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Background Granulosa cell tumors (GCT) variably express estrogen receptors (ER) and progesterone receptors (PR). The goal of this study is to evaluate the relationship between ER and PR expression patterns and clinical outcomes in women with GCT. Methods A multicenter, retrospective analysis was performed of all cases of GCT diagnosed between 1989 and 2012. Immunohistochemical staining for ER and PR was performed on formalin-fixed paraffin embedded (FFPE) tumor tissue and interpreted using a semiquantitative scoring system that incorporated tumor cell staining proportion and intensity. Demographics, disease status, and survival information were collected. Associations between ER and PR staining scores and recurrence-free and overall survival were assessed using univariate Cox proportional hazards models. Results FFPE tumor blocks were available for 149/186 GCT patients. The majority of the women had clinical stage I disease (76%). ER and PR expression was present in 52% and 98% of subjects, respectively. The median composite scores of ER and PR staining were 1 (range 0–8) and 9 (range 0–15), respectively. In univariate analysis, PR composite score >9 was strongly associated with decreased recurrence-free survival (HR = 2.9, 95% CI = 1.5–5.5) and decreased overall survival (HR = 3.7, CI 1.3–10.2). ER composite score was not a significant predictor of recurrence-free survival or overall survival (p = 0.7, HR = 1.1, 95% CI 0.6–2.0 and p = 0.06, HR = 1.1, 95% CI 0.4–2.9, respectively). Conclusions Our results reveal that high PR composite score (≥9) was associated with both decreased recurrence-free and overall survival in patients with GCT while ER expression was not associated with survival outcomes.

Objective We examined the effects of magnesium sulfate on non-neurologic neonatal outcomes with respect to cord blood magnesium level. Study Design We conducted a secondary analysis of the Maternal-Fetal Medicine Units Beneficial Effects of Antenatal Magnesium (MFMU BEAM) trial comparing the upper and lower quintiles of cord blood magnesium level. Outcomes included cerebral palsy (CP), necrotizing enterocolitis (NEC), retinopathy of prematurity (ROP), bronchopulmonary dysplasia (BPD), and assessments of mental and motor disability. Logistic regression was used to estimate adjusted odds ratios (aORs) of each outcome, controlling for gestational age (GA), birth weight, and treatment group (TG). Results A total of 1,254 women of the 2,444 included in the BEAM trial had cord blood magnesium levels recorded. GA and birth weight were lower and TG was more common in the upper quintile cohort (p Conclusion Higher cord blood magnesium levels do not appear to have adverse non-neurologic effects on the neonate and may demonstrate improvement in neurologic outcomes.

To assess patterns of Chagas disease, we reviewed results of screening umbilical cord blood from a US public cord blood bank during 2007–2014. Nineteen maternal donors tested positive for Trypanosoma cruzi parasites (0.04%). Because perinatal transmission of Chagas disease is associated with substantial illness, targeted prenatal programs should screen for this disease.

We examined the effects of magnesium on premature neonatal outcomes complicated by chorioamnionitis.We conducted a secondary analysis of data from the BEAM Trial, an RCT to determine if antenatal magnesium decreases the incidence of CP in preterm birth. We compared the effect of magnesium sulfate by the presence or absence of chorioamnionitis. Outcomes examined include CP, IVH, NEC, BPD, and assessments of mental and motor disability. Logistic regression was used to estimate adjusted odds ratios of each outcome.About 1944 women were included in this analysis of which 228 were diagnosed with chorioamnionitis. Demographic characteristics were similar between women randomized to receive magnesium or placebo. Magnesium therapy demonstrated no significant reduction in CP in the presence of chorioamnionitis (OR 0.76, CI: 0.19-2.76) but does demonstrate benefit in the absence of chorioamnionitis (OR 0.52, CI: 0.31-0.86).Antenatal magnesium did not show a clear neuroprotective effect in the setting of chorioamnionitis.

Background Informed consent (IC)comprehension is suboptimal. Repeat back (RB)—asking the patient to repeat in their own words key elements of the consent—is believed to improve the consent process. Objective This study aims to assess the impact of RB on patient perceptions of surgical informed consent. Design Secondary analysis of a randomized trial. Subjects Elective surgical patients were consented using iMedConsent, the VA’s computer-based IC platform. Patients were randomized to RB (IC could not be signed until the patient satisfactorily expressed key elements) or standard iMedConsent (no RB). Measures A questionnaire was given immediately after IC assessing time for decision, satisfaction with and ease of understanding consent, and the amount of information provided about the proposed surgery (e.g., indications, benefits, risks, and alternatives). Groups were compared with Χ2 tests. Results We enrolled 575 subjects (276 RB and 299 no RB); 92% were men with a mean age of 61.6 years and high school level reading ability. The groups were comparable in their perceptions regarding time to make a decision (RB 88% Strongly Agree (SA), no RB 88% SA; P = 0.61), satisfaction with consent (RB 90% SA, no RB 87% SA; P = 0.27), ease of understanding (RB 69% SA, no RB 67% SA; P = 0.73) receipt of the right amount of information regarding the indications (RB 85% SA, no RB 87%; P = 0.61), the benefits (RB 87% SA, no RB 86% SA; P = 0.29), and the risks (RB 87% SA, no RB 84% SA; P = 0.19) of surgery. More of the RB group felt they received the right amount of information about alternatives to surgery (RB 80% SA) than did the no RB group (69% SA); P = 0.01. Conclusions Patients were highly satisfied with RB during surgical IC RB is not detrimental to the consent process and may improve informed consent for surgery. Trial Registration Clinical Trials Identifier NCT00288899 http://www.clinicaltrials.gov

