Outcomes of endoscopically harvested saphenous vein for lower extremity bypass.

OJECTIVES: The purpose of this study was to evaluate the outcomes of endoscopically harvested saphenous vein (EHSV) for lower extremity bypass (LEB) surgery. METHODS: Data from 91 consecutive patients who underwent LEB using EHSV between February 2003 and November 2012 were analyzed. Outcomes of interest were wound infection, patency, re-intervention and limb loss. RESULTS: Fifty-eight (64%) and 33 (36%) patients underwent femoropopliteal (FP) and femorotibial (FT) bypass using EHSV. Three (3%) patients had superficial and 1 (1%) deep wound infection. Primary and primary assisted patency at 5 years was 68% and 71% in the FP group and 56% and 65% in the FT group. Six (6%) patients underwent major amputation. No predicting factors for wound infection or graft patency were found. CONCLUSIONS: EHSV carries a low incidence of perioperative wound complication and has a reasonable mid-to-long-term patency regardless of the length of vein harvested.

Intra-aortic balloon pumping: two-year experience.

Experience with 29 patients who underwent intra-aortic counterpulsation between January, 1975, and December, 1977, was reviewed to determine (1) if the results of this method of treatment were similar at the community hospital and university hospital levels and (2) if earlier institution of counterpulsation made possible by easy availability of equipment resulted in improved survival. The balloon was successfully inserted in 27 patients. Arterial blood pressure was below 80 mm. Hg in all patients prior to institution of either pharmacologic or balloon therapy. Pulmonary capillary wedge pressure was greater than 12 mm. Hg in the 22 patients in whom it was measured. In 15 patients counterpulsation was instituted less than 12 hours after infarction (Group A), and in the 14 elapsed time was greater than 12 hours (Group B). There was no difference in precounterpulsation hemodynamic measurements between Group A and Group B. Ten patients in Group A were weaned and survived hospitalization. Seven (54 percent) are long-term survivors (6 months to 2 years). Four are in New York Heart Association Class I, two are in Class II, and one is in Class III. Ten patients in Group B were weaned, seven survived hospitalization, and five are long-term survivors (35 percent). Two are in N.Y.H.A. Class I, two are in Class II, and one is in Class III. These results indicate that counterpulsation is possible at the local hospital level and that early institution of the intra-aortic balloon pumping may improve long-term results.

Delayed operative intervention in cardiogenic shock after myocardial infarction.

In a four-year period, 45 patients underwent counterpulsation for cardiogenic shock following myocardial infarction. Of these patients, 27 underwent angiography. Fifteen of them were not considered to be operative candidates because angiography demonstrated only single-vessel disease or diffuse distal coronary artery disease. Twelve patients were candidates for operation and were divided into three subgroups depending on the time of surgical intervention. One patient (Group 1) deteriorated while on counterpulsation, and underwent urgent angiography and operative intervention within 24 hours of balloon insertion. He is now in New York Heart Association (NYHA) Functional Class I. Group 2 consisted of 7 patients whose condition stabilized with use of the balloon but who could not be weaned. All underwent angiography from 7 to 14 days after insertion of the balloon. One patient died suddenly prior to operation. Six patients underwent coronary bypass from 8 to 21 days after balloon insertion. Five survived and are in NYHA Class II or III. Four patients were able to be weaned after angiography (Group 3). All had triple-vessel disease. Operation was undertaken six to eight weeks after infarction to treat persistent congestive heart failure or angina, or to improve chances of long-term survival. Two patients in this group survived. Our experience demonstrates that delayed intervention is an acceptable alternative to urgent operation.

The post endarterectomy carotid bruit. Evaluation by Duplex scan.

The presence of a bruit after carotid endarterectomy may indicate a persistent or recurrent lesion. The authors noninvasively evaluated, by Duplex scanning, 18 asymptomatic postoperative patients who underwent a total of 23 carotid endarterectomies and who developed a postoperative bruit to determine the significance of the bruit. Eleven men and seven women were studied from 6 weeks to 2 years postsurgery. Ages ranged from 49 to 75 years (63.6 +/- 8.0 years). Indications for endarterectomy were: transient ischemic attacks (including amaurosis fugax), 17 vessels; completed stroke with significant functional recovery and residual carotid disease, 3 vessels; and asymptomatic bruit with hemodynamically significant carotid stenosis, 3 vessels. Each patient had a Duplex scan performed to noninvasively evaluate the carotid artery. All scans were independently reviewed by two observers. Real-time B images were interpreted as normal in 14 vessels, mild thickening in eight vessels, and moderate thickening in only one vessel. Doppler recordings demonstrated a spectral range of 15-40 cm/sec (26 +/- 8 cm/sec). Ratio of velocity in the internal carotid artery to common carotid artery (VIC/VCC) ranged from 0.389 to 1.281 (0.779 +/- 0.250). This study demonstrates that the presence of a postoperative carotid bruit does not necessarily signify the presence of residual carotid disease or a hemodynamically significant lesion.

