Interposition grafting for reoperation on the common femoral artery

PURPOSE: This report details our experience with common femoral artery resection and Dacron interposition grafting in the management of vascular reoperations involving the common femoral artery. DESIGN: Retrospective review. SETTING: University teaching hospital. SUBJECTS: Consecutive reoperative patients who had common femoral artery interposition grafting for arteriosclerotic occlusive disease from 1986 to 1997. INTERVENTIONS: Common femoral artery resection and interposition grafting. MAIN OUTCOME MEASURES: Operative morbidity and mortality rates and long-term patency, limb salvage, patient survival, freedom-from-graft-infection, and freedom-from-reoperation rates. RESULTS: Ninety-nine common femoral arteries (16 bilateral) were resected and replaced with Dacron interposition grafts in 83 patients (50 male, 33 female; mean age, 65 years) who had had 237 previous ipsilateral common femoral artery operations (mean, 2.4 operations; range, 1-9 operations). Simultaneous infrainguinal bypass grafts were performed in 52 operations (53%), and 60 operations (61%) were performed in patients who had had previous ipsilateral proximal bypass grafts. Operative mortality was 2%, with a 14% rate of perioperative wound complications. Mean follow-up time was 22 months. One- and 3-year assisted primary patency rates for the interposition grafts were 90% and 77%, respectively. Both 1- and 3-year life-table-determined limb salvage rates were 95%. One- and 3-year life-table-determined freedom-from-reoperation rates were 74% and 43%, respectively. One- and 3-year life-table-determined freedom-from-infection rates were 99% and 92%, respectively. One- and 3-year life-table-determined survival rates were 82% and 73%, respectively. CONCLUSIONS: Common femoral artery resection and Dacron interposition grafting are safe, and they obviate many difficulties associated with reoperative common femoral artery surgery with satisfactory long-term results.     

On the reorganization of sensory hand areas after mono-hemispheric lesion: a functional (MEG)/anatomical (MRI) integrative study

The topography of primary sensory cortical hand area following a monohemispheric lesion (sudden = stroke; progressive = neoplasm) was investigated in relationship with clinical recovery of sensorimotor deficits. Twenty seven patients with monohemispheric lesions were studied in a clinically stabilized condition. Functional informations from magnetoencephalography (MEG) were integrated with anatomical data from magnetic resonance imaging (MRI). MEG localizations of the neurons firing at early latencies in primary sensory cortex after separate stimulation of median nerve, thumb and little fingers of each hand were carried out. Characteristics of cerebral equivalent current dipoles (ECDs) activated by each contralateral stimulation, the 'hand extension' (i.e., the distance in millimetres between ECDs of first and fifth digits), as well as interhemispheric differences of the tested parameters were investigated. Finally, ECDs' locations were integrated with MRI. Lesions involving cortical (C) or subcortical (s.c.) areas receiving sensory input from the hand were often combined to increase interhemispheric asymmetry of the tested parameters (22% for C and 49% for s.c. lesions). This might be due to an activation of neuronal districts which in the affected hemisphere (AH) differ from those normally activated in the unaffected hemisphere (UH) and in the control population. Moreover, the 'hand extension' was enlarged on the AH--more frequently after a SC lesion--mainly due to a medial shift of the little finger ECD, combined to a tendency of both finger ECDs to shift frontally. After a C lesion, responses from the AH were often stronger than normal. Spatial reorganizations were also seen in the UH (7% of C and 14% of SC lesions). 'Hand extension' in the UH was selectively enlarged for the P30m only when combined with a similar enlargement in the AH. Significant interhemispheric asymmetries due to neuronal reorganization in the AH were associated with worse clinical outcomes compared to patients without asymmetries.     

