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Background: Ertapenem, a group I carbapenem antibiotic, has been shown to be safe and effective in treating adults with complicated intra-abdominal (cIAI) or acute pelvic infection (API). This study evaluated ertapenem for treating these infections in children., Methods: In an open-label study, children aged 2 to 17 years with cIAI or API were randomized 3:1 to receive ertapenem or ticarcillin/clavulanate. Children 13 to 17 years of age received 1 g parenterally daily, and those 2 to 12 years of age received 15 mg/kg twice daily. Patients < 60 kg received ticarcillin/clavulanate 50 mg/kg 4 to 6 times daily and 3.1 g 4 to 6 times daily for those > or = 60 kg. Patients were assessed for safety and tolerability throughout the study and for efficacy after the completion of therapy., Results: One hundred five patients, 72 (69%) with cIAI, received > or = 1 dose of study drug and were included in the safety analysis. Eighty-one patients were treated with ertapenem. Infusion site pain was the most common drug-related adverse event in both groups. In the modified intent-to-treat analysis, the age-adjusted posttreatment clinical response rates were 87% (43/50 patients) and 100% (25/25 patients) in the cIAI and API patients, respectively, for ertapenem and 73% (11/15 evaluable patients) and 100% (8/8 evaluable patients), respectively, for ticarcillin/clavulanate. Overall age-adjusted response rates were 91% (68/75 evaluable patients) for ertapenem and 83% (19/23 evaluable patients) for the comparator., Conclusions: This study suggests that ertapenem is generally safe and efficacious for treating cIAI or API in pediatric patients.

Objective: This study was conducted to evaluate the safety of percutaneous endovascular procedures (PEPs) during integration of endovascular skills into an urban academic vascular surgery practice and assess the hypothesis that currently accepted guidelines are a valid benchmark for endovascular competency., Methods: From 2000 through 2004, an endovascular training paradigm was instituted to integrate endovascular procedures into an academic endovascular practice. The paradigm involved individual mentoring of vascular surgery faculty by a partner with mature endovascular skills. Mentoring continued until each surgeon achieved a procedural experience of 100 diagnostic angiograms and 50 percutaneous endovascular interventions. Once achieved, privileges were granted for independent endovascular practice. To assess the effectiveness of the training process and competency of the newly trained endovascular practitioner, the surgeon-specific 30-day incidence of major complications and deaths for all PEPs performed during and after the mentoring process was determined. Complications and deaths were assigned to the mentor during the training process and to the individual surgeon once endovascular privileges were granted. Complications were classified as local vascular, local nonvascular, or systemic/remote., Results: From 2000 through 2004, 1208 PEPs were performed. During this time, three faculty surgeons achieved sufficient endovascular procedural experience and were granted endovascular privileges. Major complications consisted of 17 local vascular, three local nonvascular, and four systemic/remote. Three deaths occurred. Renal percutaneous transluminal angioplasty/stent procedures had the highest complication and death rate at 9%. The major complication and death rate per year was 1.8% to 4.9% (P = .32) and did not significantly vary. The major complication and death rate for all 1208 PEPs was 2.2%. The surgeon-specific complication and death rate was 1.9% to 3.6% (P = .14) and did not vary between surgeons., Conclusion: Endovascular skills can be safely transferred using a vascular surgeon-based training paradigm. When the training paradigm is directed at satisfying currently recommended guidelines for endovascular privileging, competent endovascular surgeons are the result.

When a transmetatarsal amputation (TMA) is required, successful long-term limb salvage is questioned. We evaluated the influence of TMA on limb salvage in patients undergoing lower extremity revascularization. Patients who had distal bypasses extending to the infrapopliteal arterial tree and adjunctive TMA were retrospectively reviewed. Limb salvage was determined with life-table analysis. Twenty-four patients (29 limbs) were evaluated: 15 male and 9 female. Average age was 64.2 years old. Gangrene was the indication for bypass and TMA in 25 (86.2%) patients. Seven limbs were lost to follow-up. Nine of the remaining 22 limbs required below-knee (8) or above-knee (1) amputations, seven limbs within the first 3 months. In the group of patients who had major amputations within the first 3 months, graft thrombosis was the cause of leg amputation in six (85.7%) cases. No significant predictors of early major amputation were identified. Limb salvage was 62 per cent at 1 year in the TMA group. In comparison, among historical controls requiring distal revascularization and no adjunctive toe or foot amputations, limb salvage was 76.5 per cent (P = NS). Long-term limb salvage is dependent on successful lower extremity revascularization. Requirement for TMA should not influence the decision for limb salvage.

Purpose: This study was undertaken to define the long-term effects of renal revascularization on blood pressure, and renal and cardiac function in patients with Takayasu arteritis-induced renal artery stenosis (TARAS)., Methods: Twenty-seven patients (25 women; mean age, 27 years) with TARAS underwent intervention. Primary, primary assisted, and secondary patency rates were determined, and the late effects on blood pressure, renal and cardiac function, and survival were analyzed., Results: All patients had hypertension (mean blood pressure, 167/99 mm Hg; 2.5 antihypertensive medications per patient). Mean estimated glomerular filtration rate in patients not receiving hemodialysis was 76 mL/min, and in five patients serum creatinine concentration was greater than 1.5 mg/dL. Three patients were hemodialysis-dependent, and two had intractable congestive heart failure. Forty interventions were performed, including 32 aortorenal bypass procedures, two repeat implantations, four nephrectomies, and two transluminal angioplasty procedures. Postoperative morbidity was 19%. There were no deaths. During follow-up (mean, 68 months), three graft stenoses, all due to intimal hyperplasia, and three graft occlusions occurred. Two of three graft stenoses were successfully revised. At 1, 3, and 5 years of follow-up, primary patency was 87%, 79%, and 79%, respectively; primary assisted patency was 93%, 89%, 89%, respectively; and secondary patency was 93%, 89%, and 89%, respectively. Intervention resulted in a decrease in blood pressure to a mean of 132/79 mm Hg (P<.0001), and the need for antihypertensive medications was reduced to one per patient (P<.01). Mean glomerular filtration rate increased to 88 mL/min (P<.005), and two patients no longer required hemodialysis. Congestive heart failure resolved in both patients, and did not recur. There were three deaths during follow-up, with 5-year and 10-year actuarial survival of 96% and 80%, respectively., Conclusions: Renal revascularization to treat TARAS is durable, has a salutary effect on blood pressure, and enhances long-term renal and cardiac function. This response establishes renal revascularization as a successful and durable intervention for TARAS, and a benchmark to which other therapies should be compared.

Objective: To examine the clinical efficacy and safety of ertapenem, a novel beta-lactam agent with wide activity against common pathogens encountered in intraabdominal infection., Summary Background Data: Ertapenem has a pharmacokinetic profile and antimicrobial spectrum that support the potential for use as a once-a-day agent for the treatment of common mixed aerobic and anaerobic infections. METHODS This prospective, randomized, controlled, and double-blind trial was conducted to compare the safety and efficacy of ertapenem with piperacillin/tazobactam as therapy following adequate surgical management of complicated intraabdominal infections., Results: Six hundred thirty-three patients were included in the modified intent-to-treat population, with 396 meeting all criteria for the evaluable population. Patients with a wide range of infections were enrolled; perforated or abscessed appendicitis was most common (approximately 60% in microbiologically evaluable population). A prospective, expert panel review was conducted to assess the adequacy of surgical source control in patients who were failures as a component of evaluability. For the modified intent-to-treat groups, 245 of 311 patients treated with ertapenem (79.3%) were cured, as were 232 of 304 (76.2) treated with piperacillin/tazobactam. One hundred seventy-six of 203 microbiologically evaluable patients treated with ertapenem (86.7%) were cured, as were 157 of the 193 (81.2%) treated with piperacillin/tazobactam., Conclusions: In this study, the efficacy of ertapenem 1 g once a day was equivalent to piperacillin/tazobactam 3.375 g every 6 hours in the treatment of a range of intraabdominal infections. Ertapenem was generally well tolerated and had a similar safety and tolerability profile to piperacillin/tazobactam. A formal process for review of adequacy of source control was found to be of benefit. The results of this trial suggest that ertapenem may be a useful option that could eliminate the need for combination and/or multidosed antibiotic regimens for the empiric treatment of intraabdominal infections.

