H. Dalichau

Thermal Coronary Angiography for Intraoperative Patency Control of Arterial and Saphenous Vein Coronary Artery Bypass Grafts: Results in 370 Patients

ABSTRACT Background and aim of the study: Early graft failure is often associated with technical failures and is therefore potentially avoidable. We used thermal coronary angiography (TCA) for intraoperative graft patency control in 370 patients undergoing routine coronary artery bypass graft surgery to determine whether consequent intraoperative bypass graft control may result in improved patency rates. Methods: The temperature differences generated in between the myocardium and the grafts by injecting cold cardioplegic solution into the proximal end of a vein graft or by warmer blood running through an internal thoracic artery (ITA) graft were detected using three different infrared camera systems. The resulting “heat pictures” were evaluated for anastomotic patency and to outline graft anatomy. Results: A total of 693 vein grafts were visualized. In 9.4% TCA failed to produce usable images. In the remaining 628 grafts, TCA revealed intraoperative patency in 98.8%. Out of 370 ITA grafts, only 14 could not be sufficiently visualized by TCA. Nineteen ITA occlusions (5.3%) were found: 5 intimal flaps; 11 suture imposed strictures; and 3 proximal ITA occlusions. All occluded grafts were subsequently revised or replaced. All sequential ITA as well as 15 right ITA grafts proved to have patent anastomoses. Conclusion: Using TCA an early graft dysfunction rate of 1% for vein grafts and 5.3% for ITA grafts could be demonstrated. Most occlusions were due to technical mistakes at the distal anastomosis. TCA outlines grafts and the attached coronaries by temperature differences without the need for a contrast agent. There is no interference with the surgical procedure. It is an ideal, noninvasive method to immediately document the success or failure of myocardial revascularization.

True aneurysm of the superior gluteal artery: Case report and review of the literature

Aneurysms of the gluteal arteries are rare and mostly are caused by pelvic fractures or penetrating injuries. As such these aneurysms are pseudoaneurysms. As an absolute rarity we report the case of a 43-year-old man with a histologically verified 5 cm-diameter, true saccular aneurysm of the left superior gluteal artery. The patient was admitted with 6-weeks ongoing sciatic pain without previous trauma. He was scheduled for surgery because an initial attempt of transcatheter embolization failed. By dividing the origin of the gluteus maximus muscle from the iliac crest, the aneurysm was exposed at the pelvic outlet by an extrapelvic approach and was excluded by endoaneurysmorrhaphy. Uncontrolled bleeding was prevented by temporary occlusion of the left iliac artery by a percutaneously inserted balloon catheter, thus avoiding an additional retroperitoneal approach. The postoperative course was uneventful, and sciatic pain had resolved completely. The chosen strategy provides safe and successful surgical management of gluteal artery aneurysms.

One-Stage Surgery of Coronary Arteries and Abdominal Aorta in Patients With Impaired Left Ventricular Function

