Graft replacement of aneurysm in descending thoracic aorta: results without bypass or shunting.

During the 24-year period from 1956 to 1980, 148 patients with aneurysms confined to the thoracic aortic segment, bounded above by the left subclavian artery and below the diaphragm, were treated with replacement therapy. From 1956 to 1967, 36 patients were treated by use of temporary bypass or shunts which carried a 6% incidence of paraplegia and a mortality rate of 22%. From 1962 to 1980, 112 patients were treated without shunts or bypass; this report is concerned with the latter cases. The incidence of paraplegia and the survival rate in this group were 0.9% and 91%, respectively. There were 89 men and 25 women in the series whose ages ranged from 22 to 87 years with an average age of 61. All types of aneurysms were represented; however, arteriosclerosis and dissection were the most common causes. The extent of aneurysm was variable, but most of the descending thoracic aorta was involved in more than half the cases. Associated diseases were present in 77% of cases. Operation consisted of aneurysmal replacement using inclusion technique with cardiac hemodynamics controlled by vasodilators and fluid replacement. During the past 4 years, proximal blood pressure has been controlled with nitroprusside. Cardiovascular hemodynamics, blood gases, electrolytes, and plasma osmolarity were monitored extensively and frequently to achieve the most desirable physiologic response to aortic clamping and operation. During this time 69 patients were treated. There were four (6%) deaths. None developed paraplegia or renal failure. Concomitant subclavian artery clamping was employed in 34 of these patients and in 22 additional patients with distal arch lesions. None in either group developed paraplegia. This indicated the safety of temporary subclavian artery occlusion. Death, both early and late, was due to a number of causes, but rupture of another aneurysm was the most common. This emphasizes the value of concomitant operation in patients with multiple aneurysms and careful follow-up in all patients.

Considerations in extrathoracic reconstruction for disease of the branches of the aortic arch.

The effectiveness and decreased morbidity and mortality of extrathoracic reconstruction for disease of branches of the aortic arch has been reported by several workers; however, there has been relatively little discussion in the literature in regard to designing the operation to correct the pathophysiologic process of the disease (embolism versus flow reduction). The technique of reconstruction should be selected with regard to a patient's symptoms and arteriographic findings, with embolic phenomena more likely in patients with cerebral hemispheric symptoms and arteriographic stenosis rather than total occlusion. Simple bypass for suspected proximal embolic disease is inadequate.

How accurate are ventilation-perfusion scans for pulmonary embolism?

To evaluate the accuracy of ventilation-perfusion scanning in the diagnosis of pulmonary embolism, the pulmonary arteriograms of 55 patients suspected of pulmonary embolism were compared with their ventilation-perfusion scans. The clinical presentation was consistent for the diagnosis of pulmonary emboli in all 55 patients. The scans were divided into the following four categories according to standard guidelines: normal, low, intermediate, and high probability. Three patients had normal scans confirmed by arteriography; 34 patients had high-probability scans, but only 22 (65 percent) were positive at arteriography. The remaining 18 patients had low or intermediate-probability scans (9 patients each), 5 of whom (28 percent) were positive at angiography (sensitivity 82 percent, specificity 57 percent). This study demonstrates the inaccuracy of ventilation-perfusion scanning for the evaluation of pulmonary embolus and may represent the variability of interpretation at individual institutions. Perhaps each institution may need to compare the results of ventilation-perfusion scanning and angiography to optimally select and treat patients.

Use of a balloon-tipped perfusion catheter for renal preservation during suprarenal abdominal aortic operations.

Two cases are presented that illustrate the use of the Pruitt-Inahara vascular shunt to avoid renal failure during suprarenal aortic reconstruction. Previously reported methods of renal preservation are briefly reviewed, and the advantages of a balloon-tipped perfusion catheter over previously reported techniques are presented.

Inferior vena caval filters in heart transplant recipients with perioperative deep vein thromboses.

Heart transplant recipients may constitute a high-risk group for pulmonary embolism and subsequent complications. We present the cases of two patients who underwent prophylactic filter insertion after deep venous thrombosis developed perioperatively and discuss our rationale for this approach.

Cross-femoral venous bypass in combination with tumor resection.

The cross-femoral venous bypass procedure (also known as the Palma/Dale procedure) was introduced for unilateral iliac or common femoral vein occlusions resulting in chronic deep venous insufficiency. We have utilized the procedure successfully in a patient who required extensive pelvic tumor resection involving sacrifice of pelvic venous collateral channels and unilateral ligation of external, internal, and common iliac veins. The case report and review of the literature are presented.

True tibial artery aneurysms: case report and literature review.

True tibial artery aneurysms are rare lesions. They may manifest themselves clinically either as a painful leg mass or as evidence of ischemic changes in the foot. Asymptomatic lesions may be found incidentally during arteriography. The need for surgical intervention should be individualized depending on the presentation; the type of surgical intervention is based on coexistent tibial artery anatomy. The present report describes a patient with a true tibial artery aneurysm. Clinical presentation, radiographic findings, and surgical management are described.