The efficacy and safety of intravenous (IV) ertapenem, 1 and 1.5 g once a day, for treatment of adults with complicated intra-abdominal infection were compared with those of IV ceftriaxone 2 g once a day plus IV metronidazole 500 mg every 8 h. After at least 3 days of IV therapy and satisfactory clinical response, patients could be switched to oral ciprofloxacin plus metronidazole. Fifty-nine patients were randomized to receive ertapenem 1 g and 51 to receive ertapenem 1.5 g; 55 patients were randomized to each comparator group. At the test of cure, 4-6 weeks post therapy, in the 1 g cohort, 84% (26/31) of patients treated with ertapenem and 85% (35/41) with comparator therapy had a favourable clinical and microbiological assessment. Success rates in the 1.5 g cohort were 83% (22/29) and 77% (24/31) in the ertapenem and comparator groups, respectively. Drug-related adverse events were generally similar in both treatment groups. Ertapenem 1 or 1.5 g once a day followed by optional oral therapy appeared similar to combined therapy with ceftriaxone plus metronidazole with the same optional oral switch for treatment of complicated intra-abdominal infections in adults. Although not compared directly in a randomized fashion, the efficacy and safety profiles of ertapenem 1 and 1.5 g appeared comparable. Ertapenem was generally well tolerated and had an overall safety profile similar to ceftriaxone plus metronidazole., (Copyright 2002 Elsevier Science B.V. and International Society of Chemotherapy)

This article explores the management of carotid arterial injuries, detailing the historical evolution for the management of these injuries and delineating techniques for cerebral perfusion and preservation with shunts. It discusses the role of autogenous versus synthetic grafts in the management of these injuries and the issue of vascular complications and potential pitfalls. Jugular venous injuries are addressed also, with emphasis on the controversies of primary repair versus ligation.

Purpose: The purpose of this study was to determine the effectiveness of treatment of patients with combined arterial and venous insufficiency (CAVI), evaluate variables associated with successful ulcer healing, and better define criteria for interventional therapy., Study Design: We retrospectively reviewed the records of patients treated at four institutions from 1995 to 2000 with lower extremity ulcers and CAVI. Arterial disease was defined as an ankle/brachial index less than 0.9, absent pedal pulse, and at least one in-line arterial stenosis > 50% by arteriography. Venous insufficiency was defined as characteristic clinical findings and duplex findings of either reflux or thrombus in the deep or superficial system. Clinical, demographic, and hemodynamic parameters were statistically analyzed with multiple regression analysis and correlated with ulcer healing and limb salvage., Results: Fifty-nine patients with CAVI were treated for nonhealing ulcers that had been present from 1 to 39 months (mean, 6.4 months). All patients had edema. The mean ankle/brachial index was 0.55 (range, 0-0.86). Treatment included elastic compression and leg elevation in all patients and greater saphenous vein stripping in patients with superficial venous reflux. Fifty-two patients underwent arterial bypass grafting, three underwent an endarterectomy, one underwent superficial femoral artery percutaneous transluminal angioplasty, and three underwent primary below-knee amputation. For purposes of analysis, patients were divided into four groups according to the pattern of arterial and venous disease and the success of arterial reconstruction. Group 1 consisted of 22 patients with a patent arterial graft, superficial venous incompetence, and normal deep veins. Group 2 consisted of seven patients with a patent graft, superficial reflux, and deep venous reflux. Group 3 included 22 patients with a patent graft and deep venous thrombosis (DVT), and group 4 included eight patients with an occluded arterial graft. Follow-up ranged from 2 to 47 months (mean, 21.6 months). Forty-nine patients remained alive, and 10 died of unrelated causes. During follow-up, 48 of the 56 treated arteries remained patent and eight occluded. Thirty-four ulcers (58%) healed, 18 ulcers (31%) did not heal, and 7 patients (12%) required below-knee amputation for nonhealed ulcers and uncontrolled infection. No patient with graft occlusion was healed, and 12 ulcers persisted despite successful arterial reconstruction. Twenty-one (78%) of 27 patients undergoing greater saphenous vein stripping were healed, but none of these patients had DVT. The mean interval from bypass graft to healing was 7.9 months. Thirty-two (68%) of 46 patients without prior DVT were healed, whereas only two (15%) of 13 patients with prior DVT were healed, and this variable, in addition to graft patency, was the only factor statistically significant in predicting healing (P <.05)., Conclusions: Ulcers may develop anywhere on the calf or foot in patients with CAVI, and healing requires correction of arterial insufficiency. Patients with prior DVT are unlikely to heal, even with a patent bypass graft. Ulcer healing is a lengthy process and requires aggressive treatment of edema and infection, and successful arterial reconstruction. Patients with a prior DVT are unlikely to benefit from aggressive arterial or venous reconstruction.

Purpose: The purpose of this study was to review the natural history and clinical outcome of patients with infrainguinal autogenous graft infection (IAGI), to evaluate the effectiveness of attempted graft preservation, to determine those variables associated with graft salvage, and to better determine optimal treatment., Study Design: We retrospectively reviewed the records of patients undergoing infrageniculate vein grafts at three hospitals between 1994 and 2000 who had a wound infection involving the graft. Clinical and bacteriologic variables were analyzed and correlated with graft salvage, limb salvage, and clinical outcome., Results: During this 7-year period, 487 patients underwent an infrageniculate vein graft, and 68 (13%) had clinical evidence of IAGI. Twenty-seven patients presented with drainage from the wound, 15 with wound separation and cellulitis, 18 with soft tissue infection extending to the graft, 4 with an abscess and cellulitis, and 4 with bleeding. Ten patients (15%) had systemic symptoms (defined as a white blood cell count > 15,000 and temperature > 38.5 degrees C). Forty infections developed in the thigh, 17 in the groin, and 11 in the lower leg. An anastomosis was exposed in 15 patients. Wound cultures were positive for bacteria in 52 patients, and most infections were due to Staphylococcus aureus (18 patients) and S epidermidis (12 patients). Pseudomonas was cultured from seven infections. Twelve patients had polymicrobial infections. The interval from operation to infection ranged from 7 to 180 days. All patients were treated with oral antibiotics, 48 after intravenous antibiotics. Forty-five patients had operative debridement, including 18 who had muscle flap coverage. Four patients presented with hemorrhage, and three had immediate graft ligation and one graft excision. Follow-up ranged from 5 to 68 months (mean, 24.3 months), with 61 patients currently alive. Two patients died as a result of the IAGI (mortality rate, 2.9%). One had undergone a below-knee amputation, and one had a nonhealed wound but intact limb. Overall, 61 wounds (91%) healed, 4 patients required below-knee amputations, and 3 wounds did not heal. Fifty-eight grafts remained patent, 6 thrombosed, and 4 were ligated to control hemorrhage. Of the 61 wounds that healed, the time required for healing ranged from 7 to 63 days. No patient with bleeding died because of the acute episode. No patient had delayed hemorrhage. All 18 patients treated with a muscle flap healed. Bleeding (P <.001), elevated white blood cell count (P <.029), fever (P <.001), and renal insufficiency (creatinine level > 1.5; P <.056) were the only variables statistically significant in predicting graft failure or limb loss. With the use of life-table analysis, graft patency was 94%, 72%, and 72% at 1, 3, and 5 years, and limb salvage was 97%, 92%, and 92% at the same intervals, respectively., Conclusions: Most patients with an IAGI can be successfully treated with graft and limb preservation. In contrast to earlier studies, an exposed anastomosis, interval to infection, or Pseudomonas infection is not associated with graft failure. Graft salvage is less likely in patinets with fever, leukocytosis, and renal insufficency, but because most grafts remained patent, graft preservation is recommended for these patients. Graft ligation or excision should be reserved for patients presenting with bleeding or sepsis.