BACKGROUND Coronary artery disease (CAD) is common in patients with abdominal aortic aneurysms (AAA). Some patients will present with the combination of unstable angina, impaired left ventricular function, and a large symptomatic (ie, leaking, expanding) AAA. In this subgroup of high-risk patients, aortic cross-clamping may have a deleterious effect on cardiac function, whereas coronary artery bypass graft surgery before aneurysmectomy (staged operation) carries the risk of perioperative aneurysm rupture. One-stage surgery, ie, myocardial revascularization and simultaneous aortic aneurysm repair, has been proposed in this situation. This article summarizes our results with the combined one-stage approach in patients with symptomatic CAD, impaired left ventricular function, and large symptomatic aortic aneurysms or severe aortic occlusive disease. As yet, this cohort is the largest reported in the English literature. METHODS AND RESULTS In 25 patients (24 men) with a mean age of 69.4 years (range, 55 to 80 years), we performed combined open heart and intra-abdominal aortic surgery. Eighteen patients had severe three-vessel disease and impaired left ventricular function (ejection fraction, < 35%). In addition, 3 of these patients had severe aortic valvular stenosis and/or insufficiency. Seven patients had one- or two-vessel disease with a low left ventricular ejection fraction in the range of 15% to 30%. All patients were in New York Heart Association functional class III or IV. Twenty-one of 25 patients had symptomatic infrarenal AAA (perianeurysm hematoma was present in 9 patients, and 12 patients had signs of beginning perforation). Four patients with aortoiliac occlusive disease and limb ischemia were simultaneously operated on. The surgical procedure started with the performance of coronary artery bypass graft surgery. After completion of myocardial revascularization, aortic aneurysm repair was performed while extracorporeal circulation was continued for mechanical cardiac assist until aortic surgery was fully accomplished. An average of 3.3 (3 to 5) coronary bypass grafts were placed, including 17 internal thoracic artery grafts. In addition, three aortic valves were replaced. In the abdominal aortic position, 12 straight tube grafts and 13 bifurcation grafts were implanted, and three renal and two carotid arteries were simultaneously repaired. The total time of surgery varied from 2.3 to 8.5 hours, with a mean time of 3.9 +/- 1.4 hours. One intraoperative myocardial infarction occurred despite open grafts. Intensive care unit treatment lasted 1 to 13 days, with a mean of 3.6 +/- 2.5 days. Three patients (12%) died after surgery--1 because of acute renal failure induced by an adverse reaction to heparin, 1 because of myocardial infarction, and 1 because of multiorgan failure. One-year actuarial survival rate was 88%, which compares favorably with survival after isolated AAA surgery in this high-risk patient subgroup and equals survival in patients with severe CAD and severely depressed myocardial function. CONCLUSIONS One-stage surgery is a possible approach to highly symptomatic patients with severe multivascular disease and has acceptable early morbidity and mortality. Patients with severely impaired left ventricular function and unstable CAD carry a high risk of left heart failure and/or myocardial infarction during abdominal aortic surgery. Extracorporeal circulation protects the heart from the hemodynamic changes after aortic clamping or declamping during abdominal aortic surgery. The present study demonstrates that one-stage procedure is a reasonable option for this patient subgroup.

Ischaemic complications with intra-aortic balloon counter-pulsation: incidence and management

The most important limitation of the use of the intra-aortic balloon pump is the risk of vascular complications. The aim of this study was to identify risk factors and aspects of diagnosis and management that may decrease the risk of vascular morbidity associated with intra-aortic balloon pumps. Risk factors, surgical techniques, complications and other variables were retrospectively evaluated in 524 patients who had an intra-aortic balloon pump inserted between January 1988 and December 1998. Of the total, 140 (26.7%) patients with an intra-aortic balloon pump had ischaemic complications that needed surgery. The mean age was 65.2 +/-12.3 years (66.7% men and 27.5% women). The mortality rate was 28.1%. The mortality for patients with ischaemic vascular complications was significantly higher than in those patients without (59.6 versus 30.1%, P = 0.001). One-hundred and eight (77.2%) ischaemic complications occurred during therapy with an intra-aortic balloon pump and 32 (22.8%) complications after intra-aortic balloon pumping had been stopped. Thromboembolectomy was required in 71 (50.7%) patients. Associated surgical procedures were performed in 69 (49.3%) patients. A history of peripheral vascular disease (43.6 versus 23.6%, P < 0.05) and the presence of diabetes mellitus (49.2 versus 16.9%, P < 0.05) increased the risk of limb ischaemia significantly. Limb ischaemia remains the major complication after intra-aortic balloon pump insertion. Independent predictors for vascular complications included peripheral vascular disease and diabetes. Intra-aortic balloon pump removal and thrombectomy is usually sufficient to provide revascularization. Identification of subclinical disease may aid in the management of subsequent acute limb ischaemia.

