The use of Singapore flaps for vaginal reconstruction in women with vaginal stenosis with obstetric fistula: a surgical technique.

Gynecologic and plastic surgeons collaborate to improve vaginal reconstruction for women with vaginal stenosis and obstetric fistula. As these cases occur typically in low-resource settings, the Singapore flap is a useful technique given its reliability, safety, ease of dissection, and minimal need for additional supplies. The fasciocutaneous flap maintains cutaneous innervation and vasculature and does not require stenting. The surgical collaboration has made it possible to provide functional vaginal reconstruction as a part of the overall care of obstetric fistula patients. The technique shows promise for improving sexual function for women with obstetric fistula and may also enhance healing. TWEETABLE ABSTRACT: Gynecologic & plastic surgeons collaborate to improve vaginal reconstruction for women with obstetric fistula.

Single-stage reconstruction of Achilles tendon injuries and distal lower extremity soft tissue defects with the reverse sural fasciocutaneous flap.

OBJECTIVE: Complex wounds of the lower extremity with concomitant Achilles tendon injury can be difficult to reconstruct. We favour the reverse sural artery fasciocutaneous flap because in a single step, flap elevation affords Achilles tendon exposure and adequate soft tissue for reconstruction. It also provides significant time and resource savings for both plastic and orthopaedic surgical teams. MATERIALS AND METHODS: Our case series involved four consecutive patients who presented with Achilles tendon injuries and concomitant complex soft tissue defects. The reverse sural artery flap was planned in conjunction with the orthopaedic service to facilitate their approach for Achilles tendon repair. Outcome was measured as flap survival, time for flap elevation and total operative time. RESULTS: Partial flap loss occurred in one patient. The Achilles repair was performed successfully in all cases. The mean time for flap elevation and Achilles exposure was 43 min (range, 37-52 min). Total operative time was 287 min (range, 211-347 min). CONCLUSION: The reverse sural artery fasciocutaneous flap is a durable, efficient option for simultaneous Achilles tendon reconstruction and wound coverage. Simple flap elevation provides necessary exposure of the Achilles tendon for repair while the flap itself provides ample soft tissue with a reliable blood supply. In our experience, the reverse sural artery fasciocutaneous flap affords a practical method to address two reconstructive challenges in a single procedure.

Risk of spinal cord ischemia after endograft repair of thoracic aortic aneurysms.

BACKGROUND: Surgical repair of thoracoabdominal aneurysms may be associated with a significant risk of perioperative morbidity including spinal cord ischemia, which occurs at a rate of between 5% and 21%. Spinal cord ischemia after endovascular repair of thoracic aortic aneurysms (TAAs) has also been reported. This investigation reviews the occurrence of spinal cord ischemia after endovascular repair of descending TAAs at the Mount Sinai Medical Center. PATIENTS AND METHODS: Between May 1997 and April 2001, 53 patients underwent endovascular exclusion of their TAA. Preprocedure computed tomography scanning and angiography were performed on all patients. All were performed in the operating room using C-arm fluoroscopy. Physical examinations and computed tomography scans were performed at discharge and at 1, 3, 6, and 12 months postoperatively and then annually thereafter. Spinal cord ischemia developed in three of the 53 patients (5.7%) postoperatively. In one patient, cord ischemia developed that manifested as early postoperative left leg weakness occurring after concomitant open infrarenal abdominal and endovascular TAA repair. The neurologic deficit resolved 12 hours after spinal drainage, steroid bolus, and the maintenance of hemodynamic stability. The remaining two patients developed delayed onset paralysis, one patient on the second postoperative day and the other patient 1 month postrepair. Both of these patients had previous abdominal aortic aneurysm repair, and both required long grafts to exclude an extensive area of their thoracic aortas. Irreversible cord ischemia and paralysis occurred in both of these patients. CONCLUSIONS: Endovascular repair of TAA has shown a promising reduction in operative morbidity; however, the risk of spinal cord ischemia remains. Concomitant or previous abdominal aortic aneurysm repair and long segment thoracic aortic exclusion appear to be important risk factors. Spinal cord protective measures (ie, cerebrospinal fluid drainage, steroids, prevention of hypotension) should be used for patients with the aforementioned risk factors undergoing endovascular TAA repair.

Endovascular repair of bleeding aortoenteric fistulas: a 5-year experience.

