bluuebunny/crossref_metadata_2025 huggingface dataset:
The Impact of a Short Interval (≤1 Year) between Primary and Reoperative Coronary Artery Bypass Grafting Procedures
Authors: Christenson J. T. , Simonet F. , Schmuziger M.
Published: September 2024

Reoperative (redo) coronary artery bypass grafting is an efficient treatment for patients with progressive coronary artery disease and those with conduit failure. Previous studies have demonstrated that a short time interval between primary and redo coronary artery bypass grafting is associated with a significantly higher mortality rate. In the present report this particular group have been specifically evaluated. Between 1 January 1990 and 1 October 1994, 383 consecutive patients underwent redo coronary artery bypass grafting. Thirty-three patients (8.6%) were operated on at ≤ 1 year (group I) and 350 patients at > 1 year after the primary bypass (group II). The main indications for redo in group I were graft failure (58%), incomplete revascularization (39%) and progress of disease (3%); respective values in group II were 26%, 15%, and 23%. In addition, 36% of patients in group II had combinations of complications. Patient characteristics did not differ between groups, except a higher incidence of insulin-dependent diabetes in group I ( P < 0.05). There was a higher incidence of left main stem stenosis of >70% in group I ( P< 0.05). Group I patients had a longer aortic cross-clamping time and needed thromboendarterectomy and patching of coronary vessels more often than did those in group II ( P < 0.05). The internal mammary artery had been more frequently used at the primary coronary artery bypass grafting in group I ( P < 0.01). The overall mortality rate was 8.9%; that in group I was 18% and in group II, 8% ( P < 0.05). There was a higher incidence of non-fatal myocardial infarction and a need for prolonged ventilatory support (>24 h) in group I. Other postoperative complications did not differ. Significant risk factors for mortality in group I were preoperative Canadian Cardiovascular Society class ≥3, unstable angina, need for urgent operation and left ventricular ejection fraction <40%, and ≥70% left main stem stenosis. In group II, the risk factors were: unstable angina, urgent operation, left ventricular ejection fraction <40%, internal mammary artery not used at primary coronary artery bypass grafting and the need for coronary thromboendarterectomy. The 3-year survival and cardiac event-free survival did not differ between the groups. This study has confirmed that early redo coronary artery bypass grafting (≤ 1 year from primary bypass) is associated with an increased operative risk.
Rhythm Disturbances after Mitral Valve Surgery: Comparison between Left Atrial and Extended Trans-Septal Approach
Authors: Tambeur L. , Meyns B. , Flameng W. , Daenen W.
Published: September 2024

This study was undertaken to determine the incidence of postoperative arrhythmias in mitral valve surgery through the left atrium as compared with the extended trans-septal approach. All patients undergoing mitral valve surgery for acquired valve disease between 1 January 1991 and 31 December 1993 were reviewed. Only patients with preoperative normal sinus rhythm were included in this study. End-points for analysis were: ‘any supraventricular arrhythmia’; ‘atrial fibrillation or flutter’; and ‘ectopic atrial or junctional rhythm’. All predictive factors with a P-value <0.10 in univariate analysis were entered into the multivariate proportional hazard model of Cox. Some 72 patients were included for analysis. No variables were independently predictive of ‘any supraventricular arrhythmia’. Age is an independent predictor of ‘atrial fibrillation or flutter’ and surgical approach of ‘ectopic atrial or junctional rhythm’.
Pathogenesis and Prognostic Significance of Conduction Abnormalities after Coronary Bypass Surgery
Authors: Kirdar J. A. , Sharma G. V. R. K. , Khuri S. F. , Josa M. , Parisi A. F.
Published: September 2024

Of 200 men who underwent isolated coronary bypass graft surgery, 40 (20%) developed new postoperative, persistent conduction abnormalities. The pathogenesis of conduction abnormalities was examined by relating their presence to that of significant proximal left coronary disease before surgery, and to various intraoperative factors that included indices of myocardial preservation and revascularization. Proximal left coronary disease was observed in 92 (46%) of 200 patients, of whom 27 (29%) developed conduction abnormalities. In contrast, of the 108 patients without proximal left coronary disease, only 13 (12%) developed persistent conduction abnormalities ( P < 0.01). Intraoperative factors appeared to have little or no role in the development of such abnormalities. It is concluded that the development of persistent postoperative conduction abnormalities is related more to proximal left coronary disease than to intraoperative factors and that such abnormalities do not progress during long-term follow-up (average 53 months). Published by Elsevier Science Ltd.
Surgical Removal from the Descending Aorta of a Floating Thrombus Caused by Blunt Chest Trauma
Authors: Lukács L. , Lengyel M. , Sitkei É. , Abermann L.
Published: September 2024

A 44-year-old woman presented with a recurrent peripheral embolism. Her past history was remarkable for blunt chest trauma 7 years before presentation. Transoesophageal echocardiography showed a floating mass in the descending aorta. Operative and pathological findings revealed an aged thrombus. Reliable diagnostic methods and appropriate treatment can prevent further embolic events.
Pathogenesis of Venous Thrombosis: A New Insight
Authors: Wakefield T. W. , Strieter R. M. , Prince M. R. , Downing L. J. , Greenfield L. J.
Published: September 2024

