Contralateral internal jugular vein interposition for salvage of a functioning arteriovenous fistula.

Outflow obstruction in patients with hemodialysis access can cause venous hypertension and jeopardize the patency of the access site. Numerous surgical procedures have been described to decompress an occluded subclavian vein. In this report, we describe the use of the contralateral internal jugular vein as a bypass conduit to decompress an occluded brachiocephalic vein in a patient whose dialysis was dependent on this vein access.

Cricopharyngeal myotomy in neurogenic oropharyngeal dysphagia.

OBJECTIVE: Cricopharyngeal myotomy as an independent procedure has been performed on fourteen patients with a variety of neuromuscular disorders, suffering from neurogenic oropharyngeal dysphagia in the interval between 1994-1997. All of them were referred from a neurophysician or physiatrist after failure of improvement by medical treatment. METHODS: The selection of patients for operation was based mainly on clinical evaluation and simple exclusion criteria without manometric studies. RESULTS: There was dramatic improvement in twelve, with recurrent laryngeal nerve palsy and temporary pharyngeal fistula in two patients. No mortality was recorded. CONCLUSION: We conclude that cricopharyngeal myotomy is a simple, safe and effective procedure with acceptable morbidity. It should be considered as a rehabiliation procedure for patients with dysphagia due to various neurologic disorders based on simple, clinical exclusion criteria without the need for the tedious, time consuming and expensive manometric studies.

A comparative evaluation of femorofemoral crossover bypass and iliofemoral bypass for unilateral iliac artery occlusive disease.

The purpose of this study was to compare the results of extra-anatomic femorofemoral crossover bypass grafting to the anatomic iliofemoral bypass grafting procedure in the treatment of patients with unilateral iliac artery occlusive disease with respect to patency and limb salvage. The records of all patients with unilateral iliac artery disease who underwent revascularization between January 1988 and December 1995 at the University of Iowa Hospitals and Clinics (UIHC) were retrospectively reviewed; 108 patients were identified and divided into two groups. Group I (n=68; male/female=44/24) was composed of all patients who underwent a femorofemoral crossover extra-anatomic bypass. All patients who underwent an iliofemoral anatomic bypass constituted group II (n=40; male/female=24/16). The mean age for group I was 60 years (range 28-87) and for group II, 54 years (range 14-86). The medical risk factors between both groups were comparable. Except for the higher incidence of gangrene in group II the indications for surgery were comparable between both groups. A polytetrafluoroethylene graft was used in 88% of group I patients and in 90% of group II patients (NS). In the remaining patients, an autogenous vein conduit was used. Two patients from group I (2.9%) died in the perioperative period (NS). Graft patency was assessed by clinical evaluation, Doppler-derived ankle/brachial indices, and color duplex imaging. The cumulative primary and secondary patency rates, limb salvage, and patient survival were calculated by use of life table analysis (SE<0.1). The need for simultaneous outflow and inflow procedures at the time of surgery was comparable between both groups. The proportion of patients who underwent further revascularization during follow-up was also comparable. The 5-year primary and secondary graft patency rates were 81.7% and 90.3%, in group I and 61.3% and 80.5% in group II. Although the difference between both groups was not significant there was a tendency toward higher rates with femorofemoral bypass. The 5-year survival rates of 80.3% for group I and 73.3% for group II were comparable. These data suggest that there is no significant difference in the long-term results between the femorofemoral crossover bypass grafts and iliofemoral grafts. Both procedures result in acceptable patency and limb salvage rates. The femorofemoral bypass is, however, more attractive, for it can be performed under local anesthesia if needed and does not involve the creation of the retroperitoneal incision necessary with the iliofemoral bypass.

Entering the ninth decade is not a contraindication for carotid endarterectomy.

