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Background: Identification of the sentinel node (SN) in patients with breast cancer is done by tracking a radioactive tracer, a vital dye, or both, as the marker(s) reach the axilla. Replacing this method with ultrasonographic (US) recognition of the SN could eventually spare patients the need for systemic anesthesia, permit minimally invasive outpatient biopsy of the node, and allow the formulation of a precise therapeutic plan before a definitive surgical procedure., Methods: Eighty-eight axillae of 84 patients with a histologic diagnosis of breast cancer were studied by injecting the subareolar area of the affected breast(s) with technetium 99 and an iron preparation before the planned surgical procedure and SN biopsy. An axillary US scan was performed in all patients before the injection of the markers. After induction of anesthesia, the SN was identified, needle-localized, and extracted under US guidance. Confirmation that the SN was retrieved was established by concordance with the audible gamma signal, unless there was none. All extracted nodes had iron stains performed., Results: All except three of the SNs were identified with US after the iron marker was injected, and all except six were identified by their radioactive signal. One of the SNs undetected on US was identified by its radioactive tracer, and the other two, although seen on US, had neither a gamma signal nor concordant iron deposits. All other SNs identified with US had a concordant audible signal when there was one, and all had concordant iron deposits on microscopy. Of the six SNs without a gamma signal, three without preincision activity were identified with US; three with neither a preincision nor an ex vivo signal were seen with US, but two of these were the SNs without a concordant iron deposit., Conclusions: Using an iron preparation, the SN in patients with breast cancer can be identified with US with an accuracy equal to and perhaps better than that achieved with a radioactive tracer. These findings may change the current diagnostic model and affect the therapeutic algorithm of breast cancer patients.

Chlamydia pneumoniae is a recently discovered respiratory pathogen that has been found in a large (> 50) percentage of atherosclerotic plaques, aortic aneuryms and astenotic aortic valves. It is also found in Alzheimer plaques. C. pneumoniae should not be confused with chlamydia trachomatis, which is the cause of primarily a sexually transmitted disease. This article reviews the transmission and proliferation of C. pneumoniae and discusses its role in cardiovascular disease.

This study reviews our experience in the management of deep vein thrombosis (DVT) of the lower extremity during pregnancy and analyzes the outcome of various treatment alternatives, including conventional full-dose heparin therapy and Greenfield filter insertion. Twenty-four patients treated over an 8-year period were reviewed. Fifteen patients were treated with conventional full-dose intravenous heparin therapy for 5 to 10 days, followed by subcutaneous low-dose heparin until labor, and continued for 6 weeks postpartum (Group A); Eleven patients had Greenfield filters inserted, followed by the same low-dose subcutaneous heparin regimen (Group B). There were 18 femoral or iliofemoral, 5 femoropopliteal, and 1 popliteal and below-knee DVT. The indications for Greenfield filter insertion included two patients in Group A (one with pulmonary embolism, despite adequate heparin therapy, and one with significant bleeding). Nine other patients had prophylactic indications: two for free-floating iliofemoral DVT, three with iliofemoral DVT (occurring just 1-2 weeks before labor), and four with femoropopliteal DVT. There were three immediate major complications (pulmonary embolism, bleeding, or death) in Group A; two with pulmonary embolism, one of which was fatal, and one with significant bleeding (3 of 15 patients; 20%). No major complications occurred in Group B. On long-term follow-up (mean, 61 months), 4 of 12 patients (33%) in Group A had significant leg swelling, with partial resolution of DVT in 2 patients and venous occlusion in 2 patients by duplex ultrasound. This is in contrast to 3 of 11 patients (27%) in Group B with significant leg swelling. There was no fetal morbidity or mortality in either group. Conventional full-dose heparin therapy for DVT of the lower extremity in pregnancy can carry significant morbidity and mortality. Greenfield filters may be used safely in some of these patients.

Purpose: This study examines the long-term clinical outcome and the incidence of recurrent stenosis (> or = 50%) after carotid endarterectomy (CEA) with primary closure (PC) versus vein patch closure (VPC), saphenous (SVP), and jugular vein (JVP) and polytetrafluoroethylene patch closure (PTFE-P)., Methods: A total of 399 CEAs were randomized into the following groups: 135 PC, 134 PTFE-P, and 130 VPC (SVP alternating with JVP). Postoperative duplex ultrasound scans were performed at 1, 6, and 12 months and every year thereafter. The mean follow-up was 30 months with a range of 1 to 62 months, and demographic characteristics were similar in all groups. Kaplan-Meier analysis was used to estimate the risk of restenosis and the stroke-free survival., Results: The incidence of ipsilateral stroke was 5% (seven of 135) for PC, 1% (one of 134) for PTFE-P, and 0% for VPC (PC vs VPC, p = 0.008; PC vs PTFE-P, p = 0.034). Seven strokes occurred in the perioperative period. All three groups had similar mortality rates. The cumulative stroke-free survival rate at 48 months was 82% for PC, 84% for PTFE-P, and 88% for VPC (p < 0.01 for PC vs PTFE-P or VPC). PC had a higher incidence of recurrent stenosis and occlusion (34%) than PTFE-P (2%) and VPC (9%) (SVP 9%, JVP 8%) (p < 0.001). PTFE-P had a lower recurrent stenosis rate than VPC (p < 0.045). Restenoses necessitating a redo CEA were also higher for PC (11%) than for PTFE-P (1%) and VPC (2%) (p < 0.001). Women with PC had a higher recurrent stenosis rate than men (46% vs 23%, p = 0.008). Kaplan-Meier analysis showed that freedom from recurrent stenosis at 48 months was 47% for PC, 84% for VPC, and 96% for PTFE-P (p < 0.001). The SVP and JVP results were comparable. The mean operative diameter of the internal carotid artery was similar in patients with or without restenosis. Significantly more late internal carotid artery dilatations occurred in the VPC group compared with the PC group., Conclusions: Patch closure (VPC or PTFE-P) is less likely than PC to cause perioperative stroke. Patching was also superior in lowering the incidence of late recurrent stenoses, especially in women.

