Papers by John Iliopoulos
The Annals of Thoracic Surgery, 2002
We read with interest the recent article by Ascione and associates [1]. Although we agree in prin... more We read with interest the recent article by Ascione and associates [1]. Although we agree in principle with one-stage treatment of combined coronary and abdominal diseases, we have serious reservations regarding the surgical strategy followed. We refer to the adverse hemodynamic effects imposed on the myocardium by suprarenal aortic clamping (and unclamping) during abdominal aortic aneurysm (AAA) resection. It has been documented that this maneuver causes serious and adverse alterations in diastolic and systolic myocardial function [2, 3]. With that in mind, we devised a protocol in 11 patients with the dual pathological process. If the preoperative evaluation (angiographic, viability, and echocardiographic studies) suggests that optimal myocardial recovery can be expected, AAA resection followed the open heart surgical procedure (with or without cardiopulmonary bypass [CPB]). When CPB is used, the patient is weaned from CPB, half of the protamine sulfate is given, the aortic cannula remains in place, and AAA resection follows-a "wean and resect" strategy. On the other hand, if the immediate postoperative myocardial function is expected to be questionable or problematic (eg, bad targets, ischemic cardiomyopathy, or diastolic dysfunction from valvular heart disease), AAA resection is performed after the cardiac procedure but with the patient on CPB support-"resect on CPB" strategy. The hemodynamic and metabolic effects of suprarenal aortic clamping and unclamping are nullified by the CPB support, and myocardial recovery was uneventful in the 5 patients in the "resect on CPB" group. We were impressed by the safety and efficacy provided by CPB support in 2 patients in whom a huge (Ͼ9 cm) or a difficult (no neck) AAA was resected. Transesophageal echocardiography was used in all patients. There were no deaths and no major morbidity in this small series during a follow-up ranging from 9 to 46 months.
American Journal of Surgery, 1993
Thrombosis of the central venous system (CVT) occurs in 20% to 30% of patients with indwelling ca... more Thrombosis of the central venous system (CVT) occurs in 20% to 30% of patients with indwelling catheters. This complication is usually treated with anticoagulation, extremity elevation, and catheter removal. Thirty-eight patients with CVT at our institution were treated with thrombolytic therapy to rapidly resolve symptoms and avoid removal of the catheters. Complete clot lysis occurred in 36 of 38 patients (95%) within 1 to 5 days (mean: 2.4 days). Symptoms resolved with clot resolution. Thrombolytic therapy detected stenoses in 22 patients. Angioplasty was successful in 64% of these patients. Five catheters were removed. Complications occurred in six patients: nonfatal pulmonary embolus, three bleeding episodes, pain with infusion of urokinase, and an episode of septic phlebitis. This experience suggests that thrombolytic therapy is safe, rapidly resolves symptoms of thrombosis, uncovers anatomic abnormalities amenable to angioplasty, and allows central venous catheters to remain in place despite central venous thrombosis.
American Journal of Surgery, 1991
Twelve patients underwent tramabdominal, supra eeliac aortomesenteric bypaM for eeliac and superi... more Twelve patients underwent tramabdominal, supra eeliac aortomesenteric bypaM for eeliac and superi or mesenteric artery occlusive disease. Nine patients bad b ypaM for intestinal ischemia (live acute. four chronic) , and one patient each bad bypa88 for areu ate ligament syndrome, tboracoabdominal aneu � and an infected aortic stump "blowout." Three aortoeeliac, 9 aortohe pa tic, and 10 aorto8u perior mesenteric artery bypa88e8 were performed. Prosthetic graf'ts were used for the bypa88e8 in 11 of the 12 pa tients. One death occurred in a pa tient with preexisting he pa tic necrosis and renal failure secondary to acute mesenteric ischemia. During a mean follow-up of 26 months, one graft thrombosis occurred and required revision for recurrent symp toms. Supraeeliac aortomesenteric bypaM appears to be a safe and effective procedure for visceral re vucularition.
