Stefan H. Skotnicki

Assessment of penile blood flow by duplex ultrasonography in 44 men with normal erectile potency in different phases of erection.

Duplex ultrasonography is important in the diagnosis of vasculogenic erectile dysfunction. We measured the ultrasonographic parameters of cavernous blood flow in different phases of penile erection. We examined 44 volunteers with normal erectile potency. Doppler spectra of the cavernous artery were obtained in a time-dependent manner after intracavernous administration of papaverine. Following intracavernous pharmacological stimulation, the Doppler spectrum alters according to a specific pattern indicating the different hemodynamic phases of erection. Peak flow velocity and acceleration time, measured in the early post-injection phase, may be used to grade arterial inflow. The difference between resistance index in the pre-injection and late post-injection phases may be used to estimate veno-occlusive function. References values are defined.

Inferior epigastric artery as a conduit in myocardial revascularization: The alternative free arterial graft

When complete revascularization cannot be obtained with the internal mammary artery and greater and lesser saphenous veins, the inferior epigastric artery may be an excellent alternative conduit. We describe our experience with this conduit, review the anatomy of this artery, and present our harvesting technique.

Duplex ultrasound in the hemodynamic evaluation of the late sequelae of deep venous thrombosis

PURPOSE The use of duplex ultrasound scanning to evaluate the hemodynamic outcome of deep venous thrombosis 7 to 13 years after the original diagnosis. METHODS Duplex ultrasound was used to re-examine 1212 segments of vein from 72 patients (49 men, 23 women) with deep venous thrombosis previously diagnosed by means of phlebography to detect reflux and obstruction and evaluate flow; 611 segments were initially thrombosed and 601 segments were open. To define reflux, reversed flow in 31 healthy persons was measured. RESULTS In a review of all veins of the 72 patients, 8 patients (11%) had completely normal duplex results in all veins, 33 (46%) had reflux, 6 (8%) had at least one noncompressible vein segment, and 25 (35%) had a combination of both. In the proximal vein segments without initial thrombosis a higher percentage was normal (73%) than in segments with initial thrombosis (46%). There was a significantly higher frequency of reflux (46%, p = 0.05) and noncompressibility (12%, p < 0.01) in initially thrombosed proximal vein segments than in vein segments without initial thrombosis (reflux 25%, noncompressibility 3%). Distal to the knee 125 (17%) of 720 vein segments were not traceable. Significantly more initially thrombosed vein segments were not traceable (p < 0.01). In distal vein segments there was no significant difference in reflux (7% versus 5%) and noncompressibility (10% versus 5%) between vein segments with and without initial thrombosis. Flow was present in 99% of the 611 previously thrombosed proximal and distal segments. CONCLUSIONS Most patients with deep venous thrombosis still had venous abnormalities 7 to 13 years after the initial diagnosis. The most common abnormality was reflux. Significantly more abnormalities were found in initially thrombosed segments. The abnormalities were found in the proximal vein segments and in the distal vein segments, although less frequently in the latter.

Noninvasive hemodynamic assessment of the internal mammary artery in myocardial revascularization

Using transthoracic B-mode imaging and Doppler spectrum analysis it was found that the luminal diameter of the internal mammary artery and its hemodynamics were not significantly different among 15 preoperative patients (64 +/- 10 years) who underwent myocardial revascularization using the left internal mammary artery and young and older control groups (25 +/- 3 years and 61 +/- 9 years, respectively). These data indicate that older age does not significantly adversely influence the degree of intimal thickening and compliance in the internal mammary artery. Doppler spectrum analysis of the internal mammary artery in the patients who were operated on revealed conversion from a triphasic systolic waveform preoperatively to a unidirectional combined systolic/diastolic waveform at 1 week and 2 and 6 months postoperatively, characterized by a significant increase in the diastolic blood flow velocity and a significant decrease in the systolic blood flow velocity and the pulsatility and resistance indices. This study indicates that transthoracic B-mode imaging and Doppler spectrum analysis are promising noninvasive techniques in the preoperative assessment of internal mammary artery morphology and physiology. In addition, Doppler spectrum analysis can also be used in the long-term serial assessment of the internal mammary artery conduit after myocardial revascularization.