Over the past few years, several cases of acute mesenteric ischemic events following laparoscopy have appeared in the literature. To date, no formal description of this phenomenon has been provided. In this article, we summarize and analyze the features of the five reported cases to date as well as a sixth case encountered at our institution. The probable cause of this complication involves changes in splanchnic hemodynamics related to elevated intra-abdominal pressure. A review of the relevant literature is provided.

Background: Although a fever of unknown origin (FUO) is most often due to other causes, the few caused by pulmonary emboli, pelvic thrombophlebitis, or lower extremity venous thrombosis (DVT) present a diagnostic challenge. The purpose of this study was to evaluate the role of venous duplex imaging of the lower extremity in evaluating a large series of patients with FUO. This has not been reported previously in the English-language literature., Methods: Medical records were analyzed of patients with FUO who were referred to the vascular laboratory for venous duplex imaging of the lower extremities to rule out DVT as a cause of their fever. A FUO was defined as a temperature of greater than 38.3 degrees C on several occasions for at least 3 weeks' duration that defied 1 week of hospital evaluation. DVT was considered as a probable cause of FUO if the following criteria were met: (1) a positive venous duplex image for acute DVT, (2) subsequent fever resolution within 7 days of anticoagulation therapy, and (3) a fever that was resistant to prior treatment., Results: A total of 114 duplex examinations, gathered during a 2-year period, were analyzed. The 89 patients had a mean age of 58 years. Infections were the most common cause of FUO (57 of 89, 64%), and unknown causes constituted 19%. There were seven cases of DVT (8%), five (6%) of whom met the criteria for probable cause of FUO. The overall cost of venous duplex imaging examinations was $51,300 ($450 x 114 tests), with an average cost of $10,260 for each case of DVT detected as probable cause of FUO., Conclusions: Consistent with the literature, infections remain the most common cause of FUO; however, DVT was found to be a more common cause of FUO in our present series (6%). The cost of venous duplex imaging of the lower extremities in establishing DVT as a probable cause of FUO should be borne in mind when the work-up of these patients is planned.

Four hundred seventy-three patients with acute myocardial infarction (AMI) were treated with either saruplase (80 mg/hour, n = 236) or alteplase (100 mg every 3 hours, n = 237). Comedication included heparin and acetylsalicylic acid. Angiography was performed at 45 and 60 minutes after the start of thrombolytic therapy. When flow was insufficient, angiography was repeated at 90 minutes. Coronary angioplasty was then performed if Thrombolysis In Myocardial Infarction (TIMI) trial 0 to 1 flow was seen. Control angiography was at 24 to 40 hours. Baseline characteristics were similar. Angiography showed comparable and remarkably high early patency rates (TIMI 2 or 3 flow) in both treatment groups: at 45 minutes, 74.6% versus 68.9% (p = 0.22); and at 60 minutes 79.9% versus 75.3% (p = 0.26). Patency rates at 90 minutes before additional interventions were also comparable (79.9% and 81.4%). Angiographic reocclusion rates were not significantly different: 1.2% versus 2.4% (p = 0.68). After rescue angioplasty, angiographic reocclusion rates of 22.0% and 15.0% were observed. Safety data were similar for both groups. Thus, (1) early patency rates were high for saruplase and alteplase treatment, (2) reocclusion rates for both drugs were remarkably low, and (3) complication rates were similar. Thus, saruplase seems to be as safe and effective as alteplase.

Purpose: The early outcomes of carotid endarterectomy (CEA) with primary closure (PC) versus vein patch closure (saphenous vein [SVP] and jugular vein [JVP]) and polytetrafluoroethylene patch closure (PTFE-PC) were compared., Methods: Three hundred ninety-nine CEAs were randomized into the following groups: 135 PC, 134 PTFE-PC, and 130 vein patch closure (SVP alternating with JVP). Surviving patients underwent a carotid color duplex ultrasonographic scan 1 month after surgery. Demographic characteristics were similar in all groups., Results: The incidence of perioperative cerebrovascular accidents (CVAs) was 4.4% for PC, 0.8% for PTFE-PC, and 0% for vein patch closure (PC vs vein patch, p = 0.0165; PC vs all patching [vein and PTFE], p = 0.007). The perioperative CVA and reversible ischemic neurologic deficit (RIND) combined rates for all patching were superior to PC (1.5% vs 5.2%; p = 0.04). These combined rates were also superior for vein patch closure when compared with PC (0.8% vs 5.2%; p = 0.037). The mean diameter of the internal carotid artery was similar in patients who had perioperative neurologic deficits and those who did not. After 1 month of follow-up, 11.9% of the PC arteries were narrowed 50% or more in contrast to 2.3% for PTFE-PC, 3.1% for SVP, and 10.3% for JVP.

Spontaneous axillary-subclavian vein thrombosis in young patients produces long-term disability. Patients with secondary axillary-subclavian vein thrombosis usually require prolonged venous catheterization for chemotherapy or pacemaking. This study aimed to compare the early and late results of lytic versus anticoagulant therapy in the treatment of axillary-subclavian vein thrombosis, both spontaneous and secondary to central venous cannulation. Nine patients underwent conventional treatment (heparin and warfarin) (group 1), and 10 had initial lytic therapy followed by heparin and warfarin (group 2). Three patients had cervical or first rib resection. Thirteen patients had spontaneous thrombosis and six were secondary to central venous catheterization. The mean follow-up was 36 months. Two of nine patients (22%) in group 1 and eight of 10 patients (80%) in group 2 had total venous recanalization and symptom resolution (P = 0.018). In the spontaneous axillary-subclavian vein thrombosis subset, one of six patients (17%) in group 1 and five of seven patients (71%) in group 2 had total venous recanalization and symptom resolution (P = 0.078). The average difference in cost per patient between groups 1 and 2 was $19,039. In conclusion, lytic therapy appears superior to anticoagulation in the treatment of axillary-subclavian vein thrombosis. However, such treatment is more expensive and its benefits should be carefully weighed against the cost in each case.