PURPOSE: Aortoenteric fistula (AEF) is an uncommon but catastrophic complication that can occur either primarily or after aortic reconstruction. Untreated, it is uniformly fatal. Conventional surgical management is associated with a perioperative mortality rate of 25% to 90% and frequent major complications. We reviewed our experience with the endovascular treatment of both primary and secondary AEFs in an effort to determine whether endovascular repair is a less morbid alternative to traditional surgical treatment in select patients. METHODS: In a 5-year period, seven high-risk patients who had bleeding and an AEF documented by means of radiology or endoscopy (2 primary, 5 secondary) were treated with coil embolization (1) or placement of an endovascular aortic stent graft (3 aortouniiliac, 2 tube, 1 bifurcated). One patient underwent computed tomography (CT)-guided percutaneous catheter drainage of an infected perigraft collection. The average follow-up period was 27 months (range, 11-66 months), and follow-up consisted of physical examination, complete blood count, and contrast-enhanced helical CT scanning at 3, 6, and 12 months and yearly thereafter. All patients were treated with intravenous antibiotics perioperatively and were prescribed life-long oral antibiotics on discharge. RESULTS: There was one perioperative death (14%) caused by fungal sepsis. Persistent sepsis after stent-graft placement necessitated laparotomy and bowel resection in one patient. One patient had three bouts of recurrent sepsis that were successfully treated with a change of antibiotic. There were three late deaths (43%) unrelated to the procedure or AEF. Three patients (43%) were alive and well an average of 36 months (range, 23-67 months) after the procedure, with no clinical or radiologic evidence of recurrent bleeding or infection. CONCLUSION: Endovascular management of AEFs is technically feasible and may be the preferred treatment in select patients with bleeding and no signs of sepsis. In the setting of gross infection, it may also be considered in high-risk patients as a bridge to more definitive treatment after hemodynamic stabilization and optimization.

Achieving consistency in the lateral nasal osteotomy during rhinoplasty: an external perforated technique.

The lateral nasal osteotomy is an integral element in rhinoplasty. A reproducible and predictable technique for the lateral nasal osteotomy (when indicated) is a significant contributor to operative success. A variety of methods and instrumentation are used to produce lateral osteotomies; currently, the two different modes used most frequently are the internal continuous and external perforated techniques. A previously published study by the senior author detailed the benefits of the external perforated osteotomy after comparing the two different methods. This article describes the role of the external perforated osteotomy technique in reproducing consistent results in rhinoplasty with minimal postoperative complications.

Internal iliac artery revascularization as an adjunct to endovascular repair of aortoiliac aneurysms.

PURPOSE: Endovascular repair of aortoiliac aneurysms may be limited by extension of the aneurysm to the iliac bifurcation, necessitating endpoint implantation in the external iliac artery. In such cases the circulation to the internal iliac artery is interrupted. Bilateral internal iliac artery occlusion during endovascular repair may be associated with significant morbidity, including gluteal claudication, erectile dysfunction, and ischemia of the sigmoid colon and perineum. We have employed internal iliac artery revascularization (IIR) to allow endograft implantation in the external iliac artery while preserving flow to the internal iliac artery in patients with aneurysms involving the iliac bifurcation bilaterally. METHODS: A total of 11 IIR procedures were performed in 10 patients undergoing endovascular abdominal aortic aneurysm (AAA) repair (9 men, 1 woman; mean age, 74 years). IIR was accomplished via a retroinguinal incision in 9 cases and a retroperitoneal incision in 2 cases. Six-mm polyester grafts were used for external-to-internal iliac artery bypass in 10 cases and internal iliac artery transposition onto the external iliac artery was used in one case. Endovascular AAA repair was performed using a modular bifurcated device (Talent-LPS, Medtronics, Minneapolis, Minn) after IIR. Bypass graft patency was determined immediately after the surgery, at 1 month, and every 3 months thereafter, using duplex ultrasound scanning and computed-tomography angiography. Mean aneurysm diameters were as follows: AAA, 6.4 +/- 0.7 cm; ipsilateral common iliac, 3.7 +/- 1.0 cm; contralateral common iliac, 3.9 +/- 0.8 cm. RESULTS: Successful IIR and endovascular AAA repair were accomplished in all cases. No proximal, distal, or graft junction endoleaks occurred. Two patients demonstrated retrograde aneurysm side-branch endoleaks originating from the lumbar arteries. One thrombosed spontaneously within 3 months. One perioperative myocardial infarction occurred. Reduction in aneurysm size was documented in 5 aortic, 5 ipsilateral iliac, and 3 contralateral iliac aneurysms. Gluteal claudication, erectile dysfunction, colon and perineal ischemia, and mortality did not occur. All IIRs have remained patent during a follow-up period of 4 to 15 months (mean, 10.1 months). CONCLUSIONS: IIR may be used with good short-term to intermediate-term patency to prevent pelvic ischemia in patients whose aneurysm anatomy requires extension of the endograft into the external iliac artery. This may allow endovascular AAA repair to be performed in patients who might otherwise be at risk for developing complications associated with bilateral internal iliac artery occlusion.

