bluuebunny/crossref_metadata_2025 huggingface dataset:
Analysis of Autogenous Vein Femoral-Infrapopliteal Bypass for Limb Salvage in the Elderly
Authors: Hearn A. T. , Smith J. M. , Welling R. E. , Lohr J. M. , Thibodeaux L. C.
Published: September 2024

The hypothesis that older patients undergoing femoral-infrapopliteal bypass have a similar outcome as a matched younger group of patients undergoing the same operation was tested. Seventy-six femoral-infrapopliteal autogenous saphenous vein bypasses for critical limb ischemia were performed from 1985 to 1990. By using the life-table method, the primary and secondary patency, limb salvage and survival rates are analyzed and compared for older and younger age groups. Forty cases (53%) were performed in an elderly group, defined as age 70 or older. At 4 years, there was no significant difference between age groups in limb salvage and patency rates. However, operative mortality for the older age group was 12%, compared with 0% in the younger group (P = 0.0004). Thus, femoral-infrapopliteal autogenous vein bypass can be performed with comparable limb salvage and patency rates for an older age group, but the risk of operative mortality appears to be increased with age.
Lesion Width as a Discriminator of Plaque Characteristics
Authors: Ricotta J. J. , Schenck E. A. , Hassett J. M. , DeWeese J. A.
Published: September 2024

This study evaluated the relative ability of two techniques to quantify carotid atheroma. Diameter stenosis and lesion width were used to predict clinical significance and morphologic characteristics of 54 carotid endarterectomy specimens. Diameter stenosis was a better predictor of symptoms than lesion width (P= 0.03 versus P= 0.085). Both parameters were predictive of complex atheroma (diameter stenosis P= 0.000; lesion width P= 0.03). However, use of lesion width allowed finer definition of categories permitting more precise subclassification of plaque. This resulted in a better correlation of symptoms to complexity when lesion width was used as the discriminating variable (lesion width P= 0.04; diameter stenosis P= 0.121). Lesion width is a valuable parameter for the classification of carotid atheroma, correlating with symptoms and plaque complexity. Lesion width should be evaluated in future studies of carotid atheroma. The discriminative ability of lesion width as detected by high-resolution ultrasonography needs to be evaluated.
Measurement of Carotid Bifurcation Pressure Gradients Using the Bernoulli Principle
Authors: Illig K. A. , Ouriel K. , DeWeese J. A. , Holen J. , Green R. M.
Published: September 2024

Current randomized prospective studies suggest that the degree of carotid stenosis is a critical element in deciding whether surgical or medical treatment is appropriate. Of potential interest is the actual pressure drop caused by the blockage, but no direct non-invasive means of quantifying the hemodynamic consequences of carotid artery stenoses currently exists. The present prospective study examined whether preoperative pulsed-Doppler duplex ultrasonographic velocity ( v) measurements could be used to predict pressure gradients (ΔP) caused by carotid artery stenoses, and whether such measurements could be used to predict angiographic per cent diameter reduction. Preoperative Doppler velocity and intraoperative direct pressure measurements were obtained, and per cent diameter angiographic stenosis measured in 76 consecutive patients who underwent 77 elective carotid endarterectomies. Using the Bernoulli principle (ΔP = 4 v2), pressure gradients across the stenoses were calculated. The predicted ΔP, as well as absolute velocities and internal carotid/common carotid velocity ratios were compared with the actual ΔP measured intraoperatively and with preoperative angiography and oculopneumoplethysmography (OPG) results. An end-diastolic velocity of ⩾ 1 m/s and an end-diastolic internal carotid artery/common carotid artery velocity ratio of ⩾ 10 predicted a 50% diameter angiographic stenosis with 100% specificity. Although statistical significance was reached, preoperative pressure gradients derived from the Bernoulli equation could not predict actual individual intraoperative pressure gradients with enough accuracy to allow decision making on an individual basis. Velocity measurements were as specific and more sensitive than OPG results. ΔP as predicted by the Bernoulli equation is not sufficiently accurate at the carotid bifurcation to be useful for clinical decision making on an individual basis. However, end-diastolic velocities alone as well as internal carotid artery/common carotid artery velocity ratios are highly specific in the prediction of clinically significant carotid stenoses. An end-diastolic velocity of ⩾ 1 m/s accurately identifies a 50% or greater diameter stenosis, and thus may in some cases be sufficient for operation.
Lateral Approach to the Popliteal and Crural Vessels for Limb Salvage
Authors: Hoballah J. J. , Chalmers R. T. A. , Sharp W. J. , Kresowik T. F. , Martinasevic M. M. , Corson J. D.
Published: September 2024

Twenty-one patients underwent 23 bypasses for limb salvage via a lateral approach with subcutaneous graft tunneling. The reasons for utilizing a lateral approach were medial infection (10 bypasses), scarring from previous surgery (six), limited vein length available (three), prior local radiotherapy (two) and ‘high risk’ groin (two). The target artery was the anterior tibial in 16 cases, the peroneal in three, the above-knee popliteal in three and the dorsalis pedis in one. The median (range) follow-up was 22(< 1–52) months. There were three early (within 30 days) and four late bypass occlusions, three of which occurred in previously revised bypasses and one in a non-compliant patient. The primary patency at 1 year was 61 % and the secondary patency 86%. Only one amputation was required in the whole series. The lateral approach represents a simple solution to threatened limbs in otherwise difficult or complicated situations and may be the ideal approach for free vein grafts to the anterior tibial and distal peroneal arteries.
Dacron Stimulation of Macrophage Transforming Growth Factor-β Release
Authors: Greisler H. P. , Petsikas D. , Cziperle D. J. , Murchan P. M. , Henderson S. C. , Lam T. M.
Published: September 2024