The role of carotid endarterectomy (CEA) in stroke prevention is now better defined. However, its role in patients older than 79 years of age is controversial. This group of patients has been excluded in most clinical trials. In this study the authors reviewed their experience with CEA patients >79 years old. The records of all patients older than 79 years of age who underwent a CEA in a recent time period from January 1988 to December 1996 were retrospectively reviewed. Forty-one patients (31 men, 10 women) were identified by computer search. The indication for operation included transient ischemic attack in 12 (29.3%), amaurosis fugax in nine (22%), stroke in two (4.9%), and nonhemispheric symptoms in three (7.3%). Fifteen patients (36.6%) were asymptomatic. Medical risk factors included coronary artery disease in 26 (63.4%), hypertension in 22 (53.7%), and smoking in 12 (29.3%). The procedure was performed under EEG monitoring in all patients. General anesthesia was administered in 37 (90%) and regional anesthesia in four (10%). Shunts were used in four (10%) patients. The internal carotid artery was patched in 16 patients (39%). One patient (2.4%) developed a perioperative stroke and only one patient developed perioperative myocardial infarction (MI). None of the patients died within 30 days of surgery. In addition to the one MI case, five patients developed minor complications. The average length of time for stay after CEA was 3.4 days. Patients were followed up for an average of 20.7 months. Six patients died during follow-up. Four of those died from an MI and two from a stroke. The authors conclude that with proper selection of patients, CEA is safe in the octogenarian. Age alone should not be a contraindication for CEA.

Internal iliac revascularization during aortic aneurysm replacement: a review and description of a useful technique.

The coexistence of infrarenal aortic aneurysm and internal iliac artery aneurysm may represent a management problem with regard to preservation of the pelvic blood supply. In this article, we review the methods available for maintaining the pelvic blood flow and describe a useful technique that we have successfully utilized in seven patients to preserve the hypogastric artery blood flow.

Is color duplex surveillance of infrainguinal polytetrafluoroethylene grafts worthwhile?

BACKGROUND: Unlike vein bypasses, the role of duplex surveillance of infrainguinal prosthetic bypass grafts is controversial. The purpose of this study was to evaluate the adequacy of color duplex surveillance in identifying failing infrainguinal polytetrafluoroethylene (PTFE) bypass grafts and to assess its value in predicting continued bypass patency. METHOD: The surveillance data of primarily patent PTFE bypass grafts were compared with those of revised/occluded PTFE grafts. Ninety-five patients underwent 102 infrainguinal PTFE bypass grafts from January 1991 to December 1996 and were enrolled in a duplex surveillance program at 1 month postoperatively, every 3 months in the first year, every 6 months in the second year, and yearly thereafter. RESULTS: Seventy grafts remained primarily patent, 5 were revised and 27 occluded. There was no significant difference in the mean age, gender, indication for surgery, type of original procedure, or duration of follow-up between both groups. Four hundred and seven duplex surveillance data were available for analysis. Focal increase in peak systolic velocity (PSV) 3 x the adjacent segment or low flow manifested by PSV <45 cm/sec were considered abnormal. In the primarily patent group, 5 bypasses had abnormal duplex surveillance and were found to have no abnormality on angiogram and remained patent during the study period. In the revised/occluded group, duplex surveillance was abnormal in 8 bypasses. Twenty-four bypasses occluded without any predicting abnormalities on their last duplex examination, which was performed within 3 months from the occlusion in the majority of the patients. In the 27 occluded bypasses, no intervention was necessary following the occlusion in 7 grafts because of mild or no symptoms. Two patients were treated with a primary amputation and 2 had new bypasses. In 16 occluded grafts, salvage of the PTFE bypass was attempted. Ten of these grafts were patent at the end of the follow-up. The sensitivity of duplex surveillance was 25% with a positive predictive value of 61.5%. CONCLUSION: Duplex surveillance of infrainguinal PTFE bypass grafts has a low yield and is inadequate at predicting continued bypass patency.

Renal hilar Doppler analysis is of value in the management of patients with renovascular disease.

