Symptom-free Survival Rates Research Articles

Characteristics of patients undergoing percutaneous coronary intervention for chronically total occluded arteries: a single-center observational study in India [RETRACTED

Background and purpose: Percutaneous coronary intervention (PCI) is the gold standard for managing chronic total occlusion (CTO), but data on characteristics of the patients undergoing PCI for CTO are scarce. The present study was designed to evaluate the clinical profile of the patients who underwent PCI to CTO. Methods: This single-center, prospective, and observational study included consecutive patients who successfully underwent PCI for angiographically confirmed CTO at author’s center from March 2017 to March 2019. Follow-up was conducted at 6 and 12 months. Results: The final analysis included a total of 108 patients. The mean age was 64.5 ± 8.2 years. Majority of the patients (72.2%) were men. The most common morbid risk factors were diabetes mellitus (56.5%), hypertension (53.7%), and dyslipidemia (52.8%). Mean left ventricular ejection fraction (LVEF) was 51% ± 0.0% and 73% had New York Heart Association (NYHA) class II. The most common site of CTO was the right coronary artery (34.3%). PCI was conducted using an antegrade approach, 75.9% of the cases. The majority of patients underwent wire escalation PCI technique (52.8%) followed by adverse drug reaction (34.3%), reverse-controlled antegrade and retrograde tracking (CART) (8.3%) and CART (4.6%). Stress test was negative in 63% and 64.8% of the patients at 6 and 12 months, respectively. The 6-month symptom-free survival rate was higher in patients without hypertension. Symptom-free survival rate was 96.9%, 95.9% and 88.9% in patients with Japanese Multicenter CTO Registry (J-CTO) score of 0, 1 and >3, respectively. The rate of abnormal electrocardiogram at 12 months was higher in patients with J-CTO score of 0 or 1 versus >3. Conclusion: PCI is a viable option for patients who are not willing to undergo coronary artery bypass grafting, particularly in those with low J-CTO score.

Comparative analysis of the results of cyanoacrylate ablation and radiofrequency ablation in the treatment of venous insufficiency

BackgroundVaricose vein treatment has shifted to less invasive techniques owing to the complications associated with traditional treatment. The present study was designed to compare the effectiveness of cyanoacrylate ablation (CAA) with radiofrequency ablation (RFA). MethodsPatients who had undergone RFA vs CAA (634 vs 246 patients) to treat great saphenous vein (GSV) insufficiency during a 5-year period were included in the present study. The preoperative and postoperative CEAP (clinical, etiologic, anatomic, pathophysiologic) class, symptoms, recurrence, and Doppler ultrasound findings were compared. ResultsAll the veins in both groups were occluded at day 5. The 1-month closure rates were 97.3% and 98.7% for RFA and CAA, respectively. The overall postoperative closure rates at 5 years were 93.1% and 91.1% for RFA and CAA, respectively. The postoperative symptoms, CEAP class, and Doppler ultrasound findings were similar in both groups. The 5-year symptom-free survival rates were 73.5% and 72.0% in the RFA and CAA groups, respectively. The venous clinical severity scores had decreased from 5.9 ± 1.2 to 0.9 ± 0.8 and 5.8 ± 0.9 to 0.8 ± 0.6 in the RFA and CAA groups, respectively. The Aberdeen varicose vein questionnaire scores had decreased from 19.7 ± 5.5 to 4.8 ± 1.5 in the RFA group and from 18.9 ± 5.8 to 4.9 ± 1.4 in the CAA group. ConclusionsCAA seems to be the ideal treatment for GSV insufficiency because it is suitable for most patients and is nonthermal and nontumescent, with satisfactory results comparable to those with RFA. Long-term outcomes and cost analyses from larger series are required to confirm our findings.

Targeted therapy of multiple myeloma.

Multiple myeloma (MM) is a malignant proliferative disease of monoclonal plasma cells (PCs) and is characterized by uncontrolled proliferation of PCs and excessive production of specific types of immunoglobulins. Since PCs are terminally differentiated B cells, the World Health Organization (WHO) classifies MM as lymphoproliferative B-cell disease. The incidence of MM is 6–7 cases per 100,000 people in the world every year and the second most common cancer in the blood system. Due to the effects of drug resistance and malignant regeneration of MM cells in the microenvironment, all current treatment methods can prolong both overall and symptom-free survival rates of patients with MM but cannot cure MM. Both basic and clinical studies have proven that targeted therapy leads to a clear and significant prolongation of the survival of patients with MM, but when the disease recurs again, resistance to the previous treatment will occur. Therefore, the discovery of new targets and treatment methods plays a vital role in the treatment of MM. This article introduces and summarizes targeted MM therapy, potential new targets, and future precision medicine in MM.

