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Diagnosis and Management of Arterial Thoracic Outlet Syndrome (TOS).

Jong Won KIM ; Jin Mo KANG ; Ik Jin YUN ; Tae Seung LEE ; Jongwon HA ; Sang Joon KIM

Journal of the Korean Society for Vascular Surgery.2004;20(2):224-231.

PURPOSE: Arterial TOS is a rare condition caused by compression of the subclavian artery at the thoracic outlet area, which is composed of the anterior and middle scalene muscles, the first rib and the clavicle. We have experienced four cases of arterial TOS and we reviewed them to determine the appropriate management of arterial TOS. METHOD: We reviewed the medical records of 26 patients who were diagnosed and managed for TOS at Seoul National University Hospital from 1985 to 2004. We reviewed the clinical manifestations, diagnostic tools, mode of management and the outcomes. RESULT: The four patients with arterial TOS, 3 males and 1 female, had an average age of 41.3 years (range: 30~53 years). They complained of a tingling sense, coldness, weakness, and cyanosis of affected limb, and a gangrenous finger. They were diagnosed with CT angiography, conventional angiography and Doppler US. The findings were stenotic artery segments, post- stenotic dilatation and luminal thrombi of the subclavian artery. Two of them showed multiple peripheral arterial embolic obstructions and numerous collateral vessels. Three patients with arterial TOS underwent surgery. The operation consisted of the excision of the bony abnormality and the scalene muscle, segmental resection of subclavian artery including the aneurismal dilatation, interposition of a saphenous vein graft, and thromboembolectomy. Their symptoms improved after restoration of blood circulation, but the gangrenous finger required amputation. CONCLUSION: Arterial TOS has the definite risk of limb loss. If there is a high clinical suspicion of this lesion, early diagnosis and confirmation by angiogram may be critical to prevent limb loss. Surgical revascularization provides satisfactory results for limb salvage with low operative morbidity.
Amputation ; Angiography ; Arteries ; Blood Circulation ; Clavicle ; Cyanosis ; Diagnosis* ; Dilatation ; Early Diagnosis ; Extremities ; Female ; Fingers ; Humans ; Limb Salvage ; Male ; Medical Records ; Muscles ; Phenobarbital ; Ribs ; Saphenous Vein ; Seoul ; Subclavian Artery ; Thoracic Outlet Syndrome* ; Transplants

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Surgical Treatment of Traumatic Aortic Rupture.

Kuk Hui SON ; Joung Taek KIM ; Hyun Tae KIM ; Kyoung SUN ; Yong Han YOON ; Kwang Ho KIM ; Wan Ki BAEK

Journal of the Korean Society for Vascular Surgery.2004;20(2):219-223.

PURPOSE: The thoracic aortic rupture due to a blunt thoracic trauma is a fatal condition and majority of affected patients die before arriving at the hospital. The purpose of this study was to report our experiences of the traumatic thoracic aortic rupture. METHOD: Between January 1998 and September 2002, 6 patients with traumatic aortic rupture were experienced at out institute. All the patients had been involved in a traffic accident. There were 5 males and a female with mean age 29.8+/-7.0 years, ranging from 18 to 36 years. Preoperative chest CT and aortography confirmed the thoracic aortic rupture around the aortic isthmus in all patients. One patient died while waiting for an operation. The records of the remaining 5 patients that undergone an urgent operation were retrospectively reviewed. RESULT: There was no operative mortality. The mean aortic cross clamp time was 67.6+/-14.7 minutes. The injured portion of the thoracic aorta was just below the aortic isthmus in all cases which was resected and replaced with an artificial vascular graft. Various kinds of distal perfusion technique were employed: left atrial to femoral artery bypass in 3, Gott's shunt in 1, and femoro-femoral bypass with hypothermic circulatory arrest also in 1 patient. No signs of spinal cord injury developed postoperatively. All patients are in good clinical condition for 4 to 47 months postoperatively. CONCLUSION: Favorable outcomes could be anticipated in patients with a descending aortic rupture due to blunt thoracic trauma, if prompt diagnostic work up and surgical treatment are applied. The surgical results are thought to be improved with the employment of the distal perfusion technique, thus avoiding distal ischemia.
Accidents, Traffic ; Aorta, Thoracic ; Aortic Rupture* ; Aortography ; Employment ; Female ; Femoral Artery ; Humans ; Ischemia ; Male ; Mortality ; Perfusion ; Retrospective Studies ; Spinal Cord Injuries ; Tomography, X-Ray Computed ; Transplants

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Clinical Results of Abdominal Aortic Aneurysm from the Preoperative States.

