The safety of immediate extubation after abdominal aortic surgery: a prospective, randomized trial.

UNLABELLED: We performed this study to assess the safety of immediate extubation after elective abdominal aortic aneurysm surgery. Consecutive patients were prospectively randomized into two groups after surgery: Group 1 (n = 29) immediate extubation; and Group 2 (n = 21) delayed (at least 4 h) extubation. All patients were assessed by a senior anesthesiologist or intensivist before extubation. The following data were collected: preoperative-demographics, presence of comorbid disease, body mass index, hemoglobin level, heart rate, and blood pressure; intraoperative-duration of surgery and cross-clamping, blood loss, amount of crystalloids, colloids, and blood transfused, temperature at end of procedure, urine output, and complications; and postoperative-time to extubation, scores on the Acute Physiology and Chronic Health Evaluation-II and Therapeutic Intervention Scoring System, total fentanyl dose, and complications. Outcome variables were length of intensive care unit and hospital stay and 28-day mortality. The results showed no significant differences in preoperative or intraoperative variables between the groups, apart from a longer duration of surgery in Group 1 (P = 0.045). Group 2 patients had a significantly higher Therapeutic Intervention Scoring System score (P = 0.04) and required a significantly larger dose of fentanyl (P < 0.001). One patient in Group 2 required reintubation after a cerebrovascular accident. The overall mortality rate was 4% (2 patients in Group 2). There were no significant differences in any of the outcome variables. We conclude that immediate extubation can safely be performed after elective abdominal aortic aneurysm surgery. IMPLICATIONS: In this prospective randomized study, we compared the outcome of patients undergoing elective aortic abdominal surgery who either were extubated immediately after surgery or after 4 h of stabilization in the intensive care unit. No significant differences were found in the length of intensive care unit or hospital stay, or 28-day mortality between the 2 groups.

[Treatment of traumatic false aneurysm of the thoracic aorta with stent graft].

UNLABELLED: The treatment of traumatic false aneurysm of the thoracic aorta by endovascular stent graft may have advantages over conventional surgery. This is a case study of two women suffering from false aneurysm of the thoracic aorta caused in one by a knife injury and in the other by a car accident. After the patients became hemodynamically stable, a commercially available endothelial stent graft (Talent, Gor) was deployed. Recovery was rapid in the first patient. The second patient required emergency laparotomy for venous bleeding one day after stent placement; she died two weeks later, mainly from organ failure. CONCLUSIONS: Endovascular techniques can be used in selected cases to treat thoracic false aneurysms thereby avoiding the complexity and morbidity of conventional surgery.

[Surgery of the carotid body tumors].

Carotid body tumor is a rare tumor of obscure origin, usually benign, and commonly present as a non-painful cervical mass. Resection is the treatment of choice. When the tumor is very adherent to the carotid artery, it may be necessary to also resect the artery and to reconstruct the arterial continuity using a saphenous or synthetic interposition graft. The most common complication of surgery is damage to the cranial nerves in the vicinity of the artery. We present 8 patients with carotid body tumor who underwent surgery in our department in 1996-1999. Two had a large tumor penetrating the intima which mandated resection of the involved carotid artery and a saphenous interposition graft reconstruction. Our experience with resection of carotid body tumors is detailed, with emphasis on precautions taken to prevent damage to the adjacent cranial nerves.

Saphenous vein harvesting for coronary artery bypass grafting. Retrospective analysis of possible causes of major wound complications in patients with peripheral arterial disease.

OBJECTIVES: to retrospectively evaluate the possible reasons for major wound complications at the saphenous vein harvesting site in patients with peripheral arterial disease (PAD). DESIGN: retrospective study. MATERIALS AND METHOD: fifteen consecutive patients admitted to the vascular department for impaired healing at the saphenous vein harvesting site after successful coronary bypass artery grafting (CABG) (Group A) were evaluated for medical, perioperative, laboratory and pathological factors and outcome. Findings were compared with those in 15 matched controls followed in the outpatient clinic after CABG (Group B). RESULTS: absence of pedal pulses in the affected leg was noted in 13 patients in group A and 3 patients in group B. Ankle brachial index ranged from 0.4--0.7 in group A and 1.7--1.1 in group B; corresponding ankle pressures were 40--100 mmHg (mean 60 mmHg) and 80--160 mmHg (mean 110 mmHg). All patients in group A had PAD, whereas none did in group B, and all patients in group A required intervention to save the leg. Wound healing was noted in 11 group A patients; four patients underwent below-knee amputation. CONCLUSION: saphenous vein harvesting from limbs with severe PAD can lead to significant morbidity, including limb loss. In patients lacking a palpable pedal pulse, we recommend harvesting only the proximal saphenous vein.

