Search

Objective: The preponderance of existing literature for the treatment of Paget-Schroetter syndrome (PSS) advocates clot lysis followed by thoracic outlet decompression (TOD). We postulate that long-term anticoagulation has equal outcomes to more invasive and costly surgical intervention, and review our experience with non-operative management of PSS., Methods: A retrospective review was conducted, examining patients between 1994-2014. Forty patients were identified with PSS, and 27 of these patients had sufficient follow-up for this analysis. Charts were reviewed for details of clinical presentation, disease course, interventions, duration of oral anticoagulation, ultrasound reports, and symptoms at long-term follow-up., Results: With a mean follow-up of 54.3 months, 23/27 patients (85%) were asymptomatic after non-operative therapy. In this cohort, 16/27 patients (59%) underwent catheter-directed thrombolysis. Average treatment course with oral anticoagulation was 8.6 months. Four patients (15%) remained symptomatic at follow-up. Two patients (7%) underwent thoracic outlet decompression at another institution, with good results. At least partial recanalization of vessels was documented in 25/27 patients (93%), although recanalization did not correlate with symptoms at long-term follow-up., Conclusions: Based upon equivalent functional results, non-operative management appears to offer similar outcomes for some patients with PSS. We propose a patient-tailored approach to the treatment of PSS, in which patients presenting acutely undergo catheter-directed thrombolysis, followed by a 6-12 month course of oral anticoagulation. Persistent symptoms, recurrent disease, lengthy duration of symptoms prior to diagnosis, and identifiable structural abnormalities may be factors predictive of poor outcomes after non-operative intervention.

Background and Purpose: Statins are neuroprotective in a variety of experimental models of cerebral injury. We sought to determine whether patients taking statins before asymptomatic carotid endarterectomy exhibit a lower incidence of neurological injury (clinical stroke and cognitive dysfunction)., Methods: A total of 328 patients with asymptomatic carotid stenosis scheduled for elective carotid endarterectomy consented to participate in this observational study of perioperative neurological injury., Results: Patients taking statins had a lower incidence of clinical stroke (0.0% vs 3.1%; P=0.02) and cognitive dysfunction (11.0% vs 20.2%; P=0.03). In a multivariate regression model, statin use was significantly associated with decreased odds of cognitive dysfunction (odds ratio, 0.51 [95% CI, 0.27-0.96]; P=0.04)., Conclusions: Preoperative statin use was associated with less neurological injury after asymptomatic carotid endarterectomy. These observations suggest that it may be possible to further reduce the perioperative morbidity of carotid endarterectomy. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00597883.

Purpose: To report the frequency of endoleaks after endovascular aneurysm repair (EVAR) with the AneuRx graft., Material and Methods: The study group included 121 consecutive patients treated with the first-generation AneuRx graft before December 2005, which ensured a potential minimum follow-up of 5 years., Results: Thirty-seven patients (31%) had 45 different endoleaks at varying times in their follow-up. There were 18 type I endoleaks (15%), 56% of which developed more than 5 years after EVAR. All 12 type Ia endoleaks were associated with dilation of the neck of the aneurysm by a mean of 8.5 mm at a median follow-up of 4 years. Ten of the 12 type Ia endoleaks were judged to have very favorable necks for EVAR. Five additional patients being followed had documented neck dilation and/or migration without evidence of endoleak or aneurysm enlargement. All type II endoleaks were noted in the first 2 years, and one persisted untreated for 9 years., Conclusions: Type I endoleaks continue to appear over time, and 56% occurred at 5 years or later after EVAR. All were associated with dilation at the attachment site, and all type Ia endoleaks had migration. As type Ia endoleaks may not always be amenable to endovascular repair, EVAR should be considered a less attractive option for some patients whose life expectancy is predicted to exceed 10 years., (Copyright © 2011 SIR. Published by Elsevier Inc. All rights reserved.)

Objective: To describe our experience with a single-incision laparoscopic cholecystectomy (SILC) performed using a flexible endoscope as the means of visualization and surgical dissection. The use of flexible endoscopy in intra-abdominal surgery has never been described., Design: Prospective observational case series., Patients: Eleven patients with symptomatic cholelithiasis were selected based on age, clinical presentation, body habitus, and history of previous abdominal surgery. Patients with acute or chronic cholecystitis were excluded., Results: All procedures were completed laparoscopically via the single umbilical incision without the need to convert to an open operation and without introduction of any additional laparoscopic instruments or trocars. The mean operative time was 149.5 minutes (range, 99-240 minutes). The mean length of hospital stay was 0.36 days. There were no associated intraoperative or postoperative complications., Conclusions: In our experience, SILC performed with a flexible endoscope is feasible and safe. Further studies are needed to determine its advantages in reference to postoperative pain and complication rate in juxtaposition with the current standard laparoscopic cholecystectomy.

