Aortopulmonary fistula in a post-coarctation mycotic aneurysm.

A 21-year-old man presented with fever and septicemia resistant to antibiotic therapy. An unusual post-coarctation mycotic aortic aneurysm that had eroded into the left main stem bronchus was identified and replaced with a Dacron graft. A critical factor in achieving the satisfactory result was preparation of the femoral vessels for autotransfusion and possible cardiopulmonary bypass.

Extrapleural pneumonectomy for diffuse, malignant mesothelioma.

Extrapleural pneumonectomy for malignant mesothelioma is a radical procedure that entails en bloc removal of the parietal pleura, lung, pericardium, and diaphragm. Minimal tumor remains after this procedure; palliation and occasional long-term survival may be achieved in properly selected patients. Extrapleural pneumonectomy for diffuse, malignant mesothelioma was done in 33 patients (27 male and 6 female) with 18 procedures on the left side and 15 on the right. There was a history of exposure to asbestos in 16 (48%) of the patients. Histological classification revealed that 20 tumors were epithelial, 10 were mixed, and 3 were sarcomatous. Good palliation, defined as survival for 24 months with a return to fairly normal activities, was obtained in 8 patients (24%) and survival for 36 months was achieved in 5 patients. Three patients died of the disease at 59 months, 60 months, and 82 months. There were 3 operative deaths (9.1%), and serious postoperative complications occurred in 8 patients (24%). Postoperative adjunctive therapy consisting of chemotherapy or irradiation or both was given to approximately one-half of the patients. These findings indicate that extrapleural pneumonectomy for malignant mesothelioma can be done with an acceptable morbidity and mortality. Palliation is achieved in 24% of patients, and there may be an occasional long-term survivor.

Limited success of lumbar sympathectomy in the prevention of ischemic limb loss in diabetic patients.

The results of 93 consecutive lumbar sympathectomies performed over a five year period upon 54 patients with diabetes and 39 without diabetes were compared in terms of subsequent amputation using life table analysis methods. Cumulative success rates for avoiding amputation were significantly lower in those with diabetes as compared with rates for those without diabetes at five years and at most shorter six month intervals. Although there are a number of possible explanations for this difference, an important contributing factor may be the prior spontaneous denervation of diabetic blood vessels. The results demonstrate that better predictive indexes for lumbar sympathectomy are needed.

Inferior vena cava interruption with the Hunter-Sessions balloon: eighteen years' experience in 191 cases.

Over a period of 18 years, 191 consecutive patients had interruption of the inferior vena cava with the Hunter-Sessions balloon for complications of deep venous thrombosis and pulmonary embolism. Causes of deep venous thrombosis and pulmonary embolism included the postoperative state (33%), cancer (32%), and stroke (11%). There were 93 females and 98 males; ages ranged from 17 to 90 years (average, 57 years). Indications for placement of the Hunter-Sessions balloon were as follows: contraindication to anticoagulants (33%), anticoagulant complications (24%), pulmonary embolism despite anticoagulants (45%), and others including inferior vena cava thrombus (12%). Sixty-eight percent had clinical phlebitis and 36% had positive venography results. Pulmonary embolism had occurred in 165 patients (86%). It was diagnosed by ventilation-perfusion scanning (75%), angiography (23%), or on clinical grounds (2%) in patients with confirmed deep venous thrombosis. At the time of the procedure 52% were in significant cardiopulmonary distress, and 10% were intubated and on respirators. Transjugular placement was done in 188 patients, and transfemoral placement was performed in three. All All tolerated inferior vena cava interruption. Thirty patients (15%) died while in the hospital an average of 21 days after balloon placement, which was unrelated to the deaths. Follow-up was 45 months. Ninety-four patients are dead, 95 are alive, and the status of two patients is unknown. Twenty-nine of 64 patients (45%) who died after they left the hospital died of cancer. At last follow-up, 75% of patients had legs free of edema and 25% had need for elastic stockings. No malfunction or migration has occurred with the device. No patient had a pulmonary embolism while in the hospital after insertion of the Hunter-Sessions balloon, and no patient died of pulmonary embolism. Late minor pulmonary embolism occurred in three patients.