Richard J. Feldhaus

Leiomyosarcoma of the inferior vena cava: Analysis and search of world literature on 141 patients and report of three new cases

Leiomyosarcoma of the inferior vena cava is a rare and potentially curable tumor. Uncertainty about the results of treatment derives from lack of a large series in the same center and of a long-term follow-up of the published cases. A review of the world literature from 1871 to 1989 allowed us to collect information on 141 patients with inferior vena cava leiomyosarcoma to which our three cases have to be added. The tumor arose from the lower segment of the inferior vena cava (infrarenal portion) in 49 patients, from the middle segment (from the renal veins to the hepatic veins) in 59, and from the upper segment (from the hepatic veins to the right atrium) in 34 patients. Complete clinical, pathologic, and therapeutic data and up-to-date follow-up have been obtained through personal correspondence with several authors. All data have been examined with both univariate and multivariate analyses as predictive factors for outcome. Variables, associated with an increased risk of death from disease, included the involvement of inferior vena cava upper segment and a high-grade tumor. Patients who underwent a radical resection of the tumor (82 patients, 56.9%) had a significantly better survival (27.9% and 14.2%, 5- and 10-year survival rates, respectively). Of these patients, those with tumor of the inferior vena cava middle segment fared better than those with lower segment tumor (5- and 10-year survival rates were 48.3% and 34.4%, respectively, for middle segment tumor and 9.3% and 0.0% for lower segment tumor). Variables associated with a good outcome and longer survival were the presence of abdominal pain and the absence of a palpable abdominal mass. Despite the high rate of recurrence (52.4% of patients undergoing radical operation; median time, 25 months), radical resection of inferior vena cava leiomyosarcoma is the only chance for a long-term cure. An earlier and more accurate preoperative diagnosis, by means of modern diagnostic techniques (echography, CT scanning, magnetic resonance imaging) will allow a higher rate of radical resection to be performed with an increase in patient survival.

Factors influencing enlargement rate of small abdominal aortic aneurysms

The purpose of this study was to determine the factors influencing enlargement rate of small abdominal aortic aneurysms. Fifty-seven high-risk patients with asymptomatic abdominal aortic aneurysms initially measuring 3.5 to 5.9 cm in the largest transverse diameter were followed with serial echographic measurements for 6 to 78 months (mean 24). The mean enlargement rate (MER) and the occurrence of sudden change in size (SCS) for each aneurysm were correlated to 23 variables. MER ranged from 0 to 1.8 cm/year (mean 0.48). During the study period 17 aneurysms showed SCS. The results of univariate analysis indicated that 8 variables were statistically correlated to the degree of MER and 5 to the occurrence of SCS. A multiple regression model was generated by stepwise regression analysis and demonstrated that 2 variables were independent predictors of the degree of MER: (1) the absence of distal arterial occlusive disease and (2) the ratio of the diameter of the aneurysm to that of the aorta (RD). The overall model P value was less than 0.001. A statistically valid multiple regression model to predict the occurrence of SCS was not feasible (P = 1.0). We conclude that the occurrence of SCS of small abdominal aortic aneurysms is often unpredictable and that the RD rather than the value of the aneurysmal diameter per se must be considered in selecting high-risk patients for echographic follow-up.

Percutaneous transluminal angioplasty versus surgery for subclavian artery occlusive disease

Twenty-one patients who underwent percutaneous transluminal angioplasty (PTA) for proximal stenosis of the subclavian artery were compared with 15 patients who underwent carotid subclavian reconstruction. This represents the first attempt to directly compare the two procedures. All patients had routine Doppler examination during follow-up. Mean follow-up was 30 +/- 24 months after PTA and 40 +/- 25 months after surgery. The incidences of procedural complications were similar (PTA one complication, surgery two complications). Although better early results were achieved in patients who underwent PTA (actuarial patency: PTA 91 percent, surgery 87 percent), after dilatation, we observed a continuous deterioration of the hemodynamic status of the artery, which led to a high rate of late restenosis (actuarial patency: PTA 54 percent, surgery 87 percent). There were no significant changes postoperatively. The specific role of each procedure is analyzed in view of the new acknowledgment of the clinical importance of proximal subclavian artery disease.

Seven-year experience with polytetrafluoroethylene as above-knee femoropopliteal bypass graft: Is it worthwhile to preserve the autologous saphenous vein?

