RESUMEN
For the 48th meeting of the International Society for Cardiovascular Surgery, North American Chapter in June 2000, we were asked to organize a presentation with the title displayed above. We welcomed this opportunity because the phrase 'growing the practice' literally means giving greater service to underserved patients with vascular disorders. Underserved individuals with vascular disorders include those with nonatherosclerotic arterial disorders, patients with lymphedema, and individuals with a variety of venous disorders including venous insufficiency. The majority of these conditions are not surgical, but venous insufficiency commands attention because its treatments are interventional. Therefore, this presentation will discuss prevalence of venous insufficiency, a unifying concept of its pathophysiology, how treatment may be selected, what the new technology provides, and then a description of coding issues and whether or not interventions are actually worthwhile from the point of view of the patient.
Asunto(s)
Várices/cirugía , Procedimientos Quirúrgicos Vasculares/métodos , Insuficiencia Venosa/epidemiología , Insuficiencia Venosa/cirugía , Adulto , Factores de Edad , Anciano , Femenino , Control de Formularios y Registros , Humanos , Masculino , Registros Médicos , Persona de Mediana Edad , Satisfacción del Paciente , Prevalencia , Várices/fisiopatología , Insuficiencia Venosa/fisiopatologíaRESUMEN
Recently, carotid artery stenting (CAS) has emerged as a treatment option for carotid artery stenosis. Since the procedure is new, management of its complications is not standardized. This case report describes one method of arterial reconstruction after failed CAS. A 64-year-old male underwent CAS of his right internal carotid artery (ICA) for an asymptomatic 65% stenosis. Seven months later the stented area had narrowed to 95%. Arteriography revealed that the common and external carotid arteries (ECA) were free of disease so we elected to perform a transposition of the distal ICA onto the proximal ECA. The ECA and its branches were completely mobilized and the ascending pharyngeal and lingual arteries divided. The ICA was divided distal to the stent. Transection of the occipital artery provided an arteriotomy for an end ICA to side ECA anastamosis, thus preserving ECA flow. Postoperative surveillance after 8 months has revealed no recurrent stenosis. Operative repair of restenosis after CAS may be challenging if standard endarterectomy is not possible. Other options for reconstruction are feasible but if the common and external carotid arteries are disease-free, an ICA to ECA transposition provides a simple all-arterial repair that avoids bypass and prosthetic material.
Asunto(s)
Anastomosis Quirúrgica , Angioplastia de Balón , Arteria Carótida Externa/cirugía , Arteria Carótida Interna/cirugía , Estenosis Carotídea/cirugía , Stents , Angiografía , Estenosis Carotídea/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , RecurrenciaRESUMEN
The growth of neointima and neointimal smooth muscle cells in baboon polytetrafluoroethylene grafts is regulated by blood flow. Because neointimal smooth muscle cells express both platelet-derived growth factor receptor-alpha and -beta (PDGFR-alpha and -beta), we designed this study to test the hypothesis that inhibiting either PDGFR-alpha or PDGFR-beta with a specific mouse/human chimeric antibody will modulate flow-induced neointimal formation. Bilateral aortoiliac grafts and distal femoral arteriovenous fistulae were placed in 17 baboons. After 8 weeks, 1 arteriovenous fistulae was ligated, normalizing flow through the ipsilateral graft while maintaining high flow in the contralateral graft. The experimental groups received a blocking antibody to PDGFR-alpha (Ab-PDGFR-alpha; 10 mg/kg; n=5) or PDGFR-beta (Ab-PDGFR-beta; 10 mg/kg; n=6) by pulsed intravenous administration 30 minutes before ligation and at 4, 8, 15, and 22 days after ligation. Controls received carrier medium alone (n=8). Serum antibody concentrations were followed. Grafts were harvested after 28 days and analyzed by videomorphometry. Serum Ab-PDGFR-alpha concentrations fell rapidly after day 7 to 0, whereas serum Ab-PDGFR-beta concentrations were maintained at the target levels (>50 microg/mL). Compared with controls (3.7+/-0.3), the ratio of the intimal areas (normalized flow/high flow) was significantly reduced in Ab-PDGFR-beta (1.2+/-0.2, P<0.01) but not in Ab-PDGFR-alpha (2.2+/-0.4). Ab-PDGFR-alpha decreased significantly the overall smooth muscle cell nuclear density of the neointima (P<0.01) compared with either the control or Ab-PDGFR-beta treated groups. PDGFR-beta is necessary for flow-induced neointimal formation in prosthetic grafts. Targeting PDGFR-beta may be an effective pharmacological strategy for suppressing graft neointimal development.
