E. S. Crawford

Aortic dissection and dissecting aortic aneurysms.

Operation was employed in the treatment of 546 patients for complications of aortic dissection during the 32-year period of 1956–1988. Current concepts and operative techniques evolved during this period. Fortunately, about half the patients were treated during the latter 4 years, as modern therapy became standardized. The cumulative survival rate was 86% for all patients and 94% for those treated during recent years. Pathologic processes and requirements of operation became clearer by treating 174 patients who had had 198 previous operations by the time of referral. Rcopcration was required for complications of operations now considered outdated, heart operations in patients with ascending aortic dilatation, and progressive dilatation of residual segments of the aorta. The 546 patients were followed, and a total of 838 operations were finally employed, resulting in total aortic replacement in 18, near total replacement in 41, entire thoracic aorta in 22, near total thoracic aorta in 33, and the entire thoracoabdominal aorta in 148 patients. Long-term survival in 439 patients after final operation was 66% and 44% at 5 and 10 years, respectively, despite the fact that the median age at first admission was 59. Operative treatment appears to be well-established for this disease.

Juxtarenal infrarenal abdominal aortic aneurysm. Special diagnostic and therapeutic considerations.

Juxtarenal infrarcnal abdominal aortic ancurysms are defined as those aneurysms that involve the infrarenal abdominal aorta adjacent to or including the lower margin of renal artery origins. The misinterpretation of findings at exploratory operation or special studies may suggest renal artery involvement and result in abandonment of operation and/or referral to distant centers, thus delaying treatment. This report is concerned with 101 patients with a median age of 68 who had such aneurysms, all referred with a diagnosis of renal or visceral arterial involvement either after exploratory operation (32), because of aneurysmal size (12), or due to misinterpretation of special studies (57). Computed tomographic (CT) scans, ultrasounds, and aortograms in the anterio-posterior projection frequently suggested renal artery involvement due to the fact that the upper end of aneurysm frequently lay over the renal artery origins due to infrarenal aortic elongation and buckling of the aorta at the renal artery level. The true nature of the lesion was best demonstrated by aortography performed in the lateral position. The operation producing the best results was one performed through a midline abdominal incision. The aorta is cross-clamped at the diaphragm and the proximal anastomosis is performed from inside the aneurysm at the renal artery level. The graft then is clamped and the other clamp removed to restore flow in the visceral vessels while the distal anastomosis is completed. Early survival occurred in 93% of patients employing the operation, despite the fact that other conditions frequently were present: renal insufficiency in 19, rupture in seven, renal artery occlusive disease in 20, chronic obstructive pulmonary disease in 34, and hypertension in 77.

Doppler echocardiographic evaluation of pseudoaneurysms complicating composite grafts of the ascending aorta.

BACKGROUND Pseudoaneurysms of the ascending aorta is a rare and serious complication after composite graft surgery for combined disorders of the aortic valve and ascending aorta. METHODS AND RESULTS Echocardiographic and Doppler findings are described in eight patients (seven men, one woman; mean age, 45 +/- 12 years) with documented pseudoaneurysm of the ascending aorta and are compared with those by aortography and at surgery. The diameter of the ascending aorta ranged from 6 to 14 cm. Pseudoaneurysm was diagnosed by echocardiography in seven cases (six transthoracic, one transesophageal), by aortography in five, and by both methods in all patients. All three patients not diagnosed by aortography had a single dehiscence at the aortic annulus anastomosis. Five patients had more than one site of origin of the pseudoaneurysm. Periannular dehiscence (n = 7) was identified by color flow Doppler in six cases and by aortography in only one, and coronary artery dehiscence (n = 6) was detected by echocardiography in three and by aortography in two arteries. Of the three patients with distal graft dehiscence, one was identified by aortography and none by echocardiography. In cases of dehiscence at the aortic annulus, continuous wave Doppler further supported the diagnosis by demonstrating two distinct jets, one through the prosthetic valve and another with higher velocity through the communication. CONCLUSIONS Echocardiography with Doppler can diagnose the presence of pseudoaneurysms complicating composite grafts and identify their proximal sites of origin. Furthermore, it complements aortography in the overall evaluation of patients with suspected pseudoaneurysm, particularly in those with single dehiscence of the graft at the aortic annulus anastomosis.