A 7-year experience with 90 polytetrafluoroethylene (PTFE) femoropopliteal bypass grafts in the above-knee (AK) position is presented. The 5- and 7-year actuarial patency rate was 58.3%. No statistical difference was found between the patency rate of this series and that of a group of 17 AK and 77 below-knee (BK) femoropopliteal bypass grafts performed during the same period with the autologous saphenous vein (ASV). During the follow-up period (range 6 to 84 months, mean 42 months) a new bypass in a more distal location was required in 20 limbs. The ASV was available in seven of the eight PTFE graft failures and in only one of the 12 ASV failures. The 3-year patency rate of these new groups was 58.3% and 16.7%, respectively (p less than 0.02). Eighteen of the 48 deaths occurring during the follow-up period were related to atherosclerotic heart disease, whereas only one patient underwent coronary artery bypass grafting. Five hundred patients randomly selected from our series of myocardial revascularization procedures were reviewed. In five a femorodistal reconstruction was performed before coronary artery bypass, and in only two (0.4%), the ASV was not available. PTFE use in the AK position may be a reasonable alternative to the ASV to preserve it for additional treatment of more distal occlusive disease. There is no evidence that such a need exists for further treatment of coronary artery disease.

Sealed rupture of abdominal aortic aneurysms

Sealed rupture of abdominal aortic aneurysms, even if uncommon, deserves particular attention for the possibility of misdiagnosis and for the deleterious effects of such a misdiagnosis. Sixteen patients (mean age 72 years; range 65 to 84 years) with chronic sealed rupture of abdominal aortic aneurysms are reported. Two patients had acute rupture of the aneurysm, and at operation chronic contained rupture was found along with the recent hemorrhage. One patient died after surgery. The remaining patients underwent successful resection with long-term survival and regression of symptoms. Consideration of sealed abdominal aortic aneurysm rupture should be included when examining elderly patients with history of unexplained back pain or femoral neuropathy. Computed tomography is a useful aid in the diagnosis of sealed rupture. Ultrasonography is less accurate; in three patients ultrasonography failed to diagnose the presence of the rupture.

Abdominal aortic aneurysm in elderly patients. Selective management based on clinical status and aneurysmal expansion rate.

The records of 125 patients 75 years of age or older with a diagnosis of unruptured abdominal aortic aneurysm were reviewed. Operative mortality was 4.3 percent in 69 patients considered at low risk and 39.8 percent in 13 patients at high risk who underwent aneurysmectomy shortly after diagnosis. Forty-three patients with an asymptomatic abdominal aortic aneurysm initially measuring 3.5 to 6 cm did not undergo aneurysmal resection and were followed for 6 to 72 months (mean 24 months) with serial echography. The mean enlargement rate was 0.48 cm/year. In the 43 patients, resection of the abdominal aortic aneurysm was performed for aneurysmal expansion to greater than 6 cm, development of symptoms, or a sudden change in aneurysmal diameter. Two patients were lost to follow-up, 21 underwent elective resection, aneurysms ruptured in 2, 9 died from other causes, and 9 were alive and asymptomatic at last follow-up. An aggressive surgical approach seems appropriate, even in the asymptomatic elderly patient with a small aneurysm of 4.5 to 6 cm. Serial echographic measurement appears useful in determining which patients with a very small aneurysm of less than 4.5 cm or who are considered to be high risk surgical candidates require elective aneurysmectomy.

Influence of blunt needles on surgical glove perforation and safety for the surgeon

BACKGROUND Round-tipped blunt needle (BN) may decrease the risk of needlestick injuries and hand contamination. We prospectively determined the incidence of glove perforations in emergency abdominal procedures and the efficacy of BN in increasing the safety for surgeons. METHODS Two hundred patients were randomized to undergo closure of the abdominal fascia using sharp needle (SN) or BN. Gloves were tested at the end of the procedure. RESULTS Surgeons had 14 needlestick injuries and 76 perforations recorded in 69 pair of gloves. Sharp needles were responsible for all injuries and 58 (76%) perforations (P < 0.00004 and P < 0.00001, respectively). This difference was still higher when considering the perforations related to the abdominal fascia closure (BN 7% versus SN 50%; P < 0.0006). CONCLUSION The risk of glove perforation is sevenfold greater if SN are used. Blunt needles reduce sharp injuries and improve safety for surgeons.

