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Objective: The results of percutaneous transluminal angioplasty, atherectomy, and laser angioplasty for the treatment of long-segment (>10 cm) superficial femoral artery (SFA) occlusive disease have proved disappointing. Remote superficial femoral artery endarterectomy (RSFAE) is a minimally invasive procedure, performed through a single limited groin incision that may offer patency rates comparable with those of above-knee femoropopliteal (AKFP) bypass graft. In this retrospective multicenter study the medium-term results of RSFAE are examined., Methods: Sixty patients were included in this study. Indications for the procedure were claudication in 52 patients and limb salvage in eight patients. RSFAE was performed with the MollRing Cutter device through a femoral arteriotomy. The distal "flap" of atheroma was anchored by balloon/stent angioplasty through the femoral arteriotomy. All patients underwent a follow-up examination with serial color flow ultrasound scanning., Results: Ten patients with heavily calcified SFAs failed as "intentions to treat"; these patients underwent AKFP bypass grafting. The mean length of the endarterectomized SFAs was 22.3 cm (range, 8-37 cm). The primary cumulative patency rate by means of life-table analysis was 61.4% +/- 9% (SE), (mean, 12.9 months; range, 3-36 months). During follow-up, percutaneous transluminal angioplasty was necessary in 14 patients, for a primary-assisted patency rate of 82.6% +/- 8%. The locations of the restenoses after RSFAE were evenly distributed along the endarterectomized SFAs. There were no deaths and one wound complication (hematoma), and the mean hospital length of stay was 1.4 days +/- 0.8 days., Conclusions: RSFAE is a safe and moderately durable procedure. If long-term patency rates are similar to those of AKFP bypass graft, RSFAE may prove to be a minimally invasive adjunct for the treatment of SFA occlusive disease that will lower operative morbidity, reduce hospital LOS, and shorten recuperation.

While developing a rat model for human short bowel syndrome, we noted that untreated rats as well as rats administered buprenorphine after intestinal resection exhibited behavior and appearance consistent with visceral pain and distress. To provide appropriate analgesics, we developed criteria to assess pain-related behavioral changes and conducted an experiment to evaluate the effectiveness of buprenorphine versus oxymorphone to alleviate the pain induced by intestinal resection. Rats underwent either small-bowel resection or transection surgery; in addition, animals received jugular catheterization for the delivery of total parenteral nutrition (TPN). Rats treated with buprenorphine received 0.5 mg/kg every 6 h subcutaneously, and rats treated with oxymorphone received 0.03 mg/kg hourly for 32 h via continuous intravenous (i.v.) infusion with TPN solution. Rats treated with buprenorphine exhibited behavior and appearance consistent with pain and distress for as long as 32 h postoperatively, whereas animals treated with oxymorphone exhibited behavior and appearance similar to their preoperative state. Thus, oxymorphone alleviated the pain-related behavioral changes after intestinal resection far better than did buprenorphine. Of interest, we observed that the buprenorphine was associated with a decrease in the volume of urine collected, whereas oxymorphone was associated with urine volumes similar to those of nonresected rats maintained with TPN. Because oxymorphone appeared to be a superior analgesic, we also evaluated three routes for administering this drug. Pain-related behavior changes were alleviated by the administration of oxymorphone by either Alzet mini-pump, bolus i.v. injection, or continuous i.v. infusion. We conclude that compared with buprenorphine, oxymorphone is a superior analgesic for the alleviation of visceral pain due to intestinal resection.

Purpose: To describe an endovascular method of performing femoropopliteal in situ saphenous vein (SV) bypass and popliteal artery aneurysm (PAA) embolization., Methods: Twenty-two patients underwent PAA operations. Twelve patients had conventional SV bypasses with PAA proximal and distal ligation, whereas 10 underwent PAA embolization and an endovascular in situ SV bypass (EISB). The endovascular procedure was performed using an angioscopically guided side branch coil occlusion system. The PAAs were coil embolized under fluoroscopic surveillance., Results: No deaths or wound complications occurred in the EISB group. The mean hospital length of stay (LOS) was 2.1 days. Seven EISB procedures were performed through 2 incisions, whereas 3 operations required an additional incision. One graft occluded at 3 months. All PAAs remained occluded by color-flow ultrasonography at follow-up ranging from 4 to 23 months (mean 13.6); cumulative primary patency was 89%. In the conventional bypass group, no deaths occurred, but 3 (25%) patients had wound complications. The mean LOS was 6.2 days, and 1 graft occluded, giving an 86% cumulative primary patency at 42 months., Conclusions: This minimally invasive technique obviates an extensive incision to harvest the SV and ligate the PAA proximally and distally. If long-term endovascular bypass graft patency and PAA occlusion rates prove to be similar to open operative results, the benefits of reduced wound complications, decreased hospital LOS, and increased health care savings support further investigation of this endovascular approach for the treatment of PAA.