Penile Pharmacological Duplex Ultrasonography: A Dose-Effect Study Comparing Papaverine, Papaverine/Phentolamine and Prostaglandin E1

Alternations of penile blood flow are believed to be the most frequent organic cause of erectile dysfunction. Penile duplex ultrasonography following intracavernous injection of a vasoactive agent is an accepted method for diagnosis of penile vascular dysfunction. To determine the diagnostic efficacy of commonly used vasoactive drugs we studied the hemodynamic effects of different dosages of papaverine, the combination of papaverine and phentolamine, and prostaglandin E1 in men with erectile dysfunction and men with normal erectile potency using color duplex ultrasonography. We concluded that 12.5 mg. papaverine and 10 micrograms. prostaglandin E1 are the drugs of choice to be used in conjunction with penile duplex ultrasonography because of optimal effects on cavernous arterial dilatation and low risk of prolonged erection. However, low dose papaverine or prostaglandin E1 has a limited value in evaluating veno-occlusive function.

Detrimental sequelae on the hemodynamics of the upper left limb after subclavian flap angioplasty in infancy.

The long-term effect of two surgical techniques for repair of coarctation of the aorta in infancy, namely, resection and end-to-end anastomosis (RETE) and subclavian flap angioplasty (SFA) on the blood supply of the upper left limb, was quantified by Doppler spectrum analysis of blood flow velocities in the left brachial artery at rest and during postocclusive reactive hyperemia. Twenty-three patients participated in this study: nine patients after SFA (median age, 8 years), 14 patients after RETE (median age, 8 years), and 10 control subjects (median age, 9.5 years). At rest, a highly significant decrease of blood flow velocities in the left brachial artery was measured in all patients of the SFA group compared with those of the RETE and control groups, as documented by various Doppler spectrum parameters: maximal frequency of advancing curve (p = 0.0001), pulsatility index (p = 0.0005), and resistance index (p = 0.039). During reactive hyperemia, a moderate capacity of physiologic augmentation of blood flow velocities was observed in five patients of the SFA group. This capacity was marginal in two patients with complaints of claudication in the left upper limb during strenuous exercise, which can be related to the number of branches of the left subclavian artery ligated during operation. This study indicates that SFA in infancy may lead to compromised hemodynamics of the upper left limb with potential for symptoms of ischemia during exercise.

Anastomotic Aneurysms an Underdiagnosed Complication after Aorto-iliac Reconstructions

Anastomotic aneurysms (AA) are recognised as a long-term complication of aorto-iliac (AI) reconstructions and in the literature an incidence of 2-8% is reported. From our own experience we suspected a much higher frequency of this complication and started a follow-up study in order to establish: 1. The actual incidence of AA and 2. The value of various methods of investigation in the diagnosis of this condition. During a 4-year-period (1977-1980) 303 patients (PTS) underwent an AI reconstruction and were the subject of this study. During the mean 8-year (range 6-10 years) follow-up period 158 patients died (52%). The 145 survivors underwent physical examination (PE), ultrasonography (US), and intravenous digital subtraction angiography (i.v. DSA). Complete data were available from 122 patients. The incidence of AA in the 303 patients of the original group, established by routine follow-up examination was 16/303 (5.1%). However, the incidence of AA in the 122 patients in this study was 36/122 (29.5%). These 36 patients developed 52 AA which were located at the following anatomic sites: aortic anastomoses 3/115 (2.6%), iliac artery anastomoses 18/146 (12.3%), femoral artery anastomoses 31/70 (44.3%). Fourteen of the 52 AA (33%) were operated on and the diagnosis was confirmed. The patient characteristics (age distribution, type of arterial reconstruction, indication for operation) of the group of 122 patients were not significantly different from the original group of 303 patients. Intravenous DSA proved to be the most reliable diagnostic test. Physical examination was relatively inaccurate when compared with imaging tests with a 37% false positive and 67% false negative rate.(ABSTRACT TRUNCATED AT 250 WORDS)

Sternal wound complications after primary isolated myocardial revascularization: the importance of the post-operative variables