Background: A hypothetical advantage of the da Vinci console is its ability to integrate multiple visual data sources. Current platforms for augmented reality surgery fuse pre-operative radiographic studies but are limited with their ability to update with intra-operative imaging. The aim of our study was to evaluate the feasibility of real-time radiographic image overlay with current technology., Methods: S-video composite output from a fluoroscopic C-arm was superimposed onto the video output of the da Vinci device. Image superimposition disparity measurements were evaluated in a bench model. The feasibility of robotic dissection assisted by real-time cholangiogram and intravenous pyelogram was evaluated., Results: Image alignment resulted in a radiographic blind spot and image disparity with severely limited application in an in vivo model., Conclusions: External collisions of the robotic device and visual disparity in multiple planes negate the current implementation of fluoroscopic overlay and will require more elegant methods of computer-assisted registration.

Background: A subset of patients who undergo video-assisted thoracoscopic sympathectomy for hyperhydrosis develop post-procedure compensatory sweating that is perceived as more debilitating than their initial complaints. We propose a novel treatment to reverse sympathectomy by implantation of an intercostal nerve graft using the da Vinci robot., Methods: A robotic swine model was established using single-lung ventilation and four ports. The pleura was incised and a representative segment of sympathetic chain was transected. A nearby intercostal nerve was harvested and sutured to the sympathetic chain using four interrupted 10-0 nylon sutures on the epineurium., Results: The intercostal nerve was an excellent size match and post-procedure necropsy yielded successful anastomoses without apparent complications., Conclusions: Robotic intercostal nerve grafting for reversal of thoracic sympathectomy is technically feasible. The robotic device allows the principles of neural microsurgery to be maintained and provides a minimally invasive option for reconstruction of the sympathetic chain.

Objective: Neurocognitive dysfunction has been shown to occur in roughly 25% of patients undergoing carotid endarterectomy (CEA). Despite this, little is known about the mechanism of this injury. Recently, several groups have shown that new diffusion weighted imaging (DWI)-positive lesions are seen in 20% of patients undergoing CEA. We investigated to what degree neurocognitive dysfunction was associated with new DWI lesions., Methods: Thirty-four consecutive patients undergoing CEA were subjected to pre- and postoperative cognitive evaluation with a battery of neuropsychological tests. Postoperative magnetic resonance imaging was performed in all patients within 24 hours of surgery. Lesions that showed high signal on DWI and restricted diffusion on apparent diffusion coefficient maps but no abnormal high signal on the fluid-attenuated inversion recovery images were considered hyperacute., Results: Cognitive dysfunction was seen in eight (24%) patients. New hyperacute DWI lesions were seen in three (9%). Only one (13%) of the patients with cognitive dysfunction had a new DWI lesion. Two thirds of the new DWI lesions occurred in the absence of cognitive deterioration. Patients with cognitive dysfunction had significantly longer carotid cross-clamp times., Conclusion: Neurocognitive dysfunction after CEA does not seem to be associated with new DWI positive lesions.

We sought to study our mid-term outcomes and our patient's perceptions of robotically-assisted coronary artery bypass (RACAB). The daVinci robotic system was utilized to harvest and prepare the internal thoracic artery (ITA) as well as to open the pericardium and identify the target vessels. Anastomoses were performed by hand on the beating heart through limited incisions using an endoscopic stabilizing device. A follow-up telephone interview was conducted with patients at 3 to 6 months. Between 4/12/02 and 11/1/04, 37 patients underwent RACAB (1.2 distal anastomoses/patient). Median length of stay was 3 days (2-14 days) and 82% of patients reported full return to baseline activity within 10 days of surgery. There were two early LITA complications and one late anastomotic stenosis all of which occurred within the first two cases of each surgeon's experience. The majority of patients surveyed (95%) knew that robotics were involved in their surgery and most patients (95%) would recommend RACAB (95%). RACAB is an effective minimally invasive revascularization technique with excellent recovery times and high patient satisfaction. The early complication rate emphasizes the steep learning curve for this procedure as well as the need for intensive pre-procedure training.

Background: There currently exist several training modules to improve performance during video-assisted surgery. The unique characteristics of robotic surgery make these platforms an inadequate environment for the development and assessment of robotic surgical performance., Methods: Expert surgeons (n=4) (>50 clinical robotic procedures and >2 years of clinical robotic experience) were compared to novice surgeons (n=17) (<5 clinical cases and limited laboratory experience) using the da Vinci Surgical System. Seven drills were designed to simulate clinical robotic surgical tasks. Performance score was calculated by the equation Time to Completion + (minor error) x 5 + (major error) x 10. The Robotic Learning Curve (RLC) was expressed as a trend line of the performance scores corresponding to each repeated drill., Results: Performance scores for experts were better than novices in all 7 drills (p<0.05). The RLC for novices reflected an improvement in scores (p<0.05). In contrast, experts demonstrated a flat RLC for 6 drills and an improvement in one drill (p=0.027)., Conclusion: This new drill set provides a framework for performance assessment during robotic surgery. The inclusion of particular drills and their role in training robotic surgeons of the future awaits larger validation studies.