Ulcerated or irregular heterogeneous carotid plaque as seen by duplex ultrasound can cause hemispheric transient ischemic attacks (TIAs) and/or a cerebrovascular accident, even if only associated with nonsignificant carotid stenosis on arteriography. The purpose of this study was to review our experience in patients who underwent a carotid endarterectomy after medical treatment had failed, based on pathologic findings detected by carotid duplex ultrasound with minimal disease on arteriography. The medical records of 14 patients who underwent carotid endarterectomy for TIA symptoms related to ulcerated or irregular heterogeneous plaques were analyzed. All had had preoperative carotid duplex ultrasound, arteriography, and cardiac and neurologic workups to rule out other causes for their TIAs. Medical treatment had failed in all of them. There were 10 men and four women whose median age was 68 years. Carotid duplex ultrasound showed irregular heterogeneous carotid plaque in all patients associated with 20% to 50% stenosis in 12 and approximately 50% to 60% stenosis in two. All had normal to < 20% stenosis on arteriograms. The duplex ultrasound findings were all confirmed at operation. All had an uneventful postoperative course with relief of symptoms. Carotid duplex ultrasound is superior to carotid arteriography in detecting irregular or ulcerative heterogeneous plaque associated with nonsignificant stenosis. Carotid duplex ultrasound can be used to determine the desirability of carotid endarterectomy after failed medical treatment in patients with classical and persistent TIA symptoms despite normal or minimal disease on arteriograms. A successful endarterectomy appears to predict an asymptomatic postoperative course.

A method of performing a laparoscopic splenectomy with the aide of intraabdominal manipulation is described. We believe that this is a versatile technique that compares quite favorably with a pure cannula approach. It is likely that this approach is safer because vascular control can readily be assured by the intraabdominal operator. It is also less costly because it is more rapid than a procedure done solely by cannula techniques. Moreover, it is reproducible by an experienced general surgeon. The results appear equal in terms of access morbidity and hospitalization time to those seen with a purely laparoscopic approach. Experience with 21 splenectomies is described and compared with 20 others performed by the traditional open approach.

Purpose: To evaluate the filling of the Circle of Willis on preoperative arteriograms and to correlate this observation with the results of oculopneumoplethysmography (OPG) and severity of carotid stenosis as determined by duplex ultrasonography and angiography., Patients and Methods: Ninety-five patients underwent OPG, duplex ultrasonography, and selective carotid and vertebral arteriography., Results: In all, 45 (88%) patients with a positive OPG had interhemispheric cross-filling of the middle cerebral artery and anterior cerebral artery from a contralateral carotid injection in contrast with 10 (23%) patients with a negative OPG (P < 0.001). Of patients with carotid stenosis > or = 80% on duplex ultrasound, 39 (91%) had cross-filling from a contralateral carotid injection in contrast with 16 (31%) patients with < 80% stenosis (P < 0.001). Of patients with carotid stenosis > or = 80% on arteriogram, 37 (90%) had cross-filling from a contralateral carotid injection in contrast with 18 (33%) patients with < 80% stenosis (P < 0.001)., Conclusion: These data suggest that the Circle of Willis is frequently incompetent as a collateral pathway and that arteriographic cross-filling is not a reliable index of this pathway. Patients with a positive OPG and corresponding carotid stenosis are likely to have a physiologically incompetent collateral pathway. Perhaps these patients should undergo surgery, even if the stenosis is less than 80%.

Celiac compression syndrome occurs when the median arcuate ligament of the diaphragm and/or periarterial neural tissue causes extrinsic compression of the celiac axis. In rare cases, this syndrome can cause upper abdominal angina. The classic triad of celiac compression syndrome consists of abdominal pain, an epigastric bruit, and angiographic evidence of celiac compression. Operative therapy consists of thorough exploration, transection of the median arcuate ligament, and either celiac dilatation or a bypass. This article describes a case of celiac compression syndrome which was treated successfully by transection of the median arcuate ligament and aortosplenic bypass.

This study includes our 12-year experience with chemical sympathetic blocks and surgical sympathectomies for causalgic pain of reflex sympathetic dystrophy (RSD) with emphasis on factors affecting clinical outcome. Medical records of patients undergoing sympathectomies for causalgic pain were analyzed. The patients were classified according to Drucker et al. as stage I, II, or III. Results of chemical and surgical sympathectomies were analyzed using both univariate and multivariate methods. Twenty-one patients had lumbar and seven had cervicodorsal sympathectomies for RSD. The mean duration between initial injury and chemical sympathetic block was 10 months with a mean of 11.4 months to surgical sympathectomy. Ten patients (36%) had overt extremity trauma as the precipitating event. Ten patients (36%) had a lumbar laminectomy, three of whom developed the syndrome bilaterally. There was no operative mortality; however, 25% had transient postoperative sympathetic neuralgia. The early and late (> 6 months) satisfactory outcomes after surgical sympathectomy were 82% and 71%, respectively. Patients with stage II presentations were significantly more likely to have satisfactory early (92%) and late (79%) outcomes than stage III patients, 0% and 0% (p = 0.019). Patients with an excellent response to chemical sympathetic block were more likely to have satisfactory early and late surgical outcomes. The time between injury and chemical block and surgical sympathectomy was significantly shorter in patients who had satisfactory early and late surgical outcomes (p < 0.0001). Multivariate analyses demonstrated that the most important independent factor in determining early and late satisfactory outcomes of sympathectomy was the time between injury and sympathectomy (p = 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

We describe a method for performing laparoscopic staging laparotomy. We believe this minimally invasive approach can ease the transition between purely open and laparoscopic surgery, and it is applicable to a variety of intra-abdominal problems. The results are comparable to those of a standard staging laparotomy, with improvement in access morbidity and decreased hospitalization time.

