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PURPOSE: Recent reports suggest that carotid endarterectomy (CEA) should not be performed in patients with end-stage renal disease (ESRD) because of an unacceptable rate of perioperative stroke and other morbidity. Because these conclusions were based on a small number of patients, we reviewed the perioperative and long-term outcome of patients with ESRD and chronic renal insufficiency (CRI) who underwent CEA at our institution. METHODS: The 1081 patients who had a CEA between 1990 and 1997 were cross-referenced with those patients in whom renal insufficiency had been diagnosed. These charts were reviewed for patient demographics and perioperative and long-term outcome. Patients undergoing CEA during a 1-year period (1993) served as controls. RESULTS: Fifty-one CEAs were performed in 44 patients with CRI (32 in 27 patients) and ESRD (19 in 17 patients). In the CRI+ESRD group, 66.7% were symptomatic, and 70.7% of the control group were symptomatic. Six operations (11.8%) in the CRI+ESRD group were redo endarterectomies. There were no perioperative strokes in the CRI+ESRD group, but one patient died 29 days postoperatively because of a myocardial infarction, for a combined stroke-mortality rate of 2.0%. The control group had a 2.6% combined stroke-mortality rate. Long-term survival analysis revealed a 4-year survival rate of 12% for patients with ESRD and 54% for patients with CRI, compared with 72% for controls (P <.05). CONCLUSION: CEA can be performed safely in patients with ESRD or CRI, with perioperative stroke and death rates equivalent to that of patients without renal dysfunction. However, the benefit of long-term stroke prevention in the asymptomatic patient with ESRD is in question because of the high 4-year mortality rate of this patient population.

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BACKGROUND: Adhesion formation after abdominal operations causes significant morbidity. METHODS: Adhesion formation in pigs was compared after placement of prosthetic mesh during celiotomy (group 1), laparoscopy with large incision (group 2), and laparoscopy (group 3). After peritoneum was excised, polypropylene mesh was fixed to the abdominal wall, then to the opposite abdominal wall in the preperitoneal space followed by peritoneal closure. Adhesion area, grade, and vascularity were measured. RESULTS: More adhesions (p < 0.02) covered intraperitoneal mesh (7.57 +/- 1.89 cm2) than covered reperitonealized mesh (2.16 +/- 1.13 cm2), and adhesion grade was significantly greater (p < 0.02). Adhesion areas were significantly greater in groups 1 and 2 than in group 3 (p = 0.001 and 0.03, respectively). Adhesion grade was significantly greater in groups 1 and 2 than in group 3 (p = 0.02 and p = 0.04, respectively). Groups 1 and 2 had more vascular adhesions than group 3 (p < 0.01 and p = 0.02, respectively) CONCLUSIONS: A foreign body within the peritoneum stimulates more numerous and denser adhesions. Tissue trauma distant from the site of adhesions increases their formation. A major advantage of laparoscopic surgery is decreased adhesion formation.

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BACKGROUND: Sodium N-(8-[2-hydroxybenzoyl] amino) caprylate (SNAC) is an acetylated amino acid molecule that facilitates the gastrointestinal absorption of heparin. This study was undertaken to evaluate the efficacy of orally administered combination SNAC:heparin in preventing deep venous thrombosis in a standard rat model. METHODS: Forty-four adult male Sprague-Dawley rats were randomly divided into five groups: group I control, group II SNAC, group III oral heparin, group IV combination SNAC:heparin, and group V intravenous heparin. Thirty minutes after drug administration, the internal jugular vein was bathed in a sclerosant mixture for 2 minutes and reexplored at 120 minutes. Activated partial thromboplastin times (aPTT) were measured in 30 rats equally divided into three groups: group I SNAC, group II oral heparin, and group III combination SNAC:heparin. Forty-five minutes posttreatment, blood was obtained for aPTT levels. RESULTS: The incidence of deep venous thrombosis in the control group was 89% (8 of 9) versus 25% (2 of 8) in the combination SNAC:heparin group (p < 0.01). There was also a significant reduction in clot weight among groups. Combination SNAC:heparin significantly increased aPTT levels compared with SNAC or oral heparin alone. CONCLUSION: In a rat model of venous thrombosis, combination of orally administered heparin:SNAC elevated aPTT levels and significantly reduced the formation of deep venous thrombosis.