Background: Simulated environments present challenges to both clinical experts and novices in laparoscopic surgery. Experts and novices may have different expectations when confronted with a novel simulated environment. The LapSim is a computer-based virtual reality laparoscopic trainer. Our aim was to analyze the performance of experienced basic laparoscopists and novices during their first exposure to the LapSim Basic Skill set and Dissection module., Methods: Experienced basic laparoscopists (n=16) were defined as attending surgeons and chief residents who performed >30 laparoscopic cholecystectomies. Novices (n=13) were surgical residents with minimal laparoscopic experience. None of the subjects had used a computer-based laparoscopic simulator in the past. Subjects were given one practice session on the LapSim tutorial and dissection module and were supervised throughout the testing. Instrument motion, completion time, and errors were recorded by the LapSim. A Performance Score (PS) was calculated using the sum of total errors and time to task completion. A Relative Efficiency Score (RES) was calculated using the sum of the path lengths and angular path lengths for each hand expressed as a ratio of the subject's score to the worst score achieved among the subjects. All groups were compared using the Kruskal-Wallis and Mann-Whitney U-test., Results: Novices achieved better PS and/or RES in Instrument Navigation, Suturing, and Dissection (p<0.05). There was no difference in the PS and RES between experts and novices in the remaining skills., Conclusion: Novices tended to have better performance compared to the experienced basic laparoscopists during their first exposure to the LapSim Basic Skill set and Dissection module.

Late aneurysm formation is a well-described complication after surgical correction of aortic coarctation. Endovascular repair of such aneurysms avoids the morbidity of conventional reoperative thoracic surgery. We describe a unique case of antegrade endovascular repair of a distal coarctation-associated aneurysm with vascular access acquired through the aortic arch by an upper hemi-sternotomy.

Background: Although subtle cognitive injury as revealed by neuropsychological testing occurs in a substantial number of patients following carotid endarterectomy (CEA), there is controversy about whether this finding is a result of the surgery or the anesthesia., Objectives: To examine the changes in neuropsychological test performance in patients following CEA vs a control group of patients older than 60 years following spine surgery, so as to determine whether neuropsychological dysfunction after CEA is a result of surgery or anesthesia., Methods: Patients undergoing CEA (n = 80) and lumbar spine surgery (n = 25) were assessed with a battery of neuropsychological tests preoperatively and on postoperative days 1 and 30. The neuropsychological performance of patients in the control group was used to normalize performance for patients in the CEA group, by calculating z scores using the mean and SD of the change scores in the control group. Significant cognitive dysfunction was defined as performance that exceeded 2 SDs above the mean performance of patients in the control group., Results: Postoperative days 1 and 30 total deficit scores were significantly worse in the CEA group compared with the controls. When individual test results were examined, the CEA group performed significantly worse than the controls on the Rey Complex Figure test and Halstead-Reitan Trails B on day 1, and on the Rey Complex Figure on day 30. Overall, cognitive dysfunction was seen in 22 patients (28%) in the CEA group on day 1 and in 11 (23%) of 48 patients on day 30., Conclusions: Subtle cognitive decline following CEA occurs and persists for at least several weeks after surgery. This decline was absent in a control group.

The experience with the use of endovascular covered stents for aortic lesions has been growing. The early results of using endovascular covered stents for the exclusion of thoracic and infrarenal abdominal aortic aneurysms have been promising and are being investigated in multiple ongoing trials. Their usage for other aortic lesions has been reported sporadically, often as resourceful options in unusual and difficult clinical situations. The authors report a patient who had previously undergone resection of a thoracic aortic sarcoma and subsequently presented in extremis from an aortobronchial fistula. The evaluation and treatment of an aortic sarcoma and the successful urgent exclusion of an aortobronchial fistula through use of an endovascular covered stent are discussed.

Objective: This study compares vascular closure staples (VCSs) with conventional sutures in the rabbit carotid vein graft model to determine whether anastomotic technique affects cellular proliferation, blood velocity, or intimal changes when measured over a period of 3 months postoperatively., Methods: Twenty-six New Zealand White rabbits weighing 3.0-3.2 kg underwent interposition of jugular vein grafts in left carotid arteries. Half of the animals had anastomoses performed with small VCSs (n = 13) and half had anastomoses performed with 8-O interrupted polypropylene suture. Animals were allowed to survive for 1 week (n = 4, VCS; n = 4, suture), 2 weeks (n = 4, VCS; n = 4, suture), and 3 months (n = 5, VCS; n = 5, suture). The peak systolic velocity (PSV) at the distal anastomosis was measured after completion of the graft and again at sacrifice in the 3-month survival groups. At sacrifice, sections were taken from the middle and distal end of the vein graft and the distal carotid artery. Vascular cell proliferation was measured using 5-bromo-2'-deoxyuridine labeling and intimal changes were measured using digitized microscopic images., Results: All 26 grafts were open at the time of sacrifice. PSV at the distal clipped anastomosis was 40.52 cm/s (t = 0) and 34.3 cm/s (t = 3 months, P = 0.31). PSV at the distal sutured anastomosis was 38.30 cm/s (t = 0) and 39.23 cm/s (t = 3 months, P = 0.82). There was no difference between the two techniques at either t = 0 or t = 3 months (P = 0.51 and P = 0.31, respectively). Endothelial cell proliferation and smooth muscle cell proliferation at the anastomosis was highest during the 2 weeks after the procedure, then returned to baseline levels by 3 months. But there was no significant difference between the clipped and sutured groups with respect to vascular cell proliferation postoperatively. The intimal thickness changed significantly in the vein graft at the anastomosis for both the clipped and sutured groups (P = 0.0007 and P = 0.002). But there was no difference when the intimal changes for each technique were compared (P = 0.94)., Conclusion: No differences were observed when peak systolic velocity, vascular cell proliferation, and intimal changes were compared between sutured and stapled anastomoses in rabbit vein interposition grafts over a period of 3 months after surgery., (Copyright 2000 Academic Press.)