Kwangjo CHO ; Jongsu WOO

Journal of the Korean Society for Vascular Surgery.2004;20(2):214-218.

PURPOSE: Abdominal aortic aneurysm is a complex disease that has too many clinical manifestations for classifying these patients as the ruptured and nonruptured groups. To evaluate the effect of the patients preoperative status to the surgical outcomes, the authors classified the abdominal aortic aneurysm patient's into four groups according to their preoperative status and we studied their outcomes. METHOD: Between 1992 and 2004, 117 patients underwent abdominal aortic surgery. Among the patients, 47 asymptomatic abdominal aortic aneurysm patients were classified as group I. 34 abdominal aortic aneurysm patients with abdominal pain were classified as group II. 20 ruptured abdominal aortic aneurysm patients without hemodynamic instability were classified as group III. 16 ruptured abdominal aortic aneurysm patients with hemodynamic instability were classified as group IV. We then analysed their clinical outcomes retrospectively. RESULT: Group IV received the highest number of transfusions and they showed the highest incidence of postoperative ARDS and the highest mortality rate. Group III received more transfusions and they showed a higher incidence of ARDS than Group I and II, but they had the lowest mortality rate. There were no significant differences in the transfusion amount, complication and mortality between Group I and II. CONCLUSION: Massive transfusion causes postoperative ARDS and multiorgan failure and this causes death for patients with ruptured abdominal aortic aneurysm. Preoperative hemodynamic instablity is a definite factor for massive transfusion, whitch causes ARDS and death.
Abdominal Pain ; Aortic Aneurysm, Abdominal* ; Hemodynamics ; Humans ; Incidence ; Mortality ; Postoperative Complications ; Retrospective Studies

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The Risk Factors Influencing Postoperative Mortality in the Patients with Ruptured Abdominal Aortic Aneurysm.

Min Jeong CHO ; Hyuck Jin YOON ; Jin Young PARK ; Seung HUH ; Young Wook KIM

Journal of the Korean Society for Vascular Surgery.2004;20(2):208-213.

PURPOSE: The mortality rate for elective repair of abdominal aortic aneurysm (AAA) has gradually decreased to approximately 5%. However the mortality rate for ruptured AAA (RAAA) has not changed significantly and continues to be 45% to 50%, and the mortality rate exceeds 90% if deaths occurring before patients reach the hospital are included in the statistics. The aim of this study was to determine what factors are associated with operative death in patients with RAAA. METHOD: For January 1997 and December 2003, 35 patients underwent surgery for RAAA. The factors of the preoperative status included age, gender, history of loss of consciousness, mental change, hemodynamics, the serum creatinine level and the patients' comorbidities were analyzed. As for the aneurysmal factors, the site, etiology, maximal diameter and rupture status of the aneurysms were evaluated. Finally operative factors including the operation time and status, surgeon, type of grafting, renal dysfunction during operation and the amount of blood transfusion were also analyzed. As the statistical method, Fischer's exact test and multi-step logistic regression method were used. RESULT: The 30-day mortality rate was 17.1% (6/35). By univariate analysis, mental change, increased preoperative serum creatinine level (>2 mg/dl), intraoperative renal dysfunction, prolonged intraoperative hypotension over 30 minutes, the amount of transfusion, diameter of aneurysms and surgeon's experience were statistically significant. On multivariate analysis, the amount of transfusion and intraoperative renal dysfunction were defined as the significant risk factors. CONCLUSION: To reduce the operative mortality of RAAA, preventing massive bleeding and the subsequent acute renal failure by early operative control of bleeding, fluid resuscitation and maintenance of blood pressure are important.
Acute Kidney Injury ; Aneurysm ; Aortic Aneurysm, Abdominal* ; Blood Pressure ; Blood Transfusion ; Comorbidity ; Creatinine ; Hemodynamics ; Hemorrhage ; Humans ; Hypotension ; Logistic Models ; Mortality* ; Multivariate Analysis ; Resuscitation ; Risk Factors* ; Rupture ; Transplants ; Unconsciousness

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Correlations of Atherosclerotic Risk Factors and Carotid Artery Intima-media Thickness in Healthy Subjects.

