Implantable central venous access system.

Prolonged central venous access for outpatient chemotherapy was achieved in 74 patients utilizing a totally implantable access disc system. The system consists of a stainless steel drug reservoir implanted in the subcutaneous tissue of the anterior chest wall. The reservoir is attached to a Silastic catheter which is then tunneled to a central vein and positioned in the superior vena cava. In 6,762 patient days of observation, there was a high degree of patient acceptance and a low incidence of complications. There were four instances of thrombosis and two of catheter-related sepsis among 17 complications. Seven access discs required removal. The implantable nature of this system offers an attractive alternative to other available methods of prolonged central venous access.

Intraoperative autotransfusion in major vascular surgery.

The use of intraoperative autotransfusion provides a safe and cost-effective means of salvaging operative blood loss and reducing or eliminating the use of stored homologous bank blood with its inherent difficulties and risks. The risk of disease transmission or various reactions is minimized. Autotransfusion provides a readily available, more physiologic, and at times life-saving source of blood for patients with rare blood types or patients in whom time does not permit adequate cross-matching. This technique is acceptable to most sects of Jehovah's Witnesses, who normally refuse homologous blood. Our experience during the past six years with autotransfusion in major vascular surgery reveals a mean slavage equivalent to five units of blood loss, and avoidance of using any bank blood in almost half of elective patients. No significant problems occurred due to hemolysis, coagulation abnormalities, or particulate/air emboli, nor any morbidity or mortality specifically related to autotransfusion. We conclude that wider and more frequent use of autotransfusion technics is appropriate.

Innominate artery lesions: problems encountered and lessons learned.

Although unusual, innominate artery lesions may present challenging problems. To classify the wide spectrum of problems requiring operation and elucidate certain principles of management, a series of 71 patients undergoing operation for innominate artery problems over a 20-year period was reviewed retrospectively. Occlusive disease (37 patients) was most common, usually presenting with neurologic or ocular symptoms. Other lesions included innominate aneurysm (three), aortic dissection involving the innominate artery (three), traumatic injuries (five), tracheoinnominate fistula (10), anomalous origin or tortuosity causing tracheal compression (six), involvement in mediastinal tumor or scar (six), and thromboembolus (one). The type of operative repair and mortality rate varied with the nature of the lesion. Overall 38 patients underwent transsternal repair, whereas 12 had extrathoracic bypass, 16 resection and oversewing, and five a pexy procedure. For occlusive disease, direct repair via median sternotomy gave best long-term results with an acceptable mortality rate (3.4%). Shunting was not required. Extrathoracic grafting proved safe but less durable and should be reserved for high-risk patients or special circumstances.