Although anticoagulation remains the treatment of choice for acute pulmonary embolism, vena caval interruption represents an alternative for patients with contraindications and complications or in whom anticoagulation fails. The purpose of this study was to evaluate the effectiveness and safety of two types of caval interruption devices: the original stainless steel Greenfield filter and the Adams-DeWeese clip. Emphasis has been placed on maintaining caval patency with filters and clips and the patency of the femoral vein vs. the jugular vein after filter insertion. We retrospectively reviewed 161 patients who underwent caval interruption (92 filters and 69 clips) for both therapeutic and prophylactic reasons. The operative mortality and morbidity rates were 0% and 3.3% for filter patients and 8.7% and 2.9% for clip patients; no procedure-related mortalities occurred. The late caval patency rate as documented by duplex ultrasonography/venography was 100% for filter patients and 88% for clip patients (p = 0.011). Seven percent of the filter patients and 20% of the clip patients experienced late limb swelling postoperatively (p = 0.05). The incidence of recurrent late pulmonary embolism was 2.5% in the filter group and 1.9% in the clip group. In the filter group, 10% of patients experienced postoperative thrombosis at the femoral vein insertion site and 0% at the jugular vein insertion site. We found that both devices were effective in preventing pulmonary embolism, the filter provided better caval patency than the clip, and the jugular vein had a better patency than the femoral vein after filter insertion.

Deep vein thrombosis (DVT) of the lower extremity during pregnancy is infrequent, but its complication, pulmonary embolism, remains an important cause of maternal mortality. To evaluate the best method of caring for patients with DVT, we reviewed the records of patients at the Charleston Area Medical Center from 1987-1992 who were treated for this condition. Twelve patients were treated with conventional continuous intravenous heparin for 7 days-10 days followed by subcutaneous heparin until 6 weeks-8 weeks after delivery. The other group consisted of nine patients who were treated with lower dose subcutaneous heparin for 7 days-10 days and maintained as the first group, but a Greenfield filter was inserted for patients with iliofemoral DVT. The patients who received low-dose heparin and Greenfield filters tended to do better than those who received high-dose conventional heparin treatment. However, since there were so few patients evaluated, further verification is needed.

One hundred thirty-seven polytetrafluoroethylene infrainguinal bypass grafts were performed over 2 years. The results were analyzed using univariate and multivariate analyses. Our operative mortality was 3.2% and the post-operative amputation rate was 5.8%. Forty-eight reconstructions were done for claudication, with a 5-year secondary patency rate of 64%, no early amputations, and a 2.9% (one limb) late amputation rate. Sixty-six reconstructions were done for rest pain with a 5-year secondary patency rate of 58% and a 3-year limb salvage rate of 77%. The 5-year secondary patency rate for 23 patients with trophic changes was 30%, and the 3-year limb salvage rate was 71%. Multivariate analysis identified the ankle-brachial index as the most important independent factor predicting both primary and secondary graft patency. The cumulative primary and secondary patency rates for patients with an ankle-brachial index of less than 0.5 at 78 months was 37% and 46%, respectively; and 57% and 68%, respectively for patients with an ankle-brachial index of 0.5 or more.

Seven hundred and seven consecutive arteriograms were analyzed regarding the effects of various factors on clinical outcome. Complication rates were assessed regarding age, inpatient or outpatient procedures, operator caseload, clinical indication, preoperative renal disease, approach site, graft puncture, selective injection of arteries, amount of contrast, and catheterization time. The major complication rate for arteriography was 7% and the mortality rate was 0.7%. The complication rates for femoral and axillary approaches, respectively, were local, 9% and 27%; nervous system, 1.4% and 11%; and major, 6% and 24% (p = 0.0075, p < 0.0001, and p < 0.0001, respectively). Brachial plexus injury was noted in 13% of the patients undergoing the axillary approach. There was a trend toward a higher overall complication rate in four-vessel arch aortograms with selective vs. nonselective carotid injections, but both had similar neurologic complications. More contrast was used in patients with post-arteriogram renal failure, 224 ml vs. 168 ml. The complication rates were directly related to catheterization time, amount of contrast, and number of vessels punctured. There was a trend toward a higher complication rate in physicians with a lower caseload. In conclusion, arteriography is still associated with significant morbidity and mortality. The transfemoral approach is safer than the transaxillary route, even in patients with femoral graft punctures.

Gastrostomy can be a valuable adjunct to patient care, and percutaneous endoscopic gastrostomy is often considered the method of choice for gastrostomy placement. As with all surgical procedures, however, patient selection is important no matter how the gastrostomy is placed. In a retrospective review of 125 randomly selected patients having gastrostomy tube placement, there were certain groups of patients who received virtually no benefit from gastrostomy and may even have died sooner due to gastrostomy placement. The leading indication for gastrostomy placement was neurologic debilitation; the procedural mortality rate for these patients was 28%. However, patients with pulmonary cachexia or metastatic cachexia had much higher mortality rates: 90% and 37%, respectively. We believe patient selection has been imperfect and that certain patients should not have a gastrostomy tube. These patients suffer the moral indignation of persistent intervention and often die without receiving any real benefit.

An endolaparoscopic technique to perform a proctopexy is reported. This procedure appears to be ideally suited for this approach and, furthermore, it can be performed safely and effectively. Long-term predictions of morbidity, mortality and recurrence rates cannot yet be made, but those parameters might not be different from what would be expected with the open approach.

Nineteen cases of bronchial carcinoid tumor seen over 20 years in a 1,000-bed, tertiary medical center were retrospectively reviewed. They consisted of 0.4 per cent of all patients with lung tumors. Initial complaints were hemoptysis, persistent pulmonary infection, chest pain, and diarrhea. Two of the five patients with atypical carcinoid tumors came to the hospital with diarrhea as a result of their chemically active tumors. However, seven patients (36%) were asymptomatic and were diagnosed after an abnormal chest radiograph was noted incidentally. Of 13 patients receiving bronchoscopic examination, 9 (69%) had visible tumors. Bronchial biopsy was performed in 7 patients and led to a diagnosis in all seven. Significant bleeding was noted in 3 patients as a result of biopsy. Lobectomy was the most common surgical procedure in this series. Follow-up of these patients was from 6 months to 15 years. The general outcome for patients with typical carcinoid was good. However, all patients with atypical carcinoid died as a result of dissemination.

