Garland D. Perdue

Surgical treatment of chronic mesenteric arterial insufficiency.

The treatment of 41 patients with chronic mesenteric insufficiency is reviewed: 20 men and 21 women with a mean age of 59 years were treated and observed for an average of 42 months. Thirty-one patients had symptoms of intestinal angina whereas 10 patients underwent prophylactic revascularization during other aortic operations. All but one patient had revascularization of the superior mesenteric artery, alone or in combination with another revascularization. Various surgical techniques were used, including retrograde bypass in 24 patients, antegrade bypass in 11 patients, and endarterectomy in the remaining six patients. Seven patients had acute abdominal symptoms and required emergency operation while in the hospital awaiting elective revascularization. There were two deaths in the perioperative period (4.9%), both caused by bowel necrosis. Six patients are known to have had late revascularization failure, resulting in recurrent symptoms in three patients and two subsequent deaths. All patients who remained asymptomatic after late graft failure had undergone multiple vessel revascularization; no patient revascularized prophylactically had symptoms of intestinal angina during the follow-up period. Early mesenteric revascularization is a safe and effective method of relieving the symptoms of chronic visceral ischemia and may prevent the development of fatal bowel necrosis.

Impending aortoenteric hemorrhage: the effect of early recognition on improved outcome.

Aortoenteric hemorrhage is the result of enteric erosion and necrosis of aortic wall or anastomotic site. Mechanical or bacteriologic causes may occur singly or in combination. The temporal sequence is such that warning symptoms, often including back pain, fever, hemotochezia, and anemia, are present long before exsanguinating hemorrhage occurs. Vigorous diagnostic efforts, including gallium-67 citrate nuclear scan and computerized axial tomography, lead to a correct diagnosis. This allows planned semielective corrective operation before severe hemorrhage begins. The ideal operation consists of extra-anatomic revascularization, excision of the infected prosthesis, bowel repair with decompression, and sump drainage. Appropriate antimicrobial therapy should be continued until healing is complete. With aggressive diagnostic and therapeutic intervention according to this plan, marked improvement in survival and limb preservation can be anticipated in patients having this complication of aortic surgery. In this series, 15 of 18 patients having operation recovered, though delayed limb loss occurred in two.

Concomitant carotid and coronary artery reconstruction.

Data are presented on 68 patients who underwent concomitant carotid endarterectomy (CE) and coronary artery bypass surgery (CAB) at Emory University Hospital from January 1974 to February 1981. This group is then compared with a randomly selected, matched population without known carotid disease who underwent CAB alone. Asymptomatic bruit was the reason for investigation in 40 patients (59%); another 23 patients (34%) experienced transient cerebral ischemic attacks (TIAs); and five patients (7%) had TIA and prior stroke. Carotid stenoses (>75% luminal narrowing) were demonstrated as follows: isolated left, 24 patients; isolated right, 27 patients; and bilateral lesions, 16 patients. One patient had innominate artery stenosis. Associated total occlusion of one or both vertebral arteries was demonstrated in six patients. Ninety-seven per cent of patients had disabling angina pectoris prior to operation; the angina was unstable in 57%, 15% had congestive heart failure, and 54% had had at least one prior myocardial infarction (MI). Single-vessel coronary disease was present in 12.5% of patients, double in 37.5%, triple in 41.1%, and left main stenosis in 9%; 43% of patients had abnormal ventricular contractility. CE was performed on 67 patients (36 left and 31 right); aortocarotid bypass was performed on one. The CE procedures were performed immediately prior to the sternotomy for CAB under the same anesthesia. CAB consisted of single bypass in eight patients (11.8%); double in 16 patients (23.5%); triple in 22 patients (32.4%); and quadruple or more in 22 patients (32.4%) (mean = 2.9 grafts per patient). There was no hospital mortality. Perioperative MI occurred in 2.0% and stroke with residual deficit in 1.3%. Cumulative survival is 98.5% at two years. Sixty-three patients (92%) reported improvement or elimination of anginal symptoms after operation. Kehospitalization for stroke was necessary in 3.7% patients. Postoperative activity levels are: self-care only, 3.9%; normal daily activity only, 17.6%; moderate exercise capability, 45%; and vigorous exercise capability, 33%. Comparison was made with a group of 84 randomly selected patients who underwent CAB alone during the same time interval. Data revealed no significant difference between the groups regarding sex, angina subset, ventricular function, coronary anatomy, vessels grafted, perioperative stroke or MI, mortality, or postoperative activity capability. Older age (59.8 vs. 55.6, p < 0.01) and less complete coronary revascularization possible (66 vs. 84%, p < 0.05) in the CE-CAB group were the only significant differences. Carotid stenosis co-existing in patients requiring CAB should be concomitantly corrected with the same risk and results expected from, CAB alone.

Presidential address: The doctors' dilemmas

One of the most humbling experiences I can remember was to read the list of distinguished past presidents in your program booklet and to realize that my name will soon be added. No words I can use are adequate to express appreciation, gratitude, and pleasure for the privilege of membership and the honor of being President. I have borrowed inspiration and a title from George Bernard Shaw. He is variously remembered as a satirist, a curmudgeon, an iconoclast, a sociafist, a critic, and sometimes a witty playwright. His comedic satires almost invariably incorporated social commentary reflecting his decided views. The Doctors Dilemma 1 describes the limited availability of a curative medication that was given to one patient and not another, the choice being mandated by the physicians self-interest in allowing one patient to die while the other lived. Nowadays we use some eloquent euphemism such as defined allocation of scarce resources to obscure the dilemmas inherent in rationed medical care. Inequalities of supplies such as donor organs for potential recipients, inequalities of access and payment resources, and externally imposed limitations on the type and quality of care are an existing reality and constitute de facto rationing.

Gallium citrate Ga 67 scans and aortic prostheses.

To the Editor.— Retroperitoneal paraprosthetic infections may become manifest months or years after aortic reconstructive surgery. They may be associated with thrombosis, enteric erosion, and eventual aortoenteric fistula. Multiple diagnostic studies, including aortography, barium studies of the gastrointestinal (GI) tract, ultrasound, and endoscopy, may sometimes give abnormal findings but often give false-negative results. Computerized tomographic (CT) scanning is useful but sometimes equivocal. Diagnosis is thus often delayed until massive hemorrhage occurs. Mortality after this event is severe. Gallium citrate Ga 67 scans have been useful in diagnosis of occult intra-abdominal infections, but their value in diagnosis of paraprosthetic infection has not, to our knowledge, been previously noted. We have had five patients with paraprosthetic infection, enteric erosion, and anemia in whom other diagnostic findings were normal or equivocal and in whom gallium citrate Ga 67 scans confirmed the suspected diagnosis. This allowed a planned elective operation as exemplified by the