Patient comprehension during surgical informed consent remains problematic. Using data from our randomized trial of methods to improve informed consent comprehension, we performed an additional analysis to define independent factors associated with improved patient understanding.Patients scheduled for 1 of 4 elective operations (total hip arthroplasty [n = 137], carotid endarterectomy [n = 178], laparoscopic cholecystectomy [n = 179], or radical prostatectomy [n = 81]) at 7 Department of Veterans Affairs (VA) medical centers were enrolled. All informed consent discussions were performed using iMedConsent (Dialog Medical), the VA's computerized informed consent platform. Using a unique module within iMedConsent, we randomized patients to repeat back (RB), requiring correct reiteration of procedure-specific facts, or standard (STD) iMedConsent. Patient comprehension was tested after the informed consent discussion using procedure-specific questionnaires. Time spent completing the informed consent process was measured using time stamps within iMedConsent. Multiple linear regression identified factors independently associated with improved comprehension.We enrolled 575 patients (276 RB, 299 standard); 93% were male, 74% were Caucasian, and 89% had at least a high school education. Independent factors associated with improved comprehension included race (p0.01), ethnicity (p0.05), age (p0.02), operation type (p0.01), group assignment (+/- RB; p0.05), and total consent time (p0.0001). Patient comprehension was maximized when informed consent took between 15 and 30 minutes. RB's positive impact on patient comprehension was weaker in the analysis including consent time.Comprehension during informed consent discussions may be limited in individuals with potential language difficulty due to ethnicity or education. Total consent time was the strongest predictor of patient comprehension. Affording adequate time for informed consent discussions and using informed consent adjuncts such as RB may enhance comprehension in such individuals.

Stratigraphic records from lake sediment cores and slope deposits on Rapa Nui document prehistoric human impacts and natural environmental changes. A hiatus in sedimentation in Rano Raraku suggests that this lake basin dried out sometime after 4090–4410 cal yr BP and refilled only decades to centuries before AD 1180–1290. Widespread ecosystem changes caused by forest clearance by Polynesian farmers began shortly after the end of this drought. Terrestrial sections show a chronology of burning and soil erosion similar to the lake cores. Although changing sediment types and shifts in the pollen rain suggest that droughts occurred earlier in the Holocene, as yet there is no evidence for droughts occurring after AD 1180–1290. The timing of the agricultural colonization of Rapa Nui now seems well established at ca. AD 1200 and it was accompanied by rapid deforestation that was probably exacerbated by the island's small size, its droughty climate, and the rarity of primeval fires. Detailed records of a large interval of Rapa Nui's ecological history remain elusive due to the drought hiatus in the Rano Raraku sediment record. We find no evidence for a "rat outbreak impact" on Rapa Nui's vegetation preceding anthropogenic forest clearance.

Genital mycoplasmas are frequently found in the vaginal flora across socioeconomic and ethnic groups and have been demonstrated to be involved in adverse perinatal outcomes. Both Mycoplasma and Ureaplasma spp cause inflammation potentially leading to spontaneous preterm birth and PPROM as well as postdelivery infectious complications and neonatal infections. Herein we have provided an overview of the existing literature and supportive evidence for genital mycoplasma's role in perinatal complications. Future research will need to focus on clearly delineating the species, allowing for discrimination of their effects.

ObjectiveIn patients with prosthetic inflow (PI) grafts the proximal anastomosis of autogenous infrainguinal bypass (AIB) can be placed on the PI or on a distal native vessel in the groin. This study was performed to determine the effect of placement of an AIB proximal anastomotic site in a patient with ipsilateral PI.MethodsPatients undergoing AIB and PI between January 1990 and July 2002 were included in the study. They were classified into two groups on the basis of location of the proximal anastomosis. In group 1 the AIB proximal anastomosis was placed on the PI in the groin, whereas in group 2 the AIB proximal anastomosis was placed on a distal native groin artery. Patency, limb salvage, and patient survival in the two groups were calculated with the Kaplan-Meier method. The Cox proportional hazards model was used to determine independent risk factors affecting AIB patency.ResultsTwo hundred twenty-nine patients underwent AIB and PI. In group 1, 23 AIBs became thrombosed concurrent with 26 PI occlusions, and in group 2, 7 AIBs became thrombosed concurrent with 36 PI occlusions (P < .001). Five-year assisted primary patency, limb salvage, and patient survival in groups 1 and 2 were 50% and 75% (P < .001, log-rank test), 78% and 90% (P = .005, log-rank test), and 56% and 69% (P = NS, log-rank test), respectively. Factors independently associated with AIB occlusion are hypertension (hazard ratio [HR], 3.41; 95% confidence interval [CI], 1.65-7.05; P = .001), postoperative warfarin sodium therapy (HR, 1.86; 95% CI, 1.07-3.23; P = .03), continued smoking (HR, 1.72; 95% CI, 0.93-3.18; P = .08), AIB arising from PI (HR, 2.38; 95% CI, 1.35-4.18; P = .003), and PI occlusion (HR, 3.70; 95% CI, 2.15-6.36; P < .001).ConclusionA proximal AIB anastomosis located directly on the PI is an independent risk factor for decreased AIB patency of equal or greater importance than current smoking, hypertension, or PI occlusion. The proximal anastomosis of an AIB in a patient with an ipsilateral PI should be placed on a distal native artery.

Objective: Duplex scan surveillance (DS) for axillofemoral bypass grafts (AxFBGs) has not been extensively studied. The intent of this study was twofold: 1, to characterize the flow velocities within AxFBGs; and 2, to determine whether postoperative DS is useful in assessment of future patency of AxFBGs. Methods: We identified all patients who underwent AxFBG procedures between January 1996 and January 2001 at our combined university and Veterans Affairs hospital vascular surgical service. All grafts were performed with ringed 8-mm polytetrafluoroethylene with the distal limb of the axillofemoral component anastomosed to the hood of the femoral-femoral graft. DS was every 3 months for 1 year and every 6 months thereafter. Duplex scan results were compared in primarily patent grafts with grafts that thrombosed. Graft failures from infection were excluded. Influences of ankle-brachial index, blood pressure, outflow patency, operative indication, and comorbidities on graft patency were analyzed. Results: One hundred twenty patients underwent AxFBG procedures. Twenty-eight were excluded because of infection or death before surveillance examination. Fourteen were lost to follow-up, 23 had failed grafts from occlusion, and 55 had grafts that remained patent. In the 78 patients evaluated during long-term follow-up period, the mean peak systolic velocities (PSVs) at the proximal (axillary) anastomosis during the first postoperative year ranged from 153 to 194 cm/s. Mean PSVs at the mid portion of the axillofemoral graft during the first postoperative year ranged from 100 to 125 cm/s, whereas those for the distal axillofemoral anastomosis ranged from 93 to 129 cm/s. Mean midgraft and distal anastomotic velocities obtained before thrombosis were significantly lower in the thrombosed grafts compared with the last recorded velocities at the same sites in the patent grafts (mean PSV, 84 versus 112 cm/s; P =.015; mean PSV, 89 versus 127 cm/s; P =.024, respectively). Forty-eight percent of occluded grafts had a mean midgraft PSV at last observation of less than 80 cm/s. Blood pressure correlated with midgraft velocity (r = 0.415; P

► Cowden Syndrome is a rare hereditary cancer syndrome, which confers an increased risk of breast, thyroid, endometrial and colon cancer. ► Atypical polypoid adenomyoma does not generally represent a premalignant lesion, but must be carefully screened for foci of malignancy. ► Cancer screening must be intensified for patients who meet the diagnostic criteria for Cowden Syndrome.

