Early experience with the bifurcated Excluder endoprosthesis for treatment of the abdominal aortic aneurysm.

PURPOSE: This report describes our initial experience with the modular, bifurcated Excluder endoprosthesis and its safety and efficacy in the primary endovascular repair of infrarenal abdominal aortic aneurysms (AAAs). METHODS: AAAs (mean diameter, 58.2 +/- 14.3 mm) were repaired in 19 patients with this device between March 1999 and January 2000. The mean age of patients was 71.8 +/- 8.4 years (range, 57-86 years). This modular device was inserted through an 18F introducer sheath placed in one femoral artery, and the contralateral artery was cannulated with a 12F introducer sheath. All procedures were performed in a standard operating room with angiographic capabilities. RESULTS: Endograft deployment was successful in all patients. The average surgical time was 135 +/- 37 minutes, with a mean blood loss of 229 +/- 138 mL. In eight patients, the use of either aortic or iliac extenders was required for enhanced sealing or additional length. An external iliac artery dissection occurring at the time of endograft insertion was successfully treated with a Wallstent. Type II leaks initially found to be present by means of intraoperative completion angiography had spontaneously thrombosed by the 1-month follow-up computed tomography scan. There was one perioperative death (5.3%). Complications included superficial wound infections (n = 3) and a nonfatal myocardial infarction (n = 1). The mean length of hospital stay was 2.9 +/- 1.2 days, and only six patients required intensive care. Endoleaks were seen in four patients (21%) by means of the 30-day computed tomography scan; three of these endoleaks had spontaneously sealed at the time of the 6-month follow-up examination (5.5% 6-month endoleak rate). Aneurysm size did not increase in the patients with leaks. CONCLUSION: The Excluder endoprosthesis was an effective means of excluding an infrarenal AAA from the systemic circulation in this selected group of patients. The smaller sheath sizes may increase the pool of potential candidates. Further study of this device is warranted, and continued assessment of the long-term durability of the device will be necessary.

Percutaneous varicocele embolization versus surgical ligation for the treatment of infertility: changes in seminal parameters and pregnancy outcomes.

PURPOSE: To compare the success of percutaneous varicocele embolization to surgical ligation with regard to changes in semen characteristics and pregnancy outcome. MATERIALS AND METHODS: Infertility records from 346 men who underwent correction of their varicocele for infertility (surgical ligation 149; embolization 197) were reviewed retrospectively. Preprocedural and postprocedural semen analyses and pregnancy outcomes were obtained with use of chart and telephone follow-up. RESULTS: In men who successfully impregnated their partners, there were significant improvements in sperm density, percent total improvement, motility, and progression. Postprocedural (embolization vs surgery) percentage increases in seminal parameters were density, 156.8% versus 138.5%; total, 168.8% versus 157.91%; and motility, 2.7% versus 3.2%. The percent of individuals who had a change in sperm progression was 31% versus 41%. There was no statistical difference between the techniques based on t tests. The pregnancy rates were similar for the two groups, 39% and 34% for embolization and surgery, respectively. CONCLUSION: There is no significant statistical difference in seminal values or pregnancy outcome between the two techniques.

Transjugular intrahepatic portosystemic shunt-related arterial injuries: prospective comparison of large- and small-gauge needle systems.

PURPOSE: The authors prospectively compared the nature and incidence of hepatic arterial injuries resulting from creation of a transjugular intrahepatic portosystemic shunt (TIPS) with large- and small-gauge needle systems. PATIENTS AND METHODS: Fifty patients underwent hepatic and superior mesenteric angiography immediately before and after shunt creation. A sheathed 16-gauge needle system was used to locate and puncture the portal vein in 24 patients. A 21-gauge needle system was used in 26 patients. RESULTS: Shunts were successfully created in all patients. Three inadvertent hepatic arterial punctures were recognized during shunt placement, two with the small needle and one with the large needle system. No hepatic arterial lesions were detected in any patient. Two incidental hepatomas were identified at angiography. CONCLUSION: TIPS-related hepatic arterial injuries are rare. In this series, large and small needle systems were indistinguishable with respect to this complication.

Intentional reversible thrombosis of transjugular intrahepatic portosystemic shunts.

PURPOSE: To assess whether balloon occlusion of a transjugular intrahepatic portosystemic shunt (TIPS) will allow permanent yet reversible shunt thrombosis. MATERIALS AND METHODS: A balloon catheter was inflated in the midportion of the TIPS in two women with severe, uncontrollable encephalopathy or liver failure (aged 42 and 65 years, respectively) to allow occlusive thrombus to develop below the balloon. RESULTS: Balloon occlusion led to rapid TIPS thrombosis, which was readily reversible. CONCLUSION: Balloon thrombosis is a simple technique for complete occlusion of a TIPS. This technique may also be useful for occlusion of surgical mesocaval H-graft shunts or dialysis access shunts.

Raman spectroscopy of normal and diseased human breast tissues.