Balloon-expandable common iliac artery occluder device for endovascular aneurysm repair.

This study was performed to evaluate the efficacy of a balloon-expandable Palmaz stent common iliac artery occluder device for endovascular stent-graft repair of aortoiliac aneurysms. Eighty-four patients (79 men, 5 women; age range 60-95 yr; mean age, 76 yr) with aortoiliac aneurysms underwent endovascular stent-graft repair. The repair consisted of a stent-graft extending from the abdominal aorta to the iliac or common femoral artery, a cross-femoral bypass graft, and an endovascular arterial occluder device within the contralateral common iliac artery. The occluder device consisted of a 5-cm segment of 6-mm diameter polytetrafluoroethylene (PTFE) graft with a purse-string suture occluding the leading end and a Palmaz stent sutured to the trailing end. The occluder device was delivered through a 17F catheter via an arteriotomy. Eighty-three of the 84 patients received aortic endografts. In one case, infrarenal aortic rupture occurred during deployment of the aortic stent requiring conversion to an open surgical repair. Initial technical success for occluder device insertion was achieved in 78 of the remaining 83 patients. Failure to advance the occluder device delivery sheath through a diseased iliac artery occurred in one patient. Common iliac artery rupture occurred during balloon expansion and occluder device deployment in two patients. Two patients required additional coil embolization of the common iliac artery adjacent to the occluder device at the time of stent-graft insertion to correct incomplete iliac occlusion. Delayed occluder device-related complications included one patient with a postoperative iliac endoleak who required percutaneous coil embolization and one patient with a postoperative iliac endoleak in whom a contained aortic aneurysm rupture developed that was treated by surgical ligation of the common iliac artery. Use of the Palmaz stent-based iliac artery occluder device is an effective technique to induce common iliac artery thrombosis to facilitate endoluminal stent-graft aneurysm repair.

Intentional internal iliac artery occlusion to facilitate endovascular repair of aortoiliac aneurysms.

PURPOSE: The safety of intentional occlusion of patent internal iliac arteries (IIAs) to facilitate the endovascular repair of aortoiliac artery aneurysms (abdominal aortic aneurysms [AAAs] and iliac aneurysms [IAs]) was evaluated. METHODS: We analyzed the techniques and clinical sequelae of selective occlusion of one or both IIAs in 103 patients and correlated these findings with the results of preoperative angiograms to identify vascular anatomy that may predict postoperative pelvic ischemia. To quantify the clinical presentation of pelvic ischemia, we developed these criteria: class 0, no symptoms; class I, nonlimiting claudication with exercise; class II, new onset impotence, with or without moderate to severe buttock pain, leading to physical limitation with exercise; class III, buttock rest pain, colonic ischemia, or both. IIA occlusion was achieved in 100% of the patients by means of either catheter-directed embolization or orificial coverage with a stent-graft. No patient in this study had angiographic evidence of significant visceral occlusive disease before the procedure. Sixty-four patients had isolated AAAs, 23 patients had AAAs and IAs, and 16 patients had isolated IAs. Ninety-two patients had one IIA selectively occluded, and 11 patients had both IIAs selectively occluded. RESULTS: After IIA occlusion, 12 patients were categorized in class I, 9 patients were categorized in class II, and 1 patient was categorized in class III, for a total of 22 patients (21%) with pelvic ischemia. Sixteen (17%) of 92 patients had unilateral IIA occlusions, and six (17%) of 11 patients had bilateral IIA occlusions. Five patients in class I improved and had no symptoms within 1 year, and one patient in class II was downgraded to class I because of improved symptoms. Two unique preoperative angiographic findings were identified in the remaining 16 patients (16%) with chronic pelvic claudication: (1) stenosis of the remaining IIA origin (> 70%) with nonopacification of more than three of the six IIA branches (63%); and (2) small caliber, diseased or absent medial and lateral femoral circumflex arteries ipsilateral to the side of the IIA occlusion (25%). One patient with class III ischemia died of cardiovascular collapse associated with colon infarction caused by either acute ischemia or particulate embolization. CONCLUSION: The incidence of pelvic ischemia after IIA occlusion is 20% immediately after endovascular aortoiliac aneurysm repair. A total of 25% of patients had no symptoms within 1 year. Two preoperative radiologic findings may help identify patients who are at risk for pelvic ischemia: stenosis of the patent IIA and disease deep femoral ascending branches ipsilateral to the occluded IIA. The risk of colon ischemia appears to be small after selective IIA occlusion to facilitate endovascular AAA repair.

