Wiley F. Barker

Bacteriologic and surgical determinants of survival in patients with mycotic aneurysms

Mycotic aneurysms are a fulminant infectious process frequently resulting in rupture and death if not properly treated. A review of the University of California, Los Angeles, medical records identified 10 patients with extrathoracic, extracranial mycotic aneurysms. In addition, a search of the English literature revealed 178 patients with 243 mycotic aneurysms. These patients were reviewed to identify the aneurysm location, etiology, bacteriology, and modality of treatment in order to determine the relationship between these factors and the outcome. The femoral artery was the most common site (38%), followed by the abdominal aorta (31%). Arterial trauma was the primary etiology in 42% of mycotic aneurysms. In 25% no clear source of infection could be identified. Staphylococcus aureus was cultured from 28% of mycotic aneurysms, and Salmonella from 15%. A trend toward the involvement of more gram-negative aerobes and anaerobes is noted. Aortic aneurysms were repaired with in situ Dacron in 61% of patients with a 32% mortality rate and 16% reinfection rate. Simple ligation of femoral artery mycotic aneurysms resulted in a 34% incidence of ischemia necessitating amputation. Methods of treatment of superior mesenteric, carotid, iliac, and peripheral arteries are also analyzed. On the basis of these data, specific surgical procedures are recommended for the treatment of mycotic aneurysms.

Cause and noninvasive detection of restenosis after carotid endarterectomy

The incidence of significant restenosis after carotid endarterectomy was studied with ocular pneumoplethysmography. Of 105 operations, symptomatic restenosis occurred in 4.8 percent and asymptomatic restenosis in 6.6 percent. No preoperative factors were identified to be associated with subsequent recurrence. However, technical problems with the end-point of the endarterectomy were associated with restenosis. Half of the restenoses occurred in the first 6 months of operation. The results focus on the need for special attention to the technical management of end-point problems and the need for early noninvasive follow-up to detect a substantial proportion of early restenoses.

Selective management of extracranial carotid arterial aneurysms

Aneurysms of the extracranial carotid arteries are rare vascular lesions that produce a high incidence of unfavorable neurologic sequelae. In the past 24 years, 19 patients at UCLA Hospital were treated for angiographically demonstrable extracranial carotid arterial aneurysms. These cases were reviewed to determine the natural history of these lesions as influenced by various modes of therapy in order to develop a logical treatment plan for these difficult patients. Because of the varied location of these lesions, proper treatment requires a diversity of techniques. Gratifying results can be achieved when a carefully selected operative approach is undertaken.

Aortic saddle embolus. A twenty-year experience.

Clinical experience with aortic saddle embolus (ASE) is not extensive due to the relative infrequent lodging of emboli at the aortic bifurcation. During the period 1962–1982, 26 patients (mean age, 56 years) were treated at the UCLA Medical Center for ASE and followed from 2 to 158 months (mean, 45 months). These cases were reviewed in order to identify features of diagnosis, anticoagulation, and operation which impact on results. All 26 patients presented with bilateral lower extremity ischemia with or without extension of clot to the iliac bifurcation. Ninety-six per cent of emboli were of cardiac origin and one-third occurred in patients who had previous symptoms of chronic lower extremity ischemia. Rest pain and motor/sensory deficits were main complaints in 92% of the patients, but did not become manifest until more than 6 hours, unlike more distal emboli which have an earlier presentation. Preoperative angiography, even in the patient with a history of claudication, has a small role in planning the surgical approach to patients with ASE and, although performed in 11 patients, it influenced operation in only two. Operation within the “golden period” of 6 hours after embolization did not significantly influence outcome after ASE, since 20 patients were operated on more than 6 hours after embolization, with results similar to six patients who were operated on less than 6 hours after embolization. Early high-dose heparinization, used in all patients and maintained for a mean of 12 days, may have contributed to this effect. In 22 patients (85%) Forgarty catheter extraction via bilateral groin approaches was used with a mortality of 14%; only one death was directly attributed to the catheter embolectomy. In 15% of patients, a direct approach on the aorta was selected with a zero mortality rate. Postoperative functional result was excellent with an amputation rate of only 2% (one limb). Re-embolization occurred in seven patients (27%) after discharge, five of whom had not been maintained on Coumadin™ and two who were not anticoagulated adequately. The authors conclude that the keys to successful treatment of ASE include high dose heparin which is maintained through the perioperative period, embolectomy without pre-oprative angiogrphy, and maintenance of long-term oral anticoagulation.

Experience with the surgical management of 100 consecutive cases of abdominal aortic aneurysm

Abstract A series of 100 consecutive cases of aneurysm of the abdominal aorta is reported. The results are analyzed and observations on the development of the operation, pathologic changes of the lesion, indications for operation, problems in operative technic, prosthesis of choice and venous anomalies encountered are made. There were sixty-six nonruptured and thirty-four ruptured aneurysms in our series with an operative mortality of 15 per cent in the former and 59 per cent in the latter, with a combined figure of 30 per cent. Seven patients have died since operation, and an additional seven have been lost to follow-up study. Fifty-six patients are living and enjoying normal lives seven years following surgery.

