Improved results with resection of extensive thoracoabdominal aneurysms.

Thoracoabdominal aneurysms are the most extensive of aortic aneurysms, and their correction is associated with the greatest number of complications. The introduction of new techniques has reduced the morbidity and mortality of surgery for these formidable lesions. A description of some of these techniques, as applied to 33 patients, is summarized, and the results presented.

One-stage segmental resection of extensive thoracoabdominal aneurysms with left-sided heart bypass.

PURPOSE: The purpose of this study is to describe a technique for resection of extensive thoracoabdominal aneurysms, which the authors believe will lower morbidity and mortality rates. METHODS: In an effort to minimize the risk of spinal cord ischemia, we have used a combination of sided heart bypass (left atrium to left femoral artery) with local cooling of the intercostal and visceral arteries and segmental resection of the aneurysm. Segmental resection of the aneurysm allows perfusion of the spinal cord and abdominal viscera as the proximal anastomosis is completed and as each pair of intercostal arteries is reimplanted. An attempt is made to reimplant all pairs of intercostal arteries from T8 to L2. Before the intercostal or visceral arteries are reimplanted, that segment of aorta is cooled with cold crystalloid solution. Thus no segment of the aorta is exposed to warm ischemia for more than 30 minutes. Left-sided heart bypass allows the patient's temperature to be maintained between 35 degrees C and 37 degrees C. RESULTS: We have used this technique in 23 patients with types I and II (Crawford's classification) thoracoabdominal aneurysms. Seven patients (30%) had dissections or rupture associated with their aneurysms and underwent emergency operation. One of these seven patients became paraplegic after operation, for a 4.3% incidence of paraplegia. One patient died of multiple organ failure after operation. No patient had kidney failure requiring dialysis. CONCLUSIONS: We believe that our technique allows the operation to be performed in a deliberate manner with a low incidence of paraplegia and kidney failure.

Ruptured abdominal aortic aneurysms in a private hospital: a decade's experience (1980-1989).

Despite refinements in elective resection of abdominal aortic aneurysms, morbidity and mortality rates for ruptured abdominal aortic aneurysms (RAAAs) remain high. Between January 1, 1980 and December 31, 1989, we treated 208 patients with RAAAs whose mean age was 70 years. The overall mortality rate was 49.5%. Logistic regression analysis showed that three factors correlated with predicted patient survival. Patients < 70 years old had a survival rate of 65.7% compared with a survival rate of 37.4% in patients > 70 years old (p < 0.001). Among "stable" patients (preoperative blood pressure consistently > 90 mm Hg), 88.9% survived compared with 40.9% of "unstable" patients (blood pressure < 90 mm Hg) (p < 0.001). Of the patients with free intraperitoneal rupture, 38.3% survived compared with a survival rate of 79.6% of patients with rupture confined to the retroperitoneum (p < 0.001). Despite a high overall mortality rate in patients with RAAAs, surgical intervention remains the only hope for survival. We continue to advocate an aggressive surgical approach in this group of patients.

Severe hypoxia related to uncomplicated atrial septal defect.

A 73-year-old man was admitted to our institution with severe hypoxia. Cardiac catheterization and transesophageal echocardiography revealed an atrial septal defect with an interatrial right-to-left shunt but with no pulmonary hypertension. Direct examination at surgery revealed an elongated thoracic aorta that caused the aortic annulus to reside at the level of the diaphragm and the heart to be positioned transversely in the mediastinum. Surgical closure of the atrial septal defect normalized oxygenation. We attribute the unusual occurrence of an atrial septal defect and a right-to-left shunt in the absence of pulmonary hypertension to the spatial and mechanical changes caused by the patient's elongated aorta and by the transverse position of the heart.

Delayed postoperative bleeding from polytetrafluoroethylene carotid artery patches.

Patch angioplasty of the internal carotid artery after endarterectomy has been advocated as a means of decreasing early postoperative carotid artery thrombosis, as well as reducing the incidence of recurrent carotid artery stenosis. Noninfectious rupture of saphenous vein patches in the early postoperative period has been reported by several authors, leading others to advocate the use of prosthetic patches. This report describes three patients in whom delayed bleeding through needle holes along the suture lines in polytetrafluoroethylene cardiovascular patches occurred between 1.5 and 4 days after operation. All patients required reexploration to control bleeding, and acute respiratory distress from tracheal compression developed in one patient. Although delayed bleeding through needle holes in polytetrafluoroethylene cardiovascular patches appears to be rare, a word of caution may be in order before advocating routine patching of the carotid artery with this particular type of patch.