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BACKGROUND: Fluoroscopy, cost, and patient transport contribute to difficulties occasionally associated with the placement of vena caval filters. Follow-up data in the literature document the use of duplex ultrasonography in visualizing the filter and determining caval patency. Filter placement at the bedside or in the vascular laboratory with duplex ultrasonography may simplify this common procedure. We have attempted to define the feasibility of this method. METHODS: Patients referred to the vascular surgery service for vena caval interruption were evaluated for ability to visualize the renal veins and inferior vena cava. Location of renal veins, maximum diameter of the vena cava, and presence or absence of thrombus were documented. If visualization was adequate, placement was performed at the bedside for patients in intensive care or in the vascular laboratory for nonmonitored patients. The initial 10 patients and subsequent patients in whom there was a question of adequate deployment underwent completion abdominal roentgenography. Patient follow-up was difficult. Duplex ultrasonography was used to assess migration, thrombus adherent to the filter, and vena caval patency. Patients in whom filter placement was prophylactic were given anticoagulants at the discretion of the primary physician. Inadequate visualization or vena caval size greater than 28 mm prompted fluoroscopic placement of the vena caval filter, because only Greenfield titanium filters were used in the study. RESULTS: Twenty-nine patients were referred for vena caval interruption. Inadequate visualization occurred in four obese patients, and filters were placed by fluoroscopy. There were no vena caval measurements greater than 24 mm. Twenty-five filters were placed without technical difficulty. One filter tilted into the right renal vein, requiring a suprarenal filter placed by fluoroscopy. Patient retrieval for follow-up has been difficult, but by ultrasonography there has been one vena caval thrombosis and no major filter migration. There have been no reported pulmonary emboli other than the one patient with initial tilt of the filter. CONCLUSIONS: Placement of vena caval filters is feasible with duplex ultrasonography. Visualization is the only limiting condition to placement and occurs rarely. Reducing the need for fluoroscopy, lowering costs, and not needing to transport the critically ill patient support the use of this system. Intravascular ultrasonography in selected patients may eliminate the need for fluoroscopic placement of vena caval filters.

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PURPOSE: Early amputation has been suggested to be the optimal treatment for severe combined vascular and neural injuries of the proximal upper extremity. This retrospective study was done to evaluate the long-term clinical outcome of our policy of limb salvage by revascularization and delayed treatment of neural injuries. METHODS: Forty-six patients with neural and vascular trauma to the upper extremity were treated at our institution. All of these patients had aggressive treatment directed at limb salvage with restoration of vascular supply and nerve function. Long-term vascular and neurologic outcomes were recorded. Neurologic deficits were validated by the American Medical Association's standardized disability impairment scale (0% to 100%). RESULTS: The rate of preoperative disability was 83%, which improved to 52% (p < 0.01) after treatment (mean follow-up, 43 months). Overall, 87% showed improvement. CONCLUSION: These results suggest that early amputation should not be performed unless there is massive tissue loss or an attempt at limb salvage might endanger life. Final outcomes cannot be predicted on the basis of initial clinical presentation. As a group, the majority of these patients improved with aggressive intervention.

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Most abdominal aortic aneurysms (AAA) and thoracoabdominal aortic aneurysms (TAAA) are asymptomatic and are found on physical exam or incidentally during radiological studies for other indications. These aneurysms are repaired primarily because their risk of rupture increases geometrically as the size exceeds 5 cm. The potential morbidity of intraoperative visceral and spinal ischemia involved with TAAA repair may be reduced with various adjunctive maneuvers.

