Ultrasound imaging of the radial artery following its use for cardiac catheterization.

Our experience suggests transradial arterial access with 5Fr catheters can be used for cardiac angiography with a low incidence of clinical complications, and supports the findings of previous investigators. Subclinical complications at the catheterization site were infrequent in this study (1 patient with asymptomatic radial artery occlusion). The presence of a palpable radial pulse may not be a reliable estimate of artery patency as evidenced by our patient with a palpable pulse due to retrograde flow. The theoretical advantage of the procedure is derived from the dual vascular supply to the hand. Radial artery occlusion, while uncommon, results in no ischemic sequelae in the setting of a patent ulnar artery.

The surgical treatment of incapacitating constipation associated with idiopathic megacolon.

Results of the surgical treatment of idiopathic megacolon with incapacitating constipation in 23 patients are reviewed. The Swenson endorectal pull-through procedure, although it gave satisfactory results, was associated with high morbidity and resulted in the only death in this series. Anterior resection gave good results in six of eight patients. This procedure should give good results when the dilatation as seen on barium enema studies is confined to the rectosigmoid. However, for patients who have more extensive dilatation of the colon, extensive left hemicolectomy or total abdominal colectomy should be strongly considered, for these procedures have been associated with uniformly good results and little morbidity. There is little to recommend bilateral lumbar sympathectomy.

Radiation-induced arterial injuries.

In a 20-year period from 1961 to 1981 at the University of Kentucky Medical Center, there were 20 patients with vascular lesions directly attributable to irradiation. Two distinct patterns of arterial injury attributable to radiotherapy were identified--arterial disruption and occlusion. Arterial disruption occurred in 12 patients--11 carotid blowouts and 1 iliac artery rupture. Two patients underwent prophylactic carotid artery ligation for impending rupture. In the 11 carotid artery ruptures, ligation of the artery in nine patients resulted in stroke or death in five patients. Iliac artery disruption necessitated ligation, which eventually led to severe ischemia requiring hip disarticulation. Unusual arterial stenosis or occlusion occurred in six patients 7 to 24 years after irradiation. Three patients had severe stenosis or occlusion of the common, internal, or external carotid arteries leading to cerebrovascular insufficiency. Three other patients with focal stenosis of the iliofemoral region were successfully treated with bypass grafting.

Isolated iliac artery aneurysms.

The records of 50 patients with isolated iliac artery aneurysms seen between January 1970 and January 1982 were reviewed. Forty-seven were men and three were women. Their ages ranged from 41 to 92 years (mean 69.7 years). Aneurysm diameter ranged from 2 to 20 cm (mean 4.7 cm). Seventeen patients had multiple aneurysms. Sixty-two percent of aneurysms were on the right side. Eighty-nine percent were located in the common iliac artery, 10% in the internal iliac artery, and 1% in the external iliac artery. Twelve patients had symptoms; all presented with sudden pain. Rupture occurred in seven patients; only three patients survived. Twenty-four patients had surgical treatment. Aneurysmorrhaphy with graft interposition was the most common procedure. There were no deaths during elective operation. Nineteen patients who did not undergo operation were followed from 0.25 to 11 years (mean 4.9 years). Enlargement occurred in nine patients and rupture in one. We conclude that the natural history of isolated iliac artery aneurysms is similar to that of other atherosclerotic aneurysms. Elective resection and arterial reconstruction are recommended.

Atherosclerosis in the young: a virulent disease.

To learn more about the prognosis of young patients with atherosclerotic cardiovascular disease we reviewed our experience with patients 40 years of age or younger who required surgical intervention for cardiovascular occlusive disease. We identified 47 patients, 25 of whom required peripheral vascular reconstruction and 22 of whom underwent coronary artery bypass grafting. All but one patient were extremely heavy cigarette smokers. Of the 11 women with peripheral vascular disease, eight required operations for limb salvage and three for renovascular hypertension. Four of the 11 women required a total of 11 subsequent operations because of recurrent or progressive disease. Of the 14 men, 13 required intervention for limb salvage and one for renovascular hypertension. Forty-five additional operations, including 15 amputations, were required in these 14 male patients because of recurrent or progressive disease. Of the 22 patients (21 men and one woman) who underwent coronary artery bypass operations, there was one postoperative death. Five patients (23.8%) required a second bypass operation and one patient (4.8%) required a third procedure bypass because of recurrent symptoms and occluded grafts. One patient has occluded grafts and inoperable disease. Atherosclerotic cardiovascular disease in young patients appears to be a virulent disease process and is associated with a high rate of recurrent or progressive disease. There is a striking association between the premature development of atherosclerotic cardiovascular disease and cigarette smoking.

Abdominal aortic aneurysm and coronary artery disease.

To delineate the role of routine preoperative coronary angiography in patients undergoing elective abdominal aortic aneurysm resection, we reviewed the records of 422 such patients at the Mayo Clinic, Rochester, Minn. One hundred seventy-three patients (41%) had a history of either myocardial infarction or angina pectoris; 146 (35%) had a previous myocardial infarction; 111 (26%) had a history of stable angina. Six patients underwent coronary artery bypass grafting prior to aneurysmorrhaphy. Ten patients (2.4%) died within the first 30 postoperative days. Seven deaths (1.7%) were secondary to myocardial infarction. Mortality from myocardial infarction was 0.8% in patients who had no history of coronary artery disease and 2.9% in patients with a history. Mortality was not increased in elderly patients. Coronary angiography should be selectively obtained prior to elective aneurysmorrhaphy. A 0.8% mortality from myocardial infarction in patients without a history of coronary artery disease and an overall mortality of 1.7% do not justify routine coronary angiography prior to elective resection of an abdominal aortic aneurysm.

