E. Stanley Crawford

Dissecting Aneurysms of the Aorta

The disorder, dissection and dissecting aneurysms of the aorta, has been recognized and described for several centuries.[1] In his classical treatise on the subject, Shennan[2] in 1934 provided the most extensive investigations and review of previous reports, resulting in the conclusion that the most significant underlying cause of dissection was medial degeneration. The rapidly fatal course of the disease has also long been recognized. In Shennan’s analysis of a collected series, death occurred within twenty-four hours in 58% of the patients. A number of other reports have since been published showing that more than half the patients die within a few weeks and about 90% within a few months after the initial dissection. More recently, Anagnostopoulos and associates[3] found, in a collected series of 963 patients, that death occurred within a week in 70% and within three months in 90%.

Extracranial aneurysms of the carotid artery. Report of seven cases.

Excision with restoration of arterial continuity has become the treatment of choice for extracranial carotid aneurysms. Three of the seven cases reported here involved the common carotid artery, and four the internal carotid artery. Technics included excision and primary repair, excision and graft, temporary external or internal shunts, and permanent bypass graft. The one patient who died had congenital absence of a portion of the circle of Willis. The other six patients recovered without neurologic sequelae.

PROLONGED ASSISTED CIRCULATION DURING AND AFTER CARDIAC OR AORTIC SURGERY. PROLONGED PARTIAL LEFT VENTRICULAR BYPASS BY MEANS OF INTRACORPOREAL CIRCULATION.

Abstract A prolonged, partial left ventricular bypass was performed by means of an intrathoracic pump. A portion of blood was taken from the left atrium and pumped into the descending aorta, thus alleviating the burden on the left ventricle. The intrathoracic pump is operated by an external air system, which is triggered with the electrocardiogram, providing diastolic ejection. The system can also be used without electrocardiographic triggering. The advantages of such a system are the prolonged support of the left ventricle (during days or weeks) and the avoidance of the prolonged use of heparin while the pump is functioning. This left ventricular bypass decompresses the left ventricle, reduces left ventricular work, decreases left ventricular wall tension and increases the coronary circulation.

Open heart surgery in Jehovah's Witnesses

Abstract Open heart surgery using cardiopulmonary bypass has not been used for Jehovahs Witnesses because of their religious convictions and a church law forbidding blood transfusion. Development of bypass technics which utilize only blood substitutes for priming have made such procedures acceptable to these patients. More than 450 patients have been operated upon by using 5% dextrose in water prime, disposable oxygenators and normothermia. Seven Jehovahs Witnesses were operated upon without administration of blood before, during or after operation with one death from postoperative hemorrhage. The 6 surviving patients had a satisfactory recovery. The hemoglobin concentration and hematocrit one week after operation revealed no change in 1 patient, approximately 25 per cent fall in 4, and severe anemia in 1 after aortic valvulotomy.

Experience with 200 Renal Artery Reconstructive Procedures for Hypertension or Renal Failure

Renovascular hypertension is the most common form of reversible hypertension.An analysis of 200 renal artery reconstructive procedures identified atherosclerosis as the arteriopathic lesion in 83 per cent of cases and fibromuscular hyperplasia in 13 per cent of cases. Bilateral renovascular disease was found in 31 per cent of cases.Renal arteriography is the most significant factor in the diagnostic evaluation of the hypertensive subject.Bypass graft and patch-graft angioplasty were the most commonly employed principles of renal artery reconstruction in this series.The occlusive process in the renal artery produced a pressure gradient exceeding 25 mm. Hg in 76 per cent of cases.The average period of observation following operation in these 200 patients was 1.6 years, ranging between 3 months and 5 years. Eighty per cent of patients are now normotensive.The primary goal of operation in 12 patients was reversal of renal failure due to severe bilateral renal artery occlusive disease. Disappearance of azotemia with improved renal function followed revascularization in 11 of 12 patients.