Relation of nonobstructive aortic valve calcium to carotid arterial atherosclerosis.

Recently it was shown that subjects with aortic valve calcium (AVC) are at increased risk for future cardiovascular disease including stroke. We hypothesized that the increased risk of stroke may be due to an association with carotid artery atherosclerotic disease. Between 1995 and 1999 our laboratory made a diagnosis of AVC without significant stenosis in 3,949 patients. Of those, 279 patients without other cardiac structural exclusion criteria (148 men and 131 women; mean age 73 +/- 9 years, range 45 to 90) underwent carotid artery duplex ultrasound for various indications, and formed the study group. Age- and sex-matched patients without AVC (n = 277), who underwent carotid artery duplex ultrasound during the same period and for the same indications, served as the control group. Compared with the control group, the AVC group had a significantly higher prevalence of carotid stenosis (> 40% to 60%, 89% vs 78% [p < 0.001]; >60% to 80%, 43% vs 23% [p <0.001];and > 80% to 100%, 32%vs 14% [p < 0.001]). The AVC group had a similar, significantly higher prevalence of > or = 2-vessel disease and bilateral carotid stenosis (stenosis levels of > 20% to 40%, >40% to 60%, > 60% to 80%, and > 80% to 100%). In multivariate analysis, AVC, but not traditional risk factors, was the only independent predictor of severe carotid atherosclerotic disease (stenosis > 80% to 100%; p = 0.0001). Thus, there is a significant association between the presence of AVC and carotid atherosclerotic disease.

Association between mitral annulus calcification and peripheral arterial atherosclerotic disease.

The authors previously demonstrated a significant association between the presence of mitral annulus calcification (MAC) and aortic atheroma, carotid atherosclerotic disease, and coronary artery disease. The present study was designed to determine whether an association exists between MAC and peripheral arterial atherosclerotic disease. Of the 805 patients in whom the diagnosis of MAC was made by transthoracic echocardiography between 1995 and 1997, 77 patients (40 men and 37 women; mean age, 73.1 +/- 11.4 years; range, 44-90 years) underwent peripheral arterial testing for various indications, and comprised the study group. They were compared with 58 age-matched and sex-matched patients without MAC (30 men and 28 women; mean age, 73.2 +/- 11.8 years; range, 31-93 years) who underwent peripheral arterial testing during the same period for the same indications (control group). MAC was defined as a dense, localized, highly reflective area at the base of the posterior mitral leaflet detected by transthoracic echocardiography. An ankle/brachial systolic pressure index (ABI) was calculated by dividing the higher dorsalis pedis or posterior tibial Doppler-derived pressures by the higher of the 2 upper extremity systolic pressures. ABI was graded as follows: normal > or = 1, abnormal < 1, mild 0.71 to 0.99, moderate 0.41 to 0.7, and severe < or = 0.4. No differences were found between the groups in indications for referral for peripheral arterial testing and in risk factors for atherosclerosis except for hypertension, which was found to be significantly more prevalent in the study group (66% vs 41%, p = 0.004). The study group included 151 limbs, and the control group included 113 limbs. The mean ABI was significantly lower for all limbs in the MAC group (0.56 +/- 0.27 vs 0.87 +/- 0.24, p = 0.0001), abnormal ABI < 1 (94% vs 68%, p = 0.001), moderate peripheral arterial disease (44% vs 25%, p = 0.001), and a severe disease (27% vs 1%, p = 0.001). Of the 77 patients with MAC, 73 (95%) had a disease (right and/or left limbs) compared with 40 of 58 (69%) in the control group (p = 0.001). Bilateral disease (Doppler index < 1 for both right and left limbs), and severe bilateral disease (Doppler index < or = 0.4 for both right and left limb) were also found to be significantly more prevalent in the MAC group (87% vs 60%, p = 0.001; and 12% vs 0%, p = 0.007, respectively). There is a significant association between the presence of MAC and peripheral arterial disease. This information strengthens our hypothesis that MAC may be an important marker for generalized vascular atherosclerotic disease.