BACKGROUND: An increasing interest in the role of Doppler ultrasound and duplex scan in screening for renovascular hypertension has recently been noted. We conducted this study to define the role of renal hilar Doppler ultrasound (RHDU) in evaluating renal artery stenosis and its value in the postoperative follow-up after renal revascularization. METHODS: One hundred and fourteen patients are included in this study with a mean age of 63.7 (11 to 89) years. Seventy-two patients underwent renal revascularization. The most frequent revascularization procedure was renal artery bypass in 82%. The RHDU results were compared with 130 angiograms done within 1 month of the RHDU study. The Doppler velocity signal in a segmental artery in the renal parenchyma was recorded, and the waveform was analyzed. An acceleration index (AI) less than 3.78 KHz/sec/MHz and an acceleration time (AT) greater than 0.1 seconds were used to indicate the presence of a significant renal artery stenosis. RESULTS: The overall technical success rate of all RHDU studies was 93.5%. The AI value was higher in the group of patients with normal renal arteries than those with a stenosis (4.7 +/- 1.4 KHz/sec/MHz versus 1.23 +/- 1.13 kHz/sec/MHz, respectively, P <0.0001), and the AT was lower in the former group compared with the latter (0.052 +/- 0.011 sec versus 0.122 +/- 0.069 sec, P <0.0001). The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for AI were 89%, 92%, 85%, 94%, and 92%, respectively; and for AT were 62.5%, 97.5%, 91%, 86.5%, and 87% respectively. There was a significantly high agreement between the AI and AT results and those of arteriography (Kappa of 0.82 and 0.66, respectively, P < 0.0001). There were 10.6% kidneys with multiple renal arteries by arteriography. In these kidneys the accuracy was lower for both AI and AT and the agreement with arteriography was nonsignificant. In the postoperative period the accuracy of RHDU was 86% for AI and 95% for AT. CONCLUSIONS: Renal hilar Doppler ultrasound has a high accuracy and agreement with arteriography in the diagnosis of renal artery stenosis. Its value is limited by the presence of multiple renal arteries, renal artery occlusion, and high incidence of postoperative false-positive results. It can be useful as a noninvasive screening test for patients suspected of having renal artery stenosis and for surveillance following renal revascularization.

Intraradicular disc herniation: a case report and review of the literature.

Intradural disc herniation accounts for < 0.3% of all disc herniations. Intraradicular disc herniation accounts for 4.1% of all such cases. Preoperative diagnosis is difficult, and a high index of suspicion during surgery is required for the diagnosis. We present a patient with intraradicular disc herniation in the lumbar region whose symptoms were severe enough to recommend surgery. The myelogram showed a block at the involved nerve root. Diagnosis of intraradicular herniation was made during surgery. The symptoms were immediately relieved by surgery. The literature on intradural and intraradicular disc herniation is reviewed.

The effect of forskolin on blood flow, platelet metabolism, aggregation and ATP release.

UNLABELLED: Forskolin, a diterpene obtained from coleus forskolii, is a potent cAMP stimulator. We have evaluated the effects of forskolin on blood flow, platelet aggregation and metabolism. It was found that forskolin has a dose dependent vaso-relaxing effect in an in vivo sheep model, when infused intra-arterially. Furthermore forskolin, in a dose-dependent fashion reduced whole blood platelet aggregation and ATP release. Pretreatment of PTFE grafts with Forskolin significantly reduced platelet consumption 3 hours postoperatively and on the first postoperative day. The overall platelet metabolism, measured by a microcalorimetric technique after treatment with forskolin in vitro and ex-vivo postoperatively was significantly increased. IN CONCLUSION: Forskolin affects blood flow and platelet parameters favourably in the setting of occlusive arterial disease and reconstructive arterial surgery.

Surgical removal of an inferior vena cava thrombus.

