Edward B. Diethrich

Occlusive disease of the common carotid and subclavian arteries treated by carotid-subclavian bypass

Abstract Carotid-subclavian bypass has been employed in the treatment of cerebrovascular insufficiency, upper extremity claudication, or a combination of these syndromes in 125 patients. All patients were studied angiographically prior to operation with either bilateral carotid and subclavian puncture or retrograde aortic arch injection. Indications for carotid subclavian bypass operation included: upper extremity claudication, twenty-one cases; symptoms of vertebrobasilar insufficiency, forty-nine cases; upper extremity claudication combined with symptoms of vertebrobasilar insufficiency, subclavian steal syndrome, and brachial-basilar insufficiency syndrome, thirty cases; symptoms of cerebrovascular insufficiency due to an obstructing lesion at the origin of the carotid arteries, twentyfive cases. Left carotid-subclavian bypass was employed in ninety-one patients (72 per cent) and right carotid -subclavian bypass in twenty (16 per cent). In fourteen patients (11 per cent) thromboendarterectomy of the common carotid bifurcation accompanied the carotid-subclavian bypass. There was an operative mortality of 4.8 per cent in this series of 125 patients. Follow-up studies obtained on all patients extending from nine months to fourteen years have demonstrated the effectiveness of this method of operative treatment.

Long-Term Gene Transfer in Porcine Myocardium After Coronary Infusion of an Adeno-Associated Virus Vector

BACKGROUND Viral vector-mediated gene transfer into the heart represents a potentially powerful tool for studying both cardiac physiology as well as gene therapy of cardiac disease. We report here the use of a defective viral vector, which expresses no viral gene products, for gene transfer into the mammalian heart. Previous studies have used recombinant viral vectors, which retained viral genes and yielded mostly short-term expression, often with significant inflammation. METHODS An adeno-associated virus vector was used that contains no viral genes and is completely free of contaminating helper viruses. The adeno-associated virus vector was applied to rat hearts by direct intramuscular injection; adeno-associated virus was also infused into pig hearts in vivo via percutaneous intraarterial infusion into the coronary vasculature using routine catheterization techniques. RESULTS Gene transfer into rat heart yielded no apparent inflammation, and expression was observed for at least 2 months after injection. Infusion into pig circumflex coronary arteries resulted in successful transfer and expression of the reporter gene in cardiac myocytes without apparent toxicity or inflammation; gene expression was observed for at least 6 months after infusion. CONCLUSIONS We report the use of adeno-associated virus vectors in the cardiovascular system as well as successful myocardial gene transfer after percutaneous coronary artery infusion of viral vectors in a large, clinically relevant mammalian model. These results suggest that safe and stable gene transfer can be achieved in the heart using standard outpatient cardiac catheterization techniques.

Acute traumatic rupture of the thoracic aorta treated with endoluminal stent grafts.

BACKGROUND Endovascular technologies provide a new therapeutic option in the treatment for acute traumatic rupture of the thoracic aorta. We report our experience with endoluminal stent graft repair of thoracic aortic ruptures. METHODS Five patients underwent repair of the thoracic aorta with an endoluminal stent graft for acute traumatic rupture. Data from patient history, the procedure, hospital course, and follow-up were analyzed. RESULTS All patient were involved in motor vehicle crashes. The mean Injury Severity Score was 51.8 +/- 6.38. All procedures were technically successful. Mean operating room time was 111 minutes and mean estimated blood loss was 200 mL. There were no cases of postprocedural endoleaks or conversions. There were no procedural complications, paraplegia, or deaths. Average follow-up was 20.2 months. CONCLUSION Five cases of successful endograft repair of thoracic aortic rupture have been demonstrated. This should encourage future studies to determine whether endovascular repair of thoracic aortic ruptures is a safe and feasible alternative to conventional open repair.

Surgical management of penetrating cardiac injuries

Abstract Among the more spectacular wounds encountered by the surgeon are those involving the heart. Methods of managing these injuries have varied considerably since the first successful clinical cardiorrhaphy seventy years ago. It has been our policy to treat these patients primarily by pericardiocentesis with fluid and blood replacement and pulmonary reexpansion, reserving thoracotomy and cardiorrhaphy for those who fail to respond to such measures or whose condition again deteriorates after pericardial aspiration. Review of experience gained in the management of 197 consecutive patients in this manner during the period 1951 through 1965 continues to support this plan of treatment. Over-all mortality was 25.4 per cent, but this figure includes eleven patients who died before any form of treatment could be started and thirteen who experienced cardiac arrest prior to the onset of therapy but in whom thoracotomy was performed in an attempt at resuscitation. While thoracotomy and cardiorrhaphy should not be delayed when necessary, primary pericardiocentesis still appears to offer patients with penetrating cardiac injuries their best chance for survival.

