Surgical management of flash pulmonary edema secondary to renovascular hypertension.

BACKGROUND: Flask pulmonary edema (FPE) may be a manifestation of renovascular hypertension (RVHTN) and unresponsive to antihypertensive therapy. METHODS: Response to antihypertensive therapy and perioperative outcomes were determined in 5 consecutive patients with FPE. RESULTS: A mean of 2.3 admissions for the treatment of FPE were observed despite a mean cardiac ejection fraction of 60%. Preoperative treatment was attempted for 12 days and included ventilatory support (n = 3) and hemodialysis (n = 2). Total decreased renal perfusion was demonstrated by arteriography and radionuclide scans, no patient having a functional, contralateral kidney. Renal revascularizations were not associated with mortalities; 1 patient experienced atalectasis requiring bronchoscopy. All patients were extubated within 48 hours of surgery. A significant reduction in blood pressure (BP, 46%) and serum creatinine (Cr, 53%, P < or = 0.05) was observed. A mean of 1 antihypertensive medication was required at discharge compared with 3.4 on admission. At follow-up (mean 57 months) all patients remain cured of FPE. CONCLUSIONS: Medical management was unsuccessful in the treatment of FPE. Renal revascularization was associated with low morbidity and mortality, control of BP, restoration of renal function, and cure of FPE. These data suggest surgical intervention is the optimal mode of treatment of RVHTN associated with FPE.

Ultrasound-guided compression for the treatment of iatrogenic femoral pseudoaneurysms.

To assess the emerging use of ultrasound-guided compression (USGC) to treat iatrogenic femoral artery pseudoaneurysm (PA), we reviewed the experience in the accredited vascular laboratory of a large community teaching hospital from June 1993 to August 1994. Femoral duplex ultrasonography was done on 94 consecutive patients suspected of having PA. Twenty-eight PAs were found in 27 patients (14 women and 13 men; mean age, 62 years). Causes included cardiac angiography (n = 9), coronary angioplasty (n = 4), coronary stent placement (n = 12), and peripheral angioplasty (n = 3). Aneurysms were identified 1 to 90 days (median, 6 days) after femoral procedures, and their size ranged from 0.9 cm to 8.0 cm (mean, 2.5 cm). Fifteen patients (53%) were receiving systemic anticoagulation, 7 (25%) had spontaneous resolution, 10 (36%) were treated by femoral stitch arteriorrhaphy, and 11 (39%) were treated by USGC. Compression included vascular surgery standby, identification of PA neck (channel to native artery), 10-minute compression intervals to obliterate flow with a 5 MHz duplex ultrasound probe, and restudy at 24 hours. This protocol resulted in successful thrombosis in 8 patients (73%) but failed in 3 patients (37%), who required operative repair. Large aneurysm size, PA neck size, and systemic anticoagulation did not influence successful compression of PAs. Advanced age of the PA and operator inexperience were factors believed to negatively influence success. These data suggest that USGC is safe and effective and causes less morbidity than traditional repair, and it has emerged as the initial treatment of choice for iatrogenic femoral pseudoaneurysms.

Healing characteristics of intraarterial stent grafts in an injured artery model.

Previous investigations reveal in the absence of endothelial cell (EC) injury, intraarterial polytetrafluoroethylene (PTFE) stent graft (SG) exhibit greater EC repaving than PTFE interposition grafts (CG). The investigation evaluated EC repaving of SG compared to CG after balloon injury. Twenty adult dogs underwent SG (n = 10) or CG (n = 10) placement in the infrarenal aorta after balloon injury with harvest at 1 and 6 weeks. Endothelial repaving, intima-to-media height ratios (IMHR), and inflammatory stains were performed. Endothelial repaving was greater in 6-week SG compared to CG (51% +/- 5.0 versus 10% +/- 5.0, p < or = 0.05). IMHR was less in 6-week SG compared to CG at the proximal (1.22 +/- 0.16 versus 1.82 +/- 0.16, p < or = 0.05) and distal anastomosis (0.81 +/- 0.25 versus 1.33 +/- 0.25, p < or = 0.05). Smooth muscle cell (SMC) alpha-actin was greater in 1-week SG compared to CG at the distal anastomosis (121.5 +/- 7.2 versus 94.0 +/- 7.2, p < or = 0.05). Proliferating cell nuclear antigen (PCNA) was less in 6-week SG compared to CG at the proximal (5.6 +/- 1.4 versus 9.4 +/- 1.1, p < or = 0.05) and distal anastomosis (3.8 +/- 0.6 versus 11.2 +/- 1.1, p < or = 0.05). Macrophage CD-44 was less in 6-week SG compared to CG at the proximal (10.4 +/- 1.6 versus 32.6 +/- 3.6, p < or = 0.05) and distal anastomosis (8.6 +/- 0.9 versus 35.6 +/- 3.6, p < or = 0.05). Intraarterial SG placed after balloon injury exhibited significantly greater endothelialization and less intimal hyperplasia when compared to CG.

