bluuebunny/crossref_metadata_2025 huggingface dataset:
Adult Respiratory Distress Syndrome after Cardiac Surgery
Authors: Christenson J. T. , Aeberhard J.-M. , Badel P. , Pepcak F. , Maurice J. , Simonet F. , Velebit V. , Schmuziger M.
Published: September 2024

Adult respiratory distress syndrome, characterized by high permeability pulmonary oedema caused by endothelial cell damage, resulting in refractory hypoxemia, has a very high mortality. Cardiopulmonary bypass is said to be responsible for the development of adult respiratory distress syndrome after cardiac surgery. The present study was performed in order to identify predicting and aetiological factors of adult respiratory distress syndrome and multiple organ failure after cardiac surgery. Between January 1984 and December 1993, 3848 patients underwent cardiac surgery with cardiopulmonary bypass in the authors' institution, and were analysed in a retrospective manner. The operations performed were 3444 coronary artery bypass grafts (CABG), 267 valve and 137 combined (CABG + valve) procedures. The incidence of adult respiratory distress syndrome was 1.0% (38 of 3848) with an overall mortality rate of 68.4% (26 patients); 24 of these died from multiple organ failure. Multivariate regression analysis Identified hypertension, current smoking, emergency surgery, preoperative New York Heart Association (NYHA) class 3 and 4. low postoperative cardiac output and left ventricular ejection fraction < 40% as significant, independent predictors for adult respiratory distress syndrome. Combined cardiac surgery and diffuse coronary disease were also significant predictors: cardiopulmonary bypass time was not. Thirty-six of the 38 patients that later developed adult respiratory distress syndrome had low postoperative cardiac output. 12 requiring intra-aortic balloon pump support. The remaining two had severe hypotension caused by postoperative bleeding. Twenty-six adult respiratory distress syndrome patients (68%) had confirmed gastrointestinal complications (e.g. intestinal ischaemia). Adult repiratory distress syndrome is a rare complication after cardiac surgery but is associated with a very high mortality. Preoperative predictors were identified. Cardiopulmonary bypass alone was not found to be an Important factor. Postoperative low cardiac output leading to splanchnic hypoperfusion may be the most Important single factor in developing adult respiratory distress syndrome after cardiac surgery.
Isolated Apical Intracavitary Left Ventricular Abscess in a Normal Heart: A Rare Complication of Streptococcus Milleri Endocarditis
Authors: Hurlé A. , Nistal J. F. , Gutierrez J. A. , Rodriguez M. A. , Revuelta J. M.
Published: September 2024

A 31-year-old patient without past history of cardiac disease presented with an atypical form of Streptococcus milleri endocarditis. The disease progressed in an unusually aggressive manner, with abscess formation in the apex of the left ventricular cavity. The cardiac valves functioned normally and were not affected by the disease.
Carotid Endarterectomy in Patients with Contralateral Carotid Occlusion: Review of a 10-Year Experience
Authors: Coyle K. A. , Smith R. B. , Salam A. A. , Dodson T. F. , Chaikof E. L. , Lumsden A. B.
Published: September 2024

A total of 116 carotid endarterectomies were performed in patients with a totally occluded opposite internal carotid artery over a 10-year period from 1983 until 1992. The average age of patients was 66.4 years; 75% were men and 25% were women. The average degree of stenosis on the operated side was 76.7%. Twenty-one patients (18.1%) had had a documented previous stroke referrable to the side of the occlusion; 22 had a neurologic deficit attributable to the occluded vessel at the time of preoperative evaluation. Indications for surgery included transient ischemic attacks in 35 (30.2%), ipsilateral stroke in 10 (8.6%), amaurosis fugax in 11 (9.5%), and high-grade asymptomatic stenosis in 60 (51.7%). Forty-eight percent of the procedures were performed using local anesthesia, with intraluminal shunts inserted in all except one patient. The combined 30-day mortality and stroke morbidity in this population was 4.3%, which is comparable with a combined stroke and death rate of 4.0% among 956 patients without contralateral carotid occlusion undergoing endarterectomy during this period. This experience suggests that endarterectomy can be performed safely in the patient with internal carotid occlusion and is an important mechanism for the prevention of stroke.
Somatosensory Evoked Potential Monitoring during Carotid Surgery
Authors: Schwartz M. L. , Panetta T. F. , Kaplan B. J. , Legatt A. D. , Suggs W. D. , Wengerter K. R. , Marin M. L. , Veith F. J.
Published: September 2024

Controversy exists over the value of intraoperative monitoring and shunting in patients undergoing carotid endarterectomy. Although it is widely believed that contralateral carotid occlusion and previous stroke mandate intraoperative shunting, the susceptibility of these two groups of patients to cerebral ischemia during carotid artery endarterectomy is not well defined. Somatosensory evoked potentials (SSEPs) were monitored in 113 carotid artery endarterectomy patients. Of these, 32 (28.3%) had a previous stroke. 24 (21.2%) had a contralateral carotid occlusion and 33 (29.2%) were diabetic. There were no deaths and only one perioperative stroke (0.9%). Cerebral ischemia occurred in 14 patients (12.4%). Six of these patients had a contralateral carotid occlusion. Some 29 patients (25.7%) were shunted, including 10 with contralateral carotid occlusions that did not have major SSEP changes. In the latter half of the study. 14 patients with contralateral carotid occlusions were selectively shunted (six shunted, eight not shunted) with no neurological complications. Thirty-two patients with prior strokes were selectively shunted (nine shunted, 23 not shunted); of these, one shunted patient undergoing combined carotid artery endarterectomy and coronary artery bypass grafting had a perioperative stroke. Intraoperative monitoring with SSEPs accurately identifies cerebral ischemia secondary to carotid clamping as well as patients requiring shunts. With the use of intraoperative SSEP monitoring, selective shunting may be safely performed in patients with a contralateral carotid occlusion or a previous stroke.
Syme Amputation: Results in Patients with Severe Forefoot Ischemia
Authors: Weaver F. A. , Modrall J. G. , Baek S. , Harvey F. , Siegal A. , Rosental J. , Yellin A. E.
Published: September 2024