Pelvic exenteration surgery in patients with locally advanced castration‐naïve and castration‐resistant, symptomatic prostate cancer

To evaluate retrospectively the surgical, symptomatic and oncological outcomes of pelvic exenteration surgery (PES) in men with significant intrapelvic complications of locally advanced castration-sensitive (CSPC) and castration-resistant prostate cancer (CRPC). A total of 103 patients with locally advanced progressive and symptomatic CSPC or CRPC underwent PES (radical cystoprostatectomy, n = 71 [68.9%]; radical prostatectomy with continent vesicostomy, n = 9 [8.7%]; total exenteration, n = 23 [22.3%]). All patients underwent local staging via magnetic resonance imaging, cystoscopy and rectoscopy. Systemic staging was carried out with chest, abdominal and pelvic computed tomography scans and bone scans. Peri-operative complications were assessed according to Clavien-Dindo classification. Symptom-free and overall survival were evaluated using the Kaplan-Meier method. Statistical tests were two-tailed with a P value <0.05 taken to indicate statistical significance. After a median (range) follow-up of 36.5 (3-123) months, the symptom-free survival rate at 1 and 3years was 89.2% (n = 89) and 64.1% (n = 66), respectively. The median symptom-free survival was 27.9months. A total of 78.6% of the patients were symptom-free during their remaining lifetime. The overall survival rate at 1 and 3years was 92.2% and 43.7%, respectively, and the median overall survival was 33.6months. Clavien-Dindo grades 2, 3 and 4 complications developed in 31 (30.6%), 12 (11.6%) and eight patients (8.1%), respectively. Pelvic exenteration surgery is technically feasible in well-selected patients, resulting in symptom relief in >90% of patients, covering 80% of their remaining lifetime.

LUE 1. A Comparative Analysis of the Results of Cyanoacrylate Ablation and Radiofrequency Ablation in the Treatment of Venous Insufficiency

Varicose vein treatment has been directed toward less invasive yet lasting techniques. This study was designed to compare the effectiveness of cyanoacrylate ablation (CAA) with that of radiofrequency ablation (RFA). The study included 524 and 202 patients who had undergone RFA (ClosureFast; Medtronic, San Jose, Calif) and CAA (VenaBlock Venous Closure System; Invamed, Ankara, Turkey), respectively, within the preceding 4 years. The mean age of the patients was 48.4 ± 11.3 years, and the mean follow-up time was 24.3 ± 3.2 months. Preoperative and postoperative Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) class, symptoms, recurrence, and Doppler findings of the two groups were compared. Postoperative Doppler saphenous vein closure rates were 97.3% in the RFA group and 98.7% in the CAA group. The type of operation had no effect on postoperative symptoms, CEAP class, or Doppler findings. There is no efficiency difference between treatment methods. The predictors of postoperative CEAP class were preoperative CEAP class, bilateral limb disease, and prior deep venous thrombosis, whereas the predictors of symptom recurrence were postoperative perforator incompetence and preoperative CEAP class. The 2-year symptom-free survival rates were 66.3% in the RFA group and 61.9% in the CAA group. The Venous Clinical Severity Score decreased from 5.9 ± 1.1 to 0.8 ± 0.8 in the RFA group and from 5.7 ± 0.9 to 0.7 ± 0.6 in the CAA group. The Aberdeen Varicose Vein Questionnaire score decreased from 19.6 ± 5.4 to 4.8 ± 1.4 in the RFA group and from 18.7 ± 5.7 to 4.9 ± 1.3 in the CAA group. The major disadvantages of current thermal ablation techniques, such as postoperative pain and discomfort as well as skin bruises, paresthesia, and burns caused by thermal damage, and the need for tumescent anesthesia caused an increasing need for the development of nonthermal, nontumescent options for shorter and more successful treatment of venous insufficiency. The CAA seems to be the closest technique to the ideal and suitable for all patients because it is nonthermal and nontumescent. The results are satisfactory and are comparable to those of RFA. When two techniques are evaluated, CAA may be preferable as a simple application in a shorter time with less early postoperative discomfort. However, long-term results and cost analyses of larger series still need to be documented.

ASA404, a vascular disrupting agent, as an experimental treatment approach for brain tumors

