Robert A. Cambria

Healing of venous ulcers in an ambulatory care program: The roles of chronic venous insufficiency and patient compliance

PURPOSE A nurse-managed/physician-supervised treatment program for venous ulceration was evaluated to determine the influence of venous hemodynamics, comorbidities, patient behavior, and ulcer characteristics on time to healing and time to recurrence. METHODS The clinical course and long-term follow-up of 71 patients with 99 venous ulcers diagnosed between November 1981 and August 1994 were analyzed by a retrospective review of clinic records. Demographic data, severity of venous insufficiency, ulcer characteristics, and patient compliance were studied. Outcome variables were time to complete ulcer healing and time to first recurrence. RESULTS Ninety-one percent of the ulcers healed completely at a median 3.4 months. There were 52 (57%) recurrences at a median 10.4 months. Ulcers on limbs with a venous refill time of 10 seconds or less demonstrated a significantly longer time to complete healing (p < or = 0.03); however, no effect on time to recurrence was observed. Patients who were in strict compliance with the treatment regimen (n = 32) had significantly faster healing (p < or = 0.02) and fewer recurrences (p < or = 0.004) compared with patients who were less compliant (n = 67). CONCLUSIONS Most venous ulcers can be expected to heal when patients are enrolled in a nurse-managed/physician-supervised ambulatory ulcer clinic. Photoplethysmography-derived venous refill time of 10 seconds or less predicted delayed healing. Strict compliance with the treatment protocol significantly decreased the time to healing and prolonged the time to recurrence.

An outcome analysis of carotid endarterectomy: The incidence and natural history of recurrent stenosis ☆ ☆☆ ★ ★★

PURPOSE This report identifies the incidence of recurrent carotid stenosis after carotid endarterectomy (CEA) and records the natural history of the disease process to gain further insight into its proper management. METHODS A prospective surveillance protocol with duplex imaging and velocity spectral analysis was used to detect recurrent stenosis ( > 50% diameter reduction) and to document the clinical outcomes of patients who underwent CEA. Between 1984 and 1993, 619 consecutive CEAs were performed in 587 patients. RESULTS Recurrent carotid stenosis developed in 48 CEA sites (7.8%) during a mean follow-up interval of 34 months (range, 2 to 118 months). Normal results on intraoperative assessment correlated with a 5.6% incidence of recurrent stenosis, compared with a 19% incidence when a residual hemodynamic abnormality was present (p < 0.0003). In the first year after surgery, there were no transient ischemic attacks, strokes, or carotid occlusions from recurrent stenosis, compared with a 27% morbidity rate in later follow-up (p < 0.01). Three patients with recurrent stenosis subsequently had occlusion at the CEA site, two of whom had severe ipsilateral strokes. CONCLUSIONS The incidence of recurrent carotid stenosis is low. Patients are at significant risk for neurologic morbidity when a recurrent stenosis occludes. With a 0.3% incidence of late stroke resulting from carotid bifurcation disease, these data confirm that CEA does provide long-term protection from stroke.

In Vitro Activities of Moxifloxacin against 900 Aerobic and Anaerobic Surgical Isolates from Patients with Intra-Abdominal and Diabetic Foot Infections

ABSTRACT The in vitro activities of moxifloxacin, ciprofloxacin, levofloxacin, gatifloxacin, imipenem, piperacillin-tazobactam, clindamycin, and metronidazole against 900 surgical isolates were determined using NCCLS testing methods. Moxifloxacin exhibited good to excellent antimicrobial activity against most aerobic (90.8%) and anaerobic (97.1%) microorganisms, suggesting that it may be effective for the treatment of polymicrobial surgical infections.

Diagnosis and management of aneurysms involving the superior mesenteric artery and its branches--a report of four cases.