Since 1980, 35 patients (age range 40–77 years) with severe forefoot ischemia have undergone a unilateral Syme amputation. Thirty-one patients (89%) were diabetic. The indication for amputation was either extensive forefoot gangrene or ulceration too advanced for a digital or transmetatarsal amputation. Twenty-two amputations (63%) were immediately preceded by either percutaneous tranluminal angioplasty (four) or a bypass procedure to the popliteal artery (five) or an infrapopliteal artery (13). Primary healing occurred in 19 (86%) of 22 amputations immediately preceded by revascularization and in 10 (77%) of 13 limbs undergoing amputation alone. Twenty-eight (97%) of the 29 patients with successful primary healing were successfully rehabilitated. Rehabilitation rendered 13 patients fully ambulatory, 15 ambulatory with intermittent use of a walker or cane and one unable to walk. At follow-up of four months to 13 years (mean 42 months), the cumulative ambulatory rate at 1, 3, and 5 years was 92, 80 and 80%, respectively. Syme amputation allows a return to a functional ambulatory status in a high percentage of patients with severe forefoot ischemia. These findings suggest that Syme amputation is an acceptable option in dysvascular patients with severe forefoot ischemia.
Heart Transplant for the Failing Ischaemic Ventricle
Authors: Nataf P. , Gandjbakhch I. , Pavie A. , Bors V. , Dorent R. , Vaissier E. , Levasseur J. P. , Leger Ph. , Cabrol A. , Cabrol C.
Published: September 2024

Clinical application of heart transplantation goes beyond 28 years' experience. Ischaemic heart diseases remain, with idiopathic cardiomyopathies, the main indications for cardiac transplant. A combination of haemodynamic, contractile and viability measurements may be useful to choose between transplant and coronary revascularization for the failing ischaemic ventricle. Advances in the detection of early rejection, improved organ preservation procedures, and the introduction of new immunosuppressive therapy protocols have produced dramatic results in heart transplantation. Late graft atherosclerosis remains a serious threat despite retransplantation and, in some cases, mechanical circulatory support.
Transaortic Approach Has a Role in the Surgical Treatment of Ventricular Septal Defects
Authors: Leão L. E. V. , Buffalo E. , Coto A. E. , Maluf M. A. , Andrade J. C. S.
Published: September 2024

A transaortic approach was used for surgical closure of ventricular septal defects (VSDs), sometimes as first choice and otherwise as an alternative approach. This paper presents the experience in a group of 124 patients who underwent VSD closure by a transaortic approach in an 18-year-period, between 1974 and 1992. Patients were divided in three groups: (I) Isolated VSD, 89 patients (mean age 7.6 years); (II) VSD associated with other malformations, 27 patients (mean age 10.8 years); and (III) recurrent VSD, eight patients (mean age 15.6 years). Two deaths occurred in the postoperative period (2/124), one after closure of VSD in a patient with severe pulmonary hypertension; another death was observed after transaortic closure of the VSD as part of the repair of a complex heart malformation. There were no instances of new right bundle branch block (RBBB) in the group operated on for isolated VSDs. Three cases of left bundle branch block (LBBB) (3.4%) occurred in the isolated VSD group. There were no cases of complete aortic valve (AV) block in the whole series and no instances of AV dysfunction. The transaortic approach is an alternative for the surgical treatment of ventricular septal defects. The ease of exposure and closure of defects suggest this technique to be a particularly attractive approach in the treatment of small to moderate-sized VSDs and also in recurrent VSDs.
Cardiac Case Reports: Long-Term Extracorporeal Membrane Oxygenation in a Newborn Child after Arterial Switch Operation
Authors: Alexi-Meskishvili V. , Nürnberg J. H. , Werner H. , Lange P. E. , Hetzer R.
Published: September 2024

A 7-day-old newborn girl with d-transposition of the great arteries (d-TGA) and complex coronary anatomy developed global myocardial dysfunction after arterial switch operation despite establishment of an effective coronary circulation. Extracorporeal membrane oxygenation was used for circulatory support for 163 h after the operation. On day 7 after surgery she was successfully weaned from extracorporeal membrane oxygenation and is currently symptom-free 10 months after the operation. This case illustrates the effectiveness of extracorporeal membrane oxygenation for circulatory support after the arterial switch operation. In such cases, establishing adequate coronary circulation during surgery is mandatory to ensure a successful postoperative myocardial recovery.
A Prospective Study to Define the Optimum Rescreening Interval for Small Abdominal Aortic Aneurysm
Authors: Cook T. A. , Galland R. B.
Published: September 2024