Patients with severe short-bowel syndrome (SBS) often require long-term total parenteral nutrition (TPN) to maintain their nutritional status because of limited intestinal adaptation. Growth factors, including insulin-like growth factor I (IGF-I), are under investigation to promote intestinal adaptation and tolerance to oral feeding. We investigated structural and functional adaptation of the jejunum and colon in four groups of rats maintained with TPN for 7 days after a 60% jejunoileal resection and cecectomy or sham surgery and treatment with IGF-I or vehicle. Resection alone did not stimulate jejunal growth. IGF-I significantly increased jejunal mucosal mass, enterocyte proliferation, and migration rates. IGF-I decreased jejunal sucrase specific activity and reduced active ion transport and ionic permeability; resection alone had no effect. In contrast, resection significantly increased colonic mass and crypt depth but had no effect on active ion transport or ionic permeability. IGF-I had minimal effects on colonic structure. IGF-I but not resection stimulates jejunal adaptation, whereas resection but not IGF-I stimulates colonic growth in rats subjected to a model for human SBS. IGF-I treatment may improve intestinal adaptation in humans with SBS.

Improved survival of patients with renal failure has led to the need for complex angioaccess procedures. The use of cryopreserved femoral vein for angioaccess when prosthetic arteriovenous grafts (AVG) could not be placed, owing to infection or the loss of conventional angioaccess sites from multiple AVG failures, was prospectively evaluated. Forty-eight cryopreserved femoral vein AVGs were placed in 44 patients. Thirty-eight (82%) of the cryopreserved femoral vein AVGs were placed for infection, whereas the other 10 (18%) were placed for multiple graft failures with compromised venous outflow. Even with implantation of the cryoveins into infected patients, there were no cryopreserved femoral vein AVG infections. The 1-year primary graft patency rate was 49% and the secondary graft patency rate was 75%. During the same time interval, 68 prosthetic brachial artery-to-axillary vein AVGs were placed. The 1-year primary and secondary patency rates for the prosthetic AVGs were 65 and 78%, respectively. In this study the overall patency rate of the cryopreserved femoral vein AVGs was similar to that for the PTFE AVGs (p = 0.519). In conclusion, the cryopreserved femoral vein proved useful in difficult angioaccess cases. The lack of infection after cryovein implantation around an infected area shows promise for salvaging an angioaccess site that would otherwise have been abandoned.

In December 1997, Arkansas Medicaid in cooperation with Title V and Children's Medical Services (CMS) implemented guidelines for the preauthorization of therapy services for Children with Special Health Care Needs (CSHCN). The University of Arkansas for Medical Sciences (UAMS) in partnership with Arkansas Medicaid (MCD), and Chidren's Medical Services (CMS) were given the charge of developing clinical practice guidelines for physical therapy (PT), occupational therapy (OT), and speech/language therapy (SLP) for this population based on primary diagnosis and age appropriateness. This process involved the implementation of a statewide, internet-based, clinical information support network. The objective of this article is to describe KIDSCARE, a clinical information support network, currently under development, for the determination of medical necessity and allocation of therapy services for CSHCN.