Asunto(s)
Endotelio Vascular/fisiología , Músculo Liso Vascular/fisiología , Neovascularización Patológica , Receptor alfa de Factor de Crecimiento Derivado de Plaquetas/fisiología , Receptor beta de Factor de Crecimiento Derivado de Plaquetas/fisiología , Túnica Íntima/fisiología , Animales , Anticuerpos/farmacología , Aorta/cirugía , Apoptosis , Derivación Arteriovenosa Quirúrgica , Velocidad del Flujo Sanguíneo , División Celular , Células Cultivadas , Quimiotaxis/efectos de los fármacos , Quimiotaxis/fisiología , Endotelio Vascular/citología , Endotelio Vascular/trasplante , Arteria Femoral/cirugía , Vena Femoral/cirugía , Humanos , Hiperplasia , Arteria Ilíaca/cirugía , Masculino , Ratones , Músculo Liso Vascular/citología , Músculo Liso Vascular/trasplante , Papio , Receptor alfa de Factor de Crecimiento Derivado de Plaquetas/antagonistas & inhibidores , Receptor beta de Factor de Crecimiento Derivado de Plaquetas/antagonistas & inhibidores , Proteínas Recombinantes de Fusión/farmacología , Estrés Mecánico , Túnica Íntima/citología , Túnica Íntima/patologíaRESUMEN
A case of isolated dissection of the superior mesenteric artery is presented here. This rare condition was confirmed angiographically in a 46-year-old man with persistent abdominal pain. He was treated initially with anticoagulation alone. One year later, he developed recurrent symptoms and had radiologic documentation of progression of the condition. Operative repair was performed and recovery was uneventful. This case demonstrates a failure of the nonoperative approach to this rare condition and suggests that disease progression may be inevitable. Early surgical correction may ease operative management.
Asunto(s)
Anticoagulantes/uso terapéutico , Disección Aórtica/tratamiento farmacológico , Arteria Mesentérica Superior/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/cirugía , Femenino , Humanos , Masculino , Arteria Mesentérica Superior/diagnóstico por imagen , Persona de Mediana Edad , Trombosis/prevención & control , Tomografía Computarizada por Rayos X , Insuficiencia del TratamientoRESUMEN
The purpose of this study is to analyze causes and consequences of arterial injury complicating simple dislocations of the upper extremity. This is a multicenter, 5-year, retrospective analysis of vascular injury in patients sustaining shoulder or elbow dislocations without associated fractures. Foci of the study were mechanisms of injury, preoperative imaging, incidence of closed reductions, types of arterial injury, methods of surgical repair, and ultimate outcome. Arterial injury in this patient cohort occurred in 0.74% of patients. Axillary artery injury occurred in 0. 97% and brachial in 0.47%. Both elbow and shoulder dislocations may cause severe arterial damage and strenuously test surgical expertise to achieve successful repair.
Asunto(s)
Arteria Axilar/lesiones , Vasos Sanguíneos/lesiones , Arteria Braquial/lesiones , Lesiones de Codo , Luxaciones Articulares/complicaciones , Luxación del Hombro/complicaciones , Estudios de Cohortes , Femenino , Humanos , Luxaciones Articulares/cirugía , Masculino , Estudios Retrospectivos , Luxación del Hombro/cirugía , Trasplante de Tejidos , Heridas no Penetrantes/complicacionesRESUMEN
Surgical intervention during the early stages of Takayasu's arteritis is rarely necessary. In the chronic stages of this disease, however, surgeons may be faced with difficult decisions regarding the timing of complex arterial reconstructions. These issues can be especially challenging in the pediatric population. We report the case of an 8-year-old girl with chronic Takayasu's arteritis complicated by malignant hypertension. Despite aggressive medical therapy, her blood pressure remained uncontrolled. Imaging studies demonstrated infrarenal aortic and right common iliac artery aneurysms with concomitant segmental stenosis of the right common iliac artery. Since her transplant kidney was based off the right external iliac artery, it was felt that this high-grade stenosis was responsible for her severe hypertension. Immediate surgical reconstruction was therefore recommended. Intraoperatively, the aneurysmal aorta and iliac arteries were found to be densely calcified. The transplant kidney was perfused during aortic clamping by placement of a suprarenal aorta to the right external iliac artery shunt. Endoaneurysmorrhaphy was then performed to reconstruct the aorta after extensive endarterectomy. In the early postoperative period, antihypertensive medications were decreased to two oral agents. She was discharged on the seventh postoperative day and placed on two agents. At a 1-year follow-up visit, she is on one antihypertensive medication. Her right leg complaints have resolved. Ultrasound surveillance revealed no evidence of recurrent aneurysmal or occlusive disease. A brief review of complications related to Takayasu's arteritis in the children and indications for surgical intervention completes this report.