Malignant brain tumors, including gliomas, brain metastases and anaplastic meningiomas, are associated with poor prognosis, and represent an unmet medical need. ASA404 (DMXAA), a vascular disrupting agent, has demonstrated promising results in several preclinical tumor models and early phase clinical trials. However, two phase III trials in non-small cell lung cancer reported insufficient results. The aim of the present study was to determine the effects of ASA404 on brain tumors. The effects of ASA404 were evaluated in vitro and in vivo using subcutaneous, and orthotopical models for malignant glioma (U-87, LN-229, U-251, LN-308 and Tu-2449), brain metastasis (HT-29) and malignant meningioma (IOMM-Lee). The acute effects of ASA404 on tumor tissue were analyzed using conventional and immunohistochemical staining techniques [hematoxylin and eosin, MIB-1 antibody/proliferation maker protein Ki-67, cleaved caspase-8, stimulator of interferon genes (STING), ionized calcium-binding adapter molecule 1]. Furthermore, the sizes of subcutaneous tumors were measured and the symptom-free survival rates of animals with intracranial tumors receiving ASA404 treatment were analyzed. ASA404 demonstrated low toxicity in vitro, but exhibited strong effects on subcutaneous tumors 24 h following a single dose of ASA404 (25 mg/kg). ASA404 induced necrosis, hemorrhages and inhibited the proliferation, and growth of tumors in the subcutaneous glioma models. However, ASA404 failed to demonstrate comparable effects in any of the intracranial tumor models examined and did not result in a prolongation of survival. Expression of STING, the molecular target of ASA404, and infiltration of macrophages, the cells mediating ASA404 activity, did not differ between subcutaneous and intracranial tumors. In conclusion, ASA404 demonstrates clear efficacy in subcutaneous tumor models, but has no relevant activity in orthotopic brain tumor models. The expression of STING and infiltration with macrophages were not determined to be involved in the differential activity observed among tumor models. It is possible that the low penetration of ASA-404 into the brain prevents concentrations sufficient enough reaching the tumor in order to exhibit acute effects in vivo.

Late intestinal obstruction after radical cystectomy and urinary diversion: urological and oncological perspectives

Objective: The aim of this study was to review different management modalities and outcome of patients presenting with late intestinal obstruction (IO) after radical cystectomy (RC) or palliative cystectomy (PC).Materials and methods: Files of patients who presented with IO between January 1978 and June 2014 were reviewed. Patients who developed IO following either RC or PC more than 30 days after surgery were included. Patients’ characteristics and management protocols were evaluated. Predictors for failure of conservative management and unfavorable outcome after surgical explorations were evaluated. Symptom-free and overall survival rates of patients with malignant IO was were recorded.Results: The prevalence of IO was 2.8% after RC (118 out of 4199 patients) and 10% after PC (nine out of 87). Colonic diversions had the highest prevalence (6.2%), followed by ileal loop conduit (2.9%); the lowest prevalences followed Kock pouch and ileal W neobladder (1.7% and 1.6%, respectively). Postoperative urinary leakage from a ureteroenteric anastomosis was the only predictor for surgical intervention (p = 0.039). Nine cases had been explored for malignant obstruction (eight after RC and one after PC). The mean ± SD elapsed time before death was 3.6 ± 2 months (range 0.5–17 months).Conclusions: Urinary diversion with colonic segments carries more risk for the development of IO in comparison with ileal segments. Postoperative urinary leakage after cystectomy and urinary diversion may be a contributory factor for surgical exploration in cases with late IO.

Predictive value of upright blood pressure change for long-term prognosis of children with postural tachycardia syndrome treated with midodrine hydrochloride

To explore the predictive value of upright blood pressure change for long-term prognosis of children with postural tachycardia syndrome (POTS) treated with midodrine hydrochloride. A total of 90 children (male 41, female 49) were enrolled in this study. Their mean age was (11.8±2.7) years. They were diagnosed as POTS in Peking University First Hospital from 2005 to 2011. According to the upright change of blood pressure at the first visit, they were divided into two groups, effective group (n=55) and ineffective group(n=35). The follow-up time was 53-130 months. The orthostatic intolerance symptom score and symptom free survival rate were compared between the two groups. The change of systolic blood pressure and of diastolic blood pressure was lower in effective group than those in ineffective group (0(-6, 0) mmHg (1 mmHg=0.133 kPa) vs. 9(6, 11) mmHg, Z=-8.303, P<0.01; 0(0, 5) mmHg vs. 11(10, 16) mmHg, Z=-7.058, P<0.01). Two groups had no significant difference in symptom scores before treatment((4.8±0.9) points vs. (5.0±0.8) points, t=-0.53, P=0.595), while symptom scores were lower in effective group than that in ineffective group((1.3±0.9) points vs. (4.7±0.9) points, t=-15.60, P<0.01 ). The symptom free survival rate was higher in effective group than that in ineffective group (48/55(87.3%) vs. 23/35(65.7%), χ(2)=5.969, P<0.01). The upright change of blood pressure has a good predictive value on the long-term survival of POTS children treated with midodrine hydrochloride.

Technical considerations, outcomes, and durability of inferior vena cava stenting.