Ancillary techniques to facilitate endovascular repair of aortic aneurysms.

PURPOSE: The ability to treat abdominal aortoiliac aneurysms and thoracic aortic aneurysms may be limited by coexisting arterial disease. Device deployment may be impaired by occlusive disease and tortuosity of the arteries used to access the aneurysm or by suitability of the implantation sites. In this study we describe the auxiliary procedures performed to circumvent these obstacles and thereby enable endovascular aneurysm repair. PATIENTS AND METHODS: Between January 1, 1993, and December 31, 1999, 390 patients treated for aneurysm of the aorta with endovascular devices were entered prospectively in a vascular registry. Fifty (12%) of the 390 patients required adjunctive surgical techniques to (1) create or extend the length of the proximal or distal device implantation site or (2) permit device navigation through diseased iliac arteries. Auxiliary techniques used to extend or enhance implantation sites were elephant trunk graft (n = 2), the construction of renovisceral bypass grafts (n = 1), and subclavian artery transposition (n = 2). Plication of the common iliac artery at its bifurcation was performed in conjunction with femorofemoral bypass graft in nine patients to allow preservation of pelvic circulation by avoiding internal iliac artery sacrifice. Construction of a bypass graft to transpose the internal iliac artery orifice was performed in one patient. The auxiliary techniques used to facilitate device navigation were iliac artery angioplasty or stenting (n = 8), external iliac artery endovascular endarterectomy or straightening (n = 14), endoluminal iliofemoral bypass conduit (n = 5), and the construction of an open iliofemoral bypass conduit (n = 8). RESULTS: Successful deployment of the endovascular devices was achieved in 49 (98%) of 50 patients. Auxiliary techniques were successful in providing access for endovascular device deployment in all 35 patients (100%). Mean follow-up for techniques to facilitate device navigation is 26 months for endovascular procedures and 42 months for the open bypass graft construction patients; no occlusions were observed at this moment. There were five patients with incisional hematomas that did not necessitate intervention. Fourteen (94%) of 15 patients underwent successful device implantation after the auxiliary maneuvers to enhance implantation site. Mean follow-up for implantation site manipulation is 28 months. One of the subclavian transpositions had a new onset of Horner's syndrome, two of nine patients who had common iliac artery ligated had retroperitoneal hematomas that did not necessitate interventions, and no colon ischemia was seen. The patient who underwent nonanatomic bypass grafting of viscero-renal arteries had a retroperitoneal hematoma that necessitated reexploration. CONCLUSIONS: Significant coexisting arterial disease may be encountered in patients with aortic or iliac aneurysms. Identification of coexisting arterial diseases is essential to help tailor the appropriate supplemental surgical procedure to allow the performance of endovascular aneurysm repair in patients who would otherwise require open surgical repair.

Resorbable mesh in the treatment of orbital floor fractures.

