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  • 1
    ISSN: 1432-2323
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract. Intraarterial thrombolysis is used increasingly for management of arterial and bypass graft occlusions. Current research has been directed at the indications for and methods of catheter-directed thrombolysis. Streptokinase, urokinase, and tissue plasminogen activator (t-PA) are the most commonly used agents. They are administered by a variety of techniques and in various doses involving intrathrombic infusions, thrombus lacing, high-dose bolus therapy, and pulse-spray lysis. The latter methods appear to produce thrombolysis within a few hours, so this chemical therapy has the potential to become the first-line management for all episodes of acute limb ischemia. The role of thrombolysis is to return patients to their prethrombotic or preembolic state, so the underlying condition can be treated by radiologic intervention, surgery, or anticoagulation. Intraarterial thrombolysis is indicated for occlusions of less than 2 weeks’ duration where the limb is able to withstand a period of further ischemia. Older occlusions should be treated by surgery, reserving intraoperative lysis for specific situations.
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  • 2
    ISSN: 1615-5947
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract In a prospective study, 60 consecutive cases of vascular endoscopy were analyzed to examine the role of angioscopy in infrainguinal vascular procedures. A total of 52 patients had 60 separate vascular endoscopy procedures performed as an adjunct to various vascular procedures; results of intraoperative arteriography were available in 38 of 60 cases. All patients were followed for at least 42 months. The 19 patients who underwent thrombectomy with angioscopy were compared with 19 age-matched control subjects who underwent infrainguinal thrombectomy without angioscopy to evaluate the influence of angioscopy on primary and secondary patency rates. Angioscopy allowed observation of 50 lesions; angiography failed to detect three. These findings altered surgical management in 24 cases (40%). Primary patency rates for the control and experimental thrombectomy groups were 38.8% and 6.5% at 42 months, respectively (p=0.010 based on log-rank test). Secondary patency rates for the control and experimental groups at 42 months were 63.8% and 49%, respectively (p=0.521). The limb salvage rate was 89% at 42 months for both groups (p=0.973). Angioscopy provides the clinician with a direct view while he or she is performing vascular procedures. However, there was no statistical improvement in secondary patency and limb salvage rates. Furthermore, the use of angioscopy during thrombectomy may increase the propensity for subsequent intervention as evidenced by the frequency of changes in surgical management and the lower primary patency rate.
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  • 3
    ISSN: 1615-5947
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
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  • 4
    ISSN: 1615-5947
    Keywords: Chylous ascites ; ascites ; abdominal aortic operations
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Three patients, two women, one man (mean age 74 years), who had abdominal aortic aneurysms (2) or aortobifemoral surgery (1), developed chylous ascites postoperatively. They were studied to determine their clinical course and develop a plan for management of this complication. In each patient, the ascites was not manifest until abdominal swelling developed two weeks after operation, and the problem was confirmed by the finding of milky fluid on paracentesis. A low serum albumin (mean 2.6 gm) was also characteristic. The ascites was not altered by parenteral nutrition or reduction of dietary fat and ingestion of medium chain triglycerides. In one patient (man, age 93) the ascites resolved spontaneously two months after abdominal aortic aneurysm surgery. Another (woman, age 70) was cured following operative ligation of a lymphatic fistula identified at operation five weeks after abdominal aortic aneurysm repair. In the third (woman, age 60), the ascites resolved immediately following placement of a peritoneal venous shunt six weeks after an aortobifemoral bypass. Chylous ascites is rare after aortic surgery and manifests itself about two weeks after operation, at times after discharge from hospital. It has an indolent course, but may resolve spontaneously up to two months after operation. Its course appears not to be foreshortened by diet, including omission of fat, but can be successfully treated surgically with a shunt or fistula ligation. If done early a protracted hospital course may be avoided.
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  • 5
    ISSN: 1615-5947
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract The association between aortic pathology and congenital renal fusion adds little morbidity or mortality to the natural history of either entity. Nevertheless, it complicates the management of aortic pathology, specifically degenerative atherosclerotic disease. The therapeutic goal is to resect the aneurysm or bypass the occlusive segment while preserving renal function. Important principles in the management of these difficult patients include accurate preoperative detection and characterization of the renal abnormality, complete familiarity with the likely anatomic variations associated with this anomaly, adequate exposure of the aortic lesion while preserving renal perfusion, and avoidance of injury to a frequently abnormally located collecting system. In this review we report two cases of abdominal aortic aneurysm associated with congenital renal fusion. The principles of management are thoroughly discussed, and guidelines aimed at facilitating decisions made during the clinical treatment of these difficult patients are suggested.
