Abstracts of Current Literature

NONINVASIVECARDIOVASCULAR IMAGINGMR Imaging

Transesophageal Magnetic ResonanceImaging of the Aortic Arch and De-scending Thoracic Aorta in PatientsWith Aortic Atherosclerosis. Ken-drick A. Shunk, Jerome Garot, ErginAtalar, et al. J Am Coll Cardiol 2001; 37:2031–2035. (Joao A. C. Lima, Divisionof Cardiology, Blalock 569, The JohnsHopkins Hospital, 600 North WolfeStreet, Baltimore, MD 21287-6568)

• Objectives: We sought to determinethe feasibility and potential of trans-esophageal magnetic resonance imaging(TEMRI) for quantifying atheroscleroticplaque burden in the aortic arch anddescending thoracic aorta in comparisonwith transesophageal echocardiography(TEE). Background: Improved morpho-logic assessment of atheroscleroticplaque features in vivo is of interest be-cause of the potential for improved un-derstanding of the pathophysiology ofplaque vulnerability to rupture and pro-gression to clinical events. Magnetic res-onance imaging (MRI) is well suited foratherosclerotic plaque imaging. Per-forming MRI using a radio frequency(RF) receiver probe placed near the re-gion of interest improves the signal-to-noise ratio (SNR). Methods: High-resolu-tion images of the thoracic aortic wallwere obtained by TEMRI in 22 subjects(8 normals, 14 with aortic atherosclero-sis). In nine subjects, we compared aorticwall thickness and circumferential ex-tent of atherosclerotic plaque measuredby TEMRI versus TEE using a Bland-Altman analysis. Additional studieswere performed in a human cadaverwith pathology as an independent goldstandard for assessment of atherosclero-sis. Results: In clinical and experimentalstudies, we found similar measurementsfor aortic plaque thickness but a relativeunderestimation of circumferential ex-tent of atherosclerosis by TEE (P � .001),due in large part to the lower SNR in thenear field. Conclusions: Using TEMRI al-lows for quantitative assessment of tho-racic aortic atherosclerotic plaque bur-den. This technique provides good SNRin the near field, which makes it a prom-ising approach for detailed characteriza-tion of aortic plaque burden.Authors’ Abstract

Magnetic Resonance Phase-Shift Ve-locity Mapping in Pediatric PatientsWith Pulmonary Venous Obstruction.Neill Videlefsky, W. James Parks, JohnOshinski, et al. J Am Coll Cardiol 2001;38:262–267. (J.P., The Sibley Children’sHeart Center, Emory University, 2040Ridgewood DT. N.E., Atlanta, GA30322)

• Objectives: This study evaluated the ac-curacy, advantages and clinical efficacy ofmagnetic resonance (MR) phase-shift veloc-ity mapping, in delineating the site and thehemodynamic severity of pulmonary ve-nous (PV) obstruction in patients with con-genital heart disease (CHD). Background:Magnetic resonance phase-shift velocitymapping of normal pulmonary veins and ofobstructed PV pathways have been previ-ously reported in a mainly adult population.Methods: The study population (33 pts) un-derwent MR phase-shift velocity mappingof their PV pathways. These results werecompared with cardiac catheterization andDoppler echocardiography data. Results:The study population (0.4–19.5 years) con-sisted of a study group (PV pathway ob-struction, n � 7) and a control group (no PVobstruction, n � 26). No patients had anyleft-to-right shunt lesions. The MR imagingdisplayed precise anatomical detail of thepulmonary veins. Phase velocities in thecontrol group ranged from 20 to 71 cm/sec,whereas velocities in the study groupranged from 100 to 250 cm/sec (P � .002).The MR phase velocities (154 � 0.53 cm/sec)compared favorably with Doppler echocar-diography (147 � 0.54 cm/sec), (r � 0.76; P� .05). The MR velocity mapping was 100%specific and 100% sensitive in detecting PVobstruction, although the absolute gradientmeasurements among MR phase mapping,echocardiographic Doppler and catheteriza-tion did not show statistically significant cor-relation. Conclusions: In the absence of anyassociated left-to-right shunt lesions, PV ve-locities of 100 cm/s and greater indicatedsignificant obstruction. The MR phase-shiftvelocity mapping, together with MR spinechocardiography and MR angiography,provides comprehensive anatomic andphysiologic data that may obviate the needfor further invasive studies.Authors’ Abstract

Computed Tomography

Spiral Computed Tomography for theDiagnosis of Pulmonary Embolism inCritically Ill Surgical Patients: A Com-parison with Pulmonary Angiography.

George C. Velmahos, Pantelis Vassiliu,Alison Wilcox, et al. Arch Surg 2001;136:505–510. (G.C.V., LAC & USC Med-ical Center 1200 N. State St. Room 9900Los Angeles, CA)

• Hypothesis: Spiral computed tomo-graphic pulmonary angiography (CTPA)is sensitive and specific in diagnosing pul-monary embolism (PE) in critically ill sur-gical patients. Design: Prospective studycomparing CTPA with the criterion stan-dard, pulmonary angiography (PA). Set-ting: Surgical intensive care unit of an ac-ademic hospital. Patients: Twenty-twocritically ill surgical patients with clinicalsuspicion of PE. The CTPAs and PAs wereindependently read by two radiologists(two for each test) blinded to each other’sinterpretation. Clinical suspicion was clas-sified as high, intermediate, or low accord-ing to predetermined criteria. All but twopatients had marked pulmonary paren-chymal disease at the time of the eventthat triggered evaluation for PE. Interven-tions: Computed tomographic pulmonaryangiography and PA in 22 patients, ve-nous duplex scan in 19. Results: Elevenpatients (50%) had evidence of PE on PA.Five in central and six in peripheral pul-monary arteries. The sensitivity and spec-ificity of CTPA was, respectively, 45% and82% for all PEs, 60% and 100% for centralPEs, and 33% and 82% for peripheral PEs.Duplex scanning was 40% sensitive and100% specific in diagnosing PE. The inde-pendent reviewers disagreed only in 14%of CTPA and 14% of PA interpretations.There were no differences in risk factors orclinical characteristics between patientswith and without PE. The level of clinicalsuspicion was identical in the two groups.Conclusions: Pulmonary angiography re-mains the gold standard for the diagnosisof PE in critically ill surgical patients.Computed tomographic pulmonary an-giography needs further evaluation in thispopulation.Authors’ Abstract