A variety of materials have been used to reconstruct defects of the orbital floor. Autogenous materials such as bone and cartilage have the obvious drawback of the necessary donor site, whereas alloplastic implants carry the potential risk of infection, particularly when in communication with the maxillary sinus. Consequently, there has been interest in the use of resorbable alloplastic material that acts as a barrier until completely degraded. In this series, a total of 12 patients with orbital defects larger than 1 cm2 were treated by the placement of a resorbable mesh plate of polyglycolic and polylactic acid (Lactosorb). Of the total of 12 patients treated, 3 were lost to follow-up. Of the remaining 9 patients, the mean follow-up was 6 months, with the longest follow-up being 15 months and the shortest 1 month. Two patients developed enophthalmos. In each case, this measured 2 mm using Hertel exophthalmometry, and was present in the early postoperative period (less than 1 month). The cause of the enophthalmos in both patients was found to be a technical error in placement of the mesh. One patient developed an inflammatory reaction along the infraorbital rim requiring implant removal. This occurred at 7 months. From the above series, it is concluded that resorbable mesh is an acceptable material for reconstruction of the orbital floor in selected patients. It is believed that larger floor defects are better suited for nonresorbable alloplastic reconstruction, and that placement of the mesh over the infraorbital rim is unnecessary and places the patient at risk for a local inflammatory reaction.

Visceral artery aneurysms: experience in a tertiary-care center.

Visceral artery aneurysms (VAAs) often rupture and cause serious morbidity or death. The purpose of this study was to identify conditions associated with VAA in a series of 30 patients treated at our institution from 1988 through 1998. Demographics, types of aneurysms, associated conditions, diagnoses, treatments, and outcomes were recorded and analyzed. Thirty patients (16 men and 14 women) with VAA were identified. The arteries involved were splenic (eight), renal (ten), hepatic (nine), hypogastric (one), celiac (one), and pancreaticoduodenal (one). Five of eight (63%) splenic artery aneurysms occurred in women; however, gender was not a factor in other aneurysmal groups. Splenic artery aneurysm also was associated with cirrhosis in four of the eight (50%) patients. Five of the nine (56%) hepatic artery aneurysms were associated with cirrhosis; two of these were pseudoaneurysms that occurred after liver transplantation. Five of ten (50%) renal artery aneurysms were associated with juxtarenal abdominal aortic aneurysms. Celiac and pancreaticoduodenal aneurysms were associated with gastrointestinal bleeding. Treatments included surgery (19), embolization (eight), and observation alone (three). These data demonstrate that association with other conditions varies according to subgroups of VAA. Despite advances in diagnosis and therapy the heterogeneity of VAA suggests that management must remain individualized.

Development of a device for the delivery of agents to bone during distraction osteogenesis.

Various agents have been theoretically and experimentally implicated as mediators of distraction osteogenesis (DO). The purpose of this study was to develop a vehicle for the potential delivery of these factors to the region of the distraction site in an attempt to manipulate this biologic process. Three adult mongrel dogs (12 months old) had oblique osteotomies performed bilaterally through the gonial regions. In group I, the external distracter was affixed to the right hemimandible of two dogs (n = 2 hemimandibles) with cannulated pins (external diameter = 1.5 mm; lumen diameter = 1.0 mm; length = 60 mm), whereas the distracter on the left was affixed with standard, noncannulated pins of the same dimensions. In group II, cannulated pins were used to affix the external distracter to both hemimandibles (n = 2 hemimandibles) of a dog. The devices were activated after a 5-day latency period and were lengthened at a rate of 1 mm/day for 20 days. During the distraction period, 0.1 ml/d of sterile india ink was injected into the cannulated pins, after which the sterile stylet was replaced. The activation protocol was followed by 28 days of fixation (consolidation period). The hemimandibles from group I underwent removal of soft tissues, acetone fixation, and gross examination/photography, whereas the hemimandibles from group II were prepared for histologic evaluation (whole mount, hematoxylin and eosin staining). All dogs survived to the end of the study and demonstrated successful DO without evidence of complications. Hemimandibles in group I displayed evidence of india ink on both the lingual and buccal cortex around the cannulated pin site, in the regenerate and on the neocortices of the distracted segment. Hemimandibles of group II showed histologic evidence of the india ink being deposited densely around the cannulated pin site and extending in a radial fashion around the pin site into the regenerate. This study demonstrates for the first time a vehicle device for the delivery of an inert dye to the regenerate site during distraction osteogenesis. This vehicle offers the potential of delivery of various factors implicated in distraction osteogenesis (i.e., mitogens) in an attempt to alter this process and also substances (i.e., chemotherapy, antibiotics, etc.) for use in the treatment of various osteopathies.

