Non-cardiogenic pulmonary oedema in vascular surgery.
Non-cardiogenic pulmonary oedema, an early manifestation of the adult respiratory disease syndrome, is a serious complication following major vascular surgery. Hypovolaemia, ischaemia-reperfusion injury, massive blood transfusion, transient sepsis and transient endotoxaemia are insults responsible for initiating the process in vascular surgical patients. Free radicals, cytokines and humoral factors released secondary to the above insults activate neutrophils and facilitate their interaction with the endothelium. Activated neutrophils marginate through the endothelium where they are responsible for tissue injury by the release of free-radicals and proteases. The lungs are a large reservoir of neutrophils and bear a significant part of the injury. Conventional therapy includes treating the underlying condition and providing respiratory support. A better understanding of the pathophysiology of this process has led to new experimental treatment options. Novel therapeutic interventions have included the use of compounds to scavenge free radicals, anti-cytokine antibodies, extracorporeal lung support, nitric oxide and artificial surfactant therapy. The multifactorial nature of this process makes it unlikely that a single "magic bullet" will solve this problem. It is more likely that a combination of preventative, prophylactic and therapeutic modalities may reduce the mortality of this condition. (+info)
The endovascular management of blue finger syndrome.
OBJECTIVES: To review our experience of the endovascular management of upper limb embolisation secondary to an ipsilateral proximal arterial lesion. DESIGN: A retrospective study. MATERIALS AND METHODS: Over 3 years, 17 patients presented with blue fingers secondary to an ipsilateral proximal vascular lesion. These have been managed using transluminal angioplasty (14) and arterial stenting (five), combined with embolectomy (two) and anticoagulation (three)/anti-platelet therapy (14). RESULTS: All the patients were treated successfully. There have been no further symptomatic embolic episodes originating from any of the treated lesions, and no surgical amputations. Complications were associated with the use of brachial arteriotomy for vascular access. CONCLUSIONS: Endovascular techniques are safe and effective in the management of upper limb embolic phenomena associated with an ipsilateral proximal focal vascular lesion. (+info)
Atherosclerosis of the ascending aorta is an independent predictor of long-term neurologic events and mortality.
OBJECTIVES: This study was undertaken to determine whether atherosclerosis of the ascending aorta is a predictor of long-term neurologic events and mortality. BACKGROUND: Atherosclerosis of the thoracic aorta has been recently considered a significant predictor of neurologic events and peripheral embolism, but not of long-term mortality. METHODS: Long-term follow-up (a total of 5,859 person-years) was conducted of 1,957 consecutive patients > or =50 years old who underwent cardiac surgery. Atherosclerosis of the ascending aorta was assessed intraoperatively (epiaortic ultrasound) and patients were divided into four groups according to severity (normal, mild, moderate or severe). Carotid artery disease was evaluated (carotid ultrasound) in 1,467 (75%) patients. Cox proportional-hazards regression analysis was performed to assess the independent effect of predictors on neurologic events and mortality. RESULTS: A total of 491 events occurred in 472 patients (neurologic events 92, all-cause mortality 399). Independent predictors of long-term neurologic events were: hypertension (p = 0.009), ascending aorta atherosclerosis (p = 0.011) and diabetes mellitus (p = 0.015). The independent predictors of mortality were advanced age (p < 0.0001), left ventricular dysfunction (p < 0.0001), ascending aorta atherosclerosis (p < 0.0001), hypertension (p = 0.0001) and diabetes mellitus (p = 0.0002). There was >1.5-fold increase in the incidence of both neurologic events and mortality as the severity of atherosclerosis increased from normal-mild to moderate, and a greater than threefold increase in the incidence of both as the severity of atherosclerosis increased from normal-mild to severe. CONCLUSIONS: Atherosclerosis of the ascending aorta is an independent predictor of long-term neurologic events and mortality. These results provide additional evidence that in addition to being a direct cause of cerebral atheroembolism, an atherosclerotic ascending aorta may be a marker of generalized atherosclerosis and thus of increased morbidity and mortality. (+info)
Stripping the long saphenous vein reduces the rate of reoperation for recurrent varicose veins: five-year results of a randomized trial.