Venous thrombosis and thrombophlebitis have long been observed to result in painful inflammation around the affected veins. The full extent of the synergistic interaction between thrombosis and the inflammatory response and how this leads to the later sequelae of chronic venous insufficiency is only now beginning to be understood. Venous thrombosis is known directly to elicit an inflammatory response in the thrombus and vein wall. Leukocytes including neutrophils and monocytes roll, adhere, activate and extravasate into the vein wall based on a vein wall cytokine/chemokine gradient producing an inflammatory response. Such a response leads to amplification of thrombus formation through mechanisms such as the elaboration of tissue factor on the surface of monocytes and the release of cathespin G from activated neutrophils (distrupting the endothelial cell barrier), exposing the thrombogenic subendothelial vein wall collagen. Selectins such as P-selectin and the proinflammatory cytokine tumor necrosis factor appear important in this vein wall response. Inhibition of inflammation before the initiation of the thrombotic event may decrease the detrimental vein wall changes that contribute to vein wall and vein valve damage and thrombus formation.
Comparison of Perioperative Results Obtained with Carotid Eversion Endarterectomy and with Conventional Patch Plasty
Authors: Entz L. , Járányi Z. , Nemes A.
Published: September 2024

After limited experience with eversion endarterectomy of the internal carotid artery, comparison has been made between perioperative results obtained with the eversion technique and with the conventional method. The perioperative results of 715 consecutive cases of patch plasty of the internal carotid artery performed between January 1986 and December 1990 were reviewed and compared with perioperative data of 739 consecutive cases of eversion endarterectomy, performed between January 1991 and December 1993. The duration of surgery was also recorded. Statistical analysis was carried out, using X2 test, Fisher's Z test and Student's t-test. The postoperative stroke rate was 2.9% in the conventional endarterectomy group, and 0.95% in cases of eversion endarterectomy ( P<0.01); the stroke mortality rates were 1.8% and 0.54% respectively ( P<0.05). Overall mortality rate was 2.9% in the conventional group and 0.95% in the eversion group ( P<0.01); combined morbidity and mortality rate was 4% versus 1.35% ( P<0.001). A statistically significant difference was found in favour of the eversion method between the duration of surgery (90.9 min versus 52.8 min; P<0.005) and between the mean clamp time (34.9 min versus 22.4 min; P<0.005). On the basis of these results, it is concluded that eversion endarterectomy of the internal carotid artery is a safe and rapid technique and its immediate results were superior to those obtained after conventional endarterectomy and patch plasty.
Popliteal Artery War Injuries
Authors: Davidović L. , Lotina S. , Kostić D. , Velimirović D. , Dukić P. , Činara I. , Vraneš M. , Marković M.
Published: September 2024

The early postoperative results of 44 surgically treated popliteal arterial injuries from the Yugoslav civil war are reported. Of these patients, 41 (93%) were males and three (7%) were females, average age was 28 (range 6–45) years. Twenty patients (45%) had gunshot wounds and 24 (55%) explosive wounds. Twelve (28%) suffered isolated vascular damage, while 32 (72%) suffered concomitant bone fractures. Isolated arterial lesions were found in 24 (55%) cases, and concomitant arterial and venous lesions in 20 (45%). Twenty-four (55%) had primary reconstructions after haemostasis in the initial war hospital, and 20 (45%) secondary reconstructions after inadequate primary reconstruction in a regional war hospital. Artery procedures included 19 reverse saphenous vein graft interpositions, 10 reverse saphenous vein bypasses, 12 ‘in situ’ saphenous vein bypasses and five lateral subcutaneous saphenous vein bypasses. The early graft patency rate was 100%, and limb salvage 72%. Major amputation was performed in 28%. Concomitant bone fractures, secondary reconstructions, secondary haemorrhage from an infected graft, and explosion wounds significantly increased the amputation rate ( P < 0.01). Eleven amputations were performed after an anatomic, and only one after an extra-anatomic reconstruction ( P < 0.01). The authors recommend an in situ or lateral subcutaneous reconstruction in cases of complicated popliteal artery injuries, such as concomitant bone fractures accompanied by massive soft tissue damage, and this type of reconstruction should also be used if infection is present or the procedure is delayed.
Pulmonary Embolism: Diagnosis, Incidence and Implications
Authors: Proctor M. C. , Greenfield L. J.
Published: September 2024

The purpose of this study was to determine the prevalence of pulmonary embolism at an academic tertiary care center, to identify the methods of diagnosis, and to characterize the outcomes for this population. A retrospective analysis of multiple data sources including records from the Medical Information System, and the Departments of Pathology, Radiology. Nuclear Medicine and Pharmacy were reviewed for all patients with positive reports of pulmonary embolism. These were verified by the medical records and a listing of all positive cases was developed. A total of 320 patients developed pulmonary embolism during the study period and 121 died before discharge. The prevalence was 3.5 cases per 1000 admissions, with a mortality of 1 per 1000 cases. Significant misclassification of patients and errors in rate estimation would have occurred if multiple sources of information were not used. Definitive diagnosis and appropriate treatment with a Greenfield filter was associated with improved early survival. By relying on ICD-9 coding, 80% of fatalities and 13% of patients with positive angiograms would have been missed.
The Morphology of Venovenous Bypass Graft Endothelium
Authors: Davies M. G. , Klyachkin M.L. , Dalen H. , Svendsen E. , Hagen P.-O.
Published: September 2024