A prospective study of 99 patients with small abdominal aortic aneurysms was undertaken using serial ultrasound to assess the optimum screening interval. Fifty-three patients had aneurysms measuring 2.5–3.9 cm and 46 patients aneurysms of 4.0–4.9cm. Aneurysms measuring 2.5–3.9cm were screened annually and those >4.0cm every 6 months. There were eight deaths in the 2.5–3.9cm group, none attributable to a ruptured aneurysm and five patients have had their aneurysm repaired. Nine patients died in the 4.0–4.9cm group, one with a ruptured aneurysm measuring 5.6 cm at her previous screening visit and who was unfit for operation. No other patient had an aneurysm which ruptured between scans. There were seven elective repairs in this group. No patient died following elective operation in either group. The mean growth rate of aneurysms in the 2.5–3.9cm group was 2.2 mm in the first year, 2.8 mm in the second and 1.8 mm in the third. Corresponding growth rates in the 4.0–4.9cm group were 2.7 mm. 4.2 mm and 2.2 mm. This study supports a policy of annual screening for aneurysms measuring 2.5–3.9 cm and 6-monthly screening for those ≥ 4.0 cm.
A Prospective Randomized Study of Abdominal Aortic Surgery without Postoperative Nasogastric Decompression
Authors: Friedman S. G. , Sowerby S.-A. , Del Pin C. A. , Scher L. A. , Tortolani A. J.
Published: September 2024

Nasogastric decompression following abdominal aortic aneurysmectomy or bypass, for 3–4 days, is a routine part of postoperative care in many centers. A prospective randomized study of 80 patients undergoing abdominal aortic surgery was performed in order to determine the necessity of prolonged nasogastric decompression. Patients were divided evenly between removal of the nasogastric tube upon tracheal extubation and retention of the tube until the passage of flatus. Preoperative risk factors, aortic cross-clamp time, estimated blood loss, length of procedure, length of intensive care unit stay, numbers of days with nasogastric tube, number of days until clear liquid and regular diets commenced, and the length of hospital stay were recorded for all patients. There were no significant differences in any of the measured variables between the two groups. The length of hospital stay was similar in both groups and three patients in each group required a nasogastric tube or reinsertion of one. In conclusion, the routine postoperative use of nasogastric tubes for abdominal aortic procedures is unnecessary.
Extraluminal Endoscopic-assisted Ligation of Venous Tributaries for Infrainguinal In Situ Saphenous Vein Bypass: A Preliminary Report
Authors: Rosenthal D. , Tucker J. G. , Atkins C. P. , Walters A. S. , Newman C. L. , Lamis P. A. , Clark M. D.
Published: September 2024

In an attempt to obviate the need for an incision the length of the leg during in situ saphenous vein bypass, a minimally invasive operation using ‘laparoscopic techniques’ was developed. At operation, standard incisions were made over the proximal femoral artery/vein and the saphenous vein at the distal popliteal artery level. An angioscopic valvulotome was used to perform valvulotomy under direct vision. After valvulotomy, a distention balloon system was used to form a ‘pocket’ into which a laparoscope was inserted. Trocars were then inserted under direct vision and the saphenous vein dissected and side branches individually clipped. After occlusion of the venous side branches, proximal and distal arterial anastomoses were performed in the standard fashion. This minimally invasive operation using laparoscopic techniques precludes the need for a long leg incision and saphenous vein dissection, except at the proximal and distal arterial anastomoses.
Continuous Venovenous Haemofiltration in Neonates with Renal Insufficiency Resulting from Low Cardiac Output Syndrome after Cardiac Surgery
Authors: Leyh R. G. , Nötzold A. , Kraatz E. G. , Sievers H. H. , Bernhard A.
Published: September 2024

Acute renal insufficiency is a common complication after surgery for congenital cardiovascular defects in neonates and is associated with a high incidence of morbidity and mortality. The authors reviewed their experience with continuous venovenous haemofiltration in neonates and infants with acute renal insufficiency resulting from low cardiac output following cardiovascular surgery. Twelve critically ill patients with pharmacologically intractable fluid overload were treated with continuous venovenous haemofiltration over a period of 42 months. All patients were mechanically ventilated and dependent on high doses of catecholamines. Continuous venovenous haemofiltration was started 64.2(28.2) h postoperatively and maintained for a period of 8 to 195 h. A negative fluid balance was achieved in all patients (2.1 (0.5) ml/kg per h). No complications relating to continuous venovenous haemofiltration were evident during the treatment. The survival rate was 59% (seven of 12). Continuous venovenous haemofiltration is a valid and simple method for controlling fluid overload in neonates and infants with low cardiac output.
The Sheep as an Animal Model for Heart Valve Research
Authors: Ali M. L. , Kumar S. P. , Bjornstad K. , Duran C. M. G.
Published: September 2024

The first test used to assess new heart valve prostheses and devices is to implant them in a medium-sized animal. This is a costly piece of research and it is important to select the most appropriate animal. The authors feel that the sheep is an appropriate animal model for heart valve research and describe their experience in this area. It is hoped that the detailed description provided will be useful to any other group contemplating similar studies.
Myocardial Revascularization for Severe Left Ventricular Dysfunction. Factors Influencing Early and Late Survival
Authors: Louagie Y. , Jamart J. , Buche M. , Eucher P. , Haxhe J.-P. , Lhommel R. , Schoevaerdts D. , Gonzalez M. , Marchandise B. , Schoevaerdts J.-C.
Published: September 2024

The results of coronary bypass surgery have been assessed in 102 patients with severe left ventricular dysfunction who had a preoperative left ventricular ejection fraction of ≤0.35 (mean(s.e.m.) 0.29 (0.01)). Independent risk factors influencing operative mortality were obesity ( P = 0.0290) and the need for preoperative intra-aortic balloon counterpulsation ( P = 0.0010). Cox regression analysis using as its end-point ‘cardiac-related death’ demonstrated three variables; the need for preoperative intra-aortic balloon counterpulsation ( P < 0.001), advanced age ( P = 0.011), and obesity ( P = 0.036). In a subset of 43 patients who did not have these risk factors, the 4-year cardiac-related death rate was 95.1 (3.4)%. The operative mortality and long-term survival can be expected to be satisfactory in patients with severe left ventricular dysfunction, provided they have a viable myocardium rather than myocardial fibrosis.
Experimental Evaluation of Bleeding Complications, Thrombogenicity and Neointimal Characteristics of Prosthetic Patch Materials Used for Carotid Angioplasty
Authors: Rhee R. Y. , Gloviczki P. , Cambria R. A. , Miller V. M.
Published: September 2024