This study evaluated the effect of Dacron on the release of macrophage transforming growth factor-β (TGF-β), an endothelial cell growth inhibitor. Rabbit peritoneal macrophages were grown in minimum essential medium (MEM) with 10% fetal bovine serum (FBS) in the presence or absence of Dacron (0.5 mm x 3 mm particles). Media were collected three times each week for 7 weeks. For the TGF-β bioassay, mink lung epithelial cells (CCL64) were grown in MEM with 10% FBS. Test-conditioned media, 100 μl, were added (n = 4), and incubated 48 h. 3H-Thymidine (3H-TdR) uptake was determined and compared with 3H-TdR uptake using known pure TGF-β standards. Media samples were additionally pre-incubated with a neutralizing anti-TGF-β1 antibody and the 3H-TdR uptake again quantitated. TGF-β activity in the conditioned media of macrophages exposed to Dacron exceeded the control media groups in all weeks, reaching significance ( P<0.05) in weeks 3, 4, 5, 6 and 7. Pre-incubation of media samples with the anti-TGF-β1 antibody inhibited this TGF-β activity in all weeks with statistical significance in weeks 1, 2, 3, 5 and 7. The inhibitory effects of Dacron on endothelialization may be explained by the Dacron-induced release of TGF-β from macrophages.
Outcome of Patients with Symptomless Carotid Bruits: A Prospective Study
Authors: Tong Y. , Royle J.
Published: September 2024

Knowledge of the natural history of symptomless carotid artery disease is important in determining the best preventative treatment for symptom-free patients. To document the progression of carotid artery disease and the clinical course of a symptomless population, 336 patients with symptom-free carotid bruits were prospectively followed up initially with oculoplethysmography and subsequently with duplex scanning. During a mean follow-up of 4.87 years, eight patients (2.4%) suffered a stroke. Thirtyseven (11.0%) experienced transient ischaemic attacks (TIAs). The cumulative event rate (TIA plus stroke) was 13.4% (45/336). The annual event rates were 0.48% for stroke. 2.26% for TIA and 2.75% for all ischaemic events. In a subgroup of 69 high-grade carotid stenoses (80–99%), 31 carotid endarterectomies were performed before the development of a TIA or stroke and 21 after the development of symptoms, while 17 lesions were followed-up non-operatively. The total event rate (TIA and stroke) was significantly greater in the non-operated compared with the operated arteries (51.0% versus 6.4% at 5 years, P= 0.0034). However, most of the events which occurred in the non-operated group were TIAs (85.7%) rather than stroke. There was no difference in the death rate of the two groups (P> 0.05). Review of serial duplex studies performed on 540 carotid arteries revealed that 382 arteries (70.7%) remained unchanged and 158 (29.3%) showed disease progression. Forty-four of the 540 arteries became symptomatic (TIA or stroke). In 29 of the 44, the event occurred without any change in diameter of the artery, while in 15 there was a change of at least one category greater stenosis. In 39 patients, the stenosis was at least 40% and in five the stenosis was under 40%. Nine events occurred in the patients with severe contralateral carotid stenoses (> 60%). The incidence of TIA (32.2%), stroke (6.8%) and death (18.6%) was higher in patients with internal carotid artery stenoses in excess of 80% than in those with lesions between 0 and 79% stenosis (P< 0.0001, P= 0.0367 and P= 0.0236, respectively). In this study the incidence of cerebrovascular events was higher in patients with high-grade internal carotid artery disease, and the preservation of neurological status in patients with symptomless high-grade carotid artery stenosis was improved by carotid endarterectomy, although the overall mortality remained unchanged.
‘In Vivo’ Size of Knitted Dacron Prostheses (Gelseal®) Used in the Thoracic Aorta: A Computed Tomography Studyl
Authors: Goossens D. , Weyers L. , Engels P. , Hamerlijnck R. , Vermeulen F.
Published: September 2024

When replacing the thoracic aorta, gelatin-sealed triaxial knitted Dacron prostheses are used as they have zero porosity and are easy to handle. It is known that knitted prostheses (not triaxially constructed), when implanted in the abdominal aorta or in the peripheral vessels, show a dilatation of 10–20%. The initial in vivo expansion of this prosthesis in the thoracic aorta was assessed using computed tomography scanning in 18 patients. The graft sizes used were 18mm (n = 4), 20mm (n = 5), 22mm (n = 4), 26mm (n = 1), 28mm (n = 2) and 30mm (n = 2). All patients were kept normotensive postoperatively. Computed tomography scan measurement was performed within 4 weeks of operation, using standard computed tomography equipment and no contrast. Two radiologists checked and agreed upon the slice levels and measurements compared with the manufacturer's stated size referring to internal diameter of the crimped prosthesis. The mean(s.d.) ‘in vivo’ size was 16.2(6)% larger. This ‘true size’ should be taken as the reference measurement when considering further dilatation over the period of follow-up.
Free Internal Mammary Artery Graft in Myocardial Revascularization
Authors: Verhelst R. , Etienne P. Y. , Khoury G. El , Noirhomme P. , Rubay J. , Dion R.
Published: September 2024