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BACKGROUND: To evaluate the economic impact of performing carotid endarterectomy based only on a diagnosis of duplex scanning, we evaluated a cohort of patients treated at our institution during 1 calendar year. METHODS: Ninety-seven patients were evaluated and divided into two groups: those with and without arteriogram prior to their operation. Duplex scan and arteriogram results were reviewed to determine their effect on the operative plan. Hospital charges and physician fees were assessed for each patient admission. Operative results, complications, and total charges were compared between the two groups. RESULTS: There was one operative stroke in each group for a stroke rate of 2%. Angiographic complications included one stroke and one femoral artery thrombosis. Two arteriograms led to a change in the operative plan. The hospital charges for patients without an arteriogram was $10,292 verses $13,906 for patients with an arteriogram (P < 0.01). Physician charges for patients without an arteriogram were $3,882, with angiograms and $6,297. The total charges related to the endarterectomy were $14,174 and $20,203, respectively. Arteriograms accounted for an increase of 43% in total charges. CONCLUSION: Nonroutine use of angiography does not increase operative risk or postoperative length of stay, and preoperative angiography increases total charges by 43% ($6,029) per patient.

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A case of endovascular treatment of abdominal aortic aneurysm is discussed along with a review of the literature. This recently introduced Food and Drug Administration Phase II treatment modality may have a significant impact on the approach to the treatment of aneurysmal disease. This discussion details the treatment of one typical patient and reviews the current status of endovascular therapy as it applies to infrarenal abdominal aortic aneurysms.

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PURPOSE: The intraaortic balloon pump (IABP) is useful in the treatment of failing hearts. Although most experience with IABPs has been with acute short-term use, the safe duration of therapy and possible complications of long-term IABP use are uncertain. We evaluated the feasibility, management, and complications associated with long-term IABP therapy. METHODS: Fifty consecutive patients with 87 IABPs were evaluated retrospectively. All patients had IABP support for greater than 72 hours. Results and complications were evaluated. RESULTS: The mean duration of IABP support was 23.2 days. There were 21 IABP-related complications in 16 patients: (16 ischemic, three infections, two hemorrhage). The rate of complications was 0.13 per patient-week of support. Significant predictors of complications were total days of IABP support (p < 0.0001), use of multiple IABPs (p < 0.0001), and attempted but unsuccessful percutaneous insertions (p < 0.001). Complications led to 14 vascular procedures (five patch angioplasties, four bypass procedures, two major amputations, one fasciotomy, one groin exploration for hemorrhage, and one removal of an infected Dacron patch). Percutaneous removals had a 14% complication rate compared with none after operative removal (p = 0.02). Thirty-two patients survived (64%). Of the survivors, 27 underwent transplant. CONCLUSIONS: Prolonged IABP therapy is feasible and is associated with an acceptable rate of complications. Operative removal is superior to percutaneous removal. Percutaneous removal should be limited to short-term therapy. There is no need for mandatory removal or site rotation based solely on indwelling time.

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A 67-year-old man had symptoms of peripheral vascular disease and was noted to have a carotid bruit. Duplex ultrasound examination of the neck demonstrated a short segmental occlusion of the proximal internal carotid artery (ICA) with antegrade flow distal to the occlusion maintained by an anomalous branch of the ICA. Angiography confirmed the findings and suggested that the branch was from the distribution of the occipital artery. The ICA findings were surgically proved, and endarterectomy was successfully performed without complication. This case reinforces the usefulness of duplex ultrasonography of the carotid arteries and is a rare situation in which a completely occluded ICA can be repaired with a good clinical outcome.

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The basic electrical rhythm (BER) of the gastrointestinal tract creates minute magnetic fields that have been measured in animals using a Superconducting QUantum Interference Device (SQUID) gradiometer. The aim of this study was to measure noninvasively the biomagnetic fields of human stomach and small intestine. Twenty-one human volunteers were studied using a 37-channel SQUID gradiometer positioned over the epigastrium and umbilicus. In one volunteer additional biomagnetic recordings were performed in order to map the spatial variation of the biomagnetic fields. Cyclical waveforms consistent with gastric BER [3.0+/-0.5 cycles per minute (cpm)] and small intestine BER (10.26+/-1.74 cpm) were seen in the epigastrium and umbilicus, respectively. The mapping study identified the expected frequency gradient (12.0 cpm in duodenum, 11.3 cpm in jejunum, to 9.7 cpm in ileum) within the small intestine. Noninvasive recordings of human gastric and small intestinal BER can be obtained using a SQUID gradiometer.