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  • 6
    ISSN: 1615-5947
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract The loss of distal tissue perfusion sufficient for limb salvage following restoration of inflow to an acutely ischemic extremity has been referred to as the “no-reflow” phenomenon. We hypothesized that patients with no reflow and limb-threat ischemia might benefit from prolonged postoperative intra-arterial infusion of the thrombolytic agent urokinase (UK). Twelve patients with arteriographic and clinical evidence of no reflow following a lower extremity arterial thrombectomy and/or bypass procedure were treated with a continuous intra-arterial UK infusion in the immediate postoperative period. The mean duration of UK infusion was 47 hours (range 15 to 112 hours). The mean rate of infusion was 58,000 units/hr (range 30,000 to 100,000 units/hr). Seven patients required transfusion for bleeding from the treated extremity (mean 3.4 units packed cells) and one required reoperation for a groin hematoma. Plasma fibrinogen levels remained within the normal range in all patients, and no systemic bleeding complications were encountered. The intra-arterial UK infusion resulted in limb salvage in 7 of 12 patients. Six patients have viable, functional extremities at a mean follow-up interval of 24.9 months (range 6.4 to 49.7 months). One patient required below-knee amputation 6 months after treatment for progressive ischemia. The other five patients required below-knee amputation during the same hospitalization after UK failed to restore distal perfusion. The postoperative period is widely considered to be a contraindication to thrombolytic therapy. Our experience indicates that while UK may cause bleeding from the treated extremity, which in some cases requires transfusion, there is no evidence of systemic fibrinolysis or systemic hemorrhage. We conclude that the salvage of otherwise nonviable limbs by prolonged postoperative intra-arterial UK infusion is possible. This observation supports the theory that the no-reflow phenomenon is due, in part, to distal intravascular fibrin deposition.
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  • 7
    ISSN: 1615-5947
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
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  • 8
    ISSN: 1615-5947
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Intimal hyperplasia appears to result from the deposition of collagen and matrix by medial myofibroblasts, which are stimulated in response to vascular injury. We hypothesized that pharmacologic inhibitors of fibroblast proliferation would suppress the development of intimal hyperplasia. We evaluated the effect of two agents known to inhibit fibroblast proliferation in vitro: enalaprilat, an angiotensin-converting enzyme (ACE) inhibitor, and dimethyl sulfoxide (DMSO), an organic solvent. Thirty-five New Zealand white rabbits underwent standardized balloon catheter injury of the left common carotid artery. Experimental groups received daily intramuscular injections of the following: group I (n = 15), saline solution; group II (n = 10), 0.07 mg/kg enalaprilat; and group III (n = 10), 2 ml/kg of a 25% by weight DMSO solution. Injections were started 1 day prior to injury and continued 5 days a week for 8 weeks. Carotid arteries were perfusion-fixed at 12 weeks and cross-sectioned for measurement by planimetry. Intimal hyperplasia was measured as the ratio of the absolute area of intimal hyperplasia to the normalized area enclosed by the internal elastic lamina (IH/IEL) and was expressed as a percent. Mean values for IH/IEL were as follows: group I (control), 20.6 ± 2.3%; group II (enalaprilat), 9.5 ± 0.7%; and group III (DMSO), 17.6 ± 2.6%. Enalaprilat-treated animals demonstrated a statistically significant suppression of intimal hyperplasia compared with controls (p〈0.01, ANOVA, Student's t test), whereas the DMSO-treated group did not. We conclude that enalaprilat is effective in suppressing the development of intimal hyperplasia in this model of arterial injury. These results support the theory that the smooth muscle cell mitogen angiotensin II plays an important role in the proliferation of medial myofibroblasts following vascular injury.
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  • 9
    ISSN: 1615-5947
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
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  • 10
    ISSN: 1615-5947
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: 2 for a mean duration of 7.4 months preoperatively and 12 patients had exposed bone or tendon. Vascular reconstruction included popliteal (3), tibial (6), and pedal (6) bypass with concomitant myocutaneous free flap, using mostly rectus abdominis or latissimus dorsi muscle. There were no perioperative deaths. One patient suffered a nonfatal myocardial infarction. Two patients had a postoperative wound hematoma and one required vascular graft revision. Patients were followed for 4 to 75 months (mean = 23 months). Four patients have required amputations (3 early, 1 late), three of whom had preoperative renal failure. The limb salvage rate has been 72% at 36 months, with 10 of 11 patients having functional ambulation. Combined revascularization and free tissue transfer is safe and durable, and long-term limb salvage is obtainable. Patients with renal failure had poorer outcomes in this series.
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