Between August 1986 and March 1993, 124 patients (102 men; mean age of 59 years) underwent myocardial revascularization with the use of at least one free internal mammary artery (FIMA). This group represents 4.5% of the 2725 coronary bypasses performed during the same period. Seventy-six patients (61%) had suffered from at least one previous myocardial infarction. Forty-five patients (36%) had unstable angina; three-vessel disease was found in 100 cases (80.5%) and a left ventricular ejection fraction lower than 0.4 in 22 (17.7%). There were 18 (14.5%) redo procedures and 90 (72.5%) bilateral internal mammary artery (IMA) grafts. The reasons for using a FIMA were: too short an internal mammary artery pedicle in 83 patients, IMA injury at harvesting in 30 patients and post-bypass ischaemia in areas grafted with pedicled IMA (PIMA) in 11 patients. Cardiopulmonary bypass, moderate hypothermia (30°C) and crystalloid anterograde and retrograde cardioplegia were used in all cases. Sixty-seven FIMA grafts were anastomosed directly to the ascending aorta; 57 were sutured via a saphenous hood using a running suture of polypropylene 7/0 and three were anastomosed end-to-end to a PIMA graft. FIMA grafts were directed to the left anterior descending (34%), the circumflex (37%) and the right coronary artery (29%). In total, 179 anastomoses were constructed using 127 FIMA, 136 using PIMA and 158 using saphenous veins (3.8 anastomoses per patient). Hospital mortality and postoperative myocardial infarction rates were 5.6% (seven patients) and 3.2% (four patients), respectively. Cardiac-related mortality was 3.2% (four patients); three of these four patients had been operated on for evolving infarction and one underwent a redo procedure. Four of the 117 survivors died later on; in two, it was cardiac-related and a result of global heart failure at 9 and 12 months. Of the 113 remaining patients, 106 are symptom free after a mean follow-up of 28.2 (range 3–84) months. Fifty-nine patients (50.4%) were restudied by angiography at a mean interval of 15 months. Patency rates of FIMA anastomosed either directly to the aorta or via a saphenous hood were 82.8 or 89.7%. respectively. Patency rates of FIMA directed to the left anterior descending, the circumflex and the right coronary artery were 85.7, 88 and 83.3%. respectively. Global FIMA patency was 86.4%, while global PIMA patency was 100%. The FIMA mid-term patency rates compare unfavourably with those of PIMA: FIMA should therefore be restricted to the cases where PIMA or other pedicled arterial grafts are unavailable.
Haemodynamic and Echocardiographic Characteristics of a Stentless Allograft Mitral Prosthesis: An in Vitro Study
Authors: Vetter H. O. , Erhorn A. , Fontaine A. A. , Reichart B. , Yoganathan A. P.
Published: September 2024

Poor long-term durability and impaired haemodynamic performance are known disadvantages of bioprosthetic heart valves when compared to valve replacement using aortic allografts. A new stentless allograft mitral implant was developed and tested in vitro in a left ventricular model and pulsatile flow system to evaluate hydrodynamic function. Mitral valves were excised from sheep hearts and the mitral annulus reinforced by a strip of ovine pericardium. A patch of expanded polytetrafluoroethylene (ePTFE) was placed above the tips of the remaining papillary muscles For in vitro evaluation of a total of five valves were investigated in a pulse duplicator. Transvalvular pressure gradients (ΔP) were measured over a flow range corresponding to a cardiac output of 51/min, at a heart rate of 70 beats/min, with a systole accounting for approximately 35% of the cardiac cycle. The systolic ejection period and diastolic filling period in this model were 350 and 510 ms, respectively, and aortic pressure was 120/80 mmHg. The effective orifice area was calculated from measurements of mean pressure drop and root mean square flow. Additionally, valve performance was evaluated by Doppler echocardiography, Results of in vitro studies of a 25 mm stentless allograft mitral implant, which is similar to the valves implanted in a chronic weanling sheep model, revealed a mean(s.d.) Δ P of 2.0(1.6) mmHg (range 1.0–4.9 mmHg). The mean calculated effective orifice area was 3.38(0.52) cm2 (range 2.5–3.8 cm2). Doppler echocardiography showed excellent performance of the mitral valve components and valve competence could be achieved. During the in vitro studies no failure caused by tissue rupture was detected. The results of the in vitro studies revealed data for Δ P and effective orifice area superior to data obtained for standard 25 mm porcine bioprostheses.
T-Balloon Carotid Shunt: Its Use during Surgical Treatment of Non-Stenotic Carotid Artery Lesions
Authors: Ballotta E.
Published: September 2024

A simplified technique for employment of the T-balloon shunt during surgical correction of non-stenotic carotid lesions (coiling, kinking, elongation, aneurysm) is described. This technical device is safe and useful when an intraluminal shunt is recommended.
Screening Study of Abdominal Aortic Aneurysm in a General Population: Lipid Parameters
Authors: Simoni G. , Gianotti A. , Ardia A. , Baiardi A. , Galleano R. , Civalleri D.
Published: September 2024

