oxide/oxygen (N2O/O2). Intubation following vecuronium and 4 minutes of controlled ventilation with 2 minimum alveolar concentration (MAC) drug in O2; 1.5 MAC drug in N2O/O2 delivered for 20 minutes; then 0.75 MAC until the end of surgery. Fentanyl 1 mcg/kg was administered 15 minutes before the anticipated end of surgery, at which time anesthetics were stopped and mechanical ventilation continued until eye opening (emergence). MEASUREMENTS AND MAIN RESULTS: Blood pressure, heart rate (HR), oxygen saturation, end-tidal gas concentrations, and temperature were recorded. Induction and emergence times were measured to the nearest second. Induction (loss of eyelash reflex) was faster with sevoflurane (97 +/- 31 sec) than halothane (120 +/- 36 sec; p < 0.05), despite a lower inspired sevoflurane MAC. Emergence was faster with sevoflurane (9.9 +/- 2.9 min vs. 12.5 +/- 4.7 min; p < 0.05), despite a higher MAC multiple of end-tidal sevoflurane concentration at the end of surgery. Following intubation, HR (compared with the preinduction value in the operating room) was significantly higher in the halothane group (136.8% +/- 16.3% vs. 115.0% +/- 25.6%), as was mean arterial pressure (113.2% +/- 25.5% vs. 87.8% +/- 22.6%). This finding corresponded with a higher MAC multiple of end-tidal concentration in the sevoflurane group than in the halothane group. CONCLUSIONS: Induction of and emergence from anesthesia was faster with sevoflurane than halothane. Airway complications were low in both groups. Vital signs were more stable with sevoflurane during induction through intubation, and were comparable during maintenance. Sevoflurane is an excellent drug for inhalational induction in pediatric patients.

Thrombolysis combined with angioplasty for failed femorodistal arterial grafts.

This study examines the long-term clinical success and complications of thrombolysis-angioplasty (TLA) of failed arterial grafts performed in 17 patients (group 1) and matched with 21 patients (groups 2) who had intra-arterial thrombolysis (IAT) followed by graft revision. TLA consists of alternating thrombolysis with percutaneous transluminal angioplasty (PTA) in the treatment of occlusive arterial disease. Failed grafts consisted of 21 vein grafts, 6 ovine collagen grafts, 6 polytetrafluorethylene (PTFE) prostheses, 3 human umbilical veins and 2 polyurethane vascular grafts. All bypasses were below the knee, of which 13 were to the tibial level. Thrombolytic agents used were urokinase in 21 cases, tissue plasminogen activator in 13 cases and streptokinase in 4 cases. Following successful thrombolysis, PTA was performed with a 3 mm to 5 mm balloon catheters. Nine tandem lesions were corrected. In all 24 stenoses were treated: 14 anastomotic stenoses, 4 graft strictures and 5 peripheral stenotic lesions. The combined cumulative patency rate of both groups was 36% (SE 10.8%) at 3 years. The initial technical success rate in group 1 was 70% (12 of 17 grafts). The cumulative patency rate, as revealed by life-table analysis, was 35.6% (SE 10.2%) at one year and 21.3% (SE 9.6%) at 2 years. In all, 10 grafts failed at follow-up and in 6 of these cases secondary intervention was unsuccessful. Mid-graft and isolated lesions responded better than did anastomotic and tandem lesions. In group 2 the cumulative patency rate was 60.4% (SE 5.7%) at one year and 50.3% (SE 12.9%) at 2 years.(ABSTRACT TRUNCATED AT 250 WORDS)

Combined iliac transluminal angioplasty and femoropopliteal reconstruction for multilevel arterial occlusive disease.

Patients with multilevel arterial disease represent a challenging problem. A retrospective review of 46 consecutive femoropopliteal reconstructions combined with iliac balloon angioplasty was performed. Twenty-five procedures were below-knee and 21 to the above-knee popliteal artery segment. Mean follow-up was 26.8 months (range 4 to 84). There were 2 peroperative deaths and 3 serious complications (10.9%). In the late follow-up 4 significant restenoses and 1 reocclusion occurred for a patency rate of 81% for the inflow procedure at 5 years. Primary and secondary patency rate of combined procedures at 5 years was 61% and 76% respectively. The 5-year limb salvage rate was 93%. The mortality rate, morbidity rate and cumulative patency were not significantly different from a group of 38 patients who underwent 43 aortofemoral bypasses combined with femoropopliteal revascularization. In the latter group, the frequent incidence of anastomotic aneurysm (9.2%) was the main detrimental factor observed at follow-up. The authors conclude that femoropopliteal reconstruction combined with iliac angioplasty is effective for managing patients with multilevel disease. The possibility of intraoperative digital subtraction angioplasty and the use of no-profile co-axial balloon catheter design in the latter years of this study has improved our results.

Günther vena caval filter: clinical appraisal.

