John H. Matsuura

Transposed basilic vein versus polytetrafluorethylene for brachial-axillary arteriovenous fistulas

BACKGROUND Both transposed basilic vein (BV) and polytetrafluorethylene (PTFE) upper arm arteriovenous fistulas (AVF) are common angioaccess operations. To evaluate the patency and complication rates after AVF, a concurrent series of patients was reviewed. METHODS Ninety-eight patients underwent brachial artery to axillary vein AVF: 30 BV and 68 PTFE. The PTFE grafts were performed in the standard fashion, whereas the basilic veins were translocated subcutaneously to the brachial artery. RESULTS Risk factors were similar between the two groups. Basilic vein AVF had better patency at 24 months (70% BV versus 46% PTFE, P = 0.023). The dialysis access complications were higher in the BV group (20%) versus PTFE (5%), but the PTFE group had a higher infection rate (10%) than BV (0%). CONCLUSIONS The primary and secondary patency rates were superior in the BV AVFs. The BV AVF preserves the venous outflow tract after AVF thrombosis for a future PTFE AVF operation.

Traumatic Carotid Artery Dissection and Pseudoaneurysm Treated With Endovascular Coils and Stent

PURPOSE To report a case of post-traumatic internal carotid artery dissection and pseudoaneurysm formation at the C-1 level successfully treated by a percutaneous endovascular technique. METHODS AND RESULTS A 20-year-old female presented 72 hours after a motor vehicle accident with incomplete occulosympathetic paresis (Horners syndrome), carotidynia, and leftsided 1.5-cm x 2.5-cm pseudoaneurysm at the C-1 level. Neuroradiologists embolized the pseudoaneurysm with Guglielmi detachable coils and controlled the dissection with placement of a Wallstent. CONCLUSIONS This report illustrates successful percutaneous endovascular treatment of a carotid dissection and pseudoaneurysm near the base of the skull.

Comparison between the transabdominal and retroperitoneal approaches for aortic reconstruction in patients at high risk

PURPOSE The purpose of this study was to compare the transabdominal approach with the retroperitoneal approach for elective aortic reconstruction in the patient who is at high risk. METHODS From January 1992 through January 1997, 148 patients underwent aortic operations: 92 of the patients were classified as American Society of Anesthesia (ASA) class IV. Forty-four operations on the patients of ASA class IV were performed with the transabdominal approach (25 for abdominal aortic aneurysms and 19 for aortoiliac occlusive disease), and 48 operations were performed with the retroperitoneal approach (27 for abdominal aortic aneurysms and 21 for aortoiliac occlusive disease). There were no significant differences between the groups for comorbid risk factors or perioperative care. RESULTS Among the patients of ASA class IV, eight (8.7%) died after operation (retroperitoneal, 3 [6.26%]; transabdominal, 5 [11.3%]; P =.5). There was no difference between groups in the number of pulmonary complications (retroperitoneal, 23 [47.9%]; transabdominal, 19 [43.2%]; P =.7) or in the development of incisional hernias (retroperitoneal, 6 [12.5%]; transabdominal, 5 [11.3%]; P =.5). The retroperitoneal approach was associated with a significant reduction in cardiac complications (retroperitoneal, 6 [12.5%]; transabdominal, 10 [22.7%]; P =.004) and in gastrointestinal complications (retroperitoneal, 5 [8.3%]; transabdominal, 15 [34.1%]). Operative time was significantly longer in the retroperitoneal group (retroperitoneal, 3.35 hours; transabdominal, 2.98 hours; P =.006), as was blood loss (retroperitoneal, 803 mL; transabdominal, 647 mL; P =.012). The patients in the retroperitoneal group required less intravenous narcotics (retroperitoneal, 36.6 +/- 21 mg; transabdominal, 49.5 +/- 28.5 mg; P =.004) and less epidural analgesics (retroperitoneal, 39.5 +/- 6.4 mg; transabdominal, 56.6 +/- 9.5 mg; P =.004). Hospital length of stay (retroperitoneal, 7.2 +/- 1.6 days; transabdominal, 12.8 +/- 2.3 days; P =.024) and hospital charges (retroperitoneal,

Iliofemoral Venous Thrombosis Caused by Compression of an Internal Iliac Artery Aneurysm: A Minimally Invasive Treatment

35,587 +/-

Inducible nitric oxide synthase expression in human vein grafts

980; transabdominal,

Vena Caval Filter Placement by Intravascular Ultrasound

54,832 +/-

Popliteal Artery Aneurysm Treated with a Minimally Invasive Endovascular Approach: An Initial Report

1105; P =.04) were significantly lower in the retroperitoneal group. The survival rates at the 40-month follow-up period were similar between the groups (retroperitoneal, 81.3%; transabdominal, 78.7%; P =.53). CONCLUSION In this subset of patients who were at high risk for aortic reconstruction, the postoperative complications were common. However, the number of complications was significantly lower in the retroperitoneal group. Aortic reconstruction in patients of ASA class IV appears to be more safely and economically performed with the retroperitoneal approach.

