Abstract:

The diagnosis of abdominal aortic aneurysms (AAA) has been established with increasing frequency during the past two decades. This is probably due to the aging of the population as well as to the extensive use of ultrasonography and computerized tomography (CT) scanning for different pathologies. Although AAA may occasionally cause distal embolization, rupture remains the most common and deadly complication. Elective replacement with a synthetic graft has proved to be the most appropriate method to prevent AAA rupture for nearly 40 years, and at respected medical centers, it has been associated with a postoperative mortality of less than 5%. Non-fatal complications occur with some regularity irrespective of the setting in which the operation is performed. Increasingly, vascular surgeons are encountering older patients with severe co-morbid conditions. This can increase operative morbidity and may even elevate mortality of aortic surgery to a figure in excess of 60%. It seems inevitable that every vascular surgeon will, with some frequency, encounter patients who represent a prohibitive risk for conventional graft replacement, yet alternative forms of treatment (such as axillofemoral bypass in conjunction with induced AAA thrombosis) generally have been abandoned despite preliminary reports of their initial success.

Authors:

Juan Carlos Parodi, M.D., Instituto Cardiovascular de Buenos Aires, Universidad del Salvador, Buenos Aires, Argentina, Bowman Gray School of Medicine, Wake Forest University, Winston-Salem, NC

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Abstract:

Extracranial cerebrovascular disease (ECVD) is a major contributor to cerebrovascular accidents in the modern era. Cerebrovascular accidents (CVAs) are the third leading cause of death in the United States with 500,000 new or recurrent CVAs each year. Approximately 15,000 people die annually as a direct result of a stroke resulting in a cost of approximately $18 billion when hospital charges and loss of productivity figures are tabulated. The social and economic impact of this disease mandates a unified approach to its management.

Authors:

Steven A. Kagan, M.D., Massachusetts General Hospital, Boston, MA; Jonathan P. Gertler, M.D., F.A.C.S., Harvard Medical School, Massachusetts General Hospital, Boston, MA

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Abstract:

Accumulation of data through prospective studies has seemed painstakingly slow, but during the past 25 years several major prospective studies have published results conclusively demonstrating that carotid endarterectomy is superior to medical management in certain categories of patients with carotid stenosis. These prospective studies are as follows: (1) the Joint Study of Extracranial Arterial Occlusion; (2) the North American Symptomatic Carotid Endarterectomy Trial (NASCET); (3) the European Carotid Surgery Trial (ECST); (4) the V.A. Symptomatic Carotid Endarterectomy Trial; and (5) the Asymptomatic Carotid Atherosclerosis Study (ACAS).

Authors:

J. Crayton Pruitt, M.D., F.A.C.S., University of South Florida School of Medicine, Tampa, FL, The Vascular Institute of Florida, St. Petersburg, FL; Ricardo E. Morales, P.A.C., R.V.T., The Vascular Institute of Florida, St. Petersburg, FL

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Abstract:

Prior to the mid-1980s, nitric oxide (NO) was viewed as an environmental pollutant but not as a compound of physiological significance. Thus, it was a skeptical audience that first heard the pronouncement at a scientific meeting in 1986, that NO was the identity of the elusive endothelium-derived relaxing factor, a mediator of vasorelaxation in response to numerous endogenous stimuli. Since then, the simple gas NO has gone from obscurity to center stage, being identified as a key player in physiologic processes as diverse as blood pressure maintenance, neural transmission, and immunologic defense. In addition to its physiological roles, NO has been implicated in the pathogenesis of a multitude of disease states, many of which are of primary interest to the cardiovascular surgeon: circulatory shock, atherosclerosis, diabetes mellitus, and ischemia-reperfusion injury. Recent years has seen NO biology emerge as an exciting and extremely fertile area of biomedical investigation. To fully understand the molecular basis of many clinical problems facing the cardiovascular surgeon, appreciation of NO’s involvement is essential.

Authors:

Michael S. Suzman, B.S., Steven S. Gross, Ph.D., Cornell University Medical College, The New York Hospital, New York, NY

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Abstract:

It has been recognized for over three decades that tissue hypoperfusion is associated with the appearance of increased levels of iron in the plasma. Experimental observations have documented the liberation of iron into the circulation following reperfusion of ischemic myocardium and small intestine, and into the urine following renal ischemia-reperfusion. Similarly, we have recently demonstrated that iron is delocalized during ischemia of skeletal muscle, via a process which persists upon reperfusion. Other studies have demonstrated delocalization of iron in the parenchyma of postischemic brain, myocardium, and kidney.