Objective: To compare the safety and efficacy of intravenous (IV) ciprofloxacin plus IV metronidazole (CIP+MET) with that of IV piperacillin/tazobactam (PIP/TAZO) in adults with complicated intraabdominal infections, and to compare the efficacy of sequential IV-to-oral CIP+MET therapy with that of the IV CIP-only regimen., Summary Background Data: Treatment of intraabdominal infections remains a challenge, mainly because of their polymicrobial etiology and attendant death and complications. Antimicrobial regimens using sequential IV-to-oral therapy may reduce the length of hospital stay., Methods: In this multicenter, randomized, double-blind trial involving 459 patients, clinically improved IV-treated patients were switched to oral therapy after 48 hours. Overall clinical response was the primary efficacy measurement., Results: A total of 282 patients (151 CIP+MET, 131 PIP/TAZO) were valid for efficacy. Of these patients, 64% CIP+MET and 57% PIP/TAZO patients were considered candidates for oral therapy. Patients had a mean APACHE II score of 9.6. The most common diagnoses were appendicitis (33%), other intraabdominal infection (29%), and abscess (25%). Overall clinical resolution rates were statistically superior for CIP+MET (74%) compared with PIP/TAZO (63%). Corresponding rates in the subgroup suitable for oral therapy were 85% for CIP+MET and 70% for PIP/TAZO. Postsurgical wound infection rates were significantly lower in CIP+MET (11%) versus PIP/TAZO patients (19%). Mean length of stay was 14 days for CIP+MET and 17 days for PIP/TAZO patients., Conclusion: CIP+MET, initially administered IV and followed by CIP+MET oral therapy, was clinically more effective than IV PIP/TAZO for the treatment of patients with complicated intraabdominal infections.

Fifteen multiresistant Acinetobacter baumannii isolates from patients in intensive care units and 14 nonoutbreak strains were tested to determine in vitro activities of nontraditional antimicrobials, including cefepime, meropenem, netilmicin, azithromycin, doxycycline, rifampin, sulbactam, and trovafloxacin. The latter five drugs were further tested against four of the strains for bactericidal or bacteriostatic activity by performing kill-curve studies at 0.5, 1, 2, and 4 times their MICs. In addition, novel combinations of drugs with sulbactam were examined for synergistic interactions by using a checkerboard configuration. MICs at which 90% of the isolates tested were inhibited for antimicrobials showing activity against the multiresistant A. baumannii strains were as follows (in parentheses): doxycycline (1 microg/ml), azithromycin (4 microg/ml), netilmicin (1 microg/ml), rifampin (8 microg/ml), polymyxin (0.8 U/ml), meropenem (4 microg/ml), trovafloxacin (4 microg/ml), and sulbactam (8 microg/ml). In the kill-curve studies, azithromycin and rifampin were rapidly bactericidal while sulbactam was more slowly bactericidal. Trovafloxacin and doxycycline were bacteriostatic. None of the antimicrobials tested were bactericidal against all strains tested. The synergy studies demonstrated that the combinations of sulbactam with azithromycin, rifampin, doxycycline, or trovafloxacin were generally additive or indifferent.

Inferior vena cava (IVC) injuries continue to be associated with mortality rates of 21 to 66 per cent despite advances in prehospital, surgical, and critical care. The purpose of this study was to evaluate outcome of patients with IVC injury after treatment at a major urban trauma center and to identify factors predictive of survival. Between 1989 and 1995, 158 patients presented to the Los Angeles County + University of Southern California Medical Center with IVC injuries. One hundred thirty-six patient records were available for review, and 69 data points were collected and analyzed. Mean age was 26 years (range, 6-54), and 122 (90%) patients were male. Mechanism of injury included gunshot in 88 (65%) patients, stab in 23 (17%) patients, shotgun in 7 (5%) patients, and blunt trauma in 18 (13%) patients. The mean Injury Severity Score was 25. Seventy (52%) patients were hypotensive. Eleven (8%) patients died before surgical intervention, and 25 (18%) patients died before operative repair. Repair (79), ligation (20), or observation (1) was accomplished in 100 (74%) patients. Overall survival was 48 per cent and 65 per cent in the 100 patients surviving to operative repair, including 5 of 20 patients requiring IVC ligation. Significant differences (P<0.001) between survivors and nonsurvivors included Injury Severity Score, Glasgow Coma Score, hematocrit, hypotension, emergent thoracotomy, blood loss, level of injury, tamponade, and associated aortic injury. Logistic regression analysis identified hypotension, anatomic level of injury, and associated aortic injury as significant predictors of outcome (P = 0.001). Survival is predominantly determined by severity and anatomic accessibility of the IVC injury and by the absence of associated major vascular injuries. Ligation may control otherwise exsanguinating injuries and should be considered early in the management of complex injuries.

Background: Trovafloxacin, a new broad-spectrum fourth-generation quinolone, has in vitro activity against most gram-negative and gram-positive anaerobes and aerobes. Trovafloxacin is available as both an intravenous formulation, alatrofloxacin, and a single daily oral tablet. Excellent tissue pharmacokinetics and oral bioavailability suggest usefulness in the treatment of complicated intra-abdominal infections. Thus, the efficacy of alatrofloxacin followed by oral trovafloxacin was compared with the standard regimen of intravenous imipenem/cilastatin followed by oral amoxicillin/clavulanic acid in this prospective, multicenter, double-blind trial., Methods: Patients were randomized to receive either 300 mg alatrofloxacin daily followed by 200 mg oral trovafloxacin daily or 1 g imipenem/cilastatin intravenously thrice daily followed by 500 mg oral amoxicillin/clavulanic acid thrice daily for up to 14 days following surgical intervention of a documented intra-abdominal infection. Efficacy was assessed at the end of therapy and at follow-up (day 30)., Results: At the end of the study, cure or improvement occurred in 83% (129/156) and 84% (127/152) of clinically evaluable patients in the trovafloxacin and comparative groups, respectively. Pathogen eradication rates, adverse-event profiles, and significant laboratory abnormalities were comparable between groups., Conclusion: Intravenous alatrofloxacin with or without oral trovafloxacin was as effective as intravenous imipenem/cilastatin followed by oral amoxicillin/clavulanic acid in complicated intra-abdominal infections.

