Twelfth rib resection as an approach for portal vein cannulation in sheep.
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A surgical technique involving resection of the twelfth rib was used to insert silastic cannulas into the portal veins of three sheep to study amino acid metabolism. Good exposure to the vein was achieved by this method although it required positive ventilation due to the penetration of the thoracic cavity. All cannulas were buried subcutaneously and exteriorized near the dorsal midline. This facilitated continuous infusion into the portal cannula without disturbing cannula placement. (+info)
Transcatheter closure of patent foramen ovale using the Amplatzer septal occluder to prevent recurrence of neurological decompression illness in divers.
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OBJECTIVE: Large flap valve patent foramens may cause paradoxical thromboembolism and neurological decompression illness in divers. The ability of a self expanding Nitinol wire mesh device (Amplatzer septal occluder) to produce complete closure of the patent foramen ovale was assessed. PATIENTS: Seven adults, aged 18-60 years, who had experienced neurological decompression illness related to diving. Six appeared to have a normal atrial septum on transthoracic echocardiography, while one was found to have an aneurysm of the interatrial septum. METHODS: Right atrial angiography was performed to delineate the morphology of the right to left shunt. The defects were sized bidirectionally with a precalibrated balloon filled with dilute contrast. The largest balloon diameter that could be repeatedly passed across the septum was used to select the occlusion device diameter. Devices were introduced through 7 F long sheaths. All patients underwent transthoracic contrast echocardiography one month after the implant. RESULTS: Device placement was successful in all patients. Device sizes ranged from 9-14 mm. The patient with an aneurysm of the interatrial septum had three defects, which were closed with two devices. Right atrial angiography showed complete immediate closure in all patients. Median (range) fluoroscopy time was 13.7 (6-35) minutes. Follow up contrast echocardiography showed no right to left shunting in six of seven patients and the passage of a few bubbles in one patient. All patients have been allowed to return to diving. CONCLUSION: The Amplatzer septal occluder can close the large flap valve patent foramen ovale in divers who have experienced neurological decompression illness. Interatrial septal aneurysms with multiple defects may require more than one device. (+info)
Central autonomic activation by intracisternal TRH analogue excites gastric splanchnic afferent neurons.
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Intracisternal (ic) injection of thyrotropin-releasing hormone (TRH) or its stable analogue RX 77368 influences gastric function via stimulation of vagal muscarinic pathways. In rats, the increase in gastric mucosal blood flow evoked by a low ic dose of RX 77368 occurs via release of calcitonin gene-related peptide from capsaicin-sensitive afferent neurons, most probably of spinal origin. In this study, the effect of low ic doses of RX 77368 on afferent impulse activity in splanchnic single fibers was investigated. The cisterna magna of overnight-fasted, urethan-anesthetized Sprague-Dawley rats was acutely cannulated, and fine splanchnic nerve twigs containing at least one fiber responsive to mechanical probing of the stomach were isolated at a site immediately distal to the left suprarenal ganglion. Unit mechanoreceptive fields were encountered in all portions of the stomach, both superficially and in deeper layers. Splanchnic afferent unit impulse activity was recorded continuously during basal conditions and in response to consecutive ic injections of saline and RX 77368 (15-30 min later; 1.5 or 3 ng). Basal discharge rates ranged from 0 to 154 impulses/min (median = 10.2 impulses/min). A majority of splanchnic single units with ongoing activity increased their mean discharge rate by >/=20% after ic injection of RX 77368 at either 1.5 ng (6/10 units; median increase 63%) or 3 ng (19/24 units; median increase 175%). Five units lacking impulse activity in the 5-min before ic RX 77368 (3 ng) were also excited, with the onset of discharge occurring within 1.0-5.0 min postinjection. In units excited by ic RX 77368, peak discharge occurred 15.6 +/- 1.3 min after injection and was followed by a decline to stable activity levels +info)
Central venous catheter exchange by guidewire for treatment of catheter-related bacteraemia in patients undergoing BMT or intensive chemotherapy.