Authors:

Gary A. Fantini, M.D. F.A.C.S., Cornell University Medical College, The New York Hospital, New York, NY; Richard E. Kirschner, M.D., The New York Hospital-Cornell Medical Center, New York, NY

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Abstract:

Revascularization of the ischemic foot remains a significant challenge for even the most experienced vascular surgeons. Lower extremity revascularization can be accomplished by endarterectomy, endovascular techniques, or bypass. In experienced hands, excellent results have been reported with endarterectomy. However, this technique has limited application because of the diffuse nature of infrainguinal atherosclerotic disease. Endovascular techniques, such as atherectomy and laser-assisted balloon angioplasty, gained enormous popularity initially because they were less invasive than standard techniques. Unfortunately, the long-term results with these techniques have been disappointing.

Authors:

Jock R. Wheeler, M.D., F.A.C.S., Christopher S. Dickson, M.D., Eastern Virginia Medical School, Norfolk, VA

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Abstract:

Synthetic vascular grafts perform satisfactorily as large caliber (e.g., aortoiliac) arterial substitutes but commonly fail when employed in small diameter and low flow applications. It is likely that prosthetic grafts in humans do not become endothelialized except for a few centimeters from each anastomosis. The lack of an endothelial lining has been postulated as an important factor contributing to the poor patency rates of prosthetic bypass grafts placed in the distal arterial circulation. Increased appreciation of the diverse functions of endothelium in maintaining vascular homeostasis, coupled with improved techniques for in vitro cultivation of human endothelial cells (ECs), spawned efforts to employ endothelium to produce a less thrombogenic inner lining for vascular prostheses.

Authors:

Subodh Arora, M.D., Michael S. Conte, M.D., F.A.C.S., Yale University School of Medicine, New Haven, CT

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Abstract:

Aclear relationship between the development of coronary artery disease (CAD) and elevated levels of low-density lipoprotein cholesterol (LDL-C) has been established. The benefits of reducing LDL-C on cardiac and overall mortality have also been shown. The second report of the National Cholesterol Education Program Expert Panel has recommended an LDL-C goal of 100 mg/dL in patients with CAD. Accordingly, cholesterol lowering has become an important strategy for reducing the incidence and progression of CAD.

Authors:

Bruce R. Gordon, M.D., Stuart D. Saal, M.D., The Rogosin Institute, New York, NY

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Abstract:

The field of vascular surgery is facing an important crossroads. Increasingly, less invasive alternatives are becoming available for the treatment of vascular lesions previously amenable only to conventional operative repair. Endovascular devices and techniques have been developed in experimental and clinical settings in an attempt to reduce the morbidity and mortality seen with conventional treatments and provide for long-term function at reduced costs. One such device is the transluminally placed endovascular graft which has been used at the Montefiore Medical Center in New York to treat patients with a wide variety of vascular pathologies, including abdominal and peripheral aneurysms, aortoiliac and infrainguinal atherosclerotic occlusive lesions, and lesions of traumatic or iatrogenic origin. This work represents our initial results with the endoluminally deployed stented graft in 92 patients with 102 arterial lesions treated over a 30-month period.

Authors:

Reese A. Wain, M.D., Michael L. Marin, M.D., Frank J. Veith, M.D., F.A.C.S., Barry A. Levine, M.D., F.A.C.S., Montefiore Medical Center/Albert Einstein College of Medicine, New York, NY

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Abstract:

Multiple approaches are available to the surgeon who wishes to reduce patient exposure to the risks of allogeneic blood transfusion. These range from transfusion of the patient’s own blood through red cell salvage and reinfusion to the use of drugs such as iron and erythropoietin to restore red cell mass. Transfusion need in surgery is clearly tied to blood loss; it follows that reduction of operative blood loss should minimize the need for transfusion. All surgeons are taught according to Halstedian principles of gentle tissue handling and anatomic dissection, techniques designed in part to reduce intraoperative bleeding. Our increased knowledge about the risks of allogeneic blood has prompted many surgeons to analyze and to revise standard approaches to surgical procedures and/or to develop innovative techniques in an attempt to reduce or eliminate blood loss and transfusion. This brief report will focus on such recent efforts.

Authors:

Richard K. Spence, M.D., F.A.C.S., Cooper Hospital/University Medical Center, Robert Wood Johnson Medical School at Camden, University of Medicine and Dentistry of New Jersey, Camden, NJ

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