A total of 122 catheterizations were performed in 105 patients with femoral grafts. Ninety-five femoral grafts were punctured. The mean follow-up time was 21 months. Sixty-one patients had follow-up duplex ultrasounds of the graft puncture site at 6 months. The complication rates for patients with direct graft puncture were comparable to those of patients without grafts undergoing femoral catheter arteriography. Twenty-seven cases with femoral grafts had arteriography using the transaxillary technique. The overall complication rate for the 95 cases with graft puncture was 12% (8% were minor complications) in contrast to 30% (22% were major complications) for the 27 cases with the transaxillary approach. The local, nervous system, and major complication rates were all significantly less in patients with graft puncture than in patients with the transaxillary approach. There was no evidence of early or late pseudoaneurysm formation, disruption of the suture line, or late graft infection in patients with graft puncture. Direct graft puncture arteriography is safe and preferable to the transaxillary approach.

Eighty-nine patients with 94 stenotic segments (mostly iliac or femoral) underwent balloon angioplasty with the first-generation (no guidewire) linear extrusion (Fogarty-Chin) system, in an adjunctive mode, and the overall long-term patency rate (mean follow-up: 21 months) was 81%. Patients were grouped into those having iliac or superficial femoral artery (SFA) lesions and subdivided according to the length of lesions. The overall primary and late success rates for iliac lesions were 95% and 86%, respectively, and for SFA lesions 91% and 76%, respectively. The primary and late success rates for iliac lesions less than 2 cm were 100% and 96%, respectively, and for iliac lesions 2 cm to less than 5 cm 92% and 80%, respectively. The primary and late success rates for SFA lesions less than 2 cm were 100% and 100%, respectively; for lesions 2 cm to less than 5 cm 100% and 83%, respectively; and for lesions 5 to 10 cm 83% and 67%, respectively. A stratified analysis by vessel and segment length reveals that, in SFA lesions with a segment length greater than 5 cm, there is a significantly lower patency rate (67%) when compared with the combined results of the Fogarty-Chin balloon angioplasty system in iliac and femoral artery lesions less than 5 cm (92%). In comparing the composite results presented in a recent text on endovascular surgery by Moore and Ahn as the base data for the standard coaxial (Gruntzig) balloon system, our results (short and long term) are similar.

Sixty-seven patients who underwent carotid-subclavian bypass (CSBP) (28 CSBPs only and eight with carotid endarterectomy) or axilloaxillary artery bypass (n = 31) with polytetrafluoroethylene grafts were followed up for a mean of 69.2 and 71.9 months, respectively. Indications for surgery in the CSBP group included hemispheric transient ischemic attack (TIA)/cerebrovascular accident in five, nonhemispheric TIA in seven, upper extremity ischemia in 15, and combined TIA and arm ischemia in nine patients. In the axilloaxillary artery group, two patients had hemispheric TIA, five had nonhemispheric TIA, 12 had upper extremity ischemia, and 12 had combined TIA and arm ischemia. Graft patency was determined clinically and confirmed by segmental Doppler pressures, duplex ultrasonography, or angiography. The 30-day mortality rate was approximately 3% in both groups. The 30-day complication rate was 3% for the axilloaxillary artery group and 8% for the CSBP group (not statistically significant). Relief of symptoms was achieved in 100% of patients in both groups; however, 20% of the patients in the axilloaxillary artery group had a recurrence of symptoms, in contrast to 5.6% in the CSBP group. The cumulative 10-year primary and secondary patency rates, calculated by life-table analysis, were 66% and 84.6% for the axilloaxillary artery procedures and 93.8% and 93.8% for the CSBP procedures, respectively (statistically significant). Concomitant carotid endarterectomy with CSBP did not influence graft patency. In conclusion, both bypasses have comparable morbidity and mortality rates; however, the CSBP has a statistically significantly better primary patency rate than the axilloaxillary artery bypass. Therefore CSBP should be the procedure of choice and the axilloaxillary artery bypass should be restricted to high-risk patients.

Heparin-induced thrombocytopenia with thrombotic complications is a serious clinical problem. The diagnosis is confirmed by a positive heparin-induced platelet aggregation test and/or detection of white clots upon pathological exam after a presumptive diagnosis based on these criteria: (1) Development of thrombocytopenia of less than 100,000 mm3 while receiving heparin therapy; (2) Normalization of the platelet count after an interruption in heparin therapy; (3) The presence of thrombotic complications; and (4) Exclusion of other causes of thrombocytopenia. Eight patients with heparin-induced thrombocytopenia were encountered at the Charleston Area Medical Center, Memorial Division, in a recent 20-month period. Various types of heparin, routes of administration, and indications were implicated. The mean platelet nadir was 25,750 mm3 and the mean time to onset of of heparin-induced thrombocytopenia was 4.9 days. Thrombotic complications included seven patients with arterial occlusions of the legs, six with deep-vein thrombosis of the legs (three had pulmonary embolism), and five with combined arterial and venous thrombosis. Treatment strategies included discontinuation of heparin in all patients; intravenous infusion of dextran in five patients, followed by arterial thrombectomy in three patients; urokinase therapy in two patients for arterial thrombotic complications; and insertion of Greenfield filters in four patients for venous thrombotic complications. All surviving patients were given warfarin. The mortality rate was 25 percent and the morbidity rate was 38 percent. In conclusion, an initial platelet count should be obtained on all patients prior to receiving heparin, followed by repeat platelet counts every two to three days. Once thrombocytopenia or thrombosis is diagnosed, heparin should be discontinued and other therapeutic modalities considered.

