Harry Siderys

Delayed postoperative bleeding from polytetrafluoroethylene carotid artery patches

Patch angioplasty of the internal carotid artery after endarterectomy has been advocated as a means of decreasing early postoperative carotid artery thrombosis, as well as reducing the incidence of recurrent carotid artery stenosis. Noninfectious rupture of saphenous vein patches in the early postoperative period has been reported by several authors, leading others to advocate the use of prosthetic patches. This report describes three patients in whom delayed bleeding through needle holes along the suture lines in polytetrafluoroethylene cardiovascular patches occurred between 1.5 and 4 days after operation. All patients required reexploration to control bleeding, and acute respiratory distress from tracheal compression developed in one patient. Although delayed bleeding through needle holes in polytetrafluoroethylene cardiovascular patches appears to be rare, a word of caution may be in order before advocating routine patching of the carotid artery with this particular type of patch.

Early and late results of descending thoracic and thoracoabdominal aortic aneurysm open repair with deep hypothermia and circulatory arrest

OBJECTIVE Open repair of descending thoracic aortic and thoracoabdominal aortic aneurysms may carry low morbidity and mortality, depending on experience of the surgeon and operative technique used. Although thoracic endovascular aortic repair is less invasive, its limitations include anatomy and pathology of the aorta, proximity of major branches, and significant complication and reintervention rates. We retrospectively reviewed a 2-surgeon experience (J.W.F. and J.S.C.) with deep hypothermic circulatory arrest to repair descending thoracic aortic and thoracoabdominal aortic aneurysms. METHODS All patients (n = 343) who underwent surgical replacement of descending thoracic aortic or thoracoabdominal aortic aneurysm with deep hypothermic circulatory arrest from 1995 to 2009 were included. Segmental arteries between T8 and the celiac artery were aggressively reimplanted as indicated. Visceral and renal artery bypasses were performed for significant stenosis. Concomitant coronary artery bypass grafting was performed if targets were anterior or lateral wall vessels. Lumbar drains were not routinely used but placed postoperatively on clinical evidence of spinal cord ischemia. RESULTS Of 343 patients, 98 had descending thoracic aortic aneurysms, 69 had Crawford type I thoracoabdominal aortic aneurysms, 111 had type II, 32 had type III, and 33 had type IV. Emergency or urgent operations comprised 13% of repairs. Hospital mortalities were 5.0% for all cases, 3.7% for elective cases, and 13.3% for urgent or emergency cases. Overall incidences were 4.4% for stroke, 3.2% for paraplegia or paraparesis, 1.5% for renal failure requiring dialysis, and 3.5% for tracheostomy. The 1-, 3-, 5-, and 10-year survival rates were 90%, 79%, 69%, and 54%, respectively. CONCLUSIONS Surgical repair of descending thoracic aortic and thoracoabdominal aortic aneurysms with deep hypothermic circulatory arrest carries low operative morbidity and mortality and excellent early and late survival rates. These results can be used as a benchmark for future techniques and technologies.

One-stage segmental resection of extensive thoracoabdominal aneurysms with left-sided heart bypass.

PURPOSE The purpose of this study is to describe a technique for resection of extensive thoracoabdominal aneurysms, which the authors believe will lower morbidity and mortality rates. METHODS In an effort to minimize the risk of spinal cord ischemia, we have used a combination of sided heart bypass (left atrium to left femoral artery) with local cooling of the intercostal and visceral arteries and segmental resection of the aneurysm. Segmental resection of the aneurysm allows perfusion of the spinal cord and abdominal viscera as the proximal anastomosis is completed and as each pair of intercostal arteries is reimplanted. An attempt is made to reimplant all pairs of intercostal arteries from T8 to L2. Before the intercostal or visceral arteries are reimplanted, that segment of aorta is cooled with cold crystalloid solution. Thus no segment of the aorta is exposed to warm ischemia for more than 30 minutes. Left-sided heart bypass allows the patients temperature to be maintained between 35 degrees C and 37 degrees C. RESULTS We have used this technique in 23 patients with types I and II (Crawfords classification) thoracoabdominal aneurysms. Seven patients (30%) had dissections or rupture associated with their aneurysms and underwent emergency operation. One of these seven patients became paraplegic after operation, for a 4.3% incidence of paraplegia. One patient died of multiple organ failure after operation. No patient had kidney failure requiring dialysis. CONCLUSIONS We believe that our technique allows the operation to be performed in a deliberate manner with a low incidence of paraplegia and kidney failure.

Ruptured abdominal aortic aneurysms in a private hospital: a decade's experience (1980-1989).