The level of blood lipids and apolipoproteins in subjects being screened for abdominal aortic aneurysms have been investigated. As part of an ultrasound screening programme in a population of 65- to 75-year-olds, blood samples were collected from 1460 of 1504 subjects with a normal aorta (97.1%) and 69 of 70 patients with an abdominal aortic aneurysm >29 mm (99%). Samples were also taken from 22 of 27 patients (81%) with an ectatic aorta (26-29mm). Total cholesterol, HDL-cholesterol. LDL-cholesterol, Apo-AI and Apo-B levels were significantly higher in women than in men (P < 0.01). Levels of HDL-cholesterol and Apo-AI were significantly lower in patients with an abdominal aortic aneurysm than in normal subjects (P< 0.001). The mean(s.d.) body mass Index was 25.1(3.9) in women and 25.5(3.2) in men with aneurysms and not significantly greater than that of normal subjects (25.2(3.61) and 25.2(3.38) respectively).
The Role of Low-density Lipoprotein Apheresis as Postoperative Care of Bypass Grafting for Chronic Arterial Occlusion
Authors: Takagi M. , Yamada T. , Yamaguchi H. , Hashiyada H. , Narimatsu M. , Shibata R. , Yamauchi H. , Miyagawa N. , Kugimiya T.
Published: September 2024

Since November 1989, low-density lipoprotein apheresis has been applied to patients with intractable hyperlipidaemia following bypass grafting for chronic arterial occlusion of the lower extremities. The treatment group comprised six patients (four men, two women) with arteriosclerosis obliterans. In five patients, the ankle pressure index deteriorated and intermittent claudication recurred due to atherosclerotic progression. Results of low-density lipoprotein apheresis were dramatic; the deteriorated ankle pressure index and intermittent claudication improved significantly after several applications of low-density lipoprotein apheresis. Significant angiographic improvement was obtained in two patients. It is concluded that low-density lipoprotein aphresis appears to be an efficient method to preserve graft patency and treat postoperative patients with deteriorated ankle pressure index.
Surgical Treatment of Infected Thoracic and Abdominal Aortic Aneurysms
Authors: Chiba Y. , Muraoka R. , Ihaya A. , Kimura T. , Morioka K. , Nara M. , Niwa H.
Published: September 2024

Twelve patients with infected aneurysms of the thoracic and abdominal aorta were evaluated. Aneurysmal location, aetiology, bacteriology and treatment modality were analysed to determine the relationship between these factors and outcome. Patients were divided into two groups based on the preoperative states of their infections. Group 1 patients ( n = 7) underwent resection after resolution of their active infection. The causative organisms included Staphylococcus epidermidis (two cases), Salmonella spp. (one), Acinetobacter (one), Mycobacterium tuberculosis (one) and unknown organisms (two). Group 2 patients ( n = 5) required urgent surgery because of uncontrolled sepsis despite intensive treatment with antibiotics. The causative organisms included Staphylococcus aureus (two cases). Pseudomonas aeruginosa (two) and Salmonella spp. (one). In group 1, three patients underwent closed en bloc excision of the aneurysm with in- situgraft replacement, and four underwent partial resection with in-situ graft replacement. In group 2. three patients underwent resection of the aneurysm with ligation of aorta and extra-anatomic bypass, and two underwent in-situ graft replacement after débridement of infected tissue. Overall, patients in group 1 had a mortality rate of 14% compared with 80% in group 2. These results suggest that the operative approach and method chosen to restore arterial continuity have less of an impact on outcome. The primary determinants of outcome are virulence of the infecting organism and the preoperative state of the infection.
Aortobifemoral Surgery Induces Complement Activation and Release of Interleukin-6 but not Tumour Necrosis Factor-alpha
Authors: Swartbol P. , Pärsson H. , Truedsson L. , Sjöholm A. , Norgren L.
Published: September 2024

The aim of the present study was to determine the inflammatory response by an extended analysis of complement in 16 patients undergoing aortobifemoral bypass surgery. The patients were randomized to recieve either a bifurcated expanded polytetrafluoroethylene graft ( n = 8; group I) or a collagen-impregnated knitted Dacron graft ( n = 8; group II) to determine whether differences in graft surface properties might influence the inflammatory response during and after the procedure. The following components of complement: C1q. C4, C3, C3d, C5a and terminal complement complexes were all analysed. C-reactive protein and interleukin-6 were also determined to assess the acute phase response. The complement data were corrected for haemodilution, which was assessed from α2-macroglobulin concentrations. A significant decrease of C1q ( P < 0.0001) and an increase in CSa ( P < 0.0005) was observed in both groups. C4 and C3 levels showed slight fluctuations in group I, whereas in group II these proteins increased significantly ( P < 0.05. P < 0.005, respectively) between 2 and 7 days after surgery. Terminal complement complexes remained unchanged in both groups. Interleukin-6 levels peaked at 12–24 h and the C-reactive protein at 24–72 h. Higher interleukin-6 levels (P < 0.05) were found in group II 6h after surgery compared with group I; no release of tumour necrosis factor-alpha was identified. An early inflammatory response was found in all patients. The patterns of the complement proteins varied with a C1q depletion and a C5a increase, interpreted as complement activation. Whether the variations between the two graft groups represent any differences in graft surface properties has to be further elucidated.
Effects of Aprotinin on Plasma Levels of Neutrophil Elastase and Postoperative Blood Loss in Cardiac Surgery
Authors: Dernek S. , Sevin B. , Asian R. , Kaklikkaya I. , Atalay C. , Kural T.
Published: September 2024