Venovenous bypass grafts are commonly used in the repair of vascular trauma to large- and small-caliber veins. This study examines the morphology of the venous wall in an experimental model of the venovenous bypass graft. The morphology of the venous endothelium from unmanipulated jugular veins and from jugular veins implanted as a venovenous bypass graft in the external jugular venous system for 10 min, 6 h, and 1, 3, 5, 7 and 28 days was examined. Veins and venovenous grafts were pressure fixed in situ at 80 mmHg and were examined by scanning and transmission electron microscopy. The endothelial cell lining remained confluent and intact over the 28-day period with evidence of endothelial cell contraction (spindle-shaped cells) for the first 72 h. Pinocytotic activity in endothelial cells and underlying smooth muscle cells was observed throughout the study, strongly indicating physiologically active cells. There was some accumulation of blood cells, predominantly polymorphonuclear leukocytes on the endothelial surface. Polymorphonuclear leukocytes were observed to infiltrate into the subendothelium through endothelial cell junctions within 6 h but by day 3, none was noted in the subendothelial space. There was no major disruption of the graft wall at any time point. By day 28, there was evidence of intimal thickening in the venovenous bypass grafts but no well-demarcated intimal hyperplasia. This study shows that there is no significant endothelial injury in the venovenous bypass grafts and that the endothelial cells remain physiologically active. Short-term failure of venovenous bypass grafts, therefore, appears not be due to significant endothelial cell damage in the graft.
Benefits of Supplementing St Thomas' Hospital Cardioplegic Solution with Tetraethylammonium on Functional and Metabolic Recovery of Isolated Rat Hearts
Authors: Bozkurt A. K. , Süzer Ö. , Kaynar M.
Published: September 2024

This study was designed to evaluate whether the addition of potassium channel blockers, tetraethylammonium, 4-aminopyridine or glibenclamide, to St Thomas' cardioplegia improved myocardial preservation over that achieved by St Thomas' cardioplegic solution alone. Initially, isolated rat hearts were subjected to 30 min of continuous normothermic hypoxic cardioplegia. Control hearts were arrested with St Thomas' cardioplegia followed by tetraethylammonium, glibenclamide or 4-aminopyridine-enriched cardioplegia. Subsequently, in a second experiment, hearts were subjected to 45 min of normothermic global ischaemia, after 3 min of cardioplegia with either tetraethylammonium-enriched or standard St Thomas' cardioplegia. In both regimens, hearts arrested with tetraethylammonium-enriched St Thomas' cardioplegia showed better recovery of contractile function than controls ( P<0.001). Creatine kinase levels were significantly lower in the tetraethylammonium group ( P<0,001). 4-Aminopyridine treatment caused similar contractility to that of the control group but raised creatine kinase and lactate dehydrogenase levels ( P<0.001). Glibenclamide diminished coronary flow autoregulation, and increased lactate dehydrogenase leakage in reperfusion ( P<0.05) with similar contractility to controls. The results of this preliminary in vitro study demonstrate that, in rat heart, St Thomas' cardioplegia enriched with tetraethylammonium improves post-ischaemic contractile function and reduces creatine kinase release. It is concluded that high potassium blocks the membrane at the rapid depolarization phase with rapid sodium influx and tetraethylammonium further prevents repolarization by blocking voltage-dependent potassium channels.
Angioscopy in Vascular Surgery
Authors: Rosenthal D.
Published: September 2024

The role of Intraoperative angioscopy continues to evolve. To better define the role of angioscopy in vascular surgery, a review of the recent literature was performed. The most well-established indication for angioscopy is preparation of the saphenous vein for in situ bypass; however, angioscopy has also been demonstrated to be useful in the assessment of carotid endarterectomy, femoral vein valve repair, thromboembolectomy, and may be beneficial during endovascular stent grafting. Angioscopy is now a valuable adjunct in the management of the patient with peripheral vascular disease.
Combined Coronary Artery Bypass Grafting and Carotid Endarterectomy
Authors: Vicaretti M. , Fletcher J. P. , Klineberg P. , Richardson A. J. , Hazelton S. , Allen R. , Tomlinson P. , Nunn G. , Chard R. , Meldrum-Hanna W.
Published: September 2024

Combined carotid endarterectomy and coronary artery bypass grafting was performed in 52 patients between January 1982 and September 1994. Forty-nine patients had stable or unstable angina and three had symptom-free coronary artery disease detected by stress testing. Thirty-one patients had triple-vessel disease and 17 had left main trunk or left main equivalent coronary artery disease. Five patients had symptom-free carotid artery disease. 12 had non-specific neurological symptoms, and 35 had transient ischaemic attacks. Carotid endarterectomy was performed first, followed by coronary artery bypass grafting. There were three postoperative deaths, two cardiac and one neurological, for a mortality rate of 5.8%. One patient suffered a permanent neurological deficit (1.9%). It is concluded that combined carotid endarterectomy/coronary artery bypass grafting can be performed in selected patients with acceptable neurological morbidity, although cardiac mortality was not eliminated by the combined approach.
Transected Thoracic Aorta: Age-Specific Differences in Incidence and Possible Reasons
Authors: Tripp H. F. , Robicsek F. , Thomason M. , Thubrikar M.
Published: September 2024

The objective of this study was to determine the incidence of aortic transaction in relation to age, and to examine possible reasons for the observed differences. Data from the North Carolina Medical Database over a 7-year period were examined for the total number of motor vehicle accident victims and for the subset with aortic rupture, based on age at presentation. Data were then divided into 10-year intervals and the differences analyzed using chi-square analysis. Differences among various age groups were statistically significant ( P = 0.0001). The highest rate was in the 21–30-year-old age group and average incidence for all ages was 0.7%. High incidence of aortic transaction in the 21–30-year-old group may be due to an increase in high-risk behaviors in such persons, to an improved survival compared with other age ranges, or to an inherent susceptibility of the aorta at this stage of life. These data have important implications for the diagnosis and treatment of aortic transaction and should be taken into account when developing practice guidelines for its management.
Early Experience with the Norwood Procedure
Authors: Conte S. , Hansen P. B. , Jensen T. , Jacobsen J. Ramsøe , Helvind M. , Lauridsen P. , Pettersson G.
Published: September 2024