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Current guidelines for the treatment of catheter-related bacteraemia (CRB) advise against central venous catheter (CVC) exchange because of the potential risk of prolonging infection. However, there are no consistent data proving this recommendation. We evaluated prospectively the usefulness of CVC exchange by guidewire for the treatment of CRB in patients undergoing BMT or intensive chemotherapy. CVC exchange was considered when fever and positive blood cultures persisted after 2 days of adequate antimicrobial therapy and no potential source of bacteraemia other than CVC could be identified. The guidewire exchange was preceded and followed by a slow infusion of adequate antimicrobial therapy. Bacteraemia was confirmed as catheter-related by demonstrating concordance between isolates from the tip and blood cultures by pulsed-field electrophoresis of genomic DNA. This procedure was performed in 19 episodes of bacteraemia during a 1-year period. Fourteen episodes (74%) were catheter-related and 71% of these were due to coagulase-negative staphylococci. Guidewire replacement was accomplished uneventfully 4 days after development of sepsis (range 3-6). In all cases, clinical signs of sepsis disappeared in less than 24 h after replacement. Definitive catheter withdrawal was carried out a median of 16 days (range 3-42) after guidewire exchange; in all cases, the tip culture was negative. We conclude that CVC replacement by guidewire under adequate antimicrobial therapy may be a reasonable option for the treatment of CRB when antimicrobial therapy alone has been unsuccessful. (+info)
Tranilast suppresses vascular chymase expression and neointima formation in balloon-injured dog carotid artery.
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BACKGROUND: Activation of vascular chymase plays a major role in myointimal hypertrophy after vascular injury by augmenting the production of angiotensin (ANG) II. Because chymase is synthesized mainly in mast cells, we assumed that the chymase-dependent ANG II formation could be downregulated by tranilast, a mast cell-stabilizing antiallergic agent. We have assessed inhibitory effects of tranilast on neointima formation after balloon injury in the carotid artery of dogs, which share a similar ANG II-forming chymase with humans, and further explored the pathophysiological significance of vascular chymase. METHODS AND RESULTS: Either tranilast (50 mg/kg BID) or vehicle was orally administered to beagles for 2 weeks before and 4 weeks after balloon injury. Four weeks after the injury, remarkable neointima was formed in the carotid arteries of vehicle-treated dogs. Chymase mRNA levels and chymaselike activity of vehicle-treated injured arteries were increased 10.2- and 4.8-fold, respectively, those of uninjured arteries. Angiotensin-converting enzyme (ACE) activity was slightly increased in the injured arteries, whereas ACE mRNA levels were not. Tranilast treatment completely prevented the increase in chymaselike activity, reduced the chymase mRNA levels by 43%, and decreased the carotid intima/media ratio by 63%. In vehicle-treated injured arteries, mast cell count in the adventitia showed a great increase, which was completely prevented by the tranilast treatment. Vascular ACE activity and mRNA levels were unaffected by tranilast. CONCLUSIONS: Tranilast suppressed chymase gene expression, which was specifically activated in the injured arteries, and prevented neointima formation. Suppression of the chymase-dependent ANG II-forming pathway may contribute to the beneficial effects of tranilast. (+info)
Results of three to 10 year follow up of balloon dilatation of the pulmonary valve.
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BACKGROUND: The results of immediate and short term follow up of balloon dilatation of the pulmonary valve have been well documented, but there is limited information on long term follow up. OBJECTIVE: To evaluate the results of three to 10 year follow up of balloon dilatation of the pulmonary valve in children and adolescents. SETTING: Tertiary care centre/university hospital. DESIGN: Retrospective study. METHODS AND RESULTS: 85 patients (aged between 1 day and 20 years, mean (SD) 7.0 (6.4) years) underwent balloon dilatation of the pulmonary valve during an 11 year period ending August 1994. There was a resultant reduction in the peak to peak gradient from 87 (38) to 26 (22) mm Hg. Immediate surgical intervention was not required. Residual gradients of 29 (17) mm Hg were measured by catheterisation (n = 47) and echo Doppler (n = 82) at intermediate term follow up (two years). When individual results were scrutinised, nine of 82 patients had restenosis, defined as a peak gradient of 50 mm Hg or more. Seven of these patients underwent repeat balloon dilatation of the pulmonary valve: peak gradients were reduced from 89 (40) to 38 (20) mm Hg. Clinical evaluation and echo Doppler data of 80 patients showed that residual peak instantaneous Doppler gradients were 17 (15) mm Hg at long term follow up (three to 10 years, median seven), with evidence for late restenosis in one patient (1.3%). Surgical intervention was necessary to relieve fixed infundibular stenosis in three patients and supravalvar pulmonary stenosis in one. Repeat balloon dilatation was performed to relieve restenosis in two patients. Actuarial reintervention free rates at one, two, five, and 10 years were 94%, 89%, 88%, and 84%, respectively. Pulmonary valve regurgitation was noted in 70 of 80 patients at late follow up, but neither right ventricular dilatation nor paradoxical interventricular septal motion developed. CONCLUSIONS: The results of late follow up of balloon dilatation of the pulmonary valve are excellent. Repeat balloon dilatation was performed in 11% of patients and surgical intervention for subvalvlar or supravalvar stenosis in 5%. Most patients had mild residual pulmonary regurgitation but right ventricular volume overload was not required. Balloon dilatation is the treatment of choice in the management of moderate to severe stenosis of the pulmonary valve. Further follow up studies should be undertaken to evaluate the significance of residual pulmonary regurgitation. (+info)
Balloon-artery interactions during stent placement: a finite element analysis approach to pressure, compliance, and stent design as contributors to vascular injury.