Simplified operative procedure for proximal subclavian arterial lesions: Direct subclavian-carotid anastomosis

An operative approach to treatment of proximal subclavian occlusive lesions was used in 11 patients with claudication of the arm, vertebrobasilar insufficiency or subclavian steal syndrome. Through a supraclavicular incision, the subclavian artery is isolated proximal to the vertebral origin, dissected from the periarterial tissue into the mediastinum and then clamped above the atherosclerotic lesion. The artery is transected and the proximal end closed. The distal portion of the subclavian is then anastomosed end-to-side to the common carotid either in front of or behind the internal jugular vein. This procedure, applicable to right or left subclavian occlusive or ulcerative lesions, is particularly advantageous since it avoids major thoracotomy and the use of prosthetic bypasses in the neck. Postoperative noninvasive and angiographic evaluation in this series of patients indicates that the technique is simple, effective and without complications, making it preferable to existing procedures.

Traumatic injuries to the extrahepatic biliary tract

Abstract Injury to the extrahepatic biliary tract incidental to abdominal trauma is relatively rare. In a twenty-five year period, only sixty-one such cases were handled at three metropolitan area clinic hospitals, where the incidence of gunshot and stab wounds of all types is high. Of those injuries which did occur, fifty-four involved the gallbladder and seven involved the common bile duct. Injuries predominated in male patients by a 4:1 ratio. Ninety per cent of the injuries were of the penetrating type, that is, gunshot and stab wounds. Multiple visceral injuries occurred in all but six of the sixty-one patients. Depending on the severity of the wound, various methods of management were employed, but the trend was definitely away from simple suture closure. All major complications resulted from either blunt trauma or gunshot wounds associated with multiple visceral injuries.

Stem Cell Therapy and Tissue Engineering for Cardiovascular Repair

Stem cell therapy and tissue engineering for cardiovascular repair , Stem cell therapy and tissue engineering for cardiovascular repair , کتابخانه مرکزی دانشگاه علوم پزشکی تهران

Surgical treatment of cerebrovascular disease.

Several new concepts of surgical management of cerebrovascular insufficiency due to extracranial arterial occlusive disease have been developed since the first corrective procedure was done in 1953. The concept of the totality of cerebral blood flow, the importance of collateral circulation, and the recognition of intracranial arterial patterns are discussed and illustrated in several case reports.

Intraoperative coronary arteriography

Abstract Recent installation of radiographic equipment in the operating room permits intraoperative coronary arteriographic studies. This technic is extremely valuable for immediate evaluation after coronary artery bypass operations and angiographic study in patients with impending or acute myocardial infarction. Its use may be extended to include research as well as the diagnosis of other intraoperative problems. The initial results in 111 studies indicate that such angiograms should be performed on a routine basis in institutions equipped for such procedures.

Pseudoaneurysm of the Aortic Arch After Aortosubclavian Bypass Treated with Endoluminal Stent Grafting: A Case Report

This paper describes a case of aortic arch pseudoaneurysm treated with stent graft 2 years after aortosubclavian bypass repair of a subclavian artery aneurysm. An 84-year-old man presented with back pain. Two years before, he had had a left subclavian artery aneurysm repaired with aortosubclavian bypass. Upon examination by computed tomography (CT) scan and angiography he was found to have a bovine arch configuration, a 7-centimeter pseudoaneurysm arising from the stump of the native subclavian artery, a patent aortosubclavian bypass, and a left hemothorax. A 37 mm by 10 mm Gore Excluder thoracic graft was introduced into the right femoral artery cutdown and deployed across the arch, excluding the pseudoaneurysm and preserving the brachiocephalic vessels. Follow up CT scan at 1 year shows exclusion of the pseudoaneurysm. The patient continues to do well 1 year after implantation without evidence of endoleak. In the presence of unusual anatomical characteristics, endoluminal stent graft repair can be successfully performed across the aortic arch.