Jefferson F. Ray

Pulmonary embolectomy: Review and current status

D ISCUSSIONS regarding pulmonary embolectomy are traditionally opened with a reference to Dr. Trendelenburg. I The controversy stimulated by this procedure has resulted in continued and considerable accrual of information regarding massive pulmonary embolism. Dialogue remains heated, both in the literature and from the speakers podium. Many authors, myself included, owe Dr. Trendelenburg a great debt; how many of our patients have such an obligation remains debatable. The Congress of German Surgeons in 1908 indeed must have been a stellar event. There were reports of the benefit of early ambulation as it affects thrombotic and embolic phenomena, technique of transplantation of the thyroid gland and bone, intravenous novocaine for anesthesia of the extremities, successful transnasal hypophysectomy for acromegaly, use of positive and negative atmospheric pressure for intrathoracic operations, and the description and use of an intraoperative gastroscope. It was in this setting that Trendelenburg reported his technique for pulmonary embolectomy. Although none of the patients upon whom he operated survived, the technique still bears his name. Kirschner, 2 a student of Trendelenburg, in 1924 reported the first success utilizing the procedure. In this country the first such success was reported in 1958 by Steenburg? Temporary inflow occlusion of the circulation, and tourniquet occlusion of the inferior and superior vena cava, was first used to do embolec-

Effects of Changing Body Position upon Improved Ventilation-Perfusion Relationships

Ventilation-perfusion relationships were studied in patients in the lateral and supine positions by monitoring blood gas tensions of peripheral arterial and pulmonary vein blood samples. West observed in erect subjects that the apex of the lung, while oxygenating less blood than the base, effected a higher Po2. This study shows that in patients not in the erect position the nondependent lung, lobe or portion of lung achieved higher Po2 values than the dependent. The supine position was found to be associated with low peripheral arterial oxygen tensions. The simple maneuver of having the patient turn to a lateral position was found to increase oxygen tensions to satisfactory levels.

Combined carotid endarterectomy and myocardial revascularization

Abstract From February 1971 through December 1987, 95 patients underwent combined carotid endarterectomy and myocardial revascularization. Mortality and postoperative stroke rates were 4 percent and 2 percent, respectively, for the 16-year experience. From 1980 to 1987, when 89 percent of patients had their operation, mortality and stroke rates were 1 percent and 2 percent, respectively. Follow-up carotid duplex scan in 41 patients revealed that 25 percent had more than 50 percent restenosis. Only two in this group were symptomatic. We conclude that the combined approach to concomitant carotid and coronary artery atherosclerosis can be done safely. Continued study with noninvasive testing is important to document restenosis rates.

Vena cava umbrella placement: Its place in the over-all management of thromboembolic disease

Abstract A series of patients who underwent placement of a vena cava umbrella is presented. Morbidity was minimal and there was no mortality related to umbrella filter placement per se. One patient had a nonfatal episode of recurrent embolization. The role of umbrella placement in the over-all management of thromboembolic disease is discussed and it is concluded that only 10 to 15 per cent of patients with documented pulmonary emboli will be candidates for umbrella placement.

Combined Carotid Endarterectomy and Myocardial Revascularization

From February 1971 through December 1987, 95 patients underwent combined carotid endarterectomy and myocardial revascularization. Mortality and postoperative stroke rates were 4 percent and 2 percent, respectively, for the 16-year experience. From 1980 to 1987, when 89 percent of patients had their operation, mortality and stroke rates were 1 percent and 2 percent, respectively. Follow-up carotid duplex scan in 41 patients revealed that 25 percent had more than 50 percent restenosis. Only two in this group were symptomatic. We conclude that the combined approach to concomitant carotid and coronary artery atherosclerosis can be done safely. Continued study with noninvasive testing is important to document restenosis rates.