OBJECTIVE: The purpose of this study was to investigate the possible long-term clinical advantages of stripping the long saphenous vein during routine primary varicose vein surgery. METHODS: The study was designed as a 5-year, clinical and duplex scan follow-up examination of a group of patients who were randomized to stripping of the long saphenous vein during varicose vein surgery versus saphenofemoral ligation alone. The study was conducted in the vascular unit of a district general hospital. One hundred patients (133 legs) with uncomplicated primary long saphenous varicose veins originally were randomized. After invitation 5 years later, 78 patients (110 legs) underwent clinical review and duplex scan imaging. RESULTS: Sixty-five patients remained pleased with the results of their surgery (35 of 39 stripped vs 30 of 39 ligated; P = .13). Reoperation, either done or awaited, for recurrent long saphenous veins was necessary for three of 52 of the legs that underwent stripping versus 12 of 58 ligated legs. The relative risk was 0.28, with a 95% confidence interval of 0.13 to 0.59 (P = .02). Neovascularization at the saphenofemoral junction was responsible for 10 of 12 recurrent veins that underwent reoperation and also was the cause of recurrent saphenofemoral incompetence in 12 of 52 stripped veins versus 30 of 58 ligated legs. The relative risk was 0.45, with a 95% confidence interval of 0.26 to 0.78 (P = .002). CONCLUSION: Stripping reduced the risk of reoperation by two thirds after 5 years and should be routine for primary long saphenous varicose veins. (+info)
Video-assisted crossover iliofemoral obturator bypass grafting: a minimally invasive approach to extra-anatomic lower limb revascularization.
Graft infection continues to be one of the most feared complications in vascular surgery. It can lead to disruption of anastomoses with life-threatening bleeding, thrombosis of the bypass graft, and systemic septic manifestations. One method to ensure adequate limb perfusion after removal of an infected aortofemoral graft is extra-anatomical bypass grafting. We used a minimally invasive, video-assisted approach to implant a crossover iliofemoral obturator bypass graft in a patient with infection of the left limb of an aortofemoral bifurcated graft. This appears to be the first case report describing the use of this technique. (+info)
Posterior approach to the deep femoral artery.
Unusual surgical approaches to the deep femoral artery are valuable when the standard anterior approach is difficult because of scarring or infection. A posterior approach to the deep femoral artery in patients, in whom all other approaches were unsuitable, is described. (+info)
Access to occluded infrainguinal bypass grafts with a loopsnare.
Thrombolysis for the treatment of occluded bypass grafts is used in selected clinical circumstances. Unfortunately, a minority of these procedures are technical failures because of the inability to access the occluded graft. We describe a technique that greatly increases the chances of technical success. (+info)
The importance of surgeon volume and training in outcomes for vascular surgical procedures.
PURPOSE: Mortality and morbidity rates after vascular surgical procedures have been related to hospital volume. Hospitals in which greater volumes of vascular surgical procedures are performed tend to have statistically lower mortality rates than those hospitals in which fewer procedures are performed. Only a few studies have directly assessed the impact of the surgeon's volume on outcome. Therefore, the purpose of this study was to review a large state data set to determine the impact of surgeon volume on outcome after carotid endarterectomy (CEA), lower extremity bypass grafting (LEAB), and abdominal aortic aneurysm repair (AAA). METHODS: The Florida Agency for Health Care Administration state admission data from 1992 to 1996 were obtained. The data included all nonfederal hospital admissions. Frequencies were calculated from first-listed International Classification of Diseases-9 codes. Multiple logistic regression was used to test the significance on outcome of surgeon volume, American Board of Surgery certification for added qualifications in general vascular surgery, hospital size, hospital volume, patient age, and gender. RESULTS: During this interval, there were 31,172 LEABs, 45,744 CEAs, and 13,415 AAAs performed. The in-hospital mortality rate increased with age. A doubling of surgeon volume was associated with a 4% reduction in risk for adverse outcome for CEA (P =.006), an 8% reduction for LEAB, and an 11% reduction for AAA ( P =.0002). However, although hospital volume was significant in predicting better outcomes for CEA and AAA procedures, it was not associated with better outcomes for LEAB. Certification for added qualifications in general vascular surgery was a significant predictor of better outcomes for CEA and AAA. Certified vascular surgeons had a 15% lower risk rate of death or complications after CEA (P =.002) and a 24% lower risk rate of a similar outcome after AAA (P =.009). However, for LEAB, certification was not significant. CONCLUSION: Surgeon volume and certification are significantly related to better patient outcomes for patients who undergo CEA and AAA. In addition, surgeons with high volumes demonstrated consistently lower mortality and morbidity rates than did surgeons with low volumes. Hospital volume for a given procedure also is correlated with better outcomes. (+info)