The mechanical stability of the Günther filter, caval patency, and complications related to filter placement were evaluated in 33 patients. Indications for placement included recurrent pulmonary embolism despite anticoagulation (n = 24) and contraindication to anticoagulation (n = 5). Four filters were placed prior to pulmonary lysis. Filters were positioned via the transfemoral route in 31 patients and via the transjugular route in two. Placement was complicated by pneumothorax in one case and faulty filter position in another. Patients were followed up for 52 months (mean, 12.1 months). Four patients died of nonembolic complications; three patients were lost to follow-up. Among the remaining 26 patients, caudal migration (3-6 cm) occurred in 19 (73%), cephalic migration into the atrium occurred in one, the inferior vena cava occluded in five, and struts perforated the caval wall in five. Pulmonary embolism recurred in one patient. In 11 cases, thrombus caught inside the basket was revealed with computed tomography; in one case a 7-cm floating thrombus was observed. The authors conclude that use of the Günther filter cannot be recommended because of the high prevalence of complications.

Distal popliteal and tibioperoneal transluminal angioplasty: long-term follow-up.

The long-term efficacy of percutaneous transluminal angioplasty (PTA) for treatment of occlusive lesions involving arteries below the knee was evaluated in 168 consecutive patients. The procedure was preceded by intraarterial thrombolysis in 33 patients with failing femorodistal grafts. Indications were disabling claudication in 40 cases (24%), acute ischemia in 18 (11%), rest pain in 49 (29%), and tissue necrosis in 61 (36%). Angioplasty of tandem femoral and/or iliac lesions was performed in 58 cases (34.5%). Major complications were observed in 19 patients (11.3%) and minor complications in 12 others. Five patients died within 30 days (3%). Mean follow-up was 26.1 months (range, 4-72 months). Major amputation was required in 26 cases (15%). The cumulative clinical success at 3 years was 83% for a single stenosis, 76% for multilevel lesions, 44% following lytic therapy, 36% for segmental occlusions, and 14% for anastomotic stenoses. Infrapopliteal PTA is useful in selected patients. Factors associated with poor long-term patency include a single patent tibial artery (P = .039), acute ischemia (P = .03), anastomotic stenosis (P = .01), and, possibly, complete occlusion prior to treatment (P = .091).

[Therapy of carotid stenosis in contralateral occlusion of the internal carotid artery]. / Therapie von Karotis-Stenosen bei kontralateralem Verschluss der Arteria carotis interna.

From January 1985 up to December 1987 sixteen patients with unilateral stenosis of the internal carotid artery (ICA) and concomitant chronic contralateral carotid occlusion underwent surgical correction of the stenosis. 31.2% were asymptomatic, 18.7% had transient ischemic attacks and 50% had suffered a stroke. On the occluded side 31.2% had had a stroke. Angiography showed intracerebral shunting to the occluded side in 43.7%; 56.2% of the patients had concomitant stenoses of intracerebral vessels. Surgical correction consisted of endarterectomy and patch-plasty of the ICA-stenosis in local anesthesia under protection of an intraluminal shunt. There was no mortality and no perioperative stroke. After a mean interval of 32 months life table analysis showed a stroke-free rate of 92% from 6 to 24 months on the operated side and of 84% from 12 to 24 months on the occluded side. We conclude that ICA-endarterectomy in patients with contralateral ICA-occlusion can be done without increased perioperative risk and yields satisfactory long time results.

[Percutaneous transluminal vasodilatation. Long-term results and report on experiences with a new system of catheters: transaxillary technic]. / Perkutane transluminale Gefässdilatation. Langzeitergebnisse und Erfahrungsbericht mit einem neuen Kathetersystem: transaxilläre Technik.

A report is given on the result of 567 transluminal vasodilatations, some of which have been followed up for more than five years. The results of conventional techniques were compared with a new catheter technique. The complication rate with the newly-adopted system is much lower than with conventional ones, while the reocclusion rate is only about 10%, which is about half of the figure obtained in the period up to July 1981 when the new technique was introduced.

Effect of feline panleukopenia virus infection on development of humoral and cellular immunity.

Cats were infected with feline panleukopenia virus (FPLV) at various ages pre- and post-parturition. All fetuses infected at 35 days of gestation from one queen and a single fetus infected at 45 days of gestation from a second queen had a significant delay in time of skin allograft rejection. Older fetuses and newborn kittens infected with FPLV did not show this delay in rejection time. Adult cats infected with FPLV demonstrated a significant decrease in lymphocyte responsiveness to two T cell mitogens, phytohemagglutinin and Concanavalin A, however there was no significant decrease in lymphocyte response to pokeweed mitogen, a T cell and B cell mitogen. Primary and secondary antibody responses to rabbit red blood cells (RRBC) were not affected by FPLV infection. The results suggest that FPLV has its primary immunosuppressive effect on T cell activity. This effect does not appear to be as severe as that observed for feline leukemia virus of kittens nor as for canine distemper virus in dogs.