Osteoradionecrosis of the chest wall. Management of postresection defects using Marlex mesh and a rotated latissimus dorsi myocutaneous flap.

Full thickness chest wall resection and single stage reconstruction for osteoradionecrosis of the chest wall was performed on five patients. All patients had undergone radical mastectomy and radiation therapy from 5 to 18 years prior to chest wall resection. Defects varied from 12 X 5 cm to 15 X 15 cm, and included from two to four ribs. Reconstruction was performed using Marlex mesh to reconstruct the bony thorax and a rotated latissimus dorsi myocutaneous flap. Coverage was successfully performed in all cases, and no patient experienced postoperative pulmonary dysfunction. There were no complications related to either the bony thorax reconstruction or the latissimus flap. The use of this technique has provided a safe, convenient, and reliable method of chest wall reconstruction.

Rupture of non-traumatic thoracic aneurysms into the right hemithorax.

The natural progression of arteriosclerotic descending thoracic aneurysms results in rupture in a high percentage of patients. Reports of surgical experience with these problems are not common although much as been written about elective resection of thoracic aneurysms. Two patients with ruptured non-traumatic descending thoracic aneurysms are presented. hemorrhage into the right hemithorax was a presenting manifestation in both patients. The mechanism for this type of rupture is discussed. Both patients were operated upon with one survivor. Preoperative evaluation, operative approach, and methods of bypass are discussed.

Avulsion of the innominate vein during median sternotomy.

Two cases of disinsertion of the left innominate vein from the superior vena cava (S.V.C.) during primary median sternotomy have been encountered during the past 6 years. Methods of management consisting of either (1) ligation and division of the left innominate vein and patch angioplasty of the SVC injury, or (2) patch angioplasty of the disinsertion injury itself with preservation of the left innominate vein are presented. The rationale and possible complications of each method of treatment are discussed based on the anatomy and collateral circulation of the left innominate vein and other experiences with division of the left innominate vein.

Crossover femoral-popliteal and femoral-tibial bypass.

Crossover femoral-popliteal or femoral-tibial bypass has been employed as an alternative extra-anatomic bypass in 3 patients who had occlusion of an iliac artery with subsequent occlusion of the ipsilateral femoral artery with patency of either a popliteal or tibial artery and a patency of the contralateral common femoral artery. Each patient had a contraindication to a more conventional type of procedure. All procedures were performed with reinforced PTFE grafts. All grafts have remained patent for 6 months to 3 years. This operation should be considered as an alternative extra-anatomic reconstructive procedure in patients with the appropriate anatomy and who are not candidates for more standard types of vascular reconstruction.

Thoraco-abdominal aneurysm resection. Determinants of survival in a community hospital.

Twenty-five patients who underwent resection of a thoraco-abdominal aneurysm between 1985-1993 were reviewed to study determinants of survival in patients undergoing the procedure in a community hospital. Twelve procedures were performed electively, six urgently and seven emergently. Type I aneurysm was present in one patient (n = 1), Type II n = 7; Type III n = 5 and Type IV = 12. Hypertension (n = 17), cardiac disease (n = 10) and renal insufficiency (n = 4) were most common risk factors. Aneurysms were repaired using inclusion method without special techniques for renal or spinal cord preservation. Eighteen patients survived and were discharged; four patients died 30 days and three patients died 30 days. Causes of death were multisystem failure (n = 3), acute myocardial infarction (n = 2) coagulopathy (n = 1) and bowel infarction (n = 1). Major complications included renal failure (n = 2) myocardial infarction (n = 3), bleeding (n = 3), paraplegia (n = 1). Statistical significance was determined using Fisher's exact test-2 tail. Risk factors for death and complication included emergency or urgent surgery (4 deaths-emergent, 2 deaths-urgent) and preoperative renal insufficiency (2 deaths; 1 dialysis) 52% of patients in a community hospital setting underwent emergent or urgent operation and this accounted for 87% of deaths and most morbidity. Mortality in elective procedures was 8%. Based on this data, we believe that thoracoabdominal aneurysm resection can be reasonably undertaken in a community-type hospital.

Femoral-femoral bypass. Non-invasive hemodynamic evaluation.