Aneurysms of the superior mesenteric artery (SMA) are an uncommon but lethal entity, which must be treated expeditiously to avoid mortality and high incidence of ischemic small bowel complications. In the past 7 years the authors have treated 4 patients with a variety of types of aneurysms involving the SMA and its branches at a university-based teaching hospital. The first was a mycotic SMA aneurysm as a result of septic mitral valve, the second a jejunal aneurysm in a patient with pancreatitis, the third a spontaneous dissection distal to a small SMA aneurysm with thrombus partially occluding the distal vessel, and the fourth an SMA aneurysm associated with the diagnosis of mesenteric insufficiency. All patients presented with abdominal pain. The diagnosis was made initially in 1 patient on plain abdominal films with a calcified aneurysm, on duplex scan in the second, and on computed tomography (CT) scans in the remaining 2. Treatment consisted of bowel resection and ligation of mycotic aneurysm in the first patient, of catheter embolization of jejunal aneurysm in the patient with pancreatitis, and of vein graft bypass in the patient with a large SMA aneurysm. The patient with SMA aneurysm and distal dissection with partially occluding thrombus received anticoagulation and is being followed up with serial CT scans. There were no deaths. One patient required bowel resection, which did not result in short gut syndrome. Improved abdominal duplex scanning and CT technology facilitates the diagnosis of mesenteric aneurysm. The broad spectrum of etiologies mandates that treatment be tailored to the individual patient, and it varies from endovascular techniques to traditional bypass surgery. Prompt diagnosis and treatment results in the lowest mortality rate and minimizes the prevalence of intestinal infarction.

Ongoing vascular laboratory surveillance is essential to maximize long-term in situ saphenous vein bypass patency.

PURPOSE The purpose of this study was to assess the contribution of ongoing graft surveillance to maximize long-term patency of lower limb in situ saphenous vein bypasses. METHODS From January 1981 to October 1994, 556 autogenous grafts were constructed in 499 patients. The distal anastomosis was at the popliteal level in 207 (37%) and the tibial level in 349 (63%). All patients were enrolled in a prospective surveillance protocol to identify lesions that compromise graft patency and were evaluated at 1 day, 1 week, 6 weeks, and 3 months. Surveillance studies were then obtained every 3 months for the first 2 postoperative years and every 6 months thereafter. RESULTS Four-hundred-fifty abnormalities were detected in 236 grafts. The median interval from the initial procedure to detection of an abnormality was 12 months (range 0 to 113 months) and varied with the location of the defect. Later in the life of the graft, progression of atherosclerotic disease manifested as inflow obstruction at a median of 15 months, and outflow disease threatened the graft at a median of 29 months (r = 0.0003). Of the 450 surveillance abnormalities, 294 (65%) occurred within the first 2 years after operation, and 156 (35%) developed more than 2 years after operation. Of the 236 grafts that developed surveillance abnormalities, 50 (21%) developed the initial defect more than 2 years after the initial bypass procedure. Eleven percent of grafts remaining free of abnormality after 2 years went on to fail. Sixty-seven interventions were performed on 62 extremities after 24 months, with 30 involving previously unrevised grafts. CONCLUSIONS Because lesions amenable to revision continue to develop years after vein bypass construction, perpetual surveillance is required to ensure optimal rates of graft patency.

Women have increased risk of perioperative myocardial infarction and higher long-term mortality rates after lower extremity arterial bypass grafting.

PURPOSE The purpose of this study was to determine the effect of gender on the immediate and long-term postoperative morbidity, mortality, and patency rates for infrainguinal autogenous vein bypass grafts. METHODS Data were abstracted for consecutive patients who were followed in a prospective surveillance protocol after undergoing infrainguinal autogenous vein bypass grafting during the years 1988 to 1994. There were 165 grafts constructed in 148 patients (101 in 87 men, and 64 in 61 women). Gender differences were analyzed with Student t test or chi2 test for risk factors, indications for reconstruction, and complications. The patency rates and the long-term survival rates were compared by means of life-table analysis. Eagle criteria and long-term survival rates were compared with multivariate analysis. RESULTS The mean follow-up period was 36 months (39 months for men, and 32 months for women), with a range of 6 to 123 months for the total follow-up period. The two groups did not differ in age at the time of operation (66.6 +/- 1.2 years for men, and 66.7 +/- 1.5 years for women) or in history of diabetes (48% for men, and 56% for women). The risks were similar for hypertension (48% for men vs 45% women), preoperative myocardial infarction (23% for men vs 26% for women), and previous coronary artery bypass grafting (9% for men vs 8% for women). The thallium stress scintigraphy results showed a diagnosis of proportionately more preoperative defects in men (reversible, 34% vs 18%, P <.05; overall, 75% vs 43%, P <.05). The 30-day limb loss rates (0.9% for men, and 0% for women) and mortality rates (2.2% for men, and 5% for women) were similar. Women had statistically more perioperative myocardial infarctions than did men (6 of 61, 9.8% vs 2 of 101, 2%; P <.05), as was documented with electrocardiography and cardiac isoenzymes. Two of these women died within a 30-day postoperative period. The 3-year primary patency rate was 85% for the men and 88% for the women, and the primary assisted patency rate was 97% for the men and 97% for the women. The secondary patency rate was 98% for the men and 97% for the women. The limb salvage rate was slightly higher for the men than for the women (93% vs 87%), although this was not statistically significant. The 5-year survival rate for women was statistically less than for men, with life-table analysis (58% for men vs 42% for women; P <.05). CONCLUSION After distal bypass grafting, men and women have similar rates of patency and limb salvage, but women have a higher incidence rate of perioperative myocardial infarction and a decreased 5-year survival rate. These data suggest that women have unrecognized cardiac disease that affects them adversely in the perioperative period and the long term when compared with men who undergo the same operation.

