Arthur C. Waltman

Aspirin prophylaxis of venous thromboembolism after total hip replacement.

Abstract We assessed aspirin prophylaxis against venous thromboembolism in a prospective, controlled, double-blind study of patients over 40 years of age, who had undergone total hip replacement. Radiographic phlebography was the diagnostic end point. Thromboembolism developed in 11 of 44 patients receiving aspirin, as compared to 23 of 51 receiving the placebo (P<0.03). Unexpectedly, this protection was limited to men. In four of 23 men on aspirin thrombi developed, as compared to 14 of 25 receiving placebo (P<0.01). Corresponding figures for women were seven of 21 versus nine of 26. Review of a similar group of patients receiving aspirin revealed significantly greater protection (P<0.03) in men (three of 15) than in women (15 of 27). These data establish statistically significant prophylaxis in men over the age of 40 by 600 mg of aspirin given twice daily. The absence of a protective effect in women remains unexplained. (N Engl J Med 297:1246–1249, 1977)

Arteriography in the Management of Hemorrhage from Pelvic Fractures

Abstract Localization of the source of massive hemorrhage from pelvic fractures is not often made clinically, and the results of expectant management or of hypogastric artery ligation are frequentl...

Comparison of Warfarin, Low-Molecular-Weight Dextran, Aspirin, and Subcutaneous Heparin in Prevention of Venous Thromboembolism following Total Hip Replacement

In a prospective study of 187 patients without known prior phlebitis who underwent total hip replacement, we compared the efficacy of warfarin, low-molecular-weight dextran, aspirin, and subcutaneous heparin for prevention of postoperative venous thrombi. Detection of thrombi was by phlebography. Warfarin dextran, and aspirin were superior to heparin. There was no significant difference between the effects of warfarin, dextran, and aspirin on the number of patients with fresh thrombi. In reducing the number of thrombi formed, warfarin and dextran were superior to aspirin. For reduction of the prevalence of thrombi in the thigh, the three drugs were equally effective. Significantly fewer bleeding complications occurred with aspirin than with warfarin. Even in patients who received warfarin, dextran, or aspirin, the prevalence of fresh thrombi was high. Thrombi often formed in the thigh without an associated calf thrombus. Fifty-one of fifty-six episodes of thromboembolic disease were clinically silent at the time of detection. The prophylactic use of warfarin or aspirin, followed by warfarin treatment if a thrombus was detected on phlebograms, provided effective protection against pulmonary embolism.

Results of a multicenter study of the modified hook-titanium Greenfield filter

Initial efforts to modify the stainless steel Greenfield filter for percutaneous insertion led to development of a titanium Greenfield filter, which could be inserted by use of a 12F carrier. This device functioned well as a filter but had an unacceptable 30% rate of migration, tilting, and penetration. Therefore a titanium Greenfield filter with modified hooks was developed and has been tested in 186 patients at 10 institutions. Successful placement occurred in 181 (97%); placement of the remainder was precluded by unfavorable anatomy. A contraindication to anticoagulation was the most frequent indication for insertion (75%). All but two were inserted percutaneously, predominantly via the right femoral vein (70%). Initial incomplete opening was seen in four patients (2%), which was corrected by guide wire manipulation and asymmetry of the legs in 10 (5.4%). Insertion site hematoma occurred in one patient, and apical penetration of the cava during insertion occurred in a second patient. Both events were without sequelae. Follow-up examinations were performed at 30 days at which time 35 deaths had occurred. Recurrent embolism was suspected in six patients (3%) and two of three deaths were confirmed by autopsy. Filter movement greater than 9 mm was seen in 13 patients, (11%) and increase in base diameter greater than or equal to 5 mm was seen in 17 patients (14%). CT scanning showed evidence of caval penetration in only one patient (0.8%). Insertion site venous thrombosis was seen in 4/46 (8.7%) patients screened. The modified hook titanium Greenfield filter is inserted percutaneously or operatively through a sheath, eliminating concern for misplacement from premature discharge.(ABSTRACT TRUNCATED AT 250 WORDS)

Arteriographic Management of Hemorrhage Following Pelvic Fracture

Nine patients with massive pelvic hemorrhage were evaluated angiographically. In each case the site of bleeding was identified by pelvic aortography and hemostasis was produced by intra-arterial techniques. Embolization with autologous clotted blood was employed in 8 cases and in one patient bleeding was controlled by proximally occluding the hypogastric artery with an inflated Fogarty catheter balloon.

Angiography in the Management of Aneurysms of the Abdominal Aorta: Its Value and Safety

The course of 190 patients with aneurysm of the abdominal aorta who underwent preoperative aortography was reviewed to determine the safety and usefulness of that procedure. There were no serious complications; minor problems occurred in only four patients and did not affect operative therapy. In 21 patients, the clinical impression of aneurysm was found to be incorrect. Surgically important findings included suprarenal extension of the aneurysm in nine patients, and demonstration of stenotic lesions in the renal arteries (37 patients) or superior mesenteric artery/celiac axis (17 patients). Helpful findings were associated aneurysms (26 patients), multiple renal arteries (28 patients), and occlusive lesions in the lower extremities or aortocranial system in 82 and eight patients respectively. Such information was found useful in planning operative procedures and minimizing operative time and blood loss. In our experience, angiography in patients with aneurysm of the abdominal aorta is both safe and informative.

