Vascular surgery最新文献

The objective of this study was to elucidate the relationship between outcomes from carotid endarterectomy (CEA) in patients with and without renal insufficiency. Carotid endarterectomy is one of the most commonly performed vascular procedures. The role of cardiac comorbidity in carotid endarterectomy has been extensively studied. The relationship between renal failure and surgical outcomes has also been studied for both coronary artery bypass grafting and lower extremity occlusive disease. However, the role of renal insufficiency in relationship to decision making regarding surgical intervention for carotid stenosis is not well defined. The authors hypothesized that the outcomes from CEA were negatively influenced by renal dysfunction. A retrospective review was made of consecutive CEAs performed at their institution from 1990 to 1995. Patients were grouped into 2 categories according to their renal function. Group A, 448 patients (90%) with creatinine level 1.8 mg/dL or less, and group B, 49 patients (10%) with creatinine levels more than 1.8 mg/dL. Data from patients on dialysis are presented but were excluded for the purpose of analysis. Included in the study were 497 patients with a mean age of 70 +/-8.9 and 74 +/-8.9 for groups A and B, respectively. Preoperative creatinine was 1.1 (+/-0.25) mg/dL for group A and 2.5 (+/-0.81) mg/dL for group B. Outcomes were as follows: perioperative cardiac events 5.4% vs 28.6%, stroke rates 2.7% vs 2.0%, and mortality rates 0.9% vs 8.2%, for groups A and B, respectively. At 60-month follow-up the stroke rates were 7.6% vs 6.1 %, and the mortality rates 22.8% vs 59.2%, for groups A and B, respectively. While patients with chronic renal insufficiency have no increased risk of perioperative or long-term neurologic events, perioperative and long-term mortality rates are significantly increased. This significant reduction in survival should prompt a more cautious application of CEA in patients with increased creatinine.

The aim of this study was to prospectively investigate the clinical efficacy of Daflon therapy in patients with mild to moderate chronic venous insufficiency (CVI) (clinical class 1-4) and to assess the changes in venous hemodynamics by using air plethysmography (APG). Fifty-six limbs in 28 patients were studied. They all had primary venous insufficiency with no venous obstruction, and mixed deep and superficial venous incompetence was found in 64% of the limbs. There was a significant decrease in symptom score for swelling and heaviness after 6 months of Daflon therapy. The symptom score for cramps also showed improvement though it did not reach statistical significance. Pain was significantly reduced with a mean pain score of 21.8 +/- 19.3% before comparing to 10.4 +/- 20.2% after 6 months of Daflon therapy (p < 0.01). This was also associated with a decrease in mean calf circumference from 37.0 +/- 4.3 to 36.4 +/- 4.3 cm (p < 0.001). There was no significant change in the venous filling index (VFI), ejection fraction (EF), and residual volume fraction (RVF) before and after 6 months of Daflon therapy (VFI: 3.7 +/- 3.5 vs 3.4 +/- 2.5 mL/s, EF: 54.5 +/- 15.9% vs 57.7 +/- 19.7%, RVF: 41.4 +/- 19.2% vs 39.4 +/- 24.2%). The clinical improvement without associated changes in venous hemodynamics as measured by APG suggests that Daflon mainly works by modifying the microcirculatory environment not detected by APG and this microcirculatory change is associated with clinical improvement. In this regard, Daflon would be especially useful for symptomatic relief in patients with functional venous insufficiency who do not have clinical evidence of varicose veins but suffer from symptoms of venous insufficiency.

This is a unique case of a visceral patch rupture in a Marfan patient after a repair of a thoracoabdominal aneurysm. The patient presented with abdominal pain and in shock 6 years after repair. The retained aortic wall containing the origins of the celiac, mesenteric, and renal arteries was aneurysmal and had ruptured. Clinical presentation, diagnosis, and operative modalities are discussed.

We believe that streptokinase is safe and effective in restoring the patency of arteries that have been acutely occluded by thrombosis or embolization. It should be used on those patients in whom the branches as well as the main conduits are occluded. It should also be used when the risks of surgery are great because of concurrent medical problems. Streptokinase should not be used after major surgery, in patients with blood dyscrasias, or when there are neurologic deficits secondary to the arterial ischemia. Streptokinase should not be considered as an antagonist to arterial surgery with the use of the Fogarty catheter but as an adjunct to the ever increasing armamentarium of the vascular surgeon.

Sixty-two patients with arterial disease of the lower limbs were treated with streptokinase by intermittent administration. All patients had experienced recent aggravation of their arterial disease, and 22 had thrombolysis confirmed by arteriography. In 20 cases clinical study showed repermeation--in 8 cases during the first perfusion and in 8 cases during the third perfusion. During the first perfusion the fall in fibrinogen was significantly greater in the 8 patients with thrombolysis. Further, the third perfusion corresponded to a new phase of fibrinogenolysis. These results support the possibility of the relationship between plasminemia and thrombolysis, and emphasize the limits of the classic theory of Sherry, Fletcher, and Alkjaersig. Permitting phases of repeated but limited plasminemia, the interruption method used here is a compromise between the risk of hemorrhage and the efficacy of treatment at low dosage.

A new mode of treatment for extensive acute and subacute deep venous thrombosis of the lower extremities combines the beneficial effects of surgical thrombectomy and of thrombolysis with streptokinase during the course of a single surgical intervention. Rapid-flow regional perfusion is the vehicle used to administer streptokinase and probably represents the third arm of this therapeutic approach by adding a hemodynamic washout effect. Because the thrombolytic agent is rinsed out of the circuit at the end of regional perfusion, the usual side effects and contraindications of this drug are avoided. Early and late results of this treatment are assessed clinically and with repeat phlebograms in a group of 6 unselected patients. Highly satisfactory results were achieved by 4 patients, 3 of whom experienced complete anatomic and functional restoration of deep veins along their entire length. Continued use of this method appears to be warranted.