This study evaluated the effects of aprotinin on plasma levels of elastase, platelet count, fibrinogen levels and postoperative bleeding. Thirty cardiac surgery patients were randomly chosen for this study. The protease inhibitor aprotinin was given in high doses to 20 patients before and during cardiopulmonary bypass; 10 patients served as the control group. Mean patient age and body weight was similar in both groups. There were no significant inter-group differences in the total cardiopulmonary bypass and cross-clamp times. Mean(s.e.m.) elastase levels were significantly raised in the control group (161.9(2.57)μg/l) compared with the treated group (148.2(3.29)μg/l) at 30 min of cardiopulmonary bypass ( P < 0.01) and rose even further at the end of cardiopulmonary bypass, after protamine infusion, and 24 h postoperatively ( P < 0.001). Platelet counts decreased more in the control group ( P < 0.001). Serum fibrinogen levels were significantly lower in the controls during and just after cardiopulmonary bypass (P < 0.01). Postoperative blood loss was significantly less in the aprotinin-treated patients (315(25) ml) compared with the controls (589(154) ml) (P < 0.05). Aprotinin appears to inhibit elastase release and decrease postoperative blood loss.
Mitral Valve Replacement after Percutaneous Transvenous Mitral Commissurotomy
Authors: Kotsuka Y. , Furuse A. , Yagyu K. , Kawauchi M. , Takeda M. , Hirata K.
Published: September 2024

Percutaneous transvenous mitral commissurotomy is widely performed as the first choice of the non-pharmacological treatments for mitral stenosis. Five patients have been identified who required mitral valve replacement after percutaneous transvenous mitral commissurotomy. The causes leading to mitral valve replacement were mitral regurgitation in three cases and insufficient commissurotomy in two. Massive mitral regurgitation is one of the most serious complications of percutaneous transvenous mitral commissurotomy. This report aims to elucidate the mechanism of massive mitral regurgitation occurring during percutaneous transvenous mitral commissurotomy. In every such case, there was a large tear in the posterior leaflet without any split in the commissures. The Japanese literature reports that 16 patients have undergone mitral valve replacement for massive regurgitation after percutaneous transvenous mitral commissurotomy; 14 of these cases had a tear in one of the leaflets and no evidence of splitting of the posterior commissure. These facts indicate that relative fragility of the leaflets as compared with rigidity of commissural fusion, especially in the posterior commissure, is an important factor of massive mitral regurgitation during percutaneous transvenous mitral commissurotomy.
Aneurysm of the Coeliac Artery
Authors: Saliou C. , Kassab M. , Duteille F.
Published: September 2024

A case of coellac artery aneurysm associated with multiple splanchnic artery aneurysms is reported. This abnormality involved the gastroepiploic and hepatic arteries. The coeliac artery was ligated at laparotomy and the liver revascularized by direct anastomosis of the common hepatic artery to the aorta. Arteriography on the fifth postoperative day showed a satisfactory result. The surgical problems associated with aneurysms of the coeliac artery are reviewed.
Myocardial Ischaemia, Infarction and Cardiac-Related Death following Carotid Endarterectomy: Risk Assessment by Thallium Myocardial Perfusion Scan Compared with Clinical Examination
Authors: Nawaz I. , Lord R.S.A. , Kelly R.P.
Published: September 2024

Risk factors in 402 patients undergoing 447 carotid endarterectomies were reviewed to see whether the presence of coronary artery disease before operation influenced the likelihood of perioperative cardiac complications. A second aim of the study was to assess whether myocardial thallium scintigraphy was valuable for preoperative assessment. Fourteen patients developed postoperative cardiac complications, six (1.3%) of which were fatal. Four of these deaths occurred in 60 patients undergoing combined carotid—coronary revascularization (6.6%). In 387 carotid endarterectomies without simultaneous coronary revascularization, there were two deaths from myocardial infarcts (0.5%). These fatalities and other cardiac complications occurred in 204 patients with preoperative clinical or ECG evidence of coronary artery disease. In 198 patients with no preoperative evidence of coronary disease there were no fatalities and only one patient with reversible postoperative myocardial ischaemia (0.4%). It is concluded that carotid endarterectomy under general anaesthesia is unlikely to be followed by cardiac complications when there is no preoperative evidence of coronary artery disease. When coronary disease is detected before operation, postoperative cardiac complications occur after 5.6% of operations, including 0.9% fatalities. When coronary artery disease is severe enough to warrant combined carotid-coronary reconstruction, the perioperative mortality rate was 6.6%, all the deaths being cardiac-related. When myocardial thallium scintigraphy was normal, postoperative cardiac complications did not occur.
Late Renal Function in Patients Undergoing Renal Revascularization for Control of Hypertension and/or Renal Preservation
Authors: Acher C. W. , Belzer F. O. , Grist T. M. , Turnipseed W. D. , Hoch J. R. , Archibald J. E.
Published: September 2024