The diagnosis of peripheral vascular trauma has undergone significant evolution in the last two decades. A minority of patients with arterial trauma present with classic findings that make the diagnosis obvious. However, the diagnosis of occult arterial injuries is more challenging, and it is for this group that the diagnostic algorithm has changed most significantly. Because of the low yield of routine operative exploration and routine arteriography to evaluate potential injury to vessels in proximity to penetrating wounds, many authors now recommend the selective use of arteriography or other diagnostic modalities based on the results of clinical examination and noninvasive pressure determinations. This article reviews the evidence in support of such a selective approach to the diagnosis of arterial injuries.

Background: Alatrofloxacin, the prodrug of trovafloxacin, is a novel fluoroquinolone antimicrobial agent with a broad spectrum, including activity against gram-positive and gram-negative aerobes and anaerobes. Its pharmacokinetic properties (long half-life, excellent tissue distribution, and good safety profile) suggest a role in surgical prophylaxis. This prospective, multicenter, double-blind trial compared alatrofloxacin with cefotetan, an approved drug for surgical prophylaxis, in reducing postoperative infections., Methods: The efficacy and safety of a single 200-mg intravenous dose of alatrofloxacin were compared to a single 2-g intravenous dose of cefotetan in 492 patients undergoing elective colorectal surgery. The efficacy of alatrofloxacin as a prophylaxis for wound, intra-abdominal, or remote-site postoperative infectious complications was compared with cefotetan in 317 clinically evaluable patients; 161 received alatrofloxacin and 156 received cefotetan. The patients were monitored for infections and safety for 30 days postoperatively., Results: No statistically significant between-treatment difference was detected in successful clinical response rates at the end of the study (72% for each group). The incidence of primary wound infections at the time of hospital discharge was also similar: 21% in patients treated with alatrofloxacin and 18% in those treated with cefotetan. Safety, established by the incidence of adverse events, did not differ statistically between the groups., Conclusions: A single intravenous dose of alatrofloxacin given within 4 hours prior to surgery was as effective as an intravenous dose of cefotetan in the prevention of postoperative infectious complications in patients undergoing elective colorectal surgery. The safety profiles of the two medications were similar.

The role of combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) in patients with severe asymptomatic carotid artery disease and concurrent symptomatic coronary artery disease is controversial. The objective of this report is to investigate the safety of combined CEA/CABG. The medical records of 30 patients who underwent combined CEA/CABG for coexistent asymptomatic carotid and symptomatic coronary artery occlusive disease were reviewed. All patients were scheduled for either elective or urgent myocardial revascularization due to their symptomatic coronary artery disease. Color-flow duplex scanning identified internal carotid artery stenosis of 80 to 99 per cent in 28 patients (93%) and 50 to 79 per cent in 2 patients (7%). Seventeen patients (57%) were male. The mean age was 64 +/- 10 years (range, 42-84 years). Contralateral internal carotid artery occlusion was present in four patients. Severe left main coronary artery disease was present in 12 patients (40%) and 7 patients (23%) had an ejection fraction of less than 50 per cent. There were no perioperative deaths or strokes. One patient suffered a myocardial infarction on postoperative day 1. This study demonstrates the safety of combined CEA/CABG for coexistent coronary and asymptomatic carotid disease. Using this surgical approach for critical coexistent disease may minimize the incidence of perioperative cerebrovascular complications in patients undergoing CABG.

Early diagnosis and timely treatment of extremity vascular injuries are essential if limb salvage and limb function are to be optimized. Careful and repeated clinical examination and ankle/brachial doppler indices are pivotal for early diagnosis. Routine arteriography for proximity injury is neither cost effective nor clinically indicated and minimal non-occlusive arterial injuries do not require vascular repair. An algorithm for the diagnostic evaluation and treatment of patients with penetrating extremity trauma is presented. The early diagnosis of compartment syndrome is stressed.

Vascular complications of thoracic outlet syndrome are uncommon but may result in significant long-term disability. This report documents a retrospective review of 17 such patients. Ten patients presented with acute onset of upper extremity swelling and axillosubclavian vein thrombosis. One patient presented with chronic, intermittent arm swelling and subclavian vein stenosis. Three patients presented with acute symptoms of upper extremity emboli, and three presented with chronic arm claudication. Cervical ribs were discovered in four patients with arterial symptoms and in no patients with venous symptoms. All ten patients with acute venous thrombosis underwent successful thrombolysis, with venous stenosis uncovered in 8. Thrombolysis was also performed for two patients with arterial emboli. All 17 patients underwent surgical decompression of the thoracic outlet, 16 via a supraclavicular approach and one via a transaxillary approach. One subclavian arteriotomy with endarterectomy and one resection of a subclavian artery aneurysm were performed at the time of decompression. Repeat venography after decompression demonstrated persistent venous stenosis in one patient that was treated with balloon angioplasty and stenting. After a mean of 22 months' follow-up, 12 patients had no residual symptoms, and 5 had experienced significant improvement of symptoms. In conclusion, a combined approach of thrombolysis and surgical decompression of the thoracic outlet provides a salutary outcome in a majority of patients.

Purpose: This study was undertaken to examine the relationship between intraoperative color-flow duplex (CFD) findings and the development of restenosis in patients undergoing carotid endarterectomy (CEA)., Methods: Seventy-eight patients (43 male and 35 female; mean age, 65 years) underwent 86 CEAs (eight staged bilateral) and intraoperative CFD during a 31-month period. Three patients (three CEAs, 3%) underwent both CFD and a completion arteriographic scan. Patients were observed in a postoperative protocol using CFD surveillance. The follow-up interval ranged from 6 to 24 months (average, 12 months)., Results: After undergoing CEA, 10 patients (10 CEAs, 11%) had an abnormality detected by intraoperative CFD; one was confirmed with a completion arteriographic scan. These abnormalities consisted of elevated peak systolic velocities (PSV) with a mosaic color pattern suggesting turbulence seen in six CEAs, including one internal carotid artery (ICA) with abnormal hemodynamics and an unremarkable completion arteriogram. Intimal defects on B-mode were seen in another four CEAs. These carotid arteries were reexplored, defects (intimal flaps with platelet thrombus) were confirmed by direct examination, and all were repaired with or without a patch (six ICAs, three external carotid arteries, and one common carotid artery). No cerebrovascular events occurred in the perioperative period. No carotid restenosis (> or = 50% diameter reduction) was identified during follow-up of 43 patients (48 CEAs, 56%). Two patients had recurrent neurologic symptoms., Conclusion: Intraoperative CFD is an effective test for detecting flow abnormalities or intimal defects in patients undergoing CEA. Ensuring normal intraoperative hemodynamics after CEA may be a major factor associated with decreased incidence of perioperative cerebrovascular events and subsequent carotid artery restenosis.

Objective: To assess management of penetrating internal carotid artery (ICA) injuries., Design: Retrospective review of institutional protocol., Setting: Level 1 trauma center in a major urban area., Patients: Sixty-one patients with penetrating ICA injuries., Interventions: In the period 1975 to 1987 (group 1; n = 36), management was based on individual surgeons' preferences. Between 1988 and 1995 (group 2; n = 25), an algorithm was employed: (1) hemodynamically stable patients with suspected ICA injuries underwent a diagnostic angiography; (2) surgically accessible injuries were reconstructed regardless of neurologic status with 2 exceptions: (a) neurologically intact patients with ICA occlusion were treated by anticoagulation and mild pharmacological hypertension and (b) minimal nonocclusive injuries were managed nonoperatively and followed up by serial angiography or duplex ultrasonography; and (3) heparinization, shunting, and completion angiography were employed., Main Outcome Measures: Neurologic status at admission and discharge were compared by the Fisher exact test., Results: In group 1, 24 patients (67%) presented neurologically intact, and 12 (33%) with a deficit. Sixteen injuries were managed nonoperatively, 14 were repaired, and 6 were ligated. At discharge 6 (17%) were improved, 24 (66%) were unchanged, 6 (17%) were worse. Four patients (11%) died of cerebrovascular causes. In group 2, 19 patients (76%) presented neurologically intact, and 6 (24%) with a deficit. Eleven injuries were managed nonoperatively, 12 were repaired, and 2 were ligated. A death occurred in a patient who arrested, was admitted to the hospital in a coma, and died before ICA repair., Conclusions: Neurologic outcome after ICA injury is enhanced by an algorithm predicated on the liberal use of angiography, a predefined surgical approach, and selective observation.