Journal of Vascular Surgery, 1990
The purpose of this study was to determine the significance of collateral supply from the hypogas... more The purpose of this study was to determine the significance of collateral supply from the hypogastric arteries (HGAs) to the inferior mesenteric arterial (IMA) bed. Peak systolic "stump" IMA and radial arterial pressures were obtained before and after clamping the right HGA, the left HGA, both HGAs, the middle colic artery (MCA) only, or the MCA plus right HGA, MCA plus left HGA, and MCA plus both HGAs in patients with aortoiliac aneurysm or occlusive disease. Six patients (four with aneurysms and two with occlusive disease) had patent IMAs. Five patients (four with aneurysms and one with occlusive disease) had chronically occluded IMAs. In the six patients with patent IMAs, clamping of the HGAs decreased the IMA-stump pressure index (IMA-SPI) from 0.61 +/- 0.20 to 0.56 +/- 0.17, 0.54 +/- 0.17, and 0.54 +/- 0.19, respectively (p greater than 0.05) whereas clamping only the MCA decreased the IMA-SPI from 0.61 +/- 0.20 to 0.32 +/- 0.15 (p less than 0.01). In the five patients with chronically occluded IMAs, clamping of the HGAs decreased the IMA-SPI from 0.60 +/- 0.11 to 0.59 +/- 0.12, 0.58 +/- 0.12, and 0.57 +/- 0.11, respectively (p greater than 0.05), whereas clamping the MCA decreased the IMA-SPI from 0.60 +/- 0.11 to 0.34 +/- 0.04 (p less than 0.01). These data suggest that branches of the superior mesenteric artery provide the major collateral pathway to the IMA bed and that the contribution through branches of the HGAs is insignificant in the acute setting.
American Journal of Surgery, 1989
Primary hypercoagulable states are increasingly recognized as causes of venous and arterial throm... more Primary hypercoagulable states are increasingly recognized as causes of venous and arterial thromboembolism in surgical patients. Herein, we describe 10 patients with this syndrome who were diagnosed during a recent 1-year period. A family history and past medical history of thromboembolism and an unusual site of thrombosis are emphasized for accurate diagnosis. Although antithrombin III deficiencies were the most common abnormality found, we describe three patients with hypofibrinolytic syndromes and increased levels of tissue plasminogen activator inhibitor. The effectiveness of anticoagulation therapy in preventing recurrent thromboembolism is stressed.
Journal of Vascular Surgery, 1989
Reports of all cervicocephalic arteriograms (n = 1836) performed at one institution during a 10-y... more Reports of all cervicocephalic arteriograms (n = 1836) performed at one institution during a 10-year period were reviewed and the patients were classified into three groups according to the indication for arteriography. Group I included all patients with symptoms or findings compatible with occlusive disease of the carotid or vertebral artery (n = 806). Group II included patients with cerebrovascular symptoms unrelated to carotid or vertebral disease (e.g., patients with subarachnoid hemorrhage) (n = 367). Group III consisted of patients with no evidence of cerebrovascular disease (e.g., patients with primary and metastatic brain tumors) (n = 663). One hundred ten atherosclerotic occlusions of the internal carotid artery (ICA) were found in 106 patients in group I. Fifty-one percent of these patients had a history of stroke before arteriography, 24% had transient ischemic attacks (TIAs) or amaurosis fugax (AF), and 12% had nonhemispheric symptoms. Only 13% (1.7% of group I patients) were without symptoms. Ninety-one percent of the strokes and 75% of the TIAs or AF were ipsilateral to the ICA occlusion. Seventy-six percent of patients with stroke and 80% with ipsilateral TIAs or AF vs only 29% of patients without symptoms had contralateral stenosis of 60% diameter reduction or greater (p less than 0.003). No occlusions of the ICA occurred in groups II or III. Three hundred forty-six patients in groups II and III were more than 60 years of age. Assuming either Poisson or binomial distributions, the incidence of silent ICA occlusion in the population at large older than 60 years was estimated at less than 1% (p less than 0.03).
Journal of Vascular Surgery, 1989
This study was designed to assess the major sources of collateral supply to the hypogastric arter... more This study was designed to assess the major sources of collateral supply to the hypogastric arterial bed (HGA). Peak systolic HGA and radial arterial pressure were obtained before and after clamping a patent HGA and after additional clamping of the contralateral HGA, the contralateral external iliac artery (EIA), or the ipsilateral EIA both selectively and in combinations. These procedures were performed in 10 patients with aortoiliac (AI) aneurysms or occlusive disease. In seven patients with aneurysms, clamping the contralateral HGA decreased the HGA stump pressure index from 0.57 to 0.49 (p less than 0.05), and clamping only the ipsilateral EIA decreased the stump pressure index to 0.38 (p less than 0.001). In three patients with occlusive disease, clamping the contralateral HGA did not decrease the stump pressure index, clamping both the contralateral HGA and EIA decreased the index from 0.61 to 0.57 (p greater than 0.05), and clamping only the ipsilateral EIA decreased the pressure index to 0.40 (p less than 0.01). These data suggest that branches of the ipsilateral EIA femoral arterial system provide a more significant collateral pathway than the contralateral HGA. These results suggest that it is important to relieve occlusive disease in the ipsilateral EIA femoral arterial system if a patent HGA is ligated or bypassed during AI reconstructions. Conversely, it is especially important to preserve forward perfusion in a patent HGA in a patient with compromised ipsilateral EIA femoral runoff.