The improved results of the Norwood procedure have recently stimulated its widespread adoption in many centres. Since 1993, 19 infants with hypoplastic left heart syndrome or similar conditions underwent a first-stage Norwood procedure. Circulatory arrest time was significantly reduced by using a modified repair of the aortic arch. The early mortality rate was 31.5% ( n = 6). The addition of CO2 to the inspired gas mixture resulted in less early postoperative instability. Nine patients have subsequently undergone bidirectional cavopulmonary shunt and one fenestrated total cavopulmonary connection. Overall there have been five late deaths, two as result of failure of cavopulmonary operations. All the eight survivors are presently in good condition. One is awaiting bidirectional cavopulmonary shunt and the other seven total cavopulmonary connection. This early experience encourages the continued offering of the Norwood procedure to patients with hypoplastic left heart syndrome or its variants. Increasing experience with the perioperative care and a more careful evaluation before cavopulmonary operations may determine further improvement in the outcome.
Myocardial Revascularization without Cardiopulmonary Bypass in Pigs: A Comparison between β-Blockers and Ca2+-Channel Blockers
Authors: Podesser B. , Rajek A. , Kupilik N. , Schmiedberger A. , Vukovich Th. , Hiesmayr M. , Hamwi A. , Wolner E. , Moritz A.
Published: September 2024

The purpose of this study was to develop the surgical technique for internal mammary artery grafting on the beating heart. In 10 pigs, heart rate was reduced with esmolol ( n = 5) or verapamil ( n = 5). In addition, the anti-ischaemic and anti-arrhythmic potencies of these drugs were investigated. Haemodynamics, mechanical function and ischaemia-sensitive laboratory measurements were assessed perioperatively. There were no differences in pre-ischaemic data including ischaemic clamping time of the left anterior descending artery. At the end of ischaemia haemodynamic parameters were significantly lower in the esmolol-group ( P < 0.05). In the verapamil-group, one pig died from ventricular fibrillation during ischaemia, and one showed fibrillation during reperfusion ( P < 0.01). There were no differences in cardiac function or enzymes between the groups. Reduction of heart rate was provided by both drugs, but no conclusive evidence was provided with regard to additional anti-ischaemic and anti-arrhythmic protection.
Bifurcated Stent-Graft for Abdominal Aortic Aneurysm
Authors: Chuter T. A. M. , Wendt G. , Hopkinson B. R. , Scott R. A. P. , Risberg B. , Keiffer E. , Raithel D. , van Bockel J. H. , White G. , Walker P.
Published: September 2024

The purpose of this study was to examine bifurcated stent-graft implantation for abdominal aortic aneurysm. Fifty-seven patients were treated and followed with serial computed tomography scans for up to 3 years. Patients were allocated to three groups (first 20, second 20, last 17) according to when the repair was performed. Successful treatment is defined as exclusion of the aneurysm from the circulation, based on contrast computed tomography. Success rates in the three groups were 55%, 70% and 100%. Perigraft leak (endoleak) was present on initial assessment in 4/20, 2/20 and 1/17. Two of these aneurysms ruptured early in the postoperative period. Thereafter, leaks were sought and treated aggressively. Kinking and thrombosis occurred in six of the first 20 patients, but did not occur in any of the last 37 patients, in whom the graft limbs were routinely stent-supported throughout. Infrarenal implantation in very a short neck (< 10 mm), or a thrombus-lined neck was associated with proximal stent migration. In conclusion, changes in patient selection and technique have led to a steady rise in the short-term success rate of the stent-grafted implantation.
Closed Superficial Femoral Artery Endarterectomy: A 2-Year Follow-Up
Authors: Moll F. L. , Ho G. H.
Published: September 2024

Closed superficial femoral artery endarterectomy is a minimal invasive technique. Through a single groin incision the occluded intima is remotely removed by a newly modified ring stripper. This device has a double ring which acts like remote scissors and enables the surgeon to recanalize long segmental temoral popliteal occlusive disease. The device was used in 103 limbs in 90 patients. The cumulative assisted primary and secondary patency was 86%. This technique is an alternative to bypass grafting when vein is not available.
Quality of Life Changes after Angioplasty for Claudication: Medium-Term Results Affected by Comorbid Conditions
Authors: Cook T. A. , Galland R. B.
Published: September 2024

Rapid improvements in walking distance and quality of life have been identified in patients with intermittent claudication following percutaneous transluminal angioplasty, but the medium-term results are less well defined. The aim of this study was to assess quality of life and walking distance in the medium term. Walking distance was assessed before percutaneous transluminal angioplasty and at 6 weeks and 1 year after the procedure using a previously validated questionnaire. At the same time, quality of life was assessed using a EuroQol questionnaire and a visual analogue scoring system. Twenty-four patients (12 men, 12 women, mean age 65 years) underwent successful percutaneous transluminal angioplasty (five iliac, 17 femoropopliteal, two both). Significant improvements in walking distance and quality of life were demonstrated following percutaneous transluminal angioplasty. These were maintained at 1 year, although perceived health state deteriorated. During the study period, six patients developed other serious comorbidities. Development of comorbid conditions may affect the medium-term outcome of quality of life studies in patients treated for intermittent claudication. Data from such studies should therefore be interpreted with care.
Annular Dilatation Increases Stress in the Mitral Valve and Delays Coaptation: A Finite Element Computer Model
Authors: Kunzelman K. S. , Reimink M. S. , Cochran R. P.
Published: September 2024