The Toronto SPV bioprosthesis: One-year results in 100 patients

BACKGROUND We studied the long-term results of heart valve replacement with the Toronto SPV bioprosthesis. METHODS From March 1993 until July 1994 the Toronto stentless bioprosthesis was implanted in 100 selected patients with a mean age of 70.7 years. The predominant aortic valve lesion was stenosis in 94 and insufficiency in 6 cases. Eighty-eight patients received a valve 25 mm in diameter or larger. Additional coronary artery bypass grafting was performed in 37 cases. Hospital mortality was 4%. Seventy-four patients were seen at 6 months and 38 patients at 1 year follow-up. RESULTS Structural deterioration, thromboembolism or hemorrhage were not encountered. Nonstructural dysfunction lead to reoperation in 1 patient. Another patient presented with endocarditis at 1 year postoperatively. There were no other valve-related complications. Echocardiographic mean pressure gradients ranged from 7.7 to 11.1 mm Hg postoperatively. There was a significant decrease in pressure gradients at 6 months of follow-up. Minimal aortic valve incompetence was seen in 3 patients. CONCLUSIONS The Toronto stentless bioprosthesis has superior hemodynamics and is an excellent alternative to conventional stented bioprostheses. Long-term evaluation has to prove whether this promising new valve can live up to its expectations.

Simultaneous coronary bypass and abdominal aortic surgery in patients with severe coronary disease : indication and results. Discussion

In patients with severe coronary artery disease (CAD) abdominal aortic surgery is still associated with high morbidity and mortality rates. Some patients will present with both symptomatic CAD and large, symptomatic abdominal aortic aneurysms (AAA) or end-stage aortic occlusive disease (AOD) that does not allow for a two-stage procedure. We report a series of 29 patients who underwent simultaneous coronary artery bypass graft surgery (CABG) and abdominal aortic surgery (25 AAA, 4 AOD). In the AAA group there were 23 males and 2 females with a mean age of 68 years (50-80). Sixteen patients presented with severe three-vessel disease. Ten patients had unstable angina. Aortic stenosis or insufficiency was present in two and one patient, respectively. Four patients with three-vessel disease and an ejection fraction below 30% presented with end-stage AOD and critical limb ischemia. Coronary bypass graft surgery was performed first. With the patient still on partial cardiopulmonary bypass, abdominal aortic surgery was carried out. Patients received an average of 3.1 coronary bypass grafts. Additionally, three aortic valves were implanted. Fourteen tube grafts and 15 bi-iliacal or bifemoral bifurcation grafts were placed in the abdominal aortic position. Additional vascular surgery was performed in five patients. Intraoperative management was without complication in all but one patient, who had intraoperative myocardial infarction (AOD group). Hospital mortality was 8% (2/25) in the AAA group. There was however substantial hospital morbidity (52.2%). The mean follow-up is 20.5 +/- 2.5 months. The actuarial survival rate at 3 years is 84.9%. It is concluded that combined CABG and abdominal aortic surgery is a reasonable option for patients who present with both severe CAD and symptomatic abdominal aortic disease. The continuation of CPB during aortic surgery may effectively prevent the adverse effects of infrarenal aortic clamping on a failing ventricle.

The Effect of Coronary Bypass Graft Surgery for the Prevention of Sudden Cardiac Death: Recurrent Episodes After ICD Implantation and Review of Literature