Successful management of the difficult peripheral vascular injury requires a multidisciplinary approach. Prompt recognition of the vascular injury and adherence to the recognized principles of vascular repair provide a successful short-term surgical result. The long-term consequences of an injury are determined by the associated orthopedic, soft tissue, and nerve injuries.

We compared the findings of intraoperative color duplex scanning and completion arteriography in patients undergoing infrainguinal vein bypasses to identify hemodynamic abnormalities that could result in a predisposition to early or late graft failure. We reviewed the records of 72 patients who underwent 81 vein bypass graft procedures. Three intraoperative diagnostic methods were used. In 28 procedures (group I) both color duplex and completion arteriography were used, in 21 procedures (group II) only color duplex was used, and in 26 procedures (group III) only completion arteriography was used. Grafts were followed using a duplex surveillance protocol for a mean interval of 16.1 months. Nine grafts in group I showed an abnormality on the duplex scan but not on the completion arteriogram. Seven grafts had a peak systolic velocity (PSV) greater than 200 cm/sec and two had a PSV less than 45 cm/sec. These findings led to six immediate repairs, one early revision, and two late revisions. Arteriography demonstrated additional defects in two procedures but repairs were not performed. In group II duplex scans showed an abnormality in eight procedures (seven grafts with PSV 200 to 250 cm/sec and one graft with a retained valve) resulting in three immediate repairs and five late revisions. In the remaining 13 procedures in group II, duplex scans were normal and no revisions were required during follow-up. In group III defects were detected by arteriography in four procedures (> 50% stenosis in three grafts and one arterial spasm) leading to three immediate repairs. In the remaining 22 studies arteriograms were interpreted as normal; however, seven of these grafts required late revisions. Our data suggest that grafts that appear normal on intraoperative duplex scans are not likely to develop a stenosis requiring revision. Intraoperative duplex ultrasound may be superior to completion arteriography.

The benefit of preoperative cardiac evaluation in the diabetic patient undergoing peripheral vascular surgery is uncertain. To investigate this issue we performed a retrospective review of 192 procedures performed in diabetic patients for chronic lower extremity arterial occlusive disease. The incidence of adverse postoperative cardiac events was determined, as well as its association with several preoperative factors including symptoms of coronary artery disease (CAD), extent and results of preoperative noninvasive cardiac evaluation, and operative site (aorta vs. lower extremity). The overall death and cardiac complication rates were 10.2% for lower extremity and 25.7% for aortic procedures (p = 0.02). For myocardial infarction and cardiac death alone, the rates were 5.1% and 5.7%, respectively (p > 0.10). Although a history of symptomatic CAD predicted the occurrence of any cardiac complication (28.3% vs. 8.2% [p < 0.01] for the aortic and lower extremity revascularization groups combined), no factor was found to be associated with the occurrence of myocardial infarction and cardiac death alone. In patients with a history of symptomatic CAD, there was no significant difference in the incidence of complications whether or not preoperative noninvasive cardiac testing was performed (28.1% vs. 28.6%, p > 0.10) or, if testing was performed, if the results were abnormal or normal (35.3% vs. 20.0%, p > 0.10). Similar results were obtained in patients with no history of symptomatic CAD. In summary, this retrospective review of our experience with noninvasive evaluation to detect CAD in diabetic patients undergoing peripheral vascular surgery failed to show any benefit in terms of reducing the incidence of postoperative cardiac events.

Objective: To compare carbon dioxide-digital subtraction arteriographic (CO2-DSA) images of renal artery anatomy with standard iodinated contrast arteriographic (ICA) images., Design: One hundred patients with vascular disease who required abdominal aortography were evaluated by both CO2-DSA and ICA modalities. Two blinded readers interpreted arteriograms for the degree of renal artery stenosis, and a third reader was employed to resolve differences in reader interpretations., Setting: University medical center., Main Outcome Measures: The sensitivity, specificity, negative predictive value, positive predictive value, and accuracy were calculated for the ability of CO2-DSA to demonstrate a 60% or greater stenosis of the main renal artery; kappa values for CO2-DSA and ICA were calculated to assess intraobserver variability., Results: Of the 200 main renal arteries imaged, 17 (9 by means of CO2-DSA), 8 means of ICA) were eliminated because of inadequate visualization of the renal artery. In identifying a renal artery stenosis of 60% or greater, CO2-DSA had a sensitivity of 0.83, specificity of 0.99, positive predictive value of 0.94, and negative predictive value of 0.98. The overall accuracy was 0.97. The kappa was 0.75 for CO2-DSA and 0.70 for ICA, hence, the variation in the interpretations of CO2-DSA and ICA were comparable., Conclusion: Images by means of CO2-DSA accurately reflect pathologic changes in renal arteries and are thus useful in the diagnosis of clinically occult occlusive renal artery disease in patients at risk of contrast medium-related nephrotoxicity.

Background: Meropenem (MP), a new carbapenem antibiotic, has excellent antimicrobial activity against the enteric flora commonly encountered in acute appendicitis. Although similar to imipenem, it may have clinical advantages., Study Design: We compared patients with advanced appendicitis (gangrenous or perforated) treated with 1,000 mg MP every eight hours with those given the combination of tobramycin 5 mg/kg/day at eight hour intervals and clindamycin 900 mg every eight hours. Both treatments were given intravenously. Patients were randomized to either group of the double-blind study., Results: Of 129 evaluable cases, 63 received MP and 66 received both tobramycin and clindamycin (T/C). The two groups were similar in age, sex, and severity of disease. The mean number of days of postoperative fever (MP = 3.1 +/- 1.7 SD compared to T/C = 4.4 +/- 2.2 SD, p < or = 0.01), days of antibiotic therapy (MP = 6.1 +/- 1.6 SD compared to T/C = 7.3 +/- 2.2 SD, p = 0.01), and therefore hospital stay (MP = 8.0 +/- 3.5 SD compared to T/C = 9.4 +/- 2.6 SD, p < 0.01) were significantly better for patients treated with MP. No difference was found between the numbers of failures in each group (MP = 5 compared to T/C = 6)., Conclusions: This study demonstrates a small but significant reduction (approximately one day) in post-operative fever, duration of antibiotic treatment, and hospital stay for patients treated with MP compared to those treated with T/C.

Since 1980, 35 patients (age range 40-77 years) with severe forefoot ischemia have undergone a unilateral Syme amputation. Thirty-one patients (89%) were diabetic. The indication for amputation was either extensive forefoot gangrene or ulceration too advanced for a digital or transmetatarsal amputation. Twenty-two amputations (63%) were immediately preceded by either percutaneous transluminal angioplasty (four) or a bypass procedure to the popliteal artery (five) or an infrapopliteal artery (13). Primary healing occurred in 19 (86%) of 22 amputations immediately preceded by revascularization and in 10 (77%) of 13 limbs undergoing amputation alone. Twenty-eight (97%) of the 29 patients with successful primary healing were successfully rehabilitated. Rehabilitation rendered 13 patients fully ambulatory, 15 ambulatory with intermittent use of a walker or cane and one unable to walk. At follow-up of four months to 13 years (mean 42 months), the cumulative ambulatory rate at 1, 3, and 5 years was 92, 80 and 80%, respectively. Syme amputation allows a return to a functional ambulatory status in a high percentage of patients with severe forefoot ischemia. These findings suggest that Syme amputation is an acceptable option in dysvascular patients with severe forefoot ischemia.

