Rocco G. Ciocca

Antiphospholipid antibodies lead to increased risk in cardiovascular surgery

BACKGROUND Antiphospholipid (APL) antibodies are a heterogenous group of antibodies that have been associated with an increase in bleeding complications and a marked increase in thrombotic events, both of which result in significant patient morbidity and mortality. PATIENTS AND METHODS A retrospective analysis of patients identified to be positive for APL via a university thrombosis registry who had cardiovascular surgery between 1989 and 1994. RESULTS Seventy-one patients positive for APL antibodies were identified. Of those patients, 19 had cardiovascular surgical procedures (11 women and 8 men, mean age 58.4 years, range 38 to 78). A total of 48 cardiovascular surgical procedures (mean 2.5 procedures/patient) were performed in the 19 patients. These procedures included 13 lower-extremity reconstructions, 11 upper-extremity reconstructions/fistulas, 8 cardiac valve replacements, 5 coronary artery bypass procedures, 5 major amputations, 4 infrarenal aortic reconstructions, and 2 carotid endarterectomies. Sixteen of the 19 patients (84.2%) suffered major postoperative complications. These included 16 thrombosed grafts, 5 strokes, 5 major bleeding events, 2 pulmonary emboli, and 2 myocardial infarctions. Ultimately, 12 of the 19 patients (63.2%) died of complications related to surgery. CONCLUSIONS This series of patients confirms that patients with circulating APL antibodies are prone to excessive postoperative morbidity and mortality after cardiovascular surgical procedures. The presence of APL antibodies may be a maker of increased risk of complications after cardiovascular surgery.

The utility of dobutamine echocardiography in preoperative evaluation for elective aortic surgery

BACKGROUND Preoperative cardiac evaluations have been advocated prior to major vascular procedures to reduce the incidence of postoperative cardiac complications. This study was undertaken to evaluate the efficacy and predictive value of routine dobutamine echocardiography (DE) in the screening of patients undergoing elective aortic surgery. METHODS Dobutamine echocardiography was performed preoperatively on all patients having elective aortic procedures by our university surgical group from June 1995 to August 1996. The cardiac morbidity and mortality from this group were compared with that of a similar group undergoing elective aortic procedures from June 1993 to May 1995 with no dobutamine echocardiography (NDE). RESULTS Although there was no statistically significant difference in either overall mortality (4.4% in NDE vs. 2.3% in DE) or cardiac mortality (2.9% in NDE vs. 0% in DE) between the two groups, cardiac events occurred only in those patients with previous coronary artery disease. In addition, dobutamine echocardiography had a negative predictive value of 97% CONCLUSIONS Although routine screening is not necessary, selective screening of patients using dobutamine stress echocardiography is justified because of its high negative predictive value.

Influence of Endovascular Training on Fellowship and General Surgical Training

PURPOSE As endovascular procedures develop, there is a risk of diminished training of residents and fellows in traditional open surgery. We evaluated the effect of our endovascular program, initiated in 1999 coincident with the Federal Drug Administrations approval of endoluminal vascular aortic grafts, on the number of endovascular procedures and open abdominal aortic aneurysm (AAA) repairs performed in comparison to national trends. METHODS The experience of vascular fellows and chief residents at completion of training (1996-2002) was reviewed and compared with the national mean case numbers before and after initiation of our endovascular program. RESULTS The development of an endovascular program increased the total number of aneurysms repaired at the Robert Wood Johnson (RWJ) Medical School from 49 +/- 15 to 92 +/- 8 per year (P < 0.01). The number of vascular operations performed by the RWJ fellow increased from 320 +/- 48 to 553 +/- 155 per year (P < 0.05). The number of operations performed nationally by vascular fellows also increased during the same period, but did not reach statistical significance. There was no change in the number of open AAA repairs performed by the RWJ fellow or nationally. There was also no change in the average number of vascular operations completed by RWJ chief residents or nationally (160 +/- 17 versus 157 +/- 1 and 192 +/- 4 versus 189 +/- 4, respectively; P > 0.05). However, the average number of open AAA repairs performed nationally by general surgical chief residents decreased from 10 +/- 0.3 to 9 +/- 0.4 (P < 0.05). CONCLUSION An endovascular program can increase the total number of AAA repairs performed without influencing the total number of vascular operations performed by general surgical chief residents. There was a decrease in open AAA repairs performed nationally by general surgical chief residents. The advancement of endovascular therapies may decrease the number of open procedures available for trainees in both general and vascular surgery. Perhaps those that will specialize in the field of vascular surgery should have the benefit of those open procedures.

Increased oxygen extraction as adaptation to acute renal ischemia.

Acute renal ischemia is an infrequently encountered clinical entity with occasionally devastating consequences. The renal compensation to acute ischemia is unknown and is the purpose of this report. Eight pigs were anesthetized and ventilated. Left atrial, aortic, CVP, left renal venous, and ureteral catheters were inserted. Renal blood flow (RBF) reduction was accomplished by the graded constriction of the left renal artery using a balloon occluder. Renal oxygen extraction ratio (RER, %), renal oxygen delivery (RO2D, cc/min per 100 gm), renal oxygen consumption (RVO2, cc/min/100 gm), creatinine clearance (CrCl, ml/min), and renal lactate production (delta [L], mg/min per hgm) were measured at baseline and following sequential 90-minute intervals of moderate and then severe left renal flow reduction. Significant increases in renal oxygen extraction were observed when RBF was severely limited (.30 +/- .05 vs .64 +/- .06, p < .01). CrCl decreased precipitously (16.5 +/- 4.6 vs 0.2 +/- 0.07, p < .05). Lactate production by the ischemic organs correlated with blood flow reduction (r = .546, p = .0034). In severe ischemia, healthy kidneys increase oxygen extraction to preserve oxygen consumption.