Purpose: The purpose of this study was to compare the transabdominal approach with the retroperitoneal approach for elective aortic reconstruction in the patient who is at high risk., Methods: From January 1992 through January 1997, 148 patients underwent aortic operations: 92 of the patients were classified as American Society of Anesthesia (ASA) class IV. Forty-four operations on the patients of ASA class IV were performed with the transabdominal approach (25 for abdominal aortic aneurysms and 19 for aortoiliac occlusive disease), and 48 operations were performed with the retroperitoneal approach (27 for abdominal aortic aneurysms and 21 for aortoiliac occlusive disease). There were no significant differences between the groups for comorbid risk factors or perioperative care., Results: Among the patients of ASA class IV, eight (8.7%) died after operation (retroperitoneal, 3 [6.26%]; transabdominal, 5 [11.3%]; P =.5). There was no difference between groups in the number of pulmonary complications (retroperitoneal, 23 [47.9%]; transabdominal, 19 [43.2%]; P =.7) or in the development of incisional hernias (retroperitoneal, 6 [12.5%]; transabdominal, 5 [11.3%]; P =.5). The retroperitoneal approach was associated with a significant reduction in cardiac complications (retroperitoneal, 6 [12.5%]; transabdominal, 10 [22.7%]; P =.004) and in gastrointestinal complications (retroperitoneal, 5 [8.3%]; transabdominal, 15 [34.1%]). Operative time was significantly longer in the retroperitoneal group (retroperitoneal, 3.35 hours; transabdominal, 2.98 hours; P =.006), as was blood loss (retroperitoneal, 803 mL; transabdominal, 647 mL; P =.012). The patients in the retroperitoneal group required less intravenous narcotics (retroperitoneal, 36.6 +/- 21 mg; transabdominal, 49.5 +/- 28.5 mg; P =.004) and less epidural analgesics (retroperitoneal, 39.5 +/- 6.4 mg; transabdominal, 56.6 +/- 9.5 mg; P =.004). Hospital length of stay (retroperitoneal, 7.2 +/- 1.6 days; transabdominal, 12.8 +/- 2.3 days; P =.024) and hospital charges (retroperitoneal, $35,587 +/- $980; transabdominal, $54,832 +/- $1105; P =.04) were significantly lower in the retroperitoneal group. The survival rates at the 40-month follow-up period were similar between the groups (retroperitoneal, 81.3%; transabdominal, 78.7%; P =.53)., Conclusion: In this subset of patients who were at high risk for aortic reconstruction, the postoperative complications were common. However, the number of complications was significantly lower in the retroperitoneal group. Aortic reconstruction in patients of ASA class IV appears to be more safely and economically performed with the retroperitoneal approach.

For any attempt to understand the biology of an organism the incorporation of a cDNA-based approach is unavoidable, because it is a major approach to studying gene function. The complete sequence of the genome alone is not sufficient to understand any organism; its gene regulation, expression, splice variation, posttranslational modifications, and protein-protein interactions all need to be addressed. Because the majority of vertebrate genes have probably been identified as ESTs the next stage of the Human Genome Project is attributing functional information to these sequences. In most cases hybridization-based approaches on arrayed pieces of DNA represent the most efficient way to study the expression level and splicing of a gene in a given tissue. Similar technology, now being applied at the protein level using protein expression libraries, high-density protein membranes, and antibody screening, should allow studies of protein localization and modifications. Coupled to these approaches is the use of technologies, which although lacking the highly parallel nature of hybridization, can potentially characterize large numbers of samples individually and with high accuracy. Automated gel-based DNA sequencing is an example of such a technique; protein sequencing and mass fingerprinting are further examples. In the case of mass spectroscopic analysis, the speed and sensitivity are vastly superior to that of gel-based approaches; however, the preparation of samples is more tedious. Our laboratory is developing a system to characterize DNA samples by mass spectrometry, allowing more rapid genotyping than is currently possible using gel-based technologies ([symbol: see text]. Gut, [symbol: see text]. Berlin and H. Lehrach, personal communication, 1998). Such technology would make information on gene polymorphisms widely accessible. Data generated using all of these techniques at the DNA and protein level will be connected by both protein expression libraries and database comparisons; finally, two hybrid library screens will identify many of the protein-protein interactions, linking genes together. In this way we will start to understand the interplay between genes on a global scale, both at the level of molecular interaction and the biological processes they regulate.

Amphioxus AmphiBMP2/4 appears to be a single gene closely related to vertebrate BMP2 and BMP4. In amphioxus embryos, the expression patterns of AmphiBMP2/4 suggest patterning roles in the ectodermal dorsoventral axis (comparable to dorsoventral axis establishment in the ectoderm by Drosophila decapentaplegic and vertebrate BMP4). In addition AmphiBMP2/4 may be involved in somite evagination, tail bud growth, pharyngeal differentiation (resulting in club-shaped gland morphogenesis), hindgut regionalization, differentiation of olfactory epithelium, patterning of the anterior central nervous system, and establishment of the heart primordium. One difference between the developmental role of amphioxus AmphiBMP2/4 and vertebrate BMP4 is that the former does not appear to be involved in the initial establishment of the dorsoventral polarity of the mesoderm.