Experiments were designed to compare perioperative blood loss, early thrombogenicity and morphologic and functional characteristics of the neointima of three types of prosthetic materials used for carotid artery patch angioplasty. Bilateral carotid patch angioplasties were performed in 20 dogs, using 20 gelatin-impregnated fluoropassivated Dacron (GIF), 10 untreated knitted Dacron and 10 expanded polytetrafluoroethylene (PTFE) patches (5 cm2). Intraoperative blood loss, platelet deposition at 24 h and neointimal morphology at 6 weeks after the operation were assessed. Bioassay of the neointima was performed at 6 weeks in 16 patches. Mean (s.e.m.) blood loss was significantly less in GIF patches (14.7 (2.7) ml) compared with either PTFE (75.6 (24) ml) or untreated Dacron (64. 3 (9.5)) ( P < 0.005). Mean (s.e.m.) platelet deposition in GIF patches (1380 (328) platelets/cm2) was approximately 50% less at 24 h than in untreated Dacron (2562 (1035) platelets/cm2) or PTFE (2140 (998) platelets/cm2) patches ( P < 0.05). Neointimal coverage was greater in PTFE (94 (1.3%)) compared with GIF (79 (2.7%)) or untreated Dacron (86(2.4%)) patches ( P < 0.05). The thickness of the neointimal layer of PTFE (0.5 (0.01) mm) patches was greater than other patch types; GIF (0.2 (0.01) mm) or untreated Dacron (0.3 (0.01) mm) ( P < 0.05). Under bioassay conditions, acetylcholine caused release of vasoactive relaxing factor(s) from all patches. However, relaxations from baseline were less with GIF patches (−37.9 (11.7)% versus −54.5 (9.6) for untreated Dacron; −50.2 (15.2)% for PTFE) ( P = n.s.). Endothelin-1 release occurred from all patches and was increased with the extent of neointimal coverage. These data demonstrate that GIF patches caused the least perioperative bleeding, were the least thrombogenic at 24 h and developed the thinnest neointima at 6 weeks. All patch materials developed a functioning neointima.
Total Arterial Myocardial Revascularization without Cardiopulmonary Bypass
Authors: Sani G. , Mariani M.A. , Benetti F. , Lisi G. , Totaro P. , Giomarelli P.P. , Toscano M.
Published: September 2024

The risks associated with cardiopulmonary bypass have led to an interest in coronary surgery without the use of such a bypass. Six patients of mean(s.d.) age 62.0(8.0) (range 52–71) years were selected for elective coronary surgery without cardiopulmonary bypass. In five cases a midline sternotomy and in one case a small anterolateral thoracotomy were performed; in the latter case the harvesting of the proximal end of the left internal mammary artery was video-assisted by thoracoscopy. The left internal mammary artery was used in all cases; the right internal mammary artery was used in one case, the radial artery in four, the inferior epigastric artery in two and the right gastroepiploic artery in one. No patient died or had a stroke. There were no postoperative episodes of low cardiac output syndrome or perioperative myocardial infarction. All patients were extubated within a few hours after surgery. The mean(s.d.) intensive care unit and hospital stays were 1.3(0.5) and 5.0(0.9) days, respectively. Total arterial myocardial revascularization without cardiopulmonary bypass using composite grafts, is a new and promising technique that is feasible with low risks and good early results in selected cases.
Complex Venous Reconstruction for Chronic Iliofemoral Vein Obstruction
Authors: Schanzer H. , Skladany M.
Published: September 2024

A 35-year-old patient, physically very active, developed symptoms and signs of postphlebitic venous obstruction in the right lower extremity that was complicated by deep venous thrombosis, while recovering from a motorcycle accident. Duplex and venography demonstrated occlusion of the right superficial femoral vein and right external iliac vein. Strain-gauge plethysmography and measurements of venous pressures demonstrated functional obstruction. The patient underwent saphenous cross-femoral vein bypass, right saphenous—popliteal anastomosis accompanied with distal posterior tibial to saphenous vein arteriovenous fistula. Ten days following surgery, the arteriovenous fistula and the distal great saphenous vein closed spontaneously. The rest of the reconstruction remained patent as documented by duplex up to 24 months following the surgery. Clinically, the patient is doing well, tolerating heavy physical exertion as before his accident. The importance of selection of patients for venous bypass surgery is stressed. Only patients with co-existing anatomical and functional obstruction are good candidates for these procedures.
Venous Allografts for Infrainguinal Vascular Bypass
Authors: Rebane E. , Tikko H. , Tunder E. , Lepner U. , Helberg A. , Pulges A. , Vaasna T. , Suba S. , Lieberg J. , Tamm V. , Ellervee T. , Vasar O.
Published: September 2024