The purpose of this study was to examine the effects of annular dilatation on coaptation, and leaflet and chordal stresses, using a three dimensional finite element computer model. To do this, the whole mitral valve was simulated using ANSYS 4.4A software. Normal model geometry, collagen fiber orientation, tissue thickness, and material properties were determined from fresh porcine valves. For annular dilatation, the annular circumference was increased by 18% versus normal, Isovolumic contraction and rapid ventricular ejection were simulated. Data showed that, in the annular dilatation model, the stress magnitudes increased more than two-fold compared with normal in both the anterior leaflet and posterior leaflet. Coaptation was greatly delayed in the dilatation model, and the leaflets never fully coapted. Chordal stresses were also greatly increased in the dilatation model. In conclusion, increased stress due to annular dilatation may lead to tissue disruption, further dilatation, delayed coaptation, and increased regurgitation, in a ‘closed-loop’ degenerative process.
Differential Patterns of Atherosclerotic Disease in Patients with Unilateral Hemiparesis Resulting from Poliomyelitis: Case Reports Demonstrating the Possible Effect of Hemodynamics
Authors: McMillan W. D. , Pearce W. H. , Yao J. S. T.
Published: September 2024

The relative importance of hereditary and mechanical factors in the pathogenesis of aneurysms remains as controversial today as it was two decades ago. The cases of two patients with unilateral paresis resulting from poliomyelitis who presented with abdominal aortic aneurysms are reported. In addition, each patient had iliofemoral aneurysms contralateral to and iliofemoral occlusive disease ipsilateral to, their affected extremity. The two cases detailed within this report suggest that hemodynamic forces may alter the pattern of disease in arteries affected by arteriosclerosis.
Selective Shunting with EEG Monitoring is Safer Than Routine Shunting for Carotid Endarterectomy
Authors: Salvian A. J. , Taylor D. C. , Hsiang Y. N. , Hildebrand H. D. , Litherland H. K. , Humer M. F. , Teal P. A. , MacDonald D. B.
Published: September 2024

The purpose of this study was to identify whether EEG is an adequate method of monitoring cerebral perfusion during carotid endarterectomy and of determining the need for use of an indwelling shunt. A retrospective review of 305 carotid endarterectomies comparing the results of routinely shunted patients with patients selectively shunted based on EEG monitoring, was carried out. Of the carotid endarterectomies, 92 (30%) were routinely shunted and 213 (70%) were selectively shunted. In the selectively shunted group, 34 (16%) subsequently required shunting. The major stroke rate in the routinely shunted group was 4.4% ((4) cases) and in the selectively shunted group was 0.5% ((1) stroke). Three of the four major strokes in the routinely shunted group were embolic in origin and one was caused by acute thrombosis. The only major stroke in the selectively shunted group was from intracerebral hemorrhage. In conclusion EEG monitoring is a safe and reliable method to determine the need for shunting during carotid endarterectomy. Routine non-selective use of a shunt may increase the risk of perioperative stroke from arterial injury and associated thromboembolism.
Mechanism of Late Prosthetic Vascular Graft Infection
Authors: Jones L. , Braithwaite B. D. , Davies B. , Heather B. P. , Earnshaw J. J.
Published: September 2024

This study was a retrospective analysis of 41 patients with late prosthetic graft infections (> 30 days after operation) from six hospitals in the south-west of England. The 41 patients had a median age of 66 years and generally accepted risk factors for infection were documented in 19 patients preoperatively. Thirteen patients had postoperative wound complications and three had early reoperation at the site of subsequent infection. The median time between index operation and symptoms of infection was 10 (range 1–224) months. Abscess (46%) was the most common presentation followed by false aneurysm (20%) and graft thrombosis (20%). All patients had reoperations (median two per patient, range one to seven). Seven (17%) patients died and 10 (24%) required a major amputation. Bacteria were isolated from retrieved grafts in 23/41 patients (high virulence 14. low virulence nine) and the most frequent organism was coagulase-negative Staphylococcus epidermidis (nine patients). In the majority of cases the aetiology of the late infections in this series was consistent with bacterial implantation at the index operation, but in four cases bacteraemia or intraperitoneal spread was more likely. Dental-type antibiotic prophylaxis would not have prevented any of the infections in this study. Aggressive treatment of recognized sources of infection in patients with vascular grafts is imperative.
Central Venous Stenosis in the Hemodialysis Patient: Incidence and Efficacy of Endovascular Treatment
Authors: Lumsden A. B. , MacDonald M. J. , Isiklar H. , Martin L. G. , Kikeri D. , Harker L. A. , Allen R. C.
Published: September 2024

Central venous stenosis occurs as a complication of central venous catheterization and significantly complicates delivery of dialysis through arteriovenous grafts in the ipsilateral upper limb. This report includes two separate studies. Functioning expanded polytetrafluorethylene grafts have been prospectively evaluated using duplex scanning and angiography performed in all patients with stenoses >50%. From this, it has been prospectively established that the incidence of unsuspected central venous stenoses in patients with functioning grafts is 29%. In the second part of the report, the authors' experience in the treatment of 25 central venous stenoses with percutaneous angioplasty and stent placement has been retrospectively reviewed. Initial technical success rate was 88%. Primary patency was 84% at 1 month, 42% at 6 months, and 17% at 1 year. Mean primary patency was 5.7 months. Stents were placed in five patients. Prevention of central venous stenosis by avoiding subclavian catheterization is optimal. Balloon angioplasty provides short-term patency, but it is the only option in most cases. The role for endovascular stent placement remains to be defined but early results are not optimistic.
Early Experience of Retrograde Cerebral Perfusion
Authors: Usui A. , Abe T. , Murase M. , Tanaka M. , Takeuchi E. , Ishihara T. , Hoshino M. , Ogawa Y. , Seki A. , Okamoto H. , Moriya H.
Published: September 2024

