Randomized comparison of synchronous CABG and carotid endarterectomy vs. isolated CABG in patients with asymptomatic carotid stenosis: the CABACS trial.

RATIONALE: High-grade carotid artery stenosis is present in 6-8% of patients undergoing coronary artery bypass graft surgery. Many cardiovascular surgeons advocate staged or synchronous carotid endarterectomy to reduce the high perioperative and long-term risk of stroke associated with multivessel disease. However, no randomized trial has assessed whether a combined synchronous or staged carotid endarterectomy confers any benefit compared with isolated coronary artery bypass grafting in these patients. AIMS: The objective of this study is to compare the safety and efficacy of isolated coronary artery bypass grafting vs. synchronous coronary artery bypass grafting and carotid endarterectomy in patients with asymptomatic high-grade carotid artery stenosis. DESIGN: Coronary Artery Bypass graft surgery in patients with Asymptomatic Carotid Stenosis (CABACS) is a randomized, controlled, open, multicenter, group sequential trial with two parallel arms and outcome adjudication by blinded observers. Patients with asymptomatic high-grade carotid stenosis scheduled for elective coronary artery bypass grafting will be assigned to either isolated coronary artery bypass grafting or synchronous coronary artery bypass grafting and carotid endarterectomy by 1 : 1 block-stratified randomization with three different stratification factors (age, gender, modified Rankin scale). STUDY: The trial started in December 2010 aiming at recruiting 1160 patients in 25 to 30 German cardiovascular centers. The composite primary efficacy end point is the number of strokes and deaths from any cause (whatever occurs first) within 30 days after operation. A 4·5% absolute difference (4% compared to 8·5%) in the 30-day rate of the above end points can be detected with >80% power. OUTCOMES: The results of this trial are expected to provide a basis for defining an evidence-based standard and will have a wide impact on managing this disease.

Complicated acute type B dissections: a single-center experience with endovascular treatment.

BACKGROUND: Complicated acute type B dissections treated surgically carry a high risk of mortality. Endovascular interventions with stent-graft prostheses are a less invasive alternative and may obviate the need for surgery in most cases. We report here on our five years' experience with endovascular stenting in complicated acute type B dissections. PATIENTS AND METHODS: Between March 2001 and January 2006, 32 patients (27 males, 5 females) with a mean age of 61.4+/-11.32 years (range 29-80) underwent stent grafting for complicated acute type B dissections. Indications were progression of dissection with impending rupture (n=10), uncontrollable hypertension (n=9), intractable thoracic pain (n=7), and malperfusion syndrome (n=6). Talent-Medtronic (n=34) and Excluder-Gore (n=3) stent-grafts were used. In 5 patients two stents were necessary. In addition to stent grafting, aortic fenestration was performed in all three cases with lower limb ischemia. RESULTS: Endovascular stent placement was successful in all patients. Hospital mortality was 9.3% (3/32). No deaths occurred during follow-up (mean 32 months). CONCLUSION: Endovascular stenting of complicated acute type B dissections represents a safe alternative to surgery. Endovascular stent-grafts of appropriate sizes should be readily available in the hospital for emergency use, thus avoiding delays in treatment.

[Thoracic actinomycosis: diagnostic pitfalls and therapeutic considerations]. / Thorakale Aktinomykose: diagnostische Schwierigkeiten und therapeutische Uberlegungen.

We report two patients admitted to our hospital suspected to suffer from cancer in the lung or mediastinum, respectively. Both patients had a diagnosis of thoracic actinomycosis. A 76 year old man revealed pulmonary and endobronchial actinomycosis associated with broncholithiasis. Diagnosis was achieved by bronchoscopy. Therapy with ampicillin/sulbactam was successful. A 36 year old patient presented with bilateral pleural effusions, extended pericardial, mediastinal and pulmonary actinomycosis with pericarditis constrictiva and superior vena cava syndrome. Diagnosis was finally made by cardiac surgery with therapeutic pericardectomy. Prolonged therapy with ampicillin/sulbactam was administered with satisfactory result. Here we discuss the importance to include actinomycosis in the differential diagnosis of pulmonary affections and mediastinal masses in order to avoid diagnostic errors and to limit invasive procedures to the necessary amount. We illustrate the need of an individualized treatment approach.