Seven patients who underwent femoral-femoral by pass between June 1980 and September 1982 underwent pre-operative angiography and pre and post-operative non-invasive evaluation to determine: (1) the hemodynamic effects created by the crossover graft, and (2) if angiographic findings would be predicative of post-operative results. The mean ankle/arm (a/a) index in the donor extremity changed from 0.82 +/- 0.20 to 0.70 +/- 0.27 (NS). The a/a index in the recipient extremity increased from 0.39 +/- 0.30 to 0.74 +/- (p less than 0.02). One patient developed a "steal" syndrome. There was no correlation between angiographic findings and post-operative changes. This study demonstrated a significant increase in recipient extremity ankle pressure and a clinically insignificant decrease in donor limb pressure.

Papaverine hydrochloride as an adjunct to asanguinous cardioplegia, is it beneficial?

Papaverine hydrochloride was added to a standard asanguinous cardioplegic solution to study its effect on cardioplegic distribution by evaluating coronary resistance, myocardial temperature, and postoperative enzyme changes. Seventeen patients were randomized into a control group (8 patients) and a papaverine group (9 patients). All patients received 300 cc of a standard asanguinous cardioplegic solution into the aortic root after systemic cooling to 28 degrees C and measurement of septal temperature (To). The duration of infusion (t1), root pressure (p1), and septal temperature (T1) were recorded. All patients received a subsequent infusion of 200 cc of cardioplegia to which had been added either 10 cc normal saline (control group) or 1 mg papaverine hydrochloride in 10 cc normal saline (papaverine group). Time of infusion, root pressure, and septal temperature (t2, p2, T2) were recorded. Coronary resistance was calculated. Postoperative CPK and CPK-MB were recorded and compared. Mean high CPK in the papaverine group was 163 units and 182 units in the control group. There was no statistically significant difference in any parameter between groups. This study, in contradistinction to experience with animal research models, failed to demonstrate any significant value in adding papaverine hydrochloride to standard cardioplegic solutions.

Management of carotid coils during routine carotid endarterectomy.

BACKGROUND: A coil in the internal carotid artery (ICA), defined as a circular configuration or exaggerated S shape of the ICA, is occasionally encountered during endarterectomy for carotid bifurcation lesions. The significance of coils as an etiology for symptoms is difficult to determine. It is thought, however, that the failure to correct coils and kinks during routine carotid endarterectomy (CE) may lead to turbulence and failure of the CE. Various techniques have been discussed to repair coils. METHODS: Our technique consisted of complete dissection of the coil, routine use of a Javid shunt, standard endarterectomy, resection of the redundant ICA, re-approximation of the posterior wall of the ICA and patch angioplasty of the anterior wall. Three hundred and fifteen patients underwent CE between August, 1998 and February, 2000. Fifteen patients (4.7%) had a carotid coil that was repaired. There were ten men and five women. Mean age was 72.6+/-6.1 years. Ten patients had an asymptomatic stenosis. Four patients had lateralizing symptoms and one patient had dizziness. Fifteen patients underwent preoperative duplex scanning and 14 of these patients had MRA scans performed. All patients had a preoperative stenosis of 80-99% by duplex on the operated side. The right carotid artery was repaired in 12 patients. The left in three patients. The length of resected artery varied from 1.2-2.8 cm (1.93+/-0.49 cm). RESULTS: All patients survived surgery. One patient developed a cerebellar stroke on the third postoperative day. A postoperative carotid duplex scan demonstrated a widely patent repair. There were no cranial nerve injuries in this series. One patient died seven months after surgery from cardiac events with no follow-up duplex exam. There have been no long term strokes or anastomotic complications. Follow-up duplex scans demonstrated widely patent repairs (1-15% stenosis) in seven patients and low end 15-49% stenosis in five patients. CONCLUSIONS: Resection of redundant ICA with re-anastomosis of the posterior wall and patch reconstruction of the anterior wall gives acceptable perioperative and long term results.

Selective patching in carotid endarterectomy: is patching always necessary?

BACKGROUND: The value of carotid patching in carotid endarterectomy in achieving low perioperative morbidity and long-term freedom from restenosis is controversial. We hypothesized that if large internal carotid arteries were closed primarily and smaller arteries selectively patched, there would be no difference in early or long-term results between the two groups. METHODS: A retrospective analysis of 133 carotid endarterectomies performed by one surgeon in a community teaching hospital was performed to evaluate a selective approach to patching vs primary closure. Primary closure was performed if the arteriotomy could be closed without tension over a Javid shunt. Seventy-seven arteries underwent primary closure and 56 underwent patching (Vein-14, PTFE-17, Dacron-25). Postoperative (>6 month) duplex scans were available on 46/77 (60%) patients undergoing primary closure, and 33/56 (59%) of patients with patch repair. RESULTS: There were 2 perioperative neurologic deficits, both in the patch group. Restenosis of equal or greater than 50% at 11 months occurred in 5/46 (10.8%) of patients with primary closure and 2/34 patients (5.9%) with patch closure (p=ns). No patient in either group had a late neurologic event or required a redo operation. CONCLUSIONS: Selective primary closure is not associated with increased risk of perioperative neurologic events or statistically significant evidence of late postoperative stenosis if primary closure is performed in large internal carotid arteries.