Sixty-eight patients (79 limbs) with clinically suspected deep vein thrombosis were evaluated by duplex imaging, strain gauge plethysmography and venography. The diagnostic accuracies were projected over a spectrum of disease incidences ranging from 10 to 90 per cent of the population. The sensitivity, specificity, positive and negative predictive values, and over-all accuracy in detecting acute deep vein thrombosis were 90.9, 87.1, 83.3, 93.1, and 88.7 per cent, respectively, for venous duplex imaging, and 81.8, 69.6, 56.3, 88.9 and 73.5 per cent, respectively, for strain gauge plethysmography. The positive predictive value and over-all accuracy of venous duplex imaging were statistically significantly higher than that of strain gauge plethysmography. When both tests were combined and compared with venous duplex imaging alone, none of these parameters were statistically significant. For chronic deep vein thrombosis, the sensitivity, specificity, positive predictive value, negative predictive value and over-all accuracy for venous duplex imaging were 75, 86, 80, 86 and 82 per cent, respectively. Fourteen per cent had inconclusive results obtained at venous duplex imaging. When strain gauge plethysmography was combined with venous duplex imaging, the over-all accuracy was 82 per cent. As the true incidence of the disease increases, the positive accuracy differences between strain gauge plethysmography and venous duplex imaging decrease to a negligible level. We concluded that over-all, venous duplex imaging is superior. However, the strain gauge plethysmography has reasonable accuracy and may be used in places where venous duplex imaging is not available. Combined use of venous duplex imaging and strain gauge plethysmography would be helpful in patients with inconclusive results obtained at venous duplex imaging and, as the true incidence increases, the positive accuracy rate of strain gauge plethysmography becomes close to that of venous duplex imaging.

The relatively new field of endoscopic surgery shows much promise and allows alternative treatment options. With increasing numbers of surgeons gaining experience with this technique, new approaches to old conditions are being reported. We present the case of a young female with partial small bowel obstruction secondary to an adhesive band; the condition was readily diagnosed using the laparoscope and treated. We show that in appropriate patient selection, this method is a viable and easily performed alternative to formal laparotomy.

Forty-three patients, 24 with crossover femoral saphenous vein bypasses and 19 with saphenopopliteal vein bypasses, were observed for a mean of 5.5 years. All underwent preoperative and sequential postoperative clinical, hemodynamic and foot venous pressure measurement, and anatomic evaluations (duplex and venography). Seventy-one percent of patients undergoing crossover femoral saphenous vein bypasses and 74% of patients undergoing saphenopopliteal vein bypasses had an abnormal preoperative maximum venous outflow, in contrast to 4% and 11% after operation (p = 0.0183). The mean immediate postoperative maximum venous outflow improvement for patients having crossover femoral saphenous vein bypasses and those having saphenopopliteal vein bypasses was 16 and 17 ml, respectively, and the mean late improvement was 19 and 27 ml, respectively. Ninety percent of the patients undergoing crossover femoral vein bypasses and those having saphenopopliteal vein bypasses had abnormal foot venous pressures in contrast to 18% and 22% after operation. The final clinical outcomes (over 1 year) for both patients having the crossover saphenous vein bypasses and those having saphenopopliteal vein bypasses, respectively, were significant improvement (+3 and +2), 63% and 58%; significant worsening (-2), 4% and 5%. Eighty-eight percent of patients undergoing crossover femoral saphenous vein bypasses and 79% of patients undergoing saphenopopliteal vein bypasses with abnormal preoperative maximum venous outflow measurements had significant clinical improvement. In contrast, 86% of patients undergoing crossover femoral saphenous vein bypasses and 80% of patients undergoing saphenopopliteal vein bypasses with normal preoperative maximum venous outflow had no improvement. Seventy-seven percent of patients having saphenopopliteal vein bypasses and a normal venous refill time had significant improvement, in contrast to 17% for patients with an abnormal venous refill time (less than 10 sec). Sixty-seven percent of patients undergoing crossover femoral saphenous vein bypasses and 78% of patients undergoing saphenopopliteal vein bypasses with abnormal foot venous pressure measurements had significant improvement. The cumulative 7-year patency was 75% for patients having crossover femoral saphenous vein bypasses and 56% for those having saphenopopliteal vein bypasses. The operative mortality rate was 0% for both procedures, and the complication rate was 4% and 10%, respectively. The most important preoperative variables that correlated with a good outcome were a low preoperative maximum venous outflow, venous refill time greater than 10 sec, and venous claudication and iliac vein compression. Patients with a normal maximum venous outflow measurement and severe venous reflux should not be candidates for these bypasses.

This study describes our experience with 12 patients with white clot syndrome encountered during a recent 36-month period. The diagnosis was based on the following criteria: (1) development of thrombocytopenia of less than 100,000/mm3 during administration of heparin therapy, (2) normalization of the platelet count after an interruption in heparin therapy, (3) exclusion of other causes of thrombocytopenia, (4) a positive heparin-induced platelet aggregation test, (5) detection of white clots on pathologic examination, and (6) the presence of thrombotic complications. Of 2,500 patients who received heparin therapy, 12 (0.48%) developed white clot syndrome. Various indications, routes of administration, and types of heparin were implicated. The mean platelet nadir was 26,900/mm3, and the mean time to onset of heparin-induced thrombocytopenia was 5 days. Thrombotic complications included arterial occlusions of the legs in 11 patients, deep vein thrombosis of the legs in 9 patients (4 had pulmonary embolism), and combined arterial and venous thrombosis in 8 patients. Treatment strategies included discontinuation of heparin in all patients and intravenous infusion of dextran, followed by arterial thrombectomy in four patients, urokinase therapy in two patients for arterial complications, and insertion of Greenfield filters in six patients. All patients were given warfarin. The mortality rate was 25% and the morbidity rate was 50%. An initial platelet count should be obtained on all patients prior to receiving heparin, followed by repeat platelet counts every 2 to 3 days. Once thrombocytopenia or thrombosis is diagnosed, heparin should be discontinued and other methods of therapy considered.