Kansas Medicine, 1988
City I : °EL.VIC NEURll.EoMA is an extremely rare tumor, • ,'lith only twenty tumors reported tha... more City I : °EL.VIC NEURll.EoMA is an extremely rare tumor, • ,'lith only twenty tumors reported that fulfill the diagnostic criteria established by Stout in 1935.' Kemmann and associates 2 reported 13 collected cases; however, most reports concern single pa tients. The authors report an additional case which highlights the difficulties of diagnosis and the po tential hazards of treatment. A patient with a solitary benign pelvic neurilemmoma is presented. The im-10rtant aspects of neurilemmomas are reviewed in .luding incidence, etiology, pathogenesis, diagno sis, and treatment. Case Report A 52-year-old white female nullipara was found to have an asymptomatic pelvic mass during a routine examination by her family physician. The only his tory of medical illness was for a non-toxic goiter rliagnosed 25 years previously and treated by hor : aone replacement therapy. She denied any previous operations. The family history was strongly positive for malignancy. Her father and two paternal aunts had acute lymphocytic leukemia, her maternal grandmother had breast cancer, and a maternal aunt had an unspecified gynecologic malignancy. The review of systems was positive for tinnitus of two years' duration. Physical exam showed a well de veloped, well nourished female of 175 cm. and 81.41 J ,:gm. Vital signs were within normal limits. Exter-� nal examination revealed an intermittent systolic murmur; otherwise, there were no abnormalities. Pelvic exam showed a 6xl0 cm. firm posterior mass separate from the uterus and adherent to the left pelvic sidewall. Sonography showed a solid 5x6 ' cm. mass. Cervical cytology and endometrial bi opsy were normal. Chest x-ray, IVP, barium enema,
American Journal of Surgery, 1988
Primary hypercoagulable states are increasingly recognized as causes of venous and arterial throm... more Primary hypercoagulable states are increasingly recognized as causes of venous and arterial thromboembolism in surgical patients. Herein, we describe 10 patients with this syndrome who were diagnosed during a recent 1-year period. A family history and past medical history of thromboembolism and an unusual site of thrombosis are emphasized for accurate diagnosis. Although antithrombin III deficiencies were the most common abnormality found, we describe three patients with hypofibrinolytic syndromes and increased levels of tissue plasminogen activator inhibitor. The effectiveness of anticoagulation therapy in preventing recurrent thromboembolism is stressed.
Surgical Clinics of North America, 1988
Twenty to thirty per cent of patients with arterial injuries and some patients with venous injuri... more Twenty to thirty per cent of patients with arterial injuries and some patients with venous injuries require interpositional grafting. The first choice of grafting material for both arterial and venous injuries is autogenous vein. Injuries to large vessels such as the aorta and superior vena cava may necessitate synthetic prostheses. Synthetic aortic prostheses have excellent long-term patency rates, but the same materials are much less likely to remain patent in the vena cava. Panel or spiral grafts constructed from saphenous vein appear to be the best replacement for this vessel. Autogenous veins are present in different diameters ranging from a mean of 6.4 mm in the saphenous vein to a mean of 1.8 cm in the internal jugular vein. The thickest autogenous vein is the saphenous vein, and thus it is preferred for medium-sized and small arteries. The authors prefer the larger 7.5-mm cephalic vein for replacement of medium-sized veins. In the absence of suitable saphenous vein, the cephalic vein is also the choice for arterial interposition grafts. Although there are few reports of the use of arterial autografts in vascular trauma, the surgeon should be aware that autografts may be ideal for vascular injuries in children and for isolated injuries with severe contamination. Finally, the use of synthetic grafts in injuries where adequate tissue coverage is not possible may result in immediate limb salvage, but the incidence of limb loss in this situation will be extremely high.
World Journal of Surgery, 1988
Splenocaval shunt is an option for selective portal decompression in patients who are not good an... more Splenocaval shunt is an option for selective portal decompression in patients who are not good anatomic candidates for distal splenorenal shunts because of massive hepatosplenomegaly and downward displace ment of the splenic vein. The proximity of the splenic vein to the inferior vena cava makes the construction of this type of shunt anatomically and hemodynamically advantageous over the standard Warren shunt in these cases.
