Comparison of ultrasonically activated scalpel and traditional technique in radial artery harvesting: clinical research.

BACKGROUND: Use of the radial artery (RA) as a conduit in coronary artery bypass grafting (CABG) has become increasingly popular in recent years. The aim of this study was to compare the results of two different RA harvesting techniques. Use of the harmonic scalpel is suggested to be safe and additionally reduces spasm rates. MATERIAL AND METHODS: From January 2000, the first 200 consecutive patients who underwent RA harvesting for CABG were enrolled in this study. Patients were divided into two groups. RA was harvested by means of electrocautery + hemoclips in Group I and by harmonic scalpel + hemoclips in Group II. 30 patients (30 %) in Group I and 25 patients (25 %) in Group II were female. Mean age was 53.9 +/- 9.3 and 53.5 +/- 8.4 years in Group I and Group II, respectively. Hand circulation and ulnar collateral flow was assured with a modified Allen test in all patients preoperatively. During the operation perfusion of the hand was monitored by oximetric plethysmography. The distal end of RA was also explored and clamped with a soft vascular clamp to evaluate the saturation values in the groups. During the clamping period, oxygen saturation values did not decrease so we harvested RAs in all patients. RESULTS: There were no statistically significant differences between the groups with the exception of the RA harvesting times, the postoperative analgesia requirements, the rate of vasospasm and the need for hemostatic clips. CONCLUSION: Harmonic scalpel usage in RA harvesting causes less trauma to adjacent tissues; the analgesia requirements, the rate of vasospasm, the RA harvesting time and the need of hemostatic clips decreases. We conclude that the use of a harmonic scalpel for radial artery harvesting is safer and faster than the routine technique.

Primary pulmonary hypertension and coronary artery bypass surgery.

Coronary artery bypass surgery in patients with primary pulmonary hypertension is extremely rare. Right ventricular failure due to persistent elevation of pulmonary pressure is the most important complication in the postoperative period. Creation of an interatrial septal defect and reducing postoperative supraventricular arrhythmia by amiadarone infusion and continuous nasal oxygen therapy can reduce postoperative mortality and morbidity.

[Therapeutic approach in vascular injuries of the lower extremity: Amputation or limb salvage]. / Vasküler tutulumlu alt ekstremite yaralanmalarinda tedavi yaklasimi: amputasyon veya ekstremitenin kurtarilmasi.

The management of lower extremity trauma with vasculary involvement should be directed toward to the salvage of the extremity or to the primary amputation according to the additional pathologies, parameters of the patient and the extremity. We investigated the efficiency of Mangled Extremity Severity Score (MESS) system which is proposed as an grading system to evaluate the change to extremity salvage or the risk for onset of systemic complications. 81 patients with lower extremity trauma were analyzed according to MESS criteria. 79 of the patients were men and mean age was 23 +/- 4. Fourteen patients had higher MESS score. (MESS > 7). Seven of them were older than 50 years. Primary amputation was performed in four of these 7 patients. Vascular repair was performed in three of patients. Multiorgan failure was developed in two of them and both patients died. Secondary amputation was performed to another patients underwent vasculary repair who had MESS > 7 score. Primary amputation was not performed directly in young patients who had MESS > 7. Secondary amputation was required in two of these patients. MESS scoring system can easily predict amputation in older patients but may cause unnecessary amputation in young patients.

Removal of the thrombosed prosthetic axillofemoral graft.

Late thrombosis of prosthetic graft material is rarely managed successfully by simple thrombectomy or thrombolytic therapy. Replacement with a new graft may be necessary. Although several techniques have been described, mobilizing and removing an old thrombosed prosthetic graft is usually extremely difficult because of a firm attachment to its tunnel. This attempt is more difficult especially for ringed grafts. We describe a simple technique of using an internal varicose vein stripper for the removal of such a late thrombosed axillofemoral spiral polytetrafluoroethylene graft and positioning a new graft into the old tunnel.

Simple de-airing technique for aortic valve replacement with upper ministernotomy.

Upper ministernotomy for aortic valve replacement is intimidating for many surgeons, not only for limited surgical exposure but also for the inability to complete de-airing the apex of the heart. Conversion to full sternotomy had been reported for this inability to de-air the apex of the heart in a limited number of cases. We describe a simple de-airing method by introducing a 16 GA catheter into the apex of the left ventricle through the aorta and prosthetic valve.

Late posterior cardiac tamponade after open heart surgery.

OBJECTIVE: Late cardiac tamponade after open heart surgery is a relatively uncommon, but potentially serious complication. We retrospectively analyzed 14 patients who had posterior cardiac tamponade 13 to 210 days after open heart surgery. PATIENTS: Between May 1988 and July 1995, 3150 adult patients underwent open heart surgery at the Gülhane Military Medical Academy. In 35 of 3150 patients (1.11%) late pericardial effusions developed, and in 14 (0.44% of 3150 consecutive open heart surgery performed on adult patients in our center) of these patients had posterior tamponade. There were moderate symptoms including fatigue, malaise, and dyspnea on exertion in all patients. The diagnosis was made by echocardiography in 13 patients, and by tomographic scanning in 1 patient. Analysis of these 14 patients revealed that all of them had hemodynamic criteria consistent with tamponade physiology on right heart catheterization with Swan-Ganz catheters. RESULTS: Echocardiography guid pericardiocentesis through the left anterior axillary line was effective in decompressing of posterior cardiac tamponade in 10 of 14 patients. Three patients required operative surgical drainage after unsuccessful pericardiocentesis through subxiphoid area. Two patients who underwent surgical drainage died, and in one patient surgical pericardiotomy had complete evacuation of posterior pericardial fluid with major complication. CONCLUSIONS: 2-D echocardiography guid pericardiocentesis through left anterior axillary line was found to be a useful, safe, and simple technique. It can be used as an alternative treatment to surgical pericardiotomy for posterior cardiac tamponade after open heart surgery.

Gastrointestinal complications after cardiac surgery.

OBJECTIVE: Gastrointestinal (GI) complications after cardiac surgery with cardiopulmonary bypass (CPB) are uncommon complications with significant morbidity and mortality rates. METHODS: From 1988 to 1995, 36 GI complications were identified in 3158 patients who underwent cardiac surgery (1.14% incidence). The mortality rate was 13.9%. Complications included hemorrhage in the GI tract in 22, perforated ulcer in 3, acute cholecystitis in 3, pancreatitis in 2, mesenteric ischemia in 3, diverticulitis in 1 and liver failure in 2 patients. RESULTS: Clinical risk factors included advanced age, combined coronary artery bypass grafting (CABG)-valve operation, postoperative low cardiac output (LCO), prolonged ventilation time, re-exploration of the chest, sternal infection and a positive history of peptic ulcer. Patients with a prolonged pump time had an increased risk of GI complications (P < 0.001). CONCLUSIONS: Gastrointestinal complications, although of low incidence, carry a significantly high mortality, and the clinician must be alert to institute early appropriate treatment.