Raman spectra of histologically normal human breast biopsy samples were compared to those exhibiting infiltrating ductal carcinoma (IDC) or fibrocystic change. Experiments at 784 nm with CCD detectors reduced fluorescence interference and produced high SNR spectra with relatively low (10-200 mW) laser power. Sample to sample and patient to patient variation for normal specimens were less than 5% for the ratios of major Raman bands. The Raman spectra changed dramatically in diseased specimens, with much weaker lipid bands being evident. The spectrum of infiltrating ductal carcinoma samples is similar to that of human collagen. Differences between benign (fibrocystic) and malignant (IDC) lesions were smaller than those between normal and IDC specimens, but were still reproducible. Fiberoptic sampling through a hypodermic needle and with a remote probe were demonstrated. The possibility of rapid diagnosis with Raman spectroscopy is considered.

Characterization of human breast biopsy specimens with near-IR Raman spectroscopy.

Breast biopsy samples were examined with Raman spectroscopy with laser wavelengths ranging from 406 to 830 nm. A combination of a single-stage spectrograph, band reject filter, and CCD detector permitted low laser powers and minimal risk of sample radiation damage. Spectra of formalin-fixed human tissue revealed Raman features for lipids and carotenoids. The best defined lipid features were observed for 782- and 830-nm laser excitation, while carotenoid features were strongest in the 488-515-nm range due to resonance enhancement. Comparison of the spectra with those of fatty acid esters revealed that the major lipid component is a derivative of oleic acid. Lipid and carotenoid Raman bands were superimposed on a luminescent background which was less prominent at longer laser wavelengths. A compact, portable, diode laser spectrometer was tested in a clinical setting with fiber optic sampling. The results indicate that substantial biochemical information is available from near-IR Raman spectroscopy and the technique may have clinical applications.

Laparoscopic cholecystectomy technique for removal of the gallbladder from the peritoneal cavity.

A new laparoscopic cholecystectomy technique for removing the gallbladder from the peritoneal cavity through the umbilical incision is presented. This method is faster than the traditional technique and eliminates the necessity of transferring the camera from the umbilical port to a second port.

Young Investigator Award. Raman spectroscopy of human atherosclerotic plaque: implications for laser angioplasty.

Raman spectroscopy is a specialized technique that permits highly specific identification of specimens, in contrast to fluorescence spectroscopy with which analysis of arterial tissues generates spectra that are broad and featureless, with little difference seen between normal artery and atheroma. Various plaque types and the contributions of different arterial fluorophores were studied to determine if Raman spectroscopy could function as a potential guidance modality for laser angioplasty. Arterial specimens obtained at atherectomy and post mortem were studied in air and while immersed in blood. One hundred fifty-six Raman spectra were collected from arterial specimens and chromatographic samples of collagen, elastin, cholesterol, beta-carotene, and L-tryptophan. Analysis showed both fatty and fibrous atherosclerotic plaques to have characteristic spectral peaks at 1,002, 1,154, and 1,516 cm-1, while the Raman spectrum of normal vessel was featureless. Spectral peaks of beta-carotene were nearly identical to those of fatty plaque. The arterial fluorophores collagen, elastin, cholesterol, and L-tryptophan were non-contributory. The Raman spectrum of fatty plaque immersed in a blood field was also detectable, suggesting that this technique may be useful for in vivo plaque recognition.

The transstenotic pressure gradient trend as a predictor of acute complications after percutaneous transluminal coronary angioplasty.

The transstenotic pressure gradient recorded during coronary angioplasty (PTCA) reflects the dynamic relationship that exists between coronary blood flow and the effective cross-sectional area of the arterial lumen. An apparent relationship between the dynamic behavior of the pressure gradient and subsequent acute vessel closure was observed in our catheterization laboratory. We therefore examined the usefulness of the pressure gradient trend in predicting acute complications after 463 attempted PTCA procedures. Two pressure gradient trend patterns were identified: (1) a rising trend pattern identified by an increasing pressure gradient in the interval after deflation of the angioplasty, and (2) a stable trend pattern identified by a constant or decreasing pressure gradient. The incidence of acute vessel closure (17% vs 4%, p = .0001), emergency CABG (5.6% versus 1%, p less than .05), and myocardial infarction (13% versus 2%, p less than .0001) after the PTCA procedure was significantly higher among patients with rising trend patterns when compared with patients with stable trend patterns. Multivariate analysis identified independent predictors for an acute closure event as rising trend pattern (p less than .001), post-PTCA gradient (p less than .05), and post-PTCA percent diameter stenosis (p less than .02). Independent predictors for emergency coronary artery bypass grafting and myocardial infarction were post-PTCA gradient (p less than .001) and a rising trend pattern (odds ratio = 2.91, p less than .001), respectively. The dynamic behavior of the gradient trend provides additional useful information about the results of dilatation.(ABSTRACT TRUNCATED AT 250 WORDS)