Harris B. Shumacker

Coarctation of the Aorta

Summary The operative management of coarctation of the aorta yields good over-all results. Excision of the narrowed segment and end-to-end aortic anastomosis can be carried out in the majority of patients and various useful modifications can be applied in the exceptional cases. The risk is very low when operation is carried out in childhood and adult life. It is higher when operation is necessary in infants under age 1 or 2. In them, it is important to establish the diagnosis and to institute operative treatment without delay unless medical therapy brings about prompt and effective results. The outcome is far better with operative than with nonoperative management. The risk is very small in cases of uncomplicated coarctation. The presence of a patent ductus arteriosus does not noticeably increase the hazard of treatment. Management of coarctation can also be carried out with small risk in instances when it is associated with other well tolerated valvular and intracardiac lesions, treatment of which either is unnecessary or deferrable. Othe rcombinations of anomalies, such as coaractation, patnet ductus arteriosus and ventricular septal defect, have a considerably poorer survival rate. It is especially important that coarctation in females be corrected before the childbearing age and that untreated cases be recognized and treated operatively early in pregnancy. The superficially similar cases of subclinical coaractation and kinking of the aortic arch do not require operative treatment unless they are associated with an aneurysm.

A personal overview of causalgia and other reflex dystrophies.

This is a personal assessment of true major causalgia and the other reflex dystrophies, related but distinctly separate entities. The clinical picture of causalgia differs only in minor respects from that described by Mitchell over 120 years ago. Its management has, however, been clarified, largely through the extensive experiences of World War II. It is readily recognized and can be treated effectively by sympathetic blocks or sympathectomy together with active exercise. The other reflex dystrophies are far less understood. They appear to have a similar pattern in their early phase and to respond well to a program of exercise and control of edema--a regimen which, because of pain and paresis, cannot be carried out without sympathetic blocks or occasionally sympathectomy. When not recognized early and treated properly, the sympatomatology usually changes dramatically and treatment differs. Often control of edema and active use of the affected part are all that is necessary. Sometimes, in addition to these measures, sympathetic blocks or sympathectomy is required. Guidelines found useful in management are outlined. Puzzling features are discussed.

Stenotic and obstructive lesions in acute dissecting thoracic aortic aneurysms.

The present study of 33 operatively treated patients, 88 per cent of whom survived the procedure, is concerned with an important problem associated with acute thoracic aortic dissection, the stenotic and obstructive lesions of the aorta and its branches. Their variety and nature are described, as are the additional operative procedures deemed necessary at the time of the operation, immediately thereafter, or later on. Much has been learned about these difficulties from clinical and autopsy observations and especially from careful arteriographic surveys. They seem to be generally well withstood following resectional and grafting procedures upon the affected segment of the thoracic aorta. Occasionally, additional operative manipulations may be necessary at the same time, for example, interpolation of grafts between the ascending aortic graft and a coronary when the origin of the latter is sheared off by the dissection, and distal arterial manipulations when the patient still has ischemic lower extremities immediately after the primary procedure. Later operations must sometimes be performed because of persistence of complaints such as intermittent claudication. It is extremely rare that immediate reoperation is advisable because of indications of intra-abdominal ischemia. Much more can be learned from careful pre- and postoperative arteriographic study.

Little used surgical techniques of value

Abstract Discussion of the pros and cons of a few operative techniques leads to the conclusion that they deserve wider use, currently restricted by failure to appreciate demonstrated advantages, by exaggeration of potential or known disadvantages, and by the common policies of “letting well enough alone” and of “following the herd”.

The management of stenotic and obstructive lesions of the aortic arch branches

The stenotic internal carotid can be managed in a variety of ways and number of tests can be utilized for assessing the collateral blood flow. Except in unusual situations, carotid thromboendarterectomy with or without a patch graft is generally employed. Although some surgeons use no protective shunt at all, or only upon specific indications, intraluminal shunting is utilized extensively. Our preference is to employ the customary Javid shunt technic except in unusual circumstances that suggest that added safety may be assured by shortening to a matter of seconds the period of interruption of carotid flow. In such cases, we believe the temporary axillary-internal carotid intraluminal shunt is of considerable value. Although mediastinal and thoracic procedures and bypass grafts delivering blood from the ascending aorta are not needed nearly as often as they were formerly, they are essential in certain cases. They yield excellent results and carry small risk. Carotid-subclavian grafts have proved quite valuable in restoring pulsatile flow to the subclavian and carotid systems. Our preference, however, because of technical simplicity, is the carotid-axillary bypass procedure. Subclavian-subclavian and axillary-axillary grafts have been employed successfully. When a carotid-axillary bypass is feasible, we would choose this method instead and reserve the others for unusual anatomic-pathologic situations.

SYMPATHETIC DENERVATION OF THE EXTREMITIES.

Summary With the passage of time, the value and the limitations of sympathectomy in the management of various reflex and peripheral vascular disorders have become well defined. Its wise clinical application is dependent on establishing a clear-cut accurate diagnosis and on under-standing well the usual clinical course of the disorder under consideration and the manner in which sympathectomy can be expected to alter this course. It is generally much less dependent on preoperative assessment of the vasomotor response of the patient to a period of inhibition of vasoconstrictor impulses. Careful preoperative study of such vasomotor responses to inhibition of vasoconstrictor impulses, and of pain to sympathetic blockade, is of the greatest importance, however, in certain instances. The need for sympathectomy has been curtailed somewhat by the development of technics which permit one to maintain or restore the continuity of the artery when operating for arterial trauma, aneurysm or arteriovenous fistula, and by reconstructive surgical procedures in instances of arterial obliterative disease. Nevertheless, the procedure still has wide applicability. The results of sympathetic denervation vary. Sometimes it must be used when there is relatively small likelihood of a striking result because nothing else offers as much promise. Generally, a very satisfying outcome can be expected. Sometimes results are truly dramatic. Altogether, when utilized on proper indication, sympathectomy proves a rewarding procedure.

Better early than late

Abstract A number of little known ideas and events are reviewed together with concepts not originally appreciated as valuable but later shown to be of real worth and some conceived but never carried through to completion. These have led to speculations as to what might have happened had the ideas been explored earlier and more carefully evaluated, as well as to a proposal that one or more surgical journals might perform a valuable service by instituting a section dealing with new ideas and innovations not yet proven true and useful.

An American surgeon's contribution to Chinese health care

A prominent American thoracic surgeon, Leo Eloesser, while serving with UNICEF, contributed significantly to the health care of the Chinese people in the late 1940s, during the final years of the civil war and before the establishment of the Peoples Republic of China. The concepts he developed, especially concerning rural health service in poor, medically deprived nations, and the factors he felt must be taken into account in developing a health care system in any nation had lasting value. The story of the origin of his plan and his efforts to implement it is briefly related.

Observations on coronary sinus flow

Abstract The response of arterial blood pressure and coronary sinus flow to hemorrhage, to blood transfusion and, in moderately hypovolemic animals, to blood replacement, infusion of physiological saline solution and administration of 50 per cent dextrose solution has been determined. Hemorrhage depresses the blood pressure in about 90 per cent of the animals. It always reduces the coronary sinus flow. Rapid transfusion of blood in normovolemic animals usually brings about a negligible rise in blood pressure and in all animals studied a significant increase in sinus flow. The moderately hypovolemic animal responds to blood replacement, physiologic saline infusion and administration of 50 per cent dextrose solution with a rise in arterial pressure and coronary sinus flow.