Management of pancreatitis in infants and children

Abstract Pancreatitis is an uncommon cause of abdominal pain, emesis, and shock in children although it usually has a different etiologic basis than in the adult. Serum amylase should be measured whenever a child sustains blunt abdominal trauma or has abdominal pain of undetermined origin. Seventeen children with pancreatitis have been treated at the UCLA Hospital during the past ten years. Six children with nephrosis or lupus erythematosus were believed to have “steroid-induced” pancreatitis which was fatal in four of the patients. Idiopathic pancreatitis was seen in four children, two of whom died. Operations should be avoided in these often critically ill patients. Children with post-traumatic pancreatitis and pseudocyst are usually treated most effectively by external tube drainage providing the proximal pancreatic duct is not obstructed.

Surgical results in patients with ulcerative colitis treated with and without corticosteroids.

Abstract The postoperative course of fifty corticosteroid-treated and eighty-one nonsteroid-treated patients with ulcerative colitis is analyzed in terms of mortality and morbidity. Although the mortality for the two groups is essentially the same, the morbidity is significantly greater for the steroid-treated patients. Although some of the complications were clearly unconnected with administration of the drugs and the complications were not unique to one or the other group, severe wound infections, intra-abdominal abscess, septicemia, wound dehiscence, retraction of mucous fistulas, severe electrolyte imbalance, hemorrhage, convulsions, and psychosis were all increased with corticosteroid administration.

Femoropopliteal tibial bypass: What price failure?

The consequences of failure in 235 femoropopliteal and femorotibial operations are reviewed and compared with the benefits of success so that an accurate perspective of risk-benefit analysis can be achieved. In 72 operations performed for claudication, 10 grafts thrombosed early. The cost included nine reoperations to achieve eight patent grafts and a 12 day average increase in hospital stay. There were no deaths. The benefit obtained was 70 of 72 (97 percent) asymptomatic limbs. In 163 grafts placed for limb salvage, there were 58 initial thromboses. Reoperation in 28 produced an additional 14 patent grafts. The cost of thrombosis was an increase in mortality from 5.6 to 10.7 percent, a 12 day average increase in hospital stay, and raising of preoperative predicted amputation level from below to above the knee in 11 patients with thrombosed grafts whose distal anastomoses were below the knee. This contrasted with a 73 percent limb salvage rate in 104 patients whose preoperative predicted amputation level was below the knee, and a 54 percent limb salvage and a 12 percent lowering of amputation level in 39 patients whose preoperative amputation level was above the knee. Of patients with patent grafts, 89 percent achieved limb salvage. We conclude that the benefits of success in attempted vascular reconstruction for threatened limb loss far outweigh the risks of failure and that the combined results were far superior to the expected outcome in comparable patients undergoing primary amputation.

Role of arteriovenous shunts in venous reconstruction

Abstract Jugular venous autografts were inserted into both superficial femoral veins of twenty dogs. In half of these dogs (group A) a side to side distal arterial venous shunt was established whereas in the remaining ten dogs (group B) a distal H type arteriovenous shunt was created. The autografts in the limb without a distal arteriovenous fistula served as controls. Patency was determined by serial angiograms postoperatively. Early patency of autogenous vein grafts in the lower extremities was increased with the use of adjuvant distal arterial venous fistulas. The H type arteriovenous shunt was associated with higher patency of the venous graft, less morbidity, and greater ease of repair than was the side to side arteriovenous shunt. Forty-five per cent of the control grafts thrombosed within the first three postoperative days but 89 per cent were patent at six weeks, indicating the frequent occurrence of recanalization. Recent reports from Vietnam have emphasized the importance of venous repairs, particularly in the lower extremities. Additional experimental and clinical efforts are needed to evaluate the usefulness of autogenous vein grafts in the venous system.

Reappraisal of rectum-retaining operations for ulcerative and granulomatous colitis

Abstract 1. 1. Hospital records of 111 patients operated on for ulcerative or granulomatous colitis between 1960 and 1965 were reviewed. 2. 2. A double-blind review of tissue slides from these patients resulted in a larger proportion of patients being diagnosed as having granulomatous colitis than was the case when the medical record diagnoses were used. 3. 3. With this reclassification, the disparity in the frequency of primary rectum-retaining operations and the necessity for subsequent rectum removal between the two diseases disappeared. 4. 4. Only 15.4 per cent of all patients who had primary rectum-retaining operations were able to maintain functioning rectal segments in the seven to twelve year follow-up period. Many of these patients have continuing symptoms. 5. 5. The type of colitis present in the patient does not appear to be helpful in predicting success of a rectum-retaining operation. Duration of symptoms prior to operative treatment and location of the diseased bowel are of more value in this regard.