C. Bartels

Cardiac Risk Stratification for High-Risk Vascular Surgery

Background The best strategy for cardiac risk assessment before high-risk vascular surgery remains controversial. A cardiac risk stratification protocol was evaluated in patients undergoing high-risk vascular surgery. Our investigation paralleled the elaboration of the American College of Cardiology/American Heart Association (ACC/AHA) Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery and is highly comparable to the proposed guidelines. Methods and Results A cardiac risk stratification protocol was evaluated prospectively in 203 patients scheduled for aortic surgery. Key points of the study were cardiac mortality/morbidity and cost-effectiveness. Patients were stratified into low (n=101), intermediate (n=79), and high (n=23) cardiac risk after clinical predictors. After stratification, the degree of estimated functional capacity assessed by treadmill exercise and daily living activities and expressed by metabolic equivalents (METs) was critical for further cardiac evaluation. I...

Intraoperative autotransfusion in aortic surgery: Comparison of whole blood autotransfusion versus cell separation

Abstract Objective: Differences concerning alteration of hemostatic, hemolysis, and hematologic parameters after transfusion of blood from a cell-separation (CS) device or whole blood autotransfusion (WBA) were prospectively evaluated during major aortic surgery. Method: Thirty-two patients were randomly selected to receive autologous retransfusion by using either WBA or a CS device. Coagulation and hematologic parameters and levels of hemolytic degradation products (HDP) were assessed in the retransfused blood and in the patients plasma preoperatively and until 24 hours after autologous retransfusion, respectively. Results: Mean volume of retransfused blood was 1072 + 473 ml in the WBA group and 556 + 504 in the CS group. Level of HDP (bilirubin, free hemoglobin [free HB[, and lactic dehydrogenase [LDH[) and hemostatic disturbances (d-dimer value, fibrin degradation products) were significantly higher in the WBA device compared with the CS blood. Blood samples taken from the WBA group revealed significantly higher levels of HDP (free HB, LDH) and of d-dimer values after autotransfusion compared with the CS group. Conclusion: Levels of HDP and the degree of hemostatic disturbances were significantly higher in retransfused whole blood compared with CS blood. Hemostatic disturbances and levels of HDP were significantly pronounced in the patients plasma after WBA compared with CS. CS retransfused blood seems to be of superior quality compared with WBA and the degree of hemolysis and hemostatic disturbances is minor after CS retransfusion. (J Vasc Surg 1996;24:102-8.)

Classification of Congenital Arterial and Venous Vascular Malformations

Arterial and venous vascular malformations due to congenital abnormalities rarely occur in the daily practice of vascular surgeons. These malformations represent a heteroge neous group of isolated or multiple congenital abnormalities, sometimes associated with complex congenital syndromes. Correct recognition and classification of these rare abnor malities may sometimes be difficult. No systematic classification of arterial and/or venous vascular malformations due to congenital abnormalities is currently available. On the basis of embryologic and pathophysiologic considerations, a rational and simple classifi cation of arterial and venous vascular malformations due to congenital abnormalities can be performed. This contribution presents an appropiate classification of clinically important arterial and venous vascular malformations due to congenital abnormalities.

22.2 Cardiac risk stratification for high-risk vascular surgery

BACKGROUNDnThe best strategy for cardiac risk assessment before high-risk vascular surgery remains controversial. A cardiac risk stratification protocol was evaluated in patients undergoing high-risk vascular surgery. Our investigation paralleled the elaboration of the American College of Cardiology/ American Heart Association (ACC/AHA) Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery and is highly comparable to the proposed guidelines.nnnMETHODS AND RESULTSnA cardiac risk stratification protocol was evaluated prospectively in 203 patients scheduled for aortic surgery. Key points of the study were cardiac mortality/morbidity and cost-effectiveness. Patients were stratified into low (n = 101), intermediate (n = 79), and high (n = 23) cardiac risk after clinical predictors. After stratification, the degree of estimated functional capacity assessed by treadmill exercise and daily living activities and expressed by metabolic equivalents (METs) was critical for further cardiac evaluation. In intermediate-risk patients with an estimated functional capacity < 5 METs and in all high-risk patients, noninvasive cardiac testing and/or subsequent medical care were performed. Noninvasive testing was considered necessary in 41 patients, coronary angiography in 7, and myocardial revascularization in 1. Overall hospital mortality was 3.5%. Cardiac mortality and morbidity were 1% and 12.4%, respectively.nnnCONCLUSIONSnCardiac risk stratification for high-risk vascular surgery patients, according to a protocol similar to the ACC/AHA Guidelines for Cardiovascular Evaluation for Noncardiac Surgery, demonstrated excellent clinical outcome. This approach appears to be a safe and economical strategy for preoperative cardiac evaluation.