Clinical outcome of internal iliac artery occlusions during endovascular treatment of aortoiliac aneurysmal diseases.

PURPOSE To determine the clinical outcome of hypogastric artery occlusion in patients who underwent endovascular treatment of aortoiliac aneurysmal disease. MATERIAL AND METHODS From January 1994 to March 1998, 94 patients underwent endovascular treatment of aneurysmal diseases involving the infra-abdominal aorta or iliac arteries. Preoperative and intraoperative radiologic data were reviewed. Discharge summaries, clinic visits, and phone calls formed the basis for clinical follow-up, with a mean follow-up period of 7.3 months (range, 1-24 months). RESULTS Because of the anatomy of the aneurysms, 28 patients required occlusion of one or more hypogastric arteries. One of the 28 patients died of unrelated causes before follow-up. Seven (26%) of the remaining 27 patients developed symptoms attributable to the hypogastric artery occlusions. Five patients developed new buttock or thigh claudication; of these five patients, three with initially mild symptoms noted complete or near complete resolution of symptoms upon follow-up. One patient with originally significant claudication at 2-year follow-up noted near resolution of symptoms. The other patient with severe pain did not improve significantly on final 1-year follow-up before his death (of unrelated causes). Other clinical complications were worsening sexual function in one patient and a nonhealing sacral decubitus ulcer that developed in a debilitated patient in the postoperative setting, which required surgery. No bowel ischemia was observed. CONCLUSION When treating aortoiliac aneurysmal disease through an endovascular approach, the occlusion of internal iliac artery is often necessary but carries with it a small but finite chance of morbidity.

Low-dose warfarin versus external pneumatic compression for prophylaxis against venous thromboembolism following total hip replacement

Lower doses of warfarin are effective in the treatment of proven proximal deep vein thrombosis (DVT), and at a substantially lower risk of bleeding complications than with standard doses. The authors compared low-dose warfarin with external pneumatic compression (EPC) boots for prophylaxis against DVT and efficacy and safety in a population of total hip replacement patients at high risk for DVT and bleeding complications. DVT developed in 12 of 72 patients on low-dose warfarin and 11 of 66 patients on EPC. Both regimens were as efficacious as traditional higher doses of warfarin used in prior studies. No major bleeding complications occurred in either group. Low-dose warfarin appears to be an effective and relatively safe form of prophylaxis against postoperative DVT, as does sequential EPC of the calf and thigh.

Migration of Central Venous Catheters: Implications for Initial Catheter Tip Positioning

PURPOSE To evaluate the change in position of chest wall central venous access catheters (CVACs) after placement. Complication rates associated with catheter tip position were reviewed. PATIENTS AND METHODS Fifty patients (36 women, 14 men) with chest wall CVACs placed in the angiography suite were studied. Catheter migration was calculated as the difference between the carina-catheter tip measurements on immediate supine and upright postprocedure (within 24 hours) chest radiographs. Catheter-related complication data were gathered via telephone interview and review of the medical records. RESULTS Peripheral catheter migration occurred in 49 of 50 patients (average, 3.2 cm +/- 1.8); central catheter migration occurred in one of 50 patients (3.9 cm). Catheter type was the only significant factor that affected the amount of migration; side of insertion or the patients gender were not significant. Catheter malfunction and symptomatic upper extremity venous thrombosis rates tended to be lower in patients with right atrial versus superior vena cava catheters (18% vs 34%), but differences were not significant (P = .202). CONCLUSION Catheter migration after chest wall CVAC placement is a common event. The catheter tip should be initially positioned approximately 3-4 cm more centrally than the desired final position. Further study is necessary of catheter-related complication rates relative to the final position of the catheter tip.

Mesenteric arterial infusions of vasopressin for hemorrhage from colonic diverticulosis

Twenty-four patients with massive rectal hemorrhage and known or subsequently proved colonic diverticular disease had the bleeding site localized by mesenteric angiography and received intra-arterial infusion of vasopressin to arrest the bleeding. In twenty-two patients the bleeding was controlled with the vasopressin infusion whereas in the remaining two, hemorrhage did not stop and surgery was performed. Of the twenty-two patients in whom bleeding was arrested by vasopressin infusion, twelve received no further surgical therapy, five had elective prophylactic surgical resection after a period of hemostasis, and the remaining five underwent segmental resection for bleeding that recurred after cessation of the infusion. Of the twelve patients who were not operated on, three had rebleeding two, four, and twelve months after vasopressin infusion and two of these three patients required surgery. The remaining nine have had no recurrent bleeding for periods ranging from seven to thirty-four months. Of ten patients who had segmental resection after precise localization of the bleeding site and initial control with vasopressin, no one has had recurrent hemorrhage for periods ranging from two to eighteen months.