Lipedema complicated by lymphedema of the abdominal wall and lower limbs.

We describe a 52 year-old woman in whom lymphedema primarily of the abdominal wall was superimposed on lipedema resulting in an abdomen of enormous dimensions with marked impairment of ambulation. Treatment consisted of preoperative compression of the legs by an external pneumatic device (Lympha-Press) followed by excision of the lymphedematous abdominal fat pad in conjunction with "debulking" of the right leg. The patient illustrates the extremes of lipedema complicated by lymphedema and the technical difficulties associated with its management.

[Elective repair of infra-renal aortic aneurysm in octogenarians].

Age over 80 years is generally considered an independent risk factor in elective surgery for abdominal aortic aneurysm (AAA). As the general population increases in age, more elderly are likely to be candidates for such surgery. We studied prospectively 100 consecutive patients undergoing elective AAA surgery between 1992-1995. All were operated on by the same team of anesthetists and surgeons and all were transferred to the general ICU for at least the first 24 hours. 16 were above the age of 80 (Group I) and 84 below (Group II). We recorded preoperative factors (demographics, medical history, risk factor indices, EKG findings, as well as left ventricular ejection fraction (LVEF) and stress imaging when indicated); intraoperative factors (duration of surgery, size of aneurysm, complications and units of blood transfused); postoperative factors (length of ICU stay, duration of ventilation, APACHE II [Acute Physiological and Chronic Health Evaluation] and TISS [Therapeutic Intervention Scoring System] scores; complications in the ICU, need for readmission to the ICU, and mortality). In Group I LVEF was greater (p = 0.03) and aneurysm size significantly larger (p = 0.036), but there were no other significant differences between the 2 groups with regard to pre- and intraoperative data. Group I patients were not ventilated as long (p = 0.038), but there were no significant differences in outcome factors. Mortality for the whole group was 5% and was not significantly different in the 2 groups (1/16 in Group I and 4/84 in Group II). We conclude that there is no excess morbidity or mortality in octogenarians undergoing AAA surgery. However risk of the aneurysms rupturing is significantly greater since they are larger. We suggest that age not be considered the sole criterion for aneurysm repair, or at least not in selected patients with normal LVEF.

Femorofemoral bypass, even in pregnancy--a case report.

A 29-year-old pregnant woman sustained blunt, left lower abdominal trauma, with hip and pelvic fractures, and progressive dissection of an intimal flap in the left iliac artery, which manifested two days later as profound ischemia of the left leg. The patient underwent distal thromboembolectomy, fasciotomies and revascularization of the leg by femorofemoral polytetrafluoroethylene bypass. The patient recovered completely and gave normal birth three months later to a healthy child. Four years after the operation she gave uneventful birth to another child. Various considerations pertinent to this complex traumatic-vascular-gestational state are discussed.

Gastric emptying after elective abdominal aortic aneurysm surgery: the case for early postoperative enteral feeding.

OBJECTIVE: To assess gastric emptying with a view to early postoperative enteral nutrition after elective abdominal aortic aneurysm (AAA) surgery. METHODS: The paracetamol absorption test was used to assess gastric emptying in 13 consecutive patients at 6, 18 and 32 h following elective AAA surgery. All patients received postoperative analgesia with marcaine given via an epidural catheter during the first 48 postoperative hours. Normal emptying was defined as an area under the plasma paracetamol concentration curve at 60 min (AUC-60) of > 600 mg/min/l. RESULTS: The median time to normal gastric emptying was 18 +/- 7.7 h. One patient (7.6%) had normal emptying at 6 h, nine (69%) at 18 h and 12 (92%) at 32 h. The nasogastric tubes were removed at a median of 3.2 days after surgery, and enteral feeding was commenced on day 4. CONCLUSIONS: Gastric emptying was normal 18 h post-AAA surgery as assessed by the paracetamol absorption test. In view of the importance of maintaining an intact gastrointestinal mucosa, enteral nutrition may be commenced on the second postoperative day.