Physiologic and pathologic evaluation of chronic extra-aortic counterpulsation with latissimus dorsi flap. Preliminary results.

This study attempted to evaluate the efficacy of chronic extra-aortic counterpulsation with a latissimus dorsi neuro vascular flap. Five dogs had a preliminary procedure consisting of the creation of a latissimus dorsi flap and a thoracotomy in which the flap was wrapped around the descending aorta just distal to the left subclavian artery. An epicardial lead was placed on the left ventricle and a nerve stimulating lead placed around the thoraco-dorsal nerve. Three weeks later, both leads were connected to a cardiomyostimulator programmed to function in a counterpulsation mode with a 1:2 assist frequency. Hemodynamic measurements were made at 6 and 8 and 10 and 12 weeks and the dogs were sacrificed. Three dogs had all sets of hemodynamic measurements made. Two of the three dogs demonstrated diastolic augmentation at 6 and 8 and 10 and 12 weeks average 20 to 25 mmHg. The third dog failed to demonstrate any change. All dogs were sacrificed at 12 weeks and specimens were submitted for histologic evaluation. The muscle flap was preserved in all animals. The aorta subjacent to the flap showed, (1) normal intima with no evidence of disruption or thrombus in all animals, (2) in the animals in whom counterpulsation was observed, there appeared to be thinning of the media in the aorta subjacent to the muscle flap, and (3) no evidence of distal emboli. This study demonstrated that chronic counterpulsation can be obtained with a latissimus dorsi flap. The actual hemodynamic benefits are not determined from this study. The medial thinning in the aortic wall may limit the long-term benefit of this procedure.

The effect of asanguinous cardioplegic arrest on atrial preservation using atrial ATP as a marker.

Changes in atrial adenosine triphosphate (ATP) and the presence of postoperative arrhythmias were studied in 14 patients during routine coronary artery bypass grafting to 1) attempt to evaluate atrial preservation, and 2) determine if a relationship exists between changes in ATP and the development of postoperative arrhythmias. Atrial biopsies were obtained at the time of cannulation (preischemic sample) and after the removal of the aortic crossclamp (postischemic sample). Methods of myocardial protection included systemic hypothermia (28 degrees C), periodic reinfusion of crystalloid cardioplegia into the aortic root and completed vein grafts, and iced slush in the pericardial well. Atrial temperature was monitored. Preischemic ATP was 0.412 +/- 0.32 mu mol/gm, and the postischemic value was 0.220 +/- 0.13 mu mol/gm (p less than .02). Atrial temperature routinely decreased to 13-18 degrees C after cardioplegic infusion but rose to 24 degrees C between infusions. There was no correlation between postoperative supraventricular arrhythmias (4 patients) and changes in ATP. In conclusion, routine coronary artery bypass grafting with standard methods of cardiac preservation does not appear to satisfactorily preserve atrial tissue. The clinical correlation and significance of this remains to be elucidated.

Near fatal hemolysis following repair of ostium primum atrial septal defect.

A 15 month old black male who developed near fatal intravascular hemolysis two days after repair of an ostium primum septal defect with a teflon patch is presented. One month after initial operation, reoperation was required for control of hemolysis. At that time a piece of pericardium was placed over the underendothelialized left atrial side of the patch and the mitral cleft was repaired. He initially did well but within several days developed mitral regurgitation. Hemolysis recurred two months postoperatively, but then spontaneously subsided. We propose that the recurrent mitral insufficiency created a defect in the pericardial patch and that caused recurrent hemolysis. Normal endothelial ingrowth probably covered this small defect and hemolysis subsided. Following the second hemolytic episode six months ago, the patient continues to do well.

Congenital diaphragmatic hernia in the adult.

The onset of symptoms from a congenital posterolateral (Bochdalek Hernia) defect is rare in the adult. We are reporting a 25-year-old female with a previously asymptomatic Bochdalek hernia who presented with acute intestinal obstruction. The abnormal embryology, pathophysiology, and clinical manifestations of this condition in the adult are discussed.

DRGs: nursing documentation contributes to the bottom line.

Nursing documentation in the medical record is an important source of information for the medical record coder. Coded data are necessary for quality assurance, risk management, research and statistical purposes, as well as for proper DRG assignment for reimbursement. Facts gleaned from nursing documentation, supported by physician documentation and laboratory data, can often result in increased reimbursement for the hospital.