Septic complications after cardiac catheterization and percutaneous transluminal coronary angioplasty.

Septic complications after cardiac catheterization and percutaneous transluminal coronary artery angioplasty are distinctly uncommon. However, we have recently treated nine patients with sepsis and life-threatening complications after cardiac catheterization alone or after catheterization and subsequent percutaneous transluminal coronary angioplasty. The common denominator in all patients was either repeat puncturing of the ipsilateral femoral artery or leaving the femoral artery sheath in for 1 to 5 days after the procedure. Two patients died as a direct result of their septic complications. One death occurred in a patient in whom bacterial endocarditis with congestive heart failure developed, and the other patient had a large retroperitoneal hematoma that became secondarily infected. Infected aneurysms that were successfully treated developed in three patients. Our study suggests that colonization of the needle tract by skin flora predisposes to septic complications if repeat arterial punctures are required or if a femoral artery sheath is left in place for more than 24 hours. Patients in whom sepsis develops after these procedures should be initially treated with antibiotics effective against gram-positive organisms. CT scanning or angiography should be considered for patients with persistent sepsis, septic emboli, and abdominal or flank pain. Infected aneurysms require resection or ligation because of the propensity of these aneurysms to rupture.

Combined coronary artery bypass grafting and bilateral renal revascularization for unstable angina and impeding renal failure.

The purpose of our article is to describe a patient with severe hypertension and moderate renal insufficiency, unstable angina, and a 6 cm abdominal aortic aneurysm. A previous aortogram had demonstrated severe bilateral renal artery stenoses. Cardiac catheterization demonstrated severe coronary disease. After cardiac catheterization acute renal failure and pulmonary edema requiring dialysis developed in the patient. In addition, evidence of impending myocardial necrosis developed. Because of the critical nature of the myocardial and renal ischemia it was necessary to perform combined myocardial and renal revascularization rather than staged procedures. At the time of coronary artery bypass grafting, a vein graft was anastomosed to the right coronary artery vein graft and tunneled through the diaphragm into the abdomen to revascularize both renal arteries. After surgery renal function gradually improved, and no further dialysis was required. The abdominal aortic aneurysm was repaired at a subsequent operation. At 2-year follow-up all grafts remained patent. The serum creatinine is 1.2 mg/dl. Although most patients with combined coronary artery disease and renal artery disease can be treated with staged operations, our procedure may be of value in patients in whom staged procedure are not feasible and in whom the infrarenal aorta is severely diseased or aneurysmal.

Rupture of the distal thoracic esophagus following blunt trauma: case report.

Rupture of the distal thoracic esophagus is an unusual injury following blunt abdominal trauma. We recently encountered this injury in a patient following a relatively minor motor vehicle accident. An improperly positioned seatbelt was presumed contributory in this case. Prevention of further contamination and drainage of infection are primary objectives. Wide mediastinal drainage with repair, resection, or diversion are recommended, depending on the degree of mediastinitis present.

Post inferior myocardial infarction ventricular septal rupture.

Mortality from ventricular septal rupture after myocardial infarction (MI) is high. Ventricular septal rupture after inferior MI is particularly associated with a high risk because of difficulty in diagnosis and surgical approach. These three case reports show how diagnosis and correction can be expedited by emergency transportation and color-flow echo-Doppler cardiography. Prompt ventricular septal repair can provide excellent survival and rehabilitation potential.

Transesophageal echocardiography. A technique for intraoperative monitoring.

Cardiac ischemia and myocardial infarction continue to be major causes of perioperative morbidity and mortality, despite aggressive intraoperative monitoring. Intraoperative TEE is evolving as a helpful noninvasive monitor in patients with coronary artery disease and valvular heart disease. Early detection of ischemia and evaluation of valve function with continuous imaging has allowed the use of TEE as a dynamic tool to optimize therapeutic management of cardiac dysfunction that was not always readily available by conventional invasive techniques. As new equipment and techniques are developed, this monitoring method will undoubtedly find even more frequent intraoperative use.

Intraoperative pulmonary angioscopy using the flexible fiberoptic choledochoscope.

The use of fiberoptic angioscopy can be an important adjunct to the performance of pulmonary embolectomy. This technique can be performed rapidly and allows direct visualization of the pulmonary arteries.