Journal of vascular surgery
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Several imaging modalities are available for the evaluation of dysfunctional hemodialysis shunts. Color Doppler ultrasonography (CDUS) and digital subtraction angiography (DSA) are most widely used for the detection of access stenoses, and contrast-enhanced magnetic resonance angiography (CE-MRA) of shunts has recently been introduced. To date, no study has compared the value of these three modalities for stenosis detection in dysfunctional shunts. We prospectively compared CDUS and CE-MRA with DSA for the detection of significant (> or = 50%) stenoses in failing dialysis accesses, and we determined whether the interventionalist would benefit from CDUS performed before DSA and endovascular intervention. ⋯ We suggest that CDUS be used as initial imaging modality of dysfunctional shunts, but complete access should be depicted at DSA and angioplasty to detect all significant stenoses eligible for intervention. CE-MRA should be considered only if DSA is inconclusive.
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Comparative Study
Is abdominal aortic aneurysm repair appropriate in oxygen-dependent chronic obstructive pulmonary disease patients?
The life expectancy of patients with oxygen-dependent chronic obstructive pulmonary disease (COPD) is significantly reduced, but the risk of any intervention is considered prohibitive. However, severe COPD may increase the risk of abdominal aortic aneurysm (AAA) rupture. We reviewed our experience with AAA repair in oxygen-dependent patients to determine whether operative risk and expected long-term survival justify surgical intervention. ⋯ It is reasonable to continue to offer AAA repair to home oxygen-dependent COPD patients who are ambulatory and medically optimized and who are without untreated coronary artery disease. Although EVAR may be the most suitable treatment for oxygen-dependent COPD patients, our results show that even open repair may be safely performed in this population, with acceptable results.
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Comparative Study
Protective use of N-methyl-D-aspartate receptor antagonists as a spinoplegia against excitatory amino acid neurotoxicity.
Paraplegia remains a serious complication of thoracic and thoracoabdominal aortic operations. To avoid this dreadful complication, N-methyl-D-aspartate (NMDA) receptor antagonists have been examined in the ischemic or excitotoxic neuronal injury model. In the present study, we evaluated the protective efficacy of NMDA receptor antagonists that were infused segmentally after aortic clamping, as a spinoplegia, to reduce aspartate neurotoxicity in the spinal cord. ⋯ Paraplegia is a devastating complication during surgical repair of the thoracic and thoracoabdominal aortas. Excitatory amino acids neurotoxicity through the N-methyl-D-aspartate (NMDA) receptor is no doubt the pathologic hallmark of ischemic and postischemic spinal cord injury. Systemic administration of either a competitive or noncompetitive NMDA antagonist has been reported to have neuroprotective effect, in terms of preoperative treatment, with dose-related central sympathomimetic and sedative effects. Local administration, particularly of a noncompetitive NMDA antagonist, infused segmentally after aortic clamping could therefore be a potent intraoperative pharmacologic strategy to minimize the effective dose that retains NMDA antagonism without undesirable adverse effects. Our ability to reproduce this model could facilitate pharmacologic prevention or provide a new surgical technique as a spinoplegia for NMDA receptor-mediated neuronal injury.
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Comparative Study
Treatment of venous thromboembolism: adherence to guidelines and impact of physician knowledge, attitudes, and beliefs.
To assess the treatment of venous thromboembolism (VTE) in hospitalized patients enrolled in a national, multicenter database. ⋯ In this cross-section of United States hospitals, lower than anticipated use of LMWH, insufficient bridging from UFH or LMWH to warfarin, and continuation of anticoagulation after hospitalization were all problems discovered with the treatment of VTE. Physician knowledge, attitudes, and beliefs are partially responsible for the gap between actual practice and international guidelines. These results suggest that hospitals should evaluate their adherence to international VTE treatment guidelines and develop strategies to optimize antithrombotic therapy.
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Comparative Study
Correlation of carotid artery stump pressure and neurologic changes during 474 carotid endarterectomies performed in awake patients.
A carotid artery stump pressure (SP) of < 50 mm Hg and abnormal electroencephalography (EEG) changes have been suggested as indications for selective shunting in patients undergoing carotid endarterectomy (CEA) under general anesthesia. We attempted to determine the optimal SP threshold that correlated with neurologic changes in awake patients undergoing CEA using cervical block anesthesia (CBA) and performed a cost comparison with EEG monitoring. ⋯ Using 40 mm Hg systolic as a threshold, the need for shunting (15%) and the false-negative rate (1.0%) for SP in our series were equivalent to the results of EEG monitoring during CEA reported in the literature. However, charges for SP measurements are dramatically lower compared with EEG monitoring. Our results suggest that a carotid artery SP > or = 40 mm Hg systolic may be considered as an equally reliable but more cost-effective method to predict the need for carotid shunting during CEA under GA compared with EEG monitoring, but further investigation is warranted.