Association between mitral annulus calcification and carotid atherosclerotic disease.

BACKGROUND AND PURPOSE: It has been established that mitral annulus calcification (MAC) is an independent predictor of stroke, though a causative relationship was not proved, and that carotid artery atherosclerotic disease is also associated with stroke. The aim of this study was to determine whether there is an association between the presence of MAC and carotid artery atherosclerotic disease. METHODS: Of the 805 patients in whom the diagnosis of MAC was made by transthoracic echocardiography between 1995 and 1997, 133 patients (60 men and 73 women; mean age, 74.3+/-8 years; range, 47 to 89 years) underwent carotid artery duplex ultrasound for various indications; the study group comprised these patients. They were compared with 129 age- and sex-matched patients without MAC (57 men and 72 women; mean age, 73.6+/-7 years; range, 61 to 96 years) who underwent carotid artery duplex ultrasound during the same period for the same indications. MAC was defined as a dense, localized, highly reflective area at the base of the posterior mitral leaflet. MAC was considered severe when the thickness of the localized, highly reflective area was > or =5 mm on 2-dimensional echocardiography in the 4-chamber view. Carotid artery stenosis was graded as follows: 0%, 20%, 40%, 60%, 80%, and 100%. RESULTS: Compared with the control group, the MAC group showed a significantly higher prevalence of carotid stenosis of > or =40% (45% versus 29%, P=0.006), which was associated with > or =2-vessel disease (23% versus 10%, P=0.006) and bilateral carotid artery atherosclerotic disease (21% versus 10%, P=0.011). Severe MAC was found in 48 patients. More significant differences were found for the severe MAC subgroup (for carotid stenosis of > or =40%) in rates of carotid artery atherosclerotic disease (58% versus 29%, P=0.001), and > or =2-vessel disease (31% versus 10%, P=0.001), in addition to bilateral carotid artery stenosis (27% versus 10%, P=0.004) and even bilateral proximal internal carotid artery stenosis (21% versus 8%, P=0.015). Furthermore, significant carotid artery atherosclerotic disease (stenosis of > or =60%) was significantly more common in the severe MAC subgroup than in the controls (42% versus 26%, P<0.05) and was associated with higher rates of > or =2-vessel disease (19% versus 7%, P=0.02) and bilateral carotid artery stenosis (17% versus 7%, P=0.05). On multivariate analysis, MAC and age but not traditional risk factors were the only independent predictors of carotid atherosclerotic disease (P=0.007 and P=0.04, respectively). CONCLUSIONS: There is a significant association between the presence of MAC and carotid artery atherosclerotic disease. MAC may be an important marker for atherosclerotic disease of the carotid arteries. This association may explain the high prevalence of stroke in patients with MAC.

Combined surgical correction of bilateral congenital lower limb lymphedema with associated anomalies.

An unusual combination of congenital malformations in a 16-year-old emotionally disturbed man is described. The anomalies included severe congenital bilateral leg lymphedema, bilateral gynecomastia, unilateral cataract, and malformed external genitalia. Genetic and hormonal investigations were unremarkable. Multiple concomitant operations (vascular and plastic surgeons) to correct the deformities and restore physical well-being and self-esteem were undertaken.

Retroperitoneal endoscopic lumbar sympathectomy with balloon dissection: experience with a cadaveric model.

The objective of this study was to determine the feasibility of retroperitoneal endoscopic lumbar sympathectomy with balloon dissection technique using a cadaveric model. Retroperitoneal endoscopic lumbar sympathectomy was performed on 10 cadavers. The procedure was combined with balloon dissection to provide easier visualization and more working space. The outcome was successful in eight cadavers. Average operating time was 40 min, and visualization was good. The only major technical problems were perforation of the peritoneum and air leak into the abdomen. It was concluded that retroperitoneal endoscopic lumbar sympathectomy with balloon dissection has the advantages of minimal invasiveness, clear visualization, and controlled blunt dissection. The use of a cadaveric model may improve the clinical learning curve.