Screening Patients with Chest Pain inthe Emergency Department usingElectron Beam Tomography: A Fol-low-up Study. Demetrios Georgiou,Matthew J. Budoff, Eric Kaufer, et al. JAm Coll Cardiol 2001; 38:105–110.(M.J.B., Saint John’s Cardiovascular Re-search Center, Harbor-UCLA MedicalCenter, 1124 West Carson St., RB-2,Torrance, CA 90502)

• Objectives: The high sensitivity ofelectron beam tomography (EBT) in the

Abstracts of Current Literature

1460

detection of coronary artery calcium(CAC) and obstructive coronary arterydisease prompted us to investigate the as-sociation between CAC detection and fu-ture cardiac events in patients with acutechest pain syndromes requiring hospital-ization. Background: Three studies havedocumented that EBT is a rapid and effi-cient screening tool for patients admittedto the emergency department (ED) withchest pain, but there is a paucity of long-term follow-up data on these chest painpatients. Methods: We conducted a pro-spective observational study of 192 pa-tients admitted to the ED of a large tertiarycare hospital for chest pain syndromes.Upon admission, patients underwent EBTscanning in addition to the usual care forchest pain syndromes. During the 17-month enrollment period, 221 patientswere scanned (54% men with a mean ageof 53 � 9 years). Average follow-up was50 � 10 months using chart review. Re-sults: Fifty-eight patients had coronaryevents confirmed by a blinded medicalrecord review. The presence of CAC (atotal calcium score �0) and increasingscore quartiles were strongly related to theoccurrence of hard cardiac events includ-ing myocardial infarction and death (P �.001) and all cardiovascular events (P �.001). Stratification by age- and gender-matching further increased the prognosticability of EBT (for scores above vs belowthe age- and gender-matched CAC scores;odds ratio; 13.1, 95% confidence intervals:5.62, 35.9). Conclusions: These data supportprevious reports demonstrating that thepresence of CAC in a symptomatic cohortis a strong predictor of future cardiacevents. This study supports the use of EBTin a symptomatic cohort with prompt dis-charge of those patients with negativescans. Furthermore, the absence of CAC isassociated with a very low risk of futurecardiac risk events in this population overthe subsequent seven years (annual eventrate �1%).Authors’ Abstract

PERIPHERAL ARTERIALINTERVENTIONSStent-Grafts

Outcome after Unilateral HypogastricArtery Occlusion during EndovascularAneurysm Repair. W. Anthony Lee,James O’Dorisio, Yehuda G. Wolf, et al.J Vasc Surg 2001; 33:921–926. (Christo-pher K. Zarins, Chief, Division of Vas-cular Surgery, Stanford University, 300Pasteur Drive, Suite H3600, Stanford,CA 94305)

• Purpose: The purpose of this studywas to determine the long-term functionaloutcome after unilateral hypogastric ar-tery occlusion during endovascular stent

graft repair of aortoiliac aneurysms. Meth-ods: During a 41-month period, 157 con-secutive patients underwent elective en-dovascular stent graft repair of aortoiliacaneurysms with the Medtronic AneuRxdevice. Postoperative computed tomogra-phy scans were compared with preopera-tive scans to identify new hypogastric ar-tery occlusions. Twenty-three (15%)patients had unilateral hypogastric occlu-sion, and there were no cases of bilateralocclusions. Telephone interviews aboutpast and current levels of activity andsymptoms were conducted, and pertinentmedical records were reviewed. All 23(100%) patients were available for the tele-phone interview. A disability score (DS)was quantitatively graded on a discretescale ranging from 0 to 10 correspondingto “virtually bed-bound” to “greater-than-a-mile” exercise tolerance. Worsening orimprovement of symptoms was expressedas a difference in DS between two timepoints (�, worsening / -, improving). Re-sults: Among the 23 patients, two groupswere identified: 10 patients (43%) hadplanned and 13 patients (57%) had un-planned or inadvertent occlusions. The pa-tients in the two groups did not differsignificantly in the mean age (73.4 vs73.7 y), sex (male:female, 9:1 vs 10:3), andduration of follow-up (15.6 vs 14.4 mo).Nine (39%) of the 23 patients, five patientsin the planned and four patients in theunplanned group, reported significantsymptoms of hip and buttock claudicationipsilateral to their occluded hypogastricarteries. The mean decrement from base-line of these nine patients in their DS post-operatively was -3.3. The symptoms wereuniversally noted on postoperative day 1.Although most patients improved (89%),one (11%) never got better. Among thosewhose symptoms improved, the meantime to improvement was 15 weeks, butwith a plateau thereafter resulting in a netdecrement of DS of -2.3 from baseline. Fi-nally, when questioned whether theywould undergo the procedure again, all 23patients unanimously answered, “Yes.”Conclusions: A significant number (39%) ofpatients who sustain hypogastric arteryocclusion after endovascular aneurysm re-pair have symptoms. Although most pa-tients with symptoms have some im-provement, none return to their baselinelevel of activity. Despite this, all patients inretrospect would again choose endovascu-lar repair over conventional open repair.Authors’ Abstract

Endoleak after Endovascular Repair ofAbdominal Aortic Aneurysm. Timo-thy A.M. Chuter, Rishad M. Faruqi,Rajiv Sawhney, et al. J Vasc Surg 2001;34:98–105. (T.A.C.C., UCSF VascularSurgery, 505 Parnassus Ave., M-488,Box 0222, San Francisco, CA 94143)

• Purpose: We sought to assess therole of endovascular techniques in themanagement of perigraft flow (en-doleak) after endovascular repair of anabdominal aortic aneurysm. Method: Weperformed endovascular repair of ab-dominal aortic aneurysm in 114 patients,using a variety of Gianturco Z-stent-based prostheses. Results were evalu-ated with contrast-enhanced computedtomography (CT) at 3 days, 3 months, 6months, 12 months, and every year afterthe operation. An endoleak that oc-curred 3 days after operation led to re-peat CT scanning at 2 weeks, followedby angiography and attempted endovas-cular treatment. Results: Endoleak wasseen on the first postoperative CT scanin 21 (18%) patients and was still presentat 2 weeks in 14 (12%). On the basis ofangiographic localization of the inflow,the endoleak was pure type I in 3 cases,pure type II in 9, and mixed-pattern in 2.Of the 5 type I endoleaks, 3 were proxi-mal and 2 were distal. All five resolvedafter endovascular implantation of addi-tional stent-grafts, stents, and emboliza-tion coils. Although inferior mesentericartery embolization was successful in 6of 7 cases and lumbar embolization wassuccessful in 4 of 7, only 1 of 11 primarytype II endoleaks was shown to be re-solved on CT scanning. There were notype III or type IV endoleaks (throughthe stent-graft). Endoleak was associatedwith aneurysm dilation two cases. Inboth cases, the aneurysm diameter stabi-lized after coil embolization of the infe-rior mesenteric artery. There were twosecondary (delayed) endoleaks; one typeI and one type II. The secondary type Iendoleak and the associated aneurysmrupture were treated by use of an addi-tional stent-graft. The secondary type IIendoleak was not treated. Conclusions:Type I endoleaks represent a persistentrisk of aneurysm rupture and should betreated promptly by endovascularmeans. Type II leaks are less dangerousand more difficult to treat, but coil em-bolization of feeding arteries may bewarranted when leakage is associatedwith aneurysm enlargement.Authors’ Abstract