Patterns of neuropsychological impairment in mild dementia: a comparison between Alzheimer''s disease and multi-infarct dementia

Left ventricular wall motion abnormalities secondary to stress-induced myocardial ischemia can be detected with difficulty by mentally comparing echocardiographic images sequentially recorded on videotape. Digital stress-echocardiography, a combination of ultrasound imaging and digital archiving technologies, at least partially can overcome this problem: the technique is based on reviewing images at rest and after stress (exercise or pharmacological) side by side in dual- or quad-screen digital format, in a synchronized cine-loop, as if obtained simultaneously. This technique however is presently not widely used, due to the high cost of most commercially available systems. We have developed a digital stress-echo system, which is easy to use and relatively inexpensive, running on a Macintosh II personal computer with 8-bit graphics. The 2-D echocardiographic images recorded on videotape are digitized offline using a video digitizing board. The image can be displayed and analyzed using the public domain NIH image software developed by Wayne Rasband, without loss in image quality and resolution, particularly if using Super-VHS videotape. We have made a macro procedure for the montage in a quad-screen format of four digital recorded echocardiographic cardiac cycles of six frames that takes only a little more time than commercially available systems. In conclusion, the use of a personal computer and low-cost software may help to make digital stress-echo techniques more widely feasible in the clinical setting and increase the diagnostic power of the ultrasound technique in the evaluation of patients with known or suspected coronary artery disease.     

New evolution of the technique in trasaxillary augmentation mammaplasty: subpectoral-subglandular implant

Transaxillary subpectoral augmentation mammaplasty combines the advantages of an axillary located scar with those of a submuscular pocket. However, according to the classical technique, the caudal extension of the pectoral fascia prevents the prosthesis from filling completely the inferior breast pole, thus creating a double submammary fold and/or an excessive fullness of the superior quadrants. In order to overcome this limit Barnett (1990) proposed to disrupt the caudal extension of the pectoral fascia along with its insertions to the submammary fold, thus allowing the implant to lie in a submuscular plane superiorly and in a subglandular/subcutaneous one inferiorly. In this paper the authors present their clinical experience with this new surgical technique.     

Pregnancy after transfer of embryos which were generated from in-vitro matured oocytes

In-vitro maturation of human oocytes is an important technique in assisted reproduction due to its potential for reducing the use of fertility drugs. We offered this technique as an alternative to cancelling the cycle to a patient who was at risk of ovarian hyperstimulation syndrome (OHSS) after treatment with gonadotrophin-releasing hormone analogue (GnRHa) and human menopausal gonadotrophin (HMG). The patient had 40 visible antral follicles with a maximum diameter of 13 mm and an oestradiol concentration of 14,000 pmol/l on cycle day 12. Immature oocytes were aspirated transvaginally under ultrasound guidance. Ten cumulus-enclosed oocytes were harvested and nine of them completed nuclear maturation to metaphase II after 48 h in culture. By 18 h after an intracytoplasmic sperm injection (ICSI) procedure, seven of these metaphase II stage oocytes displayed two distinct pronuclei and two polar bodies. All fertilized oocytes but one underwent cleaveage; four of these were transferred 2 days later. Endometrial priming was initiated with 8 mg oestradiol valerate daily from the day of oocyte retrieval and 50 mg progesterone was injected i.m. daily starting 2 days after that. A single intrauterine sac was seen containing one fetus with positive fetal heart beat on ultrasound at 7 weeks of gestation. Unfortunately, the pregnancy ended at 24 weeks shortly after premature rupture of membranes; a live healthy-looking girl was delivered who died 18 days later.     

Successful outcome in Swan-Ganz catheter-induced rupture of pulmonary artery

Swan-Ganz catheter-induced pulmonary artery (PA) rupture is rare, with an incidence of 0.016 to 0.2 per cent, but it remains the most dreaded complication in the placement of these catheters with a mortality above 50 per cent. We report two cases of PA rupture after catheter placement. Both patients were managed nonoperatively and without any invasive procedure. They both stopped bleeding after the initial episode and were discharged a few days later. We believe that in the absence of high-risk factors, such as pulmonary hypertension and systemic anticoagulation, PA rupture from a Swan-Ganz catheter can be successfully treated by withdrawal of the catheter and supportive care.     

The Emperor''s new clothes

The most frequent metabolic cause of myoglobinuria seems to be carnitine palmitoyl-transferase II deficiency. The authors describe a case, trying to explain the peculiarities and the importance, for the prognosis, of the residual enzymatic activity. The genetical etiology of the disease emphasize the role of hygienic behavior and of the L-carnitine as pathogenetic therapy.