F. P. Weber Syrldrome Associated with a Brachial Artery Aneurysm A Case Report

Klippel-Trenaunay syndrome is characterized by the triad of unilateral port-wine heman giomas, varicose veins, and hypertrophy of bone and soft tissue affecting one or more limbs. The rare F. P. Weber syndrome describes the mentioned entity and additional arteriovenous malformations. The association of an arterial aneurysm with the F. P. Weber syndrome has never been described in the current literature. A case of a brachial artery aneurysm in a patient with F. P. Weber syndrome is presented and the etiology of arterial aneurysm combined with congenital vascular abnormalities is discussed.

Significance of radiological diagnosis for detection and staging of inflammatory abdominal aortic aneurysm

Operative morbidity and mortality are elevated in patients with inflammatory abdominal aortic aneurysm. Preoperative identification of inflammatory abdominal aortic aneurysm. the detection of the proximal level and of adhesions to adjacent structures are important for surgical management. The sensitivity and specificity of ultrasonography and computed tomography (CT) for identification and staging in 13 patients with inflammatory abdominal aortic aneurysm were studied. Preoperative radiological diagnoses were validated by intraoperative findings. Correct identification of inflammatory abdominal aortic aneurysm could be achieved in 85% by the use of CT and in 62% by ultrasonography. The proximal level of inflammatory abdominal aortic aneurysm was correctly determined by CT in all patients and by ultrasonography in 62%. Using a transperitoneal approach, the condition was considered inoperable in two patients as a result of the suprarenal extent of the aneurysm and because of unremovable adhesions in two other cases. In the latter pair, it was impossible to predict inoperability by radiological findings. Sensitivity (85%) and specificity (100%) of standard radiological techniques to identify inflammatory changes are high. Inoperability caused by suprarenal extent could be detected correctly by routine radiological procedures. However, identification of dense adhesions appears uncertain.

Treatment of severe peripheral arterial and vasospastic disease of the upper extremity by spinal cord stimulation

Spinal cord stimulation (SCS) has been successfully introduced for treatment of severe peripheral arterial disease of the lower limbs. However, the effect of SCS for treatment of severe vasospastic disease (VD) and peripheral arterial disease (PAD) of the upper extremities remains uncertain. Therefore, the efficacy of SCS for pain reduction and increase of blood supply was studied in four patients with severe PAD and in six patients with VD of the upper limbs. Transcutaneous oxygen tension index (chest TcpO2/hand TcpO2), Doppler wrist pressure index (WPI), capillary microscopy (CM), and a patients pain score (PS) graded from 1 to 10 (1=no pain) were used as follow-up parameters. Pain reduction after SCS was excellent in all patients and remained significant throughout the follow-up period. TcpO2 index decreased significantly (2.01±0.79 prae-OP vs 1.57±0.62 at 18 months). Capillary microscopy improved regarding red blood cell velocity and capillary density. Doppler WPI remained unchanged throughout the course. The results demonstrate that treatment of severe PAD and VD by use of thoracic SCS reduces pain significantly in these patients and increases blood supply. SCS provides a successful method of treatment for refractory VD and PAD of the upper extremity.

Spinal cord stimulation in the treatment of Buerger’s disease

Buerger’s disease is a segmental, inflammatory occlusive disease primarily involving small and medium-sized arteries and veins of the extremity, affecting males who are in the third or fourth decade of life and heavy smokers.

Intraoperative assessment of cerebral ischemia: somatosensory evoked potentials, transcranial Doppler and oxymetry

Present-day discussions amongst specialists show that carotid surgery has to stand up to constantly increasing demands. Apart from strict guidelines for surgical indications as well as involved surgical technique, the necessity of perioperative monitoring is increasingly stressed.

Spinal cord stimulation (SCS) in the treatment of non-reconstructable arterial occlusive disease of upper extremities

Ischemic vascular disease of the upper extremity is less common than peripheral arterial vascular disease of the lower limbs. Arterial occlusive vascular disease of the upper extremities as a result of severe generalized atherosclerotic disease represents a difficult therapeutic problem. In the presence of extensive distal atherosclerotic disease, arterial reconstruction is frequently impossible (15). Aggressive medical treatment has been the mainstay of treatment in these situations. Medical treatment, however, sometimes fails and tissue loss, dysfunctional limbs or major amputation may occur (16). The importance of the hand in daily living activities mandates aggressive therapeutic attempts.