Jan Lundbom

Regional Anesthesia for Endovascular Treatment of Abdominal Aortic Aneurysms

Purpose: To investigate the feasibility of regional anesthesia for endovascular repair of abdominal aortic aneurysms (AAAs). Methods: Since February 1995, 21 patients (17 men and 4 women; median age 67 years, range 49 to 80) have been treated with endovascular technique for true infrarenal AAA using Mialhe Stentor bifurcated grafts. A single dose of spinal anesthesia combined with epidural anesthesia was used in all procedures. Electrocardiography and arterial blood pressure were monitored. Results: No cases of emboli, hematoma, or graft migration were seen, and there were no reoperations or conversions to open operation. Arterial blood pressure was stable at a satisfactory level from induction of anesthesia throughout the procedure, and there was no period of clinically significant hypotension during any implantation. One patient died on the second postoperative day from cardiac and renal insufficiency. Three endoleaks were observed during the procedure; one healed spontaneously within 5 weeks, and the other two were repaired by endovascular techniques after 1 and 4 months, respectively. During follow-up, one patient died at 6 months from pancreatic carcinoma. Conclusions: The application of regional anesthesia is feasible for endovascular treatment of AAA. The arterial blood pressure remained stable throughout the procedure, and all patients, with two exceptions, were mobilized on the first day and placed on a regular diet. Based on these early results, it appears that regional anesthesia is feasible, effective, and safe for endovascular AAA repair.

Digital dipyridamole stress echocardiography in silent ischemia after coronary artery bypass grafting and/or after healing of acute myocardial infarction☆

This study evaluates dipyridamole stress echocardiography in silent ischemia. Fourteen patients with previous coronary artery bypass grafting (group A) and 16 patients with healed myocardial infarction (group B) were studied. All had > or = 1 mm ST depression without chest pain during bicycle exercise testing. Left ventricular wall motion was analyzed using a computerized display of digital systolic cineloops with a high frame rate. Test results were compared with coronary angiography. Dipyridamole echocardiography accurately identified patients with significant coronary artery stenosis in both groups (3 of 4 in group A, 11 of 14 in group B). Retrograde flow to the occluded native artery was associated with positive results on dipyridamole testing in 6 of 7 patients in group A and all 3 in group B. Sensitivity, specificity and diagnostic accuracy for detecting significant coronary stenosis or occlusions with retrograde flow was 78, 100 and 83%, respectively. Patients with angiographic multivessel disease had a significantly larger increase in wall motion score index during dipyridamole stress than patients with 0- or 1-vessel disease, 0.18 +/- 0.11 versus 0.05 +/- 0.18 (p < 0.05). Two patients developed symptomatic bradycardia and hypotension during dipyridamole infusion. It is concluded that dipyridamole echocardiography accurately identifies myocardial regions with restricted coronary flow. Stress echocardiography is a valuable tool for assessing coronary flow in silent ischemia.

Factors Influencing Return to Work after Aortocoronary Bypass Surgery

Factors influencing the effect on employment status were investigated in 250 patients (males: females 224:26) who underwent coronary artery bypass surgery between March 1983 and November 1985. The median age at operation was 57.9 (range 36.6-69.4) years and the median follow-up time 32 (19-52) months. Preoperatively 149 patients (59.6%) were receiving sick pay or disability pension because of their heart disease. Only 64 (25.6%) were gainfully employed, in contrast to 97 (38.8%) at follow-up. Of those who were working at the time of operation, all but eight returned to work postoperatively. At follow-up 183 (80.3%) were free from symptoms or much improved, with degree of improvement somewhat greater in those who were working postoperatively. The period of sick leave and the preoperative waiting time were significantly shorter for patients who were working postoperatively than for those who were awarded disability pension. Age, previous myocardial infarction, duration of preoperative angina and type of work were also found to influence postoperative employment status.

Type III Endoleak from a Thoracic Aortic Stent-Graft

Purpose: To present an as yet unreported late complication of an Excluder thoracic endograft. Case Report: A 78-year-old man underwent surgery for a ruptured type V thoracoabdominal aortic aneurysm in 1996. Four years later, an aneurysm was detected in the proximal thoracic aorta and repaired with 2 Excluder endoprostheses. At 12 months, computed tomography showed an increase in the aneurysm sac diameter and a type III endoleak, which was traced to a hole in the stent-graft fabric on arteriography. No fracture of the metal components was detected in the stent-grafts. Another Excluder device was implanted within the distal endograft. Satisfactory exclusion of the leak has been maintained for 6 months. Conclusions: The risk of type III leaks must be minimized before stent-grafting can be regarded as a routine procedure in the treatment of thoracic aortic aneurysms.

Exercise tolerance and work ability following aorto-coronary bypass surgery.

This investigation was performed to study the reasons for receiving disability pension after aortocoronary bypass surgery. During the period March 1983 to November 1985, 250 patients underwent aortocoronary bypass surgery. At a mean follow-up of 4.9 years (range 3.6–6.7) after the operation, 31 patients were dead. Of the 219 survivors, all except four underwent a follow-up examination including an exercise test. The mean physical work capacity had increased from 92.2 W preoperatively to 119.3 W at follow-up (p < 0.001). At follow-up, however, 72 patients had received disability pension. The percentage of positive ECG-tests were equal among those who were working and those who had received disability pension. We suggest that, among those who had received disability pension, about 50% were in sufficient physical condition to manage their previous jobs or another type of job. Reasons other than physical working capacity played an important part as criteria for receiving disability pension.

Delayed-onset Paraplegia after Thoracic and Thoracoabdominal Aortic Aneurysm Repair: Reversal with Cerebrospinal Fluid Drainage

Abstract Objectives: To discuss the management of late paraplegia following thoracic and thoracoabdominal aortic surgery. Design: Retrospective description of patients. Materials: Two case reports. Results: Recovery from late paraplegia was obtained by removal of cerebrospinal fluid. Conclusions: The immediate recovery from symptoms following CSF drainage strongly supports the effect of this measure in the treatment of late paraplegia following thoracic/thoracoabdominal surgery.

Endovascular Treatment of Aortic Disease.

A review is given of endovascular treatment for AAA, thoracic aortic aneurysms, dissections as well as complications following previous aortic surgery. In several of these conditions endovascular treatment has advantages like a reduced operative trauma, shorter stay in hospital, and the possibility of treating patients who would have been unfit for open surgery. On the other hand, problems like endoleak, deformation of the endoprosthesis, retrograde filling of the aneurysmal sack, and graft limb occlusion need to be solved before the place of endovascular treatment can be defined. It is possible that the steadily improving quality of the implants as well as the introducer systems will widen the indications for endovascular surgery, but randomised clinical trials are warranted and a longer follow-up period is necessary to draw final conclusions.