Redo operations for recurrent aneurysmal disease of the ascending aorta and transverse aortic arch

Sixty-seven operations were performed in 59 patients for aneurysmal disease occurring after previous operations involving the ascending aorta and transverse aortic arch. The initial aortic pathological condition included the following: fusiform aneurysm due to medial degenerative disease in 34 patients, 12 of whom had Marfans syndrome; aortic dissection in a previously undilated aorta in 23; and aneurysm persisting or occurring after brachiocephalic bypass in 2. One of the latter had an aneurysm because of aortitis. Various operations initially performed did not completely treat the disease, and certain complications occurred spontaneously, including infection and dissection. The residual pathological condition led to the development of aortic insufficiency, aortic dissection, coronary artery insufficiency, and progressive aneurysmal dilatation. These complications were treated by composite valve graft replacement of the aortic valve and ascending aorta or the transverse aortic arch or both, simple aortic valve replacement, graft replacement of the ascending aorta or arch or both, and suture of false aneurysm with viable tissue wrap. Twenty patients (34%) had an aneurysm of the distal aorta. The entire aorta was replaced in 3, thoracoabdominal segments in 9, and the abdominal aorta in 1. Of the 59 patients, 49 (83%) were early survivors and 40 (68%) were alive on January 1, 1985. Principles of therapy that may have prevented the complications leading to reoperation include aneurysm replacement at the time of aortic valve replacement and coronary artery bypass; total replacement of the ascending aorta and aortic valve in patients with Marfans syndrome; the same procedure or aortic valve replacement and separate graft replacement in patients with non-Marfans medial degenerative disease; ascending aortic replacement in all patients with dissection combined with valve resuspension, aortic valve replacement, or composite valve graft depending on the involvement of the aortic sinuses and the presence of aortic insufficiency.

Perforation of the pulmonary artery with Swan-Ganz catheters: diagnosis and surgical management.

Swan-Ganz catheters have become a very valuable and frequently used method of monitoring hemodynamics in sick patients. Although the incidence of complications is very low, more reports are beginning to appear. One of the more serious complications is the rupture of the pulmonary artery. This report concerns three patients who had a rupture of the pulmonary artery who survived, including one of almost fatal ex-anguination. A literature review of all cases of pulmonary artery rupture is presented. Fifty-three per cent (8/15) were fatal. Emphasis is placed on the prevention of this by using the guidelines. Discussion also covers possible contributing causes and treatment. A high index of suspicion is necessary whenever a patient with the catheter has hemoptysis or unexplained cardiac or respiratory changes.

Total aortic replacement for chronic aortic dissection occurring in patients with and without Marfan's syndrome.

Total aortic replacement including aortic valve was performed successfully in the two patients in whom this method of treatment was utilized to correct a chronic dissecting aortic aneurysm. Both patients had moderately severe aortic insufficiency producing increasing heart strain and progressive enlargement of the false lumen of aortic dissection involving the entire aorta despite ideal blood pressure control. In addition, one patient had Marfans syndrome. The surgical treatment for both patients was performed in two stages. At the first operation, cardiopulmonary bypass, profound hypothermia, and circulatory arrest were employed while the aortic valve and the ascending and transverse aortic arch were replaced and the coronary and brachiocephalic vessels were reattached to the composite valve-graft used for replacement. At the second operation, the entire descending thoracic and abdominal aortic segments were replaced with a graft and the intercostal, lumbar, and visceral arteries reattached thereto. Left vocal cord paralysis occurred in both patients and transient mild paraparesis occurred in only one. Both patients are alive and well, one at 13 months and one at 6 weeks. This experience suggests an additional treatment modality for selected patients with complications of chronic aortic dissection.

Current Concepts in Coronary Artery Surgery: A Critical Analysis of 1,287 Patients

Abstract The clinical experience gained by performing aorta-to-coronary artery bypass grafts on 1,287 patients over the past four years is analyzed. Multiple procedures such as valve replacement and left ventricular aneurysmectomy were performed in 65 of these patients. In the remaining 1,222 patients, modifications in technique are demonstrated by comparing the recent group of 759 patients operated upon in 1971 to 463 patients operated upon previously. Both groups were similar with regard to the severity of disease. The recent group of 759 patients had more multiple graft procedures and a greater incidence of left circumflex coronary artery bypass. The mortality in that group was decreased to 4.5%. In the entire group the mortality rate was 6.4%, including operative and late mortality. Postoperative complications decreased with regard to ventricular arrhythmias and postoperative myocardial infarctions. Emergency coronary artery bypass was done in 20 of the patients over the past year, with a mortality of 35%. Postoperative assessment revealed marked to moderate improvement in all but 13% of the patients. Late results in patients with congestive heart failure and angina or with intractable Functional Class IV angina are compared with results in the remainder of the patients. A standard surgical approach for the treatment of coronary artery disease has resulted from review of these data.

Aortic arch aneurysm. A sentinel of extensive aortic disease requiring subtotal and total aortic replacement