Surgical Considerations of Aneurysms and Atherosclerotic Occlusive Lesions of the Aorta and Major Arteries

This report is an analysis of aneurysms and atherosclerotic occlusive lesions based on the treatment of 3,324 patients in the past 10 years.Symptoms were relieved and pulses restored in 97 per cent of aortAiliac occlusions, 90 per cent of femoropopliteal occlusions, 95 per cent of operable lesions of the internal carotid artery, and 91 per cent of vertebral arterial occlusions.Mortality in 116 aneurysms of the descending thoracic aorta was 20 per cent, in 62 dissecting aneurysms 29 per cent, and in 829 aneurysms of the abdominal aorta 6 per cent.

Renovascular hypertension. Experience with renal artery reconstruction in 115 patients.

Abstract Renovascular hypertension as produced by narrowing of one or both renal arteries is the most common surgically curable form of unremitting high blood pressure. Frequently, renal artery constriction is produced by atherosclerosis, usually localized in the proximal arterial segment. Other forms of renal artery narrowing include fibromuscular intimal and medial hyperplasia, as commonly observed in young patients, and aneurysms of the renal artery. Selection of hypertensive patients for renovascular study or operative treatment is fundamentally a matter of exclusion. Subjects with serious cerebrovascular insufficiency or coronary artery disease make poor candidates for surgical reduction of arterial pressure. Renal arteriography is the cardinal feature in the diagnostic study of patients with severe hypertension. Selection of technic for renal artery reconstruction depends upon varying anatomic and pathologic considerations. In this surgical series of 115 hypertensive patients renal artery bypass and patch graft angioplasty were the methods of renal revascularization most frequently used. Blood pressure following operation ultimately became normal in 80 per cent of patients, and significant improvement was observed in an additional 8 per cent.

Aorto-Inferior Vena Caval Fistula of Neoplastic Origin Hemodynamic and Coronary Blood Flow Studies

A case report of a 51-year-old man is presented, who spontaneously developed an aorto-vena caval fistula in the region of a mesenchymal tumor involving both the abdominal aorta and vena cava. The disease was manifested clinically by rapidly progressive and massive leg swelling, prominent abdominal and leg veins, a machinery murmur over the abdomen and in the flanks, and a pulsatile abdominal mass, with signs of cardiac enlargement and a high output state. The fistula was demonstrated preoperatively by translunmbar aortography and closed surgically by resection of the tumor en masse, with a part of the vena caval wall and the distal aorta and proximal common iliac arteries. Vascular continuity was restored by lateral suture of the vena cava and by insertion of a bifurcation graft bridging the defect in the aorta and iliac arteries. The patient has been relieved of all clinical manifestations of the fistula to date, 1 year after operation.Preoperative hemodynamic studies revealed certain alterations characteristic of systemic arteriovenous fistula, including increased pulse pressure, high cardiac output and stroke volume, reduced systemic vascular resistance and arteriovenons oxygen difference, and increased plasnma and circulating blood volumes. Some degree of cardiac failure appeared to be present. Coronary arteriovenous oxygen difference was normal, indicating that the observed increase in coronary blood flow closely paralleled the augmented energy requirement of the heart as reflected by the ventricular oxygen uptake. Reversion to normal of the observed changes in systemic hemodynamics, coronary blood flow, and myocardial metabolism was demonstrated 2 weeks postoperatively.

Arterial reconstructive operation for occlusive disease of the innominate, carotid, subclavian, and vertebral arteries*

Summary Arteriographic studies have been performed in 565 patients with clinical manifestations suggestive of cerebral arterial insufficiency. Extracranial arterial occlusion was demonstrated in 226 patients (40 per cent). Operation has been employed in the treatment of 310 lesions occurring in 208 patients. Of the 310 lesions operated upon, 293 were found to be localized and amenable to reconstructive operation. By employing endarterectomy in the well localized lesions of the internal carotid and vertebral arteries and bypass graft in the more extensive lesions occurring principally in the great vessels arising from the aortic arch, circulation was successfully restored in the treatment of 280 lesions. The functional results of operation have been satisfactory. Progression of the occlusive process and recurrent symptoms have not occurred in patients who had had transient recurrent attacks of cerebral arterial insufficiency before operation. Improvement or relief of neurologic symptoms occurred in the majority of patients who had neurologic deficit, at the time of operation. Complete hemiplegia and aphasia were relieved in some instances.