Jock R. Wheeler

Primary tumors of the aorta: report of a case and review of the literature.

A patient with an unusual vascular tumor, an angiosarcoma of the upper abdominal aorta, is described. The clinical, radiologic and pathologic features of this case along with 19 previously reported cases of primary aortic tumor are discussed. Primary aortic neoplasms are uncommon. They are histologically and morphologically diverse tumors in which major vascular obstruction and arterial tumor embolization dominates the clinical picture. At present, aortography combined with computerized tomography offer the best means of preoperative diagnosis.

Subfascial perforator vein ablation: comparison of open versus endoscopic techniques.

Purpose: To compare the outcomes and complications of open (OSPS) versus endoscopic subfascial perforator surgery (SEPS) for treatment of chronic venous insufficiency. Methods: Data were retrospectively collected on 25 patients who underwent 27 SEPSs from February 1996 to August 1997 and from 22 patients who underwent 29 OSPSs between March 1978 and May 1993. Outcomes were evaluated for postoperative complications, ulcer healing, recurrence, and venous dysfunction scores on the last follow-up for the SEPS group and at 1-year follow-up for the OSPS group. Results: The 2 groups were similar in age, sex, history of previous venous surgery, healed or active ulcers, etiology, deep venous incompetency, pathophysiology, and venous refill times. Eighteen (90%) of 20 active ulcers in the SEPS group healed with recurrences in 5 (28%) limbs at 7.5 ± 5.4-month follow-up. All 19 ulcers in the OSPS group healed, with recurrences in 13 (68%) limbs at 35 ± 35-month follow-up. Clinical venous dysfunction scores showed significant improvement following SEPS (10.0 ± 3.6 to 5.4 ± 4.1, p < 0.001) and OSPS (10.0 ± 3.2 to 6.7 ± 3.6, p < 0.001) with no significant difference between groups. Both groups also had significant improvement in anatomical and disability scores. There was no postoperative mortality in either group. The OSPS group had significantly more wound complications (45%) than the SEPS group (7%) (p < 0.005). The hospital stay and readmission rate for wound problems were also higher in the OSPS group. Conclusions: The early outcome showed equal improvement in clinical venous dysfunction scores in the 2 groups, but with significantly fewer complications in the SEPS group. Although the long-term durability of the endoscopic approach has not been determined, the short-term results would favor SEPS for treatment of severe venous insufficiency when perforator incompetence is a significant component.

Arterialization of reversed autogenous vein grafts: Quantitative light and electron microscopy of canine jugular vein grafts harvested and implanted by standard or improved techniques***

To provide sequential, quantitative analysis of the cellular events occurring in reversed autogenous vein grafts after implantation and potential modifications of these events, two groups of veins were evaluated. Veins prepared by standard techniques of unmonitored pressure distension with cold heparinized saline solution, tributary ligation adjacent to the wall, and storage at 4 degrees C were morphometrically compared with veins harvested by means of a modified protocol of papaverine irrigation, tributary ligation away from the graft wall, pressure distension to 100 mm Hg with heparinized blood containing papaverine at body temperature, storage in identical solution at 4 degrees C, and implantation while distended. Unilateral jugular veins harvested from dogs with the modified technique (IRJV,N = 9) or standard technique (SRJV,N = 9) were implanted into carotid arteries, retrieved at 30 minutes, 2 days, and 10 days postoperatively along with the contralateral control vein after perfusion fixation in situ, and examined microscopically to quantitate intimal-medial thickness and endothelial damage (denudation and ultrastructural alterations). All IRJVs remained endothelialized, whereas SRJVs had 19% and 40% endothelial denudation at 30 minutes and 2 days, respectively, as well as massive neutrophil, platelet, and monocyte involvement. In contrast, IRJVs had only a modest infiltration of monocytes beginning early after implantation and culminating in their localization beneath endothelial cells; these endothelial cells increased in number during the 10-day period. Although SRJVs exhibited nearly complete reendothelialization over the luminal surface of macrophages by 10 days, endothelial damage was consistently higher than that of IRJVs at all periods and intimal-medial thickness was significantly greater at 10 days (65 +/- 0 vs. 57 +/- 0 micron, respectively; p less than 0.001). These findings suggest that endothelial preservation with improved harvesting techniques inhibits thrombosis and limits wall thickening and also that macrophages may play a protective role by promoting endothelial proliferation.

