Joseph J. Piotrowski

Evidence for lipid peroxidation in atherosclerosis.

Lipid peroxidation may play a significant role in the initiation and progression of atherosclerotic plaque. Freshly harvested normal and atherosclerotic human aortic tissue, coronary arteries and explanted vein grafts were snap frozen at -70 degrees C. Folch reagent (chloroform-methanol 2:1, v/v) was used to extract lipids from the homogenates. These extracts were assayed for cholesterol, phospholipid and triglyceride content. Lipid peroxide complexes in vessels were measured fluorometrically. Atherosclerotic plaque from patients with aortic aneurysmal and occlusive disease and coronary artery disease contained significantly greater amounts of cholesterol (15.54 +/- 9.71 vs 3.39 +/- 1.14 mg/g tissue) than controls (p less than 0.01). Lipid peroxide fluorochromes were similarly elevated in all atherosclerotic tissue (4.159 +/- 1.065 vs 3.087 +/- 0.497 fluoro units/g tissue) compared to control (p less than 0.01) with significant elevations in saphenous vein grafts and occlusive aortic disease. Although lipid peroxidation and lipid accumulation occur in close association in atherosclerotic plaque, the role of lipid peroxides in the pathogenesis of atherosclerosis remains to be determined.

Abdominal aortic aneurysm in the patient undergoing cardiac transplantation

In the past 3 years at our institution 130 patients have undergone cardiac transplantation for ischemic cardiomyopathy in 49 (38%), idiopathic cardiomyopathy in 42 (32%), viral cardiomyopathy in 9 (6.9%), pulmonary hypertension in 8 (6%), and graft atherosclerosis in 2 (1.5%). Routine preoperative abdominal ultrasonography was performed on 98 (75%) of these patients with specific visualization of the abdominal aorta in 93 (95%). Abdominal aortic aneurysms (all infrarenal) were found before operation in four patients and only in the subgroup undergoing transplantation for ischemic heart disease (10.5%). They measured 3.4, 4.5, 3.6, and 3.8 cm before transplantation. Periodic evaluation by ultrasonography was carried out after transplantation during the 3-year period of this study. One aneurysm that was initially 3.6 cm increased to 4.0 cm and ruptured 2 months after transplantation. The patient died despite emergent surgery. Aneurysms in three patients who demonstrated rapid aneurysm expansion after transplantation were successfully repaired at 5, 20, and 33 months after transplantation when the lesions reached 5.5, 5.9, and 4.8 cm. A fifth patient with an initially normal (1.5 cm) aorta developed a symptomatic aneurysm of 4.1 cm, which was repaired uneventfully. The average expansion rate of these aneurysms after transplantation was 0.74 +/- 0.15 cm/year. This experience suggests that aneurysms are limited to patients undergoing transplantation for ischemic heart disease. Ultrasound examination may be appropriate for preoperative screening. Careful aortic surveillance after transplantation is important in patients having transplantation for ischemic cardiomyopathy because of the apparent rapid expansion rate compared to aneurysms in the population not receiving transplants.

Value of radiographs and bone scans in determining the need for therapy in diabetic patients with foot ulcers

Thirty-two diabetic patients with foot ulcers were evaluated. Twenty-five patients had foot radiographs, technetium-99m bone scans, and wound and bone cultures; the remaining seven patients had all the studies except bone scanning. Bone changes compatible with osteitis were present on 15 of 32 foot radiographs (47 percent) and on 16 of 25 bone scans (64 percent). Bacterial growth was present in 27 of 32 wounds (84 percent) and 23 of 32 bone cultures (72 percent). Twelve of 23 patients (52 percent) with positive bone cultures had evidence of bone destruction and periosteal reaction on radiographs. The remaining 11 of 23 patients (48 percent) without radiographic signs of osteitis had bacterial growth from their bone cultures. Bone scans were positive in 12 of 18 patients (67 percent) with positive bone cultures and negative in 6 of 18 positive bone cultures (33 percent). We conclude that neither foot radiographs, technetium-99m bone scans, nor wound cultures should be used as the sole criterion for determining the use of antibiotic therapy or amputation in diabetic patients with foot ulcers.

