RESUMEN
Tumors of the carotid body are relatively rare and may pose a difficult surgical problem because of their vascularity and compression of cranial nerves in the neck. This article reviews the physiology of the carotid body, its surgical history, and retrospectively reviews the management and outcome of 17 carotid body tumors occurring in 14 patients over an 18-year period at the University of Louisville Hospitals. The average age at presentation was 54.4 years. Three patients had bilateral tumors. Two patients (12%) had postoperative cranial nerve paralysis lasting greater than 6 months. One patient had a postoperative stroke after discharge from the hospital and subsequently died 2 months later from a pulmonary embolus. One patient had a malignant carotid body tumor and pulmonary metastasis and died 11 years after her original operation during an attempted embolization of recurrent carotid lesion. Early operation for the tumor is indicated to prevent nerve dysfunction due to compression and stretch injury as the lesion increases in size.
Asunto(s)
Tumor del Cuerpo Carotídeo/cirugía , Adulto , Anciano , Biopsia , Tumor del Cuerpo Carotídeo/complicaciones , Tumor del Cuerpo Carotídeo/patología , Tumor del Cuerpo Carotídeo/secundario , Enfermedades de los Nervios Craneales/etiología , Femenino , Humanos , Neoplasias Pulmonares/secundario , Ganglios Linfáticos , Metástasis Linfática , Masculino , Persona de Mediana Edad , Cuello , Síndromes de Compresión Nerviosa/etiología , Paresia/etiología , Resultado del TratamientoRESUMEN
BACKGROUND: Revascularization is the only alternative to amputation for patients with severe, symptomatic infrainguinal ischemia. It is the purpose of this study to determine the success of revascularization as defined by limb salvage in a personal 10-year operative experience. METHODS: Primary infrainguinal bypass procedures were performed on 312 threatened limbs of 271 consecutive patients in the period between January 1, 1983, and December 31, 1992. Repeat revascularization was performed for failing/failed grafts as long as the extremity was viable and an outflow vessel could be found by either preoperative or intraoperative angiography. RESULTS: Ten patients died within 30 days of the primary procedure (4%) and the 5-year patient survival was 57%. Major amputations (AK or BK) were performed on 50 extremities over the 10-year period; cumulative 72-month limb salvage was 72%. Fifty-eight of the 312 extremities (19%) required 81 reoperations for failing/failed grafts, including a second procedure in 58, a third procedure in 14, and a fourth procedure in 9. Graft occlusions in which revision was either not attempted or was ultimately unsuccessful occurred in 72 extremities and led to 44 amputations. Cumulative primary and secondary graft patency for autologous conduit was clearly superior to nonautologous conduit (57% and 67% vs 20% and 21% respectively at 60 months). CONCLUSIONS: We believe that this approach to infrainguinal revascularization is warranted as the mortality is low and the likelihood of success is high. A long term commitment to careful postoperative surveillance is mandatory as reintervention is frequently required to maintain graft patency and limb salvage.
Asunto(s)
Oclusión de Injerto Vascular/cirugía , Isquemia/cirugía , Pierna/irrigación sanguínea , Adulto , Anciano , Anciano de 80 o más Años , Amputación Quirúrgica , Prótesis Vascular , Femenino , Oclusión de Injerto Vascular/mortalidad , Humanos , Isquemia/mortalidad , Masculino , Persona de Mediana Edad , Reoperación , Estudios Retrospectivos , Tasa de Supervivencia , Venas/trasplanteRESUMEN
OBJECTIVE: The authors determined the impact of an intensive surveillance program of autogenous vein bypasses on patency and limb salvage. SUMMARY BACKGROUND DATA: Surveillance protocols of vein bypasses can identify graft-threatening lesions to permit elective revisions before thrombosis. The authors compared follow-up based on clinically indicated procedures with intensive surveillance. METHODS: From 1985 to 1994, 615 autogenous vein bypasses (454 in situ, 161 reversed/composite) to popliteal (n = 169) and tibial (n = 446) arteries were performed for critical limb ischemia (n = 507), claudication (n = 88), and popliteal aneurysm (n = 20). Intensive surveillance of autogenous vein bypasses consisted of ankle brachial index and duplex scan with graft velocities measured at 1 month, 3 months, 6 months, and every 6 months subsequently. After surgery 317 bypasses had intensive surveillance, 222 bypasses were clinically indicated for follow-up, and 76 bypasses were excluded because follow-up or patency was less than 31 days. RESULTS: Primary patency at 5 years was similar for bypasses treated by intensive surveillance (56%) and those treated with clinically indicated procedures (67%). Secondary patency and limb salvage at 5 years was significantly improved (p < 0.02) for bypasses followed by intensive surveillance (80% and 94%) compared with clinically indicated procedures (67% and 73%). Revision of patent bypasses was higher (p < 0.000001) for bypasses treated by intensive surveillance (61 of 70, 87%) compared with those treated with clinically indicated procedures (9 of 34, 26%). Secondary patency at 2 years was significantly higher (p < 0.02) for revision of patent bypasses (79%) compared with thrombosed bypasses (55%). CONCLUSIONS: Long-term autogenous vein bypass patency and limb salvage is significantly improved by intensive surveillance, permitting identification and correction of graft threatening lesions before thrombosis.