Purpose: To report the success of a minimally invasive treatment for phlegmasia cerulea dolens without gangrene caused by compression from an internal iliac artery aneurysm., Methods and Results: An 81-year-old male with a 1-month history of paralysis owing to a hemorrhagic stroke presented with massive edema and skin mottling of the right lower extremity. Imaging confirmed right iliofemoral deep vein thrombosis caused by compression from a 4-cm internal iliac artery aneurysm. With thrombolysis ruled out, a minimally invasive treatment plan was undertaken, featuring percutaneous coil embolization of the aneurysm and surgical venous thrombectomy with proximal arteriovenous fistula creation and iliac vein stent placement. Failure of the coils to embolize the iliac aneurysm prompted the use of an endovascular graft to exclude the aneurysm. The patient's symptoms subsided, and he has a patent right iliofemoral venous system and internal iliac artery at his latest (16-month) follow-up., Conclusions: This case demonstrates that minimally invasive endovascular and open techniques can be combined to achieve an optimum outcome in patients at high risk for standard surgical approaches.

Abnormal venous valvular function may produce venous reflux and venous insufficiency. While valvular agenesis is a known, but rare cause of venous insufficiency. While valvular agenesis is a known, but rare cause of venous insufficiency, little work has been done on the relative number of greater saphenous vein (GSV) valves in patients with venous insufficiency. This study investigates whether the GSV in patients with symptomatic venous insufficiency has fewer valves than the GSV of patients without venous insufficiency. The number of GSV valves in patients (n = 51) with symptomatic venous insufficiency undergoing saphenectomy (VI) were compared with the number of GSV valves in patients (n = 26) without venous insufficiency undergoing in situ GSV bypass under angioscopic surveillance who served as a control group. The two groups differed, as expected, in age and sex distribution. The VI group had a mean of 25.7 +/- 11.0 centimeters of GSV between valves, while the control group had 19.0 +/- 9.7 centimeters of GSV between valves (F = 6.99; p = 0.01). The mean number of valves in the saphenous veins of the two groups also differed significantly: VI = 2.3 +/- 0.83 versus control (CTRL) = 4.8 +/- 2.01 (F = 61.86; p < 0.0001). That properly functioning valve leaflets help maintain physiologic antegrade venous flow is indisputable. This study, however, suggests that the relative lack of valves may be related to the development of venous insufficiency. This report documents that patients with symptomatic reflux in the GSV have significantly fewer valves than patients with apparently normal functioning saphenous veins.

Purpose: To report a minimally invasive approach to popliteal artery aneurysm (PAA) treatment., Methods and Results: A 48-year-old male with a 3-cm PAA was treated electively with an endovascular in situ saphenous vein bypass and transluminal antegrade coil embolization of the PAA prior to completion of the proximal anastomosis. Two short incisions at the anastomosis sites resulted in no wound complications, and the patient was discharged after 2 days. After 14 months of follow-up, the patient is asymptomatic with continued patency of the in situ bypass and occlusion of the PAA., Conclusions: This endovascular approach for minimally invasive femoropopliteal in situ saphenous vein bypass grafting appears feasible for treatment of PAAs. This method may reduce the rate of wound complications attending classic open in situ bypass grafts.

A case of an aortocaval fistula documented by contrast-enhancement computed tomography is reported. In the presence of a large abdominal aortic aneurysm, the computed tomography (CT) triad findings of: (1) vena caval effacement, (2) loss of the fat plane between the aorta and vena cava, and (3) rapid flow of contrast from the aorta into a dilated inferior vena cava is characteristic of an aortocaval fistula.

Purpose: To report a case of post-traumatic internal carotid artery dissection and pseudoaneurysm formation at the C-1 level successfully treated by a percutaneous endovascular technique., Methods and Results: A 20-year-old female presented 72 hours after a motor vehicle accident with incomplete occulosympathetic paresis (Horner's syndrome), carotidynia, and leftsided 1.5-cm x 2.5-cm pseudoaneurysm at the C-1 level. Neuroradiologists embolized the pseudoaneurysm with Guglielmi detachable coils and controlled the dissection with placement of a Wallstent., Conclusions: This report illustrates successful percutaneous endovascular treatment of a carotid dissection and pseudoaneurysm near the base of the skull.

The impact of a loss is felt throughout the family system with the parent-child relationship being particularly vulnerable. The experience of The Mount Carmel Hospice Evergreen Center with a parenting program is presented. Responding to the expressed concerns of grieving parents, a time-limited parenting group was held. The quantitative and qualitative results of that experience are presented. In addition to normalizing the experience of parenting grieving children, the group provided the opportunity for parents to enhance skills and learn about the need to respect the individuality and uniqueness of the grief work of the child.