American Journal of Surgery, 1987
Eleven patients had ischemic complications secondary to ligation, hypoperfusion, exclusion, or th... more Eleven patients had ischemic complications secondary to ligation, hypoperfusion, exclusion, or thrombosis of the hypogastric arteries after aortoiliac reconstruction or spontaneous aortoiliac thrombosis. Ligation of one hypogastric artery resulted in persistent ipsilateral buttock claudication in three patients. Bilateral acute hypogastric artery ischemia occurred in eight patients and resulted in paralysis in all eight patients, buttock necrosis in four patients, anal and bladder sphincteric dysfunction in two patients, and colorectal ischemia in three patients. Five of these patients (63 percent) died. The mortality rate was 100 percent when buttock necrosis developed. In most of these patients, the neurologic deficit suggested ischemic injury of the lumbosacral plexus rather than spinal cord ischemia. These complications occurred despite patent bypass grafts to the iliac or femoral vessels. These observations suggest that it is essential to maintain patency of the hypogastric vessels in all aortoiliac reconstructions.
American Journal of Surgery, 1987
Eighty-three patients receiving pentoxifylline for stable claudication were evaluated to identify... more Eighty-three patients receiving pentoxifylline for stable claudication were evaluated to identify factors associated with response to treatment. Patients with isolated aortoiliac occlusive disease and those with arterial occlusive disease of moderate severity were more likely to have an improvement in claudication distance.
American Journal of Surgery, 1986
Two hundred twenty-one patients undergoing thyroidectomy were analyzed for factors increasing the... more Two hundred twenty-one patients undergoing thyroidectomy were analyzed for factors increasing the risk of postoperative hypocalcemia. Eighty-three percent of all patients experienced hypocalcemia postoperatively, with 13 percent requiring some treatment for symptoms. Patients with advanced thyroid cancer, Graves' disease, or other manifestations of preoperative hyperthyroidism had significantly increased rates of hypocalcemia compared with patients with small cancers or benign euthyroid disease. Total thyroidectomy, repeat thyroidectomy, and thyroidectomy plus neck dissection all significantly increased the incidence of permanent hypocalcemia, whereas lobectomy or subtotal thyroidectomy for benign euthyroid disease were low risk operations. Inadvertent excision of more than one parathyroid gland during thyroidectomy also significantly increased the rate of permanent hypocalcemia.
American Journal of Surgery, 1985
A review of 64 profundoplasties performed in conjunction with inflow procedures for multilevel va... more A review of 64 profundoplasties performed in conjunction with inflow procedures for multilevel vascular occlusive disease of the lower extremity revealed that the extent of deep femoral artery disease had a strong influence on results. Profundoplasty for proximal deep femoral artery disease resulted in an 80 percent success rate when carried out for claudication, and an approximately 65 percent success rate for limb salvage and in limbs with poor runoff. In contrast, profundoplasty for diffuse or distal deep femoral artery diseases resulted in a 62 percent success rate for claudication and decreased to approximately 20 percent for limb salvage or in extremities with poor runoff.
American Journal of Surgery, 1985
Arterial reconstruction in 50 consecutive male patients with aortoiliac aneurysmal or occlusive d... more Arterial reconstruction in 50 consecutive male patients with aortoiliac aneurysmal or occlusive disease was performed with PTFE bifurcation grafts. Follow-up intervals ranged from 1 to 39 months. All patients were evaluated by physical examination at 19.5 +/- 1.3 months. In addition, 46 patients were evaluated by ultrasonography at 18.2 +/- 1.2 months, 19 by angiography at 19.8 +/- 2.2 months, and 4 by computerized axial tomography at 21.5 +/- 5.2 months. Intraluminal thrombus or pannus was found in one graft in a patient with compromised outflow, but all graft limbs were patent. There were no accumulations of perigraft fluid, graft dilatations, or anastomotic aneurysms. The results of this study provide support for the continued use of PTFE bifurcation grafts for aortic reconstruction.