The effect of tennis racket string vibration dampers on racket handle vibrations and discomfort following impacts.

In this study, we evaluated the effect of the use of tennis racket string vibration dampers on racket handle vibrations, and perceptions of hand and arm discomfort experienced by tennis players owing to stationary racket impacts. Twenty tennis players (10 males, 10 females) aged 18-29 years volunteered for the study. Two different racket models were impacted at the geometric centre of the racket face and 100 mm distal to the centre both with and without string vibration dampers in place. The participants could neither see nor hear the impacts, and they indicated their discomfort immediately after each impact using a visual analogue scale. An analysis of variance (2 x 2 x 2 factorial) was performed on the scaled discomfort ratings with the factors damping condition, racket type and impact location. No significant differences in discomfort ratings between damped and undamped impacts or between the two racket types were found. Also, central impacts were found to be more comfortable than impacts 100 mm distal to the centre (P< 0.05). There were no significant interaction effects. Vibration traces from an accelerometer mounted on the racket handle revealed that string vibration dampers quickly absorbed high-frequency string vibration without attenuating the lower-frequency frame vibration. In conclusion, we found no evidence to support the contention that string vibration dampers reduce hand and arm impact discomfort.

Defective binding of the third component of complement (C3) to Streptococcus pneumoniae in multiple myeloma.

Patients with multiple myeloma (MM) are at an increased risk for infections with bacteria that require opsonization with complement. Because Streptococcus pneumoniae is the most frequently encountered pathogen in these patients, we investigated the ability of serum from patients with MM to mediate the binding of C3b, the major opsonin of the complement system, to S. pneumoniae. S. pneumoniae types 3, 14, and 25 were chosen for study, since S. pneumoniae type 3 activates primarily the classical complement pathway (CCP), type 25 primarily the alternative complement pathway (ACP), and type 14 both pathways. S. pneumoniae were treated with normal serum or serum from 17 patients with MM, and the bound C3b was quantified with fluorescein-conjugated anti-C3 in a spectrophotofluorometric assay. Despite normal or elevated serum concentrations of C3, total hemolytic complement, and C-reactive protein in all of the MM sera, factor B in 16/17 such sera, and C4 in 14/17 MM sera studied, all 17 sera demonstrated a defect in C3b binding to type 3 (32.7% +/- 6% of normal). In addition, serum from 15/17 patients bound decreased amounts of C3b to types 14 (39.6% +/- 8%) and 25 (52.2% +/- 8%). Mixing normal serum with MM serum restored MM C3b binding activity to all three S. pneumoniae types, suggesting that the defect was related to a deficiency rather than an inhibitor of C3 activation. Although MM patients are unable to produce specific antibodies to bacterial antigens, the addition of anti-S. pneumoniae antibodies to MM serum did not enhance C3b binding to any of the S. pneumoniae types. However, when S. pneumoniae were opsonized in a mixture of MM serum and C3-depleted normal serum, C3b binding was restored to all three S. pneumoniae types, demonstrating that MM C3 functions normally in the presence of other normal serum factors. In the present studies, the MM C3b binding defect appeared to correlate with the incidence of S. pneumoniae infections. Serum from patients with a history of an S. pneumoniae infection bound significantly less C3 (20.5% +/- 4%) than those study patients without a history of an S. pneumoniae infection (55.8% +/- 8%) (p less than 0.0025). Thus, MM serum has a defect in the activation of C3, and this may contribute to the increased susceptibility of MM patients to S. pneumoniae infections.

Percutaneous placement of a hepatic vein stent in the treatment of Budd-Chiari syndrome.

The authors describe the first reported use, to their knowledge, of an intravascular stent to relieve hepatic vein stenosis causing the Budd-Chiari syndrome. A patient with severe stenosis of the left hepatic vein is described. Multiple balloon angioplasty procedures were performed over a period of several months and provided only transient relief of symptoms. As an alternative to surgical management, an intravascular stent was placed, with complete resolution of symptoms. Intravascular stent placement may play an important role in treatment of the Budd-Chiari syndrome.

Magnetic resonance imaging of the pediatric spine.

The authors conclude that MRI is the imaging mode of choice for the evaluation of extradural and intramedullary tumors and for the screening of all children with suspected spinal pathology.

Sonographic evaluation of renal artery aneurysm in childhood.

We report a child presenting with renovascular hypertension and sonographic evidence of a renal artery aneurysm (RAA). The diagnosis of RAA was made sonographically by demonstrating vascular flow in an aneurysmal segment adjacent to but continuous with the right renal artery and externally compressing the inferior vena cava. Comparison of the sonographic studies and an abdominal angiogram illustrate the sensitivity of sonography in diagnosing this condition. We suggest that with renal doppler sonography, RAA may be diagnosed less invasively and possibly with greater frequency yet believe that the gold standard of angiography is necessary prior to surgical intervention.