Attribution research has identified student ability and effort expended as causes of achievement outcomes that result in differing teacher affect, evaluative feedback, and expectation of future performance. Ninety-seven elementary-school general education teachers (84 women and 13 men) rated their responses to the test failures of hypothetical boys with and without learning disabilities. In most cases, greater reward and less punishment, less anger and more pity, and higher expectations of future failure followed the negative outcomes of the boys with learning disabilities, when compared with their nondisabled ability and effort matches, indicating that learning disability acts as a cause of achievement outcomes in the same way as ability and effort. This pattern of teacher affect and response can send negative messages that are often interpreted as low-ability cues, thus affecting students' self-esteem, sense of competence as learners, and motivation to achieve.

In an attempt to obviate the need for an incision the length of the leg during in situ saphenous vein bypass, a minimally invasive operation using 'laparoscopic techniques' was developed. At operation, standard incisions were made over the proximal femoral artery/vein and the saphenous vein at the distal popliteal artery level. An angioscopic valvulotome was used to perform valvulotomy under direct vision. After valvulotomy, a distention balloon system was used to form a 'pocket' into which a laparoscope was inserted. Trocars were then inserted under direct vision and the saphenous vein dissected and side branches individually clipped. After occlusion of the venous side branches, proximal and distal arterial anastomoses were performed in the standard fashion. This minimally invasive operation using laparoscopic techniques precludes the need for a long leg incision and saphenous vein dissection, except at the proximal and distal arterial anastomoses.

Inflow control of a rapidly expanding or ruptured femoral anastomotic "pseudoaneurysm" can be fraught with hazard. Occlusion of an anastomotic femoral aneurysm with a balloon catheter offers the surgeon a simple method of gaining inflow control prior to surgery. After achieving inflow control with the balloon catheter, the surgeon can incise the anastomotic aneurysm without significant blood loss, control back bleeding with balloon occlusion catheters, and with relative ease and safety repair or replace the anastomotic aneurysm as indicated. An illustrative case is presented.

Purpose: With 70 cm "cutter" valvulotomes for valvulotomy and an electronically steerable nitinol catheter to occlude venous tributaries with platinum coils, endovascular in situ saphenous vein (EISV) bypass can be safely performed from within the saphenous vein. To determine whether EISV bypass could reduce hospital length of stay (LOS) and perioperative morbidity without compromising patency, another 53 EISV bypasses for limb salvage were performed., Methods: Tributary occlusion was accomplished with only fluoroscopic surveillance with a new, smaller, and more steerable silicone-tipped nitinol catheter., Results: Two (3.7%) wound complications occurred. The mean hospital LOS after operation was 4.2 days (range 2 to 29 days). All tributaries initially embolized remained occluded, and three "missed" arteriovenous fistulas were identified during follow-up extending to 15 month (mean 8.4 months). Eighty-eight percent (49 of 54) of phase II bypasses remained patent, whereas life-table analysis of all bypasses (phase I and II) was 77% (69/99) at 24 months follow-up (mean 13.6 months). By comparison, 41 infrainguinal saphenous vein in situ bypasses with "classic" open techniques were performed concurrently. The mean postoperative LOS was 11.6 days (range 4 to 42 days), wound complications occurred in 24% (10) of patients, and two "missed" arteriovenous fistulas were identified during follow-up. Eighty-three percent (34 of 41) of bypasses remain patent at 24 months follow-up (mean 16.2 months)., Conclusions: If EISV bypass long-term patency rates remain similar to classic in situ bypass patency results, the additional benefits of decreased hospital LOS, reduced wound-related complications, shortened recuperation, and therefore increased health care savings gives this endovascular technique strong consideration as the possible future operation for infrainguinal saphenous veins in situ bypass.

Patients with major trauma often cannot be given the benefit of preventive measures such as pneumatic compression boots and low-dose heparin against pulmonary embolism. The Greenfield filter is accepted as a safe and effective method of prophylaxis of this complication. The aim of this study was to evaluate the efficacy of placement of the Greenfield filter in 161 patients with major trauma. Between January 1984 and July 1988, 94 patients with an injury severity score (ISS) of > 16 were treated. This score is predictive of a mortality rate of at least 10% and defines major trauma based on anatomic injury. Some 20% (19 of 94) of these patients developed deep vein thrombosis despite standard prophylactic measures and 8% (eight of 94) suffered pulmonary embolism, two of which were fatal. Pulmonary embolism occurred without antecedent evidence of deep vein thrombosis in another 15% of patients (14 of 94), three of which caused death. From August 1988 until July 1992, of 67 other patients with an ISS > 16, 13% (nine of 67) developed deep vein thrombosis and 1% (one of 67) had a pulmonary embolism; this was not statistically significant (P > 0.25). Of these 67 patients who were considered to be at high risk of pulmonary embolism, because of a contraindication to anticoagulation or physical impediment to sequential compression boots, 29 had prophylactic placement of a Greenfield filter. No pulmonary emboli occurred in these patients. During long-term follow-up (mean 32.8 (range 4-58) months), 84% of the surviving patients (21 of 25) underwent duplex ultrasonography of the inferior vena cava; patency of the vessel was confirmed in all patients.