Long-term outcome after transaxillary approach for thoracic outlet syndrome

BACKGROUND Recurrence or persistence of neurologic symptoms after surgical treatment of patients with thoracic outlet syndrome (TOS) are reported to be as high as 25%. To identify factors affecting the long-term outcome of surgical treatment of patients with TOS, we reviewed our 20-year experience. METHODS One hundred thirty-four transaxillary first rib resections were performed on 118 patients (43 men, 75 women, mean age 38 +/- 13 years). Eighty-three operations (61.9%) were undertaken to relieve symptoms resulting from compression of the lower roots of the brachial plexus, 37 (27.6%) for compression of both lower and upper roots, and 14 (10.5%) for lower root and vascular symptoms. All patients underwent a transaxillary extraperiosteal first rib resection with transection of the scalene muscles. In 73 cases (54.5%) a resection of the anterior scalene muscle was also performed. A cervical rib was removed in 28 cases (20.1%), and anomalous fibrous bands adjacent to the neurovascular bundle were resected in 41 cases (30.6%). RESULTS No major complications were observed. Of 105 patients (118 procedures) followed up (mean follow-up, 99 +/- 72 months), good to excellent results were obtained in 96 cases (81.4%) and fair to poor results were recorded in 22 cases (18.6%). The presence of a long posterior first rib stump, measured from the chest x ray films, was the strongest determinant of the long-term results among the variables examined (p < 0.0001). Reoperation, consisting of neurolysis and resection of the stump, was performed in 16 patients. The results were excellent in all cases at a mean follow-up of 66 +/- 46 months. Primary and secondary 10-year, actuarial freedom rates from recurrent symptoms were 80.9% and 93.1%, respectively. CONCLUSIONS Our results suggest that the long-term outcome after surgery for TOS was strongly influenced by the extent of the first rib resection.

Early and Late Results in Patients with Carotid Disease Undergoing Myocardial Revascularization

A ten-year review of 1,360 patients undergoing coronary artery bypass grafting (CABG) by the same surgeon was undertaken. Sixty-two patients with symptoms of coronary artery insufficiency underwent carotid endarterectomy prior to or at the time of CABG (Group I). Ninety-seven patients had asymptomatic carotid bruits but did not undergo carotid endarterectomy (Group II). Sixty of these patients were studied by ultrasonic duplex scanning or ocular pneumoplethysmography or both, and hemodynamically significant stenosis was detected in 50 (Group IIa). Group III included 80 patients without carotid artery disease matched with Group II for sex, age, and clinical status. Group IV consisted of 200 patients without carotid artery disease randomly selected from our series. Follow-up ranged from 3 to 120 months (median, 41 months). In patients with proven carotid artery disease (Groups I and IIa), operative mortality was greater than in the patients randomly selected (Group IV) (p less than 0.05) but similar to that in the matched Group III. Late neurological deficits were greater in patients with carotid disease not undergoing carotid endarterectomy (p less than 0.01). Patients with carotid artery disease had lower survival than Group IV patients (p less than 0.01) but similar survival to that in the matched Group III. This study suggests that (1) asymptomatic patients with carotid artery disease who undergo CABG are not at increased risk of perioperative stroke; (2) these same patients are at increased risk of late neurological deficit; and (3) carotid artery disease is an indirect sign of severe associated disease and therefore is associated with increased operative mortality and decreased life expectancy.

Comparative results of carotid-subclavian bypass and axilloaxillary bypass in patients with symptomatic subclavian disease

The results of 26 carotid-subclavian bypass (CSB) and 17 axillo-axillary bypass (AAB) procedures, performed to treat symptomatic lesions of the proximal subclavian artery, were reviewed. Nine graft failures (seven CSB and two AAB) occurred (mean follow-up: CSB = 60.5 +/- 41 months; AAB = 67.8 +/- 48 months). All CSB graft thromboses were observed in patients with an associated ipsilateral carotid lesion, surgically treated or not (p less than 0.05). Cumulative 5- and 10-year patency rates were 78.3 and 62.9% for the CSB group and 87.9% for the AAB group (N.S.). In patients with an associated ipsilateral carotid lesion, 5- and 10-year patency rates were 66.0% and 40.8% for the CSB group and 100% for the AAB group (p less than 0.05). Both the surgical procedures were safe and effective with excellent results in terms of operative mortality, major morbidity and long-term patency. CSB is the procedure of choice for the treatment of proximal subclavian artery disease for its physiological characteristics and for graft shortness. However AAB must be considered a suitable alternative and preferred when a concomitant ipsilateral carotid lesion is present. Recurrence of carotid stenosis or carotid lesion progression may cause the carotid-subclavian failure.