Gui Ae JEONG ; Jeong Hwan CHANG ; Seong Hwan KIM ; Chul Gab LEE ; Dong Hyun KIM ; Young Chul KIM

Journal of the Korean Society for Vascular Surgery.2004;20(2):200-207.

PURPOSE: Atherosclerotic risk factors are highly associated with the progression and severity of cerebrovascular disease; the carotid artery intima-media thickness (IMT) correlates well with the known risk factors for atherosclerosis. The aims of this study are to evaluate the associations of the carotid artery IMT with the atherosclerotic risk factors and to determine the reference values of the carotid artery IMT in healthy subjects who were without cardiovascular symptoms. METHOD: Ultrasound high-resolution B-mode imaging of the carotid artery was performed in 273 subjects (168 men, 105 women). We investigated the mean carotid artery IMT and the correlation between the carotid artery IMT and the atherosclerotic risk factors. RESULT: The mean carotid artery IMT values were 0.70+/-0.25 mm in the common carotid artery, 0.61+/-0.15 mm in the internal carotid artery, 0.55+/-0.26 mm in the external carotid artery and 0.92+/-0.45 mm in the carotid bulb. The mean carotid artery IMT was significantly increased with increasing age (P<0.05), and particularly in males. Age, systolic and diastolic blood pressure, body mass index, total cholesterol and LDL cholesterol levels correlated with the mean carotid artery IMT. Especially, the presence of plaque (26 subjects) was correlated with the mean carotid artery IMT in the internal carotid artery (P<0.05) and bulb (P<0.01). CONCLUSION: This study revealed the correlation between the carotid artery IMT and the atherosclerotic risk factors; we also elucidated the reference values for the mean carotid artery IMT in healthy subjects who were without cardiovascular diseases and symptoms.
Atherosclerosis ; Blood Pressure ; Body Mass Index ; Cardiovascular Diseases ; Carotid Arteries* ; Carotid Artery, Common ; Carotid Artery, External ; Carotid Artery, Internal ; Cholesterol ; Cholesterol, LDL ; Humans ; Male ; Reference Values ; Risk Factors* ; Ultrasonography

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Inhibitory Effect of Inducible Nitric Oxide Synthase Gene Transfer on Intimal Hyperplasia and Fibronectin Expression Induced by Carotid Artery Denudation.

Bong Hyeon KYE ; Sun Young HONG ; Keun Ho YANG ; Sun Cheol PARK ; Jang Sang PARK

Journal of the Korean Society for Vascular Surgery.2004;20(2):192-199.