A 10 year retrospective study of 103 patients with amaurosis fugax was done. Sixty-two patients with symptoms of amaurosis fugax underwent arteriography, which demonstrated ulcerated carotid plaque in 36 and hemodynamically significant stenoses (greater than 75% diameter reduction) in 26. These 62 patients underwent carotid endarterectomy. The other 41 patients who had proven ulcerated plaque (33 patients) or hemodynamic stenoses (eight patients) were not treated surgically and served as a control series. No strokes or deaths occurred in the immediate postoperative period. Follow-up of the 62 operated patients extending to 10 years (mean 4.2 years), revealed one (1.6%) patient with recurrent amaurosis fugax symptoms, two (3.2%) with transient ischemic attacks, and one (1.6%) with a stroke in the operated hemisphere. In the nonoperated group, despite aspirin or warfarin treatment, four (9.7%) patients had ongoing amaurosis fugax symptoms, and two (4.8%) developed transient ischemic attacks that led to carotid endarterectomy. One (2.4%) other patient developed sudden, permanent monocular blindness, and two (4.8%) suffered hemispheric strokes, one of which was fatal. The cumulative morbidity (ongoing ocular or transient ischemic attack symptoms, perioperative and late stroke) in the operated group was 6.4% (four patients), while the cumulative morbidity in the nonoperated group was significantly higher at 21.9% (nine patients) (p = 0.02). When patients present with symptoms of amaurosis fugax and have demonstrable carotid bifurcation disease, carotid endarterectomy is recommended. Amaurosis fugax should be regarded as a harbinger of monocular blindness and stroke.

In this study, the information processing strategies of Gallaudet University students who are profoundly and prelingually deaf were evaluated. The subjects demonstrated the highest levels of recognition to the left and right of the fixation point, often referred to as a reading strategy when found in hearing people. Additionally, they demonstrated higher levels of recognition at positions in the top right quadrant of the display, a pattern not found in hearing people. A main effect was found: subjects whose primary and secondary school backgrounds were oral and manual combined had significantly higher levels of recognition overall than did subjects from oral-only educational backgrounds. Differences in background did not interact with strategy use in this study. These findings lead to the conclusion that the information processing strategies of deaf people need to be evaluated closely before general conclusions can be made. Alternative means for evaluating these types of findings are suggested.

Laser assisted balloon angioplasty with a laser heated metallic capped fiberoptic catheter may be effective in the treatment of femoral and iliac artery occlusive disease. In order to avoid the inherent trauma of balloon angioplasty, yet at the same time "debulk" atheroma, 75 patients underwent laser angioplasty of the superficial femoral and iliac arteries as "sole therapy". Laser angioplasty was performed using an Nd:YAG laser coupled to a 600 micron fiber and a 3.5 mm probe (22-28 watts), 4.2 mm or 5.0 probe (32-40 watts). Fifty-nine patients had laser angioplasty for claudication and 16 for limb salvage. The initial angiographic success rate was 84% (41/49) (lesion length 2-14 cm) for the superficial femoral and 69% (18/26) (lesion length 2-14 cm) for the iliac arteries. In follow-up extending to 21 months (mean 14.4 months) 73% (30/41) of the superficial femoral artery and 76% (14/18) of the initially recanalized iliac arteries remain patent. When initial failures are included, this represents an overall intermediate-term patency rate of 52% (32/49) for superficial femoral and 49% (14/26) for iliac arteries respectively. By avoiding the disruptive effect on the arterial wall architecture caused by balloon angioplasty, while at the same time ablating and vaporizing more atheromatous material with larger laser probes, the long-term patency rates of laser angioplasty as "sole therapy" may prove to be superior to those of laser assisted balloon angioplasty.