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OBJECTIVE: The authors addressed whether a repeat hepatic operation is warranted in patients with recurrent isolated hepatic metastases. Are the results as good after second operation as after first hepatic operation? SUMMARY BACKGROUND DATA: Five-year survival after initial hepatic operation for colorectal metastases is approximately 33%. Because available alternative methods of treatment provide inferior results, hepatic resection for isolated colorectal metastasis currently is well accepted as the best treatment option. However, the main cause of death after liver resection for colorectal metastasis is tumor recurrence. METHODS: Records of 95 patients undergoing initial hepatic operation and 10 patients undergoing repeat operation for isolated hepatic metastases were reviewed for operative morbidity and mortality, survival, disease-free survival, and pattern of failure. The literature on repeat hepatic resection for colorectal metastases was reviewed. RESULTS: The mean interval between the initial colon operation and first hepatic resection was 14 months. The mean interval between the first and second hepatic operation was 17 months. Operative mortality was 0%. At a mean follow-up of 33 +/- 27 months, survival in these ten patients was 100% at 1 year and 88% +/- 12% at 2 years. Disease-free survival at 1 and 3 years was 60% +/- 16% and 45% +/- 17%, respectively. After second hepatic operation, recurrence has been identified in 60% of patients at a mean of 24 +/- 30 months (median 9 months). Two of these ten patients had a third hepatic resection. Survival and disease-free survival for the 10 patients compared favorably with the 95 patients who underwent initial hepatic resection. CONCLUSIONS: Repeat hepatic operation for recurrent colorectal metastasis to the liver yields comparable results to first hepatic operations in terms of operative mortality and morbidity, survival, disease-free survival, and pattern of recurrence. This work helps to establish that repeat hepatic operation is the most successful form of treatment for isolated recurrent colorectal metastases.

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OBJECTIVE: The authors assessed the ability of a Superconducting Quantum Interference Device (SQUID) magnetometer to noninvasively detect mesenteric ischemia in a rabbit model. SUMMARY BACKGROUND DATA: Superconducting Quantum Interference Device magnetometers have been used to detect magnetic fields created by the basic electrical rhythm (BER) and to detect changes in BER of exteriorized bowel of anesthetized rabbits during mesenteric ischemia. METHODS: The BER of rabbit ileum was noninvasively measured transabdominally using a SQUID magnetometer and compared with the electrical activity recorded with surgically implanted serosal electrodes before, during, and after snare occlusion of the superior mesenteric artery. RESULTS: Transabdominal SQUID recording of BER frequency was highly correlated to the measurements obtained with electrodes (R = 0.91). Basic electrical rhythm frequency decreased from 16.4 +/- 0.8 to 8.3 +/- 0.3 cpm (p < 0.001) after 25 minutes of ischemia. Reperfusion of ischemic bowel resulted in recovery of BER frequency to 14.3 +/- 0.4 cpm 10 minutes after blood flow was restored. CONCLUSIONS: A SQUID magnetometer is capable of noninvasively detecting mesenteric ischemia reliably and at an early stage by detecting a significant drop in BER frequency. These positive findings have encouraged the authors to continue development of clinically useful, noninvasive, detection of intestinal magnetic fields using SQUID magnetometers.

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Verrucous carcinoma of the esophagus is a very rare esophageal cancer, with only 12 cases reported in the literature. Although this cancer is slow growing and rarely metastasizes, it is associated with a significantly high mortality. Because of the disease's insidious onset and its rarity, diagnosis has often been late, after local invasion has produced significant symptoms. We present the thirteenth reported case of verrucous carcinoma of the esophagus and support resection as the best form of treatment for this disease.

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