Journal of vascular surgery
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Randomized Controlled Trial Comparative Study Clinical Trial
A prospective randomized study of cerebrospinal fluid drainage to prevent paraplegia after high-risk surgery on the thoracoabdominal aorta.
This article is concerned with the study of the effect of several variables, principally that of cerebrospinal fluid drainage, on the incidence of neurologic deficit in a prospective randomized series of patients with extensive aneurysms of the descending thoracic and abdominal aorta (thoracoabdominal type I and II). Forty-six patients had cerebrospinal fluid drainage, and 52 were controls, with a total of 98 available for study. ⋯ Thus cerebrospinal fluid drainage as we used it, was not beneficial in preventing paraplegia. On appropriate statistical analysis we found that the only significant predictor of delayed deficits was postoperative hypotension (p = 0.006).
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In patients with aortoiliac occlusive disease interruption of critical collaterals during another nonvascular or cardiac operation may threaten limb viability. This occurred in four patients whose limb-threatening ischemia was precipitated by radical cystectomy with bilateral hypogastric artery ligation, left colon resection, or coronary artery revascularizations by means of the internal mammary artery. Important collateral pathways, the interruption of which may account for this phenomenon, are detailed, and approaches are outlined for prevention and management of acute ischemia in this setting.
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Recurrent symptoms develop in 15% to 20% of patients undergoing either first rib resection or scalenectomy for thoracic outlet syndrome. Over the past 22 years 134 operations for recurrence were performed in 97 patients. Four operations were used: transaxillary first rib resection (26); supraclavicular first rib resection with neurolysis (15); scalenectomy with neurolysis (58); and brachial plexus neurolysis (35). ⋯ The primary success rates of three initial operations for thoracic outlet syndrome were compared to their secondary success rates (improved after reoperation). By use of life-table methods, reoperation improved the 5- to 10-year success rate of transaxillary first rib resection from 69% to 86% and for scalenectomy from 69% to 84%. Reoperation is successful in most cases of recurrent thoracic outlet syndrome and better when recurrence is the result of a neck injury.
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Case Reports
Primary aortoesophageal fistula from aortic aneurysm: successful surgical treatment by use of omental pedicle graft.
A 65-year-old woman sought treatment for sentinel upper gastrointestinal hemorrhage. Three years previously she had undergone graft replacement of her ascending aorta for aneurysm. In the interim she was followed for chronic dissection of her remaining aorta, and 6 months before this admission she had undergone graft replacement of a large abdominal aortic aneurysm. ⋯ Development of a primary aortoesophageal fistula caused by aneurysms of the aorta is a rare but lethal complication. We present a technique for treatment of primary aortoesophageal fistula using omentum and preservation of gastrointestinal continuity as a one-stage operation. It is possible in selected cases to manage the esophageal perforation with primary closure and omental coverage to achieve healing free of infection without temporary or permanent discontinuity of the gastrointestinal tract.
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Epidural spinal cord electrical stimulation has been suggested as an alternative treatment in patients with limb-threatening ischemia in whom vascular reconstructive surgery is not possible anymore. We studied the effects of epidural spinal cord electrical stimulation on microcirculatory blood flow in 20 patients with ischemic rest pain and ulcers. Angiography showed occluded crural arteries technically unsuitable for reconstructive surgery. ⋯ In 12 patients pain relief continued, and ischemic ulcers healed; capillary microscopy confirmed improved microcirculatory blood flow. Microcirculatory parameters were significantly higher in respondents than in nonrespondents (p less than 0.001). Life-table analysis revealed a cumulative foot salvage of 80% and 56% after 1 and 2 years, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)