Bryan K. Richmond

Effect of contralateral severe stenosis or carotid occlusion on duplex criteria of ipsilateral stenoses: Comparative study of various duplex parameters

PURPOSE This study compares the accuracy of various duplex parameters in grading ipsilateral carotid stenoses in patients with contralateral severe stenoses or occlusion. METHODS Four duplex criteria were correlated to arteriography in 356 carotid arteries in blind fashion: (1) standard criteria: a peak systolic frequency (PSF) of the internal carotid artery (ICA) of > or = 4 kHz was used to diagnose > or = 50% stenosis; (2) new criteria: a PSF of the ICA of > or = 4.5 kHz was used; (3) Fujitani criteria: a PSF of the ICA of > 4.5 kHz and an end-diastolic frequency of < 5.0 kHz was used; (4) internal carotid/common carotid artery (ICA/CCA) PSF ratio of > or = 1.5 was used. RESULTS The standard method overestimated 56 (16%) of 356 stenoses in contrast to 3% for the new method (p < 0.001), and this effect was most evident in the 50% to < 80% stenosis category (30%). The Fujitani method underestimated 97 (27%) of 356 stenoses, and the ICA/CCA ratio overestimated stenoses in 77 (22%) of 356. The overall exact correlation was 94%, 82%, 70%, and 75% for the new, standard, Fujitani, and ICA/CCA ratio, respectively. The kappa statistic and corresponding confidence intervals for the new method (kappa = 0.923, +/- 0.016) are significantly higher (p < 0.001) than those for the standard method (kappa = 0.760, +/- 0.027), the Fujitani method (kappa = 0.608, +/- 0.031), and the ICA/CCA ratio method (kappa = 0.642, +/- 0.051). The overall accuracy in diagnosing > or = 50% ipsilateral stenosis in the whole series was 85% for the standard method, 97% for the new method, 95% for the Fujitani method, and 81% for the ICA/CCA ratio. The new method was superior to the standard and ICA/CCA ratio methods (p < 0.001) and the Fujitani method (p = 0.024). CONCLUSIONS The presence of significant contralateral stenosis (> or = 50%) can lead to overestimation of ipsilateral stenosis if the standard criteria are used; however, this problem can be avoided by using a PSF of the ICA of > or = 4.5 kHz for the diagnosis of > or = 50% stenosis.

Cholecystokinin-Cholescintigraphy in Adults: Consensus Recommendations of an Interdisciplinary Panel

BACKGROUND & AIMS Cholecystokinin-cholescintigraphy (CCK-CS) provides a physiologic, noninvasive, and quantitative method for assessing gallbladder contraction and calculation of a gallbladder ejection fraction (GBEF). At present, it is used most commonly to identify patients with suspected functional gallbladder disorder. However, the methodology of CCK infusion and normal values differ markedly among imaging centers. METHODS This document represents the consensus opinion of an interdisciplinary panel that gathered to assess the current optimal method for performing CCK-CS in adults, potential uses and limitations of CCK-CS, and questions that require further investigation. RESULTS The panel recommended the use of a single, standardized, recently described CCK-CS protocol that involves infusion of 0.02 μg/kg of sincalide over 60 minutes with a normal gallbladder ejection fraction defined as ≥38%. The panel emphasized the need for a large, multicenter, prospective clinical trial to establish the utility of CCK-CS in the diagnosis of functional gallbladder disease. Although not without controversy regarding its clinical utility, the primary indication for CCK-CS at present is the well-selected patient with suspected functional gallbladder disorder. CONCLUSIONS Agreement was reached that the adoption of this standardized protocol is critical to improve how CCK-CS is used to direct patient care and will represent an improvement over the diverse methods currently in use by eliminating the current lack of uniformity and adding both reliability and credibility to the results.