Hypogastric Artery Aneurysm Rup-ture after Endovascular Graft Exclu-sion with Shrinkage of the Aneurysm:Significance of Endotension from a“Virtual,” or Thrombosed Type II En-doleak. Maseer A. Bade, Takao Ohki,Jacob Cynamon, et al. J Vasc Surg 2001;33:1271–1274. (F.J.V., Montefiore Medi-cal Center, Division of Vascular Sur-gery, 111 E. 210th St., Bronx, NY 10467)

• Type II endoleaks, resulting from ret-rograde branch flow, after endovasculargraft aneurysm exclusion are considered

Abstracts • 1461Volume 12 Number 12

benign because they usually thromboseand are commonly associated with stableor shrinking aneurysm sacs. We report ahypogastric artery aneurysm rupture fromendotension from an undetected, throm-bosed Type II endoleak, associated withsac shrinkage. The patient had undergonean endovascular graft repair of a 4-cmright common iliac artery and 9-cm hypo-gastric artery aneurysm with distal hypo-gastric artery coil embolization. Serialcomputed tomography scans revealed noendoleak and a hypogastric aneurysmthrombosis with shrinkage. Eighteenmonths later, the aneurysm ruptured as aresult of pressurization from backbleed-ing, patent branches.Authors’ Abstract

Lessons Learned in Adopting Endo-vascular Techniques for Treating Ab-dominal Aortic Aneurysm. Mark A.Patterson, Jessie M. Jean-Claude, Mar-tin R. Crain, et al. Arch Surg 2001; 136:627–634. (Jonathan B. Towne, MedicalCollege of Wisconsin, 9200 W. Wiscon-sin Ave., Milwaukee, WI 53226)

• Hypothesis: Endovascular exclusionof abdominal aortic and common iliacaneurysms can be performed safely, andin the short term represents a feasiblealternative to traditional, open aneu-rysm repair. Patients and Methods: Forty-one patients were treated with endovas-cular grafts for 39 abdominal aortic andtwo common iliac artery aneurysms. Re-sults: All devices were successfully de-ployed. The size of the abdominal aorticaneurysms varied from 4.9 to 11.9 cm(average, 6.13 cm). The median proce-dure time was 195 minutes. There wasone iliac artery rupture, which requiredceliotomy for repair. The hospital stayvaried from 2 to 39 days (average, 6.7days). The perioperative mortality ratewas 2.4%. Sixteen patients (39%) hadgroin wound complications. Ten pa-tients (24%) had evidence of contrast(endoleak) within the aneurysm sac oncompletion of the procedure. There wereno obvious direct leaks from either thepoint of proximal or distal fixation.Seven of these endoleaks have resolvedspontaneously. Two patients requiredadditional procedures in the postopera-tive period to treat endoleak. The finalpatient has evidence of persistent en-doleak on 3-month surveillance com-puted tomography scan. Major lateproblems occurred in three patients.Conclusion: Patients with large abdomi-nal aortic aneurysms and considerablecardiac comorbidity can safely undergoendovascular aneurysm repair. Femoralgroin wound complications resulting inprolonged hospitalization remain themajor cause of perioperative morbidity.In contradistinction to open aneurysm

repair, long-term surveillance is essen-tial to detect migration of the device andidentify flow within the residual aneu-rysm sac—complications that could leadto aneurysm rupture following endovas-cular repair.Authors’ Abstract

Vascular Surgery

Long-term Outcomes of Revasculariza-tion for Peripheral Vascular Diseasein End-Stage Renal Disease Patients.Donal N. Reddan, Richard J. Marcus,William F. Owen, Jr, et al. Am J KidneyDis 2001; 38:57–63. (D.N.R., Duke Insti-tute of Renal Outcomes Research andHealth Policy, Box 3646. Duke Univer-sity Medical Center, Durham, NC27710)

• The occurrence of peripheral vas-cular disease (PVD) and atraumatic low-er-extremity amputations is significantlygreater in patients with end-stage renaldisease (ESRD) than those with normalrenal function. Moreover, the mortalityfor dialysis patients undergoing atrau-matic lower-extremity amputations is fargreater. Because PVD requiring amputa-tion is an extreme form of PVD, wetested the hypothesis that mortality andintermediates outcomes for patientswith ESRD undergoing lower-extremityrevascularization, a less extreme form ofPVD, would be equivalent to that forpatients without ESRD. This is a retro-spective case-control analysis of lower-extremity revascularization in patientswith ESRD. Procedures in patients withESRD were matched with procedures innon-ESRD controls for patient age, sex,race, diabetes mellitus, and hospital set-ting. Patient survival, graft survival, andlimb salvage rates were determined us-ing Kaplan-Meier analysis. Subjective in-terpretation of functional and symptom-atic improvement was determined bytelephone interviews with patients orrelatives. Thirty-one procedures wereperformed on 20 patients with ESRD and64 matched procedures were performedon 57 patients without ESRD. In theESRD group, median patient survivalwas 1.72 years compared with 6.17 yearsfor the control group (P � .001). Time to50% limb loss was 1.24 years in the ESRDgroup and longer than 5.65 years in thecontrol group (P � .001). Time to 50%graft patency loss was 0.70 years in theESRD group and longer than 5.65 yearsin the control group (P � .05). Subjectiveimprovement was less in patients withESRD. Outcomes of lower-extremity re-vascularization in patients with ESRDare inferior to those in non-ESRD con-trols. The mortality rate for patients withESRD who undergo revascularization isextremely high. Patient-related variables

(eg, increased prevalence of hyperten-sion and cardiovascular disease) and/orprovider-specific factors (eg, timing ofsurgery in the course of PVD) may beresponsible for poorer outcomes.Authors’ Abstract

CAROTID INTERVENTIONS

Technical Aspects and Current Resultsof Carotid Stenting. Alexandred’Audiffret, Pascal Desgranges, HichamKobeiter, et al. J Vasc Surg 2001;33:1001–1007. (Jean-Pierre Becquemin,Hopital Henri Mondor, Service deChirurgie Vasculaire, 51 Avenue duMal de Lattre de Tassigny, 94010 Cre-treil cedex, France)