Single proximal anastomosis for multiple vein coronary artery bypasses in diseased ascending aorta.

Minimization of the manipulation of the diseased ascending aorta has been shown to be associated with a reduced risk of postoperative stroke during coronary artery bypass surgery. We describe in this paper a novel method in which a single proximal anastomosis has been performed in the same ostium on the ascending aorta for multiple coronary artery vein grafts.

Right coronary ostial plasty without patch material.

Isolated right coronary ostial stenosis may require coronary revascularisation during an open-heart operation, especially during aortic valve replacement. We describe here a new method of right coronary ostial plasty without patch material.

[Acute gastrointestinal bleeding caused by perforation of a Greenfield caval filter into the duodenum]. / Akute gastrointestinale Blutung durch Perforation eines Cavafilters in das Duodenum.

HISTORY AND CLINICAL FINDINGS: A 77-year-old woman was admitted to a nearby hospital because of acute upper gastrointestinal bleeding and collapse. A Greenfield caval filter had been implanted nine years before admission because of pulmonary embolism. INVESTIGATIONS: Gastroduodenoscopy showed two hooks of the caval filter having penetrated the duodenum. The diagnosis was confirmed by an abdominal CT scan. TREATMENT AND COURSE: The patient was transferred to our hospital for surgical removal of the cava filter, which was done through the right-flank retroperitoneal approach. She had an uneventful recovery and was discharged from the hospital on the 7th postoperative day. CONCLUSIONS: Acute upper gastrointestinal bleeding caused by by a Greenfield cava filter perforating the duodenum is an extremely rare complication. But in case of acute gastrointestinal bleeding in a patient with an implanted caval filter or vascular prosthesis this should be considered and the filter removed surgically.

A simple method to reduce ischemic time of the spinal cord in extensive thoracoabdominal aneurysm operations.

OBJECTIVE: Although the incidence of paraplegia from surgery of extensive thoracoabdominal aneurysms Crawford type I - Ill.could be reduced to about 10 % in more recent series, development of additional measures to avoid this disastrous complication seems worthwhile. One of of the major determinants of preventing ischemia is obviously keeping ischemic time of the spinal cord below 30'. In this regard, we introduced a surgical technique that allowed reperfusing the intercostal arteries within 30 min. METHODS: In a consecutive series 17 Patients with thoracoabdominal aneurysms (9 Crawford type II, 7 type I and one type III) underwent thoracoabdominal aortic replacement using either fem.-fem.-or left atrio-fem. bypass with selective perfusion of the visceral vessels. To keep the ischemic time of the spinal cord as short as possible, the first step of aortic replacement consisted of reattachement of the intercostal arteries of the segments Th 10-L 1 followed by immediate reperfusion via a side branch of the prostheses with the aid of the heart and lung machine. RESULTS: Mean ischemic time was 25 min. The mean number of reperfused intercostal arteries was five. One patient died of bleeding complications and could not be evaluated for paraplegia. There was no further hospital mortality. One patient developed paraplegia. With the exception of two patients, all had a very fast recovery and limited stay on the ICU. CONCLUSIONS: Compared to our former experience, we were able to reduce the incidence of paraplegia dramatically. Our observations to date strongly support the hypothesis that an ischemic period of less than 30' is fairly well tolerated by the spinal cord.

[Pericardial tamponade in rupture of a right coronary artery aneurysm]. / Perikardtamponade bei Ruptur eines Aneurysmas der RCA.

Cardiovascular magnetic resonance is a valid and accurate tool for the assessment of structural and functional disorders of the heart. Through combination of morphologic and functional studies, it is possible to form a quick diagnosis with a noninvasive examination. In this case, MR-imaging shows a pericardial effusion and a 5 x 5 cm large, well-circumscribed hematoma with displacement of the right coronary artery, which was also visible with other examination techniques as an unclear intracardial mass. At operation a large aneurysm of the right coronary artery was exposed, in addition to a hemorrhagic pericardial effusion.

[Acute type A dissection of the ascending aorta after aortocoronary bypass operation]. / Akute Dissektion der Aorta ascendens Typ A nach aortokoronarer Bypass-Operation.