Objective: We report a comprehensive review of our patients on hemodialysis with end-stage renal disease (ESRD) with finger gangrene to determine etiology, natural history, and prognosis of this condition. Methods: Patients with ESRD with finger gangrene were identified from our computerized vascular registry. Presence of an ipsilateral arteriovenous fistula was determined, and patients were compared with a group of patients with ESRD without finger gangrene. Management consisted of arteriography, selective arteriovenous fistula management, and finger amputation. A multivariate analysis to determine risk factors associated with finger gangrene was performed. Repeat finger amputation and survival rates were determined with life-table analysis. Results: Twenty-three patients (mean age at start of dialysis, 53 years) with finger gangrene were identified, with 48% (n = 11) having a functional ipsilateral arteriovenous fistula. Arteriography was consistent with diffuse atherosclerosis involving the radial, ulnar, palmar, and digital arteries precluding attempts at distal arterial bypass. Repeat finger amputations were necessitated in 52% of patients (n = 12), and bilateral finger gangrene developed in 61% of patients (n = 14). Starting dialysis at age less than 55 years (P = .0004), diabetes (P = .001), coronary artery disease (P = .0212), and lower extremity arterial occlusive disease (P < .0001) were significantly associated with finger gangrene. Conclusion: The young diabetic patient with diffuse vascular disease and ESRD is at high risk for the development of finger gangrene on chronic hemodialysis. Finger gangrene is the result of distal atherosclerosis and is not primarily related to dialysis access. (J Vasc Surg 2002;36:245-9.)

Background: Surgical revision to repair stenosis is necessary in about 20% of lower extremity vein grafts (LEVGs). Alternate conduit, especially arm vein, is often necessary to achieve a policy of all-autogenous revisions. Although basilic vein harvest necessitates deep exposure in proximity to major nerves, it typically uses a large vein unaffected by prior intravenous lines and as such appears ideally suited for revisions in which a segmental interposition conduit is needed for revision within the graft or for extension to a more proximal inflow or distal outflow site. In this report, we describe our experience with the use of the basilic vein for LEVG revisions compared with other sources of autogenous conduit. Methods: All patients who underwent LEVG were placed in a duplex scan surveillance program. LEVGs that developed a focal area of increased velocity or uniformly low velocities throughout the graft with appropriate lesions confirmed with angiography were candidates for revision. All patients who underwent graft revision with basilic vein segments from January 1, 1990, to September 1, 2001, were identified, and their courses were reviewed for subsequent adverse events (further revision or occlusion) and complications of harvest. These revisions were compared with revisions in which cephalic and saphenous vein were used. Results: One hundred thirty basilic veins were used to revise 122 LEVGs. The mean follow-up period after revision was 28 ± 27 months. Ninety-three grafts (71%) remained patent with no further revision, and 37 grafts (29%) either needed additional revisions (22 grafts) or were occluded (15 grafts). Only four of these adverse events (11%) were directly attributed to the basilic vein segment. Ten of 43 grafts revised with cephalic vein (23%) were either revised or occluded, of which three were related to the cephalic vein segment (P = not significant, compared with basilic vein). Twenty-four of 81 grafts revised with saphenous vein (30%) were either revised or occluded, of which 11 were attributed to the saphenous vein segment (P < .01, compared with basilic vein). Two patients (1.5%) had complications from basilic vein harvest (one hematoma, one arterial injury). No neurologic injuries resulted from basilic vein harvest. Conclusion: The basilic vein is a reliable and durable conduit when used to segmentally revise LEVGs. Stenoses rarely occur within interposed basilic vein segments, and excellent freedom from subsequent revision or occlusion is possible. We conclude the basilic vein can be safely harvested with minimal complications and is ideally suited for use as a short segment interposition graft for LEVG revision. (J Vasc Surg 2002;36:238-44.)

Purpose: There have been few studies of the natural history of peripheral arterial disease (PAD), and none have used serial noninvasive laboratory examinations for the objective quantification of disease progression. The relationship between the site of initial symptoms of PAD (lower-extremity disease [LED] vs cerebrovascular disease [CVD]) and the site of subsequent symptomatic progression (LED vs CVD vs coronary heart disease [CHD]) has not been examined. Methods: This is a long-term, blinded prospective clinical research study of the relationship of PAD progression to multiple clinical, laboratory, and noninvasive vascular laboratory parameters. Patients with symptomatic LED, CVD, or both underwent comprehensive risk-factor assessment and were seen every 6 months for follow-up examinations. In addition to history and physical examination, all subjects underwent serial noninvasive lower-extremity and carotid artery testing. The relationship between the initial symptomatic site(s) and subsequent progression was examined by means of multivariate proportional hazards analysis, which was adjusted for age, diabetes mellitus, hypertension, smoking, cholesterol, homocysteine level, lowest initial ankle/brachial index (ABI), worst carotid stenosis, ABI progression, and carotid stenosis progression, because each of these factors was significantly associated with one or more aspects of progression. Results: There were 397 study subjects (mean age, 66 years; 38% women) with a mean follow-up period of 48.5 months. LED was initially present in 88% of subjects and CVD in 37% of subjects (both were present in 25% of subjects). There were 78 deaths, 47 (60%) of which were caused by cardiovascular disease (18% mortality rate after 5 years by means of life table). Progression of disease as documented by means of vascular laboratory findings occurred in 90% of subjects by means of life table after 5 years (ABI progression, 31%; carotid stenosis progression, 40%). Symptomatic clinical progression of disease occurred in 52% of subjects by means of life table after 5 years (LED progression, 22%; CVD progression, 23%; CHD progression, 31%). By means of multivariate analysis, no significant relationship was found between the site of initial symptoms of PAD and the site(s) of subsequent symptomatic clinical progression (LED vs CVD vs CHD; P = not significant for all hazard ratios). Conclusion: Patients with symptomatic PAD experience symptoms of ongoing LED, CVD, and CHD with a frequency that is not influenced by the site(s) of their original symptoms. The hypothesis that lesions and resulting symptoms of systemic atherosclerosis occur at various anatomic sites as a matter of random chance should be tested with other studies. (J Vasc Surg 2002;35:38-47.)