Surgical repair of an abdominal aortic aneurysm in conjunction with radical cystectomy and orthotopic urinary diversion can be safely performed without morbidity secondary to excessive blood loss, operative time, or vascular graft infection. The techniques required for this combined procedure and a case report are discussed.

During a 62-month period, carbon dioxide was used to supplement or completely replace iodinated contrast agents in performing 27 transluminal angioplasties in 26 patients. The arterial segments addressed included the following: renal in two cases, iliac in five, femoral/popliteal in 15, infrapopliteal in two, and combined in three. Indications for intervention included lower extremity gangrene in 11 cases, ischemic ulceration in 10, rest pain in three, claudication in one, and ischemic nephropathy in two. Contraindications to iodinated contrast agents included renal insufficiency resulting from diabetes (n = 20) or ischemic nephropathy (n = 2) and congestive heart failure (n = 4). Eight procedures used carbon dioxide as the sole contrast agent, whereas 19 required supplementation of carbon dioxide with a mean of 39 ml of nonionic contrast medium. Technical success was achieved in 25 procedures with significant hemodynamic improvement in 20 patients. Complications included transient deterioration in renal function in two patients and myocardial infarctions in two. At 30 days 18 patients had demonstrated significant clinical improvement. Patients at high risk for iodinated contrast-related complications may undergo transluminal angioplasty using carbon dioxide/digital subtraction arteriography to reduce or eliminate the need for iodinated contrast agents.

This report describes the surgical management of 24 patients with concurrent abdominal aortic aneurysm (AAA) and urinary tract neoplasm. The patient population consisted of 22 men and two women whose average age was 65.5 years. AAA sizes ranged from 3.1 to 9.0 cm (mean 5.2 cm) in diameter. Urinary tract neoplasms included transitional cell carcinoma (TCC) of the bladder (n = 19), adenocarcinoma of the prostate (n = 3), and TCC of the renal pelvis (n = 2). Urologic procedures included radical prostatectomy, radical nephroureterectomy, and radical cystoprostatectomy with continent or ileal loop urinary diversion. The AAA was resected at the time of the urologic procedure in 12 patients (group I) or prior to the urologic procedure in five patients (group II) and was left in situ in seven patients (group III: AAA diameter 3.1 to 5.5 cm). All patients but one in group I recovered without complications. One patient developed an infection postoperatively as a result of fluid collection anterior to the aortic vascular graft; the fluid was successfully drained and the patient subsequently recovered uneventfully. All patients in group II had a marked retroperitoneal desmoplastic reaction at the time of the urologic procedure as a result of prior aneurysmectomy, which complicated the ureteral dissection. One patient later required an ileal ureteral reconstruction for obliterative fibrosis of the ureter. At a mean follow-up of 34 months, no infectious or mechanical complications of the vascular prosthesis occurred in group I or II. Eight patients in group I and two in group II are alive. Three have died of metastatic disease and two of myocardial infarction. Of the seven patients in group III, four subsequently required AAA resection for an increase in AAA size and three have died.(ABSTRACT TRUNCATED AT 250 WORDS)

Objective: The authors examined the natural history of choledochal cysts in adults treated surgically., Background: An initial diagnosis of choledochal cyst is uncommon in adults. The recommended treatment is excision, rather than bypass, to achieve effective biliary drainage and because of the risk of cancer., Methods: A retrospective study of 27 adult patients was completed to determine the frequency of anastomotic complications and the incidence of cancer., Results: Fifteen patients were treated by cyst excision, and one developed an anastomotic stricture, treated by percutaneous dilation. Eight of 11 patients treated by cyst enterostomy required additional surgery for anastomotic revision. A final patient was treated by T-tube drainage. Five of the seven patients with cancer have died at a mean of 21.6 months., Conclusion: This experience documents the high incidence of cancer (26%), and high rate of stricture after cyst enterostomy (73%). The dismal prognosis once cancer has developed warrants cyst excision, even in asymptomatic patients, including those with prior cyst enterostomies.

Study Objective: To determine the appropriate compartmental and noncompartmental pharmacokinetic parameters for intravenous piperacillin and tazobactam., Design: Sequential selection of patients entered into a randomized, open-label clinical efficacy trial., Setting: Los Angeles County-University of Southern California Medical Center., Participants: Sequential sample of 18 patients admitted for intraabdominal infections and consented into a comparative antibiotic trial., Interventions: Patients received piperacillin 4 g plus tazobactam 500 mg by intravenous intermittent infusion every 8 hours., Measurements and Main Results: The estimated noncompartmental pharmacokinetic parameters (mean +/- SD) for piperacillin and tazobactam, respectively, were as follows: maximum concentration in plasma 218.7 +/- 48.9 micrograms/ml and 27.8 +/- 9.1 micrograms/ml; half-life 1.07 +/- 0.22 hours and 1.00 +/- 0.27 hours; elimination rate constant 0.67 +/- 0.13 hr-1 and 0.73 +/- 0.18 hr-1; area under the concentration-time curve from zero hour to infinity 288.5 +/- 71.25 mg.hr/L and 36.3 +/- 9.55 mg.hr/L; total plasma clearance 14.75 +/- 3.93 L/hour and 14.78 +/- 4.39 L/hour; renal clearance 5.69 +/- 1.94 L/hour and 7.85 +/- 3.37 L/hour; volume of distribution at steady state 21.00 +/- 4.18 L and 22.47 +/- 8.27 L; and mean residence time 1.72 +/- 0.29 hours and 1.79 +/- 0.35 hours., Conclusion: Our findings were similar to those in other surgical patient models. The two-compartmental model best described piperacillin and tazobactam disposition in our patients. Bayesian analyses of the two-compartment models of piperacillin and tazobactam were able to predict trough, peak, and 2-hour postadministration levels without bias.

Between 1989 and 1993, 97 patients with stages B3 and/or C nonseminomatous germ cell tumors of the testes underwent induction chemotherapy followed by retroperitoneal lymph node dissection. Of these patients 6 (ages 22 to 41 years) had gross extension of tumor into the aortic adventitia at operation, which necessitated en bloc aortic and, on 3 occasions, iliac artery resection for complete tumor removal. Aortic continuity was restored by a woven Dacron tube or bifurcated graft. All grafts were covered with omentum. There were no postoperative vascular complications. Pathological study of the residual retroperitoneal disease demonstrated that 2 patients had mature teratoma only, 2 had mature teratoma with occasional nests of immature teratoma and 2 had residual yolk sac, embryonal or choriocarcinoma elements. The latter 2 patients underwent postoperative salvage chemotherapy with varying combinations of bleomycin, etoposide, ifosfamide and cisplatin. At 4 to 55 months 4 patients were disease-free, while 2 died of metastatic disease. No problems related to the aortic reconstruction have occurred. This small experience demonstrates that, if necessary, complete surgical en bloc extirpation of bulky metastatic germ cell tumors and the aorta/iliac artery can be performed safely with a satisfactory long-term outcome.