Vitamin A and its derivatives (retinoids) are capable of inhibiting vascular smooth muscle cell proliferation in vitro. The present study examines the effect of two retinoids, all-trans retinoic acid and 13-cis retinoic acid, on intimal hyperplasia following arterial injury. After receiving varying doses of all-trans retinoic acid or 13-cis retinoic acid, 78 male Sprague-Dawley rats underwent standard balloon catheter denudation of the left common carotid artery. Morphometric analysis and immunohistochemistry for proliferating cell nuclear antigen was performed at early and late time points. Intimal/medial ratios were reduced in a dose-dependent fashion for animals treated with all-trans retinoic acid (P = 0.001) and 13-cis retinoic acid (P = 0.004). Proliferating cell nuclear antigen labeling indices were reduced after treatment with all-trans retinoic acid and 13-cis retinoic acid at early time points post-injury. At a dose of 10 mg/kg, both all-trans retinoic acid and 13-cis retinoic acid inhibited vessel remodeling as measured by increases in luminal diameter (P < 0.05) and external elastic lamina (P < 0.05). Retinoids are an attractive clinical option for the treatment of restenosis following angioplasty and arterial surgery.

True aneurysms of the axillary artery and its branches are rarely identified. Our recent experience with successful repairs of symptomatic aneurysms of the axillary arteries at the origin of the circumflex humeral arteries in 2 major league baseball pitchers suggests a condition that may be more common than recognized previously. We report this unique experience with baseball pitchers to focus attention on a condition that should be considered in all athletes with hand pain, numbness, or signs of digital ischemia. In addition, a schedule of rehabilitation and the timing of an appropriate return to competition is presented.

Background and Purpose: One hundred twelve patients undergoing elective carotid endarterectomy for symptomatic and asymptomatic carotid artery stenosis were enrolled in a prospective study to evaluate the incidence of change in postoperative cerebral function., Methods: Patients were evaluated preoperatively and postoperatively before hospital discharge and at follow-up 1 and 5 months later with a battery of neuropsychometric tests. The results were analyzed by both event-rate and group-rate analyses. For event-rate analysis, change was defined as either a decline or improvement in postoperative neuropsychometric performance by 25% or more compared with a preoperative baseline., Results: Approximately 80% of patients showed decline in one or more test scores, and 60% had one or more improved test scores at the first follow-up examination. The percentage of declined test scores decreased and the percentage of improved test scores increased with subsequent follow-up examinations. Group-rate analysis was similar for group performance on individual tests. However, a decline in performance was seen most commonly on verbal memory tests, and improved performance was seen most commonly on executive and motor tests., Conclusions: Neuropsychometric evaluation of patients undergoing carotid endarterectomy for significant carotid artery stenosis demonstrates both declines and improvements in neuropsychometric performance. The test changes that showed decreased performance may be associated with ischemia from global hypoperfusion or embolic phenomena, and the improvement seen may be related to increased cerebral blood flow from removal of stenosis.