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Endovascular stents expand the arterial lumen more than balloon angioplasty and reduce rates of restenosis after coronary angioplasty in selected patients. Understanding the factors involved in vascular injury imposed during stent deployment may allow optimization of stent design and stent-placement protocols so as to limit vascular injury and perhaps reduce restenosis. Addressing the hypothesis that a previously undescribed mechanism of vascular injury during stent deployment is balloon-artery interaction, we have used finite element analysis to model how balloon-artery contact stress and area depend on stent-strut geometry, balloon compliance, and inflation pressure. We also examined superficial injury during deployment of stents of varied design in vivo and in a phantom model ex vivo to show that balloon-induced damage can be modulated by altering stent design. Our results show that higher inflation pressures, wider stent-strut openings, and more compliant balloon materials cause markedly larger surface-contact areas and contact stresses between stent struts. Appreciating that the contact stress and contact area are functions of placement pressure, stent geometry, and balloon compliance may help direct development of novel stent designs and stent-deployment protocols so as to minimize vascular injury during stenting and perhaps to optimize long-term outcomes. (+info)
How can videolaparoscopy be used in a peritoneal dialysis programme?
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BACKGROUND: Recently videolaparoscopy is considered to have a vaster use in surgery due to the undeniable benefits such as low operatory traumatism, quick recovery of canalization, a short stay in the hospital and minor scarring. METHODS: Forty patients were treated with peritoneal dialysis (PD); 15 videolaparoscopic procedures were performed on 13 patients before starting PD and two during the course of PD. The videolaparoscopy procedure was started by inducing pneumoperitoneum after initiation of general anaesthesia through endotracheal intubation. RESULTS: Peritoneal catheter placement was carried out in 11 ESRD patients showing abdominal scars due to previous laparotomies; their abdominal condition precluded safe PC placement using conventional non-laparoscopic procedures with local anaesthesia. Release of adhesions was performed only in two patients. Videolaparoscopy was also used in three patients for elective cholecystectomy; 2/3 underwent concomitant PC insertion. One patient was submitted to cholecystectomy during the course of CAPD; following the procedure we left the peritoneum dry overnight and then we started temporary IPD, using small volumes, avoiding haemodialysis (HD). Regular CAPD was resumed 6 days later. Finally, videolaparoscopy was also used for diagnostic purpose i.e. in one 59-year-old man patient who had a peritoneal catheter obstruction. Repeated rescue attempts using urokinase solution to irrigate the peritoneal catheter had been used in vain attempts prior to the procedure. CONCLUSIONS: Videolaparoscopy proves to be a useful tool in a PD programme. Firstly, it may be used as a technique for catheter implantation, not as a routine procedure but in patients with extensive abdominal scars due to previous laparotomy, i.e. at risk for accidental viscera perforation due to the possibility of adhesions between intestinal loops and parietal peritoneum. Secondly, videolaparoscopy used for abdominal surgery allows the resumption of PD immediately after surgical procedure and thus avoiding HD. Videolaparoscopy is fundamental for diagnosis and rescue of catheter dysfunction and has an integral role in the successful management of these patients in extending catheter function and permitting safe replacement of peritoneal catheter if it becomes necessary. Along with the undeniable advantages, remains the disadvantages that it must be carried out by an expert surgeon in an operating theatre while the patient is under general anaesthesia. (+info)