Objective: To examine the evolving operative strategies in the treatment of recurrent pyogenic cholangitis (RPC)., Design: Case series of patients with RPC treated surgically at the Los Angeles County-University of Southern California Medical Center between 1980 and 1994., Setting: Public teaching hospital., Patients: Twenty patients with RPC were studied. The clinical diagnosis of RPC was made in patients with a syndrome of chronic intermittent attacks of biliary sepsis associated with intrahepatic biliary strictures and intrahepatic stones., Main Outcome Measure: The need for repeated biliary intervention after surgical treatment of RPC., Results: Four patients had a hepatic lobectomy without biliary enteric bypass. One patient had an uneventful course. Three patients had postoperative biliary sepsis, and one of these patients died. A hepaticojejunostomy without a cutaneous stoma was performed in eight patients. Five (63%) of these eight required repeated operation for biliary sepsis 1 to 4 years after surgery. In eight patients, a Roux-en-Y hepaticojejunostomy was performed after attempted clearance of intrahepatic stones with construction of a temporary cutaneous stoma. Postoperatively, these eight patients had 16 transstomal endoscopic cholangiograms (mean follow-up, 10 months). Stones proximal to intrahepatic strictures were identified in seven endoscopic sessions in five of these patients (63%). The stones were removed, and the strictures were endoscopically dilated. None required repeated biliary operation., Conclusion: RPC is a progressive, lifelong disease. Construction of a hepaticojejunostomy with a cutaneous stoma allows future therapeutic intervention without the need for repeated surgery.

The Program on the Surgical Control of the Hyperlipidemias (POSCH) was a secondary atherosclerosis intervention trial employing partial ileal bypass surgery as the intervention modality. For this report, we analyzed 105 subgroups in 35 variables in POSCH, chosen predominantly for their potential relationship to the risk of atherosclerotic coronary heart disease (ACHD). We defined potential differential effects as those with: (1) an absolute z-value > or = 2.0 for the subgroup, if the absolute z-value for the overall effect was < 2.0; and (2) an absolute z-value > or = 3.0 for the subgroup and a relative risk < or = 0.5, if the absolute z-value for the overall effect was > or = 2.0. For each of three major POSCH endpoints of overall mortality, ACHD mortality and ACHD mortality or confirmed nonfatal myocardial infarction, we found seven subgroups with a differential risk reduction in the surgery group as compared to the control group. Allowing for identical subgroups for more than one endpoint, there were 13 individual subgroups with differential effects. Of these, seven demonstrated internal consistency across endpoints, and five of these seven displaced external consistency with known ACHD risk factors and for biological plausibility: triglyceride concentration > or = 200 mg/dl; cigarette smoking; overt or borderline diabetes mellitus; a Minnesota ECG Q-QS code of 1-1; and obesity. A greater risk reduction, in comparison to the overall treatment effect, by the reduction of a single risk factor, hypercholesterolemia, in patients with at least two major ACHD risk factors was a provocative and an hypothesis-generating outcome of this analysis. The clinical implications of this finding may lead to more aggressive cholesterol intervention in patients with multiple ACHD risk factors.

Costs involved in using piperacillin 4 g/tazobactam 500 mg, given as intermittent intravenous infusions every 8 hours, were compared with those for imipenem/cilastatin 500 mg, given as intermittent intravenous infusions every 6 hours, for the treatment of patients with gangrenous or perforated appendicitis. A total of 88 patients were included in our cost analyses: 42 patients in the piperacillin/tazobactam group and 46 patients in the imipenem/cilastatin group. Durations (mean +/- SD) of antibiotic therapies were 7.8 +/- 3.3 days and 7.1 +/- 2.6 days for the piperacillin/tazobactam and imipenem/cilastatin groups, respectively. No statistical significance was found for the difference in duration of therapy (P = 0.376). Total drug treatment costs were $538.83 +/- $385.33 for the piperacillin/tazobactam group and $687.66 +/- $345.37 for the imipenem/cilastatin group. This difference in treatment cost was statistically significant (P = 0.0001). The need for laboratory tests and the use of other medications were not different between the two groups. Total hospital-days charges were higher for the piperacillin/tazobactam group ($18,339.76 +/- $6090.38) compared with the imipenem/cilastatin group ($16,150.00 +/- $5088.60) (P = 0.052). These findings suggest that length of hospital stay should be the economic focus of antibiotic therapy.

Purpose: This study was designed to evaluate a recently introduced form of stripping of primary varicose veins by the technique of perforate-invaginate (PIN) stripping., Methods: One hundred twelve consecutive limbs presenting with 91 long and 21 short saphenous varicosities displaying saphenofemoral or saphenopopliteal junctional escapes with varying length of greater or lesser saphenous (axial) reflux underwent operation in 1 year. All surgeries were performed in an office setting with the patient receiving locoregional anesthetic with use of the invaginated PIN stripping in conjunction with tributary hook-stab avulsion., Results: In the 112 procedures performed, there were no tract hematomas or dysesthesias caused by nerve damage. Postoperative morbidity was nonexistent, permitting all patients to resume normal daily occupational and sporting activities immediately., Conclusions: PIN stripping is an excellent method of invagination stripping. There is a minimal likelihood of vein tearing. Compared with conventional ankle-to-groin (or popliteal fossa) stripping, PIN stripping is minimally invasive, does not cause damage to structures around the vein, does not require convalescence, eliminates the need for a lengthy distal second incision, can be performed in an office setting with the patient receiving locoregional anesthetic, and is most cost-efficient.

During a 20-year period from 1973 to 1992, 109 patients underwent early operation for acute popliteal artery trauma. Clinical variables were analyzed for their association with amputation. Gunshot wounds accounted for the majority of injuries (73%), followed by shotgun wounds (18%), stab wounds (6%), iatrogenic injuries (2%), and lacerations (1%). Fasciotomies were performed selectively in 41% of patients. Seven patients (6%) lost the injured extremity despite arterial repair. The mean time from injury to arterial repair was not significantly different for patients with or without subsequent amputation (8.6 +/- 3.6 and 9.7 +/- 7.4 hours, respectively; p = 0.69). Delay in diagnosis longer than 6 or 12 hours after the injury did not increase the risk of amputation. Other factors not associated with limb loss were preoperative ischemic neurologic deficit or compartmental hypertension, concomitant fracture, and popliteal vein injury. Severe soft tissue injury (p < 0.0001) or postoperative wound sepsis (p < 0.0001) substantially increased the risk of amputation. Delayed fasciotomies were uncommon (4%) but were associated with a significantly increased risk of amputation (p < 0.0001). Vein grafting for arterial repair (p = 0.0017) and shotgun injuries (p < 0.0001) were associated with amputation to the extent that they were related to severe soft tissue injury. The degree of soft tissue trauma and subsequent infection of devitalized tissue limits the success of popliteal arterial repair. Changes in the mechanism of trauma, liberal use of four-compartment fasciotomies, and aggressive management of soft tissue injury resulted in a significant decline in the amputation rate from 21% (4/19) in the first 5 years to 0% (0/39) in the last 5 years of the study.