• Purpose: We reviewed our experi-ence with carotid stenting (CS), focusingon technical evolution and results. Meth-ods: From September 1995 to February2000, 77 patients with 83 internal (n �68) and common carotid artery lesions (n� 15) were selected for CS. This patientpopulation was categorized into threeconsecutive periods based on patient se-lection, material, and technical skills. Forinternal carotid artery lesions, period Iincluded 11 patients treated by means ofdirect carotid puncture with balloon ex-pandable stents; period II included 42patients treated by means of a femoralapproach with self-expandable stents;and period III included 15 patients inwhom monorail system and cerebralprotection devices were used. Commoncarotid artery lesions were treated bymeans of carotid puncture in five pa-tients and by means of a femoral ap-proach in 10 patients. In only two of thelatter cases, cerebral protection deviceswere used. Results: The overall immedi-ate success rate, defined as successfullytreated stenosis with no neurologicalevents, was 89.7% for internal carotidartery lesions and 100% for common ca-rotid artery lesions. All neurologicalevents, which consisted of reversibleevents (4.4%), minor stroke (1.5%), andmajor stroke (2.9%), occurred during pe-riods I and II. In periods I, II, and III, therate of surgical conversion was 18%,9.5%, and 0%, respectively, the rate oftransient ischemic attack and reversibleischemic neurologic deficit was 0%, 7%,and 0%, respectively, and the rate of mi-nor and major stroke was 0%, 7%, and0%, respectively. All major strokes werecleared with intra-arterial thrombolysis.At discharge, the success rates definedby means of the absence of conversionand neurological events were 82% dur-ing period I, 76% during period II, and100% during period III. The freedomfrom neurological deficits rates were100%, 97.6%, and 100%, respectively.During follow-up, six significant asymp-

1462 • Abstracts December 2001 JVIR

tomatic restenoses were detected withduplex scanning; however, only one pa-tient required reintervention. Conclusion:Technical skills and technological im-provement, including low-profile bal-loon and catheter, cerebral protectiondevice, and intra-arterial rescue tech-niques, may reduce the rate of neurolog-ical events associated with CS. Technicalimprovements should be given carefulconsideration before the initiation of ran-domized trials comparing CS and ca-rotid endarterectomy.Authors’ Abstract

Poor Durability of Carotid Angio-plasty and Stenting for Treatment ofRecurrent Artery Stenosis after Ca-rotid Endarterectomy: An InstitutionalExperience. Andre R. Leger, MichaelNeale, and John P. Harris. J Vasc Surg2001; 33:1008–1014. (J.P.H., Room 401,Blackburn Building D06, University ofSydney NSW 2006)

• Purpose: Recurrent stenosis after ca-rotid endarterectomy (CEA) is often re-garded as an optimal application of ca-rotid artery angioplasty and stenting(CAS). The extended durability of CASfor recurrent carotid artery stenosis afterCEA is unknown. We present the inter-mediate-term surveillance results for alleight CAS procedures performed over a28-month period at a single tertiary re-ferral center. Methods: Patients had re-current carotid stenosis after CEA,whether symptomatic or asymptomatic,of 80%–99% stenosis on preproceduralcarotid duplex scan examination. Un-covered, self-expanding metal stents, inconjunction with angioplasty, were usedin all patients. Baseline and scheduledinterval follow-up duplex ultrasoundscan was used to assess intrastent reste-nosis. Further angiography was reservedfor those patients obtaining additionalintervention. Results: One transient isch-emic attack was observed 1 day after theprocedure, and no cerebral infarcts oc-curred. All patients had angiographicresolution of the stenosis and postproce-dural duplex scan studies without resid-ual stenosis. Subsequent interval surveil-lance duplex scan examinations revealedsignificant (60%–79%) to critical (80%–99%) recurrent stenosis in six (75%) ofeight patients, two of whom went on tofurther interventions. Of those with in-trastent restenosis, four (75%) pro-gressed to critical (80%–99%) stenosis.Mean follow-up was 20.2 months (range,12–37 months). The two lesions thathave not yet shown restenosis are thosewith the shortest follow-up interval,each at 12 months. Conclusions: In con-trast to the optimistic claims in otherseries, this limited series suggest that an-gioplasty with stenting for recurrent ca-

rotid artery occlusive disease after CEA,although relatively safe in the shortterm, has significant limitations in termsof durability of results.Authors’ Abstract

RENOVASCULARINTERVENTIONS

Endovascular Revascularization of Re-nal Artery Stenosis: Technical andClinical Results. Ruth L. Bush, SasanNajibi, M. Julia MacDonald, et al. JVasc Surg 2001; 33:1041–1049. (Alan B.Lumsden, Division of Vascular Sur-gery, Emory University Hospital, 1364Clifton Rd, Room H124A, Atlanta, GA30322)

• Purpose: The natural history of re-nal artery stenosis is progression withsubsequent deterioration of kidney func-tion and development of renovascularhypertension. Percutaneous translumi-nal renal angioplasty is effective in thetreatment of nonostial lesions but lesseffective for ostial stenoses. Because ofthe poor technical success experiencedwith percutaneous transluminal renalangioplasty, stenting of ostial stenoses isbecoming the standard of endovascularcare. In this retrospective study we ana-lyzed the technical and clinical outcomesafter renal artery stenting in 73 consecu-tive patients. Patients and Methods: FromJuly 1992 to January 1999, 88 Palmazstents were deployed in 85 renal arterystenoses in 73 patients, with a mean ageof 67.9 � 9.4 years. Twelve patients(16%) underwent bilateral stent place-ment. Atheromatous lesions were themost prevalent (99%: 82% ostial, 16%nonostial). Most stents were implantedfor sub-optimal balloon dilation (52%) ordissection (24%). Mean percent stenosiswas 86% � 12%. Renal insufficiency (cre-atinine level �1.5 mg/dL) was presentin 50 (68%) patients, and uncontrolledhypertension (systolic �160 mm Hg ordiastolic �90 mm Hg with more thantwo medications) was present in 57(78%). Results: Primary technical successwas achieved in 89%. At the initial pro-cedure, three additional stents wereplaced for residual stenoses, and uroki-nase was used to treat one intraproce-dural stent thrombosis, resulting in anassisted primary technical success rate of94%. Major complications occurred in9.1% of stents placed: access arterythrombosis (n � 4), renal artery extrav-asation (n � 1), renal artery thrombosis(n � 1), and hematoma requiring opera-tion (n � 2). Long-term clinical datawere available on 69 (95%) patients at 20� 17 months. Overall, a significant de-crease in systolic and diastolic pressures(P � .001) and reduction of medication(P � .01) were noted without a change in

renal function (P � NS). Angiographywas performed on 22 patients at 11.3 �10.3 months for persistent or worseningrenal function or hypertension or forother reasons; 10 patients had significantrestenoses in 14 renal arteries. Conclu-sion: Our retrospective analysis demon-strates that endovascular stenting of re-nal artery stenosis in patients withpoorly controlled hypertension or dete-riorating renal function is a safe and ef-fective alternative treatment to surgicalmanagement.Authors’ Abstract