OBJECTIVE Select pre-, peri-, and post-operative variables, predictive for sternal wound complications (SWC), in a clinical setting. METHODS We analyzed pre-, peri-, and post-operative data of 3815 patients who underwent a primary isolated bypass grafting. 100 patients (2.6%) had post-operative SWC. Unifactor and multifactor risk analysis, were used for statistical analysis. RESULTS Unifactor analysis identified age (P=0.05), obesity (P=0.001), lung disease (P=0.001), extracorporeal circulation >100 min (P=0.02), graft choice (P=0.01), post-operative low cardiac output, reoperation, nephrological, pulmonary problems (P<0.001) as risk factors. Multifactor analysis, identified obesity (P=0.005), reoperation (P=0.01), nephrological (P=0.0001), pulmonary problems (P=0.001) and No-IMA-use (P=0.05) as independent predictors. Age <50 years (P=0.04) decreased the risk for SWC. There is, however, an interaction of the graft-use and the pre-operative and post-operative predictors, that can mask the precise effect of the graft-use. CONCLUSION Reoperation, nephrological and pulmonary problems are strong predictors, obesity and age independent preoperative risk factors for sternal wound complications.

Coronary bypass surgery: what is changing? Analysis of 3834 patients undergoing primary isolated myocardial revascularization

OBJECTIVE The patient population undergoing myocardial revascularization has changed during the last few years. Knowledge of these changes, and of the subsequent influence on morbidity and/or mortality is important, not only for up-dating quality control, but also to support decision-making in financial and economical aspects, and in further research concerning coronary artery surgery. METHODS Pre-, per- and postoperative data of 3834 primary isolated coronary bypass operations, January 1987 December 1995 were analyzed. The total group was divided into three time cohorts. Group A: 1987 1989 (n = 1292); group B: 1990-1992 (n = 1130); and group C: 1993-1995 (n = 1412). RESULTS Mean age increased from 60.4 +/- 9.0 (S.D.) years in group A to 62.9 +/- 9.9 (S.D.) years in group C (P < 0.0005). Patients with insulin-dependent diabetic (P = 0.005), uro-nefrological (P = 0.002), pulmonary (P < 0.0005)and neurological (P = 0.003) pathology increased significantly, and there was a significant increase in the use of arterial grafts (P < 0.05). Postoperative, hospital mortality remained stable (+/- 2.5%). However, there was a significant increasing percentage of patients with pulmonary (P = 0.04), neurological (P = 0.02) and uro-nefrological (P < 0.0005) problems. CONCLUSION During the last few years there has been a trend in myocardial revascularization of older patients, with more coexisting disease. Despite the fact that hospital mortality seems stable, there is an increase in major postoperative morbidity.

Renal allograft artery stenosis: results of medical treatment and intervention. A retrospective analysis

In a retrospective analysis of 1165 renal transplantations in our center, 65 cases of renal allograft artery stenosis were diagnosed angiographically (prevalence 5.5%). Hypertension was present in all case; a bruit over the allograft and an increase in serum creatinine level were additional reasons for angiography. Shortly after diagnosis of the stenosis, two patients died and two others lost their grafts due to thrombosis. In 24 patients the decision was made not to correct the stenosis. One of these grafts was lost because the stenosis could not be corrected. Medical management of hypertension in these patients resulted in a decrease in diastolic blood pressure from 109±22 to 96±12 mm Hg (P<0.01) 3 months after diagnosis with the use of almost twice as many antihypertensive drugs as at the time of diagnosis (P<0.01). The stenosis was corrected if the angiography showed it to be so severe that it jeopardized renal allograft function or caused uncontrollable hypertension. Only three of nine percutaneous transluminal angioplasty (PTA) procedures resulted in a definitive correction of the stenosis. Surgical intervention was performed in 30 patients, including two patients whose PTAs had proved unsuccessful. Surgery led to graft loss due to thrombosis in 6 of 30 operations (20%), whereas restenosis occurred twice (7%). In three other case (10%), the correction was not successful due to local anatomical variations or concomitant rejection. Successful correction of the stenosis by either PTA or surgical intervention (n=22) resulted in a significant decrease in systolic (171±31 vs 145±27 mm Hg; P<0.01) and diastolic (103±15 vs 89±14 mm Hg; P<0.05) blood pressures 3 months after correction. Concomitantly, a decrease in the number of antihypertensive drugs from 2.1±1.0 to 1.5±1.0 (P<0.01) was achieved. In conclusion, renal allograft artery stenosis could successfully be managed pharmacologically, provided that allograft perfusion was not jeopardized. Successful surgical correction of a stenosis with effective control of hypertension was achieved in 63% of the cases. PTA was less frequently successful but did not cause any graft loss.