Tissue inhibitor of metalloproteinase-1 is increased in the saphenofemoral junction of patients with varices in the leg

PURPOSE The goal of the present study was to examine the role of matrix metalloproteinase (MMP) activity in the development of varicose changes in the superficial veins of the lower extremity. METHODS Normal-caliber vein segments from the saphenofemoral junction were harvested from patients undergoing saphenous vein ligation for varices and from patients undergoing infrainguinal bypass graft procedures. The activity and quantity of MMPs and their inhibitors (tissue inhibitors of metalloproteinases [TIMPs]) in the vein segments were compared. Vein segments were obtained from 13 patients. Seven patients had varicose disease in the leg, including 6 women and 1 man (average age, 48 years). Six patients had no evidence of varicose disease, including 2 women and 4 men (average age, 59 years). Proteolytic activity was determined with substrate gel zymography, and enzyme content was determined with Western immunoblotting using monoclonal antibodies directed against MMP-2, MMP-3, MMP-9, TIMP-1, TIMP-2, and alpha2-macroglobulin. Signals were quantified by scanning densitometry and normalized to a positive control (densitometric index [DI]). Immunohistochemistry was performed for enzyme localization. RESULTS Zymography did not detect a difference between groups at loci consistent with the major MMPs; however, a small but significant decrease in proteolytic activity was noted in veins from patients with varices. TIMP-1 is increased in vein segments from patients with varices (DI 0.8 +/- 0.1 vs 0.2 +/- 0.05, P < .05) while MMP-2 levels were decreased (DI 1.5 +/- 0.3 vs 0.5 +/- 0.1, P < .05). Immunohistochemistry localized MMPs to the adventitia of the vein wall. CONCLUSION A decrease in proteolytic activity may be responsible for the histological and structural alterations leading to varicose degeneration of superficial lower extremity veins.

Health-related quality of life and functional outcome following arterial reconstruction for limb salvage

Vascular surgery outcomes have traditionally been measured by limb salvage and graft patency. However, as health care resources are rationed, the patients functional outcome and quality of life will require assessment. The in situ saphenous vein graft has proven successful in achieving long-term limb salvage for patients with critical ischemia, with the expectation of preserving a life-style and sense of well-being that would be lost with limb amputation. This study was conducted to measure functional capacity and quality of life in these patients. Seventy patients with successful in situ saphenous vein bypass grafts constructed for limb-threatening ischemia, followed for a mean of 45.6 months in a surveillance program with normal graft flow characteristics, were compared with a group of age and gender-matched controls with normal limb pressures and no history of vascular occlusive disease. A questionnaire was designed from standardized health status scales and administered to the two groups to assess symptoms, health perceptions, physical functioning and life quality. When comparing the groups of revascularized and control patients, symptoms and perceptions about their health were similar. However, the revascularized patients had significantly decreased functional capacity in their ability to walk various distances (P< or =0.005), perform household tasks (P< or =0.001) and bathe (P< or =0.001). The patient group with vascular grafts functioned as well as the controls only in activities of dressing and using the toilet. Indicators of life quality that rate independence and mobility, including the ability to procure groceries (P< or = 0.001), prepare meals (P< or =0.005) participate in social activities (P< or =0.001) and drive an automobile (P< or =0.01), were also significantly limited in the patients with successful vascular reconstructions. Although achieving long-term limb salvage and graft patency, the patients in this group of successful vascular reconstructions retain functional disabilities that require significant care. Despite these physical handicaps, these patients have a remarkably similar sense of well-being and lack of somatic complaints compared with the control group. This medical outcome study identifies the functional capacity and lifetime needs for vascular surgery patients that will provide useful data for those responsible for allocating health care resources.

Endothelial damage due to ischemia and reperfusion is prevented with SIN-1.