Since 1990, retrograde cerebral perfusion has been applied in aortic arch surgery in the Nagoya University group to protect the brain. This study reviews the group's early clinical results, and especially of neurological outcome in patients undergoing aortic arch surgery via mid sternotomy by using retrograde cerebral perfusion only via the superior vena cava. Seventy-three cases (47 men, 26 women; mean age 62.3 (range 26–82 years)) participated in the study. True aneurysm was diagnosed in 17 cases and aortic dissection in 56. Emergency operations were performed in 49 cases (67%). The proximal aortic arch was replaced in 38 cases, the total aortic arch in 21, the distal arch in six, and the aortic root in two. Mean (s.d.) retrograde cerebral perfusion duration was 55(23) (range 12–115) min and superior vena cava flow rate 350(143) ml/min. Excluding four cases of early surgical death, a total of 10 patients (14.5%) showed neurological dysfunction. Symptoms were coma in eight cases and motor paralysis in two. Three of these 10 cases were recovered without symptoms and six died. The early mortality rate was 19.2%. Significant differences in retrograde cerebral perfusion duration (49(20) versus 83(18)minutes, P < 0.001), superior vena cava pressure (23.2(7.2) versus 28.2(7.4) mmHg. P = 0.046). and preoperative cardiac arrest P < 0.05) were evident between groups with and without neurological dysfunction. There were no neurological dysfunctions in patients undergoing retrograde cerebral perfusion for < 60 minutes at under 30 mmHg of superior vena cava pressure. In conclusion, retrograde cerebral perfusion may be used to extend the duration of safe cerebral circulatory arrest.
Long-Term Follow-Up of Surgical Patients with Single-Ventricle Physiology: Prognostic Anatomical Determinants
Authors: Aeba R. , Katogi T. , Takeuchi S. , Kawada S.
Published: September 2024

Although univentricular or biventricular repair is not always possible for hearts with single-ventricle physiology, it has been proven to produce a satisfactory outcome. It is hypothesized that patient prognosis can be predicted by anatomical diagnosis at presentation. Between 1961 and 1995, 158 patients with single-ventricle physiology, including tricuspid atresia and hypoplastic left heart syndrome, were referred to the authors' institute, and underwent 260 surgical interventions. Follow-up was 99% complete. Patient survival and anatomical risk factors were examined by the Kaplan-Meier method, and multivariate analysis including the Cox proportional hazard model. Mean (s.e.m.) actuarial survival rates at 1, 5, 10 and 20 years following birth were 70.3(3.6)%, 56.3(4.0)%, 48.8(4.2)%, and 40.9(4.7)%, respectively. Definitive palliation was attempted in 38 patients (univentricular in 35 and biventricular in three). Multivariate analysis identified systemic ventricular outflow tract obstruction, mitral atresia, situs ambiguus, and pulmonary vein drainage tract obstruction as independent prognostic factors for overall survival. Visceral heterotaxy was the only independent risk factor for lack of application or failure (death or take-down within 30 days of operation) of univentricular or biventricular repair. In conclusions, these anatomical factors in hearts with single-ventricle physiology affect long-term mortality, despite multiple and heterogeneous surgical efforts.
Effects of Heparin-Coating of Cardiopulmonary Bypass Circuits on Leukocytes during Simulated Extracorporeal Circulation
Authors: Borowiec J. , Jaramillo A. , Venge P. , Nilsson L. , Thelin S.
Published: September 2024

Heparin-coated circuits used during extracorporeal circulation reduce many postoperative complications occurring after heart surgery. Such complications are partly related to leukocyte activation with subsequent release of active substances, e.g. oxygen free radicals, myeloperoxidase and lactoferrin. This experiment was performed to elucidate a possible influence of heparin-coating on leukocytes. A 2-h-long simulated extracorporeal circulation was performed on two groups of five extracorporeal circulation circuits, primed with heparinized, fresh whole human blood and Ringer's solution. Heparin-coated circuits (HC group) were compared with uncoated circuits (NC group). Oxygen free radical production was estimated by determination of malonyldialdehyde in plasma and erythrocyte suspension. Granulocyte activation was measured in terms of myeloperoxidase and lactoferrin release. Time-related changes in leukocyte subset counts were analysed. Heparin-coating diminished myeloperoxidase and lactoferrin release. There were significant inter-group differences after 90 and 120 min of extracorporeal circulation for myeloperoxidase (101 (12) μg/l and 107(12) μg/l in the HC group versus 154(20) μg/l and 174(23) μg/l in the NC group), and after 120 min of extracorporeal circulation for lactoferrin (78(5) μg/l in the HC group versus 212(49) μg/l in the NC group). No significant changes of MDA concentration were observed in plasma or erythrocytes; however, a tendency towards lower MDA levels was seen after 90 and 120 min of extracorporeal circulation in the NC group. Neutrophil, monocyte and eosinophil numbers decreased significantly in the NC group but were unchanged in the HC group, as were lymphocyte counts. Heparin-coated extracorporeal circulation circuits significantly reduce granulocyte activation and better preserve the number of circulating neutrophils, eosinophils and monocytes, but do not change oxygen free radical production during simulated extracorporeal circulation.
Aortic Valve or Root Replacement with Cryopreserved Homograft for Active Infectious Endocarditis
Authors: Riberi A. , Caus Th. , Mesana Th. , Goudard A. , Mouly A. , Habib G. , Monties J. R.
Published: September 2024