Between 1978 and 1993, 107 patients received venous allografts for infrainguinal revascularization because autogenous material was unavailable. These operations comprised 7.4% of 1442 reversed vein bypass procedures performed during the same period. Alloveins were harvested during varicose vein stripping and stored up to 10 days in saline solution containing heparin and antibiotics. Veins with or without minimal degenerative changes were used and when necessary segments were sutured end-to-end to obtain a convenient length. The patients comprised 95 men and 12 women of age range 44–87 years. All operations were performed for limb salvage (rest pain and gangrene); 40 femoropopliteal and 67 femorocrural bypasses were performed; 66 were primary reconstructions and 41 secondary reconstructions. The operative mortality rate was 3.7%. Early thrombosis occurred in 18 patients (16.8%), nine of whom were successfully reoperated upon. The cumulative patency rates for all bypass operations was 82.9%, 38.7% and 21.3% at 30 days, 3 and 5 years, respectively, the limb salvage rates being 84.8%, 48.0% and 29.2%, respectively. Allografts may have a place in lower-limb bypass surgery in the absence of veins, polytetrafluoroethylene or human umbilical vein.
Traumatic First Rib Fracture: Is Angiography Necessary? A Review of 730 Cases
Authors: Gupta A. , Jamshidi M. , Rubin J. R.
Published: September 2024

The two most common sites of first rib fracture were at the subclavian sulcus and in the neck of the first rib, posteriorly. Five distinct mechanisms for rib fracture were identified and included: (i) posteriorly directed trauma to the upper thorax or shoulder girdle; (ii) a direct blow to the sternum and anterior chest wall; (iii) a blow fracturing the clavicle; (iv) a strong sudden contraction of the scalenus anticus muscle: and (v) radiographic findings of a first rib fracture without history of trauma. Isolated first rib fracture regardless of mechanism of injury, results in a low incidence of major vascular injury (mean 3%), although with fracture displacement, the incidence is higher. First rib fracture associated with concomitant head, thoracic, abdominal, or long bone trauma was associated with vascular injury in 24% of cases. According to this review, specific indications for subclavian artery and aortic arch arteriography in patients with traumatic first rib fracture include widened mediastinum on chest radiography, upper-extremity pulse deficit, posteriorly displaced first rib fracture, subclavian groove fracture anteriorly, brachial plexus injury and expanding hematoma.
Comparison of Transperitoneal and Retroperitoneal Approaches for Infrarenal Aortic Surgery: Early and Late Results
Authors: Sieunarine K. , Lawrence-Brown M. M. D. , Goodman M. A.
Published: September 2024

The retroperitoneal approach to the infrarenal aorta was purported to have a shorter recovery and reduced degree of surgical stress than the transperitoneal approach. Hence, this study aimed to determine any advantages of one approach over the other. One hundred patients undergoing infrarenal aortic surgery between 1989 and 1992 were randomized to the transperitoneal or retroperitoneal approach; 64 operations were for aneurysms (32 transperitoneal. 32 retroperitoneal) and 36 for occlusive disease (18 transperitoneal, 18 retroperitoneal). Parameters monitored were operating time, cross-clamp time, blood loss, fluid requirement in first 24 h, analgesia requirements, gastrointestinal function, morbidity, mortality and length of stay in intensive care and hospital. A minimum 3-year follow-up was obtained to assess mortality and wound problems. Inter-group demographic data were comparable. There was no significant difference between the two approaches for: operating time 190 versus 202 min, P = 0.26); cross-clamp time (72 versus 81 min, P = 0.93); blood loss (1095 versus 1072 ml, P = 0.56); 24-hour fluid requirements (6900 versus 7000 ml, P = 0.45); analgesia requirements (60 versus 55mg, P = 0.37), gastrointestinal function, morbidity ( P = 0.75), mortality, and length of stay in intensive care (2 versus 2 days. P = 0.80) and hospital (10.5 versus 10 days, P = 0.76). In the long term there were significantly more wound problems (bulging, hernias and wound pain) in the retroperitoneal group. Long-term mortality was similar in both groups.
Surgery of Descending Thoracic Aortic Aneurysms with Centrifugal Pump Support
Authors: Biglioli P. , Spirito R. , Agrifoglio M. , Pompilio G. , Parolari A. , Dainese L. , Arena V. , Sala A.
Published: September 2024

Fifty-five patients with descending thoracic aortic aneurysms were operated upon between October 1987 and October 1994. All patients were supported by a centrifugal pump during operation. The mean(s.d.) duration of cross-clamping was 39(13) min. In order to evaluate the efficacy of the centrifugal pump, haemodynamic and metabolic measurements were made on four occasions (before cross-clamping, immediately after cross-clamping and before cross-clamp removal) and again after cross-clamp removal. The haemodynamic data remained stable throughout the procedure: central venous pressure (15(4.6) versus 16(4.8) versus 16(4.6) versus 15(4.6) mmHg; P = n.s.), pulmonary artery pressure (25(6.2) versus 24(5.1) versus 22(5.3) versus 23(4.4) mmHg: P=n.s.), radial systolic pressure (119(19.9) versus 116(25.2) versus 111 (25.9) versus 111(20.7) mmHg; P = n.s.) and heart rate(75(12.6) versus 77(14) versus 76(15.6) versus 78(16) beats/min; P = n.s.). The acid-base status deteriorated slowly during surgery. Values before and after cross-clamping were: pH (7.42 (0.04) versus 7.37(0.06); P < 0.05), base excess (−0.67(2.20) versus −3.70(2.50); P < 0.05) and bicarbonates (24(8.9) versus 20(1.9); P < 0.05). The cerebrospinal fluid pressure remained constant: 20(5.7) versus 19(5.9) versus 18(5) versus 19(5) mmHg; P = n.s. Renal function, measured before, and at 1, 3 and 7 days after the operation also remained stable (creatinine: 1.1(0.4) versus 1.2(0.4) versus 1.2(0.4) versus 1.2(0.4); P = n.s.; blood urea nitrogen: 46(18.7) versus 46(18.6) versus 51(24.9) versus 55(27.9); P = n.s.). Step-wise multiple linear regression comparing cerebrospinal fluid pressure against haemodynamic and metabolic data showed that during aortic cross-clamping there was a significant relationship between central venous pressure ( P <0.0013) and arterial pH ( P <0.0148), while before and after cross-clamping multivariate analysis showed a relationship only between central venous pressure and cerebrospinal fluid pressure ( P <0.0035). The results confirm that centrifugal pump support is effective in stabilizing haemodynamics and protecting the kidney during thoracoabdominal aneurysm repair.
Abdominal Aortic Aneurysm Repair during Cardiopulmonary Bypass: Rationale for a Combined Approach
Authors: Falk V. , Walther T. , Mohr F. W.
Published: September 2024

