Vena caval filter placement by intravascular ultrasound.

OBJECTIVE: Placement of vena caval filters under fluoroscopic surveillance incurs significant expense and potential risks associated with the transportation of critically ill patients. Intravascular ultrasound (IVUS) allows direct intraluminal visualization of the vena cava and the renal veins. The purpose of this study is to evaluate the accuracy of vena caval filter placement under IVUS in an animal model. METHODS: Fifteen Simon-Nitinol venal cava filters (C.R. Bard, Inc., Covington, GA) were placed under IVUS guidance into four anesthetized sheep. Twelve were placed transfemorally, and three were placed transjugularly. Accuracy of placement was confirmed with fluoroscopy by measurement between the filter tip and the targeted side branch. RESULTS: The vena caval filters placed femorally averaged 0.33+/-0.42 cm distance from the target vein side branch. Jugular approach filter placement was less accurate. Although two out of three filters placed from the jugular vein were correctly positioned, the distance from the target vein side branch was much greater averaging 2.5+/-1.04 cm. CONCLUSION: Femoral placement of vena caval filters under IVUS is extremely accurate. The transjugular route, however, was technically challenging and standard fluoroscopic vena caval filter placement appears to be more appropriate. Our success with the femoral approach merits further clinical investigation in the use of IVUS for critically ill patients that would benefit from bedside vena caval filter placement.

Healing response of normal canine aorta and iliac artery to a nitinol stent encapsulated in carbon-lined ePTFE.

PURPOSE: To evaluate the healing response of normal canine arteries to a self-expanding nitinol stent encapsulated in carbon-lined expanded polytetrafluoroethylene (ePTFE). METHODS: Twenty-eight dogs were divided into aortic (n = 18) or iliac (n = 10) groups. In the latter, 2 animals were assigned to implantation intervals of 7, 30, and 90 days, respectively; 4 were designated for 180-day implantation. Half of the animals in each subgroup received a second overlapping stent-graft in one iliac artery. In the aortic cohort, 6 animals were assigned to the 180-day implantation group (2 with dual devices) and 3 to each of the others (1 dual implantation in each group). The devices were evaluated with angiography and intravascular ultrasound at implantation and explantation. After harvesting and gross examination, the specimens were examined microscopically and with scanning electron microscopy. RESULTS: The 49 implanted devices (24 aortic and 25 common iliac) were all widely patent at explantation, save for 2 iliac stents that had moderate (<40%) stenosis. No neointima was present at the 7-day interval. All stents were covered by thin neointima (<150 microm) at 30 days. At 180 days, an endothelial lining was present in the proximal and distal segments of all stents; in 4 of the 6 aortic stents, this endothelial lining was complete, whereas none of the iliac devices had endothelium in the midsegment at 180 days. At 1 year, 2 of the aortic specimens had an incomplete endothelial lining, whereas the lining was complete in the third. There was no evidence of stent-graft migration or inflammation associated with any device. CONCLUSIONS: The carbon-lined ePTFE-encapsulated stent is a novel approach to arterial stenting. The progressive endothelialization and lack of inflammatory reaction may provide improved long-term patency. Further study of this stent-graft design is warranted.

Posttraumatic carotid cavernous fistula: frequency analysis of signs, symptoms, and disability outcomes after angiographic embolization.

OBJECTIVE: To increase awareness and understanding of posttraumatic carotid cavernous fistula (PTCCF) with the intent to expedite diagnosis and treatment of this disabling injury, a 14-year retrospective review of patients with angiographically identified PTCCF was conducted at this Level I trauma center. A frequency analysis of signs, symptoms, and disability was performed. The impact on disability of demographics, number of embolization attempts required for closure of the PTCCF, and time from injury to diagnosis was assessed by t test for independent samples. RESULTS: Nine patients were diagnosed with 10 PTCCFs. Mean patient age was 41.5 years. All patients with PTCCF had basilar skull fracture, loss of consciousness, bruit, and chemosis; 90% had exophthalmos; 70% had visual changes; 50% complained of headache; and 80% had some lasting disability. Mean age of patients with partial to total disability was 47 years, while the mean age of patients without lasting disability was 19.5 years (p = 0.013). No statistical correlation could be found between disability and sex, blunt versus penetrating injury, days to diagnosis, or number of embolization attempts. CONCLUSION: Patients sustaining head trauma with basilar skull fractures and presenting with the described signs and symptoms should be evaluated for PTCCF. Risk of disability does not appear to be influenced by number of attempts at embolization or time to diagnosis. However, age may have a significant impact on outcome.