Wound occurrence (WO) after major lower extremity amputation (MLEA) can be due to wound infection or sterile dehiscence. We sought to determine the association of nasal methicillin-resistant Staphylococcus aureus (MRSA) colonization and other patient factors with overall WO, WO due to wound infection, and WO due to sterile dehiscence.The medical records of all patients undergoing MLEA from August 1, 2011, to November 1, 2013, were reviewed. Demographic data, hemoglobin A1c level, albumin concentration, dialysis dependence, peripheral vascular disease (PVD), nasal MRSA colonization, and diabetes mellitus (DM) were examined as variables. The overall WO rate was determined, and the cause of WO was categorized as either a sterile dehiscence or a wound infection.Eighty-three patients underwent 96 MLEAs during a 27-month period. The rates of overall WO, WO due to infection, and WO due to sterile dehiscence were 39%, 19%, and 19%, respectively (1% developed a traumatic wound). On univariate analysis, PVD, MRSA colonization, DM, and dialysis dependence were all associated with higher rates of overall WO (P.05). On multivariate analysis, MRSA colonization was associated with higher rates of overall WO (P = .03) and WO due to wound infection (11% vs 45%; P.01). DM and PVD were associated with higher rates of overall WO and WO due to sterile dehiscence on both univariate and multivariate analysis (P.05).Nasal MRSA colonization is associated with higher rates of overall WO and WO due to wound infection. DM and PVD are associated with higher rates of overall WO and WO due to sterile dehiscence but are not associated with WO due to wound infection. Further studies addressing the effect of nasal MRSA eradication on postoperative wound outcomes after MLEA are warranted.

Importance Because of the similarity in clinical outcomes after elective open and endovascular repair of abdominal aortic aneurysm (AAA), cost may be an important factor in choosing a procedure. Objective To compare total and AAA-related use of health care services, costs, and cost-effectiveness between groups randomized to open or endovascular repair. Design, Setting, and Participants This unblinded randomized clinical trial enrolled 881 patients undergoing planned elective repair of AAA who were candidates for open and endovascular repair procedures. Patients were randomized from October 15, 2002, to April 15, 2008, at 42 Veterans Affairs medical centers. Follow-up was completed on October 15, 2011, and data were analyzed from April 15, 2013, to April 15, 2016, based on intention to treat. Main Outcomes and Measures Mean total and AAA-related health care cost per life-year and per quality-adjusted life-year (QALY). Results A total of 881 patients (876 men [99.4%]; 5 women [0.6%]; mean [SD] age, 70 [7.8] years) were included in the analysis. After a mean of 5.2 years of follow-up, mean life-years were 4.89 in the endovascular group and 4.84 in the open repair group ( P = .68), and mean QALYs were 3.72 in the endovascular group and 3.70 in the open repair group ( P = .82). Total mean health care costs did not differ significantly between the 2 groups (endovascular group, $142 745; open repair group, $153 533; difference, −$10 788; 95% CI, −$29 796 to $5825; P = .25). Costs related to AAA, including the initial repair, constituted nearly 40% of total costs and did not differ significantly between the 2 groups (endovascular group, $57 501; open repair group, $57 893; difference, −$393; 95% CI, −$12 071 to $7928; P = .94). Lower costs due to shorter hospitalization for initial endovascular repair were offset by increased costs from AAA-related secondary procedures and imaging studies. The probability of endovascular repair being less costly and more effective was 56.8% when effectiveness was measured in life-years and 55.4% when effectiveness was measured in QALYs for total costs and 31.3% and 34.3%, respectively, for AAA-related costs. Conclusions and Relevance In this multicenter randomized clinical trial with follow-up to 9 years, survival, quality of life, costs, and cost-effectiveness did not differ between elective open and endovascular repair of AAA. Trial Registration clinicaltrials.gov Identifier:NCT00094575

Purpose: Neurogenic thoracic outlet syndrome (NTOS) in the absence of bony and electrodiagnostic abnormalities, often referred to as disputed NTOS, remains enigmatic. Optimal treatment, especially the role of surgery, is controversial. The long-term functional outcome of a cohort of patients undergoing independent medical examination for disputed NTOS with symptoms sufficiently severe to cause inability to work forms the basis for this report. Methods: Patients with disputed NTOS and symptoms sufficiently severe to cause at least temporary inability to work seen for independent medical examinations from 1990-1998 formed the study group. None of the patients were treated by our group. Functional outcome was assessed with information from a standardized telephone interview or patient questionnaire. The patients' ability to return to work and an assessment of their current level of symptoms and symptom progression since the time of onset were determined. Results: Seventy-nine patients were reevaluated at a mean follow-up of 4.2 years (range, 2-7.5 years) after our initial evaluation. Fifteen patients (19%) underwent first rib resection surgery performed by others, whereas 64 (81%) had no surgery. Patients undergoing surgery had missed more work time than those undergoing conservative management (27.6 ± 6.0 months vs 14.9 ± 2.6 months, P

We describe clinicopathologic and immunohistochemical features of an unusual case of cystic fibrosis manifesting in the cervix as a mass lesion, mimicking cervical adenocarcinoma. A 24-year-old nulligravida with cystic fibrosis developed heavy postcoital vaginal bleeding 4 months after starting oral contraceptives and was found to have a cervical mass. She underwent a loop electrosurgical excision of the mass, and microscopic examination revealed a florid endocervical proliferation, extending to the margins. This lesion was initially interpreted as an invasive, well-differentiated endocervical adenocarcinoma. However, on subsequent review, the lesion was found to have a low rate of proliferation, no evidence of an infiltrative growth pattern, and abundant acute inflammation. Given these findings and the absence of any residual endocervical lesion on a subsequent cold knife conization, we determined that this was a benign, likely reactive, lesion. This case, together with previous studies, suggests that women with cystic fibrosis can develop proliferative endocervical lesions and that oral contraceptives may contribute to their development.