Long-term outcome was studied in 233 patients who had undergone renal artery revascularization (51 with balloon angioplasty, 182 with surgery) between 1976 and 1992. Patients (excluding renal transplants) were treated for renal vascular hypertension without or with renal insufficiency (serum creatinine >1.6 mg/dl. All patients still alive (n = 188) were contacted to determine current blood pressure, medications, serum creatinine, and subsequent significant medical events. In patients who had died the cause of death was determined and renal function status at the time of death noted from medical records. Some follow-up information was obtained on all 233 patients; follow-up serum creatinine data were obtained in 193 (82.8%) patients. Some 24 patients (10.3%) became dialysis-dependent. Using a multiple logistic regression analysis only, preoperative creatinine maintained significance ( P <0.001) for increased dialysis risk. There was no statistically significant association of dialysis for type of revascularization (percutaneous transluminal angioplasty, autogenous artery, saphenous vein, endarterectomy or synthetic material), simultaneous or previous aortic or other vascular surgery (carotid endarterectomy, femoropopliteal bypass, etc.), pathology (atherosclerosis or fibromuscular dysplasia), number of renal arteries stenosed or treated, length of follow-up, age, coronary artery disease, congestive heart failure, stroke, chronic lung disease or type II diabetes. It is concluded that, in patients with renal artery stenosis, the timing of renal artery revascularization relative to the level of renal function is the most important determinant for long-term renal salvage.
Thyroid Hormone Alterations during and after Cardiopulmonary Bypass
Authors: Keçeligil H. T. , Kolbakir F. , Adam B. , Arikan A. , Erk M. K.
Published: September 2024

The haemodynamic effects of thyroid hormones are well known and include those on heart rate, contractility and myocardial oxygen consumption. Cardiopulmonary bypass produces various alterations in endocrine homoeostasis and may exert important haemodynamic effects postoperatively. The purpose of this prospective study was to determine the relation of cardiopulmonary bypass to changes in thyroid function. Blood samples were obtained from 20 patients preoperatively, at specific times before, during and after cardiopulmonary bypass. Total thyroxin (TT4), total triiodothyronine (TT3), free thyroxin (fT4), free triiodothyronine (fT3), thyroid-stimulating hormone (TSH), thyroid-binding globulin (TBG) and albumin were measured by radioimmunoassay and competitive immunoassay. Values of TT4, TT3 and fT3 were significantly depressed up to 24 h after cardiopulmonary bypass ( P < 0.05). TSH and fT4 levels remained within normal ranges at all sampling times. It is increasingly evident that cardiopulmonary bypass affects thyroid hormone metabolism, leading to a transient depression characterized by low levels of circulating TT4, TT3 and fT3.
Chordal Preservation Improves Postoperative Ventricular Performance following Valve Replacement for Chronic Mitral Regurgitation
Authors: Popovic Z. , Barac I. , Jovic M. , Ristic M. , Panic G. , Miric M. , Bojic M.
Published: September 2024

Worsening of left ventricular performance had been recognized after mitral valve replacement for mitral regurgitation. The effects of chordal preservation on ventricular performance after mitral valve replacement have been assessed. Twelve patients with mitral regurgitation were allocated to group A (undergoing mitral valve replacement with chordal preservation), or to group B (undergoing mitral valve replacement with chordal excision). Transoesophageal echocardiography was recorded simultaneously with radial artery and pulmonary capillary wedge pressures. Load was varied by withdrawal of blood from a venous line of cardiopulmonary bypass and/or nitroglycerine bolus. Ventricular performance was assessed by the slope of peak systolic pressure—end-systolic volume relation (Eps), and by the slope of the left ventricular stroke work — end-diastolic volume relationship. Eps significantly decreased immediately after mitral valve replacement ( P < 0.02), with no difference among two groups. Eps gradually increased to preoperative levels 10 days after surgery. Pre-load recruitable stroke work also significantly decreased after mitral valve replacement ( P = 0.01). The decrease was significantly larger in group B ( P < 0.04). These data support the hypothesis that chordal preservation during mitral valve replacement has beneficial effects on left ventricular performance.
A New Technique of Reinforced Sternal Closure
Authors: Watanabe G. , Misaki T.
Published: September 2024

A technique of reinforced sternal closure with stainless steel Kirschner wires is described. This technique is useful for patients with a fractured or friable sternum, or pectus excavatum.
The Perth Endoluminal Bifurcated Graft System — Development and Early Experience
Authors: Lawrence-Brown M. M. D. , Hartley D. , MacSweeney S. T. R. , Kelsey P. , Ives F. J. , Holden A. , Gordon M. , Goodman M. A. , Sieunarine K.
Published: September 2024