Despite refinements in elective resection of abdominal aortic aneurysms, morbidity and mortality rates for ruptured abdominal aortic aneurysms (RAAAs) remain high. Between January 1, 1980 and December 31, 1989, we treated 208 patients with RAAAs whose mean age was 70 years. The overall mortality rate was 49.5%. Logistic regression analysis showed that three factors correlated with predicted patient survival. Patients <70 years old had a survival rate of 65.7% compared with a survival rate of 37.4% in patients >70 years old (p<0.001). Among “stable” patients (preoperative blood pressure consistently >90 mm Hg), 88.9% survived compared with 40.9% of “unstable” patients (blood pressure <90 mm Hg) (p<0.001). Of the patients with free intraperitoneal rupture, 38.3% survived compared with a survival rate of 79.6% of patients with rupture confined to the retroperitoneum (p<0.001). Despite a high overall mortality rate in patients with RAAAs, surgical intervention remains the only hope for survival. We continue to advocate an aggressive surgical approach in this group of patients.

Cryopreservation and Microsurgical Implantation of Rabbit Carotid Arteries

Use of cryopreserved small-diameter elastic arterial allografts for an arterial bypass procedure has been suggested. But, the long-term patency of the cryopreserved arteries in vivo has not been 100%. Thirty New Zealand White rabbits were used in this study. The experimental arterial segments were cooled and cryopreserved in liquid nitrogen, and warmed with a precooled water jacket apparatus. The frozen/thawed autologous carotid artery was attached end to end by anastomosis with microsurgery. Patency and structural characteristics of implanted arteries were periodically assessed for 12 months using duplex/Doppler ultrasound. Histopathological analysis was performed after 1 year of observation. The results showed that (1) the thawing device we designed was useful in preventing fractures during warming processes; (2) the immediate patency was 100% following autograft implantation; (3) after 4 months, blood flow was not observed via ultrasonography in two cryopreserved arteries and in one control group arter...

Use of BioGlue in aortic surgery: proper application techniques and results in 92 patients.

BACKGROUND Surgery for pathology of the proximal aorta requires aortic wall reconstruction, re-approximation of the graft to native vessels, and potentially root replacement and valve resuspension or replacement. The purpose of this study is to describe proper application techniques and the results obtained with the adjunctive use of BioGlue Surgical Adhesive in this challenging patient population. METHODS Between August 1998 and June 2002, 92 consecutive patients underwent ascending/arch repairs, ascending/root repairs, Ross procedures, or ascending/arch repairs with a concomitant Ross procedure using BioGlue as an adjunct for anastomotic hemostasis. RESULTS Twenty-six patients (28.3%) in this series required no postoperative blood products. The mortality rate for this single-surgeon series was 3.3%. No device-related complications were observed. The incidence rate for postoperative pseudoaneurysm formation was 3.3%. CONCLUSIONS This series demonstrates the safety and effectiveness of BioGlue as a hemostatic adjunct in proximal aortic surgery. Use of the product helped to facilitate a minimal reliance on blood products and a low mortality rate.

The Superior Approach for Operative Decompression of the Left Side of the Heart

Abstract A new technique to decompress the left side of the heart is described. A catheter is guided from the superior aspect of the left atrium through the mitral valve to the apex of the left ventricle. This is a direct route, and the catheter lies in a straight line and therefore can be placed with minimal manipulation. The technique is simple, effective, and atraumatic.

Intraoperative pulmonary angioscopy using the flexible fiberoptic choledochoscope

The use of fiberoptic angioscopy can be an important adjunct to the performance of pulmonary embolectomy. This technique can be performed rapidly and allows direct visualization of the pulmonary arteries.

Combined coronary artery bypass grafting and bilateral renal revascularization for unstable angina and impending renal failure

The purpose of our article is to describe a patient with severe hypertension and moderate renal insufficiency, unstable angina, and a 6 cm abdominal aortic aneurysm. A previous aortogram had demonstrated severe bilateral renal artery stenoses. Cardiac catheterization demonstrated severe coronary disease. After cardiac catheterization acute renal failure and pulmonary edema requiring dialysis developed in the patient. In addition, evidence of impending myocardial necrosis developed. Because of the critical nature of the myocardial and renal ischemia it was necessary to perform combined myocardial and renal revascularization rather than staged procedures. At the time of coronary artery bypass grafting, a vein graft was anastomosed to the right coronary artery vein graft and tunneled through the diaphragm into the abdomen to revascularize both renal arteries. After surgery renal function gradually improved, and no further dialysis was required. The abdominal aortic aneurysm was repaired at a subsequent operation. At 2-year follow-up all grafts remained patent. The serum creatinine is 1.2 mg/dl. Although most patients with combined coronary artery disease and renal artery disease can be treated with staged operations, our procedure may be of value in patients in whom staged procedure are not feasible and in whom the infrarenal aorta is severely diseased or aneurysmal.