A 63-year-old man with a history of hypertension and coronary artery bypass grafting (1 year ago) was admitted with acute onset severe chest pain suggesting bypass dysfunction. Biplane cineangiography revealed acute aortic dissection Stanford Type A without involvement of the aortic valve, the coronary arteries or the proximal anastomoses of the two venous bypass grafts, one of which was occluded. Urgent repair of the aorta by a prosthesis and reinsertion of the patent venous graft in the innominate artery by interposition of saphenous vein was performed without complications. Sixteen months later on routine follow-up a pseudoaneurysm of the ascending aorta surrounding the aortic prosthesis was discovered by transesophageal echocardiographic examination. Reoperation was performed with prosthetic replacement of the ascending aorta. The operative course and further follow-up of now 1.5 years were uneventful.

[Regional hyperthermic fibrinolytic perfusion as ultima ratio in critical ischemia of the lower extremities]. / Regionale hypertherme Fibrinolytika-Perfusion als ultima ratio bei kritischer Ischämie der unteren Extremitäten.

In 19 patients (male-female: ratio 10:9; median age 67.1 (42-90) years) with a critical ischaemia of the lower extremities either after failed attempt of revascularization (n = 4) or because of lacking possibility for vessel reconstruction measures (n = 16) a regional extremity perfusion with a fibrinolytic agent has been performed using a heart lung machine. In one patient both lower extremities were treated. In the first 30 minutes of the total 60 minutes perfusion time on average 31 mg (20-50 mg) of recombinant tissue-plasminogen activator (Actilyse) have been added to the perfusion solution. In order to enhance the fibrinolysis-activity the perfusion solution was warmed up to 40 degrees C. Systemic side effects have not been observed. Two patients died postoperatively because of their underlying diseases (mesenteric artery embolism, myocardial infarction), two patients experienced postoperative haemorrhage and one patient had a wound infection. In 11 cases (55%) an opening of the stem-arteries has been reached. Seven of these were successfully revascularized with a femoro-crural bypass in a following operation. Nine extremities (45%) remained without opening of the stem-arteries, however, in four cases (20%) an improved radiographic contrast of the collaterals has been reached. 11 (61%) of the followed-up extremities were successfully revascularized. Amputation has been performed in seven cases (39%). The regional hyperthermic perfusion with fibrinolytic drugs enables a reopening of the stem-arteries and the creation of accepting vessels for vascular procedures in primarily inoperable arterial occlusions.

"The antero-axillary thoracotomy for operations of the distal aortic arch and the proximal descending aorta".

Antero-axillary thoracotomy in a 45 degrees position has become the most frequent approach for lung resection in our country. This approach also offers an ideal view of the aortic arch with the supraaortic vessels being closer to the incision site than in sternotomy or standard thoracotomy. We have therefore used this approach in our last 14 patients with lesions of the distal aortic arch and proximal descending aorta. Operative diagnoses included three arteriosclerotic aortic arch aneurysms, one post-traumatic aneurysm and two acute traumatic transections, as well as four acute type B dissections, three aneurysms after coarctation patch plasty and one recurrent stenosis after primary interposition of a vascular graft. Two patients died of sudden cardiac arrest on the 4th and 6th postoperative day, respectively, both following repair of a ruptured aneurysm. Except for recurrent laryngeal nerve palsy in six patients there were no further operations or morbidity. All operations were performed with the aid of left heart bypass. Induction of deep hypothermia and circulatory arrest, as is advocated for some of these lesions, was not required. This approach is especially useful in those cases where there is indecision as to whether a median sternotomy or a standard thoracotomy would provide the most optimal exposure.

[Regional hyperthermic fibrinolytic perfusion in postoperative deep venous thrombosis of the leg]. / Regionale hypertherme Fibrinolytika-Perfusion bei postoperativer tiefer Beinvenenthrombose.