BACKGROUND Acute ischemia followed by reperfusion results in direct endothelial damage characterized by cell swelling, increased permeability and loss of acetylcholine-mediated vasorelaxation. Ischemia followed by reperfusion in a New Zealand white rabbit hindlimb has been shown to result in loss of acetylcholine-induced relaxation of superficial femoral arteries. This loss of relaxation in response to acetylcholine is a reflection of the decreased nitric oxide availability that occurs with reperfusion injury. The purpose of this investigation was to evaluate the effect of SIN-1, a direct nitric oxide donor, on this endothelial injury. METHODS New Zealand white rabbits underwent complete ischemia of the right hindlimb for 3 h followed by 2 h of reperfusion. Aliquots of 20 ml of either 0.88-mM SIN-1 or normal saline was infused via a lateral branch of the right common iliac artery during the first 20 min of reperfusion. Sham vessels were subjected to the 5-h operative intervention to control for anesthetic effect. Control vessels were harvested from rabbits not exposed to ischemia or reperfusion. Superficial femoral artery rings were evaluated in vitro for endothelial cell-mediated relaxation. Rings were contracted with potassium chloride and norepinephrine and then exposed to standardized incremental doses of acetylcholine to measure percent relaxation. Artery sections were sent for hematoxylin and eosin staining. RESULTS No significant differences were seen in contraction caused by either potassium chloride or norepinephrine in all four experimental groups. Saline infused vessel rings relaxed a mean of 8.42 +/- 2.39% and 49.57 +/- 8.65% in response to acetylcholine doses of 3 x 10(-8) M and 1 x 10(-7) M, respectively. In contrast, SIN-1 infused vessels relaxed a mean of 57.82 +/- 2.65% and 100.23 +/- 1.53% to the same doses of acetylcholine. Control and sham arteries showed a similar relaxation response as compared with SIN-1 infused vessels. Differences in relaxation when comparing saline infused vessels with SIN-1 infused, sham and control arteries, were significantly different at each dose of acetylcholine from 3 x 10(-8) M to 1 x 10(-7) M (P < 0.05, ANOVA). Histologic examination of the vessels revealed no morphologic differences among the experimental groups. All vessels were structurally normal with an intact endothelium. CONCLUSION In this model of rabbit hindlimb ischemia, preservation of endothelial cell-mediated vasorelaxation occurs with administration of intra-arterial SIN-1 during reperfusion. This preservation of endothelial function cannot be explained by histologic changes in the arterial wall or attributed to altered arterial contractility in response to potassium chloride or norepinephrine.

Duplex morphologic features of the reconstructed carotid artery: Changes occurring more than five years after endarterectomy

PURPOSE To determine the late morphologic appearance of the carotid artery after endarterectomy and to relate the morphologic characteristics to the development of recurrent carotid stenosis and subsequent neurologic symptoms. METHODS Eighty-eight carotid reconstructions (51% included patch angioplasty) in 82 patients were studied 5 or more years after carotid endarterectomy. Duplex color flow imaging was used to determine morphologic characteristics of the carotid endarterectomy site and to document the occurrence, time interval, and progression of recurrent internal carotid artery stenosis. The spatial orientation of recurrent wall thickening, presence of calcium, arterial wall texture, and presence of laminar flow were evaluated. Recurrent stenoses were categorized using standard duplex criteria. RESULTS The mean duration of follow-up was 99 months (range, 60 to 138 months). Arterial wall calcium was identified in 23% (n = 18), a smooth luminal surface in 57% (n = 46), and laminar flow in 52% (n = 42). Recurrent wall thickening developed in 58 vessels (66%), involving the posterior segment of the vessel in 95%, and anterior, lateral, or medial aspects in 24% (n = 14). Restenosis > 50% diameter reduction occurred in 4% of common carotid arteries (n = 3) and in 15% of internal carotid arteries (n = 13). Ten of the internal carotid artery restenoses occurred after a mean of 76 months (range, 13 to 132 months), and the three remaining patients had asymptomatic occlusions after a mean of 61 months (range, 1 to 96 months). Neurologic events referable to the reconstructed carotid artery occurred in three patients at a mean of 77 months; two were a result of recurrent carotid disease. One symptomatic patient and two asymptomatic patients (3.7%) underwent a second ipsilateral reconstruction for recurrent high-grade stenosis. CONCLUSIONS The carotid artery remains smooth, with laminar flow and without calcification, in the majority of reconstructions that were observed over a long term. There is a low incidence of subsequent ipsilateral neurologic events or significant recurrent stenosis, both of which usually occur late in the postoperative period. This study documents the long-term durability of carotid endarterectomy in providing risk reduction for stroke.