A comparison of surgery for neurogenic thoracic outlet syndrome between laborers and nonlaborers

OBJECTIVEnTo determine factors of outcome following surgical intervention for neurologic thoracic outlet syndrome (NTOS).nnnMETHODSnIn a retrospective study of patients surgically treated for NTOS, outcome was evaluated by postoperative symptoms and the ability of patients to return to work.nnnRESULTSnGood, fair, and poor results were obtained in 26 (48%), 21 (39%), and 7 (13%) patients, respectively. The best predictor of a good outcome was occupation. Nonlaborers were more likely to have good outcome (21 of 32, 66%) when compared with laborers (5 of 22, 23%; P = 0.0025). Only 6 of 20 (30%) laborers were able to return to their original occupation compared with 17 of 26 (65%) nonlaborers (P = 0.036).nnnCONCLUSIONSnLaborers with NTOS are less likely to have a good result from surgical intervention, are unlikely to return to their original occupation, and may require retraining for a non-labor-intensive occupation if they cannot return to their original work.

Duplex Scanning for the Intraoperative Assessment of Infrainguinal Arterial Reconstruction: A Useful Tool?

Duplex scan, arteriography, and graft flow rates were used intraoperatively to assess 56 infrainguinal arterial reconstructions for technical error. Intraoperative duplex scan identified a technical defect or low graft flow velocity in 22 of 56 (39%) grafts. Eleven of the defects were judged to be clinically significant and were corrected. Four of these defects were missed by the completion arteriogram. One technical defect identified by completion arteriography was missed by duplex scan. Fifty percent (5/10) of grafts with an abnormal intraoperative duplex scan which were not corrected occluded within 30 days. Graft flow rates measured by the electromagnetic flowmeter were neither predictive of technical defect nor early graft outcome. Although the sensitivity of arteriography and duplex scan (88% sensitivity for both) were both high for predicting early graft occlusion, the combination of duplex scan and completion arteriography was significantly more accurate (p<.0001) in predicting early graft outcome than either study alone. Duplex scan identified significant graft defects which were not detected by completion arteriography or graft flow rate measurement. The duplex scan also provided hemodynamic information which was predictive of early graft outcome. The duplex scan can be an important adjunct to completion arteriography for the intraoperative assessment of infrainguinal arterial reconstruction.

The Kensey catheter: Preliminary results with a transluminal atherectomy tool

The Kensey dynamic angioplasty instrument is an atherectomy device approved by the Food and Drug Administration that uses a rotating cam tip housed within a flexible polyurethane catheter to recanalize obstructed and stenotic arteries. Twenty patients with significant femoral arteriosclerotic occlusive disease underwent attempted transluminal endarterectomy of 23 extremities with the Kensey catheter. Significant improvements of superficial femoral artery luminal diameter was achieved in 10 of 13 patients with stenosis and passage of the spinning catheter tip at 60,000 to 90,000 rpm through areas of complete occlusion was successful in 4 of 10 cases. Balloon dilatation was used as an adjunct to increase the diameter of the superficial femoral artery lumen in 11 of 14 successful cases. This preliminary report provides technical data and short-term follow-up of this new innovative vascular tool.

Vein Harvest Ischemia: A Peripheral Vascular Complication of Coronary Artery Bypass Grafting

Lower-extremity ischemia can lead to impaired healing of saphenous vein excision sites in patients with significant peripheral vascular disease (PVD). Five patients who required infrainguinal revascularization for wound necrosis of the harvest site after coronary artery bypass grafting are described. The male/female ratio was 2:3 with a mean age of 67 (range 45-87) years. The most commonly associated problems were insulin-dependent diabetes mellitus (80%) and congestive heart failure (60%). The saphenous vein was harvested from the thigh and leg in three patients and exclusively from the leg in the others. Manifestations of ischemia ranged from persistent ulceration to complete wound disruption threatening limb loss. Impaired healing was isolated to infragenicular wounds in all patients. Pedal pulses were not detected in any of the affected extremities. Determination of the ankle/brachial pressure indices (ABI) revealed values of < 0.5 in three affected limbs. Non-compressible vessels resulted in falsely raised ABI of > 1.0 in the remaining two limbs; however, Doppler waveform analysis in these patients demonstrated significant PVD. Aggressive wound care and antibiotic therapy were continued for mean of 9 weeks before operative intervention. Infrainguinal reconstruction included femoropopliteal (two), femorotibial (two) and popliteal-tibial bypass (one). Autologous arm and saphenous veins in addition to expanded polytetrafluoroethylene grafts were used effectively. Limb salvage and wound healing were achieved in 100% of the patients without untoward sequelae. It is concluded that unrecognized PVD in patients undergoing coronary artery bypass grafting can lead to significant morbidity. Patients at risk may be identified with a combination of history, physical examination and non-invasive testing. In limbs with ABI < 0.5 or significantly abnormal Doppler-derived waveforms, alternate sites of vein harvesting should be sought. Nonetheless, once wound necrosis develops as a result of vascular insufficiency, this study supports lower-extremity revascularization to achieve healing and limb salvage.