Long-Term Effects of Arterial Stentingon Kidney Function for Patients withOstial Atherosclerotic Renal ArteryStenosis and Renal Insufficiency.Jaap J. Beutler, Jacobine M.A. vanAmpting, Peter J.G. van de Ven, et al. JAm Coll Cardiol 1475–1481. (J.J.B., De-partment of Napirology and Hyperten-tion, University Medical Center, RoomF03,226, P.O. Box B5500, 3506 GA Utre-cht, The Netherlands)

• Abstract. It is uncertain whether re-nal artery stent placement in patientswith atherosclerotic renovascular renalfailure can prevent further deteriorationof renal function. Therefore, the effectsof renal artery stent placement, followedby patency surveillance, were prospec-tively studied in 63 patients with ostialatherosclerotic renal artery stenosis andrenal dysfunction (ie, serum creatinineconcentrations of �120 mmol/L (medi-an serum creatinine concentration, 171�mol/L; serum creatinine concentrationrange, 121–650 �mol/L). Pre-stent renal(dys)function was stable for 28 patientsand declining for 35 patients (defined asa serum creatinine concentration in-crease of �20% in 12 mo). The medianfollow-up period was 23 mo (innerquar-tile range, 13–29 mo). Angioplasty totreat restenosis was performed in 12cases. Five patients reached end-stagerenal failure within 6 mo, and this wasrelated to stent placement in two cases.Two other patients died or were lost tofollow-up monitoring within 6 mo, withstable renal function. For the remaining56 patients, the treatment had no effecton serum creatinine levels if functionhad previously been stable; if functionhad been declining, median serum cre-atinine concentrations improved in thefirst 1 year (from 182 �mol/L [135 to 270�mol/L] to 154 �mol/L [127 to 225�mol/L] P � .05) and remained stableduring further follow-up monitoring. Inconclusion, stent placement, followed bypatency surveillance, to treat ostial ath-erosclerotic renal artery stenosis can sta-bilize declining renal function. For pa-tients with stable renal dysfunction, theusefulness is less clear. The possible ad-


vantages must be weighed against therisk of renal failure advancement withstent placement.Authors’ Abstract

VENOUS INTERVENTIONSThromboembolic Disease

Iliofemoral Deep Vein Thrombosis:Conventional Therapy versus Lysisand Percutaneous Transluminal An-gioplasty and Stenting. Ali F. Abu-Rahma, Samuel E. Perkins, John T.Wulu, et al. Ann Surg 2001; 233:752–760. (A.F.A., 3100 MacCorkle Ave., SE,Suite 603, Charleston, WV 25304)

• Objective: To compare conventionaltreatment (heparin and warfarin) of il-iofemoral venous thrombosis with mul-timodality treatment (lysis and stenting).Summary Background Data: Several stud-ies have reported on conventional ther-apy for iliofemoral venous thrombosiswith disappointing results. However,more recent studies have reported betterresults with multimodality treatment.Methods: Fifty-one consecutive patientswith extensive iliofemoral venousthrombosis were treated during a 10-year period. If there were no contraindi-cations, patients were given the optionto choose between conventional therapy(group 1) and multimodality therapy(group 2). The multimodality treatmentstrategy included catheter-directed lysisfollowed by percutaneous transluminalballoon angioplasty (PTA) and stentingfor residual iliac stenoses. All patientsunderwent routine venous duplex imag-ing at 30 days, 3 months, 6 months, andevery 6 months thereafter. Results: Therewere 33 patients in group 1 and 18 pa-tients in group 2. Demographic and clin-ical characteristics were comparable forboth groups. Initial lysis was achieved in16 of 18 patients (89%) in group 2. Ten of18 patients in group 2 had residual ste-nosis after lysis (eight primary and twosecondary to malignancy), and theywere treated with PTA/stenting with aninitial success rate of 90%. Two patientsin group 1 (6%) had a symptomatic pul-monary embolism (none in group 2). At30 days, venous patency and symptomresolution were achieved in one of 33patients (3%) in group 1 versus 15 of 18(83%) in group 2. Kaplan-Meier analysisshowed primary iliofemoral venous pa-tency rates at 1, 3, and 5 years of 24%,18%, and 18% and 83%, 69%, and 69%for groups 1 and 2, respectively. Long-term symptom resolution was achievedin 10 of 33 patients (30%) in group 1versus 14 of 18 (78%) in group 2. Kaplan-Meier life table analysis showed similarsurvival rates at 1, 3, and 5 years of100%, 93%, and 85% for group 1 and

100%, 93%, and 81% for group 2. Conclu-sions: Lysis/stenting treatment wasmore effective than conventional treat-ment in patients with iliofemoral veinthrombosis.Authors’ Abstract

Diagnosis and Endovascular Treat-ment of Iliocaval Compression Syn-drome. Darren R. Hurst, Andrew R.Forauer, Jess R. Bloom, et al. J VascSurg 2001; 34:106–113. (David M. Wil-liams, Department of Radiology/UHB1D530, University of MichiganMedical Center, 1500 E Medical CenterDrive, Ann Arbor, MI 48109-0326)