The study aim was to develop a reliable endoluminal graft system that would enable the deployment of a bifurcated graft for infrarenal abdominal aortic aneurysms. A life-size plastic model was made of an abdominal aorta and iliac arteries, with a 50-mm infrarenal abdominal aortic aneurysm. This model was used to develop and test self-expanding graft systems, based on a barbed Gianturco stent and series of stainless-steel ‘Z’ stents within a woven Dacron graft. The bifurcated system developed involves a trouser graft with one long leg and one short. This graft system is delivered through one femoral artery with deployment of the proximal aortic end infrarenally and the longer trouser leg within the ipsilateral common iliac artery. The short trouser leg is left hanging free within the distal end of the aneurysm cavity, just above the bifurcation. It is held open by a self-expanding stent and is cannulated from the contralateral femoral artery with a guide wire. A simple straight self-expanding stented graft is then deployed to extend this short trouser leg down into the common iliac artery, effectively creating an extension to the short leg. The graft system has been deployed in 21 patients with satisfactory exclusion of the aneurysm in 17 (81%). There has been one mortality and no conversion to open repair. All 17 aneurysms remain excluded at median follow-up of 30 (range 4–60) weeks. None of the four graft stents that leaked (two proximal and two distal) sealed spontaneously. Deployment of the uncovered Gianturco stent across the renal artery origins in 18 cases (85%) has not been associated with renal artery occlusion or deterioration in renal function at a median follow-up of 30 (range 4–60) weeks. The ability to deploy a bifurcated system increases the potential for endoluminal treatment of abdominal aortic aneurysm.
Advances in the Surgical Repair of Ruptured Abdominal Aortic Aneurysms
Authors: Darling R. C. , Cordero J. A. , Chang B. B. , Shah D. M. , Paty P. S. K. , Lloyd W. E. , Leather R. P.
Published: September 2024

Over the past two decades, the mortality rate for elective repair of infrarenal abdominal aortic aneurysms has improved to an acceptable level (<5%). However, surgical results of ruptured abdominal aortic aneurysms have remained fairly constant with about 50% in hospital mortality rates. Growing experience with the use of the left retroperitoneal exposure for elective aortic surgery allowed the authors to extend the use of this technique to the repair of ruptured abdominal aortic aneurysm. The extended left retroperitoneal approach using a posterolateral exposure through the 10th intercostal space allowed the surgeon expeditiously and reliably to obtain supraceliac aortic control by dividing the left crus of the diaphragm in all patients. In total, 104 aortic replacements were performed for ruptured abdominal aortic aneurysm during the past 7 years. Of these patients, 87 were men and 17 women; mean(range) age was 72(52–95) years. Hemodynamic instability (as defined by a systolic blood pressure of <90 mmHg) was present before surgery in 41% (43/104) of patients. The operative mortality rate was 27.9% (29/104). Preoperative hemodynamic instability, time of operative delay and aortic cross-clamp time did not correlate with operative mortality. The median duration of intensive care unit stay was 4 (range 1–60) days and hospital stay 11 (range 6–175) days. The results of this series identified that a change in the operative technique for the repair of ruptured abdominal aortic aneurysm beneficially affected patient survival. The authors suggest that expeditious supraceliac control without thoracotomy is an excellent alternative and offers an advantage in the surgical management of ruptured abdominal aortic aneurysm.
Potential Influence of Intraluminal Thrombus on Abdominal Aortic Aneurysm as Assessed by a New Non-Invasive Method
Authors: Vorp D. A. , Mandarino W. A. , Webster M. W. , Gorcsan J.
Published: September 2024

Intraluminal thrombus may play a role in abdominal aortic aneurysm pathogenesis and rupture. The purpose of this work was to demonstrate the feasibility of a new non-invasive method for the determination of the biomechanical features of the aortic wall and luminal boundary in abdominal aortic aneurysm containing intraluminal thrombus. Automated ultrasonographic measures of infrarenal aortic cross-sectional area ( A) were obtained on-line along with non-invasive arterial pressure ( p) from eight patients of mean(s.e.m.) age 74(3) years, with abdominal aortic aneurysm (mean dimensions 5.9(0.4) × 5.3(0.5) cm) containing intraluminal thrombus. Luminal boundary and abdominal aortic aneurysm wall were scanned separately. Compliance ( C) was computed as C = (Amax — Amin)/[ Amax( pmax — pmin)], where ‘max’ and ‘min’ represent maximum and minimum values, respectively. Mean compliance was lower for the abdominal aortic aneurysm wall alone than for the luminal surface enclosed by intraluminal thrombus: 4.0(0.9) × 10−4/mmHg versus 9.8(1.7) × 10−4/mmHg ( P < 0.01). Intraluminal thrombus area was nearly constant over the cardiac cycle, indicating that the thrombus is virtually incompressible. This non-invasive method to assess biomechanical features of abdominal aortic aneurysm has potential to further the understanding of the influences of intraluminal thrombus on aneurysm disease.
Medical Cost Savings through Stroke Prevention from 100 Consecutive New Carotid Duplex Scans
Authors: Lavenson G. S. , Sharma D.
Published: September 2024

Recent studies have shown that carotid endarterectomy for significant lesions lowers the risk of stroke and also reduces medical costs by averting the high costs of strokes. However, there has been no information on the cost effect of duplex ultrasound examination which has evolved as the prime means of discovering these carotid lesions. This study reviewed the findings and management of 100 consecutive new patients referred for duplex ultrasound management of the carotid arteries and the cost effects resulting. Seventy-three patients with <70% stenosis were managed non-operatively; the remaining 27 with 33 lesions producing >70% stenosis were treated by carotid endarterectomy. It was estimated that 6.5 patients would have had a stroke within 18 months if not operated on. While the medical costs of these strokes would have been $958 838, the cost of avoiding them was $300 494; the result was a significant medical costs saving of $658 344.
Bilateral Carotid Endarterectomy during the Same Hospital Admission
Authors: Darling R. C. , Kubaska S. , Shah D. M. , Paty P. S. K. , Chang B. B. , Lloyd W. E. , Leather R. P.
Published: September 2024