Sudden cardiac death (SCD) accounts for at least 50% of the mortality of patients with ischemic heart failure. Ventricular arrhythmias are responsible for most cases of sudden cardiac death. There is some evidence that coronary artery bypass graft (CABG) surgery may reduce the incidence of recurrent episodes of SCD by prevention of myocardial ischemia. To test the hypothesis that CABG surgery is effective in the prevention of SCD, we compared the recordings of implantable cardioverter defibrillators (ICD) in patients who underwent ICD implantation alone (n = 64) or ICD implantation and concomitant CABG surgery respectively (n = 11). All patients had experienced out of hospital cardiac arrest. ICD recordings were obtained every 3 months and the number of recurrent episodes of ventricular tachycardia (VT) for each time period was noted. Three months foilowing ICD implantation patients in the surgically treated group had an average of one episode of VT per patient as compared to 2.7 episodes in the nonsurgical group. This difference was observed during the following months as well. However, at nlo time (up to 18 months of follow‐up) this difference reached statistical significance. There were no deaths in the surgically treated group. Although we could not demonstrate a statistical significant difference between the two groups, there was a tendency in the surgically treated group to have less episodes of recurrent VT than in the medically treated group. We, therefore, conclude that survivors of SCD presenting with multivessel coronary artery disease (CAD) should undergo coronary artery bypass grafting to prevent myocardial ischemia as the triggering event for lethal ventricular arrhythmias.

Recanalization of Aged Venous Thrombotic Occlusions with the Aid of a Rheolytic System: An Experimental Study

PurposeThe suitability of a rheolytic system for recanalization of aged venous thrombotic occlusions was tested in an animal experiment.MethodsThe system consists of a flush-suction catheter and a high-pressure liquid pump. Thrombosis was experimentally induced in 13 venous segments of 10 adult goats.ResultsAfter a mean period of 12 days, a complete thrombectomy using the flush-suction system was achieved in 12 cases. No complications such as perforation or dissection were observed.ConclusionThis system seems to be an appropriate device for percutaneous transluminal venous thrombectomy, even in older occlusions.

Renal function and safety of heart transplant recipients switched to mycophenolate mofetil and low-dose cyclosporine

BACKGROUND We evaluated cyclosporine (CSA) dose reduction and mycophenolate mofetil (MMF) treatment versus maintained CSA dosage and azathioprine (AZA) in HTX regarding renal function and safety from CSA nephrotoxicity (creatinine > 1.7 mg/dL). METHODS Fourteen recipients (group 1: 12 men, 2 women) with CSA-based immunosuppression (plus azathioprine and/or steroids) were started on 2000 mg MMF/d. Azathioprine was discontinued and CSA tapered to trough whole blood levels of 70 to 120 microg/L. Ten recipients (group 2: seven men, three women) were maintained on their CSA dosages. Creatinine clearance, serum creatinine, uric acid, urea nitrogen, and rejection were monitored. RESULTS Mean age was 58 (range 44 to 69 years) and 48 years (range 24 to 61 years) in groups 1 and 2, respectively. In group 1 creatinine fell from 2.7 +/- 0.8 to 1.9 +/- 0.5 mg/dL (baseline vs control 2: P =.001); uric acid and urea nitrogen remained constant. CSA levels decreased from 173 +/- 56 to 110 +/- 33 microg/L (P =.02). In group 2 creatinine (2.4 +/- 0.7 vs 2.3 +/- 0.5 mg/dL), uric acid, urea nitrogen, and CSA levels remained constant. Comparison between groups showed higher creatinine clearance (50 +/- 18 vs 29 +/- 14 mL/min; group 1 vs group 2: P =.02), lower CSA levels (110 +/- 33 vs 161 +/- 35 microg/L; P <.001) and a trend toward lower serum creatinine (1.9 +/- 0.5 vs 2.3 +/- 0.5 mg/dL, P =.077). There were two rejections >/= 1B according to ISHLT in the study and four in the control group. Two deaths occurred in each group. CONCLUSIONS Conversion from AZA to MMF after CSA reduction improves creatinine clearance in HTX recipients and reduces serum creatinine. No negative effect on patient safety was identified by rejection rate or survival.

Kidney salvage in a case of ruptured renal artery aneurysm: case report and literature review

A 79-year-old woman presented with hypovolaemic shock caused by rupture of a left renal artery aneurysm. She was successfully treated by arterial reconstruction with functional salvage of the kidney. The frequency of renal artery aneurysms, their risk of rupture and the results of urgent surgery are discussed.