Surgical treatment of ascending aortic aneurysms associated with aortic valve insufficiency.

From 1965 to 1978, 111 patients underwent combined operation for ascending aortic aneurysms and aortic valve insufficiency. Fifteen patients had direct coronary implantation (Group 1). In 25 patients operated on between 1972 and 1977, the aortic root was retained (Group 2). An additional 71 patients operated on between 1965 and 1972 were included (Group 3): 40 who had synthetic graft replacement and retention of the aortic root and 31 who had aortoplasty and associated aortic valve repair. In 8 patients in Group 3, recurrent aneurysms were detected an average of 6.5 years after operation. The mortality rate for repaiajor complication after incomplete resection of the aortic root. Total exclusion of the aneurysm should be considered.

Computed tomographic findings in cerebral arterial ectasia.

The computed tomographic findings in 15 patients with angiographically documented cerebral arterial ectasia are reported. In addition to demonstrating the majority of pathologic arterial segments, computed tomography also documents the presence and extent of associated intracranial abnormalities. In this study these included cerebral atrophy (10 patients), infarction (three patients), and subarachnoid hemorrhage (one patient).

Upper-extremity vascular injuries.

Although upper-extremity injuries alone are usually not life-threatening, they can produce significant immediate or long-term morbidity, especially if there is an associated nerve injury. The diagnosis of an arterial injury may be readily apparent, but the excellent upper-extremity collateral circulation may create palpable distal pulses despite a significant proximal arterial injury. Therefore, a high index of suspicion and the liberal use of arteriography are necessary to avoid missing these injuries. Compression of the brachial plexus by a hematoma can produce a serious neurologic deficit. Prompt evacuation of the hematoma may significantly reduce the deficit, another fact that supports an aggressive surgical approach in these patients. The long-term results of upper-extremity vascular injuries are usually determined by the extent of any associated nerve injuries.

Recurrence and rupture of an axillary artery aneurysm.

Aneurysm of the axillary is an uncommon type of peripheral artery aneurysm. most of these aneurysms are symptomatic and present with signs and symptoms of thromboembolism. Rupture of an axillary artery aneurysm is uncommon. We present a patient who ruptured a recurrent true axillary artery aneurysm four years after surgical treatment by exclusion and bypass of the aneurysm. We believe that the preferred treatment of an axillary artery aneurysm is resection and insertion of an end-to-end interposition graft.

Adult Hirschsprung's disease: results of surgical treatment at Mayo Clinic.

Fifty adult patients with Hirschsprung's disease were operated on at the Mayo Clinic between 1950 and 1978. Six different operations were used. Of the three patients treated by the Soave endorectal pull-through procedure, two suffered anastomotic leaks and required diverting colostomies; all three had excellent long-term results, however. All four patients who underwent the Duhamel procedure had excellent results, with only one minor complication. Of the 17 patients undergoing the Swenson procedure, 6 had major postoperative complications, including 2 with impotence; 3 (17.6 per cent) patients who underwent rectal myectomy, there was one minor complication, although 5 (38.5 per cent) had unsatisfactory results. Six patients had anterior resection, one of whom died of generalized peritonitis from an anastomotic leak, and one patient suffered recurrent megacolon that required resection of an additional segment of colon. Four of the five survivors had excellent results. Of the seven patients who underwent left hemicolectomy or total abdominal colectomy, two had serious postoperative complications, and two required resection of an additional segment of colon because of recurrent symptoms. All seven patients eventually had excellent results.

A technique for intraoperative arteriography following carotid endarterectomy.

This technique provides a simple and reliable means of obtaining an operative arteriogram after carotid endarterectomy. Detection of unsuspected abnormalities before the wound is closed allows the surgeon to correct any abnormalities immediately with hopes of decreasing the incidence of postoperative neurological deficits.

Subclavian-axillary vascular trauma.

Traumatic vascular injuries to the subclavian and axillary vessels are often associated with permanent neurologic impairment either by direct injury to the brachial plexus or by compression from an expanding hematoma. Prompt decompression of the plexus by evacuation of the hematoma may avoid permanent neurologic damage and decrease the morbidity of these injuries. We reviewed our experience with these injuries with particular reference to the effect of early decompression of the brachial plexus. From 1963 to 1984 we treated 40 patients. The causes of the injuries were penetrating trauma in 85% and blunt trauma in 15%. The results of arterial repair were excellent with only two failed repairs; neither resulted in severe ischemia. Two patients were suspected of having thrombosed venous repairs. Among the 12 patients with direct injury to the brachial plexus (partial or complete transection), only six had subsequent improvement of their neurologic dysfunction. In contrast, six of seven patients in whom there was only compression of the plexus by hematoma but no direct injury, had neurologic improvement following evacuation of the hematoma. This finding suggests that prompt decompression of the brachial plexus following these injuries may reduce the amount of neurologic impairment and reduce the morbidity of these injuries.

Renal revascularization by extra-anatomic bypass.

Patients who suddenly become anuric and in whom no urinary obstruction is found should undergo arteriography both to confirm acute renal arterial occlusion and to plan surgical treatment. In acute renal arterial occlusion collateral circulation is often sufficient to maintain kidney viability and subsequent successful revascularization. Because there are no clinical or radiologic criteria to determine salvageability of the kidney, surgical exploration is advised in these patients. Such individuals who undergo successful renal revascularization often have gratifying return of renal function. Axillofemoral-renal bypass is suggested as a method to accomplish this objective.

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.