David S. Starr

Late results of reconstructive surgery for renovascular disease.

In order to determine the late results of reconstructive surgery for renovascular disease, a review was made of a series of 505 consecutive patients who underwent operation over a 20-year period. There were 257 males (50.9%) with an age range of 3–80 years. Renal artery bypass grafts were used in 75.4% (471/625) and thromboendarterectomy and/or patch angioplasty in 15.0% (94/625) of reconstructions. Associated vascular procedures were performed in 38.0% (186/489) of patients. Operative mortality (30-day) was 1.8% (9/489) overall, and 4.8% (9/186) with associated procedures but there was no operative mortality in 303 consecutive isolated renal artery reconstructions. The blood pressure was normal or improved in 65% of patients at a mean follow-up interval of 49.3 months, range 1–240 months. The best response rate was obtained in younger patients with isolated renal lesions. Linear regression analysis showed age at operation to be the most important determinant of blood pressure response (p < 0.003) with the presence or absence of diffuse atherosclerosis as another but less powerful determinant of responsiveness (p < 0.07). Crude 15-year survival was 70% (340/489). The overall five- and ten-year actuarial survival probabilities were 80 and 62% respectively. The most common causes of death were myocardial infarction, stroke, and cancer. Cox regression analysis for variables influencing survival indicated that age at operation (p < 0.001), sex (p < 0.01) and the presence or absence of fibromuscular disease (p < 0.002) were the major determinants of late survival with persistent severe hypertension exerting an important but lesser influence. The results of this study indicate that about two-thirds of patients will experience long-term relief of hypertension after operation and that the best long-term survival and blood pressure relief will be obtained in patients less than 50 years of age. Because hypertension in females is better tolerated, younger, male patients appear to have the most to gain from successful renovascular reconstruction.

Fibromuscular disease of carotid arteries: long term results of graduated internal dilatation.

From 1967 to 1979,25 patients (pts) were operated on for fibromuscular disease (FMD) of the internal carotid artery (ICA). Eleven patients (44%) had transient weakness of an extremity, 4 had amaurosis fugax and 6 (24%) had an asymptomatic carotid bruit. Bilateral carotid arteriograpby showed significant stenotic lesions in 23 pts (92%) (bilateral in 10), arterial dissection in 1, and severe associated atherosclerosis in 1. Of these, 22 pts had arteriotomy and graduated internal dilatation (GID) (9 bilateral); 2 underwent G1D with ICA endarterectomy and patch graft: 1 pt had tube graft replacement of the ICA. There was no operative mortality. One pt had a stroke during operation after tube graft replacement of the ICA. Of the 19 pts followed for 2 to 12 years (mean 7 3 years), 2 had late recurrence of mild symptoms. One pt required GID of the contralateral ICA for recurrence of symptoms 4 years postoperatively. Graduated internal dilatation of fibromuscular disease of the internal carotid artery can produce long term relief of symptoms; recurrence is rare. Stroke, Vol 12, No 2, 1981

Unusual presentation of bronchogenic carcinoma. Case report and review of the literature

Although blood spread of pulmonary malignancy presumably occurs through microembolization, frank embolization of tumor fragments is uncommon. The first reported case of bronchogenic carcinoma appearing as a peripheral arterial embolus is described.

EKG guided placement of subclavian CVP catheters using J-wire.

In an attempt to improve the accuracy of central venous pressure (CVP) catheter tip location, 84 consecutive cardiac surgery patients in sinus rhythm were studied prospectively with respect to subclavian insertion of a CVP catheter using a guidewire technique. The presence of cardiac arrhythmia was used as an index of right atrial (RA) location of the guidewire tip, before threading the catheter over the guidewire. Correct catheter tip location (superior vena cava [SVC] or RA) was achieved in 100% of patients (N = 78) with premature atrial contractions (PACs) related to guidewire insertion. This fell to 50% (N = 4) if no arrhythmias were noted from the guidewire. Ventricular arrhythmias were noted in two of 84 patients (2.4%). Other problems related to the use of this technique are discussed.

Prevention of distal embolism during arterial reconstruction

Distal embolization of fragmented laminated thrombus and atheroma producing peripheral ischemia or gangrene is an underemphasized complication of arterial reconstruction. A set of techniques has been developed to minimize this important complication. To assess their effectiveness, the incidence of distal embolism in patients undergoing resection of abdominal aortic aneurysm with and without the use of these techniques was studied. In the 434 patients who underwent elective resection of abdominal aneurysm, measures to prevent distal embolism were used in all cases. The incidence of distal embolism was only 0.23 per cent (1 of 434), in contrast to reported incidences of up to 11 per cent. In the 21 patients who underwent emergency resection of ruptured aneurysm, these techniques were not used due to the need for early proximal control for resuscitation; distal embolism of atheromatous material occurred in 2 cases, an incidence of 9 per cent. The application of these techniques to other peripheral vascular procedures has resulted in similar low rates of postoperative distal ischemia.

Clinical Experience with the Smeloff-Cutter Prosthesis: 1- to 12-Year Follow-up

To determine the long-term results of aortic valve replacement with the Smeloff-Cutter prosthesis, the fate of 358 of 459 (78%) consecutive patients was determined 1 to 12 years postoperatively. There were 319 male patients (70%). Mean age at operation was 57 years (range, 15 to 84 years). Aortic stenosis was the dominant lesion in 267 patients (58%) and aortic regurgitation in 133 patients (29%). Fifty-nine patients (13%) had both aortic stenosis and regurgitation. In addition to aortic valve replacement, 93 patients (20%) had coronary artery bypass, 30 (6.5%) had mitral commissurotomy, 23 (5%) had mitral valve replacement, and 41 (9%) had other procedures. Preoperative status by New York Heart Association Functional Class was: Class I, 3 (1%); Class II, 39 (8%); Class III, 148 (32%); and Class IV, 269 (59%). Operative (30-day) mortality was 8.5% (39 out of 459). Functional improvement was obtained in all postoperative survivors: 345 (82%), Class I; 63 (15%), Class II; and 12 (3%), Class III. A perivalvular leak developed in 6 patients (1%) and subacute bacterial endocarditis in five (1%). Actuarial long-term survival was 80% at 5 years and 71% at 8 years. Thromboembolism occurred in 34 patients (9.5%). The incidence of thromboembolism per 100 patient-years for patients receiving no anticoagulants was 5.4; antiplatelet agents, 2.9; and Coumadin (sodium warfarin), 2.6. Major thromboembolism was uncommon in patients on a regimen of sodium warfarin but major morbidity from bleeding was significant.

Treatment of postradiation stricture of the rectum by the modified duhamel procedure

Benign rectosigmoid stenosis secondary to pelvic radiation presents a difficult problem in management and is usually treated by permanent colostomy with its attendant discomfort and inconvenience. Other approaches include low anterior resection or even transsacral resection of the affected area of rectosigmoid, but they involve risk to rectal, bladder, and sexual function. The Martin modification of the Duhamel procedure is specifically designed to avoid these problems and was used successfully in the present case for treatment of rectosigmoid stenosis. The patient has been followed up 8 years and reports normal sensation and function of bladder and rectum and no disturbance of sexual function.