The left renal vein can be ligated during aortic operation to attain better access to the perirenal aorta. This maneuver has been considered safe, with a low incidence of postoperative renal complications. This study was done to evaluate the risk of left renal vein ligation and its influence on renal function in patients with elective resection of abdominal aortic aneurysms. The records of 332 patients undergoing elective repair of abdominal aortic aneurysms during a five year period were reviewed. The clinical and operative data of patients who had left renal vein ligation and those who did not were similar. Left renal vein ligation was not associated with an increased mortality rate but was strongly associated with an increase in serum creatinine level and a clinical diagnosis of postoperative azotemia. Nine of 13 patients who had left renal vein ligation had postoperative azotemia compared with 21 of 319 patients without left renal vein ligation (p less than 0.001). The mean change of preoperative and postoperative creatinine value was an increase of 1.92 milligrams per deciliter in patients with left renal vein ligation in contrast with 0.26 milligram per deciliter in patients without ligation (p less than 0.00075). Thus, ligation of the left renal vein increases the risk of postoperative renal complications and its use should be selective.

The hospital records for patients treated for ruptured abdominal aortic aneurysms in southern West Virginia during a recent five year period were reviewed. The over-all mortality rate was 62 per cent. Patients with intraperitoneal rupture had a higher mortality rate (97 per cent) than patients with retroperitoneal rupture (25 per cent). Patients at increased risk were more than 80 years of age, presented with syncope, experienced a short duration of symptoms before seeking medical attention, had preoperative systolic blood pressure levels of less than 90 millimeters of mercury and had a preoperative hemoglobin level of less than 8. Other factors associated with death were a delay in beginning surgical treatment, a larger total blood loss and amount of blood transfused. The results of multivariate analysis demonstrated that preoperative blood pressure, preoperative hemoglobin, presence of syncope and the amount of blood loss were, in large part, reflections of the type of rupture and had only slight independent relationship to mortality. The most effective method of preventing fatal outcome is elective resection of the aneurysms before rupture occurs.

Traditionally, cancer of the prostate has been staged by digital exam, ultrasound, CT scan, bone scan, prostatic acid phosphatase (PAP), and prostate specific antigen (PSA) determinations. These methods commonly lead to understaging, resulting in surgical or radiation therapy of questionable benefit. Pathologic staging, even though reliable and accurate, requires laparotomy with its associated morbidity and lengthy hospitalization/recovery period. Following national trends, we have recently introduced the technique of Laparoscopic Pelvic Lymph Node Dissection (LPND) at our institution. In July 1990 we performed the first LPND at CAMC (Memorial Division). This report details our experience with the first three patients treated in this manner and suggest that the procedure can be performed safely, effectively, and with a significant reduction in morbidity, thus allowing the surgeon to obtain an adequate specimen for pathologic staging. Possible cost containment, minimal discomfort, and little scarring are other advantages that appeal to both patients and surgeons alike.

Effort axillary-subclavian vein thrombosis in young patients has produced long-term disability because of the failure of the thrombosed vein to recanalize. Ten consecutive patients treated in our institution were analyzed. All patients were diagnosed by venography. Four patients received thrombolytic therapy. Three of these had complete resolution and one had partial resolution of the symptoms and thrombus, that was confirmed by venography and duplex imaging. The remaining six patients were treated with conventional anticoagulant therapy. Three of these patients had no resolution, one had complete resolution of both symptoms and thrombus, and two had only partial resolution of symptoms but no resolution of thrombus. Thrombolytic therapy appears to be superior to anticoagulation in the dissolution of symptoms in effort vein thrombosis and should be considered in its management if the diagnosis is made early.

The hospital records of patients treated with ruptured abdominal aortic aneurysm in a recent 5-year period were reviewed to collect data on factors which may be associated with mortality. Overall mortality was 62%. Patients with intraperitoneal rupture had a higher mortality (97%) than patients with retroperitoneal rupture (25%). Patients at increased risk were older than 80 years, presented with syncope, experienced a short duration of symptoms prior to emergency department (ED) arrival, had initial systolic blood pressure less than 90 mm Hg, and/or initial hemoglobin level less than eight on arrival at the ED and delay in beginning surgery. Multivariate analysis demonstrated preoperative blood pressure, preoperative hemoglobin, presence of syncope, and the amount of blood transfused were largely reflections of the type of rupture and had only slight independent relationship to mortality. The authors concluded that treating emergency physicians and surgeons have little control over the most important risk factors for mortality after aneurysm rupture, but may improve the prognosis by expediting diagnosis in the ED and surgical therapy.

This study analyzed 33 variables that might potentially affect outcome in a series of 332 consecutive elective abdominal aortic aneurysm repairs in a southern West Virginia community. One of the interesting features of this series was that the repairs were done by 22 surgeons with varying degrees of experience. The mortality and complication rates were compared for various potential risk factors by both univariant methods (chi 2, Fisher's exact, and Student t tests) and multivariant methods of analysis. Our early mortality (2.1%) and postoperative complication rates were consistent with those of other series. With multiple linear regression models, five factors were selected as significant independent risk factors associated with an increasing number of postoperative complications: the number of blood transfusions (p less than 0.0001), left renal vein ligation (p less than 0.0001), the presence of greater than 50% renal artery stenosis (p = 0.0012), the lesser experience of the surgeon (p = 0.0203), and the history of prior cardiac catheterization (p = 0.0245). The only factor statistically correlated with mortality rate was an increased number of postoperative complications (p less than 0.0001). Neither postoperative complications nor mortality rate was found to be significant and independently influenced by other demographic, clinical, or operative factors. It is tempting to speculate that surgeons with less experience might be well served to refer patients with significant renal artery stenosis and coronary artery disease. Our mortality and complication rates were not increased by performing preoperative angiography and therefore prudent surgeons may find this helpful in selecting patients for safer repair.