To determine the benefit of carotid patch angioplasty, a retrospective study of 1000 consecutive carotid endarterectomies was done. Based on the type of carotid endarterectomy closure, patients were divided into four groups: 250 had primary closure, 250 had expanded polytetrafluoroethylene patch, 250 had Dacron patch, and 250 had saphenous vein patch. On the basis of operative technique or type of carotid artery closure, no statistical difference was found in the incidence of postoperative stroke (p greater than 0.25): primary closure 1.6% (4), expanded polytetrafluoroethylene 2.0% (5), Dacron patch 1.6% (4), and saphenous vein patch (0). Postoperative carotid patency was determined by B-mode ultrasonography, and 717 patients were evaluated in follow-up extending to 6 years (mean 37.8 months). Based on the method of carotid endarterectomy closure, no significant difference (p greater than 0.25) was found in the incidence of significant restenosis (greater than 50% diameter reduction): primary closure 4.0% (7), expanded polytetrafluoroethylene 4.0% (6), Dacron 5.4% (9), and saphenous vein 1.0% (2). Significant restenosis was most frequent in habitual smokers (93%, 25/28) and females (78%, 22/28) despite the method of carotid endarterectomy closure. No statistical difference was found in the incidence of late ipsilateral stroke either (p greater than 0.25): primary closure 2.9% (5), expanded polytetrafluoroethylene 2% (3), Dacron 5% (3), and saphenous vein 0%. These results indicate that the incidence of postoperative stroke, regardless of method of arterial closure, was not statistically different. The method of carotid closure did not appear to affect the occurrence of late ipsilateral stroke or restenosis; however, patch angioplasty with saphenous vein appears appropriate in habitual smokers, and likely in patients with small internal carotid arteries.

There is no consensus about the most appropriate management of the patient with intermittent claudication due to a superficial femoral artery occlusion. To evaluate the natural history of prosthetic above-knee femoropopliteal (AKFP) bypass, 200 operations for intermittent claudication were reviewed. One hundred AKFP bypasses were done with PTFE and 100 with dacron. In the 30 day postoperative period, four PTFE and three dacron grafts occluded without consequence and only one patient died. Analysis of results by the life-table method demonstrated statistically similar primary graft patency rates at five years (PTFE 65% SE +/- 6.5, dacron 57% +/- 6.2) and ten years (PTFE 31% +/- 18/9, dacron 32% +/- 13.2) (p greater than 0.10). Redo procedures (e.g., thrombectomy, angioplasty) were necessary on 21 grafts (12 PTFE, 9 dacron) and "secondary" patency rates at five years were 76% PTFE and 62% dacron; no grafts which required a redo procedure were patent at ten year follow-up. Major amputations during ten year follow-up were necessary in 16 (8%) patients; all amputations were in diabetic patients. Survival rates were 79% at five and 42% at ten years. An anticipated, the leading cause of death was cardiac related (25 patients); 28 (14%) patients underwent aortocoronary bypass during follow-up. A prosthetic AKFP bypass graft is a safe and durable operation which provides relief from the symptoms of intermittent claudication while allowing for the preservation of the saphenous vein for use later in the coronary or infrapopliteal circulations, should the need arise. These results indicate that the risk of amputation after AKFP is no greater than the natural history of untreated claudication; however, AKFP offers a significant improvement in life-style.

Aspirin (ASA) and dipyridamole (DIP) have been shown to reduce the incidence of transient ischemic attacks (TIAs), but aspirin's ability to reduce the incidence of postoperative neurologic deficits in patients who require carotid endarterectomy (CE) is controversial. To evaluate the role of adjunctive ASA/DIP in conjunction with CE, 908 CE cases were reviewed. Four hundred sixty-seven patients took ASA (650 mg/day) and DIP (150 mg/day) preoperatively, while 381 received no ASA/DIP. There was no statistical difference in the distribution of postoperative neurologic deficits. Twenty-six transient deficits occurred: 14 (53%) patients were taking ASA/DIP, whereas 12 (47%) were not. Seventeen permanent deficits occurred: ten (58%) patients were taking ASA/DIP and seven (42%) were not. ASA/DIP are useful medications in combating ischemic cerebrovascular disease, but ASA/DIP cannot replace precise operative technique which affords unequaled protection against a postendarterectomy neurologic deficit.