Inferior vena cava (IVC) thrombosis is an uncommon condition but can cause devastating complications to those affected. Historically, this has been treated with an open surgical approach (with high morbidity) and with angioplasty in more recent years. Herein we describe technical aspects of stenting of the IVC in patients with recalcitrant chronic occlusive disease and evaluate its outcomes. We reviewed all the patients treated in an endovascular fashion for venous disease at our institution from 2005 to 2014 to identify and to include those with IVC stent placement in this study. Clinical characteristics, treatment details, and outcomes data were collected from medical records. Primary end points were technical success, symptom resolution, freedom from reintervention, and patency rate at follow-up. Twenty-eight patients (15 men) with a mean age of 48 ± 2.7 years underwent IVC stent placement for 16 occlusions (4 congenital) and 12 high-grade stenoses. Hypercoagulable state was noted in 14 patients, 7 of whom had malignant disease. A previously placed IVC filter was present in 13 patients. Median time from onset of symptoms to presentation was 81 months (3-480 months). Lytic therapy with tissue plasminogen activator (Alteplase) was performed in 12 patients for a median of 2 days (range, 1-3 days). Self-expanding stents (Wallstent; Boston Scientific, Natick, Mass) were used most commonly in the IVC (n = 22) with or without adjunctive use of balloon-expandable stents (Palmaz stent; Cordis, New Brunswick, NJ). Technical success was 100%. At median follow-up of 10 months (range, 0-56 months), thrombotic complications requiring reintervention occurred in four patients at 1, 4, 8, and 37 months. One patient died at 2 weeks secondary to underlying malignant disease. Freedom from reintervention, patency rate, and symptom-free survival rate at 2 years were 84%, 90%, and 80%. Endovascular stenting for chronic occlusive disease of the IVC is safe and effective in the midterm follow-up, with minimal morbidity. Reintervention rate is low, with excellent functional outcomes.

Study on clinical features and etiology of primary Budd-Chiari Syndrome

To prospectively study clinical features and etiology in patients with incident Budd-Chiari syndrome (BCS) in China. Taking consecutive case series of patients with incident BCS as who were diagnosed in our hospital, enrolled from September 2010 to January 2012 as the object of research, and the follow-up was lasting until June 2012. Taking records for all patients' symptoms, signs, laboratory findings, radiology findings, treatment, interventional treatment survival and symptom-free period. There are total 149 incident cases of BCS. In which, the median age was 46 years old (range 10 to 82); 61.7% of them were male patients, 38.3% were female patients; 85.9% of them were chronic, the other patients (14.1%) were diagnosed during acute or subacute periods; the median duration of symptoms before diagnosis was 96 months (range 1 day to 360 months). In terms of causes, 30.9% of the patients caused by hepatic venous block, 5.4% of them resulted from inferior vena cava block, and the rest 63.8% were suffered from combined hepatic venous and inferior vena cava block. 80.5% patients have at least one etiological factor, Furthermore, the most common cause was the web (61.1%), only 4.8% have myeloproliferative diseases (JAK2 V617F mutation), and none Factor V Leiden mutation cases was found. 144 patients were treated by percutaneous transluminal angioplasty, the technical success rate was 95.1%, and took oral anticoagulation therapy for 12 months. At 18 months, The survival rate and the symptom-free survival rate after percutaneous transluminal angioplasty were 97.8% and respectively. Web is the most prevalent etiological factor for BCS in China. It is different in western countries; the common reasons of BCS are risk factors related to thrombosis, such as myeloproliferative disease and Factor V Leiden mutation, etc., which are seldom found in Chinese BCS patients. In China, most chronic BCS patients were treated with percutaneous transluminal angioplasty and have excellent clinical outcome.

An Alternative Treatment for Varicose Veins: Ligation Plus Foam Sclerotherapy

Varicose vein treatment has been directed toward less-invasive yet lasting techniques. To compare the effectiveness of an alternative treatment (ligation plus foam sclerotherapy) with that of a classic stripping technique. The study included 216 and 156 patients who had undergone classic stripping and foam sclerotherapy, respectively, within the previous 5 years. Preoperative and postoperative CEAP class, symptoms, recurrence, and Doppler findings of the two groups were compared. There were no differences between treatments in terms of postoperative symptoms, Doppler findings, or CEAP class. The predictors of postoperative CEAP class were bilateral limb disease and prior deep vein thrombosis (DVT), whereas the predictors of symptom recurrence were bilateral limb disease, preoperative CEAP class, occupation, and familial or genetic predisposition. The predictors of postoperative perforator incompetence (PI) were occupation, aged 60 and older, preoperative CEAP class, and preoperative PI, whereas the only predictor of postoperative deep vein incompetence (DVI) was preoperative DVI. Five-year symptom-free survival rates were 51 ± 0.8% in the foam sclerotherapy group and 46 ± 0.9% in the stripping group. The safety and efficacy of ligation plus foam sclerotherapy as an alternative technique allowing for same-day surgery to treat varicose veins are the same as those of classic stripping. The predictors of postoperative outcome depend on individual patient characteristics.

Factors affecting successful palliative surgery for malignant bowel obstruction due to peritoneal dissemination from colorectal cancer.