Active aortic endocarditis is a serious condition that carries a high mortality and morbidity. The aim of this study was to analyse results obtained from 24 patients who underwent aortic valve or root replacement with cryopreserved homograft for aortic endocarditis. Eleven patients had native valve endocarditis, and 13 had prosthetic valve endocarditis. The mean age was 47.7 years; there were seven women and 17 men. Causative organisms were staphylococci (12). streptococci (four), serratia (one), Candida (one), pneumococci (one), while no organisms were isolated in the remaining five patients. Complete reconstruction of the aortic annulus with homograft conduits was necessary in 20 patients (six total root and 14 mini-root). Infracoronary homograft aortic valve replacement was performed in the remaining patients. One patient died 1 day after the operation from ventricular failure, and two others died after 4 and 6 months as a result of arrhythmia. One patient died of recurrent endocarditis 1 year after surgery. The actuarial survival rate at 3 years was 83.4%. All survivors are symptom-free, with no evidence of recurrent endocarditis. Doppler echocardiography showed minimal aortic regurgitation in four patients.
Prevention of Reoxygenation Injury in Hypoxaemic Immature Hearts by Priming the Extracorporeal Circuit with Antioxidants
Authors: Ihnken K. , Morita K. , Buckberg G. D. , Ihnken O. , Winkelmann B. , Sherman M.
Published: September 2024

This study tests the hypothesis that abrupt reoxygenation of cyanotic immature hearts when starting cardiopulmonary bypass produces an unintended reoxygenation injury that: (i) nullifies the cardioprotective effects of blood cardioplegia; and (ii) is avoidable by adding the antioxidants, N-(2-mercaptopropionyl)-glycine (MPG) plus catalase to the cardiopulmonary bypass prime. Twenty immature piglets (aged 2–3 weeks) underwent 30 min of blood cardioplegic arrest (BCP) with standard clinical blood cardioplegia (hypocalcaemic, alkalotic, hyperosmolar, substrate-enriched). Six piglets remained normoxaemic (BCP). Fourteen others were made hypoxic ( PO2 20–30 mmHg) for up to 2 h by lowering ventilator FiO2 (5–7%) before undergoing reoxygenation on cardiopulmonary bypass at PO2 400 mmHg. In eight animals, the pump prime was not supplemented with antioxidants (Reox + BCP), whereas MPG (80 mg/kg) and catalase (CAT; 5 mg/kg) were added to the pump prime in the other six (MPG/CAT). Myocardial function (end-systolic elastance, conductance catheter), oxidant damage (myocardial conjugated diene production), oxygen consumption and antioxidant reserve capacity were evaluated. Blood cardioplegic arrest caused no functional or biochemical changes in controls without preceding hypoxia. In contrast, hypoxia and reoxygenation in animals undergoing the same blood cardioplegic protocol (Reox + BCP) caused profound myocardial dysfunction, as end-systolic elastance recovered only to 21(2)% ( P < 0.05 versus control) of baseline values. Additionally, it reduced antioxidant reserve capacity (malondialdehyde, MDA at 4.0 mM of t-BHP: 1342(59) ( P < 0.05 versus control) versus 788(53) mmol/g protein), and led to significantly greater production of conjugated dienes during warm induction (42(4.4) ( P < 0.05 versus control) versus 3.3(1.4) A233 nm/100 g per min) and reperfusion (22(2.7) ( P < 0.005 versus control) versus 2(0.6) A233 nm/100 g per min). Conversely, supplementation of MPG plus catalase to the pump prime reduced lipid peroxidation (conjugated diene production during warm induction: 22.3(7) A233 nm/100 g per min P < 0.05 versus Reox + BCP), restored antioxidant reserve capacity (MDA at 4.0 M of t-BHP: 975(139) mmol/g protein P < 0.05 versus Reox + BCP) and allowed almost complete functional recovery (80(8)%). Abrupt reoxygenation of hypoxaemic immature hearts on cardiopulmonary bypass causes oxidant damage, nullifies the cardioprotective effects of blood cardioplegia, and leads to reduced myocardial contractility. Antioxidant supplementation of the cardiopulmonary bypass prime avoids these detrimental effects, and results in improved biochemical and functional status.
Retrograde Cold Blood Cardioplegia. Obliteration of the Posterior Interventricular Vein in the Coronary Sinus Improves Cooling of the Left Ventricle Posterior Wall
Authors: Bezon E. , Barra J. A. , Mondine P. , Karaterki A.
Published: September 2024