PURPOSE: Intimal hyperplasia is a pathologic condition that is commonly observed with the atherosclerotic change of blood vessels; this condition is usually observed after arterial operation and interventions such as angioplasty, endaterectomy and bypass grafting, and it remains a major cause for hindering for arterial patency. It is a multiple processes that includes smooth muscle cell migration, proliferation, and expression of extracellular matrix proteins, such as fibronectin. Nitric oxide (NO) has been found to possess many different vasoprotective properties: inhibition of platelet aggregation and adherence, inhibition of leukocyte chemotaxis, inhibition of vascular smooth muscle cell proliferation and migration, inhibition of endothelial cell apoptosis and stimulation of endothelial cell growth. Overexpression of nitric oxide synthase (NOS) in the vascular wall has been used to regulate vasomotor function, prevent neointimal formation after balloon injury or vein grafting, and to prevent transplant vasculopathy. NOS gene transfer to the vascular wall holds great promise as a means of controlling local vascular function. METHOD: We investigated whether the inducible NOS (iNOS) gene transfer to the arterial wall has an inhibitory effect on intimal hyperplasia after endothelial denudation and on the change of the level of extracellular matrix fibronectin expression in the rabbit common carotid artery. Rabbits were divided into three groups: the saline only (without injury) normal group, the injury + saline intima injury group, and the injury + recombinant adenoviral vector encording human iNOS (AdiNOS) gene transfer group (n=5 per group). AdiNOS (1.6x10(10) plaque-forming units [pfu]) were used for the iNOS gene delivery and the virus was intraluminally infected to the balloon-injured common carotid arterial wall for 20 minutes. The NO levels were assessed in the blood of all the animals at the three time point: before-, 1 hr after-, and 14 days after the surgical procedures. The left common carotid arteries were harvested from the animals at 14 days after balloon injury and they were then assessed for fibronectin expression and intimal hyperplasia. RESULT: 14 days after AdiNOS infection, the NO levels were increased 67% in the gene transfer group compared with those levels obtained before the gene transfer (333.5+/-11.5 vs. 557.4+/-72.1, respectively, P<0.05), and the intima/intima+media ratio and the FN expression were reduced by 60% and 50%, respectively, in the gene transfer group compared with the intima injury group (41.5+/-5.6 vs. 16.6+/-2.8, respectively, P<0.05 and 307.9+/-38.3 vs. 154.3+/-20.2, respectively, P<0.05). CONCLUSION: Our results show that iNOS gene transfer to the arterial wall resulted in increased NO levels in the blood, and the procedure greatly inhibited intimal hyperplasia and it reduced fibronectin expression in the arteriaql wall.
Angioplasty ; Animals ; Apoptosis ; Blood Vessels ; Carotid Arteries* ; Carotid Artery, Common ; Cell Proliferation ; Chemotaxis, Leukocyte ; Endothelial Cells ; Extracellular Matrix ; Extracellular Matrix Proteins ; Fibronectins* ; Humans ; Hyperplasia* ; Muscle, Smooth, Vascular ; Myocytes, Smooth Muscle ; Nitric Oxide ; Nitric Oxide Synthase ; Nitric Oxide Synthase Type II* ; Platelet Aggregation ; Rabbits ; Transplants ; Veins

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The Effect of Tissue Plasminogen Activator on Intimal Hyperplasia after Balloon Injury to Rat Aorta.

Jun Kyung LEE ; Woo Hyung KWUN ; Jong Sung HWANG ; Bo Yang SUH ; Koing Bo KWUN

Journal of the Korean Society for Vascular Surgery.2004;20(2):186-191.

PURPOSE: Thrombus formation enhances both neointima formation and clinical restenosis after vascular injury or angioplasty. Thrombotic occlusions and intimal hyperplasia limit the success of vascular reconstructive procedures. Thrombolysis is expected to improve the outcome for both restenosis and acute arterial occlusion after injury. Tissue-type plasminogen activator (tPA) is commonly used clinically, and it is thought to play a critical role in vascular remodeling by mediating intravascular clot lysis and modulating cell migration within the vessel wall. However, there is controversy about the late effects of tPA on the vascular lumen either for preventing or enhancing intima hyperplasia in vivo. Thus, this study was done to evaluate the impact of a clinical infusion of tPA on the neointima formation after a balloon injury. METHOD: Forty male Sprague- Dawley rats weighting of 250~300 gm each were underwent aortic intimal denuation with a 2F balloon catheter. The rats were divided into two groups: the control group (n=20: normal saline infusion), and the*ean IMAR on the 21st day was 1.14+/-0.16 in the control group and 1.10+/-0.11 in the experiment group. The mean IMAR was lower in the experiment group, but the result was not statistically significant. In comparison to the gelatinolytic activity of MMP-9 and, activated MMP-2, there was no significant difference between the two groups. CONCLUSION: These results suggest that the effect of tPA on intimal hyperplasia after balloon injury to rat aorta showed minimal significance.
Angioplasty ; Animals ; Aorta* ; Catheters ; Cell Movement ; Humans ; Hyperplasia* ; Male ; Negotiating ; Neointima ; Rats* ; Thrombosis ; Tissue Plasminogen Activator* ; Vascular System Injuries

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Presidential Address: Past, Present, and Future of Vascular Surgery (I) Control of Massive Exsanguinating Bleeding from Liver Injury in Shock (II) Management of Traumatic Pancreatic Transection (III) Traffic Injuries in Passenger Cars. -Comments on Seatbe.

Jin Sun BAE

Journal of the Korean Society for Vascular Surgery.2004;20(2):173-185.

