Joel Berman

Enhanced angiogenesis and growth of collaterals by in vivo administration of recombinant basic fibroblast growth factor in a rabbit model of acute lower limb ischemia dose-response effect of basic fibroblast growth factor

The purpose of this study was to evaluate the effects of exogenous recombinant basic fibroblast growth factor (bFGF) on angiogenesis in severely ischemic tissue beds. We used a two-stage procedure to produce severe ischemia of the hindlimb of 34 New Zealand rabbits. The ischemic hindlimb received intramuscular injection of saline (group A), 1 microgram bFGF (group B), or 3 micrograms bFGF (group C), daily for 2 weeks. Tissue perfusion, skeletal muscle infarction, angiogenesis, and collateral growth were assessed by angiography, transcutaneous oximetry (TcPO2), quantitative spectrophotometric assay of triphenyltetrazolium chloride reduction in muscle, capillary density (capillaries per square millimeter), and capillary per muscle fiber ratio. There were no significant differences in baseline TcPO2 among the three groups for both thigh and calf measurements. Angiography revealed extensive perfusion of the left hindlimb in all the assessed bFGF treated animals. Both thigh and calf TcPO2 values showed a significant increase in all groups over the 14 days ischemia was induced (p less than 0.0001), but the two treatment groups exhibited a much more rapid rise in TcPO2 than the control group (p less than 0.0001). The capillaries per square millimeter and capillaries per muscle fiber ratios were significantly increased in all posttreatment measurements for all animals that received bFGF. The treatment groups with bFGF had a significant (p = 0.025) increase in thigh muscle viability compared with controls based on triphenyltetrazolium chloride reduction. Whereas there was evidence of muscle infarction in both the thighs of groups A and B, there was none in group C.(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective comparison of two expanded polytetrafluoroethylene grafts for linear forearm hemodialysis access: does the manufacturer matter?

BACKGROUND The function and patency of standard 6-mm Goretex (W.L. Gore and Associates, Flagstaff, AZ) and Impra (Impra, Inc., Tempe, AZ) expanded polytetrafluoroethylene (e-PTFE) grafts for hemodialysis as radial-antecubital linear arteriovenous fistulae for dialysis are compared. STUDY DESIGN A randomized clinical trial was conducted in two community dialysis centers and in one hospital-based center serviced by one vascular surgical practice, that performed the access surgery. Selection of linear forearm access, as opposed to other hemodialysis graft configurations, was at the discretion of the surgeon. Candidates for linear grafts had palpable radial pulses with a normal Allen test and normal digital Doppler flow in the hand. Linear grafts were placed using end-to-side anastomoses to the artery and vein, and the graft type was determined by randomization. Primary patency was determined by first episode of thrombosis, first revision, or angioplasty of the graft. Secondary patency after thrombectomy, revision, or angioplasty was determined when the graft was no longer clinically usable, and a new graft needed to be placed as a parallel conduit in the forearm or in another site. Statistical analysis was by actuarial life-table methods. RESULTS There were 131 linear forearm grafts in 117 patients. The Impra and Goretex groups were equally matched for gender and major risk factors, except for smoking, which was more common in the Goretex group. Minimum followup was 24 months. Life table primary patencies at 1 year (Impra 43%, Goretex 47%) and at 2 years (Impra 30%, Goretex 26%) were not statistically different (p = 0.78); secondary patency was also equal at 1 year (Impra 49%, Goretex 69%) and at 2 years (Impra 33%, Goretex 41%) (p = 0.15). Discontinuance of use of a patent graft, complications, episodes of thrombosis, and the need to replace the original graft occurred in the two groups without a statistically significant difference. CONCLUSIONS In the linear forearm position from the radial artery to an antecubital vein, there is no difference in the performance of 6-mm standard e-PTFE grafts on the basis of manufacturer, whether Goretex or Impra. On the basis of performance, linear forearm dialysis grafts are an acceptable method for hemodialysis access.

Carotid endarterectomy. Clinical results in a community-based teaching hospital.