Induced thrombosis ("nonresective" therapy) of aortic aneurysms by distal arterial ligation, coil/wire embolization, and extraanatomic bypass was devalued by anecdotal reports emerging during the mid-1980s. Nevertheless, we have recently found the technique to be life-saving in occasional cases and worth revisiting. Since 1990, standard aortic aneurysm repair has been performed in 231 patients (99.1% survival), endovascular aortic aneurysm repair in 6 patients (83.3% survival), and combined surgical/interventional "nonresective" repair of a variety of aneurysms in 10 patients (100% survival). Mean age of the group was 67.9 years. Repair was performed for aortoiliac aneurysms (4), common iliac aneurysms (3), internal iliac aneurysms (2), and a large proximal subclavian artery pseudoaneurysm (1). Four of the patients had been explored and declared to be "inoperable" (retroperitoneal fibrosis) prior to transfer to the Columbia-Presbyterian Medical Center. All patients survived. Aneurysm rupture has not occurred in any patient, but one patient with a presumably thrombosed subclavian pseudoaneurysm presented 26 months postcoil-induced thrombosis with progressive aneurysm enlargement due to incomplete aneurysm thrombosis and required repair using circulatory arrest. Eight of the patients remain alive (80%) at a mean follow-up of 40.3 months (range 14-88 months). Two patients died of malignancy (30 months) and cardiac disease (15 months). It is concluded that combined surgical/interventional techniques can be life-saving in the rare instances when conventional or endovascular aneurysm repair is not advisable but that complete aneurysm thrombosis is essential and occasionally difficult to achieve. Since small proximal portions of the aneurysm may remain patent and not be visualized on magnetic resonance imaging (MRI) or computed tomography (CT) scans, contrast angiographic documentation of complete aneurysm thrombosis is essential prior to hospital discharge and close follow-up is necessary to ascertain long-term adequacy of the repair. Incomplete thrombosis is suspected as a major factor in earlier reports of aneurysm rupture after seemingly successful nonresective therapy.

We report a case of spontaneous rupture of a nonaneurysmal infrarenal aorta through an area of atherosclerotic thinning. Close follow-up, aggressive antihypertensive therapy, and serial imaging of asymptomatic patients with documented aortic ulceration is warranted. In symptomatic patients, surgical intervention should be undertaken so that transmural aortic rupture can be averted.

Inflammatory aortic aneurysms (IAAs) are characterized by a markedly thickened aortic wall and dense perianeurysmal fibrosis. The presence of such inflammation and subsequent organ adherence makes surgical repair of IAAs more challenging than repair of simple atherosclerotic aneurysms. From March 1987 to June 1994, twelve patients underwent surgical repair of an IAA by a single surgeon. Ten patients were men (83%) and the mean age was 68.3 years (range 58 to 93 years). All patients except one were symptomatic with back or abdominal pain, yet none had evidence of aneurysm rupture at operation. Preoperatively 90% (9/10) of the patients had an elevated erythrocyte sedimentation rate (ESR), 100% (12/12) had a predictive CT scan, and all patients with aortic wall pathology specimens had their diagnosis confirmed. Six patients had a left flank retroperitoneal surgical approach, five had a transabdominal approach, and one had ligation and extra-anatomic reconstruction. The choice of repair technique was based on the degree and anatomic distribution of perianeurysmal fibrosis. The 30-day operative mortality rate was 0%. Mean follow-up was 56.3 months. Aortoduodenal fistula occurred in one patient 5 months after transperitoneal repair. Technical difficulties encountered during subsequent transperitoneal repairs led to the evolution of a policy in which the retroperitoneal approach was preferred in all patients with CT evidence of IAA. It is concluded that IAA represents a spectrum of retroperitoneal fibrosis and inflammation that is best treated surgically via a retroperitoneal approach.

Objectives: To determine the incidence of a long QT interval as a marker for sudden death in patients with anorexia nervosa and to assess the effect of refeeding. To define a long QT interval by linear regression analysis and estimation of the upper limit of the confidence interval (95% CI) and to compare this with the commonly used Bazett rate correction formula., Design: Prospective case control study., Setting: Tertiary referral unit for eating disorders., Subjects: 41 consecutive patients with anorexia nervosa admitted over an 18 month period. 28 age and sex matched normal controls., Main Outcome Measures: maximum QT interval measured on 12 lead electrocardiograms., Results: 43.6% of the variability in the QT interval was explained by heart rate alone (p < 0.00001) and group analysis contributed a further 5.9% (p = 0.004). In 6 (15%) patients the QT interval was above the upper limit of the 95% CI for the prediction based on the control equation (NS). Two patients died suddenly; both had a QT interval at or above the upper limit of the 95% CI. In patients who reached their target weights the QT interval was significantly shorter (median 9.8 ms; p = 0.04) relative to the upper limit of the 60% CI of the control regression line, which best discriminated between patients and controls. The median Bazett rate corrected QT interval (QTc) in patients and controls was 435 v 405 ms.s-1/2 (p = 0.0004), and before and after refeeding it was 435 v 432 ms.s1/2 (NS). In 14(34%) patients and three (11%) controls the QTc was > 440 ms.s-1/2 (p = 0.053)., Conclusions: The QT interval was longer in patients with anorexia nervosa than in age and sex matched controls, and there was a significant tendency to reversion to normal after refeeding. The Bazett rate correction formula overestimated the number of patients with QT prolongation and also did not show an improvement with refeeding.