Studies on the management of inferior vena cava (IVC) thrombosis have rarely focused upon the risk of later development of post-thrombotic syndrome of the lower limbs. From 1983-1989, 52 patients with ilio-femoral thrombosis with an extension of thrombus into the IVC were treated. In addition to lower limb pain and swelling, 12 (23%) patients had symptomatic pulmonary embolism on admission. Perfusion/ventilation pulmonary scans were positive in 63%. Twelve patients received only anti-coagulant treatment. Thrombectomy was attempted in 40 patients, but failed in 13 patients due to old thrombi. Twenty-seven patients had surgical removal of thrombus combined with anti-coagulation [temporary arterio-venous fistula (AVF) and IVC interruption (n = 15); AVF alone (n = 9); and without fistula n = 3)]. The mortality and morbidity were low and hospital stay was not prolonged. Thirty-eight legs were examined at 7-66 months (mean: 23 +/- 3) after initial treatment. The limbs in which the IVC thrombus could not be removed (n = 20) were symptomatic in 25% of patients, venous ulcer developed in 4 of 20 limbs. The ilio-femoral segment was patent in only 35%. The thrombectomised limbs (n = 18) were asymptomatic in 56%; none had developed ulcer and iliac patency was 72%. Doppler investigations and refilling times were normal in 39% of the thrombectomised limbs. All patients without surgical IVC thrombus removal developed contralateral deep venous thrombosis during the follow-up period. This study shows that femoro-ilio-caval thrombectomy is successful only in patients with a short history and fresh clot, and can be safely performed with low morbidity and mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

Iliofemoral venous thrombectomy followed by percutaneous closure of the temporary arteriovenous fistula.

Iliofemoral venous thrombosis treated by anticoagulants alone almost invariably results in postthrombotic sequelae with deep venous reflux alone or combined with an outflow obstruction. This study evaluates the result of iliofemoral venous thrombectomy with temporary proximal arteriovenous fistula (AVF) performed on 48 consecutive patients. In 10 patients the thrombus extended in the inferior vena cava, and the thrombectomy was combined with inferior vena cava interruption. The AVF closed spontaneously in 8 of 48 patients (patency rate, 84%). An attempt to close the AVF by placing a detachable balloon percutaneously under radiographic control was made 6 to 12 weeks later (success rate, 87%; complications, rare). A preclosure arteriovenography of the femoro-iliaco-caval segment revealed 34 of 38 segments open (patency rate, 89%). Four patients had severe stenosis of the iliac segment, and a transvenous percutaneous dilatation was successfully performed in three of the four patients, keeping the fistula. At AVF closure 4 weeks later the arteriovenography showed sustained dilatation in only two patients. Thirty-seven patients were followed for 3 to 48 months (median, 24 months) and 30 of 37 patients (81%) who had no symptoms were not using compression stockings. Doppler investigation revealed patent and competent femoral and popliteal veins and normal photoplethysmography in 56% of the patients. Four iliac veins were occluded (patency rate, 88%). No recurrence of fistula had occurred. Venous iliofemoral thrombectomy seems to better preserve valve function. The percutaneous balloon closure of the AVF has decreased the complication rate, facilitated venographic evaluation of the result, and made possible the performance of percutaneous interventions under the protection of the AVF.

The brachiocephalic fistula: a successful secondary vascular access procedure.

In the period from January 1988 to July 1989, 185 arteriovenous conduits for hemodialysis were created in 150 patients with end stage renal disease including 20 procedures (13 patients) performed as emergency external shunts. Of the remaining patients 125/137 (139 procedures) could be followed. The procedures included 85 end-to-side radiocephalic wrist fistulas, 42 end-to-side brachiocephalic elbow fistulas and 12 brachioaxillary grafts. Complications associated with brachiocephalic fistulas were not significantly higher than with radiocephalic fistulas, except for the development of arterial steal and pseudoaneurysm formation. The 12-month patency rates were 72% and 75% in radiocephalic and brachiocephalic fistulas respectively. The end-to-side brachiocephalic fistula is a successful secondary vascular access procedure and is recommended when a primary radiocephalic fistula fails.