Coronary artery disease and poor left ventricular function are the most important risk factors for morbidity and mortality in patients undergoing abdominal aortic aneurysm repair. Effective screening programmes and prior revascularization procedures (percutaneous translumincal coronary angiography and coronary artery bypass graft surgery) have helped to decrease the risk of cardiac-related adverse events. There is however, a subgroup of patients presenting with both severe coronary artery disease and/or severely impaired left ventricular function and an acutely expanding or extremely large aneurysm that represents a therapeutic challenge. Surgery is often denied to these patients for their high risk. For this selected subgroup combined coronary artery bypass graft surgery and abdominal aortic aneurysm repair rather than a staged approach represents a therapeutic alternative. This article summarizes the pathophysiological concept, that favours a simultaneous approach performing abdominal aortic aneurysm repair during cardiopulmonary bypass and updates the current indications and results for this extensive surgery.
Supraceliac versus Infrarenal Aortic Cross-Clamp for Repair of Non-Ruptured Infrarenal and Juxtarenal Abdominal Aortic Aneurysm
Authors: Schneider J. R. , Gottner R. J. , Golan J. F.
Published: September 2024

Repair of abdominal aortic aneurysms may require aortic occlusion above the renal arteries. Despite fears of renal, hepatic and intestinal ischemia, recent publications have suggested that when repair would be difficult or impossible with infrarenal aortic clamping, supraceliac clamping may not be associated with significantly increased morbidity. Between February 1985 and January 1994. 169 patients underwent elective or urgent (symptomatic but not ruptured) repair of infra- or juxtarenal abdominal aortic aneurysm. Twenty-three patients (14%) required supraceliac clamping for juxtarenal abdominal aortic aneurysm, inflammatory abdominal aortic aneurysm, or other difficult exposure problems. Supraceliac clamping and infrarenal aortic clamping patients were indistinguishable with respect to age, gender, abdominal aortic aneurysm diameter, and other co-morbidities. There was a trend toward more frequent use of supraceliac clamping in urgent operations. Preoperative angiography was used selectively and was obtained more often in supraceliac clamping patients, reflecting suspected juxtarenal or renal involvement based on computed tomography findings, but the decision to employ supraceliac clamping was made at surgery. Mean (s.d.) supraceliac clamping clamp time was 22(5) (range 12–30) min. Similar numbers of supraceliac clamping and infrarenal aortic clamping patients required bifurcated grafts, operative times were comparable, and numbers of early complications were similar in the two groups. Transfusion requirements were slightly greater and length of stay was insignificantly shorter in supraceliac clamping patients (due to a few prolonged hospital stays in infrarenal aortic clamping patients). No supraceliac clamping patient required dialysis or suffered clinically apparent hepatic failure, coagulopathy, or intestinal ischemia. There were no operative deaths and all patients were discharged from the hospital. Supraceliac clamping was not associated with greater perioperative morbidity and may have contributed to a lack of mortality by facilitating repair of difficult abdominal aortic aneurysm. Supraceliac clamping should be considered for elective and urgent abdominal aortic aneurysm repair when there is inadequate length or quality of infrarenal aorta for anastomosis, severe associated pararenal atherosclerosis, inflammatory aneurysm, or previous aortic surgery. It is concluded that selective supraceliac clamping is safe and facilitates repair of difficult aortic problems.
Research and Clinical Issues in Chronic Venous Disease
Authors: Ricotta J. J. , Dalsing M. C. , Ouriel K. , Wakefield T. W. , Lynch T. G.
Published: September 2024

The purpose of this study was to summarize the current issues in chronic venous disease by reviewing of the literature relating to the condition. The review was conducted by members of the Committee on Research of the American Venous Forum and includes the Committee's venous disease and current/future directions. Progress in the understanding and management of chronic venous problems has lagged behind that in arterial disease, despite the large number of patients affected. The complex pathophysiology of venous problems, lack of accepted evaluation standards and lack of prosthetic conduits are some of the factors which contribute to this. New information in these areas has laid the foundation for advances in both operations and non-operative therapy. In conclusion, many opportunities for clinical and basic research in the area of chronic venous disease are available. Application of basic science techniques, including those of molecular biology, will lead to new insights into pathophysiology of chronic venous syndrome. Developments in technology, classification and basic science suggest multiple new potentials therapeutic approaches in the next decade.
Aortico-Left Ventricular Tunnel: Late Reoperations
Authors: Lukács L. , Richter T. , Kádár K.
Published: September 2024

Aortico-left ventricular tunnel is a rare congenital anomaly that presents as aortic regurgitation in infancy or childhood. Information on late results of surgery, especially with reoperations for progressive aortic regurgitation and recurrences are limited. The case histories of two patients with reoperations following correction of aortico-left ventricular tunnel are reported.
Canine Model of Abdominal Aortic Aneurysm Treated by Endovascular Graft Implantation
Authors: Chuter T. A. M. , Viscomi S. , Slater J. L. , Nowygrod R. , Risberg B.
Published: September 2024