Asunto(s)
Arteritis de Takayasu/cirugía , Antihipertensivos/uso terapéutico , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/etiología , Aneurisma de la Aorta Abdominal/cirugía , Niño , Endarterectomía , Femenino , Humanos , Hipertensión Maligna/tratamiento farmacológico , Hipertensión Maligna/etiología , Aneurisma Ilíaco/diagnóstico por imagen , Aneurisma Ilíaco/etiología , Aneurisma Ilíaco/cirugía , Trasplante de Riñón , Radiografía , Arteritis de Takayasu/complicacionesRESUMEN
The breakdown of myofibrillar and sarcoplasmic (nonmyofibrillar) proteins are regulated independently in sepsis, however, the factors regulating their synthesis are unknown. In this study, we assessed the effects of sepsis and interleukin-1 receptor antagonist on sarcoplasmic and myofibrillar protein synthesis in gastrocnemius. The rate of sarcoplasmic protein synthesis was 3.5 times that of myofibrillar proteins in control and septic rats. The synthesis of both sarcoplasmic and myofibrillar proteins was diminished proportionately during sepsis (p < .05). Infusion of interleukin-1 receptor antagonist (2 mg.kg.-1.h.-1) prevented the sepsis-induced inhibition of total, sarcoplasmic, and myofibrillar protein synthesis. Changes in the abundance of messenger RNA could not account for the inhibition of protein synthesis observed in sepsis. Furthermore, in vitro translation of messenger RNA isolated from control and septic muscle revealed no major differences. These results suggest the following: 1) the inhibition of total mixed proteins during sepsis is a consequence of reduced synthesis of both myofibrillar and sarcoplasmic proteins; 2) IL-1ra maintains control values of protein synthesis by sparing the reduction in synthesis of both myofibrillar and sarcoplasmic proteins during sepsis; and 3) the abundance of messenger RNA is not a rate-limiting determinant of protein synthesis in muscle from septic rats. An alteration in the translational efficiency of existing mRNA appears to be the major mechanism responsible for the inhibition of protein synthesis during sepsis.
Asunto(s)
Bacteriemia/metabolismo , Proteínas Musculares/biosíntesis , Músculo Esquelético/metabolismo , Miofibrillas/metabolismo , Retículo Sarcoplasmático/metabolismo , Sialoglicoproteínas/farmacología , Absceso Abdominal/metabolismo , Animales , Infecciones por Bacteroides/metabolismo , Bacteroides fragilis , Peso Corporal , Infecciones por Escherichia coli/metabolismo , Infusiones Intravenosas , Proteína Antagonista del Receptor de Interleucina 1 , Masculino , Miofibrillas/efectos de los fármacos , Biosíntesis de Proteínas/efectos de los fármacos , ARN Mensajero/análisis , ARN Mensajero/biosíntesis , Ratas , Ratas Sprague-Dawley , Retículo Sarcoplasmático/efectos de los fármacos , Sialoglicoproteínas/administración & dosificación , Transcripción Genética/efectos de los fármacosRESUMEN
Sepsis induces a net catabolic state in gastrocnemius by increasing protein degradation and decreasing protein synthesis. To determine whether or not sepsis induces a preferential effect on the expression of individual proteins, proteins from gastrocnemius muscle of control and septic rats were separated by two-dimensional isoelectric focusing/sodium dodecyl sulfate-polyacrylamide gel electrophoresis. Laser densitometry of proteins stained with silver provided evidence that the relative abundance of thirty-five proteins was significantly (p < .05) and reproducibly increased during sepsis compared to control. No individual protein underwent significant down-regulation in their relative abundance during sepsis. Twenty-three of the 35 proteins identified in two-dimensional gels of the gastrocnemius were also present in the plasma of septic rats. The remaining 12 proteins, therefore, were taken to represent skeletal muscle proteins. One of the 12 proteins was identified by immunoblot analysis to be carbonic anhydrase III. Another of the proteins was identified as triosephosphate isomerase based upon microsequencing of the N terminus.
Asunto(s)
Bacteriemia/metabolismo , Expresión Génica , Proteínas Musculares/biosíntesis , Músculo Esquelético/metabolismo , Secuencia de Aminoácidos , Animales , Infecciones por Bacteroides/metabolismo , Anhidrasas Carbónicas/biosíntesis , Anhidrasas Carbónicas/aislamiento & purificación , Electroforesis en Gel Bidimensional , Electroforesis en Gel de Poliacrilamida , Infecciones por Escherichia coli/metabolismo , Humanos , Focalización Isoeléctrica , Isoenzimas/biosíntesis , Isoenzimas/aislamiento & purificación , Masculino , Datos de Secuencia Molecular , Proteínas Musculares/aislamiento & purificación , Ratas , Ratas Sprague-Dawley , Valores de Referencia , Homología de Secuencia de AminoácidoRESUMEN
Children with continuous ambulatory peritoneal dialysis (CAPD) run an increased risk of infection when swimming. In CAPD, the catheter and transfer set are the lifeline and must be kept free of contaminants. Children receiving CAPD treatments were given the opportunity to go swimming by using a pouching system. Instructions were given by both the enterostomal therapist and pediatric dialysis nurse. No cases of infection, peritonitis, or leakage developed with this system.