Asunto(s)
Arteria Femoral/cirugía , Isquemia/cirugía , Pierna/irrigación sanguínea , Arteria Poplítea/cirugía , Cuidados Posoperatorios , Arterias Tibiales/cirugía , Grado de Desobstrucción Vascular , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Reoperación , Resultado del TratamientoRESUMEN
PURPOSE: We compared autogenous vein pedal and peroneal bypasses, focusing on extremities that could have a bypass to either artery. METHODS: From 1985 to 1993 we performed a total of 175 pedal and 77 peroneal autogenous vein bypasses for rest pain (n = 75, 30%) and tissue loss (n = 177, 70%). One hundred ninety-six (78%) in situ saphenous vein and 56 (22%) reversed or composite vein bypasses were performed. One hundred fifty-two of these 252 bypasses were performed in extremities with both the pedal and peroneal arteries patent by arteriography. The vascular surgeon chose to perform 99 pedal and 53 peroneal vein bypasses in these 152 extremities. RESULTS: The angiogram score of the outflow arteries were similar for pedal and peroneal bypasses with the Society for Vascular Surgery and the International Society for Cardiovascular Surgery and modified scoring systems. At 2 years the primary and secondary patency rates for pedal bypasses (70% and 77%) were not significantly different compared with those for peroneal bypasses (60% and 72%). Limb salvage rates at 2 years were similar for pedal and peroneal bypasses for all patients (74% and 73%), patients with both pedal and peroneal arteries patent (83% and 72%), diabetics (76% and 66%), and patients with tissue necrosis (77% and 71%). CONCLUSIONS: Pedal and peroneal artery bypasses with equivalent angiogram scores have similar long-term graft patency and limb salvage. The choice between pedal or peroneal artery bypass should be based on the quality of vein and the surgeon's preference.
Asunto(s)
Tobillo/irrigación sanguínea , Derivación Arteriovenosa Quirúrgica/métodos , Venas Braquiocefálicas/trasplante , Pie/irrigación sanguínea , Isquemia/cirugía , Vena Safena/trasplante , Arterias Tibiales/cirugía , Anciano , Anciano de 80 o más Años , Tobillo/patología , Tobillo/fisiopatología , Arterias/cirugía , Femenino , Estudios de Seguimiento , Pie/patología , Pie/fisiopatología , Oclusión de Injerto Vascular/diagnóstico por imagen , Oclusión de Injerto Vascular/epidemiología , Oclusión de Injerto Vascular/fisiopatología , Humanos , Incidencia , Isquemia/complicaciones , Isquemia/mortalidad , Isquemia/patología , Isquemia/fisiopatología , Masculino , Persona de Mediana Edad , Necrosis , Dolor/etiología , Cuidados Posoperatorios , Complicaciones Posoperatorias/epidemiología , Radiografía , Descanso , Tasa de Supervivencia , Arterias Tibiales/diagnóstico por imagen , Arterias Tibiales/fisiopatología , Factores de Tiempo , Grado de Desobstrucción Vascular , Cicatrización de HeridasRESUMEN
Treatment of patients with limb-threatening ischemia after multiple failed bypasses remains difficult and controversial. Further revascularization procedures despite failure of the original procedure may be viewed as futile. The purpose of this report is to determine the efficacy of third or fourth revascularization procedures after the original and second procedures fail. Over a 10-year period from January 1, 1983, to December 31, 1992, 312 infrainguinal bypasses were performed on 271 consecutive patients for foot salvage. The overall limb salvage rate was 84%, and the operative mortality rate was 3.7% (10 patients). Sixteen patients (5.8%) had repeat infrainguinal bypasses performed after failure of two or more prior bypass procedures in the same leg. Twenty-three reconstructions were performed in these 16 patients. There were no operative deaths. One half of these patients had major amputations performed within the first year following their tertiary or fourth reconstructive procedure. Sixty-two percent of patients have survived longer than 3 years after their third or fourth procedure. One half of these patients have maintained graft patency and an excellent quality of life. Only 22% of the patients requiring amputation ambulated with a prosthesis, whereas all revascularized patients ambulated. Although this subset of patients is known to have an increased risk of repeated graft failure and limb loss, we believe continued efforts at limb salvage despite multiple previous graft failures is justified.
Asunto(s)
Isquemia/cirugía , Pierna/irrigación sanguínea , Pierna/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Amputación Quirúrgica , Anastomosis Quirúrgica , Prótesis Vascular , Femenino , Arteria Femoral/cirugía , Estudios de Seguimiento , Pie/irrigación sanguínea , Humanos , Masculino , Persona de Mediana Edad , Politetrafluoroetileno , Reoperación , Estudios Retrospectivos , Vena Safena/trasplante , Insuficiencia del Tratamiento , Grado de Desobstrucción Vascular , Venas/trasplanteRESUMEN
Cerebral hyperperfusion syndrome after carotid endarterectomy is an uncommon but distressing complication. Findings in nearly all these patients include the presence of ipsilateral high-grade carotid artery stenosis, postoperative ipsilateral headache followed by seizures, and transient neurologic deficits. It appears to be caused by the loss of autoregulation within the brain, usually occurring between 5 and 7 days postoperatively.