Objective: Complete revascularization is recommended by many authors for treatment of intestinal ischemia. The observation that postprandial intestinal hyperemia is limited to the superior mesenteric artery (SMA) has suggested to us that SMA revascularization alone should be adequate treatment. We preferentially manage intestinal ischemia with a single bypass graft to the SMA and herein update our results using this approach. Methods: Patients were identified from a prospectively established vascular surgical registry. Each patient was assessed for acute versus chronic intestinal ischemia, preoperative angiographic findings, operation used, perioperative morbidity and mortality, late symptomatic relief, cause of death, and life table–determined survival and graft patency. Graft patency was determined by follow-up angiography or duplex scanning. Results: Fifty bypass grafts to the SMA alone were performed in 49 patients (31 women, 18 men; mean age, 62 years) for treatment of intestinal ischemia. In all patients additional splanchnic arteries were available for bypass grafting. Operative indications were acute symptoms in 21 patients, 14 of whom had bowel infarction; chronic symptoms in 26 patients; and prophylaxis in conjunction with infrarenal aortic surgery in 3 patients. Thirty-two grafts originated from the aorta or an iliac artery, and 18 originated from an aortic graft. There were 40 prosthetic and 10 autogenous conduits. Perioperative mortality was 3% in patients with chronic symptoms and 12% overall. All survivors were symptomatically improved. Mean follow-up was 44 months. Nine-year assisted primary graft patency was 79%, and 5-year patient survival was 61%. Two late deaths occurred in patients with recurrent intestinal ischemia resulting from graft occlusions. Conclusions: Bypass grafting to the SMA alone appears to be both an effective and durable procedure for treatment of intestinal ischemia. Our results appear equal to those reported for "complete" revascularization for intestinal ischemia. When the SMA is a suitable recipient vessel, multiple bypass grafts to other splanchnic vessels are unnecessary in the treatment of intestinal ischemia. (J Vasc Surg 2000;32:37-47.)

Purpose: Duplex scanning is often the sole imaging study before carotid endarterectomy (CEA). Patients with bilateral severe internal carotid artery (ICA) stenosis may be considered for bilateral CEA. High-grade ICA stenosis, however, may artifactually elevate velocity measurements used to quantify stenosis in the contralateral ICA. It is unknown whether ipsilateral CEA will influence duplex determination of the presence of a contralateral 60% to 99% ICA stenosis. This study was performed to determine whether a single preoperative duplex scan is sufficient to plan bilateral CEA. Methods: Preoperative and early postoperative carotid duplex scans in patients with bilateral ICA stenosis who underwent unilateral CEA were reviewed. Changes in duplex scans that determined stenosis in the ICA contralateral to the CEA were analyzed. Previously validated criteria used to determine 60% to 99% ICA stenosis were a peak systolic velocity (PSV) of 260 cm/sec or more combined with an end diastolic velocity (EDV) of 70 cm/sec or more. Results: Over an 8-year period, 460 patients underwent CEA; 107 patients (23.3%) had an asymptomatic 50% to 99% contralateral ICA stenosis by standard criteria (PSV, >125 cm/sec) and an early postoperative duplex scan examination. Of these 107 patients, 38 patients (35.5%) had duplex scan criteria for 60% to 99% contralateral ICA stenosis. In these 38 patients, there was a mean postoperative PSV decrease of 47.7 cm/sec (10.1%) and a mean EDV decrease of 36.0 cm/sec (19.3%) in the ICA contralateral to the CEA. Eight of 38 (21.1%) preoperative contralateral 60% to 99% ICA lesions were reclassified as less than 60% on postoperative duplex scanning. Six of 69 (8.7%) preoperative lesions of less than 60% were reclassified as 60% to 99% on postoperative duplex scan. These six preoperative examinations were all close to the criteria for 60% to 99% stenosis (mean PSV, 232.5 cm/sec; mean EDV, 62.5 cm/sec). Conclusion: One-fifth of patients with apparent 60% to 99% contralateral ICA lesions before the operation have less than 60% stenosis when restudied with duplex scan after unilateral CEA. Lesions below but near the cutoff for 60% to 99% may be reclassified as 60% to 99% on the postoperative duplex scan. These findings mandate that when duplex scanning is used as the sole imaging modality before CEA, patients with severe bilateral carotid stenosis must have an additional carotid duplex examination before operation on the second side. (J Vasc Surg 2000;31:282-8.)

Purpose: Interest in alternative methods, such as autogenous vein grafts and aortic allografts, for the management of infrarenal aortic infection (IRAI) has been stimulated by the historically disappointing results with conventional surgical management. Recently, there have been dramatic improvements in the results of axillofemoral bypass grafting (AXFB) followed by excision of the IRAI that have gone relatively unrecognized. The purpose of this report is the presentation of modern-day results in the treatment of IRAI with conventional surgical methods. Methods: From January 1, 1983, through June 30, 1998, patients with IRAI underwent treatment with AXFB and complete excision of the IRAI. The patients were followed for survival, limb salvage, and AXFB graft patency. The results were tabulated with life-table methods. Results: During the 15-year study period, 60 patients (51 men, nine women; mean age, 68 years) underwent treatment for IRAI (50 graft infections, including 16 graft-enteric fistulae, and 10 primary aortic infections). The mean follow-up period was 41 months. The perioperative mortality rate was 13% (12% for graft infection, and 20% for primary infection). The overall 2-year and 5-year survival rates were 67% and 47%, respectively. The limb salvage rates at 2 and 5 years were 93% and 82%, respectively. The 5-year primary AXFB graft patency rate was 73%. Conclusion: These results show an improvement with the conventional management of IRAI equal or superior to those results reported with alternative methods, including femoral vein grafts or aortic allografts. These results should be regarded as the modern standard with which alternative therapies can be compared. (J Vasc Surg 1999;30:76-83.)

Diagnosis and treatment of upper extremity ischemia within the prevue of vascular surgery. It is, however, a relatively infrequently encountered problem in most vascular practices. The following exchange highlights the principles of evaluation of patients with upper extremity ischemia. In general, such patients should be evaluated for two specific questions : Is the upper extremity ischemia produced by large or small artery diseased And, if it is produced by small artery disease, is it occlusive disease or vasospastic disease? Large artery disease generally produces symptoms as a result of embolization. Large artery disease can be localized by a combination of physical examination and segmental pressures. It usually occurs in vessels proximal to the wrist and requires evaluation by angiography and eventually intervention of some type to eliminate the embolic source. Symptoms are generally unilateral. Small artery disease, by definition, occurs in vessels distal to the wrist, generally produces bilateral s...