• Purpose: The purpose of this studywas to evaluate the clinical presentation,diagnosis, and endovascular treatmentof iliocaval compression syndrome(ICS). Patients and Methods: During a3-year period, 18 patients (17 women, 1man; mean age, 42 years) presented withclinical and imaging findings consistentwith ICS. All patients were evaluatedwith venography and Doppler ultra-sound (DUS), 13 of 18 with intravascularpressure measurements, 12 of 18 withintravascular ultrasound, 9 of 18 with airplethysmography (APG), and 4 of 18with magnetic resonance venography.Seventeen patients were treated with en-dovascular stenting, one was treatedwith angioplasty alone, and six receivedadjunct thrombolysis. Results: Despitethe presence of stenosis or occlusion inall cases, APG indicated no iliac veinobstruction (outflow fraction �40%) innine patients. DUS revealed acute (n �6) or chronic (n � 7) unilateral iliofemo-ral deep venous thrombosis in 13 of 18patients, whereas the results of five of 18DUS studies were normal. Recanaliza-tion and stent placement (n � 17) orangioplasty (n � 1) was achieved in allpatients. The average pressure gradientwas 5.6 mm Hg preprocedure and 0.6mm Hg postprocedure. The primary pa-tency rate demonstrated with DUS (n �17) and venography (n � 7) at 6 monthswas 89%. The primary patency rate at 12months was 79%. Conclusions: ICS oftenpresents as sudden unilateral left lowerextremity pain and swelling in young tomiddle-aged female patients after preg-nancy, surgery, or a period of inactivity.Venography, intravascular ultrasound,and magnetic resonance venographydemonstrate high sensitivity, whereasAPG-outflow fraction demonstrates lowsensitivity in the diagnosis of ICS. Endo-vascular stenting and angioplasty pro-vide safe and effective early and inter-mediate-term treatment of symptomaticICS.Authors’ Abstract

Vena Cava Filters

Bedside Vena Cava Filter PlacementGuided with Intravascular Ultra-sound. James L. Ebaugh, Andy C.Chiou, Mark D. Morasch, et al. J VascSurg 2001; 34:21–26. (J.L.E., 251 EastHuron St, Wesley 626, Chicago, IL60611)

• Objective: The purpose of this studywas to report a feasibility trial approvedby the Institutional Review Board for in-sertion of inferior vena cava (IVC) filterswith intravascular ultrasound (IVUS)guidance in the intensive care unit.Methods: Between October 1998 and May2000, 26 patients (15 men, 11 women; agerange, 22–86 years; mean, 55 years) wereenrolled. Eight patients (31%) under-went prophylactic filter placement, and18 patients (69%) had venous thrombo-embolism (deep venous thrombosis �16, pulmonary embolism � 2) with con-traindications to anticoagulation. A sin-gle groin puncture was used for IVUSand filter placement. Location of majorbranch veins, thrombosis, and caval di-ameter were readily demonstrated with-out the use of radiocontrast agents. Map-ping of the IVC permitted assessment ofideal filter location. Postprocedure ra-diographs (23 of 26) were obtained todocument filter position. Seventeen of 26had follow-up lower extremity duplexstudies. Results: Twenty-four (92%) of 26patients underwent successful filter de-ployment. The two other patients hadfilters subsequently placed by means oftraditional fluoroscopic techniques. Onefemoral vein insertion site thrombosisresolved after a month. One patient ex-perienced symptomatic caval thrombo-sis thought to be caused by thrombustrapping 55 days after the procedure. Nopulmonary emboli occurred after filterplacement. One patient’s death was un-related to vena cava filter placement.The hospital charge for bedside filterswas $3,623 compared with $4,165 (P �.281) for fluoroscopic placement. Conclu-sion: Bedside insertion of an IVC filterwith IVUS guidance is feasible and maybe an effective alternative in the inten-sive care unit. No additional costs wereincurred in this small series. Protocol re-finements should reduce the incidenceof complications. The results of thisstudy support the need for further eval-uation comparing it with standard tech-niques.Authors’ Abstract

TRAUMA

Vascular Complications in High-per-formance Athletes. Frank R. Arko, E.John Harris, Christopher K. Zarins, etal. J Vasc Surg 2001; 33:935–942. (Corne-


lius Olcott IV, Division of VascularSurgery, Stanford University MedicalCenter, 300 Pasteur Dr., H3600, Stan-ford, CA 94305-5642)

• Purpose: The purpose of this studywas to evaluate our experience with thediagnosis and management of vascularinjuries in a group of high-performanceathletes. Methods: Between June 1994 andJune 2000, we treated 26 patients whosustained vascular complications as a re-sult of athletic competition. Clinical pre-sentation, type of athletic competition,location of injury, type of therapy, anddegree of rehabilitation were analyzedretrospectively. Results: The mean age ofthe patients was 23.8 years (range, 17–40). Twenty-one (81%) patients weremen, and five (19%) were women. Ath-letes included eight major-league base-ball players, seven football players, twoworld-class cyclists, two rock climbers,two wind surfers, one swimmer, onekayaker, one weightlifter, one marks-man, and one volleyball player. Therewere 14 (54%) arterial and 12 (46%) ve-nous complications. Arterial injuries in-cluded 7 (50%) axillary/subclavian ar-tery or branch artery aneurysms withsecondary embolization, 6 (43%) popli-teal artery injuries, and 1 (7%) case ofintimal hyperplasia and stenosis involv-ing the external iliac artery. Subclavianvein thrombosis (SVT) accounted for allvenous complications. Five of the sevenpatients with axillary/subclavian branchartery aneurysms required lytic therapyfor distal emboli, and six required oper-ative intervention. All popliteal arteryinjuries were treated by femoropoplitealbypass graft with autogenous saphenousvein. The external iliac artery lesion,which occurred in a cyclist, was repairedwith limited resection and vein patchangioplasty. All 12 patients with SVTwere treated initially with lytic therapyand anticoagulation. Eight patients re-quired thoracic outlet decompressionand venolysis of the subclavian vein.Thirteen arterial reconstructions have re-mained patent at an average follow-upof 31.9 months (range, 2–74). One patientwith a popliteal artery injury requiredreoperation at 2 months for occlusion ofhis bypass graft. Eleven of the patientswith an arterial injury were able to re-turn to their prior level of competition.All of the patients with SVT have re-mained stable without further venousthrombosis and have returned to theirusual level of activity. Conclusions: Ath-letes are susceptible to a variety of vas-cular injuries that may not be easily rec-ognized. A high level of suspicion, athorough workup including noninvasivestudies and arteriography/venography,

and prompt treatment are important fora successful outcome.Authors’ Abstract

HEPATOBILIARY

Budd-Chiari Syndrome: Current Man-agement Options. Douglas P. Slakey,Andrew S. Klein, Anthony C. Venbrux,et al. Ann Surg 2001; 233:522–527.(A.S.K., Johns Hopkins Hospital, 600 N.Wolfe St., Baltimore, MD 21287-8611)