Five hundred and twenty consecutive heart transplant cases (458 adult, 62 pediatric) were reviewed to assess the impact of peripheral vascular problems. Peritransplant interventions requiring vascular cannulation (e.g., intraaortic balloon pump procedures, catheterization of the right and left sides of the heart, femoral bypass) resulted in 10 complications that necessitated nine surgical procedures. Five aortic aneurysms (three infrarenal and two suprarenal) were resected. There was one death unrelated to the aneurysm resection. Sixteen patients had evidence of peripheral vascular disease (PVD). There were three deaths in this group, none directly related to the PVD. Three patients required vascular reconstruction (axillobifemoral, bilateral femoral distal and popliteal endarterectomy) in the posttransplant period, all for advanced ischemic symptoms. Except for one patient in whom ischemia-related ulcers developed on the heels, all patients had improved or stable symptoms that did not require intervention. There were no limb losses or vascular infections. We conclude that despite the rigors of posttransplant immunosuppression, patients with stable manifestations of PVD may successfully undergo heart transplantation and subsequent vascular reconstruction, when indicated, without prohibitive risk.

A case of recurrent intravenous leiomyomatosis with cardiac extension and a temporally extended presentation is described. Complete excision was achieved employing simultaneous sternotomy and laparotomy and deep hypothermia with circulatory arrest. Coronary revascularization was performed concomitantly with complete tumor resection. Diagnostic, operative, and pathologic considerations are reviewed and a preferred surgical approach discussed.

As CT scanning has evolved as a reliable clinical tool, the use of angiography in the diagnosis of aortic aneurysmal disease has diminished. Fewer than 25% of patients with aortic aneurysmal disease undergo aortic angiographic evaluation at our institution. A prospective clinical study was undertaken to assess the validity of this policy. One hundred patients with clinical or ultrasonographic evidence of aortic aneurysms were evaluated prospectively during the period July 1987 to December 1989. All patients underwent CT scanning as an initial evaluation. Patients were selected for angiography if they fulfilled any of the following criteria: radiographic evidence of thoracoabdominal or juxtarenal aneurysms, or horseshoe kidney; or clinical suggestion of renal artery stenosis, mesenteric arterial insufficiency, aortoiliac occlusive disease, or lower extremity aneurysmal disease. During this period 19 patients (19%) underwent both CT scanning and angiography. The indications for angiography were thoracoabdominal aneurysms (7), juxtarenal aneurysms (2), clinical evidence of mesenteric insufficiency (1) or renal insufficiency (2), evidence of lower extremity aneurysmal disease (3), or severe aortoiliac occlusive disease (4). Eighty-one patients (81%) underwent CT scanning as the only radiographic evaluation. No patient was adversely affected by elimination of angiographic evaluation. CT scanning revealed inflammatory aneurysms (4), retroaortic renal veins (2), and horseshoe kidney (1). This study suggests that most (81%) patients with aortic aneurysmal disease can be adequately evaluated by CT scanning, and that a very selective policy of angiographic evaluation is indicated.

The records of more than 1,000 patients who underwent colonoscopy were reviewed. The study group consisted of 55 of these 1,000 patients who had persistent unexplained bleeding per rectum and negative radiographic examinations. Colonoscopy was helpful in defining the site of bleeding in approximately 50 per cent of the patients studied.

Although it is clear that there is a significant frequency of recurrent volvulus after cecopexy, there is no evidence from either this series or previous reports that resection is associated with a lower recurrence rate than tube cecostomy. In the absence of data suggesting a clear superiority of colon resection, it appears that tube cecostomy should be the treatment of choice for cases of cecal volvulus that are not complicated by vascular compromise.

This retrospective review of 206 colostomy closures performed by different methods and at various intervals from the time of creation of the stoma suggests that attention to meticulous surgical technic is the most important factor in limiting the morbidity and mortality of this commonly performed procedure. Considerations of the location and type of colostomy, timing, method of closure, and patient population seem to be less importnat than suggested in previous reports.

A percutaneous intra-aortic balloon pump (PIABP) was inserted in 112 patients. Successful placement was achieved in 102 patients, 67 of whom survived long enough to have the device removed. Vascular complications related to the PIABP were noted in 15 patients. Reversal of ischemic signs followed PIABP removal in six patients, but nine required femoral artery exploration for thrombectomy, repair of femoral laceration, or repair of false aneurysm. No patient died as a result of PIABP or correction of associated vascular complications, though five of the patients with vascular problems died of cardiac complications. Nine of ten survivors in this group were asymptomatic, and one had persistent paresthesias six months postoperatively. Most clinically significant vascular complications were due to the technique of balloon removal, and several modifications that were effected recently are expected to decrease the incidence of complications requiring surgical intervention.

One hundred and twenty four percutaneous transluminal angioplasties performed over a 5 year period for lower extremity arterial occlusive disease were reviewed to evaluate clinical efficacy and define parameters of success. Technical success was achieved in 82%, clinical success in 71%. The important predictive variables were severity of disease, anatomic site and length of diseased vessel segment. Best results (94% success rate) were obtained in the proximal single segment lesion with lesser initial disease as reflected by flow study, calf vessel runoff and claudication as the indication for treatment. The poorest results (33% success rate) were obtained in distal vessels with multisegmental disease where limb salvage was the indication for intervention. Stenosing or recently occluded bypass grafts were successfully dilated in 7 of 8 patients. With a complication rate of 3%, percutaneous angioplasty is clearly a highly effective treatment for lower extremity arterial insufficiency in the properly selected patient judged by immediate and relatively short term follow-up observations.