Aneurysm of the thoracic aorta is a serious form of disease because it may be extensive or associated with a more distant aneurysm. This manifestation occurs in about one-third of the cases. The actuarial 5-year survival of nontreated patients is only 13% with many patients dying from aortic rupture. The 5-year survival of our patients with aneurysm of the descending thoracic aorta treated by graft replacement is 58% with the two most common causes of late death being myocardial infarction and rupture of another aortic aneurysm. Effective treatment consists of initial total aortic examination, continued follow-up examination, and total replacement of disease. Aneurysmal disease that involves the entire aortic arch is especially prone to extensive involvement because it is due to diffuse aortic dissection or medial degenerative disease in most cases. The latter is most common, being present in 63 of our 81 patients requiring total arch replacement. The disease was extensive in all cases with degenerative medial disease and required extensive graft replacement. In fact, the entire thoracic aorta was involved in ten, the entire thoracic aorta and substantial segments of abdominal aorta in ten, and the entire aorta in 12 patients. Most of these patients were women (84%) over 65 years of age (63%) or older, ten (37%) were over 70 years. Associated pulmonary disease was frequent, aortic valvular insufficiency was present in 12 (38%), and symptoms were present in most. Treatment consisted of removing the disease when possible in stages, the arch in one and the remaining disease in another with the sequence and interval depending upon indications and condition of the patient. A total of 53 operations were performed in these 32 patients, the arch replaced in 29, the descending thoracic aorta in eight, and the thoracoabdominal aortic segment in 16 patients. All of the disease was replaced in 21, including the entire aorta in eight and incompletely replaced in 11 patients. Sixteen (76%) of the former are still alive 4 months to 6 1/3 years. Six (55%) of those in whom operation was limited to replacement of the symptomatic aortic segment because of limited risk are still alive. Of the ten deaths occurring during the study period, four (40%) and perhaps five (50%) were due to natural rupture of unresected disease which indicates its progressive nature and suggests the need for aggressive surgical treatment.

A Prospective Study of Respiratory Failure After High-Risk Surgery on the Thoracoabdominal Aorta

From June 1960 to September 1990, 1414 patients underwent repair of thoracoabdominal aortic aneurysms, of whom 112 (8%) had pulmonary complications requiring respiratory support with tracheostomy; subsequently 45 (40%) died in the hospital. We determined by stepwise logistic regression analysis, in a prospective study of high-risk type I and II thoracoabdominal aortic aneurysms repairs, the independent predictors of respiratory failure, defined as respiratory ventilation exceeding 48 hours after operation. In 98 patients studied, 38 (39%) were women, 60 (61%) were men, 54 (55%) had type II thoracoabdominal aortic aneurysms, 34 (35%) had aortic dissection, 19 (19%) were nonsmokers, 40 (41%) exsmokers, and 39 (40%) active smokers. Before operation, 55 (56%) had chronic pulmonary disease with respiratory failure developing in 58% (p = 0.0005 versus no chronic pulmonary disease, 10/43, 23%), and of the 26 patients in the lower quarter of forced expiratory volume (1 sec) (FEV1 less than or equal to 1.45 L) respiratory failure developed in 61% (p = 0.035). In-hospital survival was 98% and 83% (p = 0.008), respectively, and cumulative survival at 6 months by Kaplan-Meier analysis was 96% and 80% (p = 0.004, log-rank test), respectively, for patients without respiratory failure (N = 56/98, 57%) and with respiratory failure (N = 42/98, 43%). On univariate analysis, the following were associated with respiratory failure (p less than 0.05): FEV1, FEV1% predicted, FVC, FEF25, FEF25% predicted, FEF25-75, FEF25-75% predicted, PaCO2 Pao2, symptoms, smoking history, chronic pulmonary disease, cryoprecipitate volume, postoperative neuromuscular deficit, cardiac complications, reoperation for bleeding, renal complication, stress ulceration, postoperative creatinine level, postoperative dialysis, and postoperative encephalopathy. The independent predictors of respiratory failure were (p less than 0.05): chronic pulmonary disease, smoking history, cardiac and renal complications. In patients with chronic pulmonary disease, the only independent predictor was FEF25 (p = 0.030). These observations may be of value in selecting patients for elective operation.

131. Aortocoronare Venenbypässe in normothermer Ischämie ohne Möglichkeit der Transfusion von Blut- oder Blutderivaten

SummaryIn more than 1350 coronary bypass operations performed from Oct. 1969 through Feb. 1972, techniques developed which were used for 6 patients who could not receive blood transfusions. 1. Ischemic heart arrest without hypothermia for a dry field; 2. preference for the double left coronary bypass so as to shorten the operation. One patient died after 13 months in left heart failure from advanced coronary disease. The results show that coronary bypass procedures are possible in hearts in ischemic arrest without blood transfusion. Declines of hemoglobin down to 6.8 g-% f u were well tolerated by the revascularized myocardium.ZusammenfassungBei über 1350 Coronarbypassoperationen von Okt. 1969 bis Febr. 1972 bewährten sich Techniken, die bei der Operation von 6 Patienten ohne Möglichkeit einer Bluttransfusion zur Anwendung kamen: 1. Herzstillstand in Blutleere ohne Unterkühlung; 2. Bevorzugung des linken Kranzarteriensystems zur Verkürzung der Operationszeiten. Von den 6 Patienten verstarb einer nach 13 Monaten bei weit fortgeschrittener Coronarerkrankung am Linksversagen.Zur Vermeidung von Blutverlusten wurde kaum von dem üblichen Vorgehen abgewichen.Die Ergebnisse zeigen, daß dieser Eingriff ohne Bluttransfusion möglich ist und der entstehende Hämoglobinabfall vom revascularisierten Herzen gut toleriert wird.