• Objective: To assess the outcomes ofcurrent treatment strategies for Budd-Chiari syndrome. Summary BackgroundData: Budd-Chiari syndrome, occlusionor obstruction of hepatic venous out-flow, is a disease traditionally managedby portal or mesenteric-systemic shunt-ing. The development of other treatmentoptions, such as catheter-directed throm-bolysis, transjugular portosystemicshunting (TIPS), and liver transplanta-tion, has expanded the therapeutic algo-rithm. Methods: The authors reviewedthe medical records of all patients diag-nosed with Budd-Chiari syndrome at theJohns Hopkins Hospital during the past20 years. Results: A total of 54 patientswere identified: 13 (24%) male patientsand 41 (76%) female patients, ranging inage from 2 to 76 years (median 33 years).Twenty-one (39%) had polycythemiavera, 3 (5.6%) used estrogens, 11 (20%)had a myeloproliferative or coagulationdisorder, and in 7 (13%) the cause re-mained unknown. Forty-three patientswere treated with surgical shunting, 24mesocaval and 19 mesoatrial. Actuarialsurvival rates at 1, 3, and 5 years aftershunting were 83%, 78%, and 75%, re-spectively. Of 33 patients survivingmore than 4 years, 28 (85%) had relief ofclinical symptoms. Five patients re-quired shunt revision and eight had ra-diologic procedures to maintain shuntpatency. Primary and secondary shuntpatency rates were 46% and 69% respec-tively for mesoatrial shunts and 70% and85% respectively for mesocaval shunts.Clot lysis was successful as primarytreatment in seven patients. TIPS wasperformed in three patients, one after afailed mesocaval shunt. During an aver-age of 4 years of follow-up, these pa-tients required multiple procedures tomaintain TIPS patency. Six patients un-derwent liver transplantation. Of these,three had previous shunt procedures.Five of the transplant recipients are alivewith follow-up of 2–9 years (median, 6).Conclusions: Both shunting and trans-plantation can result in a 5-year survivalrate of at least 75%, and other treatmentmodalities may be appropriate forhighly selected patients. Optimal man-agement requires that treatment be di-rected by the predominant clinical

symptom (liver failure or portal hyper-tension) and anatomical considerationsand be tempered by careful assessmentof surgical risk.Authors’ Abstract

Value of Lipiodol Computed Tomog-raphy and Digital Subtraction Angiog-raphy in the Era of Helical BiphasicComputed Tomography as Preopera-tive Assessment of HepatocellularCarcinoma. Ataru Nakayama, HiroshiImamura, Yutaka Matsuyama, et al.Ann Surg 2001; 234:56–62. H.I., Divi-sion of Hepato-Biliary-Pancreatic Sur-gery, Department of Surgery, GraduateSchool of Medicine, University of To-kyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo113-8655, Japan)

• Objective: To compare the diagnos-tic accuracies of Lipiodol computed to-mography (CT) and helical biphasic CTas preoperative imaging modalities forhepatocellular carcinoma (HCC). Sum-mary Background Data: Lipiodol CT afterdigital subtraction angiography has longbeen used as a highly sensitive imagingmodality for HCC. The recent advent ofhelical CT has allowed scanning the en-tire liver during both the arterial andportal venous phase of contrast enhance-ment. Methods: The authors analyzeddata from 164 patients who underwenthepatic resection for HCC to calculatethe sensitivity and specificity of thesemodalities. Findings of intraoperativeultra-sonography followed by histologicconfirmation were set as the gold stan-dard. Results: Although sensitivity de-creased with both modalities as tumorsbecame small and well differentiated,helical CT showed a higher sensitivitythan Lipiodol CT in detecting well-dif-ferentiated HCC nodules smaller than 2cm. In contrast, Lipiodol CT was supe-rior to helical CT for the detection ofsmall but moderately to poorly differen-tiated nodules. The overall sensitivity ofhelical CT was higher than that of Lipi-odol CT. These findings suggest that he-lical CT is superior in delineating earlyHCC, whereas Lipiodol CT is specific tothe detection of intra-hepatic metastases,in terms of specificity, helical CT wassuperior to Lipiodol CT. Conclusions: He-lical CT and Lipiodol CT are comple-mentary modalities. At present, helicalbiphasic CT does not obviate the needfor invasive techniques such as angiog-raphy and Lipiodol CT as preoperativeexaminations for HCC.Authors’ Abstract

Long-term Results of Metallic Stentsfor Benign Biliary Strictures. RichardR. Lopez, Jr, Carlos A. Cosenza, JuanLois, et al. Arch Surg 2001; 136:664–669.(R.R.L., Director, Comprehensive Liver


Disease Center, St. Vincent MedicalCenter, 2200 W. Third St., Los Angeles,CA 90057)

• Background: Historically, surgicalcorrection has been the treatment ofchoice for benign biliary strictures (BBS).Self-expandable metallic stents (MSs)have been useful for inoperable malig-nant biliary strictures; however, theiruse for BBS is controversial and theirnatural history unknown. Hypothesis: Totest our hypothesis that MSs provideonly short-term benefit, we examinedthe long-term outcome of MSs for thetreatment of BBS. Our goal was to de-velop a rational approach for treatingBBS. Data Extraction: Between July 1990and December 1995, 15 patients had MSsplaced for BBS and have been followedup for a mean of 86.3 months (range,55–120 months). The mean age of thepatients was 66.6 years and 12 werewomen. Stents were placed for surgicalinjury in 5 patients and underlying dis-ease in 10 patients (lithiasis, n � 7; pan-creatitis, n � 2; and primary sclerosingcholangitis, n � 1). One or more MSs(Gianturco-Rosch “Z” for 4 patients andWallstents for 11 patients) were placedby percutaneous, endoscopic, or com-bined approaches. We considered pa-tients to have a good clinical outcome ifthe stent remained patent, they required2 or fewer invasive interventions, andthey had no biliary dilation on subse-quent imaging. Data Synthesis: Metallicstents were successfully placed in all 15patients, and the mean patency rate was30.6 months (range, 7–120 months). Fivepatients (33%) had a good clinical resultwith stent patency from 55 to 120months. Ten patients (67%) requiredmore than 2 radiologic and/or endo-scopic procedures for recurrent cholan-gitis and/or obstruction (range, 7–120months). Five of the 10 patients devel-oped complete stent obstruction at 8, 9,10, 15, and 120 months and underwentsurgical removal of the stent and bilio-enteric anastomosis. Four of these 5 pa-tients had strictures from surgical inju-ries. The patient who had surgicalremoval 10 years after MS placement de-veloped cholangiocarcinoma. Conclu-sions: Surgical repair remains the treat-ment of choice for BBS. Metallic stentsshould only be considered for poor sur-gical candidates, intrahepatic biliarystrictures, or failed attempts at surgicalrepair. Most patients with MSs will de-velop recurrent cholangitis or stent ob-struction and require intervention.Chronic inflammation and obstructionmay predispose the patient to cholangio-carcinoma.Authors’ Abstract

