Albert D. Hall

Technical result of carotid endarterectomy: Arteriographic assessment

Abstract To evaluate the technical results of operative treatment of stenosis of the internal carotid artery, arteriographic assessment was used in one hundred consecutive procedures. Operative arteriograms were taken routinely at the completion of the endarterectomy and again two to eight weeks later. Late follow-up assessment was obtained by repeating the arteriograms whenever symptoms recurred or when the five-year follow-up period was reached. One fourth of the hundred arteriograms taken at the completion of operation revealed an unsuspected defect in the repair. In all but one of these patients immediate revision was carried out. The end point of the operation was a widely patent vessel as demonstrated by angiography. Follow-up arteriography at the time of discharge from the hospital revealed the only technical failure in the hundred operations, which was in the one patient in whom revision was not performed. Late follow-up examination revealed continued patency at the five year period in all but one instance, an asymptomatic occlusion which was found in a patient who had died of myocardial infarction. Since 25 per cent of the patients had unsuspected intraluminal defects or thrombosis, it is obvious that routine operative arteriograms will increase the technical success of carotid endarterectomy. When the operative arteriogram demonstrates a good result, long-term patency of the artery after endarterectomy is assured.

Late results of axillary-femoral bypass grafting

Abstract An analysis of the results of axillary-femoral bypass demonstrates that a single axillary artery can restore satisfactory blood flow to both lower extremities, but the late patency of the reconstruction does not compare favorably with conventional intra-abdominal aortic reconstruction. Technical modifications, including the use of a 10 mm weaveknit prosthesis combined with a crossover femorofemoral bypass, have substantially improved late patency, so that a comparison of the cumulative patency rates with this prosthesis closely parallels the cumulative survival rate of the group of poor risk patients for whom the operation was intended. Current indications for the use of the operation include the restoration of blood flow to the leg after removal of an infected intra-abdominal prosthesis, and treatment of advanced ischemia in elderly poor risk patients in whom conventional intra-abdominal vascular reconstruction carries a high morbidity and mortality.

Ulcerated atheroma of the carotid artery: A cause of transient cerebral ischemia☆☆☆

Abstract The two principal theories of transient cerebral ischemia, arterial stenosis reducing cerebral blood flow and intermittent embolization from carotid atheromas, are discussed. Although the concept of cerebral embolization has the most theoretic support, this has been difficult to prove on the basis of operative results since virtually all cases have been preselected on the basis of a high grade arterial stenosis. To settle this issue, we have performed twelve carotid endarterectomies on nine patients for the relief of symptoms of transient cerebral ischemia. None of these lesions was “stenotic”, but all had ulcers containing loose atheromatous or platelet material. There were no deaths or complications and all patients have been asymptomatic since operation. The operative criterion now recommended for patients with lateralizing transient cerebral ischemia is the presence of an atheromatous plaque in the appropriate carotid artery regardless of whether or not the lumen of the carotid artery has been compromised.

Transient bacteremia: A cause of infection in prosthetic vascular grafts

Abstract To test the theory that freshly implanted vascular prosthetic grafts are susceptible to infection via circulating bacteria, the infrarenal aortas of twelve dogs were replaced with Dacron grafts during experimentally induced bacteremia from Staph. aureus. Three weeks after graft placement, all grafts showed infection with Staph. aureus. The results of this study indicate that a prosthetic vascular graft, unprotected by pseudointima, is vulnerable to circulating bacteria in the blood stream. It is suggested that prophylactic antibiotics be used in patients who are scheduled to receive a prosthetic vascular graft.

LIGATION TREATMENT OF AN ABDOMINAL AORTIC ANEURYSM.

Summary Surgical therapy of abdominal aortic aneurysms is well established, and surgical mortality has progressively lessened to as little as 4 per cent in one major clinic. Arteriosclerosis, the most common cause of aneurysm, is a generalized disease and an occasional patient with aneurysm and severe associated cardiovascular or pulmonary disease may be a significant risk for abdominal aortic surgery. A case of symptomatic abdominal aneurysm in a poor risk patient is presented. It was thought that predictable surgical mortality was greater than 10 per cent and for this reason a staged operation was performed. The initial procedure consisted of a subcutaneous graft from the axillary to the femoral artery and an additional graft from one femoral artery to the other. At a second operation the aorta was ligated; the previously placed graft now provided the entire circulation to the lower half of the body. There was minimal morbidity from the operation, the circulation in the lower half of the body has been excellent, and the large aneurysm is no longer palpable four months after surgery. Conventional resection of an aneurysm with plastic prosthetic replacement is optimal therapy. It may be well to consider the occasional patient with recent myocardial infarction or associated chronic degenerative disease as a candidate for this staged reconstruction rather than to abandon consideration of surgical therapy.