Oxygen delivery is an important predictor of outcome in patients with ruptured abdominal aortic aneurysms.

OBJECTIVE The purpose of this study was to evaluate the relation of oxygen delivery (DO2) to the occurrence of multiple organ dysfunction (MOD) in patients with ruptured abdominal aortic aneurysms (AAA). SUMMARY BACKGROUND DATA Patients with ruptured AAA are at high risk for the development of MOD and death. Previous reports of high-risk general surgical patients have shown improved survival when higher levels of DO2 are achieved. METHODS Hemodynamic data were collected at 4-hour intervals on 57 consecutive patients (mean age, 70.5 years) who survived 24 hours after repair of infrarenal ruptured AAA. Patients were resuscitated to standard parameters of perfusion (pulse, blood pressure, urine output, normal base deficit). MOD was determined based on six organ systems. Standard parametric (analysis of variance, t tests) and nonparametric (chi square, Wilcoxon) tests were used to compare hemodynamic data, red blood cell requirements, colon ischemia, and organ failure for patients with and without MOD. RESULTS Patients who developed MOD had a significantly lower cardiac index and DO2 for the first 12 hours; the difference was most significant at 8 hours. Logistic regression analysis demonstrated that the strongest predictors of MOD were DO2, early onset of renal failure, and total number of red blood cells transfused. CONCLUSIONS DO2 is an earlier and better predictor of MOD after ruptured AAA than previously identified risk factors. Failure to achieve a normal DO2 in the first 8 hours after repair is strongly associated with the development of MOD and a high mortality. Strategies to restore normal DO2 may be useful to improve outcome in these high-risk patients.

Outcome of complex vascular and orthopedic injuries of the lower extremity

Thirty-two patients undergoing limb salvage procedures for complex vascular and orthopedic injuries of the lower extremity were studied in order to identify prognostic indicators for delayed amputation in this select group. A high incidence of nerve (38%), soft tissue (66%), and remote injury (47%) was noted. A comprehensive and integrated approach to vascular, orthopedic, and plastic reconstruction was utilized. Of the 32 patients studied, 1 (3.1%) died as a result of remote injury and sepsis. Amputation was required in 9 patients (28%), while 13 (56%) of the patients with limb salvage showed persistent functional or neurologic deficits. Infection was the most significant factor associated with amputation (p less than 0.0005) and was not avoided by the perioperative use of antibiotics. Delayed amputation resulted in a significant extension of total hospitalization (p less than 0.005). The authors favor an aggressive approach to limb salvage with IIIC injury but recommend early amputation in the presence of significant nerve disruption. An attentive use of tissue debridement, intravenous antibiotics, and early wound coverage is needed to limit infection.

Effect of chronic consumption of ethanol and vitamin E on fatty acid composition and lipid peroxidation in rat heart tissue

Lipid peroxidation products and the fatty acid composition of phospholipids were studied in the hearts of rats chronically consuming ethanol supplemented with large amounts of vitamin E. Ethanol representing 36% of the total calories was ingested for 7 weeks in a modified Lieber-DeCarli liquid diet that contained vitamin E at 30 IU/L in the control or 172 IU/L in the supplemental dietary group. Ethanol and/or vitamin E did not change the absolute content (micrograms per mg of phospholipids) of the main fatty acids (C18:0, C18:2, and C20:4) of heart phospholipids but increased the amount of the minor C20-C22 fatty acids. Cardiac phospholipid levels increased in rats chronically consuming excess vitamin E and/or alcohol. Chronic ethanol consumption caused elevations of the relative content (percent of total fatty acids) of tri-, tetra-, and hexaenoic acids and peroxidizability index (PI) of the cardiac phospholipids. Supplementation with vitamin E blocked this ethanol-induced shift in the fatty acid profile toward unsaturation and decreased the PI. Ethanol enhanced accumulation of vitamin E in heart tissue by 30% irrespective of the vitamin E content in the diet. Enrichment of the diet with vitamin E coincided with the low levels of fluorescent products in heart lipids. A positive correlation (r = 0.36; p = 2%) was found between vitamin E and diene conjugates in the heart cells. Thus, vitamin E has a stabilizing effect on heart phospholipids by preventing changes in their fatty acid composition and peroxidative deterioration.

