Chiriano J, Molkara AM, Teruya TH, Abou-Zamzam AM Jr. "Acute cholangitis secondary to hepatic artery aneurysm and acute aortic dissection: A case report." Surgical Rounds . (2007): -.

Purpose: In an aging population with significant co-morbidities, primary major amputations (below-knee or above-knee) are frequently performed despite advances in revascularization. A prospective analysis of patients presenting with critical limb ischemia (CLI) was undertaken to determine whether patient-specific factors or health care delivery factors (system-related) influenced treatment with primary amputation (Amp) versus lower extremity revascularization (LER). Methods: A prospective study of all patients presenting to a university vascular service over a four-year period was undertaken. Patient-specific factors: age, gender, ethnicity, presence of coronary artery disease, cerebrovascular disease, tobacco use, diabetes mellitus (DM), dialysis-dependence (ESRD), hypertension, hyperlipidemia, stage of CLI (rest pain, tissue loss), location of foot lesion (forefoot, hindfoot), history of revascularization, and functional status (living situation and ambulatory status) were recorded. The system-related factors: time from onset of CLI to vascular surgery evaluation; and type of insurance (managed care/other insurance) were also noted. The influence of these patient-specific and system-related factors on the primary treatment modality (Amp versus LER) was determined with univariate and multivariate analysis. Results: A total of 224 patients presented with CLI between March 1, 2001 and March 1, 2005. Patients were treated with primary major amputation in 97 cases (43%) and revascularization in 127 cases (57%). On univariate analysis, non-white ethnicity/race, DM, ESRD, tissue loss, dependent living situation, and nonambulatory status were all significant predictors of Amp versus LER (all p

Chronic use of ergot alkaloids has been recognized as a rare cause of lower extremity ischemia. Most patients with ergot toxicity present with symptoms of lower extremity claudication. Herein we present a woman with bilateral lower extremity rest pain and a history of chronic ergot use for migraine headaches. Arteriography demonstrated extensive pruning of the distal arterial tree along with bilateral external iliac artery dissections - a finding that is not often associated with young, normotensive patients who present with chronic ergot toxicity. This patient was treated with endovascular stenting of the dissections along with cessation of ergot. Her symptoms improved markedly, and follow-up arteriography 6 weeks later demonstrated resolution of the iliac dissections along with restoration of nearly-normal lower extremity runoff vessels. Discontinuation of ergot-containing products and cessation of tobacco and caffeine use are the cornerstone of therapy in chronic ergot toxicity. The association of ergot toxicity and iliac dissection has not been previously described. Endovascular or surgical interventions may be considered in patients with ergot toxicity for specific indications or those whose symptoms progress despite conservative management.

Abstract Purpose: Carotid artery interventions are predicated on favorable early and late patient survival to provide the patients with the benefit stroke prevention. The technical feasibility and short-term results of carotid artery stenting (CAS) are clear. The longterm protective benefits of CAS, however, are less established, especially in the high-risk patients. Analysis of the mid-term results of CAS in our high-risk protocol was undertaken to determine the specific and all-cause mortality rate beyond 30 days. Methods: Retrospective evaluation of a prospective carotid artery stent registry from October 2003 to February 2006. Demographics, high-risk indication, presence of carotid symptoms, prior history of cancer, peri-procedural success, and complications were recorded. Freedom from stroke, all-cause and specific mortality rates were determined. Results: During the study, 50 patients with critical internal carotid stenosis (mean stenosis 90%) underwent CAS. This cohort met high-risk criteria due to physiologic reasons in 26 patients and anatomic factors in 22 cases. Two patients meet both criteria. Indications for CAS were symptomatic disease in 14 (28%) and asymptomatic in 36 cases. The overall 30-day stroke, MI and death rate was 2%. No minor or major strokes were recorded within 30 days. Average follow up was 11 months (2-28 months). Oneyear freedom from stroke was 93%. One-year survival was 75% for all patients and significantly higher for the asymptomatic group versus the symptomatic group (88% vs. 51%, p