Clinical manifestations of adrenal hemorrhage

Abstract Thirty-four patients with adrenal hemorrhage were treated at the University of California Hospitals, San Francisco, from 1960 through 1973. In two cases the condition was diagnosed at operation and in thirty-two the diagnosis was made at postmortem examination. In only seven of these thirtyfour patients were the abdominal symptoms and signs clearly attributable to adrenal hemorrhage. In the remaining twenty-seven patients the clinical manifestations were marked by other intra-abdominal problems or by severely altered mentation. The most common clinical manifestations in these seven patients were profound prostration, fever, mental aberrations, emesis, and weakness with severe, constant, localized, upper abdominal pain. Awareness of the sequence of symptoms and the predisposing factors of adrenal hemorrhage will make the diagnosis more apparent and treatment more successful.

Revascularization of severely ischemic extremities with an arteriovenous fistula

Abstract Patients with severely ischemic extremities frequently have multiple occlusive lesions. The surgeons ability to salvage these limbs is frequently compromised by impaired “runoff” at the level of the popliteal artery which results in early thrombosis of endarterectomies or bypass grafts. This is ascribed to low rates of flow through the areas of reconstruction resulting from obstruction of the arterial outflow by disease. One method of artificially augmenting the outflow and thus preventing failure of an operation is the production of a “leak” or arteriovenous fistula immediately distal to the reconstruction. In the four cases we have reported, extensive disease prevented the use of standard operations and peripheral arteriovenous fistulas were placed to increase flow artificially through the critical vessel. This has resulted in an immediate success of the operation. The fundamental aspect of the technic is control of flow through the fistula. By so doing, it is possible to ensure flow in the arterial bed distal to the fistula and simultaneously prevent any adverse systemic effects of the fistula. This technic will permit vascular reconstruction to be used on arteries formerly considered inoperable as it provides a means of assuring blood flow through the operated area.

Below the knee amputation for ischemic gangrene: Comparative results of conventional operation and immediate postoperative fitting technic☆

Abstract Two technics of below the knee amputation-rehabilitation are presented. The results of a standard operative technic are compared with those of amputation with immediate postoperative fitting of a prosthesis. In every parameter of comparison the group receiving an immediate postoperative prosthesis was superior as evidenced by a zero mortality compared to 15 per cent in the standard group, an 85 per cent primary healing rate compared to 53 per cent, and 100 per cent rehabilitation compared to 85 per cent. The time from amputation to fitting of a permanent prosthesis was 32 days in the group with an immediate postoperative prosthesis as compared to 125 days in the standard amputation series. A combination of factors comprising the immediate postoperative prosthesis program, including a long posterior flap, rigid dressing, and immediate ambulation, seems to account for the improved results in this amputation series.

Use of knitted Marlex mesh in the repair of ventral hernias

Abstract Knitted Marlex mesh, a recently developed polyethylene plastic, has significant advantages over previously used prostheses in the repair of difficult ventral hernias. Twenty cases of ventral hernia repaired with Marlex are reported. Most of these were large or complicated defects, averaging 105 sq. cm. in cross-sectional area. In two instances the hernia recurred at the margin of the repair a few months after the primary operation. The average follow-up period was fifteen months. Complications included nine instances of serum accumulation, which required needle aspiration, and one case of skin necrosis with secondary infection. Reexploration of the wound was necessary to remove the cotton sutures two months after the operation. Various methods of implanting Marlex were utilized. The double layer “sandwich” method gave excellent results in the larger defects. Marlex should not be used indiscriminately in hernias that can be closed primarily using sound surgical principles.

Subfascial ligation of perforating veins in recurrent stasis ulceration

Abstract The evaluation and indications for radical subfascial ligation of perforating veins for recurrent postphlebitic leg ulcers are presented. The surgical technic utilizing a single posterior longitudinal incision is illustrated and described in detail. Twenty-nine operations have been carried out with three wound complications in the immediate postoperative period. Recurrent ulcers developed in three patients five, three, and one half year postoperatively. The remaining patients were followed up to six years without recurrence of ulcer.