Josef G. Vincent

Inferior epigastric artery as a conduit in myocardial revascularization: The alternative free arterial graft

When complete revascularization cannot be obtained with the internal mammary artery and greater and lesser saphenous veins, the inferior epigastric artery may be an excellent alternative conduit. We describe our experience with this conduit, review the anatomy of this artery, and present our harvesting technique.

Pectus excavatum: a clinical study with long-term postoperative follow-up

Between 1972 and 1987, 192 patients have been operated upon for pectus excavatum of which 152 patients were included in the study (79%). Mean age at operation was 15.3 +/- 5.5 years; 117 were male. Mean follow-up was 8.1 +/- 3.6 years. The deformity was noted before the age of 5 in 90%. Type I symmetrical and localized deformity was seen in 33.2%, type II symmetrical but diffuse depression in 23.7% and type III localized or diffuse asymmetrical deformity in 43.1%. It was considered severe in 68.9%, fair in 16.9% and mild in 14.2%. There were significantly more asymmetrical defects in the older age groups. The operation consisted of subperichondral chondrectomy, transverse sternotomy and division of the intercostal bundles at the outer limit of the chondrectomy and suturing the edge of this broad sheet of muscle and perichondrium to the anterior surface of the chest wall more laterally and under tension, elevating and stabilizing the sternum. Results were satisfactory in 83.6% (excellent 44.1%, good 39.5%). Results were not significantly influenced by age, sex, severity, type, symmetry, the extent of cartilage resection or follow-up. Results were inversely influenced by the occurrence of wound problems. The optimal age for operation is considered to be between 5 and 10 years. Both physical as well as psychological cosmetic factors may serve as an indication for operation.

Detrimental sequelae on the hemodynamics of the upper left limb after subclavian flap angioplasty in infancy.

The long-term effect of two surgical techniques for repair of coarctation of the aorta in infancy, namely, resection and end-to-end anastomosis (RETE) and subclavian flap angioplasty (SFA) on the blood supply of the upper left limb, was quantified by Doppler spectrum analysis of blood flow velocities in the left brachial artery at rest and during postocclusive reactive hyperemia. Twenty-three patients participated in this study: nine patients after SFA (median age, 8 years), 14 patients after RETE (median age, 8 years), and 10 control subjects (median age, 9.5 years). At rest, a highly significant decrease of blood flow velocities in the left brachial artery was measured in all patients of the SFA group compared with those of the RETE and control groups, as documented by various Doppler spectrum parameters: maximal frequency of advancing curve (p = 0.0001), pulsatility index (p = 0.0005), and resistance index (p = 0.039). During reactive hyperemia, a moderate capacity of physiologic augmentation of blood flow velocities was observed in five patients of the SFA group. This capacity was marginal in two patients with complaints of claudication in the left upper limb during strenuous exercise, which can be related to the number of branches of the left subclavian artery ligated during operation. This study indicates that SFA in infancy may lead to compromised hemodynamics of the upper left limb with potential for symptoms of ischemia during exercise.

Appraisal of resection and end-to-end anastomosis for repair of coarctation of the aorta in infancy: preference for resection

Between 1973 and 1987, 70 consecutive infants under-went repair of coarctation of the aorta. Age at operation was 80.0 +/- 77 days (mean +/- standard deviation); mean weight was 3.0 +/- 0.5 kg. Isolated coarctation was present in 25 patients (group 1); in 19 patients coarctation existed in association with ventricular septal defect (group 2); and in 26 patients coarctation was associated with major intracardiac defects (group 3). Subclavian flap angioplasty was performed in 19 patients and resection and end-to-end anastomosis in 51 patients. Hospital mortality was not significantly different between subclavian flap angioplasty (11%) and resection and end-to-end anastomosis (24%). Freedom from reintervention for recoarctation after 5 years was 87% in the subclavian flap angioplasty group and 95% in the group having resection and end-to-end anastomosis. Actuarial survival at 5 years was 100% for group 1, 73% for group 2, and 28% for group 3. In the subclavian flap angioplasty group, we observed detrimental effects of the sacrifice of the left subclavian artery: 1 patient had a 2.5-cm shortening of the left upper arm, and 5 others complained of claudication in the left upper limb during strenuous exercise. As no major advantage in terms of mortality and recoarctation to either technique of coarctation repair was found, and as subclavian flap angioplasty carries the possible disadvantage of late contracture of isthmic ductal tissue and possible detrimental effects on the left upper limb, resection and end-to-end anastomosis is recommended.

Late pulmonary metastases from chondroblastoma of the distal femur: A case report

A patient treated with curettage and bone grafting for a chondroblastoma of the distal femur sustained a pathologic fracture after a local recurrence. He then underwent a local, radical resection and an arthrodesis of the knee. Ten years after the first operation, pulmonary metastases were found, for which he underwent a metastasectomy (thoracotomy). At the latest follow-up, 1 year later there were no signs of tumor.

Update on Sternal Osteosynthesis

Interfragmental compression enables primary bone formation in the bone fracture line and results in better and faster contact bone healing. The Controlled Tension Osteosynthesis System is a simple and uniform sternal closure method that makes use of the principles of widely used modern osteosynthesis techniques. A review of tensile tests of currently available sternal closure methods has shown that the wire closure is the weak link in all procedures. An anchor plate has been developed as a more efficient means of wire closure. In contrast to the most commonly used wire twist closure, which has an optimum strength that is only 20% to 33% of the original wire tensile strength, the anchor plate closure retains up to 80% of the wires tensile strength. Used in combination with a steel alloy wire with a metallurgically increased tensile strength, it results in a sevenfold to ninefold increase in effective fixation stability. A specially designed instrument, the Strainsqueezer, enables easy clinical application of the anchor plate under controlled, standard conditions. The system offers an optimal compression osteosynthesis fixation using a minimal amount of foreign body material (thin, prestressed wire). Its development was based on technical experience gained through 6 years of clinical practice involving 800 sternotomies.