The study hypothesis was that obliteration of the posterior interventricular vein in the coronary sinus avoids the back leak of cardioplegia to the right atrium and forces cardioplegia towards the posterior wall of the left ventricle and interventricular septum. A new retrograde cardioplegia cannula with a long balloon (3 cm) was designed which obstructs the posterior interventricular vein in the coronary sinus. The hypothesis was tested by a prospective randomized study in 52 consecutive patients who underwent coronary or aortic valve surgery. In group I ( n = 26), the cannula prototype was used, while a standard cannula (balloon length 8 mm) was used in group II ( n = 26). The cardioplegic solution was cold blood (14°C). The posterior wall temperature was recorded when the anterior wall temperature reached 15°C. In group 1, 91% of patients had the same temperature in the anterior and posterior walls of the left ventricle versus 19% in group II ( P < 0.05). The mean of the difference of left ventricular temperatures between anterior and posterior walls was 0.5°C (σ = 1.7) in group I versus 8°C (σ = 4.1) in group II (α < 0.05). In group 1.9.5% of patients had a posterior wall temperature > 20°C versus 81% in group II ( P < 0.05). Cooling of the posterior wall of the left ventricle is better in group 1 than in group II. As cooling and cardioplegia flow are closely linked, obliteration of the posterior interventricular vein in the coronary sinus improves left ventricular distribution of the cardiplegia.
Patency of Infrainguinal Polytetrafluoroethylene Bypass Grafts with Distal Interposition Vein Cuffs
Authors: Pappas P. J. , Hobson R. W. , Meyers M. G. , Jamil Z. , Lee B. C. , Silva M. B. , Goldberg M. C. , Padberg F. T.
Published: September 2024

Polytetrafluoroethylene (PTFE) prosthetic bypasses in the lower extremity have poor patency rates, particularly in limb salvage cases. Patency and limb salvage rates of PTFE bypasses supplemented by distal interposition vein cuffs were assessed in patients requiring revascularization for critical limb ischemia, in the absence of a suitable autologous saphenous vein. Between October 1993 and April 1996, 163 patients underwent 185 infrainguinal bypasses. Forty-three limbs in 42 patients (12 women, 30 men; mean age 67 years) did not have a suitable autologous saphenous vein (24%) and had femoropopliteal (20) and infrapopliteal (23) bypasses performed. Patients were examined prospectively at 3-month intervals during the first year and at 6-month intervals thereafter to determine graft patency and limb salvage. Postoperative anticoagulation with warfarin was used in 26 patients. Indications for operation included limb salvage in 41 extremities (21 rest pain/ulceration or gangrene, 20 rest pain alone), and disabling claudication in two. Patients were followed clinically for 2–30 months (mean 10 months). Cumulative 2-year life-table patencies for all grafts, femoropopliteal and infrapopliteal bypasses were 64%, 75% and 62%, respectively. Previous primary patencies at the authors' institution for PTFE bypasses without vein cuffs were 35%, 46% and 12% for the same categories. Cumulative life-table limb salvage for all PTFE/vein cuff bypasses in the present series was 76% compared with 37% in previous PTFE bypasses without vein cuffs. Adjunctive use of distal interposition vein cuffs improves prosthetic graft patency, while producing satisfactory limb salvage. Postoperative anticoagulation did not influence graft patency. PTFE/vein cuff for lower-extremity revascularization shows good 2-year patency and is an acceptable alternate conduit in patients with critical limb ischemia when autologous saphenous vein is absent.
Nondissection Method for Tibial Bypass Surgery Using Esmarch's Rubber Bandage or An Automatic Sequential Pneumatic Tourniquet: Long-Term Results
Authors: Shindo S. , Lyori K. , Kobayashi M. , Suzuki O. , Kamiya K. , Tada Y. , Takayama Y. , Miyata T. , Sato O. , Takagi A.
Published: September 2024

It is suspected that operative injury to the native arteries during a vascular bypass procedure causes periarterial fibrosis contributing to late graft failure. A a nondissection method for tibial artery bypass has been developed using Esmarch's rubber bandage or an automatic sequential pneumatic tourniquet. This retrospective study examined patency and other late results in distal bypass operations using the nondissection method. Between June 1982 and July 1995, 78 tibial bypasses were performed using reversed autogenous saphenous vein grafts in 70 patients (57 men, 13 women: mean age 57.4 years). Graft patency was assessed angiographically. When a stenotic lesion was recognized, the graft was revised and considered an assisted primary patency. Primary patency rates at 1, 3, 5, and 10 years were 82.8%, 75.3%, 63.4% and 63.4%, respectively, by life-table analysis. Six grafts required revision for stenosis; one involved distal anastomotic stenosis. As a result, assisted primary patency rates resembled secondary patency rates of 87.7%, 84.3%, 80.3%, and 80.3% at the same respective intervals. In conclusion, the nondissection method improved long-term patency by preventing late distal anastomotic stenosis.
Mesenteric Bypass for Chronic Mesenteric Ischaemia
Authors: Wolf Y. G. , Verstandig A. , Sasson T. , Eidelman L. , Anner H. , Berlatzky Y.
Published: September 2024

Chronic mesenteric ischaemia is an uncommon disease that requires treatment to relieve the symptoms of abdominal angina and to prevent intestinal infarction. Over a period of 3 years. 12 patients with visceral artery stenosis or occlusion were referred to the authors' service and 10 underwent mesenteric bypass grafting. Both the coeliac and the superior mesenteric arteries were revascularized in four patients, and the superior mesenteric artery alone in six patients, using a variety of grafts and graft configurations. This was done in conjunction with aortic graft placement in four cases and with renal bypass in three. All patients survived the procedure. At a mean follow-up of 28 months, one patient died of myocardial infarction 42 months after surgery, while all survivors are symptom-free. Chronic mesenteric ischaemia can be treated safely and effectively. The variation in the pattern of mesenteric occlusions and the frequent association with aortic and renovascular disease does not allow for a single ‘best’ technical solution but requires the surgical procedure to be individually tailored.