An Unusual Case of Celiac and Splenic Artery Aneurysms Related to Fibromuscular Dysplasia

The authors describe a thirty-nine-year-old man whose celiac artery aneurysm and multiple splenic artery aneurysms were found to be secondary to fibromuscular dysplasia. This is only the eight such case in the modern medical literature.

Adenocarcinoma Arising within a Testicular Metastasis

Teratoma with malignant transformation is defined as the emergence of a non-germ cell tumor from a teratoma. Although extremely rare in extraovarian sites, cases have been reported that involve primary extragonadal germ cell tumors with transformation to variants of sarcoma. We report a 54-year-old man who was found to have adenocarcinoma arising within a mature teratomatous retroperitoneal metastasis 15 years after treatment of a nonseminomatous testicular germ cell tumor. The tumor was successfully excised and he remains without evidence of disease.

Phlegmasia Cerulea Dolens in a Patient with Ulcerative Colitis Treated by Iliofemoral Venous Thrombectomy A Case Report

The authors present the case of a 17-year-old woman with ulcerative colitis who presented with phlegmasia cerulea dolens (PCD) of the right leg. On examination, the compartments of her right leg were tense, sensory and motor function were greatly diminished, and pedal pulses were absent. Venous duplex revealed extensive venous thrombosis from the tibial veins to the external iliac vein. Treatment consisted of anticoagulation with systemic heparinization, and she was brought to the operating room for intraoperative venography, inferior vena caval filter placement, and four-compartment fasciotomy. Arterial pulses did not return; therefore, venous thrombectomy was performed by extrusion of distal thrombus with an Esmarch bandage, and fluoroscopic guided balloon catheter thrombectomy of the distal inferior vena cava and iliac veins proximally. Completion venography revealed the absence of residual thrombus. Postoperatively, the patient developed a lower gastrointestinal hemorrhage and anticoagulation was terminated. The fasciotomy skin incisions underwent delayed closure on postoperative day 6, and the patient was subsequently discharged with compression stockings. Total abdominal colectomy with creation of a J-pouch was performed 1 month following discharge. After 1 year, the patient had no complaints related to her leg. On examination, no evidence of venous insufficiency was present. Venous duplex demonstrated a patent deep venous system with no evidence of reflux. Uncomplicated PCD responds to heparin therapy in 50-80% of patients, but the risk for developing the postphlebitic syndrome is high. Venous thrombectomy has been reported to provide better long-term functional outcome. Catheter-directed thrombolysis has the added theoretical benefit of preserving endothelial and valvular function, and high technical success rates have been reported. No long-term functional outcome results for thrombolysis are available. Thrombolysis is contraindicated if compartment syndrome or venous gangrene is present. The aggressive surgical management of PCD may result in improved outcome.

Endovascular Treatment of Chronic Superior Vena Cava Syndrome Associated with Hemodialysis Access A Case Report

Superior vena cava (SVC) syndrome was first described in 1757 by William Hunter as a complication of a syphilitic aneurysm. With the advent of antibiotics, 74% to 93% of reported cases are now secondary to a malignant process. Benign causes include goiter, mediastinal fibrosis, pericardial constriction, Behçets disease, polyarteritis nodosa, and thrombosis secondary to catheter placement, most notably pacing wires. This case report describes a patient who was diagnosed with chronic SVC syndrome after multiple hemodialysis access procedures were performed over a short span of time. The patient is a fifty-five-year-old man with hypertension and end-stage renal disease, etiology unknown, who presented with left upper limb swelling one week after placement of an arteriovenous (AV) graft in his left forearm. One month prior he had had an AV fistula created in the left distal forearm. Owing to difficulty in accessing the fistula, a Shiley catheter was placed in the left internal jugular vein for temporary dialysis. The AV graft was placed later that week. He presented the following week with progressive left upper limb edema associated with limitation of hand movement and pain/numbness of the fingers. The pain was relieved with upper limb elevation. An outpatient fistulogram showed a patent AV graft and AV fistula, a small amount of thrombosis around the Shiley catheter tip, and occlusion of the SVC. Collaterals were noted involving the right innominate vein, SVC, and the left innominate vein. A catheter and guidewire were then passed through the venous limb of the AV graft into the SVC. Urokinase was delivered as a bolus and then as a continuous infusion into the left innom inate vein and SVC to dissolve any clots that might be in the SVC or around the Shiley catheter. A computed tomography scan of the chest failed to reveal any pathology around the SVC. Systemic heparin therapy was also started. Twenty-four hours later the patient underwent repeat venography, which demon strated some clot lysis and a patent but severely narrowed SVC. Three self-expanding Wallstents were then placed. The stents were dilated to 14 mm. Completion venography revealed adequate patency of the SVC. After the procedure the patient did well with prompt resolution of his left upper limb swelling and pain. The Shiley catheter was removed during this hospitalization and his dialysis was initiated via the AV graft. Endovascular treatment of chronic SVC syndrome manifesting after hemodialysis access procedures is a viable option that is associated with excellent short-term patency.

Descending Aortic Dissection in an Elderly Weight Lifter A Case Report

Acute aortic dissections are rare but not uncommon. The etiology of aortic dissections has been attributed to collagen abnormalities or systemic hypertension. Prognosis is predi cated on a timely diagnosis, location of the dissection, and appropriate intervention. Dissections of the aorta associated with weight lifting have been described and tend to involve the ascending aorta in young male weight lifters. This report describes the second reported descending aortic dissection associated with weight lifting. Aortic dissections associated with weight lifting are exceedingly rare; however, this entity may become more prevalent with an increase in exercise and cardiovascular condi tioning among all age groups.