The efficacy of carotid endarterectomy for the prevention of strokes has been well demonstrated in recent multicenter randomized trials. However, patients presenting with bilateral significant disease pose a difficult problem to the vascular surgeon. Currently, bilateral carotid endarterectomies are staged at varying intervals between operations, with the surgeon and patient weighing the risks of waiting for surgery versus the risks of having both procedures done within a shortened interval. There are few data and no consensus on the optimal time interval between these operations. In order to evaluate the timing of carotid endarterectomies in patients with severe bilateral disease, the authors reviewed their experience with patients who had bilateral procedures performed during one hospitalization. Over the past 5 years, they have performed 204 such carotid endarterectomies in 102 patients. Cervical block anesthesia was used in 99% (201/204) of these procedures. All patients either had symptomatic disease, >60% stenosis or severe ulcerative plaque as defined by duplex scan and/or preoperative angiography. Symptomatic stenoses were the operative indications in 39% (80/204) of the patients; the remaining 61% (124/204) were symptom-free. The majority of patients (80%; 164/204) had their second procedure performed within 2 days of their first operation. There was one operative mortality and only one permanent neurologic defect in this group for a combined stroke mortality rate of 1 %. Three patients (1.5%) had transient neurologic deficits postoperatively which completely resolved by discharge. These data show that bilateral carotid endarterectomies can be performed safely and effectively during one hospital admission with a short interprocedural interval and without an increase in mortality or morbidity.
Access to the Right Renal Artery from the Left Retroperitoneal Approach
Authors: Shah D. M. , Darling R. C. , Chang B. B. , Paty P. S. K. , Leather R. P. , Lloyd W. E.
Published: September 2024

One of the perceived limitations of the left retroperitoneal approach to the aorta is inadequate access to the right renal artery. Many consider the need for a concomitant right renal artery revascularization a contraindication to performing an aortic reconstruction through the left retroperitoneum. Exposure of the right renal artery can be difficult due to the posterior course of the artery behind the vena cava. However, when the aorta is transected, the right renal artery can be easily approached with anterior and cephalad displacement of the aortic root. Over the past 3 years, 52 patients have had right or bilateral renal artery revascularization via the left retroperitoneal approach; of these procedures, 37 were performed with concomitant aortic procedures. In total, 34 patients had bilateral and 18 had unilateral revascularizations. Five patients had a transaortic endarterectomy performed, and 36 were bypassed with 6-mm expanded polytetrafluoroethylene side limbs from the aortic graft. Indications for revascularization were: 39 for suprarenal aortic bypass, seven for renal salvage and six for primary renovascular hypertension. All reconstructions have remained patent and all have been followed by serial duplex and renal flow scans (follow-up for 1–42 months). The operative mortality rate was 5.8% (3/52). There were no major cardiorespiratory complications in this group. Adequate exposure to the proximal right renal artery can be obtained through the left retroperitoneal approach to the aorta, and successful revascularization of one of both renal arteries can be technically performed with acceptable mortality and morbidity.
Subcutaneous, Video-Assisted Saphenous Vein Harvest: Report of the First 30 Cases
Authors: Lumsden A. B. , Eaves F. F. , Ofenloch J. C. , Jordan W. D.
Published: September 2024

Harvest of the saphenous vein is a commonly performed procedure in cardiovascular surgery. The incision required for its removal is the longest used anywhere. In this report, the authors describe a minimally invasive technique for removal of the vein. This has been used in 30 patients undergoing peripheral arterial bypass ( n = 27), venovenous bypass ( n = 2), and a saphenopopliteal fistula ( n = 1). There were three perioperative complications: skin necrosis over tunnel (one), bulla (one), and saphenous vein injury (one). Harvest time averaged 1.25 h. There was minimal postoperative discomfort in the harvest site and minimal scarring. Endoscopic harvest of the saphenous vein differs from most laparoscopic procedures because of its linear course. Consequently, visualization and dissection is coaxial rather than triangulation. This study demonstrates the technical feasibility of vein harvest. Development of appropriate instrumentation for opening the optical cavity and vein manipulation will reduce operative times.
Hyperhidrosis Treated by Thoracoscopic Sympathicotomy
Authors: Drott C. , Claes G.
Published: September 2024

Hyperhidrosis of the palms, axillae and face has a strong negative impact on social and professional life. The existing non-operative therapeutic options seldom give sufficient relief and have a transient effect. A definitive cure can be obtained by upper thoracic sympathectomy. The traditional open surgical techniques are major procedures and few patients and surgeons have found that the risk—benefit consideration favoured surgery. Since 1987, the authors have divided the upper thoracic sympathetic chain on 1163 patients with a simple endoscopic technique by using standard urological equipment. A bilateral procedure takes less than 20 min and requires just one night in hospital. There have been no mortality or life-threatening complications. Ten patients (< 1%) required intercostal drainage because of haemo- or pneumothorax. Horner's syndrome occurred in four cases. Primary failure occurred in 23 cases (<2%) and 24 (<2%) developed recurrent symptoms. The patients with failure and recurrence were successfully reoperated on and only three have required a third operation. At the end of postoperative follow-up (median 31 months) 98% of the patients were satisfied. Endoscopic transthoracic sympathicotomy is an efficient, safe and minimally invasive surgical method for the treatment of palmar, axillary and facial hyperhidrosis.