Surgery, 1985
The present study compares the hemodynamic effectiveness of closed-chest cardiac massage (CCCM) w... more The present study compares the hemodynamic effectiveness of closed-chest cardiac massage (CCCM) with closed subdiaphragmatic massage (CSDM) and four open transdiaphragmatic cardiac massage techniques during cardiac arrest with an open abdomen. In 10 dogs CCCM resulted in the lowest cardiac index (CI), mean arterial pressure (MBP), and carotid blood flow (CBF) of all cardiac massage techniques tested. CSDM was not statistically superior to CCCM in the dog (p greater than 0.05) but did result in a 23% increase in CI and a 54% increase in CBF. Transdiaphragmatic retrocardiac massage through an incision in the diaphragm resulted in the highest CI, MBP, and CBF of all the four open transdiaphragmatic techniques and had significantly higher values than those for CCCM in the dog (p less than 0.05). In three cadaveric renal donors, all four open transdiaphragmatic techniques and CSDM were noted to be equal to or superior to CCCM. Three patients have been successfully resuscitated with diaphragmatic cardiac massage techniques for cardiac arrest while undergoing abdominal operations. These studies reveal that all subdiaphragmatic or transdiaphragmatic techniques for cardiac massage are hemodynamically equivalent to or superior to the standard CCCM without such complications as fractured ribs and should be considered the treatment of choice for cardiac arrest in the patient with an open abdomen.
American Journal of Surgery, 1984
To evaluate the effect of levels of serum bilirubin on morbidity and mortality after pancreatoduo... more To evaluate the effect of levels of serum bilirubin on morbidity and mortality after pancreatoduodenectomy, a prospective study was designed to compare patients who underwent preoperative biliary decompression to those who did not. Preoperative biliary decompression decreased the mean serum bilirubin level from 15.8 to 5.8 mg/dl in one group of 10 patients (Group A). The only statistical differences between this group and the two other groups of patients (Groups B and C) who were not treated with preoperative biliary decompression was the level of serum bilirubin before pancreatoduodenectomy (5.8, 22, and 1.3 mg/dl in Groups A, B, and C, respectively). Only one death occurred in each group of patients. The numbers of nonfatal complications were comparable. These results suggest that there is no decrease in morbidity or mortality after pancreatoduodenectomy when the serum bilirubin level is decreased by preoperative biliary drainage.
Surgery, 1984
Controversy exists regarding the relative merits of subtotal parathyroidectomy (SPTX) versus tota... more Controversy exists regarding the relative merits of subtotal parathyroidectomy (SPTX) versus total parathyroidectomy with autotransplantation in the treatment of secondary hyperparathyroidism (HPT). Fourteen patients who underwent SPTX for secondary HPT were evaluated to determine the efficacy of this treatment in view of modern dialysis, diet, and drug treatment. Indications for operation included intractable symptoms (two patients), progressive renal osteodystrophy (eight patients), or both (four patients). Duration of renal failure ranged from 3 to 15 years (mean 7.8 years) before SPTX. The operative serum calcium level was normal in 10 patients, elevated in three patients, and low in one patient. Preoperative parathyroid hormone (PTH) levels ranged from 3.9 to 144 ng/ml (average 41 ng/ml) and decreased after operation to an average of 3.6 ng/ml (normal PTH less than 1 ng/ml). There were no deaths or major postoperative complications. Clinical or radiographic improvement occurred in 80% of patients but did not correlate with absolute reductions in PTH levels. Our results reveal that SPTX is a simple and effective treatment in the initial surgical management of uremic, secondary HPT and appears to be comparable to those obtained with more complicated surgical approaches such as total parathyroidectomy and autotransplantation.
American Journal of Surgery, 1984
The results of recent reports of nonselected patients studied by noninvasive techniques suggest t... more The results of recent reports of nonselected patients studied by noninvasive techniques suggest there is a 10 to 36 percent rate of restenosis within the first 1 to 2 years after carotid endarterectomy. In the present study of nonselected patients examined by intravenous digital subtraction angiography, only 6.7 percent of operated vessels had recurrent stenosis with a 50 percent or greater decrease in vessel diameter at a mean of 28.5 months postoperatively. These data, when compared with the results of most noninvasive studies, suggest that many of the early lesions regress after 1 to 2 years, as suggested by Zierler et al [8] or that there is a true difference in the rates of restenosis between centers, possibly due to subtle differences in surgical technique or patient risk factors, or both. A symptomatic recurrence rate of only 2.7 percent and a 6.7 percent overall rate of hemodynamically significant recurrent stenosis support the conclusions from earlier and larger series that carotid endarterectomy is a highly effective and durable operation. Although it is important that research centers continue to study the natural history of carotid artherosclerosis and serial changes after carotid endarterectomy, these results suggest that for routine clinical follow-up, frequent and expensive periodic tests to detect recurrent stenosis may not be warranted.
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Papers by John Iliopoulos
Conclusions: 1. Synchronous CEA+CABG can be done with low risk. 2. We will continue to recommend these combined proce- dures to our parents. 3. In addition to citations, institutional review of CEA+CABG results is necessary before denying the patients the benefits of these synchronous procedures.