Nonresectable colorectal cancer often causes malignant intestinal obstruction due to peritoneal dissemination. However, no previous report has specifically investigated which patients, with peritoneal dissemination from colorectal cancer, would actually benefit from palliative surgery. This study defines the selection criteria for patients who are likely to benefit from palliative surgery. Twenty-one patients underwent palliative surgery for malignant bowel obstruction due to peritoneal dissemination from colorectal cancer. In all cases, the advanced and nonresectable nature of the tumor was confirmed at laparotomy. Clinical factors such as age, gender, serum level of carcinoembryonic antigen, amount of ascites, location of the primary cancer, surgical procedure, and postoperative chemotherapy were analyzed for prognostic significance in symptom-free and overall survival using the Kaplan-Meier product limit method and the log-rank test. All the postoperative courses were uneventful. Obstruction recurred after a median symptom-free interval of 61 days in the group with less than 100 ml of ascites, whereas it recurred after 9 days in the group with more than 100 ml of ascites. Symptom-free survival rates in patients who manifested ascites were significantly lower than in those without ascites (P = 0.0321, log-rank method). The symptom-free and overall survival rates in patients who underwent postoperative chemotherapy were significantly higher (P = 0.0225 and 0.0003). Palliative surgery can be performed effectively for patients without ascites. For patients who do not meet this criterion, a non-surgical procedure may be preferable.

Current results of open revascularization for chronic mesenteric ischemia: A standard for comparison

Objective: Questions remain concerning the optimal site of graft origin and the extent of revascularization necessary to achieve excellent results for chronic mesenteric ischemia (CMI). Endovascular therapy also is performed for CMI. These factors prompted us to review our results to provide a current standard. Methods: Ninety-eight patients who underwent operation for CMI from 1989 to 1998 were reviewed. Patients with acute ischemia and arcuate ligament syndrome were excluded. Results: Seventy-six women (78%) and 22 men (22%), with an average age of 66 years (range, 36 to 87 years), participated in the study. Abdominal pain was present in 95 patients (97%), and weight loss in 92 patients (94%). The superior mesenteric artery was severely diseased (70% to 99% stenosis or occlusion) in 90 patients (92%), the celiac artery in 81 patients (83%), and both arteries in 76 patients (78%). Bypass grafts were performed in 91 patients (93%), 77 antegrade and 14 retrograde. Of the other seven patients, five had endarterectomies, one reimplantation, and one patch angioplasty. Multivessel reconstruction was performed in 79 patients (81%), and single-vessel reconstruction in 19 (19%). Twelve patients had concomitant aortic reconstruction. Three early graft thromboses were seen. Five hospital deaths occurred (5.1%); one case had concomitant aortic reconstruction (1/12 versus 4/86; P = not significant). All five patients who died were older than 70 years (5/41 versus 0/57; P =.011). The median follow-up period was 1.9 years (range, 0 to 9.6 years). Follow-up was complete in all survivors. The 1-year, 5-year, and 8-year survival rates were 83%, 63%, and 55%, respectively. These rates were worse than the rates of the age-matched/gender-matched control subjects (P <.001). Survival was worse in patients greater than 70 years of age (P =.0013). Survival was unaffected by the number of vessels revascularized. The patients with retrograde grafts had decreased median survival rates (4.0 versus 5.7 years; P =.026), but they were older (75 versus 65 years; P =.0013). The 1-year and 5-year symptom-free survival rates were 95% and 92%, respectively. Symptoms recurred in six patients (6%): four had recurrent stenosis/occlusion and two had patent grafts. Symptom-free survival was unaffected by the number of vessels revascularized or by graft orientation. Conclusion: Operation for CMI was successful for most patients, with low operative mortality and excellent long-term relief of symptoms. Selective concomitant aortic procedures did not increase mortality rates. The rate of symptomatic recurrences was not different for single-vessel versus multiple-vessel reconstructions or for antegrade versus retrograde grafts. Patients older than 70 years had increased operative mortality and decreased survival rates. Endovascular therapy may be appropriate for this subset of patients. (J Vas Surg 2002;35:853-9.)

Hepatic cytoreduction followed by a novel long-acting somatostatin analog: A paradigm for intractable neuroendocrine tumors metastatic to the liver

Background. Optimal management of symptomatic neuroendocrine tumors that metastasize to the liver is controversial. We investigated aggressive hepatic cytoreduction and postoperative administration of octreotide long-acting release (LAR), a long-acting somatostatin analog. Methods. Between December 1992 and August 2000, 31 patients underwent hepatic surgical cytoreduction (20 carcinoid, 10 islet cell, and 1 medullary). All patients had progressive symptoms refractory to conventional therapy. Results. Hepatic cytoreduction (resection, cryosurgery, and/or radiofrequency ablation) eliminated symptoms in 27 patients (87%) and decreased secretion of hormones by an overall mean of 59%. When minor symptoms returned and/or hormonal levels increased during follow-up, adjuvant therapy was started. Ten patients received adjuvant octreotide LAR once a month, and 21 received other adjuvants. At a median postoperative follow-up of 26 months, 16 patients had progressive/recurrent disease, 13 had died of their disease, and 2 remained free of disease. Median symptom-free interval was 60 months (95% confidence interval, 48-72) with octreotide LAR and 16 months (95% confidence interval, 10-29) with other adjuvants (P =.0007). Two-year symptom-free survival rate was 100% with octreotide LAR and 33% with other adjuvants. Conclusions. Hepatic surgical cytoreduction can palliate progressive symptoms associated with liver metastases from intractable neuroendocrine tumors. Postoperative adjuvant therapy with octreotide LAR can prolong symptom-free survival. (Surgery 2001;130:954-62.)