Purpose: The Asymptomatic Carotid Atherosclerosis Study (ACAS) indicated significant benefit from endarterectomy compared with medical therapy for patients with 60% to 99% asymptomatic internal carotid artery (ICA) stenoses. To date, optimal selection of patients for vascular laboratory follow-up to determine progression from

Purpose: The antiphospholipid antibodies (APL) anticardiolipin antibodies (ACL) and lupus anticoagulant (LA) are widely believed to be associated with decreased lower extremity bypass graft patency rates. To date, no prospective cohort study has confirmed this assumption. A prospective comparison of the result of infrainguinal revascularization procedures performed since 1990 in patients with and without APL forms the basis of this report. Methods: Patients who underwent elective infrainguinal bypass procedures from 1990 to 1994 were evaluated for hypercoagulable states (ACL, LA, protein C, protein S, and antithrombin III). Patient data were prospectively entered in a computerized vascular registry, and postoperative follow-up was maintained for life. Graft patency, limb salvage, and patient survival rates were calculated by life-table methods. Results: Three hundred twenty-seven lower extremity bypass grafting procedures were performed in 262 patients. APLs were present in 83 patients (32%); 70 patients (84%) had ACLs only, 11 patients (13%) had LA only, and two patients (3%) had both ACLs and LA. There was no significant difference between APL-positive and APL-negative patients with respect to demographics, associated medical conditions, indication for operations, and type of procedures performed. More patients who had APLs had warfarin treatment after surgery (43% vs 24%, p = 0.002). Life table 4-year primary patency rates showed minimal difference (APL-positive, 43%; APL-negative, 59%; p = 0.087), and no significant difference was noted in assisted primary patency rates (APL positive, 72%; APL negative, 73%; p = NS), limb salvage rates (APL positive, 79%; APL negative, 88%; p = NS), and patient survival rates (APL positive, 67%; APL negative, 66%; p = NS). Conclusions: APLs were found in a surprising one third of the patients who underwent leg bypass grafting procedures. The majority of APLs identified were ACLs (87%). There was minimal difference in graft primary patency rates, and no difference in assisted primary patency, limb salvage, and survival rates between patients with and without APLs who underwent leg bypass grafting procedures. The extreme morbidity rate associated with APLs in previous reports is not confirmed by this prospective study. APLs should not be regarded as a contraindication to indicated leg bypass grafting procedures. (J Vasc Surg 1996;24:524-33.)

Purpose: Knowledge of the long-term clinical outcome of Raynaud's syndrome (RS), essential both for patient counselling and formulation of optimal therapeutic recommendations, is conspicously deficient in current medical literature. We have prospectively monitored 1039 patients with RS, 118 (11.4%) for more than 10 years to determine whether initial characterization was able to predict outcome. Methods: At initial presentation, patients were divided into four groups on the basis of vascular laboratory and serologic testing results: vasospatic, serologically positive (spast,sero+) and negative (spast,sero-) and obstructive, serologically positive (obst,sero+) and negative (obst,sero-). Results: Connective tissue disease (CTD) was present initially in 48.6% of patients with spast,sero+ results and 72.9% of patients with obst,sero+ results. Of the remaining patients in these groups, progression to CTD during follow-up occurred in 16.4% of patients with spast,sero+ results and 30.4% of patients with obst,sero+ results. In the >10-year follow-up group, progression to CTD occurred in 81.8% of patients in the obst,sero+ group. Progression to CTD occurred in 2.0% of patients in the spast,serogroup and 8.5% of patients in the obst,sero- group. Digital ulcers occurred in 15.5% of patients in the spast,sero+ group, 5.2% of patients in the spast,sero- group, 55.6% of patients in the obst,sero+ group and 48.2% of patients in the obst,sero- group. Digital or phalangeal amputations were required in 1.4%, 1.6%, 11.6%, and 19.0% of these patients, respectively. Conclusions: The long-term outcome of patients with RS can be predicted by initial serologic studies and separation into vasospastic and obstructive categories. Initial serologic positivity strongly predicts the development of CTD. Initial vascular laboratory classification of obstructive RS strongly predicts digital ulcerations, which occurred in half of these patients regardless of initial serologic study results. Amputations were required in 10% to 20% of patients with obstructive RS. These occurrences did not increase with increased duration of disease. Ulcerations and amputations were rare in patients initially with vasospastic RS.

Purpose: Patients undergoing lower extremity amputation are perceived to be at high risk for deep vein thrombosis (DVT). Limited data are available, however, to confirm this impression. The purpose of this study is to prospectively document the incidence of DVT complicating lower extremity amputation. Methods: During a recent 28-month period, 72 patients (71 men, 1 woman; mean age 68 years) undergoing major lower extremity amputation (31 above-knee and 41 below-knee) were prospectively evaluated with perioperative duplex scanning for DVT. Results: DVT was documented in nine (12.5%) patients (one bilateral, four ipsilateral, and four contralateral to amputation). Patients with a history of venous disease were at significantly higher risk for development of DVT ( p = 0.02). Thrombi were located at or proximal to the popliteal vein in eight patients and were isolated to the tibial veins in one patient. DVT was identified before operation in six patients and after operation in three. Patients with DVT were treated with heparin anticoagulation, with no patient experiencing clinical symptoms compatible with pulmonary embolism. Conclusions: In our recent experience, lower extremity amputation is associated with DVT at or proximal to the popliteal vein in 11% of patients. Documentation of DVT prevalence is essential to assist surgeons in planning a management strategy for prevention, diagnosis, and treatment of DVT associated with lower extremity amputation. (J VASC SURG 1995;22:612-5.)