Asunto(s)
Endarterectomía Carotidea/efectos adversos , Epilepsia Tónico-Clónica/etiología , Anciano , Humanos , Masculino , Persona de Mediana Edad , Síndrome , Factores de TiempoRESUMEN
Sixty-eight patients underwent femorofemoral bypass (FFB) at the University of Louisville Affiliated Hospitals over a 9-year period from 1980 to 1989. There were patients with acute ischemia requiring emergency operation, those with chronic ischemia following failed aortic reconstruction, good-risk patients with chronic ischemia who had FFB as the procedure of choice, and poor-risk patients who were unsuitable for other procedures. Patients operated on for acute ischemia had a significant number of infectious complications, with five of eight graft failures in this group due to infection. Primary patency rates were similar in all groups, with a 5-year primary patency of 42 per cent. Overall operative mortality was 4.4 per cent. Satisfactory limb salvage rates (75%) suggest that FFB is an acceptable option for providing inflow in patients with acute ischemia or for patients with a failed previous vascular prosthesis. FFB provides adequate inflow in poor-risk patients not suitable for aortic reconstruction, but patency rates do not warrant its use as a procedure of choice in good-risk patients.
Asunto(s)
Arteria Femoral/cirugía , Isquemia/cirugía , Pierna/irrigación sanguínea , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Enfermedad Crónica , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Reoperación , Factores de Riesgo , Vena Safena/trasplante , Grado de Desobstrucción VascularRESUMEN
Sixty-five patients received 68 inframalleolar arterial grafts for severe rest pain, foot ulceration, or gangrene. Patients were elderly with an average age of 68 years (median 72); most had several operative risk factors. Reversed saphenous vein grafts were used early, but most conduits were in situ vein grafts. The recipient vessel was the dorsalis pedis artery in 39 patients, the posterior tibial in 27, and tarsal branches in two. Preoperative angiography was routinely performed with biplanar and digital arterial techniques, but in nearly a third a suitable bypass vessel was not identified preoperatively. When vessels were identified there was usually only a single patent artery suitable for bypass grafting below the knee. There were five postoperative deaths (7.6%). Eight grafts (11%) required early revision for thrombosis or retained valve, and six were salvaged and remained patent. Poor vein quality appeared responsible for the two early failures. Six late graft occlusions occurred from 4 to 39 months (mean 14 months). Three of these patients had no recurrence of their ulceration, but two required amputation, and one has continued rest pain. One additional amputation was required in a patient with a patent graft. Eleven late deaths (16%) occurred (nine with patent grafts) primarily of cardiac causes.
Asunto(s)
Tobillo/irrigación sanguínea , Arterias/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Enfermedades del Pie/cirugía , Gangrena , Humanos , Masculino , Persona de Mediana Edad , Dolor/cirugía , Descanso , Úlcera/cirugíaRESUMEN
An aggressive approach to limb salvage for infrainguinal arteriosclerosis obliterans in the elderly is recommended because of the generally poor rehabilitation and poor quality of life resulting from primary amputation. Profundaplasty, femoral-popliteal, and femoral-distal infrageniculate bypasses yield excellent results with minimum mortality.
Asunto(s)
Arteriosclerosis Obliterante/cirugía , Amputación Quirúrgica , Arteria Femoral/cirugía , Oclusión de Injerto Vascular/terapia , Humanos , Isquemia/cirugía , Pierna/irrigación sanguínea , Pierna/cirugía , Arteria Poplítea/cirugía , Cuidados Preoperatorios , Tibia/irrigación sanguínea , Procedimientos Quirúrgicos VascularesAsunto(s)
Corazón/fisiopatología , Sustitutos del Plasma/uso terapéutico , Choque Hemorrágico/fisiopatología , Animales , Presión Sanguínea , Transfusión de Sangre Autóloga , Gasto Cardíaco , Perros , Cardiopatías/etiología , Frecuencia Cardíaca , Lactatos/uso terapéutico , Contracción Miocárdica , Choque Hemorrágico/complicaciones , Choque Hemorrágico/terapiaRESUMEN
In 23 patients with laryngotracheal trauma at the Louisville General Hospital during a ten-year period, 19 survived. One death was directly atributable to the airway injury. The most common postinjury complication was hoarsensess attributable to direct injury to the cords or recurrent nerve paralysis. One patient had further operation for subglottic stenosis. In general, blunt injuries were more severe than penetrating injuries. Subcutaneous emphysema, aphonia or dyshonia, hemoptysis, signs of injuries, a sucking wound, are presumptive findings of laryngotracheal injury. Appropriate endoscopy and radiographic studies should confirm the diagnosis. Control of the airway is achieved by emergency tracheostomy or intubation followed by tracheostomy. Prompt operative intervention and primary repair follow.