Carotid-subclavian bypass grafting with polytetrafluoroethylene grafts for symptomatic subclavian artery stenosis or occlusion: A 20-year experience

Background and Purpose: Since the advent of subclavian artery percutaneous transluminal angioplasty/stenting, several authorities advocate it as the treatment of choice for patients with subclavian artery disease, claiming results equal to or better than those of reconstructive vascular surgery. However, most of their quoted surgical series included patients who may have other brachiocephalic disease who were treated nonuniformly by means of various bypass grafts with different grafts in the same series (eg, Dacron, polytetrafluoroethylene [PTFE], or vein). In this study, we analyze the long-term results of a large series of carotid-subclavian bypass grafts for subclavian artery disease in which PTFE was uniformly used; the study can be used as a future reference to compare the results of subclavian artery percutaneous transluminal angioplasty/stenting. Patient Population and Methods: Fifty-one patients with symptomatic subclavian artery disease (40 occlusions and 11 stenoses) who were treated with carotid-subclavian bypass grafts (PTFE [Goretex]) during a 20-year period were analyzed. Graft patency was determined clinically and confirmed with Doppler scanning pressures and duplex ultrasound scanning. The cumulative patency, overall survival, and symptom-free survival rates were calculated with the life table method. Results: Indications for surgery were arm ischemia in 34 patients (67%), vertebrobasilar insufficiency (VBI) in 27 (53%), and symptomatic subclavian steal in 7 (14%). A combination of arm ischemia and VBI occurred in 17 (33%) of these patients. The mean follow-up was 7.7 years with a median of 7.0 years (range, 1-19 years). The 30-day morbidity rate was 6%, with no perioperative stroke or mortality. Immediate relief of symptoms was achieved in 100% of patients; however, four patients (8%) had late recurrent symptoms (three with VBI). The primary patency and secondary patency rates at 1, 3, 5, and 10 years were 100%, 98%, 96%, and 92% and 100%, 98%, 98%, and 95%, respectively. The symptom-free survival rates at 1, 3, 5, and 10 years were 100%, 96%, 82%, and 47%, respectively. The overall survival rates at 1, 3, 5, and 10 years were 100%, 98%, 86%, and 57%. The mean hospital stay was 3.5 days in the late 70s and 80s and 2.1 days in the 90s (P <.001). Conclusions: Carotid-subclavian bypass grafts with PTFE grafts for subclavian artery disease are safe, effective, and durable and should remain the procedure of choice, particularly in good-risk patients. (J Vasc Surg 2000;32:411-9.)

Elective surgical treatment of symptomatic chronic mesenteric occlusive disease: Early results and late outcomes

Purpose: The purpose of this study was to determine the safety and efficacy of the elective surgical treatment of symptomatic chronic mesenteric occlusive disease (SCMOD) and to identify the factors that influence the results of this procedure. Methods: From 1977 to 1997, 85 patients (mean age, 62 years) underwent elective surgical treatment of SCMOD. The presenting symptoms were abdominal pain in 78 patients (92%) and weight loss in 74 patients (87%). The surgical procedures included retrograde bypass grafting in 34 patients (40%), antegrade bypass grafting in 24 patients (28%), transaortic endarterectomy in 19 patients (22%), local arterial endarterectomy with patch angioplasty in six patients (7%), thrombectomy alone in one patient (1%), and superior mesenteric artery reimplantation in one patient (1%). Thirty-five patients (41%) underwent concomitant aortic replacement. All the involved mesenteric vessels were revascularized in 21 patients (25%), whereas revascularization was incomplete for the remaining 64 patients (75%). Late information was available for all 85 patients at a mean interval of 4.8 years. Results: There were seven early (<35 days) postoperative deaths (8%). The cumulative 5-year survival rate was 64% (95% confidence interval [CI], 53% to 75%), and the 3-year symptom-free survival rate was 81% (95% CI, 72% to 90%). Serious complications occurred in 28 patients (33%). The results of univariate analysis identified advancing age at operation ( P < .001), cardiac disease ( P = .03), hypertension ( P = .03), and additional occlusive disease ( P = .05) as variables associated with mortality. Concomitant aortic replacement ( P = .037), renal disease ( P = .011), advancing age ( P = .035), and complete revascularization ( P = .032) were associated with postoperative morbidity including mortality. Late recurrent mesenteric occlusive disease was seen in 21 patients (16 symptomatic and five asymptomatic). Nine patients (43%) died, and 8 patients (38%) required subsequent surgical or endovascular procedures to treat their recurrent lesions. The 3-year survival rate from recurrent mesenteric occlusive disease was 76% (95% CI, 66% to 86%). Conclusion: We conclude that the elective surgical treatment of SCMOD may be performed with reasonable early and late mortality rates and that most of the patients remain free from recurrent symptoms of mesenteric ischemia. Advancing age, cardiac disease, hypertension, and additional occlusive disease significantly influenced the overall mortality rates, and concomitant aortic replacement, renal disease, and complete revascularization were significantly associated with postoperative morbidity rates. Surveillance and appropriate correction of recurrent disease appear to be necessary for optimal long-term results. (J Vasc Surg 1999;29:821-32.)

