Andrew B. Roberts

Giant Splenic Artery Aneurysm

Giant aneurysms of the splenic artery are uncommon. The mean size of splenic artery aneurysms is reported to be 2.1 cm; they are rarely larger than 3 cm. We present two cases in which the splenic artery aneurysm was larger than 8 cm, discuss the management and operative approach to these infrequently encountered entities, and provide a brief review of the relevant literature.

Association of Carotid Artery Intima-Media Thickness with Complex Aortic Atherosclerosis in Patients with Recent Stroke

This study was undertaken to determine whether carotid intima-media thickness can predict complex aortic atherosclerosis. A retrospective review was conducted of 64 consecutive patients who underwent transesophageal echocardiography and carotid ultrasonography for evaluation of recent ischemic stroke at MCP Hahnemann University, Medical College of Pennsylvania Hospital between January 1, 1999, and December 31, 1999. The mean age was 65 ± 14 years and 59% of the patients were women. Thirty-nine patients (61 %) had carotid atherosclerosis (defined as an intima-media thickness ≥ 1 mm) and seven patients (11%) had complex aortic atherosclerosis (defined as the presence of protruding atheroma ≥4 mm thick, mobile atherosclerotic debris, or plaque ulceration in any aortic segment by transesophageal echocardiography). Compared to patients without complex aortic atherosclerosis, patients with complex aortic atherosclerosis were more likely to have hypercholesterolemia (19% vs 57%, p = 0.05) and a carotid intima-media thickness of 2 mm or greater (35% vs 86%, p = 0.02). A carotid intima-media thickness of 2 mm or more had 86% sensitivity, 65% specificity, 23% positive predictive value, 97% negative predictive value, 2.5 positive likelihood ratio, and 0.22 negative likelihood ratio for the diagnosis of complex aortic atherosclerosis. Carotid intima- media thickness measurement can be used to noninvasively estimate the probability of complex aortic atherosclerosis. A carotid intima-media thickness less than 2 mm makes complex aortic atherosclerosis very unlikely.

Toe amputation in the diabetic patient.

BACKGROUND We considered whether it is more practical to amputate the toe of a diabetic patient with osteomyelitis and good circulation or to treat the patient with antibiotics for a prolonged period. METHODS We undertook a retrospective study of 141 diabetic patients who had undergone a toe-ray amputation for proven or documented osteomyelitis. RESULTS The mean ankle/brachial index of all patients was 0.81 (range, 0.68 to 1.14); the mean functional days lost on antibiotic therapy was 39 (range, 7 to 84 days). The cost of 6 to 8 weeks of preoperative antibiotic therapy was

Correlation of venography, venous pressure, and hemoaccess function

900 to

Response of Cutaneous Laser Velocimetry to a Temperature Change: Normal and Dysvascular Patients Compared

2240 (mean,

Percutaneous Transluminal Angioplasty in the Treatment of Vein Graft Stenosis

1440). CONCLUSIONS Diabetic patients with good circulation and osteomyelitis of the toe may benefit from prompt toe amputation.

Changing Patterns in the Diagnosis and Treatment of Pancreaticoduodenal Artery Aneurysms A Case Report

We analyzed the anatomic features of both grafts and fistulas and correlated these features with access function. We also attempted to determine venous pressures predicting access dysfunction (critical venous pressures) at various blood flow rates (BFRs). Therefore, accesses of 46 chronic hemodialysis patients were studied by venography in a prospective fashion. We defined the incidences of various lesions and the effects of venous collaterals on graft function, and determined critical venous pressures at various BFRs. Eighty-three percent of the accesses had outflow obstruction. Five types of anatomic lesions were identified. The incidences were venous stenosis of the draining vein immediately proximal to the venous anastomosis, 36.4%; central vein, 23.6%; venous anastomosis, 25.5%; arterial anastomosis, 10.9%; and intragraft hyperplasia, 3.6%. Twelve patients had multiple lesions. When the homogenous polytetrafluoroethylene arm graft population was studied for the effect of venous collaterals, we found that venous collaterals conferred protection but did not prevent graft failure. Venous pressure measurements were good predictors of access failure at the lower BFRs. Venous pressures increased with increasing BFRs. A critical venous pressure of 145 mm Hg was found for a BFR of 250 mL/min. At a BFR of 300 mL/min, the critical venous pressure was 170 mm Hg. A critical venous pressure could not be found for a BFR of 400 mL/min.

Stationary Arterial Wave Phenomena

In previous studies of skin blood flow using a helium flux technique, we found a linear relationship between blood flow and skin temperature. In this paper we compared the helium flux method to laser Doppler velocimetry (LDV) over a range of temperatures in 5 normal healthy volunteers. In a separate normal group we measured the increase in LDV signal to a temperature change in both the volar aspect of the forearm and the dorsum of the foot. We then compared the LDV temperature response data from the normal subjects with data from a group of 20 patients with known peripheral vascular disease of the lower extremities and found a highly significant reduction in LDV output vs temperature in the patient groups. We concluded that the LDV temperature response data provide a convenient method for comparison of LDV data be tween patients and between sites on the same patient.

Failed Vascular Reconstructive Procedures with Profoundly Ischemic Limbs—Treated by Lumbar Sympathectomy

Vein graft stenosis is a precursor to graft failure and its management is controversial. The authors reviewed their experience with percutaneous transluminal angioplasty (PTA) for these lesions. Thirty-one infrainguinal vein grafts (30 patients) underwent 59 PTAs at 44 different sites. Mean patient age was 66.7 years, and 17 (57%) were men. Hemodynamically significant lesions (>50% diameter reduction) were established by duplex scan or angiography. All patients had follow-up duplex graft surveillance. Determination of recurrence was based on duplex criteria (peak systolic velocity >200 cm/sec, velocity ratio >2). PTA outcomes at 3 months were divided into successful and unsuccessful categories. Eight stenoses were excluded from this assessment secondary to follow-up < 3 months. All bypass grafts were patent through their last evaluation. Ninety percent of lesions (46/51) received adequate initial dilations. The successful group (41/51 lesions, 80%) had a mean follow-up of 10.8 months (range 3.0-26.3). In this group, 12 lesions recurred with a mean time from PTA of 5.3 months (range 3.0-13.6). Of the 10 unsuccessfully treated lesions, five were angioplasty failures and five recurred within 3 months. The distal anastomosis was the most unsuccessful location to be treated (P=0.01). The length of the lesions and the age of the graft did not influence outcome (P>0.05). There were two complications from PTA: an occlusion effectively treated with thrombolytic therapy and one distal embolization. In conclusion, 80% (41/51) of stenoses treated with PTA were successful for at least 3 months. Two thirds of first-time lesions were stenosis-free at 1 year. PTA is a safe, reasonable method for the management of vein graft stenosis. The distal anastomosis is the most difficult site to manage.

Thyrocervical trunk transection : A rare cause of massive hemothorax

An aneurysm of the pancreaticoduodenal artery was identified in a 60-year-old woman with the primary complaint of epigastric pain that radiated through to her back. A computerized tomography (CT) scan with contrast established the initial diagnosis; an angiogram confirmed the diagnosis and vascular anatomy. The aneurysm was opened and a reverse saphenous vein reestablished circulation.