Combination endovascular and open treatment of peripheral arterial occlusive disease performed by surgeons.

The endovascular treatment of peripheral arterial occlusive disease has historically been performed by interventional radiologists and cardiologists. With additional training in endovascular techniques, surgeons become uniquely suited to manage arterial lesions with both endovascular and conventional surgical techniques. Over a 14-month period, 13 patients underwent combination endovascular and open reconstruction on limbs with peripheral arterial occlusive disease. There were 10 males and 3 females. The mean age was 66 years. All procedures were performed in the operating room by surgery residents under the direct supervision of vascular surgeons. After intraoperative angiography, 26 arterial lesions underwent percutaneous transluminal angioplasty (aorta, 1; common iliac, 14; external iliac, 10; superficial femoral, 1). Twenty-five of 26 lesions were further treated with intraluminal stent placement, the lone exception being a case of superficial femoral artery angioplasty. Concomitant open reconstruction was performed on all limbs, 14 as outflow and 1 as inflow. There were two cases of procedural morbidity and one perioperative death secondary to myocardial infarction. There were no wound-related complications. The mean ankle-brachial index of the affected lower extremity improved from 0.41 (+/- 0.15) to 0.74 (+/- 0.14) at 30 days. Mean follow-up was 8 months (range, 2-14). Based on our early experience, simultaneous combination endovascular and open reconstruction of multisegment arterial occlusive disease can be performed safely and efficiently by surgeons.

The Sexual Interaction System Scale: a new inventory for assessing sexual dysfunction and sexual distress.

This paper reports on the development, reliability, and validity of a new self-report instrument: the Sexual Interaction System Scale (SISS). Initial research on 143 couples supports reliability as measured by the internal consistency of the five factors. Validity is supported by several tests: the SISS differentiated between a nonclinical group and couples in therapy for sex dysfunction and also between two clinical groups--couples with sex dysfunction and couples with other problems. It also correlated strongly with a measure of sexual satisfaction and with the Affection subscale and overall score of the Dyadic Adjustment Scale. Discussion focuses on interpretation of results via case examples and on the utility of the SISS in research and clinical practice.

Operative treatment of abdominal aortic aneurysms in octogenarians. When is it too much too late?

OBJECTIVE: This study evaluated the value of operation for treatment of all octogenarians with ruptured abdominal aortic aneurysms (AAA). SUMMARY BACKGROUND DATA: Elective AAA resection in octogenarians is safe, with published operative mortality rates of approximately 5%. Published operative mortality rates of ruptured AAA in this age group, however, vary from 27 to 92%. METHODS: To evaluate this question, we extracted the clinical course of the 34 octogenarians submitted to AAA resection by the authors from our total experience of 548 resections performed during the past 7 1/2 years. In this subgroup of octogenarians, 18 underwent elective AAA replacement, 5 were submitted to urgent resection of active but intact AAAs, and 11 had operations for ruptured AAAs. There were 23 males and 11 females in the group. The ages ranged from 80 to 91 years. RESULTS: Operative mortality in the patients managed electively was 5.6%. Two of the five patients (40%) submitted to operation for active yet unruptured aneurysms died in the preoperative period. Finally, 10 of the 11 patients (91%) with ruptured AAAs were operative mortalities. All of these operative mortalities in the ruptured AAA subgroup had severe hypotension preoperatively (mean systolic blood pressure: 23 mm Hg). The charges associated with the management of the ruptured AAA group averaged $84,486 (range $12,537-$199,233). CONCLUSIONS: Although elective replacement of AAA in properly selected octogenarians appears valuable to prolong worthwhile life expectancy, this experience leads us to consider observation only in the treatment of octogenarians with ruptured AAA who present with severe hemodynamic instability.

The reality of an integrative sex therapy.

Although sex therapy from its inception has been acknowledged to be an integrative modality, little attention has focused on integrating various systemic approaches into sex therapy; yet the majority of sex therapists are probably familiar with these approaches. This article attempts to convey the reality of a newer sex therapy that integrates systemic thinking. Through a detailed case analysis and explication of the conceptual framework, it demonstrates the utility of several systemic strategies in treating sexual dysfunction; accounts for which techniques were and were not effective; and acknowledges the significance of the therapeutic relationship and of ethical and value issues that are present in all therapy.