Embolization of caval umbrella. Discussion and report of successful removal from the right ventricle.

The first case of successful diagnosis and operative removal of a vena caval umbrella which had become detached and migrated to the right ventricle is reported. Complications from the employment of this device are discussed. In all cases of umbrella embolization to the right heart and pulmonary arterial tree, immediate operative removal is indicated. Precautions regarding umbrella insertion which minimize the likelihood of dislodgment and embolization are also mentioned.

Long-term follow-up of unusual ball-valve aortic substitute.

On March 19, 1962, prior to the availability of Starr-Edwards ball-valve prostheses for aortic substitution, a mitral valve turned upside down was implanted for marked calcific aortic stenosis. It worked well and the patient was in good health for 15 years. Late annular calcification and loosening of sutures with marked perivalvular regurgitation made valve replacement necessary 16 years after operation. The original valve was perfectly preserved.

Left carotid steal. A new observation.

A patient had an occlusion of the left subclavian artery just proximal to the takeoff of a previously placed subclavian-carotid graft. This caused reversal of flow in the graft and a symptomatic steal of blood via to the intracranial arteries. An axilloaxillary graft restored forward flow. In a second patient, a steal occurred from the right carotid and vertebral systems into the distal carotid system of the left side that has been isolated by a proximal carotide artery occlusion from arteriosclerosis. A saphenous vein, used as a bypass from the subclavian to the carotid artery, restored normal flow. Thus, the carotide system may be the low-pressure area responsible for the steal, although this is rarer than the subclavian.

The management of stenotic and obstructive lesions of the aortic arch branches.

The stenotic internal carotid can be managed in a variety of ways and number of tests can be utilized for assessing the collateral blood flow. Except in unusual situations, carotid thromboendarterectomy with or without a patch graft is generally employed. Although some surgeons use no protective shunt at all, or only upon specific indications, intraluminal shunting is utilized extensively. Our preference is to employ the customary Javid shunt technic except in unusual circumstances that suggest that added safety may be assured by shortening to a matter of seconds the period of interruption of carotid flow. In such cases, we believe the temporary axillary-internal carotid intraluminal shunt is of considerable value. Although mediastinal and thoracic procedures and bypass grafts delivering blood from the ascending aorta are not needed nearly as often as they were formerly, they are essential in certain cases. They yield excellent results and carry small risk. Carotid-subclavian grafts have proved quite valuable in restoring pulsatile flow to the subclavian and carotid systems. Our preference, however, because of technical simplicity, is the carotid-axillary bypass procedure. Subclavian-subclavian and axillary-axillary grafts have been employed successfully. When a carotid-axillary bypass is feasible, we would choose this method instead and reserve the others for unusual anatomic-pathologic situations.

Temporary axillary-carotid shunting for unusual instances of carotid stenosis.

A method has been developed which entails the introduction of the larger end of a Javid shunt tube in the axillary artery and the other in the internal carotid with only momentary interruption of blood flow. The method of closing the incision after the thromboendarterectomy almost entirely eliminates a second period of carotid occlusion. This procedure may be useful in unusual instances in which it is believed advantageous to avoid even the relatively short occlusion periods usually necessary when using the standard intraluminal shunt technique.

Stenotic and obstructive lesions in acute dissecting thoracic aortic aneurysms.

The present study of 33 operatively treated patients, 88 per cent of whom survived the procedure, is concerned with an important problem associated with acute thoracic aortic dissection, the stenotic and obstructive lesions of the aorta and its branches. Their variety and nature are described, as are the additional operative procedures deemed necessary at the time of the operation, immediately thereafter, or later on. Much has been learned about these difficulties from clinical and autopsy observations and especially from careful arteriographic surveys. They seem to be generally well withstood following resectional and grafting procedures upon the affected segment of the thoracic aorta. Occasionally, additional operative manipulations may be necessary at the same time, for example, interpolation of grafts between the ascending aortic graft and a coronary when the origin of the latter is sheared off by the dissection, and distal arterial manipulations when the patient still has ischemic lower extremities immediately after the primary procedure. Later operations must sometimes be performed because of persistence of complaints such as intermittent claudication. It is extremely rare that immediate reoperation is advisable because of indications of intra-abdominal ischemia. Much more can be learned from careful pre- and postoperative arteriographic study.

Cardiac myxoma: the Indiana Heart Institute experience.

Surgical resection of a cardiac myxoma was performed in 14 patients at the Indiana Heart Institute at St. Vincent Hospital and Health Care Center in Indianapolis from 1974 to 1989. Thirteen were located in the left atrium and one in the right atrium. The 10 women and four men ranged in ages from 28 to 75 years. Surgical complications included one perioperative death, one late death and one late recurrence requiring reoperation. Physicians must be highly suspicious to correctly diagnose this unusual but surgically correctable entity. Two-dimensional echocardiography is the diagnostic technique of choice for both early diagnosis of a cardiac myxoma and late follow-up after resection.

Risk factors for leg wound complications following endoscopic versus traditional saphenous vein harvesting.

BACKGROUND: Risk factors for leg wound complications following traditional saphenectomy have included: obesity, diabetes, female gender, anemia, age, and peripheral vascular disease. Use of an endoscopic saphenectomy technique may modify the risk factor profile associated with a traditional longitudinal incision. METHODS: From September 1996 to May 1999, 276 consecutive patients who underwent elective isolated coronary artery bypass grafting performed by a single surgeon (K.B.A.) had their greater saphenous vein harvested endoscopically. During the period from January 1999 to May 1999, the surgical records of 643 patients who underwent the same operation and had a traditional longitudinal saphenectomy were reviewed for postoperative leg wound complications. Group demographics were similar regarding preoperative risk stratification and traditionally identified wound complication risk factors (diabetes, gender, obesity, preoperative anemia, and peripheral vascular disease). Leg wound complications were defined as: hematoma, dehiscence, cellulitis, necrosis, or abscess requiring dressing changes, antibiotics and/or debridement prior to complete epithelialization. Follow-up was 100% at six weeks. RESULTS: Leg wound complications following endoscopic harvest occurred in 3% (9/276) of patients versus 17% (110/643) of traditional harvest patients (p < 0.0001). No univariate risk factors for wound complications were associated with endoscopic saphenectomy. Univariate predictors of wound complications following traditional saphenectomy included: diabetes (p = 0.001), obesity (p = 0.0005), and female gender (p = 0.005). Multivariable risk factors for leg wound complications following saphenectomy were traditional harvest technique (OR 7.56, CI 3.8-17.2, p < 0.0001), diabetes (OR 2.10, CI 1.4-3.2, p = 0.0006) and obesity (OR 1.82, CI 1.2-2.8, p = 0.007). CONCLUSIONS: Traditional longitudinal saphenectomy is a multivariable risk factor for development of leg wound complications. Endoscopic saphenectomy modifies the risk factor profile for wound complications and should be the standard of care, particularly for obese and/or diabetic patients who require venous conduit during coronary artery bypass grafting.