Outcome after elective infrarenal aortic aneurysm surgery.

We conducted a prospective case series study to investigate the causes of and factors influencing morbidity and mortality in 102 consecutive patients after elective infrarenal abdominal aneurysm (AAA) surgery between 1992 and 1995. Preoperative factors (demographics, risk factor indexes, electrocardiographic findings, ejection fraction, and stress imaging scans were indicated) and intraoperative factors (duration of surgery, size of aneurysm, complications, units of blood transfused, and additional procedures performed) were recorded. Patients were admitted to the intensive care unit (ICU) for at least 24 hours and followed for 30 days postoperatively. The mortality rate was 4.9%, due in all cases to multiorgan dysfunction syndrome (MODS). Death was preceded by colon ischemia (two patients), intraabdominal bleeding (two patients), or sepsis (one patient). Only the preoperative blood urea nitrogen correlated with mortality (p = 0.042). Complications occurred in 59% of patients in the ICU and involved the cardiovascular system in 83% of them (heart rate > 90 bpm in 49%). On multivariate analysis, only duration of surgery was associated with ICU complications (p = 0.018). No complication resulted in mortality. Ward complications occurred in 13%, and 5% of these patients required readmission to the ICU. Although cardiac complications are considered the major cause of mortality after infrarenal AAA surgery, all five deaths in the present series were due to MODS. Preoperative screening should be more selective, and intraoperative and postoperative care should be stressed.

[Popliteal vascular trauma].

6 cases of popliteal vascular trauma are presented, 3 due to posterior dislocation of the knee and 3 due to crush injury. The patients were referred from another hospital and some had undergone unnecessary angiography when ischemia was present, leading to delay in surgery. All patients presented with distal ischemia and underwent reconstructive surgery; 2 subsequently underwent below-knee amputation because of irreversible ischemia and sepsis. Urgent operation for popliteal vascular trauma is necessary whenever there is ischemia and intraoperative angiography may be necessary. There should be reconstruction of the artery and vein when there is concomitant venous damage, and fasciotomy and debridement are important. The harmful potential of occult popliteal vascular injuries and their ostensible mild presentation present a challenge for the emergency room surgeon.

"Veno-Press"--a new sequential intermittent pneumatic device for the prevention of perioperative deep vein thrombosis.

The prevention of peri-operative deep vein thrombosis (DVT) and the potentially hazardous pulmonary embolism that may follow is still a major medical issue. Intermittent pneumatic compression is one of the many methods currently in use for this purpose. No information is available, however, regarding the venous flow alterations that occur during employment of a pneumatic compression device under general anesthesia. The aim of this study is to delineate these venous flow variations and to determine the optimal pump setting for the prevention of operative venous stasis and its sequelae, postoperative DVT. A new sequential intermittent pneumatic device, the "Veno-Press", was applied on 20 volunteers of whom 10 were undergoing surgery unrelated to the lower limbs, during the pre-anesthesia and during general anesthesia. The venous velocity patterns over the femoral vein were depicted via duplex scanning under different pressure and rhythm settings of the device. The "Veno-Press" induced a marked augmentation in venous blood velocity flow. A further 10-30% augmentation was noted when the patients were under general anesthesia, as well as a 10-30% increase in the femoral vein diameter. None of the patients developed postoperative DVT. This device is a very efficient tool for augmentation of venous blood velocity, especially during general anesthesia. Its effectiveness is most probably the result of the compressive action over the relaxed--and hence enlarged--capacitant veins of the anesthetized patient. We suggest that the "Veno-Press", if properly timed, is very efficient in venostasis prevention, leading presumably to a decline in the occurrence of DVT and pulmonary embolisms in the surgical patient.

Primary long-standing chylous reflux into skin: combined operative and non-operative treatment.

Chylous discharge into cavities or skin is rare and usually arises after operations in the vicinity of the cisterna chyli (secondary chylous reflux). When chylous discharge is primary, however, chylous reflux has usually been present since birth probably as a consequence of obstruction to lymph flow at or above the cistern chyli. We report a patient who had had chylous reflux into lacerated skin in a lymphedematous thigh for more than 30 years. The condition was successfully managed using both operative and non-operative methods.