The femorofemoral bypass has become a popular technique of reconstruction for unilateral iliac artery occlusion because of low morbidity and excellent long-term patency. A "steal phenomenon" is infrequently seen, but even in relatively sedentary patients with limb-threatening ischemia femorofemoral grafting has been associated with severe donor limb ischemia in occasional instances. This report describes five high risk elderly patients who underwent femorofemoral bypass for limb-threatening ischemia due to unilateral iliac artery occlusion in association with bilateral superficial femoral artery occlusions. All patients underwent successful bypass as judged by relief of rest pain and healing of ulcerations. Despite a pre-operative resting donor limb mean ankle/brachial index of .45, there was no deterioration of donor limb perfusion when patients were followed for a mean of 15.6 months. It is concluded that femorofemoral bypass is the procedure of choice for limb salvage in poor risk patients with adequate donor limb inflow regardless of the degree of outflow occlusive disease.

Intracoronary injection of 14 mcg. of tetrodotoxin into the ischemic isolated rat heart resulted in immediate cessation of mechanical activity. Upon reperfusion with oxygenated, modified Krebs-Henseleit bicarbonate buffer in a modified Langendorff apparatus, all hearts recovered normal rate, rtythm, and contractile vigor after up to 60 minutes of ischemia. In contrast, all hearts not administered tetrodotoxin showed bradycardia, irregular rhythm, and weak contraction upon reperfusion after 30 and 45 minutes of ischemia; after 60 minutes, no mechanical activity was evident. The improved cardiac function following ischemia in the tetrodotoxin-treated hearts was associated with persistence of normal adenosine triphosphate (ATP) levels after up to 30 minutes of ischemia and normal or elevated creatine phosphate (CP) levels after up to 60 minutes of ischemia. On the other hand, ATP and CP levels progressively declined to reach 50 per cent of normal values after 30 minutes in the ischemic hearts without tetrodotoxin. These findings indicate that postarrest ATP and CP levels play an important role in myocardial recovery after ischemic arrest.

Interruption of coronary flow during cardiac surgical procedures provides a bloodless flaccid heart and allows precise and rapid correction of complex cardiac defects. However, myocardial damage occurs in direct proportion to the duration of the ischemia. As the induction of cardioplegia simulataneous with the initiation of cardiac ischemia helps to preserve cardiac energy reserves and thus myocardial integrity, the identification of a consistently reliable cardioplegic technique is desirable. Isolated perfused working rat hearts were made ischemic for one hour by aortic cross-clamping and were compared with hearts rendered cardioplegic at the onset of ischemia by the intracoronary administration of 5 ml of a hypothermic solution: 1) Krebs-Henseleit buffer, 2) Ringer's lactate, 3) tetrodotoxin, 4) potassium chloride, or 5) potassium citrate. Cardiac output, heart rate, aortic pressure and coronary flow were determined pre and post-ischemia. When compared to time-matched controls and hearts arrested with potassium or tetrodotoxin, the ischemia and ischemia-Ringer's lactate groups showed significant post cross-clamp depression of all measured parameters. Intracoronary Ringer's lactate, although often used as an adjunct to ischemic arrest, was not of significant value. In contrast, hearts arrested with tetrodotoxin, potassium chloride or potassium citrate showed no significant post-ischemic functional or histologic deficit. Perfusion with hypothermic Krebs-Henseleit buffer protected the myocardium better than did Ringer's lactate but less well than the tetrodotoxin or isotonic high potassium solutions. The induction of hypothermic metabolic arrest of the heart by briefly perfusing the coronary arteries via the aortic root with isotonic buffered solutions results in markedly improved myocardial tolerance to one hour of ischemia and avoids the problems of low cardiac output and ventricular irritability previously reported with hypertonic potassium citrate arrest.

There is little information available concerning the alterations in skeletal muscle energy metabolism which occur in response to chronic arterial occlusive disease. In addition, the effect of arterial reconstruction on skeletal muscle energy metabolism in patients with peripheral vascular disease has not been defined. Needle biopsies were obtained from the quadriceps femoris muscle of 7 patients with aortoiliac disease and 15 patients with femoropopliteal disease and from the gastrocnemius muscle of 9 patients with femoropopliteal disease. Muscle samples were analyzed for ATP, ADP, AMP, phosphocreatine, creatine, and lactate. Eleven patients were rebiopsied after vascular reconstruction. Patients with rest pain had decreased total adenine nucleotides, energy charge potential, and ATP/ADP ratios as compared to those of controls. ATP levels were significantly decreased in muscle samples obtained distal to the arterial occlusion (i.e., quadriceps/aortoiliac, gastrocnemius/femoropopliteal) in patients with rest pain (compared with controls). ATP levels did not differ significantly from those of controls in muscle samples obtained from patients with claudication. However, energy charge potential was significantly decreased in all patients with claudication regardless of biopsy site and location of arterial occlusive disease. Normalization of muscle energy metabolism was not demonstrated following arterial reconstruction. We conclude that resting skeletal muscle energy metabolism is abnormal in patients with chronic arterial insufficiency and that progression of disease toward more severe ischemia is associated with more marked derangement. Whether the possible beneficial effects of revascularization on muscle energy metabolism are masked by the concurrent effect of injury in the early postoperative period remains to be clarified.