Since 1971, 688 consecutive carotid endarterectomies were performed in 612 patients in a community-based teaching hospital by 16 surgeons; 82% of the procedures were performed in patients who had suffered a transient ischemic attack, amaurosis fugax, or a previous stroke. Seven patients (1%) died, five of perioperative stroke and two of myocardial infarction. Thirty-one patients suffered a perioperative stroke (4.5% of the 688 endarterectomies); 20 patients (2.9% of 688) were left with moderate to severe neurologic deficits. The combined mortality/major neurologic deficit morbidity rate (number of patients divided by number of endarterectomies) is 3.2%. Both operative mortality and morbidity have progressively declined in successive 5-year periods, with no deaths and a 2.7% stroke rate in 148 endarterectomies performed after 1984. Our results indicate that carotid endarterectomy as practiced in a community-based teaching hospital can be performed without excessive risk.

Male college students' compliance with testicular self-examination

The role of the physician and written educational material were assessed for effectiveness in increasing the regular performance of monthly testicular self-examination (TSE) by male college students. Of 633 students from three New England colleges, 4.7% (n = 30) performed monthly TSE. These respondents then received written material or written material plus a physicians lecture on testicular cancer and TSE. In follow-up, 18% of the students that received written material alone (n = 24 of 130) reported performing monthly TSE. Of the students that also received a physicians lecture, 36% (n = 58 of 163) reported performing monthly TSE, a statistically significant increase in performance. Still the majority of the students followed did NOT adopt the practice of monthly TSE. Although the physician appears to be able to make a significant difference in the groups performance of TSE, a search for more effective methods to increase this populations practice of TSE should be sought.

Coumarin Skin Necrosis in a Patient with Heparin-Induced Thrombocytopenia — A Case Report

A patient with evidence of both heparin-related thrombocytopenia and coumarin-induced skin necrosis is presented. Etiology, diagnostic evaluation, histopathology, and therapeutic options are discussed.

Effects of Acute Lower Limb Ischemia on Femoral Venous Efflux

Revascularization of an acutely ischemic limb may lead to the development of a reperfusion syndrome, characterized by acidosis, hyperkalemia, myoglobinuria, and disseminated intravascular coagulation. The authors evaluated the components of the femoral venous efflux after reperfusion of an acutely ischemic limb in both an experimental model and in a small clinical series.

Blunt Axillary Artery Injury in Children — Case Reports

The authors report 2 cases of acute axillary artery thrombosis in children with blunt trauma. The incidence and etiology of this injury are discussed, par ticularly as they relate to injury of the great vessels in blunt chest trauma. Diagnostic and therapeutic approaches are outlined for this uncommon but po tentially disabling condition.

Upper Arm Arteriovenous Bridge Grafts for Hemodialysis

Upper arm arteriovenous bridge grafts are often required after failure of more distal access grafts. A retrospective review was performed comparing 57 brachioaxillary bridge grafts fistulas (BAGF) with 79 brachiosubclavian bridge graft fistulas (BSGF) performed over a twelve-year period. There was no statistical difference in primary or secondary patency rates. There was a statically higher rate of infection in the BSGF group (p<05). while thrombosis was more com mon in the BAGF group (p<.05)

Revascularization of an abdominal aortic aneurysm after surgical exclusion : case report and literature review

A high-risk patient underwent exclusion of an abdominal aortic aneurysm with aortofemoral bypass. During the procedure a horseshoe kidney was found to be overlying the aorta. Postoperatively retrograde perfusion of the aneurysm via a recanalized right iliac artery occurred and led to doubling of the aneu rysms size, necessitating reoperation. The operative approach and pertinent literature are reviewed.

A paraprosthetic-enteric fistula associated with a duodenal tumor.

An unusual etiology and presentation of a paraprosthetic-enteric fistula is reported involving a duodenal tumor. Review of the possible mechanisms of graft-enteric fistula formation and diagnostic evaluation is presented. Initial insertion of an extraanatomic bypass followed by graft excision was performed in the present case and is encouraged in hemodynamically stable patients. Additionally, resection of the eroded duodenum with end-to-end anastomosis was performed in order to restore intestinal continuity.