Vascular endothelial growth factor and heparin in a biologic glue promotes human aortic endothelial cell proliferation with aortic smooth muscle cell inhibition.

BACKGROUND: Incomplete luminal endothelialization may contribute to small diameter vascular graft failure. Vascular endothelial growth factor (VEGF) can be used to stimulate endothelialization without provoking smooth muscle cell (SMC) proliferation. Heparin and VEGF in a fibrin glue (FG) were investigated for their ability to promote selective human aortic endothelial cell (HAEC) proliferation and human aortic smooth muscle cell (HASMC) inhibition. METHODS: HAECs and HASMCs were seeded on FG containing VEGF (2.5, 10, 30, 100 ng/ml) or VEGF and heparin (5, 50, 500 units/ml). Proliferation assays were performed with tritiated thymidine on days 1 and 3. Results were analyzed by ANOVA, with p < or = 0.05 significant. RESULTS: HAEC proliferation on FG with 10, 30, and 100 ng/ml VEGF was significantly greater than FG alone at days 1 and 3. The addition of 50 units/ml heparin to VEGF significantly increased HAEC proliferation to greater than FG with VEGF alone at day 1. Human aortic SMC proliferation was not stimulated by the addition of VEGF. The addition of 5, 50, and 500 units/ml heparin significantly inhibited HASMC proliferation regardless of VEGF concentration. DISCUSSION: VEGF at 10 ng/ml combined with heparin at 50 units/ml exhibited maximal stimulation of HAECs with inhibition of HASMCs. VEGF and heparin in a biologic glue may improve patency by selectively promoting HAEC proliferation without HASMC growth on synthetic vascular bypass grafts.

Results and complications of arteriovenous access dialysis grafts in the lower extremity: a five year review.

Virtually no objective data exist regarding the natural history of arteriovenous (AV) dialysis access grafts placed in the lower extremity for routine hemodialysis. From March 1988 until October 1993, 45 consecutive lower extremity AV dialysis access grafts were placed in 39 patients (16 males; 23 females; mean age 58 years) at a large teaching community hospital. All 39 patients had long-standing end stage renal disease and had required chronic hemodialysis from 7 to 237 months mean, 72 months) prior to leg graft placement. Polytetrafluorethylene (n=39) or bovine (n=6) loop lower extremity dialysis grafts were placed after multiple upper extremity dialysis graft failures (mean, 2.7 previous grafts with 9.6 thrombectomies and/or access revisions per patient). There were no operative deaths; however, in follow-up (1-132 months; mean 20 months; median 18 months), 33 percent of the patients had died from systemic complications of their renal disease, and only 20 (44%) leg grafts are currently patent [correction of patient] . Graft complications, excluding graft thromboses, occurred in 20 grafts including graft infection (n=8; 18%), severe ipsilateral leg ischemia (n=7; 16%), graft aneurysmal degeneration requiring revision (n=3; 7%), fistula-induced congestive heart failure (n=2; 4%), and major lower extremity amputation (n=3; 7%). Primary patency by life-table analysis was 47 percent at 24 months. Fifteen (33%) grafts thrombosed at least once, and all but one were salvaged with thrombectomy. The need for lower extremity AV dialysis access appears to be a significant marker for late mortality in this group of chronically ill patients. They are associated with multiple complications and should probably be placed only if significant patient morbidity can be accepted and justified.

Carcinoma of the ampulla of Vater: a community hospital experience.

Carcinoma of the ampulla of Vater is an uncommon malignancy often treated at tertiary referral centers. Most published series are derived from these centers and show resectability rated of 80 to 90 percent, with overall 5 year survival rates of 25 to 60 per cent. Twenty cases of ampullary carcinoma treated in a community hospital setting were reviewed. The mean age at diagnosis was 69 years (range, 49-89), and 65 per cent of the patients were female. The most common presenting symptoms were jaundice (85%) and abdominal pain (50%). Stages at diagnosis included stage II, 12 patients; stage III, 5 patients; and stage IV, 3 patients. Nine patients underwent curative resections (resectability rate, 45%), of which five were pylorus-preserving pancreaticoduodenectomies and four were standard pancreaticoduodenectomies. There were no operative mortalities. Overall survival was 23 per cent, while survival in the resected patients was 60 per cent at 2 years. The majority of the patients not resected were felt to be poor candidates for major surgery either because of significant comorbid disease or advanced age. Three patients presented with advanced disease, and two patients died within 7 days of presentation. This review demonstrated a significantly lower resectability rate for carcinoma of the ampulla of Vater, with comparable survival rates. Differences from published studies at tertiary referral centers reflect a selection bias of patients referred to these centers.