The most common cause of failure of hemodialysis access sites is stenosis within the site. The stenoses have traditionally been corrected surgically, but endovascular techniques may be an alternative method to treat these flow-limiting lesions and maintain graft patency. Over a recent 17-month period, endoluminal stents to relieve stenoses resistant to balloon dilatation alone were placed in 14 access sites. All sites were located on the upper extremity (13 PTFE bridge grafts and 1 A-V fistula). A total of 20 stents were placed: seven at the venous anastomosis, 12 in the venous outflow tract (including 3 in the subclavian vein), and one within the graft. Nine patients had placement of a single stent, four patients had two stents placed, and one patient had three. An additional eight stenotic lesions within these 14 sites were successfully dilated without need of a stent. After stent placement, these 14 sites have remained functional for a mean of 6.2 months. Four were functioning without further intervention at a mean of 8.5 months. Nine sites occluded at a mean of 4.7 months. The remaining site remained functional until death of the patient 10 months after stent placement. Of the nine failed sites, four developed restenosis at the site of stent placement, four developed stenoses at other sites, and the other site was abandoned. Three stents were placed in subclavian vein stenoses, and none of these has failed. Further study is necessary to determine whether endovascular stenting of dialysis access site stenoses will prove to be a durable, cost-effective alternative to surgical revision.

Intra-arterial thrombolytic therapy is an important advance in the treatment of arterial occlusive disease. Reports of results, morbidity, and mortality have been highly variable. This review was undertaken to assess the recent results of thrombolytic therapy with urokinase (UK) at our institution. From 1988-1992, 42 lower extremities in 41 patients with severe peripheral vascular disease underwent intra-arterial thrombolytic therapy. Sites of occlusion consisted of 6 iliac, 21 superficial femoral, 11 popliteal, and 20 infra-popliteal segments. Lytic therapy consisted of a regional infusion of UK with concomitant heparin anticoagulation. The most common UK loading dose was 250,000 units (60,000-750,000) followed by a continuous infusion of approximately 100,000 units/hour (60,000-240,000) for up to 72 hours. Technical success, defined as partial or total resolution of the arterial occlusions, occurred in 26 (62%) limbs. A concomitant endovascular procedure was required in 19 extremities following successful lysis. Immediate clinical success, defined as restitution of a distal pulse or increase in ABI > 0.10, occurred in 22 of 26 technically successful procedures. The four clinical failures and all 16 technical failures required either a major amputation or revascularization. There were 18 major complications in 18 patients (43%): seven thromboembolic, two arterial dissections, nine hemorrhagic. Seven hemorrhagic complications required transfusion of 1-6 units of blood, and two deaths occurred due to postprocedural hemorrhage, shock, and myocardial infarction. Hemorrhage was not related either to the dose of UK or the duration of UK infusion. A combination of thrombolysis and endovascular intervention can be of significant benefit in selected patients with extremity ischemia. However, complications are frequent and may be lethal.(ABSTRACT TRUNCATED AT 250 WORDS)

The ideal regimen for the prevention of postoperative infections occurring after elective cholecystectomy has been widely debated. This double-blind, randomized study was conducted to compare the effectiveness and safety of cefuroxime with that of cefazolin in 295 patients undergoing elective cholecystectomy who were considered to be at high risk for postoperative infection. Patients were randomly assigned to receive either a single 1.5 gram dose of cefuroxime plus three doses of placebo, or four 1 gram doses of cefazolin. Each regimen was begun 30 to 60 minutes preoperatively and repeated every six hours for three doses postoperatively. Patients were evaluated during the hospitalization period and again at 30 days. All postoperative infections, including remote infections, were included in the definition of failure. Bacteriologic success rates were 95.5 percent in the cefuroxime group and 98.2 percent in the cefazolin group (p > 0.05). Corresponding clinical success rates were 91.4 and 94.9 percent (p > 0.05), respectively. There was no association between intraoperative bile cultures and the risk of failure or the type of microorganism isolated from postoperative infections. Both regimens were well-tolerated. In view of the additional costs and time associated with preparation and administration of multiple doses, a single preoperative 1.5 gram dose of cefuroxime may be a cost-effective alternative to four 1 gram doses of cefazolin in patients undergoing elective cholecystectomy who are at high risk for postoperative infection.

Noncompartmental and compartmental analyses of meropenem disposition in patients receiving 1-g intravenous intermittent infusions every 8 h were performed. Twelve patients (one woman and 11 men) participated in the meropenem pharmacokinetic analysis. Operative findings included perforated appendicitis (five patients), gangrenous appendicitis (five patients), peri-appendical abscess (one patient), and gunshot wound to the abdomen (one patient). The most common associated adverse drug reactions to meropenem were diarrhea and increased liver enzymes. The estimated noncompartmental pharmacokinetic parameters, mean +/- standard deviation, are as follows: maximum drug concentration in plasma, 47.58 +/- 17.59 micrograms/ml; half-life, 1.04 +/- 0.19 h; elimination rate constant, 0.68 +/- 0.12 h-1; area under the concentration-time curve from 0 h to infinity, 57.5 +/- 20.12 micrograms x ml/h; total plasma clearance, 315.40 +/- 71.94 ml/min; renal clearance, 136.7 +/- 89.20 ml/min; volume of distribution at steady state, 26.68 +/- 6.88 liters; and mean residence time, 1.47 +/- 0.28 h. The two-compartment model best described meropenem disposition in our patients. Our findings differed from estimates for healthy volunteers possibly because of the physiologic changes as a result of surgery. Our findings suggest that meropenem (1,000 mg) administered intravenously every 8 h provides adequate concentrations for most intra-abdominal infections.

Phlegmasia cerulea dolens (PCD) is an uncommon, severe form of lower extremity deep venous thrombosis characterized by extremity swelling, cyanosis, and pain. Progression of the thrombotic process may result in extremity gangrene, amputation, and death. The relative value of specific therapeutic regimens in the treatment of this disease remains uncertain. Twelve patients, 9 females and 3 males, with PCD were treated during a 10-year period. Eighteen lower extremities were involved. Pre-existing conditions included malignancy (eight), postoperative state (four), diabetes (three), previous deep venous thrombosis (three), and hypercoagulation (two). Venous gangrene was present in four patients. All patients were treated initially with bedrest, fluid resuscitation, extremity elevation, and systemic high-dose heparin therapy. Five patients had complete resolution with this regimen alone. One patient required cessation of heparin therapy due to heparin-induced thrombocytopenia and developed gangrenous toes. Two patients whose condition failed to respond to heparin therapy underwent catheter-based delivery of urokinase with marked clinical improvement. Four patients, two with venous gangrene, died, three of whom had disseminated malignant disease. A significant percentage of patients with PCD will respond to extremity elevation, fluid resuscitation, and aggressive systemic anticoagulation therapy. Thrombolytic therapy selectively administered is beneficial in patients whose disease fails to respond promptly. Venous thrombectomy should be reserved for patients with contraindications to thrombolysis.

Thrombosis of central veins has become more prevalent because of increased use of long-term central venous catheterization. Candida superinfection of the thrombus can occur particularly in patients on long-term antibiotic therapy and on parenteral nutrition. Removal of the catheter, thrombolytic therapy, anticoagulation, and antifungal therapy with amphotericin B will usually eradicate the candidemia and restore venous patency. Occasionally this therapeutic regimen fails. This case report illustrates such a failure in which multiple pulmonary emboli could have caused death. Surgical thrombectomy of the innominate vein effectively removed the source of the Candida sepsis and maintained patency of a major vein. Thrombectomy should be considered as a therapeutic option in septic central vein thrombosis.

Effective diagnosis and management of associated vascular injuries is imperative to minimize morbidity after extremity trauma. An algorithm is presented for the diagnostic evaluation of patients with extremity trauma. The value of physical examination and Doppler indices in identifying occult injuries is discussed. The natural history of certain occult, nonocclusive injuries suggests that nonoperative management may be considered. The intraoperative management of major arterial and venous injuries, including current controversies, is addressed also.