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1/249. Carotid endarterectomy and intracranial thrombolysis: simultaneous and staged procedures in ischemic stroke.

    PURPOSE: The feasibility and safety of combining carotid surgery and thrombolysis for occlusions of the internal carotid artery (ICA) and the middle cerebral artery (MCA), either as a simultaneous or as a staged procedure in acute ischemic strokes, was studied. methods: A nonrandomized clinical pilot study, which included patients who had severe hemispheric carotid-related ischemic strokes and acute occlusions of the MCA, was performed between January 1994 and January 1998. Exclusion criteria were cerebral coma and major infarction established by means of cerebral computed tomography scan. Clinical outcome was assessed with the modified Rankin scale. RESULTS: Carotid reconstruction and thrombolysis was performed in 14 of 845 patients (1.7%). The ICA was occluded in 11 patients; occlusions of the MCA (mainstem/major branches/distal branch) or the anterior cerebral artery (ACA) were found in 14 patients. In three of the 14 patients, thrombolysis was performed first, followed by carotid enarterectomy (CEA) after clinical improvement (6 to 21 days). In 11 of 14 patients, 0.15 to 1 mIU urokinase was administered intraoperatively, ie, emergency CEA for acute ischemic stroke (n = 5) or surgical reexploration after elective CEA complicated by perioperative intracerebral embolism (n = 6). Thirteen of 14 intracranial embolic occlusions and 10 of 11 ICA occlusions were recanalized successfully (confirmed with angiography or transcranial Doppler studies). Four patients recovered completely (Rankin 0), six patients sustained a minor stroke (Rankin 2/3), two patients had a major stroke (Rankin 4/5), and two patients died. In one patient, hemorrhagic transformation of an ischemic infarction was detectable postoperatively. CONCLUSION: Combining carotid surgery with thrombolysis (simultaneous or staged procedure) offers a new therapeutic approach in the emergency management of an acute carotid-related stroke. Its efficacy should be evaluated in interdisciplinary studies.
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2/249. Percutaneous fenestration of the aortic dissection membrane in malperfusion syndrome.

    We present two cases of malperfusion syndrome due to aortic dissection type-B. A supra-renal blind sac phenomenon resulted in renal failure and absent femoral pulses in both patients. Additionally, one patient suffered from spinal cord ischemia, the other from severe abdominal pain. By interventional techniques, catheter perforation of the blind sac was achieved. The resulting re-entries were enlarged with a balloon catheter. Distal perfusion without pressure gradients was restored by this technique in both patients and resulted in complete relief of symptoms. Percutaneous fenestration of the aortic dissection membrane may be an alternative to operative treatment in malperfusion syndrome.
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3/249. Left ventricle to pulmonary artery conduit in treatment of transposition of great arteries, restrictive ventricular septal defect, and acquired pulmonary atresia.

    Progressive cyanosis after banding of the pulmonary artery in infancy occurred in a child with transposition of the great arteries and a ventricular septal defect, and a Blalock-Taussig shunt operation had to be performed. At the time of correction a segment of pulmonary artery between the left ventricle and the band was found to be completely occluded so that continuity between the left ventricle and the pulmonary artery could not be restored. A Rastelli type of operation was not feasible as the ventricular septal defect was sited low in the muscular septum. Therefore, in addition to Mustard's operation, a Dacron conduit was inserted from the left ventricle to the main pulmonary artery to relieve the obstruction. Postoperative cardiac catheterization with angiocardiography indicated a satisfactory haemodynamic result. The patient remains well 11 months after the operation. This operation, a left ventricle to pulmonary artery conduit, may be used as an alternative procedure in patients with transposition of the great arteries, intact interventricular septum, and obstruction to the left ventricular outflow, if the obstruction cannot be adequately relieved.
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4/249. Acquired protein s deficiency with multiple thrombotic complications after orthotopic liver transplant.

    BACKGROUND: Orthotopic liver transplantation (OLT) is frequently complicated by thrombotic events that may threaten the viability of the allograft and severely compromise the overall outcome in these patients. Although multiple prothrombotic pathogenic mechanisms may be involved, a role for inadequate natural anticoagulant levels in the early postoperative period has been postulated. methods: We describe a case of a woman who suffered multiple thrombotic complications after a second OLT. Prospective assays of procoagulant and natural anticoagulant factor levels, in addition to screening tests for a variety of inherited and acquired hypercoagulable states, were carried out. RESULTS: Serial studies confirmed an acquired, isolated deficiency of Protein S associated with the second transplanted liver. Protein S levels were normal after the patient's first and third OLTs. There was no laboratory evidence of other underlying prothrombotic conditions. CONCLUSIONS: This unusual case of acquired protein s deficiency demonstrates that the hypercoagulable phenotype may develop in the recipient of a liver from a heterozygous deficient donor. Furthermore, isolated low Protein S may be causally associated with hepatic artery thrombosis after OLT.
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5/249. Transverse cervical artery bypass pedicle for treatment of common carotid artery occlusion: new adjunct for revascularization of the internal carotid artery domain.