Outcomes in the management of vascular prosthetic graft infections confined to the groin: a reappraisal.

The management of vascular prosthetic graft infections confined to the groin continues to be controversial. To critically evaluate this problem, we reviewed the records of our vascular registry from December 1992 through February 1995 and found 17 incidences of groin sepsis involving a vascular prosthesis in 10 patients. These included a proximal prosthetic femoropopliteal bypass (n = 6), an aortobifemoral graft limb (n = 5), an ileofemoral bypass (n = 3), a prosthetic femoral patch (n = 2), and an aortofemoral/femorofemoral bypass (n = 1). The mean age of these patients was 65 years. Six patients were diabetic, four were on systemic steroids, and two were diabetic and on steroids. All infections were Szilagyi grade III including three in which the patients presented with local hemorrhage. Treatment consisted of irrigation, radical debridement with or without in situ graft replacement, and local rotational muscle flap coverage in nine cases, graft excision with extra-anatomic (obturator ileofemoral bypass) graft replacement in six cases, and excision alone in two cases. Of the 17 infections treated operatively and followed from 1 week to 18 months (median 5 months), eight (47%) showed no evidence of recurrence, six (35%) recurred, two (12%) caused early death, and one resulted in a thrombosed graft requiring extra-anatomic reconstruction. Of the nine infected grafted treated locally with muscle flaps, six showed recurrent infection from 3 weeks to 15 months and one thrombosed for a total local treatment failure rate of 78%. Only two grafts are free of infection at 4 and 5 months, respectively. Of the six incidences of infection treated with obturator bypass, four (66%) are free of infection and two resulted in patient death; both infections treated with excision alone were eradicated but resulted in a major lower extremity amputation. These data question the growing acceptance of debridement and local muscle flap coverage for the treatment of all prosthetic vascular graft infections confined to the groin, especially in patients who are diabetic or on systemic steroids.

Thoracoscopy versus thoracotomy: indications and advantages.

Although the diagnosis and treatment of intrathoracic diseases have been affected by the use of thoracoscopy, the indications and advantages of this procedure are poorly defined. To review the indications and results in a community practice, 52 consecutive cases of thoracoscopy were reviewed and the postoperative courses were compared to a control group of 43 simultaneous thoracotomies. Operative indications for thoracoscopy included investigation or treatment of a lung mass (n = 33), spontaneous pneumothorax (n = 10), mediastinal mass (n = 4), pleural effusion (n = 2), mesothelioma (n = 2), and a ruptured hemidiaphragm (n = 1). General endotracheal anesthesia was used in each case. Overall, thoracoscopy was successful in 40 cases (77%). Conversion to formal thoracotomy was required in 14 cases (27%) secondary to poor visualization or to aid in further dissection. Compared to thoracotomy, complication rates were less (7.6 vs 16.2%), hospital stay shorter (5.5 vs 8 days), ICU stay shorter (0 vs 2 days) and pleural drainage time less (2 vs 5 days) in the thoracoscopy group. In summary, 73% of the patients in this study who formerly would have undergone thoracotomy were successfully managed with thoracoscopy alone, with acceptable morbidity and mortality. These data define the indications, morbidity, and mortality of thoracoscopy and suggest that thoracoscopy may emerge as the procedure of choice in the diagnosis and management of many thoracic diseases.

Antithrombin III and trauma patients: factors that determine low levels.

A prospective (cohort) study was conducted to determine the incidence of low antithrombin III (AT III) levels and the association with selected clinical variables in adult trauma patients. One hundred sixty AT III levels were obtained on 50 consecutive trauma admissions to a community-based level I trauma center. Antithrombin III levels were drawn as soon after admission as possible and every other day thereafter. Thirty-one patients (62%) had at least one low AT III level (< 80%), whereas 15 concurrently drawn control levels were all > or = 90%. Low AT III levels were more common in patients with one or more of the following: base deficit less than -4 (39% vs. 0, p = 0.002); Injury Severity Score > 15 (48% vs. 16%, p = 0.04); and blood transfusion (32% vs. 5%, p = 0.04). All other variables (shock, surgical intervention, subcutaneous heparin, and sequential compression devices) were not statistically significant, although all six patients with shock had low levels. In conclusion, over 60% of adult trauma patients had low AT III levels at some time during hospitalization and these patients were clearly more severely injured. Further studies are required to determine if these patients are more susceptible to thromboembolic phenomena.

Vascular malformation: case report and literature review.

The therapeutic outcome of congenital vascular malformations generally parallels the complexity of the lesion. The less extensive malformations that are prone to regression may be observed. Larger lesions that produce facial asymmetry or have diffuse extremity involvement require a more aggressive approach. Even with the limitations of current treatment methods these extensive malformations can usually be controlled thus affording the patient a better life.