Laser-assisted thermal balloon angioplasty was performed in 48 arteries (iliac, superficial femoral, and popliteal). Indications for surgery were limb salvage (25%), rest pain (38%), and claudication (38%). Patients were categorized into three groups: lesions less than 5 cm, greater than 5 to 10 cm, or greater than 10 cm in length. Demographic characteristics, risk factors, and outcome measures were compared by use of Fisher's exact test and Student's t test. The time for vascular patency failure was compared by use of a standard Kaplan-Meier survival analysis for the three groups. Initial failure to recanalize was noted in 14% in lesions less than 5 cm, 40% in lesions greater than 5 to 10 cm, and 73% in lesions greater than 10 cm. The overall success rate was 38%, with a mean follow up of 1 year. The less than 5 cm lesion group had a significantly higher rate of overall success (59%, p = 0.005) than the other two groups combined. The greater than 10 cm lesion group did significantly worse (9%) than the other two groups combined (p = 0.028). Patients in the less than 5 cm group had significantly longer patency than the other two groups (p less than 0.01). Iliac lesions had a higher overall success rate (73%) than superficial femoral and popliteal artery lesions (35%) (p = 0.038). In conclusion, the widespread application of laser-assisted thermal balloon angioplasty cannot be justified without further long-term clinical and laboratory investigation. Conversely, the potential of this technique should not be dismissed out of hand. Proper patient selection, length and nature of the lesion to be treated, and the appropriate forms, doses, and method of delivery of laser energy, remain to be defined.

Unlabelled: Forty-one cases of arterial embolism were reviewed. The work-up included M + 2D echocardiography in 29 patients (71%), arteriography in 22 (54%), both echocardiography and arteriography in 19 (46%), and abdominal aortic ultrasound in 18 (43%). The sources of emboli were probable cardiac (8 = 20%)--mural cardiac thrombus detected by echocardiogram; possible cardiac (12 = 29%)--arrhythmias or other cardiac pathology detected without mural thrombus; probable arterio-arterial (7 = 17%)--proximal arterial thrombus detected; probable paradoxical embolism (2 = 5%)--fulfills the Johnson criteria with cardiac defect and right-to-left shunt detected by contrast echo in one patient and cardiac catheterization in the other; possible paradoxical embolism (3 = 7%)--meets two of three Johnson criteria without evidence of other source; and unknown source (9 = 22%)--conventional work-up negative or incomplete. Five of nine patients (56%) less than 50 years old had probable or possible paradoxical embolism, while in two patients (22%), the origin was unknown., Conclusion: (1) A significant proportion of patients with an arterial embolus are discharged with the source of emboli unknown, (2) paradoxical embolism must be considered and contrast saline or transesophageal echocardiogram should be done in patients under 50 years old.

Immediate reconstruction of head and neck defects due to various causes is required to restore structure, function, and appearance. The pectoralis major myocutaneous flap (PMMF) is the ideal reconstructive tissue for its accessibility, versatility, reliability, and cosmeticity. This paper reports a 10-year experience on the use of the PMMF for restoration of extensive head and neck defects.

In recent months, the technique of Laparoscopic Laser Cholecystectomy (LLC) was introduced at our institution. A small series is presented here involving 14 patients, seven of whom underwent LLC and seven in which a "mini-lap" cholecystectomy was performed. Symptomatic cholelithiasis was the indication for surgery in all cases, and operative cholangiograms were employed in 12 patients. Comparisons are made regarding length of hospitalization, recovery time and operative time. An improved recovery period is indeed demonstrated with LLC allowing return to normal activities and employment much sooner than with an open cholecystectomy. We suggest that, though some prudence and caution is advised, this appears to be a safe and feasible adjunct in the treatment of cholelithiasis.

Despite complex massive defects, reconstruction can be reliably undertaken with microvascular free tissue transfers. In a single stage, this technique permits restoration of composite tissue loss, restoration of function, and acceptable aesthetic results. When confronted with extensive tissue loss, a multidisciplinary team approach is optimal. The risk associated with sophisticated reconstructive procedures is justified when managing these patients. The success of these procedures allows a better quality of life by reestablishing function and maintaining acceptable aesthetic appearance.

Anastomotic aneurysms can occur at all sites of arterial revascularization. Recurrent aneurysmal disease, both true and anastomotic, is the third leading cause of late mortality after aortic aneurysm resection behind coronary artery disease and neoplastic disease (8). For this reason, long-term follow-up after resection is mandatory. If an anastomotic aneurysm is found at one site, a search should be undertaken at other sites. If a heretofore unrecognized intraabdominal anastomotic aneurysm is found, it should be repaired promptly.

Unlabelled: One hundred and fifty-four carotid endarterectomy plaques were studied to determine the correlation of multiple intraplaque hemorrhages to (1) carotid symptoms, (2) the percentage of carotid stenosis, and (3) the preoperative antiplatelet therapy. The plaques were evaluated histopathologically for the presence of multiple hemorrhages. The data were analyzed using the chi 2 test. Multiple hemorrhages were noted in 60.4% and single or not hemorrhage in 39.6% of patients with hemispheric symptoms. In patients with nonhemispheric symptoms, 9.4% had multiple hemorrhages and 90.6% has single or no hemorrhages; 89.4% plaques with multiple hemorrhages had stenosis greater than 75% in contrast to 37.5% in plaques with single or no hemorrhage; and 62.5% with single or no hemorrhage had stenosis of less than 75% (p less than 0.001). In patients receiving antiplatelet therapy, 80.1% of plaques with multiple hemorrhages were removed, in contrast to 19.7% from patients not receiving antiplatelets (p less than 0.001)., In Conclusion: Multiple intraplaque hemorrhages were seen more often in patients with hemispheric symptoms and are associated with more critical carotid stenosis. Preoperative antiplatelet therapy increases the incidence of repeated plaque hemorrhages; therefore, we question the validity of this therapy in certain patients with carotid disease.

A technique for a four-compartment decompression of the leg is described in three patients with return to normal of compartment pressures. The technique involves incision of the interosseous membrane, and the posterior intermuscular septa. No fibulectomy was performed.