Cholecystokinin-cholescintigraphy in adults: Consensus recommendations of an interdisciplinary panel

Background and aims: Cholecystokinin-cholescintigraphy (CCK-CS) provides a physiologic, noninvasive, and quantitative method for assessing gallbladder contraction and calculation of a gallbladder ejection fraction (GBEF). At present, it is used most commonly to identify patients with suspected functional gallbladder disorder. However, the methodology of CCK infusion and normal values differ markedly among imaging centers. Methods: This document represents the consensus opinion of an interdisciplinary panel that gathered to assess the current optimal method for performing CCK-CS in adults, potential uses and limitations of CCK-CS, and questions that require further investigation. Results: The panel recommended the use of a single, standardized, recently described CCK-CS protocol that involves infusion of 0.02 &mgr;g/kg of sincalide over 60 minutes with a normal GBEF defined as ≥38%. The panel emphasized the need for a large, multicenter, prospective clinical trial to establish the utility of CCK-CS in the diagnosis of functional gallbladder disease. Although not without controversy regarding its clinical utility, the primary indication for CCK-CS at present is the well-selected patient with suspected functional gallbladder disorder. Conclusion: Agreement was reached that the adoption of this standardized protocol is critical to improve how CCK-CS is used to direct patient care and will represent an improvement over the diverse methods currently in use by eliminating the current lack of uniformity and adding both reliability and credibility to the results.

Effect of statins on early and late clinical outcomes of carotid endarterectomy and the rate of post-carotid endarterectomy restenosis.

BACKGROUND This study analyzed the effect of statins on clinical outcomes after carotid endarterectomy (CEA) and the rate of restenosis. STUDY DESIGN We performed a retrospective analysis of prospectively collected data on 500 consecutive CEAs followed at 1, 6, and 12 months and every year. RESULTS There were 299 patients on statins vs 201 without. Combined perioperative MI/death rates were 2.7% vs 4% (p = 0.416) and MI/stroke/death rates were 4% vs 5% (p = 0.607) for statins vs no statins. At mean follow-up (27 months), MI, stroke, and death rates were: 9.7%, 2.3%, and 2.3% vs 9%, 2.5% and 4.5% (p = 0.18) for statins vs no statins, respectively. Diabetic patients not on statins had 4 times more deaths (8.5% vs 2.3%) and twice as many strokes/deaths (10.2% vs 5.3%). Patients with hypercholesterolemia who were not on statins had twice as many deaths (4.3% vs 2.2%). Rates of freedom from stroke/MI/death at 1, 2, 3, and 4 years were: 94%, 90%, 85% and 77% vs 94%, 89%, 85%, and 82% (p = 0.87) for statins vs no statins, respectively. Rates of freedom from death only for patients on statins vs no statins at 1, 2, 3, and 4 years were: 98%, 98%, 97.4% and 97.4% vs 98%, 96%, 94.8% and 94.8%, respectively (p = 0.191). For diabetic patients, rates of freedom from death at 1, 2, 3, and 4 years were 99%, 99%, 97%, and 97% for statins vs 97%, 90%, 90%, and 90% without statins, respectively (p = 0.048). Post-CEA restenosis rates ≥ 50% were not significantly different between statins vs no statins (p = 0.64). CONCLUSIONS Statins significantly lowered death rates in patients with diabetes and tended to lower both death and stroke rates in diabetic patients and patients with hypercholesterolemia. Statins had no effect on post-CEA restenosis.

Utilization of cholecystokinin cholescintigraphy in clinical practice

Cholecystokinin-cholescintigraphy (CCK-HIDA) is commonly performed to evaluate patients with upper abdominal pain thought to be biliary in origin and with a normal gallbladder on abdominal ultrasonography. The nomenclature of this disease entity, based on the finding of an abnormally low gallbladder ejection fraction (GBEF) on the CCK-HIDA examination, varies in the literature and has been known as biliary dyskinesia, gallbladder dyskinesia, functional gallbladder disorder, chronic acalculous cholecystitis, and chronic acalculous biliary dysfunction, just to name a few. For the purposes of this review, we will use the term gallbladder dyskinesia because this is the term most referenced in the surgical literature. Cholecystectomy is commonly recommended as the treatment of choice in these patients. 1 Although used commonly in today’s clinical surgical practice, the CCK-HIDA testing methodology, test interpretation, patient selection, and controversies surrounding long-term treatment outcomes pertaining to surgical intervention for gallbladder dyskinesia are controversial and poorly understood by many practicing clinicians. This review details the controversies surrounding the testing methodology, the method of determining normal vs abnormal CCK-HIDA values, and the data both supporting and questioning its clinical use to select patients for cholecystectomy based on the current available literature. In addition, evidence-based recommendations for the use of CCK-HIDA in clinical practice are presented.