The long-term clinical outcome of patients diagnosed with digital artery obstruction and symptomatic hand ischemia is largely unknown. Our long-term experience with the diagnosis of symptomatic digital artery obstruction and the long-term natural history of this condition forms the basis for this report.From 1971 to 1985, 44 patients with symptomatic hand ischemia and palmar or digital arterial obstruction underwent arteriography and digital photoplethysmography (PPG). Patients were grouped according to severity of hand ischemia symptoms, including ulceration and digital amputation and the presence of a connective tissue disease (CTD). Arteriography was compared with PPG by creating an objective severity scale (digital obstruction index [DOI]).Average follow-up was 15.2 years (range 10 to 22 years). Initially 21 patients (48%) had moderate symptoms, and 23 patients (52%) had severe symptoms of hand ischemia. Follow-up symptoms in 28 patients improved (13 of 26 with CTD, 15 of 18 without CTD), in 15 patients (12 of 26 with CTD, 3 of 18 without CTD) remained unchanged, and in only 1 patient (1 of 26 with CTD) worsened. Seventeen (65%) patients with CTD (n = 26) had development of one or more ulcers, and six (24%) underwent one or more digital amputations. Four (22%) patients without CTD (n = 18) had finger ulceration (p0.012 compared with patients with CTD), and one patient (6%) underwent subsequent digital amputation (p = NS). The arteriography-DOI and PPG-DOI were equally accurate in determining severity of finger ischemia as manifested by severity of symptoms or ulcer development.The favorable long-term prognosis of symptomatic finger artery occlusion described herein mandates the avoidance of premature finger amputation. Patients with CTD fare worse, but even in this group tissue loss is modest. Finger PPG is as accurate as arteriography for determining severity of hand ischemia.

Objectives To compare patient outcomes of primary open operation for aortoiliac occlusive disease (AIOD) with those of secondary open operations for failed endovascular therapy (ET) of AIOD. Design A retrospective cohort study was performed analyzing demographic characteristics, comorbidities, and outcomes. Setting Affiliated Veterans Affairs Hospital from January 1, 1998, through March 31, 2010. Patients Patients who underwent primary open operation for AIOD or secondary open operation for failed ET of AIOD. Main Outcome Measures Overall survival and limb salvage. Results Primary open operations (n = 153) were 67 aortobifemoral grafts (43.8%), 38 axillobifemoral grafts (24.8%), and 48 femoral-femoral grafts (31.4%). Secondary open operations (n = 35) were 28 aortobifemoral grafts (80.0%), 5 axillobifemoral grafts (14.3%), and 2 femoral-femoral grafts (5.7%). Mean (SD) 5-year survival was 48.2% (5.6%) and 66.8% (10.0%), respectively, for patients undergoing primary vs secondary open surgery for AIOD (P = .01). There were 7 amputations during a mean follow-up of 3 years, all in the primary open surgery group. Conclusions Despite a higher proportion of coronary artery disease and a 20% conversion of claudication to critical limb ischemia after failed ET for AIOD, survival was longer in patients undergoing secondary vs primary open surgery. Patients who underwent open surgery after failed ET for AIOD did not require amputation. Failed ET for AIOD does not lead to worse outcomes for patients undergoing open surgery for AIOD.

Purpose: Revascularization for chronic lower extremity ischemia (CLEI) in patients 80 or more years of age is controversial. High operative mortality, short remaining life span, and nonambulatory nursing home existence are cited as frequent outcomes in this patient group. Despite these considerations we have maintained an aggressive policy of lower extremity revascularization in functional and potentially functional patients 80 or more years of age with limb-threatening ischemia or claudication sufficient to threaten their independence. Methods: The records of all patients 80 or more years of age who underwent lower extremity revascularization for CLEI from 1981 through 1991 were reviewed. Patients were evaluated for surgical indication, perioperative mortality, late survival, graft patency, and limb salvage. In addition, the patient's preoperative and postoperative independence determined by living situation (home versus nursing home) and ambulatory status were examined. Results: During the period reviewed 88 patients 80 or more years of age underwent 95 arterial reconstructions for CLEI; 95% for limb salvage and 5% for short-distance claudication. There were 81 (85%) infrainguinal bypasses and 14 (15%) extraanatomic bypasses, 5 of which also included a simultaneously placed infrainguinal bypass. The perioperative mortality rate was 6%. Mean hospitalization was 18 days (range 6 to 62). The 1- and 3-year primary graft patency rates were 88% and 66%, limb salvage rates 94% and 91%, and patient survival rates 73% and 51%, respectively. One year after operation 88% of patients were ambulatory, 85% were living at home, and 80% were both living at home and ambulatory. At 3 years these results were 86%, 76%, and 71%, respectively. Of the patients living at home and ambulatory before operation, 100% and 84% of survivors were still living at home and ambulatory 1 and 3 years after operation. Of patients living at home who had late graft occlusions, 67% required amputation and subsequent nursing home placement. Conclusion: Although survival in this group is predictably lower than that of age-matched control subjects, octogenarians have satisfactory 1- and 3-year graft patency, limb salvage, and functional results. Revascularization for CLEI in patients 80 or more years of age is appropriate and results in maintenance of independent living in a large majority. (J VASC SURG 1993;18:618-26.)

Animal models have been used to assess the function of vascular smooth muscle and endothelium of veins grafted into arterial circulation. The primary model consists of grafting the external jugular vein into the carotid artery of the rabbit. These studies suggest a selective increase in the responsiveness of the grafted veins to serotonin. However, in both human cardiac and peripheral vascular operations, the saphenous, not the jugular, is the vein most frequently used. Thus the propriety of the rabbit model is unknown.Human saphenous veins and vein grafts were obtained from patients undergoing leg vein bypass graft revisions (n = 8). The reversed vein grafts were placed into arterial circulation for periods ranging from 4 to 26 months before removal (mean 16 months). All vessels were immediately cut into rings and suspended in organ chambers for recording isometric contractions to norepinephrine and serotonin.The maximal contractions elicited by both norepinephrine and serotonin were reduced in human vein grafts in comparison to the results in human saphenous vein (maximal response to norepinephrine 1.42 +/- 0.34 gm [vein graft] vs 4.59 +/- 1.13 gm [saphenous vein], p = 0.031; maximal response to serotonin 2.68 +/- 0.58 gm [vein graft] vs 4.72 +/- 1.11 gm [saphenous vein], p = 0.042). Human vein grafts were less responsive to norepinephrine than was saphenous vein (negative log of concentration that caused 50% of the maximal response -5.91 +/- 0.10 and -6.84 +/- 0.22, respectively; p0.009). After precontraction with norepinephrine (to 30% of the maximal response), saphenous vein, but not vein grafts, demonstrated endothelium-dependent relaxation to acetylcholine (maximum relaxation 27.4% +/- 6.8%; p = 0.001).Human saphenous veins grafted into arterial circulation exhibit loss of endothelium-dependent relaxation to acetylcholine and diminished contractions to agonists (norepinephrine and serotonin). In contrast to rabbit data, serotonin elicits dose-dependent contractions in both human saphenous vein and human vein grafts. Since the vascular wall contractility varies widely across species, the relevance of rabbit vein graft data to human bypass grafts is uncertain.