The purpose of this study was to monitor the effects of endovascular graft implantation on a canine model of aortic aneurysm. Aneurysms were created in 10 dogs by fascial patch angioplasty of the infrarenal aorta. In five dogs, aneurysm creation was immediately followed by insertion of an endovascular graft. Central aortic and aneurysm sac pressures were then measured by needle puncture. The remaining five dogs were left untreated, as controls. Angiography was performed after aneurysm creation, after endovascular graft implantation, and at 1 month and 3 months. Following insertion of an endovascular graft, mean (s.d.) systolic pressure was lower in the aneurysm sac (82.9 (20.20) mmHg) than in the adjacent aorta (113.4 (25.9) mmHg; P < 0.002) in all the treatment group. The effects on diastolic pressure and mean pressure were less pronounced. Aneurysm size was increased in all controls (25.2 (9.55)%) and decreased in all of the treated group (22.5 (11.7)%: P < 0.001). In conclusion this model of aortic aneurysm has two important characteristics; it has multiple collateral branches, and it grows. Insertion of an endovascular graft was associated with a reduction in aneurysm sac pressure, reduced aneurysm growth, and fibrosis of the space between the aneurysm sac and the graft.
Clinical Variables Influencing the Appearance of Right Bundle Branch Block after Cardiac Surgery
Authors: Ueyama K. , Jones J. W. , Ramchandani M. , Beall A. C. , Thornby J. I.
Published: September 2024

Right bundle branch block following coronary surgery is a common occurrence. Among 759 coronary surgery cases. 104 patients (13.7%) had a new right bundle branch block. Of these right bundle branch blocks, 62 were transient, and 42 (40.4%) were permanent. The large number of bypasses (3.20 versus 2.75 P = 0.0001) and stenosis of the right coronary artery (81.7% versus 66.5% P = 0.003) was strongly associated with a new right bundle branch block. In the analysis of the permanent right bundle branch block, blood cardioplegia prevented the block from becoming permanent (35.7% versus 75.8%, P = 0.0001). Therefore, it is concluded that perioperative right bundle branch block occurs predominantly in patients who have a critical stenosis in an artery which supplies the conduction system and in those undergoing more extensive procedures. In addition, blood cardioplegia affects the conduction system less severely than does crystalloid cardioplegia.
War Injuries of the Femoral Artery and Vein: A Report on 67 Cases
Authors: Radonić V. , Barić D. , Giunio L. , Bill B. , Kovačević H. , Sapunar D.
Published: September 2024

During the war in Croatia (from May 1991 to December 1995), 67 patients with war injuries of the femoral vein and/or artery were treated at the Surgical Clinic of Split Clinical Hospital. All the wounded were admitted directly from the battlefield or from front-line hospitals. There were five women and 62 men with a median age of 29 (range 15–54) years. There were 70 arterial (28 isolated) and 49 venous injuries (six isolated). Forty-six arterial injuries were repaired by reverse vein graft. Four proximal profound femoral arteries were reconstructed. Major venous injuries were repaired. 11 by compilation autogenous vein graft. No synthetic grafts were used. Repair of veins with large defects using compilation saphenous vein grafts gave good results. Six profound femoral veins and two superficial femoral veins were ligated. Vein ligation should be avoided unless another life-threatening injury demands priority. Twenty-one patients required open prophylactic fasciotomy. Two patients died (3%) and three ultimately underwent amputation (5%). Intermittent hyperbaric oxygen therapy was given to 18 heavily wounded patients with beneficial effect. The results support an immediate and coordinated approach to femoral vascular trauma with repair of arterial and venous injuries.
Should Claudicants Receive Angioplasty or Just Exercise Training?
Authors: Whyman M. R. , Ruckley C. V.
Published: September 2024

Robust clinical and scientific data to support the use of angioplasty or exercise for intermittent claudication are scanty. The purpose of this article is to explore the evidence for each of these treatments. A computer search of relevant published material. Very few randomised controlled trials are available on which to base a sound treatment policy. Currently, the evidence in favour of exercise therapy for short term improvement in symptoms is more compelling than that for angioplasty. The mechanisms of action, the magnitude of effects on walking, the relative efficacy and the hazards of the treatments are discussed. The only way to seriously address the question of which treatment is best for claudicants is by means of the randomised trial and until this has been done angioplasty will remain an expensive treatment of unproven benefit for claudication.
Microemboli Detected by Transcranial Doppler Monitoring in Patients during Carotid Angioplasty Versus Carotid Endarterectomy
Authors: Jordan W. D. , Voellinger D. C. , Doblar D. D. , Plyushcheva N. P. , Fisher W. S. , McDowell H. A.
Published: September 2024