The ideal management of the patient with an asymptomatic stenosis of the extracranial internal carotid artery remains controversial. The purpose of this article was to evaluate the effects of prophylactic carotid endarterectomy (CE) done to treat asymptomatic carotid stenosis (greater than 50% diameter reduction by angiography) 10 years later. In 1976, 42 prophylactic CEs were performed. There were no postoperative deaths or strokes. During 10-year follow-up two strokes occurred in the operated hemisphere; one stroke was fatal and was due to an intracranial hemorrhage, whereas the other stroke was thromboembolic in origin. Two other patients suffered strokes in the contralateral hemisphere and seven patients had transient ischemic attacks in the contralateral hemisphere, which necessitated CE. The survival rate at the end of the study period by life-table analysis was 57% (mean 8.7 years). Sixteen late deaths occurred, with coronary artery-related disease the most common cause of death. This review with actual 10-year follow-up demonstrated that prophylactic CE may be performed with minimal risk, that late stroke in the operated hemisphere was negligible, and that long-term survival was similar to that of a comparable age-matched population, possibly because late deaths attributed to stroke were reduced. On the basis of long-term follow-up, CE to treat asymptomatic high-grade carotid stenoses appears to be indicated in appropriate patients.

To evaluate the efficacy and long-term patency results of axilloaxillary bypass, a review of 32 patients with follow-up extending to 11 years was done. Twenty-two bypasses were performed for vertebrobasilar symptoms or subclavian steal and 10 for upper extremity claudication and/or ischemia. The mean age of the operative group was 66 years, 94% of patients had more than one atherosclerotic risk factor (hypertension, diabetes, coronary artery disease, smoking), and 75% had undergone a previous arterial reconstruction operation. There were no operative deaths, and the only postoperative complication was a sterile seroma which responded to aspiration. At late follow-up extending to 11 years, three grafts had thrombosed while another became infected and had to be removed; no limb loss resulted from these graft failures and the actual late patency rate was 87%. Carotid-subclavian bypass, intrathoracic bypasses, and endarterectomy at the site of occlusion have all been suggested for the treatment of symptomatic proximal subclavian artery disease. With axilloaxillary bypass, however, the hazards associated with carotid artery manipulation, operation on the notoriously treacherous subclavian artery, and the morbidity related to thoracotomy in this older, high-risk patient population can be avoided. The axilloaxillary bypass is safe and simple, and the excellent long-term patency rates make it the procedure of choice for symptomatic subclavian artery disease.

To evaluate the role of carotid endarterectomy (CE) in patients 80 years and older an 8-year study of 172 nonrandomized cases of octogenarians with cerebrovascular disease was done. Ninety octogenarians underwent CE whereas 82 octogenarians, with arteriographically established carotid artery disease, were not operated on and served as a control series. The stroke rate after CE was 6%. In follow-up extending to 8 years the late stroke rate was only 2%, whereas the cumulative long-term stroke rate in the nonoperated group was 16%. These late strokes were appropriate to the side of the arteriographically demonstrated disease. In 1008 nonoctogenarians who underwent CE during this same time interval, the stroke rate after CE was 2% and the mortality rate was 0.6%. In the octogenarian population, however, the mortality rate after stroke was an alarming 40% in the operated group and 62% in the nonoperated control group. Arteriographic flow-limiting (greater than 75% stenosis) intracranial occlusive disease was identified in 53% of the octogenarians undergoing operation and in all patients who suffered a postoperative neurologic deficit. This incidence of severe intracranial disease was nearly five times that of the nonoctogenarian patients undergoing CE. Although the stroke rate after CE in the octogenarian patient was 6%, the late stroke rate was only 2% compared with the cumulative stroke rate of 16% in the nonoperated octogenarian patients. Severe intracranial occlusive disease and, therefore, flow deprivation may play a more significant role as a cause of postoperative deficits than in younger patients, but CE is appropriate for selected octogenarians on the basis of physiologic rather than chronologic age.

Educational workshops were developed to enrich volunteers' services to a large metropolitan hospital. Staff also benefit by acquiring useful input from the volunteers.

Penetrating arterial injuries can result in the formation of a traumatic false aneurysm or an arteriovenous fistula. Traumatic arteriovenous fistulas of the mesenteric circulation are extremely rare, with only 15 operated cases reported in the English language literature that involved the superior mesenteric artery and vein. Although surgical intervention has been considered the most successful method to treat traumatic mesenteric arteriovenous fistulas, percutaneous transcatheter embolization has been occasionally advocated in the management of small iatrogenic fistulas. We report a case of a gunshot wound patient who had an 8 cm abdominal aortic false aneurysm, as well as a high-flow arteriovenous communication between the superior mesenteric artery and vein, which were successfully treated by a combination of aorto-superior mesenteric bypass and postoperative percutaneous transcatheter embolization. A review of the literature is also included.

Nurse administrators are in a key position to develop strategies to deter drug abuse by their staff. This two-part series of articles discusses the development of a prevention program. This first article describes risk factors associated with initial and continuing drug use by nurses. The second article (January 1989) will present an educational program based on these risk factors and suggest ways to provide staff with support.