Purpose: The North American Symptomatic Carotid Endarterectomy Trial (NASCET) has thus far demonstrated conclusive benefit for carotid endarterectomy for patients with symptomatic 70% to 99% internal carotid artery (ICA) stenosis. In the NASCET, ICA stenosis was classified angiographically: % ICA stenosis=(1—[narrowest ICA diameter/diameter normal distal cervical ICA]) × 100%. However, widely used duplex scan criteria for ICA stenosis correlate with different angiographic categories of high-grade stenosis (50% to 79%, >80%) and were developed on the basis of estimated bulb diameter. We therefore blindly evaluated with separate observers carotid angiograms from 100 patients who also underwent carotid duplex scanning in our vascular laboratory. Methods: "Angiographic stenosis" was calculated as in NASCET. Duplex scan measurements of ICA peak systolic velocity (PSV), ICA end-diastolic velocity, and the ratio of ICA PSV to common carotid artery (CCA) PSV were analyzed for sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy to identify a 70% to 99% ICA stenosis. Results: Analysis of the data revealed that an ICA PSV/CCA PSV ratio of 4.0 provided the best combination of sensitivity (91%), specificity (87%), positive predictive value (76%), negative predictive value (96%), and overall accuracy (88%) for detection of a 70% to 99% stenosis. Conclusion: We conclude duplex scan determination of 70% to 99% stenosis as defined in the NASCET requires the adoption of duplex criteria modified from those in current use in most vascular laboratories. (J VASC SURG 1993;17:152-9.)

In this randomized, controlled, unblinded trial, we sought to test Repeat Back's (RB) effect on comprehension following informed consent discussions.RB has been suggested as a method to improve patient comprehension when obtaining informed consent. In this technique, patients are asked to recount what they have been told in the informed consent discussion. Despite preliminary data, this practice has not been evaluated in any large scale study.This study was conducted in 7 Veterans Health Administration Medical Centers where informed consent is obtained using iMedConsent, the VA's computer based platform. Patients scheduled for elective surgeries were randomized to RB (a module added to the iMedConsent package) or standard iMedConsent (no RB). Comprehension was tested after the informed consent using procedure-specific questionnaires. Time stamps in the iMedConsent program estimated the time spent completing the informed consent process. Provider and patient satisfaction were measured using 5-point Likert scales. Statistical comparisons of groups were performed using t-tests and chi tests.A total of 575 patients were enrolled. In the RB group, providers spent 2.6 minutes longer (P0.0001) obtaining informed consent. The mean comprehension score was significantly higher in the RB group (71.4%) versus the no RB group (68.2%, P = 0.03); the effect was greatest in carotid endarterectomy patients (RB = 73.4% vs. no RB = 67.7%, P = 0.02). Quality of decision making was rated similarly. Providers were neutral to slightly favorable regarding RB.RB implemented within an electronic informed consent system improved patient comprehension. The additional time required was acceptable to providers. RB should be considered as an enhancement to surgical informed consent.This clinical trial was registered at http://www.clinicaltrials.gov (Identifier NCT00288899).

The authors describe Charlottesville Health Access (CHA), an initiative to get people who are homeless into the health care system. A community homeless shelter worked with faculty and students from the Univ. of Virginia Schools of Medicine and Nursing to create and run the program.

Renal artery fibromuscular dysplasia is a well-known cause of hypertension whose presence is confirmed by its typical arteriographic appearance. The functional significance of these lesions is often difficult to determine, particularly when both renal arteries are involved. Duplex scanning has been shown to be accurate for the detection of renal artery stenosis and estimation of the degree of narrowing. To test whether duplex scanning results after intervention correlate with clinical outcome, we reviewed the studies on nine patients with renal artery fibromuscular dysplasia who had been treated by either angioplasty or surgery. A total of 18 arteries were treated. Fourteen of the 18 treatments were successful as measured by a reduction in blood pressure and antihypertensive drugs. In four instances treatment was unsuccessful. For those patients who had clinical improvement, the hemodynamic parameters from the renal artery also improved. In the patients for whom treatment failed, the velocities recorded from the site of narrowing did not improve after intervention. Thus it appears that duplex scanning along with the clinical results may be used to document the basis for failing to improve after treatment be it angioplasty or operation. (J Vasc Surg 1992;15:604–11.)

Although the reported incidence of intraabdominal paraanastomotic aneurysms after abdominal aortic bypass grafting ranges from 1% to 15%, the true incidence is unknown because few studies have used routine, serial radiographic or sonographic imaging studies. Since July 1, 1988, we have used yearly abdominal sonography examinations to monitor our patients with aortic grafts. In the first 33 months we studied 138 patients. Medical records of 111 of these were available for review and form the basis of this report. Eleven patients (10%) were found to have intraabdominal paraanastomotic aneurysms ranging in overall size from 4.1 to 6.2 cm (mean, 5.0 ± 0.7 cm). The mean time between operation and detection of an aneurysm was 144 ± 101 months (range, 8 to 336 months). Three paraanastomotic aneurysms occurred within 3 years of operation, and the remaining eight occurred late (7 to 28 years). By life-table analysis, the incidence of paraanastomotic aneurysms was 27% at 15 years. Paraanastomotic aneurysms were classified as either pseudoaneurysms (presumed disruption of the anastomotic suture line, n = 7) or as true aneurysms (widening of the adjacent aorta, n = 4). True aneurysms occurred only after repair of an abdominal aortic aneurysm, whereas pseudoaneurysms were more frequent after bypass for occlusive disease. The finding of paraanastomotic aneurysms in 10% of our patients supports the use of yearly sonography for routine follow-up after aortic grafting. (J Vasc Surg 1992;15:344–53.)