Microemboli, as detected by transcranial Doppler monitoring, have been shown to be a potential cause of strokes after carotid endarterectomy. We retrospectively reviewed 105 patients who underwent transcranial Doppler monitoring during 112 procedures for the treatment of 115 carotid bifurcation stenoses: 40 by percutaneous angioplasty with stenting and 75 by carotid endarterectomy. In PTAS procedures (n = 40), there was a mean of 74.0 emboli per stenosis (range 0–398, P = 0.0001) with 4 neurologic events per patient ( P = 0.08). In CEA procedures ( n = 76), there was a mean of 8.8. emboli per stenosis (range 0–102, P = 0.0001) with 1 neurologic event per patient ( P = 0.08). The post-procedural neurological events in the percutaneous angioplasty with stenting population included two strokes (5.6%) and two transient ischemia attacks (5.6%). Microemboli for each of these cases totalled 133, 17, 29 and 47 (with one shower), respectively. One postoperative carotid endarterectomy patient was noted to have a stroke (1.4%), with 48 microemboli noted during that procedure. The mean emboli rate for percutaneous angioplasty with stenting patients with neurological events was 59.0: without complications it was 85.1. The mean emboli rate for carotid endarterectomy patients without complications was 8.3. Three percutaneous angioplasty with stenting patients had no emboli (7.5%), whereas 29 carotid endarterectomy patients had no emboli (38.7%). Conclusion: The percutaneous angioplasty with stenting procedure is associated with more than eight times the rate of microemboli seen during carotid endarterectomy when evaluated with transcranial Doppler monitoring. Larger patient groups are needed to determine if this greater embolization rate has an associated risk of higher morbidity or mortality.
‘High Dose’ Aprotinin and Heparin-Coated Circuits: Clinical Efficacy and Inflammatory Response
Authors: Parolari A. , Alamanni F. , Gherli T. , Salis S. , Spirito R. , Foieni F. , Rossi F. , Bertera A. , Oddono P. , Biglioli P.
Published: September 2024

Heparin-coated cardiopulmonary bypass circuits reduce the inflammatory response to cardiopulmonary bypass circuit, improve biocompatibility and may protect the postoperative hemostasic mechanisms in routine coronary bypass operations. ‘High-dose’ aprotinin reduces blood-loss, transfusion needs, and re-explorations as a result of bleeding, and may have an additional role in reducing the inflammatory response of the body to cardiopulmonary bypass circuit. It has not been established, however, if the addition of a heparin-coated circuit to the intraoperative administration of ‘high dose’ aprotinin further reduces the whole-body inflammatory response to cardiopulmonary bypass circuit and improves the postoperative clinical course of the patients who are undergoing coronary surgery. Thirty patients undergoing primary elective coronary artery bypass grafting were studied. All the patients received, intraoperatively, the serine-protease inhibitor aprotinin according to the ‘Hammersmith’ protocol and full heparin dose. Patients were randomly allocated to be treated either with a circuit completely coated with surface-bound heparin ( n = 15) or with an uncoated, but otherwise identical, circuit ( n = 15). Differences in the clinical course of the two groups of patients, as well as differences in the behavior of hematological and inflammatory (interleukin-6 (IL-6) and C-reactive protein) factors before, during and after bypass, were analyzed. There were no significant differences between the two groups in terms of bleeding and transfusional requirements, the time spent on a ventilator, or in duration of stay in the intensive care unit (ICU). In all patients, a significant increase in the total white blood cell count, neutrophils, serum IL-6 and C-reactive protein occurred in relation to cardiopulmonary bypass. This was not influenced by heparin precoating of the circuit. In addition, there was an increase in the monocyte count during follow-up, and there was a trend towards higher monocyte counts in the patients who were treated with heparin-coated circuits. These results suggest that the addition of a heparin-coated circuit to the intraoperative ‘high-dose’ aprotinin therapy probably had little influence on the clinical course and on the time-course of the inflammatory parameters of the adult patients undergoing primary coronary surgery with a full heparinization protocol.
Argatroban as a Potential Anticoagulant in Cardiopulmonary Bypass-Studies in a Dog Model
Authors: Sakai M. , Ohteki H. , Narita Y. , Naitoh K. , Natsuaki M. , Itoh T.
Published: September 2024

Argatroban is a selective thrombin inhibitor synthesized in Japan. Argatroban, which has a high affinity for thrombin, and markedly inhibits thrombin-induced reactions, has been used in patients with artherosclerosis obliterans. The efficiency of argatroban, instead of heparin, as an anticoagulant in dog models of cardiopulmonary bypass was explored. In the first study, argatroban was administered as a bolus plus infusion for 1 h during cardiopulmonary bypass at doses of 1.0 mg + 10 μg/kg per min, 2.0 mg + 10 μg/kg per min and 3.0 mg + 10 μg/kg per min ( n = 2 per group). Activated clotting time and arterial gas analyses were performed beforehand and 10 min thereafter. In the second study, there were four groups. In the first group ( n = 5) no coated extracorporeal circuit was used and heparin (2 mg/kg) was used as an anticoagulant. In the second group ( n = 5). a coated extracorporeal circuit was used and heparin was used (2 mg/kg) as an anticoagulant. In the third group ( n = 3), no coated extracorporeal circuit was used and argatroban (2.0 mg + 10μg/kg per min) was used as an anticoagulant. In the fourth group ( n = 5), a coated extracorporeal circuit was used and argatroban was used (2.0 mg + 10 μg/kg per min) as an anticoagulant. All animals were perfused for 120 min at 40 ml/kg per minute. Platelet count, activated clotting time, thrombin—antithrombin III complex, antithrombin III. fibrinogen, fibrinogen degradation products and C3a were measured to evaluate platelet, coagulofibrinolytic and the complement system. Activated clotting time values and the effect of argatroban during cardiopulmonary bypass indicated a dose-dependent response. The next highest dosing group (2.0 mg + 10 μg/kg per minute) had activated clotting time values of 250–300 seconds during cardiopulmonary bypass and fell after reaching near-normal levels within 60 minutes. No clots were noted in the extracorporeal circuit. The argatroban group showed lower levels in their coagulofibrinolytic system compared with the heparin group. The platelet count remained at a high level in the argatroban group. It is concluded that the combination of heparinized cardiopulmonary bypass circuits, and the use of argatroban as an anticoagulant, is safe and reduces the activation of coagulation and fibrinolytic systems and preserves platelet count.