No abstract available.
Anniversaries and Special Events* ; Hemorrhage* ; Liver* ; Shock*

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The Prevalence of Abdominal Cystic Lesion in Patients with Vascular Disease.

Young Nam ROH ; Hae Sol KIM ; Woo Sung YUN ; Ui Joon PARK ; Kyung Bok LEE ; Young Wook KIM ; Young Soo DO ; Kwang Bo PARK ; Hong Suk PARK ; Dong Ik KIM

Journal of the Korean Society for Vascular Surgery.2011;27(1):19-22.

PURPOSE: This study evaluated the prevalence of cystic disease in the intra-abdominal organs in a normal population and a group of patients with vascular disease. METHODS: We reviewed the medical records and computed tomography scans of the vascular disease group and the control group. Vascular disease group (n=586) were patients who suffered with abdominal aortic aneurysm (AAA), aorto-iliac occlusive disease (AOD) and peripheral arterial occlusive disease (PAOD) and who were treated in our institute. The control group (n=424) were patients who visited the health promotion center in our institute during the same period. RESULTS: The prevalence of abdominal cysts in the control group and the vascular disease group was 41.7% and 65.2%, respectively. The vascular disease group showed a higher prevalence of abdominal cystic lesion for all the specific vascular diseases. However, when the two groups were stratified according to age, the vascular disease group displayed no significant difference in the prevalence of abdominal cyst compared to that of the control group. CONCLUSION: Abdominal cystic lesions are common in patients with vascular disease, including AAA, AOD, and PAOD. But this high prevalence of abdominal cystic lesions seems to be associated with the advanced age of vascular disease patients. Further molecular-based research is needed to clarify the pathogenetic relationship between vascular disease and abdominal cystic lesions.
Aortic Aneurysm, Abdominal ; Arterial Occlusive Diseases ; Health Promotion ; Humans ; Medical Records ; Prevalence ; Vascular Diseases

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The Effects of the Preoperative Serum Homocysteine Level on Restenosis after Infraninguinal Bypass Surgery or Endovascular Surgery for Peripheral Arterial Disease.

Shin Hyuk KIM ; Oh Jung KWON

Journal of the Korean Society for Vascular Surgery.2011;27(1):14-18.

PURPOSE: Hyperhomocysteinemia is accepted as an independent risk factor for peripheral arterial disease (PAD). The purpose of this study is to evaluate the correlation between the preoperative plasma homocysteine concentration and restenosis after therapeutic revascularization. METHODS: We retrospectively analyzed the clinical records of 58 consecutive patients (they were confined to Trans Atlantic Inter-Society Consensus [TASC] type C & D) among 103 patients who were diagnosed as having infrainguinal PAD and who were treated with bypass surgery or endovascular surgery from July 2003 to July 2009. We analyzed the effect of several factors such as gender, age, the plasma lipid profile and the protein C, protein S, fibrinogen, C-reactive protein, diabetes mellitus, hypertension, ankle-brachial index (ABI), and homocysteine levels, which are all considered to be risk factors for restenosis. Multivariate and univariate analyses were performed to assess the effect of possible confounders. RESULTS: The subjects were 50 men and 8 women (mean age: 63.8+/-10.9). There were 33 (56.9%) cases of bypass surgery and 25 (43.1%) cases of endovascular surgery. Of them, 19 cases (32.8%) showed restenosis after revascularization. In the patients with restenosis, 18 cases (94.7%) showed a preoperative high plasma homocysteine level and 1 case (5.2%) showed a normal level. A lower ABI and hyperhomocysteinemia were significantly more common in the patients with restenosis (P=0.025, P<0.001). There were no significant differences of the other factors, except for the plasma homocysteine level on multivariate analysis (P=0.001). CONCLUSION: We can regard the preoperative hyperhomocysteinemia level as a predictive marker of restenosis after revascularization. Special attention may need to be given to the patients who have a lower preoperative ABI and hyperhomocysteinemia after revascularization.
Ankle Brachial Index ; C-Reactive Protein ; Consensus ; Diabetes Mellitus ; Female ; Fibrinogen ; Homocysteine ; Humans ; Hyperhomocysteinemia ; Hypertension ; Male ; Multivariate Analysis ; Peripheral Arterial Disease ; Plasma ; Protein C ; Protein S ; Retrospective Studies ; Risk Factors

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