CARDIAC/CORONARY

Risk of Stroke Associated with Abcix-imab among Patients Undergoing Per-cutaneous Coronary Intervention. K.Martijn Akkerhuis, Jaap W. Deckers, A.Michael Lincoff, et al. JAMA 2001; 286:78–82. (K.M.A., Thoraxcenter, Univer-sity Hospital Rotterdam, H-543, DrMolewaterplein 40, 3015 GD Rotter-dam, the Netherlands)

• Context: Abciximab, a potent inhib-itor of the platelet glycoprotein IIb/IIIareceptor, reduces thrombotic complica-tions in patients undergoing percutane-ous coronary intervention (PCI). Becauseof its potent inhibition of platelet aggre-gation, the effect of abciximab on risk ofstroke is a concern. Objective: To deter-mine whether abciximab use among pa-tients undergoing PCI is associated withan increased risk of stroke. Design: Com-bined analysis of data from four double-blind, placebo-controlled, randomizedtrials (EPIC, CAPTURE, EPILOG, andEPISTENT) conducted between Novem-ber 1991 and October 1997 at a total of257 academic and community hospitalsin the United States and Europe. Patients:A total of 8,555 patients undergoing PCIwith or without stent deployment for avariety of indications were randomly as-signed to receive a bolus and infusion ofabciximab (n � 5,476) or matching pla-cebo (n � 3,079). One treatment group inEPIC received a bolus of abciximab only.Main Outcome Measure: Risk of hemor-rhagic and nonhemorrhagic strokewithin 30 days of treatment among ab-ciximab and placebo groups. Results: Nosignificant difference in stroke rate wasobserved between patients assigned ab-ciximab (n � 22 [0.40%]) and those as-signed placebo (n � 9 [0.29%]; P � .46).Excluding the EPIC abciximab bolus-only group, there were nine strokes(0.30%) among 3,023 patients who re-ceived placebo and 15 (0.32%) in 4,680patients treated with abciximab bolusplus infusion, a difference of 0.02% (95%confidence interval [Cl], -0.23% to0.28%). The rate of nonhemorrhagicstroke was 0.17% in patients treated withabciximab and 0.20% in patients treatedwith placebo (difference, -0.03%; 95% Cl,-0.23% to 0.17%), and the rates of hem-orrhagic stroke were 0.15% and 0.10%,respectively (difference, 0.05%; 95% Cl,-0.11% to 0.21%). Among patientstreated with abciximab, the rate of hem-orrhagic stroke in patients receivingstandard-dose heparin in EPIC, CAP-TURE, and EPILOG was higher than inthose receiving low-dose heparin in theEPILOG and EPISTENT trials (0.27% vs0.04%; P � .057). Conclusions: Abciximabin addition to aspirin and heparin doesnot increase the risk of stroke in patients

undergoing PCI. Patients undergoingPCI and treated with abciximab shouldreceive low-dose, weight-adjusted hepa-rin.Authors’ Abstract

Neighborhood of Residence and Inci-dence of Coronary Heart Disease.Ana V. Diez Roux, Sharon Stein Mer-kin, Donna Arnett, et al. N Engl J Med2001; 345:99–106. (A.V.D.R., Division ofGeneral Medicine, Columbia Presbyte-rian Medical Center, 622 W. 168th St.,PH9 E., Rm. 105, New York, NY 10032)

• Background: Where a person lives isnot usually thought of as an indepen-dent predictor of his or her health, al-though physical and social features ofplaces of residence may affect health andhealth-related behavior. Methods: Usingdata from the Atherosclerosis Risk inCommunities Study, we examined therelation between characteristics of neigh-borhoods and the incidence of coronaryheart disease. Participants were 45–64years of age at base line and were sam-pled from four study sites in the UnitedStates: Forsyth County, North Carolina;Jackson, Mississippi; the northwesternsuburbs of Minneapolis; and Washing-ton County, Maryland. As proxies forneighborhoods, we used block groupscontaining an average of 1,000 people, asdefined by the U.S. Census. We con-structed a summary score for the socio-economic environment of each neighbor-hood that included information aboutwealth and income, education, and oc-cupation. Results: During a median of 9.1years of follow-up, 615 coronary eventsoccurred in 13,009 participants. Resi-dents of disadvantaged neighborhoods(those with lower summary scores) hada higher risk of disease than residents ofadvantaged neighborhoods, even afterwe controlled for personal income, edu-cation, and occupation. Hazard ratios forcoronary heart disease among low-in-come persons living in the most disad-vantaged neighborhoods, as comparedwith high-income persons in the mostadvantaged neighborhoods, were 3.1among whites (95 percent confidence in-terval, 2.1–4.8) and 2.5 among blacks (95percent confidence interval, 1.4–4.5).These associations remained unchangedafter adjustment for established risk fac-tors for coronary heart disease. Conclu-sions: Even after controlling for personalincome, education, and occupation, wefound that living in a disadvantagedneighborhood is associated with an in-creased incidence of coronary heart dis-ease.Authors’ Abstract


THORACIC

Outcomes after Surgery for ThoracicOutlet Syndrome. David A. Axelrod,Mary C. Proctor, Michael E. Geisser, etal. J Vasc Surg 2001; 33:1220–1225.(D.A.A., 6312 Medical Science BuildingI, 1150 W Medical Center Dr, Ann Ar-bor, MI 48109-0604)

• Purpose: This study determinedwhether there is an association betweenpsychological and socioeconomic char-acteristics and the long-term outcome ofoperative treatment for patients withsensory neurogenic thoracic outlet syn-drome (N-TOS). Methods: Clinicalrecords, preoperative psychological test-

ing results, and long-term follow-upquestionnaire data were reviewed forconsecutive patients who underwentsurgery for N-TOS from 1990 to 1999.Multivariate logistic regression modelswere developed as a means of identify-ing independent risk factors for postop-erative disability. Results: Operative de-compression of the brachial plexus via asupraclavicular approach was per-formed for upper extremity pain andparesthesia with no mortality and mini-mal morbidity in 170 patients. After anaverage follow-up period of 47 months,65% of patients reported improvedsymptoms, and 64% of patients were sat-isfied with their operative outcome.

However, 35% of patients remained onmedication, and 18% of patients weredisabled. Preoperative factors associatedwith persistent disability include majordepression (odds ratio [OR], 15.7; P �.02), not being married (OR, 7.9; P � .04),and having less than a high school edu-cation (OR, 8.1; P � .09). Conclusion: Op-erative decompression was beneficial formost patients. Psychological and socialfactors, including depression, maritalstatus, and education, are associatedwith self-reported disability. The impactof the preoperative treatment of depres-sion on the outcome of TOS decompres-sion should be studied prospectively.Authors’ Abstract


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