An automated enzymatic procedure suitable for determination of ATP, ADP, AMP, phosphocreatine, creatine, and lactate in needle biopsies of human skeletal muscle (ca. 30 mg dry wt) using a fast centrifugal analyzer (Multistat III, Instrumentation Laboratory Inc.) is presented. Coefficients of variation ranged from 0.7 to 4.2% for multiple determinations of ATP, ADP, phosphocreatine, and creatine; from 6 to 24% for lactate; and from 9 to 20% for AMP. The procedure should be usable, with appropriate modification, with other tissues and with other fast centrifugal analyzers. Muscle samples are collected into liquid freon, lyophilized, and extracted with 600 microliter of 0.65 M perchloric acid. Neutralized supernatants can be stored for up to 3 years at -80 degrees C with no significant deterioration. The procedure takes much less time than similar manual procedures and gives better reproducibility, particularly for ADP and AMP.

To determine the reasons for clinical failure of Melrose solution, potassium arrest was studied in isolated working rat hearts. Eight control hearts were stable for 2-1/2 hours. After 1/2 hour of work, 42 experimental hearts were subjected to 1 hour of ischemis by aortic cross-clamping with unmodified ischemia in eight hearts and ischemia with simultaneous intracoronary injection of 5 ml. of 4 degrees C. (1)Krebs-Henseleit buffer in seven hearts (2)potassium chloride buffer in six hearts, (3)potassium citrate buffer in eight hearts (both 26 mEq. per liter of K, approximately 300 mOsm. per liter), (4)Melrose solution in seven hearts (greater than 200 mEq. per liter of K, greater than 400 mOsm. per liter), (5)hypertonic potassium citrate buffer in six hearts (26 mEq. per liter of K, greater than 400 mOsm. per liter). The pH of all solutions was 7.8 plus or minus 0.1. After recovery isotonic potassium citrate- and potassium chloride-arrested hearts and time-matched control hearts showed no significant differences in cardiac output, coronary flow, systolic pressure, or heart rate. Hypertonic potassium citrate decreased the recovery of cardiac function after arrest and Melrose arrest was not significantly different from unmodified ischemia. Intracoronary cold isotonic Krebs-Henseleit buffer was better than Melrose arrest but inferior to 26 mEq. er liter of potassium arrest. Arrest with 26 mEq. per liter of potassium augments perfusion hypothermia and prevents significant functional and histologic myocardial damage during 1 hour of ischemis. Previous authors assumed that hypertonicity and citrate were responsible for poor results with Melrose solution, but high potassium concentration is the major deleterious factor with hypertonicity playing a contributory role.

A retrospective study of 18 episodes of upper gastrointestinal (UGI) bleeding secondary to Mallory-Weiss syndrome occuring in 16 patients is presented. Reported cases published since 1969 have been summarized and compared with earlier collected series. It is evident that the clinical spectrum, prognosis, and opinion regarding etiology and treatment of the syndrome have changed in the last decade. Increased awareness of gastroesophageal lacerations secondary to emesis as well as other causes of significantly increased intraesophagogastric pressures, and widespread utilization of fiberoptic endoscopy have resulted in identification of Mallory-Weiss syndrome with increasing frequency. Less severe lacerations which are healing with medical therapy are being recognized. It is recommended that endoscopy by performed in all cases of UGI hemorrhage and that patients with Mallory-Weiss syndrome be managed medically unless hemorrhage is massive or persistent since nearly three of four patients can be successfully treated without operation.

We report a single case of urokinase perfusion of axillary-subclavian vein thrombosis with the restoration of normal venous outflow of the arm. It is hoped that this will halt the usual sequelae causing chronic venous insufficiency.

During reperfusion, functional and metabolic recovery of the isolated working rat heart from one hour of ischemia was best in hearts selectively cooled at the onset of the ischemic interval by perfusion with 5 to 10 ml. of 10 degrees C. or 15 degrees C. Krebs-Henseleit buffer. Hearts similarly perfused at 4 degrees C., 20 degrees C. recovered significantly less well or not at all. Immediately after the hour of ischemia and prior to reperfusion, the absolute levels of glycogen and high-energy phosphates were best in the hearts perfused at 4 degrees C. However, metabolic function was best preserved in those perfused at 10 degrees C. and 15 degrees C., as evidenced by rapid recovery of high-energy phosphates and glycogen to control levels compared to metabolic deterioration in the 4 degrees C. group.