Tumescent anesthesia reduces pain associated with balloon angioplasty of hemodialysis fistulas

PURPOSE To report the success of a minimally invasive treatment for phlegmasia cerulea dolens without gangrene caused by compression from an internal iliac artery aneurysm. METHODS AND RESULTS An 81-year-old male with a 1-month history of paralysis owing to a hemorrhagic stroke presented with massive edema and skin mottling of the right lower extremity. Imaging confirmed right iliofemoral deep vein thrombosis caused by compression from a 4-cm internal iliac artery aneurysm. With thrombolysis ruled out, a minimally invasive treatment plan was undertaken, featuring percutaneous coil embolization of the aneurysm and surgical venous thrombectomy with proximal arteriovenous fistula creation and iliac vein stent placement. Failure of the coils to embolize the iliac aneurysm prompted the use of an endovascular graft to exclude the aneurysm. The patients symptoms subsided, and he has a patent right iliofemoral venous system and internal iliac artery at his latest (16-month) follow-up. CONCLUSIONS This case demonstrates that minimally invasive endovascular and open techniques can be combined to achieve an optimum outcome in patients at high risk for standard surgical approaches.

Minimally Invasive Vein Harvesting: A Comparison of Endoscopic Versus Traditional Open Saphenectomy:

BACKGROUND The patency of vascular reconstructive procedures is limited by the development of intimal hyperplasia (IH). Nitric oxide (NO) seems to be beneficial in abrogating this process. Currently, there is little information concerning inducible nitric oxide synthase (iNOS), the enzyme responsible for NO synthesis, and human vein grafts. The purpose of this study was to examine iNOS gene expression in human aortocoronary vein grafts (ACVG) and infrainguinal vein bypass grafts (IVG). METHODS Nonthrombosed sections from ACVG (n = 5), IVG (n = 5), and control saphenous vein (SV; n = 4) were harvested and processed for RNA isolation. Quantitative reverse transcription-polymerase chain reaction (RT-PCR) was performed on samples using 32P radioactively end labeled primers. Glyceraldehyde-3-phosphate-dehydrogenase (GAPDH) was the internal control, and results were expressed as iNOS pmol/GAPDH pmol. RESULTS There was a significant increase in the iNOS gene expression in the ACVG (0.049 +/- 0.01) when compared with IVG (0.019 +/- 0.001) or normal SV (0.011 +/- 0.002; P < or = 0.05). There was no significant difference between normal vein and the infrainguinal grafts. Sequencing of a fragment of the amplified 428 bp gene product confirmed 84% homology with the available gene bank human sequence. CONCLUSIONS This study proves that iNOS is expressed in human vein bypass grafts. Additionally, there is a significant elevation of iNOS message in human ACVGs compared with IVG or normal SV. This difference may be the result of the unique vascular beds supplied by these grafts. Ultimately, manipulation of iNOS expression may lead to therapies to alleviate IH in these grafts.

MINIMALLY INVASIVE IN SITU BYPASS

OBJECTIVE Placement of vena caval filters under fluoroscopic surveillance incurs significant expense and potential risks associated with the transportation of critically ill patients. Intravascular ultrasound (IVUS) allows direct intraluminal visualization of the vena cava and the renal veins. The purpose of this study is to evaluate the accuracy of vena caval filter placement under IVUS in an animal model. METHODS Fifteen Simon-Nitinol venal cava filters (C.R. Bard, Inc., Covington, GA) were placed under IVUS guidance into four anesthetized sheep. Twelve were placed transfemorally, and three were placed transjugularly. Accuracy of placement was confirmed with fluoroscopy by measurement between the filter tip and the targeted side branch. RESULTS The vena caval filters placed femorally averaged 0.33+/-0.42 cm distance from the target vein side branch. Jugular approach filter placement was less accurate. Although two out of three filters placed from the jugular vein were correctly positioned, the distance from the target vein side branch was much greater averaging 2.5+/-1.04 cm. CONCLUSION Femoral placement of vena caval filters under IVUS is extremely accurate. The transjugular route, however, was technically challenging and standard fluoroscopic vena caval filter placement appears to be more appropriate. Our success with the femoral approach merits further clinical investigation in the use of IVUS for critically ill patients that would benefit from bedside vena caval filter placement.