Angioscopic Evaluation of Valvular Disruption During In Situ Saphenous Vein Bypass

Several valvulotomes are currently available to achieve valvular disruption; however, studies comparing the efficacy of these endoluminal instruments are lacking. This prospective study evaluates the efficacy and safety of the three most commonly employed valve cutters: the Hall, LeMaitre, and Mills valvulotomes. A total of 30 in situ greater saphenous vein bypass grafts were included in this investigation. Valvular disruption was attempted with either the LeMaitre (11 cases), Hall (12 cases), or Mills (7 cases) valvulotomes. Subsequently, angioscopy was employed to assess the completeness of valvulotomy and to identify vein wall injury. Incomplete disruption of one or more valve complexes was identified in 2 of 12 (17%) grafts in the Hall group, 10 of 11 (91%) grafts in the LeMaitre group, and 0 of 7 grafts in the Mills group (p <0.01). Intact valve cusps were noted in 2 of 36 (5.5%) valves, 31 of 42 (74%) valves, and 0 of 38 valves after valvulotomy with the Hall, LeMaitre, and Mills instruments, respectively (p <0.01). A total of three valvulotome-related injuries occurred; two injuries were noted in conjunction with the Hall instrument, one was associated with the Mills valvulotome, and no injuries were detected after use of the LeMaitre instrument (p=0.33). These data demonstrated a significantly increased incidence of retained valve cusps when the LeMaitre valvulotome was used. No significant difference in the rate of vein wall injury was noted in the three groups. Thus this study suggests that the LeMaitre instrument is not as effective as either the Hall or Mills valvulotomes for achieving valvular disruption.

Complications of End-to-Side Renal Artery Anastomosis in Renal Transplant Infection

In most circumstances an end-to-side anastomosis is an acceptable alternative. However, in the presence of an infected transplanted kidney, major complications directly related to the end-to-side anastomosis may occur. Three cases are presented in which serious complications developed following an end-to-side anastomosis. Similar problems have been reported, but the anastomotic construction has rarely been identified as a significant factor.4~ 5

Gore-Tex autogenous vein composite grafts for tibial reconstruction

The concept of composite grafts for revascularization of the ischemic lower extremity has been reported on numerous occasions. We have utilized this technique for approximately 8 years as an alternative for those patients who do not have an adequate length of autogenous vein for bypass grafting. We have studied composites utilizing Gore-Tex and umbilical vein for the prosthetic portion with autogenous saphenous vein, cephalic vein, or endarterectomized superficial femoral artery. Subsequent evaluation has led us to discontinue the use ofendarterectomized superficial femoral artery, as we believe that this is not a satisfactory autogenous component. Whenever possible, satisfactory angiograms are obtained prior to tibial bypass surgery; when this is not possible, intraoperative angiograms are utilized to demonstrate distal tibial circulation and to determine the site of distal anastomosis. Two, and sometimes three, operating teams are employed to minimize operating time, with one team constructing the prosthetic autogenous vein anastomosis on a separate table. Improved magnification, such as 21/2 • power magnification, is used in all cases. For the composite anastomosis and all tibial anastomoses, meticulous technique utilizing fine sutures in the form of 6-0 and 7-0 Prolene is stressed. The tibial vessels are handled in an atraumatic fashion using either vessel loops or intraluminal occluders and avoiding the use of clamps. We have stressed technique in harvesting the autogenous vein, utilizing atraumatic dissection, and irrigation of the graft with gradual distention not to exceed 100 mm Hg with a solution of heparinized autogenous whole blood containing papaverine. After harvesting, the grafts are stored in the same solution at 4 ° C. Following completion of the distal tibia] anastomosis, angiograms are performed in each case. No effort has been made to procure sufficient length of autogenous material to cover the crossing of the joint surface, as this has not proved a