Endovascular stent grafting in the presence of aortic neck filling defects: early clinical experience.

OBJECTIVE: Although endovascular grafts have been increasingly applied to the treatment of abdominal aortic aneurysms, their use in clinical trials is limited by well-defined anatomical exclusion criteria. One such criterion is the presence of thrombus within the infrarenal neck of an aneurysm, which is thought to (1) prevent the creation of a permanent watertight seal between the graft and the vessel wall, resulting in an endoleak; (2) contribute to stent migration; and (3) increase the risk of thromboembolism. This article summarizes our experience with endovascular abdominal aortic aneurysm exclusion in 19 patients with large aortic aneurysms, significant medical comorbidities, and apparent thrombus extending into the pararenal aortic neck. METHODS: Of 268 patients undergoing abdominal aortic aneurysm repair, 19 (7%; 17 men; mean age, 71 years) demonstrated computed tomographic and angiographic evidence of intramural filling defects at the level of the aortic neck. In no instance did these filling defects extend above the renal arteries. Endovascular grafting was performed through use of a balloon-expandable Palmaz stent and an expanded polytetrafluoroethylene graft, delivered and deployed under fluoroscopic guidance. Follow-up at 3, 6, and 12 months and annually thereafter was performed with computed tomography and duplex ultrasound scan. RESULTS: Spiral computed tomography and aortography revealed an irregular flow-limiting defect, occupying up to 75% of the aortic circumference, in every case. The mean aneurysm size, aortic neck diameter, and neck length before the procedure were 6.1, 2.43, and 1.4 cm, respectively; the mean aortic neck diameter after the procedure was 2.61 cm. No primary endoleaks were observed after graft insertion, and no delayed endoleaks have been detected during follow-up, which ranged from 7 to 48 months (mean, 23 months). In one patient, an asymptomatic renal artery embolus was detected on immediate follow-up computed tomography, and in another patient, an asymptomatic posterior tibial embolus occurred. CONCLUSION: No primary endoleaks, endograft migration, or significant distal embolization were observed after endografting in patients with aortic neck thrombus. The deployment of the fenestrated portion of the stent, above the thrombus and across the renal arteries, allows for effective renal perfusion, graft fixation, and exclusion of potential mural thrombus from the circulation. The presence of aortic neck thrombus may not necessarily be a contraindication to endovascular repair in select patients.

Update on the bifurcated EXCLUDER endoprosthesis: phase I results.

Many devices are being investigated for treatment of infrarenal abdominal aortic aneurysms. This report describes the particular characteristics of a next generation modular endograft and the Phase I results in 29 patients. Larger comparative studies are in progress to assess the safety and efficacy of this new design.

Current use of endovascular grafts for the treatment of abdominal aortic aneurysms.

The development of endovascular techniques for the treatment of abdominal aortic aneurysms has significantly reduced the major morbidity associated with standard surgical repair. The indications for use of endovascular grafts and the limitations of their use have not been fully defined. The effectiveness of the numerous commercially fabricated devices is currently being evaluated. This article describes the general principles of use for endovascular devices and details the features and results for the devices in current use.

Relationship of the 20S proteasome and the proteasome activator PA28 to atherosclerosis and intimal hyperplasia in the human vascular system.

Down-regulation of the proteasome activator PA28 results in abnormal proteasome activation and has been implicated in the development of intimal hyperplasia (IH) in animal models. Demonstration of proteasome and PA28 expression has not yet been documented in the human vascular system. This study sought to define the distribution of the 20S proteasome and its activator PA28 in human vessels and determine the relationship between the expression of the proteasome and PA28 and the development of atherosclerosis and IH. Vascular biopsies were obtained from 70 patients at the time of surgery, were snap frozen and sectioned in 5-micron sections, and prepared using standard histological techniques. The immunoperoxidase technique was used to identify 20S proteasome and PA28 expression in diseased and normal human arteries and veins as well as in patent bypass grafts with and without IH. Expression was graded by a blinded pathologist (scale: 1-4). Repeat quantification of the immunopositive cells was also performed. Expression of 20S proteasome and PA28 was identified in all vascular tissues examined. The proteins were identified predominately within the cytoplasm of vascular smooth muscle cells and endothelial cells. PA28 was more intensely expressed in quiescent regions of the vessel wall as compared to areas undergoing active proliferation and remodeling. PA28-mediated activation of the proteasome may be necessary to maintain normal cellular homeostasis and prevent excessive cellular proliferation in the human vascular system. Abnormalities of proteasome activation may have a significant role in the development of atherosclerosis and IH.