Adult presentation of giant retroperitoneal cystic lymphangioma: Case report

This case describes the rare presentation of a retroperitoneal cystic lymphangioma in a 35 year old female patient. The lymphangioma ultimately progressed to the point of inducing clinical symptoms, thus requiring surgical removal - which was accomplished without incident. The relevant clinical pictures are included for educational value.

Splenic Artery Embolization for the Treatment of Bleeding Gastric Varices Secondary to Splenic Vein Thrombosis

Splenic vein thrombosis can lead to gastric varices. Subsequent upper gastrointestinal bleeding may ensue related to the change in venous outflow to the portal system. Vascular surgeons are infrequently asked to assist in the management of this entity. However, with many vascular surgeons providing diverse endovascular-based interventions, understanding catheter-based solutions is imperative. This report presents a case in which arterial embolization was used to treat gastric variceal bleeding.

New Duplex Criteria for Threshold Stenoses Used in the Asymptomatic Carotid Atherosclerosis Study

The current Doppler frequency spectral criteria used to classify internal carotid artery (ICA) stenosis into 1%-15%, 16%-49%, 50%-79%, 80%-99% stenoses may not be applied to stenoses of >60%, which is used by the Asymptomatic Carotid Atherosclerosis Study (ACAS) to justify carotid endarterectomy. Therefore, this study was done to determine the best duplex frequency criteria to identify? 60% stenosis. Three hundred fifty-six carotid arteries were studied in patients who had both carotid color duplex and arteriography. Correlation of duplex and arteriography was done in blind fashion. Four different duplex criteria were analyzed: (1) the peak systolic frequency (PSF) of the ICA, (2) end-diastolic frequency (EDF) of the ICA, (3) PSF times EDF of the ICA, and (4) the ratio of the PSF of the ICA to the PSF of the common carotid artery. Four optimum criteria were noted: (1) PSF of the ICA of >5 kHz with 98% sensitivity, 75% specificity, 83% positive predictive value (PPV), 96% negative predictive value (NPV), and 87% overall accuracy; (2) EDF of ICA of?2.5 kHz with 82% sensitivity, 96% specificity, 96% PPV, 81% NPV, and 89% overall accuracy; (3) PSF x EDF of the ICA of 15 kHz with 84% sensitivity, 96% specificity, 97% PPV, 83% NPV, and 89% overall accuracy; (4) the ratio of the PSF of the ICA/PSF of the common carotid artery of?2.7 with 85% sensitivity, 86% specificity, 89% PPV, 82% NPV, and 86% overall accuracy. There was no statistically significant difference among these four parameters. A PSF of the ICA of?6.5 kHz had a PPV of 95% and an overall accuracy of 87%, which can be used for clinicians who perform carotid endarterectomy without a preoperative arteriogram. A PSF of the ICA of?5.0 kHz, an EDF of the ICA of >2.5 kHz, and a ratio of the PSF of the ICA/PSF of the common carotid artery of?2.7 have the best overall accuracy in identifying?60% carotid stenosis. A PSF of the ICA of?6.5 kHz had a PPV of 95%, which can be used for clinicians who perform a carotid endarterectomy without preoperative arteriography.

Review and Update on New Horizon in the Management of Venous Ulcers

Chronic venous ulcers (CVUs) contribute to functional deficits and are a source of significant morbidity among the affected population. In addition, they directly impact the quality of life of patients and are a significant economic burden on the health care system. In this review, we critically evaluate the current strategies for treating CVUs that have emerged within the last decade and outlined a suggested algorithm for treating patients with this difficult condition.

Current Update on the Status of Totally Percutaneous Aneurysm Repair

The evolution of minimally invasive procedures to treat aortic aneurysms has expanded to include access interventions as well. Traditionally, groin exposures have been the standard approach for common femoral artery exposure with open cutdown; however, inherent and related complications to that approach have paved the road to the percutaneous approach. Current available evidence from the literature supports the feasibility and the safety of percutaneous endovascular aneurysm repair (PEVAR); however, predictors of success are not well defined. We should examine all available studies (both prospective and retrospective) in order to draw a conclusion and evidence-based outcome for selecting patients who would benefit the most from PEVAR.