Effective long-term palliation of symptomatic, incurable metastatic medullary thyroid cancer by operative resection.

To evaluate the short- and long-term consequences of palliative reresection of specific symptomatic lesions in patients with widely disseminated (incurable) medullary thyroid cancer (MTC). Although reoperative neck microdissections can normalize calcitonin levels in patients with metastatic MTC confined to regional lymph nodes, there is no curative therapy for widely metastatic disease. However, these patients frequently have prolonged survival, but often with debilitating symptoms. Between October 1981 and January 1997, 16 patients (mean age, 46 +/- 3 years; 10/16 female) underwent 21 palliative reoperations for unresectable MTC at the Johns Hopkins Hospital. All patients had significant symptom(s) or impending compromise of vital structures by a discrete lesion and had unequivocal preoperative evidence of a total disease burden that was unresectable. The mean interval from initial thyroidectomy to palliative surgery was 5.8 +/- 1.5 years. All patients had significant tumor burdens as evidenced by preoperative calcitonin values ranging from 900 to 222,500 pg/mL (nL < or = 17 pg/mL). The palliative operations consisted of reoperative neck dissection/mass excision (11), mediastinal mass resection (4), esophagectomy (1), liver trisegmentectomy (1), sigmoidectomy (1), bilateral simple mastectomies (1), pituitary resection (1), and subcutaneous mass excisions (1). All but two of the operative specimens contained MTC. There was no perioperative mortality. The long-term morbidity rate was limited to one recurrent laryngeal nerve injury. All patients had initial relief of the index symptom(s) after the palliative surgery, followed by a median actuarial symptom-free survival rate of 8.2 years. Patients with widely metastatic MTC often live for years, but many develop symptoms secondary to tumor persistence or progression. Judicious palliative, reoperative resection of discrete, symptomatic lesions can provide significant long-term relief of symptoms with minimal operative mortality and morbidity. In selected patients with metastatic MTC lesions causing significant symptoms or physical compromise, palliative reoperative resection should be considered despite the presence of widespread incurable metastatic disease.

Reoperation for recurrent chronic visceral ischemia

Purpose: Recurrent visceral ischemia after a failed visceral revascularization occurs in up to one third of patients, yet no comprehensive report has described the management of this problem. The purpose of this study was to examine the presentation, surgical management, and outcome of patients with recurrent visceral ischemia. Methods: Between 1959 and 1997, 109 patients underwent primary visceral revascularization at the University of California, San Francisco. Nineteen patients (17.4%) had recurrent visceral ischemia (12 chronic visceral ischemia, seven acute visceral ischemia). Fourteen additional patients with recurrent chronic visceral ischemia were referred after failed primary revascularization (two patients underwent multiple operations before referral). Thirty visceral reoperations were performed for recurrent visceral ischemia in 24 patients (10 patients with recurrence at University of California, San Francisco, 14 referred patients). Symptom-free and overall survival rates were determined by life table analysis. Results: Of seven patients (6.4%) who had recurrent acute visceral ischemia, six (85.7%) died of bowel infarction. Twelve patients (11%) had recurrent chronic visceral ischemia. Patients with recurrent chronic visceral ischemia received their diagnoses earlier and lost less weight than at their initial presentation ( p = 0.004 and 0.001, respectively). Recurrent ischemia was associated with younger age, greater weight loss, and modification of surgical technique at the time of initial operation ( p = 0.5, 0.009, and 0.02, respectively). For 20 (90.9%) of the 22 first reoperations, antegrade aortovisceral bypass (n = 10) or transaortic visceral endarterectomy (n = 10) was used. Multiple techniques (four antegrade bypass, two retrograde bypass, one endarterectomy, one anastomotic revision) were used in the eight second or third reoperations. Postoperative mortality and complication rates were 6.7% and 33.3%, respectively. Symptoms recurred in six of 22 patients (27.3%) after the first reoperation, three of whom were cured or improved after additional reoperations. The life table symptom-free survival rate after reoperation was 77.3% and 62.8% at 1 and 5 years, respectively. The life table overall survival rate after reoperation was 74.6% at 5 years. Conclusions: Recurrent visceral ischemia is not uncommon after primary visceral revascularization. These results show that reoperation for recurrent chronic visceral ischemia can be accomplished safely and effectively with established revascularization techniques. Furthermore, after repeat visceral revascularization patients achieve durable relief of symptoms and have life expectancy rates comparable with those of patients who undergo primary visceral revascularization. (J Vasc Surg 1998;27:276-86.)

