Topical use of aprotinin in open heart operations.

Among various pharmacological agents used to reduce bleeding after open-heart operations, high-dose aprotinin therapy seems most promising. However, its long-term effects are still obscure; there is almost always possibility of bypass graft occlusions produced by the hypercoagulable state induced by aprotinin in coronary bypass operations. Topical application of aprotinin into the pericardial cavity could prevent the adverse effects. Fifty patients were prospectively studied to evaluate the effects of topical aprotinin. One million KIU of aprotinin was poured into the pericardial cavity before closure of the sternotomy in group 1 (n = 25). Patients in group 2 (n = 25) served as controls. Total postoperative bleeding was significantly reduced in group 1 when compared with that of group 2 (722.7 +/- 230.8 versus 1,282.6 +/- 225.7 mL; p < 0.01). The use of banked donor blood products was significantly less in group 1 than in group 2 (0.33 +/- 0.67 versus 1.36 +/- 0.86 units; p < 0.01). These results show that topical use of aprotinin reduces post-operative blood loss and need for transfusion. It seems promising and warrants further studies to be done.

Acute occlusion of the abdominal aorta.

BACKGROUND: Acute aortic occlusion most commonly results from aortic saddle embolus or thrombosis of an atherosclerotic abdominal aorta. The purpose of this study was to review the experience at a university hospital to better define the diagnosis and management of this uncommon process. METHODS: A retrospective chart review was performed from patients admitted to Emory University Hospital with acute occlusion of the abdominal aorta from 1985 through 1997. RESULTS: Thirty-three patients were identified. In group EMB (n = 16), occlusion was due to saddle embolus. In group IST (n = 17), occlusion was attributed to in situ thrombosis of a severely diseased aorta. Operative procedures performed included transfemoral embolectomy (15), aorto-bifemoral bypass (9), axillobifemoral bypass (5), fasciotomy (3), and thrombolysis (1). The in-hospital mortality rate was 21% (31% EMB, 12% IST), and morbidity was significant and included mesenteric ischemia (6%), bleeding complications (9%), subsequent amputation (12%), renal failure (15%), recurrent embolization or thrombosis (21%), and cardiac complications (42%). CONCLUSIONS: Acute aortic occlusion has tremendous morbidity and mortality even with optimal surgical care.

Ligation in adult persistent ductus arteriosus.

Seventy one patients with a persistent ductus arteriosus were operated upon at the Cardiovascular Unit in Gülhane Military Medical Academy. The mean age of these cases was 24 years. Twenty five patients (35%) were asymptomatic. The average pulmonary artery systolic pressure was 50 +/- 22 mmHg. In the majority of the cases the ductus was ligated (91.5%), but 6 of the cases were treated by division (8.5%). Early and late complications or mortality were not encountered. In this study 71 cases are reviewed: the preoperative cardiac catheterization and the operative findings are studied in relation to the surgical procedures used. Ligation is a simple, quick and effective surgical treatment for persistent ductus arteriosus in adults.

Incidence and characteristics of patients with hand ischemia after a hemodialysis access procedure.

The purpose of this study was to determine the clinical characteristics of chronic renal failure patients who developed hand ischemia in the limb carrying the dialysis angioaccess. A retrospective review of the charts of 352 patients who underwent 409 upper extremity arteriovenous access, and who were subsequently diagnosed as steal syndrome, was performed at the Emory University Hospital between February 1992 and January 1997. Hand ischemia occurred after 13 of 299 arteriovenous grafts (4.3%) and after 2 of 110 direct forearm arteriovenous fistulas (1.8%). Six patients developed ischemic manifestations immediately postoperatively, 2 in the first week, 4 after 1 month, and 1 after 1 year. Thirteen occurred in association with the primary access procedure. Two cases occurred following graft thrombectomy and outflow dilatation. Seven patients were mildly symptomatic with dialysis-induced pain, coldness, or numbness; 8 patients developed severe ischemic manifestations in the form of sensory loss in 3, severe intolerable pain with impalpable pulse in 3, and digital gangrene and amputation in 2, one of whom developed an unhealed amputation stump and required a higher amputation level with satisfactory healing of the revised stump. Three patients were treated conservatively, 6 by banding, 4 by ligation, 1 by embolization, and 1 by distal ligation and bypass operation. Clinical characteristics of patients with hand ischemia included long-standing insulin-dependent diabetes (10), chronic hypertension (12), peripheral arterial disease (14; 93.3%), coronary artery disease (8), and systemic lupus erythematosis (1). Severe peripheral arterial diseases are commonly found and may be markers for risk of hand ischemia after access surgery.

Central venous stenosis in the hemodialysis patient: incidence and efficacy of endovascular treatment.

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.