Lipid peroxidation: A possible factor in late graft failure of coronary artery bypass grafts☆

Atherosclerosis is the paramount cause of late vein graft failure after coronary artery bypass grafting. Lipid peroxidation, which may play a significant role in the initiation and progression of atherosclerosis, was examined in segments of vein grafts (n = 6) harvested at reoperation for coronary disease. These were analyzed for cholesterol, phospholipid, triglyceride, and lipid peroxides. Nonatherosclerotic vascular tissues, including coronary arteries (n = 6), saphenous veins (n = 9), and donor aortic specimens (n = 11) were analyzed for comparison. Risk factors for atherosclerosis including elevated serum cholesterol and triglycerides, smoking, and hypertension were more frequent in patients with coronary artery disease compared to organ donors. Lipid peroxides were elevated in explanted vein grafts when compared to either saphenous vein, coronary artery or donor aorta. Lipid peroxides were not significantly different in saphenous vein when compared to coronary artery, but levels in both of these tissues were greater than in donor aorta. Although increased levels of lipid peroxides in explanted veins may simply reflect morphologic changes in these grafts, the known effects of lipid peroxides on a number of biochemical events suggest that they may contribute directly to graft failure after coronary artery bypass grafting.

Vascular Steal in Hemodialysis: Still Unpredictable

Vascular steal remains a significant cause of morbidity after placement of access for hemodialysis and has been reported to occur at an incidence of 2-8%. The purpose of this study was to identify which factors may predict the development of steal. A retrospective review of new-access placement over a three-year period revealed 275 procedures on 129 patients. There were 225 (82%) prosthetic conduits and 50 (18%) native fistulas placed. Thrombectomies and revisions were excluded. There were 23 cases (8.4% incidence by access) of steal in 19 patients (15% incidence by patient). The consequences of steal included development of a Volkmanns contracture in 4 patients despite ligation of the access in 3, gangrene with loss of digits in 2 patients, decreased motor function in 3 patients, and refusal of dialysis and subsequent death in 1 patient. Five patients had mild symptoms that resolved spontaneously. Thirty-nine percent (n = 9) of the steal cases occurred in secondand third-access placements. By univariate analysis the factors that predicted steal were increased age (63.1 ± 14 years versus 52.0 ± 16.2 years; P = 0.002), female sex (14.4% in women compared with 1.6% in men; P = 0.003). Diabetes mellitus was also more prevalent (12.3% compared with 3.4% in non-diabetics; P = 0.08) but did not reach statistical significance. There was no relationship to type of access performed, conduit used, and location. When combinations of these factors are fitted to a multivariate logistic regression, the best combination results in only 19% of the variation in outcome (steal) being explained (r = 0.43; P = 0.001). Vascular steal remains a common, serious cause of morbidity in dialysis access placement. Although it is more common in elderly diabetic women, accurate prediction based on clinical variables alone is not possible.

Angioscopic Assessment of Fibrinolysis for Impending In Situ Saphenous Vein Graft Thrombosis

A failing femorotibial in situ saphenous vein bypass graft was found by angioscopic examination to be lined with white thrombus and was successfully treated by intraoperative lytic therapy rather than by thrombectomy with a balloon catheter. The platelet-fibrin debris was completely cleared by 250,000 units of urokinase. There were no bleeding complications and the potential for mechanical damage to the venous endothelium was prevented. The in vivo angioscopic observations of fibrinolysis are described.