Current results of surgical therapy for chronic mesenteric ischemia.

Although recognition of chronic mesenteric ischemia has increased in recent years, this disorder has continued to present diagnostic and therapeutic challenges. To examine the modern results of surgical revascularization for chronic mesenteric ischemia. Retrospective review. University medical center. The management of 24 consecutive patients (mean +/- SEM age, 58 +/- 3 years; 5 men, 19 women) who were undergoing surgical treatment of chronic mesenteric ischemia between 1986 and 1996 was reviewed. Surgical mesenteric revascularization. Postoperative course, long-term graft patency rate, and long-term symptom-free survival rate. The most frequent presenting symptoms were postprandial abdominal pain (18 patients [75%]) and weight loss (14 patients [58%]). Less specific complaints included nausea and vomiting (8 patients [33%]), diarrhea (7 patients [29%]), and constipation (4 patients [17%]). Atherosclerotic risk factors were common, including tobacco use (20 patients [83%]), coronary artery disease (10 patients [42%]), and hypertension (10 patients [42%]). The cause was identified as atherosclerosis in 21 patients, median arcuate ligament compression in 2 patients who were monozygotic twins, and Takayasu arteritis in 1 patient. Lesions were localized to all 3 major visceral vessels (celiac artery, superior mesenteric artery [SMA], and inferior mesenteric artery) in 8 patients, celiac artery and SMA in 13, SMA alone in 2, and SMA and inferior mesenteric artery in 1. Seventeen patients underwent antegrade reconstructions from the supraceliac aorta to the SMA and/or celiac artery; 7 patients underwent revascularization by use of a retrograde bypass that originated from the infrarenal aorta or a prosthetic graft. There were no perioperative deaths although 1 patient died in the hospital 6 weeks after early graft failure and sepsis (overall in-hospital mortality, 4%). Follow-up ranged from 3 months to 10 years (median, 2.4 years). The mean +/- SEM 5-year primary graft patency rate, as objectively documented by use of contrast angiography or duplex scanning in 19 of 24 patients, was 78% +/- 11%. Primary failure was documented in 3 patients (at 3 weeks, 5 months, and 7 months). Two patients required a thrombectomy; 1 of these patients subsequently died of an intestinal infarction. The mean +/- SEM 5-year survival rate by use of life-table analysis was 71% +/- 11%. No patient with a patent graft experienced a symptomatic recurrence. Chronic mesenteric ischemia is usually a manifestation of advanced systemic atherosclerosis. Symptoms almost always reflect midgut ischemia in the distribution of the SMA. An antegrade bypass from the supraceliac aorta can be performed with acceptable operative morbidity and is currently the preferred reconstructive technique. Surgical revascularization affords long-term symptom-free survival in a majority of patients with chronic mesenteric ischemia.

Carotid-subclavian bypass for brachiocephalic occlusive disease. Choice of conduit and long-term follow-up.

Atherosclerotic disease of the proximal brachiocephalic circulation may produce disabling symptoms referable to cerebral or upper extremity hypoperfusion and embolization. Bypass of occlusive lesions can provide durable relief of symptoms with minimal complications. The ideal conduit for carotid-to-subclavian and subclavian-to-carotid bypass remains controversial, and it is not clear whether the outflow vessel influences patency and survival. We performed a retrospective analysis of 60 consecutive carotid-to-subclavian and subclavian-to-carotid bypass procedures. Occlusive lesions were documented preoperatively by arteriography. Patency was determined during follow-up by ultrasound or duplex examination. Actuarial patency, symptom-free survival, and overall survival rates were calculated by the life-table method and analyzed by log-rank test. Arterial transposition demonstrated the highest long-term patency rate (100.0 +/- 0.0%). Polytetrafluoroethylene grafts demonstrated the highest bypass graft patency rate (95.2 +/- 4.6%), followed by Dacron grafts (83.9 +/- 10.5%) and saphenous vein grafts (64.8 +/- 16.5%). Symptom-free survival paralleled patency rates, but these differences did not achieve statistical significance. While there were no differences in patency or symptom-free survival by outflow vessel, the overall survival of patients with common carotid lesions was significantly lower than that of patients with subclavian lesions (62.7 +/- 12.8% versus 100.0 +/- 0.0%; P < .05). The outflow vessel does not affect long-term patency in carotid and subclavian bypass procedures; however, patients with common carotid disease demonstrate significantly poorer long-term survival. Transposition results in superior long-term patency, with a trend toward lower results for synthetic grafts and relatively poor results for autogenous vein grafts.