    OBJECTIVE: We present two cases of common carotid artery occlusion that were treated by vascular reconstruction using the transverse cervical artery. methods: Two patients with common carotid artery occlusion presented with transient ischemic attacks resulting from decreased cerebral blood flow on the affected side. Both patients underwent vascular reconstruction using the transverse cervical artery. The transverse cervical artery was anastomosed to the ipsilateral external carotid artery at its origin, as a pedicle graft. A superficial temporal artery-middle cerebral artery anastomosis was then performed. RESULTS: The postoperative courses were uneventful. The transverse cervical artery bypass grafts were patent, and cerebral blood flow increased to normal levels. CONCLUSION: Transverse cervical artery grafting provides a less tedious alternative to saphenous vein interposition grafting for revascularization of the internal carotid artery domain.
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6/249. Cerebral microembolus generation in different extracorporeal circulation systems.

    Microemboli generated during extracorporeal circulation (ECC) are likely to induce neurological sequelae. This study examines whether the choice of a distinct type of ECC can reduce intracerebral emboli counts. middle cerebral artery blood flow during coronary artery bypass grafting was monitored continuously by transcranial Doppler ultrasound in 45 patients. The ECC systems used were a roller pump (n = 16), a centrifugal pump (n = 18) and a combination of centrifugal pump and heparin-coated ECC system (n = 11). patients' characteristics as well as surgical and anesthesiological procedure did not differ between the groups. Total counts did not differ significantly between the three groups. Intraoperative events in individual patients may lead to massive embolus generation overcoming positive properties of a distinct ECC system.
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7/249. Assessment of outcome by EC/IC bypass with 123I-iomazenil brain SPECT.

    We report two patients with occlusive cerebrovascular disease who were examined by means of benzodiazepine receptor SPECT(BZR-SPECT) with 123I-iomazenil (IMZ) before extracranial-intracranial bypass surgery (EC/IC bypass). Preoperative low perfusion areas detected by cerebral blood flow SPECT (CBF-SPECT) were divided into two parts on BZR-SPECT images. In the low perfusion areas where the BZR were preserved, regional cerebral blood flow (rCBF) increased on postoperative CBF-SPECT, but where the BZR were not preserved, rCBF did not increase on postoperative CBF-SPECT. On visual inspection, the SPECT images of postoperative CBF-SPECT appeared similar to those of preoperative BZR-SPECT. For evaluation of the ischemic brain condition itself, instead of the cerebral metabolism, the distribution and activity of cerebral neurons indicated by BZR-SPECT with IMZ might be utilized.
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8/249. Aortic reconstruction in the hiv infected patient.

    Major vascular reconstruction using prosthetic implantation is uncommon in the hiv infected patient. We describe a 52-year-old man with hiv infection and hiv-induced thrombocytopenia, who underwent successful aorto-bifemoral bypass for lower extremity ischemic symptoms. Postoperative progressive thrombocytopenia and subsequent hemorrhage were successfully treated with intravenous steroid replacement, platelet transfusion, alpha-globulin administration and expectant management. This report serves to illustrate that major vascular reconstruction can be successfully accomplished in the hiv infected population, even in the presence of significant hematologic dysfunction.
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9/249. Unusual complications in an inflammatory abdominal aortic aneurysm.

    An unusual case of an inflammatory abdominal aortic aneurysm (IAAA) associated with coronary aneurysms and pathological fracture of the adjacent lumbar vertebrae. The associated coronary lesions in cases of IAAA are usually occlusions. In the present case, it was concluded that a possible cause of the coronary aneurysm was coronary arteritis and the etiology of the pathological fracture of the lumbar vertebrae was occlusion of the lumbar penetrating arteries due to vasculitis resulting in aseptic necrosis. Inflammatory AAA can be associated with aneurysms in addition to occlusive disease in systemic arteries. The preoperative evaluation of systemic arterial lesions and the function of systemic organs is essential.
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10/249. Arterial occlusion and thrombus aspiration after total knee arthroplasty.

    Arterial occlusion after total knee arthroplasty is an uncommon complication. In the literature only a few cases have been reported, and non consensus exists on the optimal management for this condition. The authors report two patients with popliteal artery thrombosis in the early postoperative period. Both patients were treated with percutaneous thrombus aspiration, a technique that has not been reported previously for this indication. In both patients complete restoration of arterial perfusion and limb salvage was achieved, although ischemic necrosis of the anterior compartment muscles of the lower leg could not be prevented.
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