Four days after an operation for fusion of lumbar and sacral vertebrae a 30-year-old man developed bilateral deep-vein thrombosis in the legs, extending on the left from the fibular group of veins to the popliteal vein. On the right all deep veins of the lower leg were occluded, including the confluence of the popliteal vein. As systemic fibrinolysis was contraindicated, surgical thrombectomy was undertaken. After incomplete removal of the thrombi, regional hyperthermic perfusion with streptokinase was performed using a heart-lung machine. After a compression bandage had been applied to the right leg above the veins the leg was perfused via the common femoral vein at 40 degrees C from the heart-lung machine, at a flow rate of 600-800 ml/min, for 60 min with a solution containing 1 million IU streptokinase. Measurement of various components in the perfusate indicated marked fibrinolysis (fibrinogen: not measurable; fibrinogen breakdown products: > 80 micrograms; streptokinase: 100 FU/ml after 30 min, 62 FU/ml after 60 min). At the same time there was no demonstrable fibrinolytic activity in the systemic circulation. Fibrinogen concentration fell from 340 mg/dl 30 min before the onset of perfusion to 245 mg/dl 90 min after it. After 60 min of perfusion the blood from the right leg was discarded and the leg flushed through with 1.5 l of an electrolyte solution and then filled up with previously obtained and stored patient's own blood concentrate. Subsequent phlebography and venous occlusion plethysmography demonstrated complete recanalization of the deep-vein system with normal venous valve function.

Extra-intracranial bypass procedure with saphenous vein grafts.

This study reports on 13 cases of extra-intracranial bypass procedures using saphenous vein grafts. Ten patients had arteriosclerotic occlusive vascular disease, one patient had a giant aneurysm of the internal carotid artery, another 2 females, 18 and 28 years of age, respectively, suffered from Takayasu's disease. Preoperatively all patients had severe neurological symptoms. To keep the venous graft as short as possible, as a first choice the carotid artery, in case of occlusive disease of the latter as a second choice the ipsilateral subclavian artery, or as a third choice the ascending aorta, were used as donor vessels. Perioperatively, one patient sustained an intracerebral/intraventricular hemorrhage and, despite immediate reoperation, died in a vegetative state early postoperatively. Another patient had a minor perioperative cerebral stroke with complete recovery. None of the other patients had any additional neurological deficit perioperatively, and they had complete relief from ischemic attacks postoperatively. There was one early occlusion due to high competitive collateral flow, and one late occlusion due to technical problems. The overall patency rate of surviving patients was 83.3% (follow-up 3 to 23 months).

[Knee joint exarticulation in arterial occlusive disorders of the lower extremity]. / Die Kniegelenksexarticulation bei arteriellen Durchblutungsstörungen der unteren Extremität.

In 35 patients suffering from peripheral ischemic disease of the legs, disarticulation of the knee joint was performed instead of above-knee amputation. Operations were executed primarily or after failed bypass procedures for the salvation of the limb. 24 cases (67%) showed primary or delayed secondary stump healing. In 11 cases (31%), however, no stump healing was achieved due to either a wound infection (4 cases) or a necrosis of the anterior flap covering the weight bearing area of the stump (7 cases). Factors influencing the outcome of stump healing are discussed and different techniques of knee disarticulation are evaluated as to their benefits and disadvantages in ischemic limbs. As the method offers several advantages over above-knee amputation, a more frequent use of knee disarticulation in the surgical treatment of ischemic legs which cannot be preserved by other surgical measures and usually would be amputated at above-knee level is recommended.

Restoration of cerebral blood flow by extraanatomic bypass in acute aortic dissection.

This report describes a case of acute type A aortic dissection which had resulted in coma. Angiography had revealed obstruction of the right common carotid artery. Since signs of impending aortic rupture or severe aortic insufficiency were missing, an extraanatomic femoro-carotid bypass was inserted and resulted in the patient's regaining consciousness. Two days after the first operation, the ascending aorta and aortic valve were reconstructed successfully anastomosing the divided caudad end of the bypass to the ascending aortic graft.

[Percutaneous transluminal angioplasty in proximal subclavian stenoses]. / Die perkutane transluminale Angioplastik (PTA) von proximalen Subklaviastenosen.

Between August 1980 and June 1982, 12 left-sided proximal subclavian stenoses were dilated with balloon catheters. The dilatation was successful in all patients. Differences in blood pressure in the arm could be demonstrated subsequently. Recurrences occurred in two patients after seven and eleven months. Follow-up of nine patients up to 24 months showed them to be symptom-free.