Nontropical pyomyositis: analysis of eight patients in an urban center.

Nontropical pyomyositis is rare and usually associated with immunodeficiency virus (HIV) infection. This study assessed manifestations and response to treatment of nontropical pyomyositis in an area with a high prevalence of HIV seropositivity. We undertook a chart review of eight consecutive patients treated for pyomyositis - primary infection of skeletal muscles - from 1988 through 1998. All patients complained of myalgia; four (50%) had fever and six (75%) had leukocytosis. Muscles involved were deltoid, quadriceps, gluteus, and psoas. Six (75%) patients had identifiable risk factors for pyomyositis: HIV seropositivity (two), history of intravenous drug abuse (one), chronic paraplegia and malnutrition (one), diabetes and chronic renal failure (one), and leukemia (one). One patient had had streptococcal pharyngitis previously but was otherwise healthy; another, a 2-year-old, had no evidence of underlying disease. Staphylococcus aureus was the most common organism isolated (50%). Four patients were treated with incision and drainage plus antibiotics; the remaining four patients were treated with intravenous antibiotics only; all recovered. Nontropical pyomyositis, which is often associated with HIV seropositivity or chronic illness, has a favorable outcome. Treatment can be effective even without surgical intervention.

Safety and efficacy of high-dose adenosine-induced asystole during endovascular AAA repair.

PURPOSE: To assess the safety and efficacy of high-dose adenosine administration to increase the precision of endovascular abdominal aortic aneurysm (AAA) repair using a balloon deployed stent-graft. METHODS: From January 1997 to March 1999, 98 AAA patients (79 men; mean age 71 years, range 62-91) were treated with balloon-expandable stent-grafts under an approved protocol. After placing a temporary transvenous ventricular lead or an external transthoracic pacing electrode, adenosine (24 mg initially) was administered in an escalating dose fashion to induce at least 10 seconds of asystole, during which the proximal stent was expanded. RESULTS: Adenosine dosages ranged from 24 to 90 mg (median 24 mg). Nine (9.2%) self-limiting cardiac events were observed: 2 (2.0%) episodes of transient myocardial ischemia, 2 (2.0%) cases of atrial fibrillation requiring cardioversion, 1 (1.0%) transient left bundle branch block lasting <10 seconds, and 4 (4.1%) prolonged periods of asystole requiring temporary pacemaker activation. There were no cases of bronchospasm or worsening obstructive pulmonary disease, and no patients required inotropic support after adenosine-induced asystole. CONCLUSIONS: Cardiac events following adenosine-induced asystole are infrequent, mild, and easily treated. The perioperative use of high-dose adenosine to ensure precise stent-graft placement appears to be a safe method of inducing temporary asystole during endovascular aortic repair.

Splenic artery aneurysm in the 1990s.

Splenic artery aneurysms (SAA), although rare, are the most common visceral artery aneurysms and are known for their potential for rupture. Pregnancy and portal hypertension have been known as major risk factors. With improved methods of diagnosis and minimally invasive therapy, management and outcome of SAA may change significantly. The purpose of this study was to analyze our institutional experience with SAA during the past decade. Charts of all patients (six women, three men; mean age, 60.5 [range: 31 to 81] years) with diagnoses of SAA from 1988 to 1999 were reviewed. Associated conditions included essential hypertension (6), portal hypertension (3), diabetes (1), intracranial aneurysm (1), and polyarteritis nodosa (1). Six patients were asymptomatic, and three had ruptured SAA. Diagnosis was made by angiography (2), computed tomography (3), ultrasonography (3), and exploratory laparotomy (1). Six patients underwent surgery (five required splenectomy), one had embolization, and two had no intervention. Three postoperative deaths occurred-two (intracranial aneurysm, myocardial infarction) in the first month, one (sepsis) in the ninth month. An association of liver disease with SAA was confirmed; however, no association with pregnancy was noted. Surgical treatment followed traditional methods, and mortality correlated with presence of severe comorbidity.