Josef Rösch

Transjugular intrahepatic portacaval shunt. An experimental work.

Abstract A new method for transhepatic portacaval shunting accomplished on a percutaneous basis by puncture of the jugular vein and by the use of a modified Ross needle-catheter system is described. The shunt was accomplished in forty dogs and the technic was used successfully in cadavers. The shunt technic and its possible clinical application are discussed.

Left main coronary artery disease: Risks of angiography, importance of coexisting disease of other coronary arteries and effects of revascularization

To elucidate the determinants of the poor prognosis of patients with left main coronary artery disease and to assess the efficacy of diagnostic and therapeutic interventions the angiographic features and clinical course of 58 patients with left main coronary artery disease studied between September 1967 and June 1974 were analyzed. Eighty-three coronary arteriograms were obtained in these 58 patients using the Judkins technique; there were no immediate complications although one patient died 3 days after study. Previously cited predictors of left main coronary artery, unstable or nonexertional angina and marked S-T segment depression with exercise were found in a minority of patients; thus, the presence of the disease could not reliably be predicted before arteriographic study. Coexisting disease was found in either two or three other coronary arteries in 46 of 58 patients; only 2 patients had isolated left main coronary artery disease. Because the criteria for operability have changed in recent years, current criteria without knowledge of the treatment actually given or its outcome. The condition of 10 of 58 patients was judged inoperable in retrospect because of severe coexisting distal coronary artery disease (8 patients) or ventricular dysfunction (2 patients). Of 19 patients whose condition was judged operable in retrospect but who were treated without surgery, 9 died, 8 within 18 months; 10 have survived 12 to 83 months. Another 27 patients with a condition judged operable in retrospect had received saphenous vein bypass grafts. In this group, there were four operative and three late deaths. The severity of angina decreased in survivors treated surgically but was unchanged in survivors treated without surgery. The improvement in survival rates of surgically treated patients was not statistically significant. The data indicate that coronary arteriography can be performed at low risk with the Judkins technique even though preangiographic prediction of left main coronary artery disease is unreliable. Coexisting disease in oter major coronary arteries is an important determinant of the poor prognosis of patients with left main coronary artery disease and precludes surgery in 13 percent. Isolated left main coronary artery disease is uncommon. Surgical therapy relieves symptoms more effectively than nonsurgical therapy.

Improvement in left ventricular wall motion following nitroglycerin.

Coronary artery disease patients frequently have left ventricular wall motion abnormalities. Though nitroglycerin is commonly used in ischemic heart disease, its effects on wall motion abnormalities is unknown. In this study we have evaluated the effects of nitroglycerin on wall motion abnormalities and on ejection fraction in 25 patients. Sixteen had coronary artery disease (>70% luminal narrowing). Six had no evidence of heart disease and three had congestive cardiomyopathies with normal coronary arteries. Left ventricular angiography was performed prior to and six minutes after administration of 0.4 mg of sublingual nitroglycerin. Twelve of the 16 coronary artery disease patients had wall motion abnormalities, and in seven of these, segmental wall motion improved after nitroglycerin. In five, wall motion did not change. The initial heart rate, left ventricular systolic and end-diastolic pressure, and left ventricular end-diastolic volumes were not different for those whose wall motion improved versus those whose did not. The increase in the former and fall in the latter three hemodynamic parameters were significant (P < 0.01) and similar for the two groups. In those whose wall motion abnormalities improved after nitroglycerin, ejection fraction (mean ± se) increased significantly (P < 0.05), from 0.47 ± 0.025 to 0.62 ± 0.046. In those without improvement, the ejection fraction went from 0.55 ± 0.056 to 0.58 ± 0.051 (NS). Three patients with congestive cardiomyopathy showed no improvement in ventricular wall motion or ejection fraction after nitroglycerin. Left ventricular wall motion abnormalities and ejection fraction improved in some coronary artery disease patients following nitroglycerin. The mechanism for this is unknown; however, ventriculography before and after nitroglycerin may be of potential usefulness for identifying areas of reversible wall motion abnormalities.

Complications of Selective Percutaneous Transfemoral Coronary Arteriography and their Prevention A Review of 445 Consecutive Examinations

Complications encountered during a typical 12-month period of routine work with the Judkins percutaneous transfemoral method of selective coronary arteriography are reviewed. In 445 examinations, 20 complications (16 local and four cardiac) occurred. Local complications included nine delayed hemorrhages, five thromboses of femoral arteries, and two peripheral emboli. Cardiac complications included one ventricular fibrillation, one significant bradyarrhythmia, and two myocardial infarctions. Causes of individual complications are analyzed and means for their prevention discussed. Guidelines of the procedure are proposed to minimize the complications of selective coronary arteriography. Emphasis is placed on patient evaluation, preparation for the procedure, and meticulous examination technique.

Deep Vein Thrombosis Treated With Streptokinase or Heparin Follow-Up of a Randomized Study

Twenty-seven patients with deep vein thrombosis whose primary therapy was randomized between streptokinase and heparin were reevaluated clinically and by ascending venography after a mean period of 7 months. Normal venograms were found in 6 (40%) of the streptokinase-treated patients and in 1 patient (8%) who had heparin therapy. Segmental valve preservation was found in 1 patient from each group. All patients with complete or partial valve preservation became asymptomatic. Vein re canalization without preservation of valves occurred in 18 patients: 8 (54%) of those on streptokinase, and 10 (83%) of those on heparin. At the time of follow-up, 11 of these 18 patients, including 8 who had had prior thrombosis, reported peripheral edema; the postphlebitic syndrome devel oped in 1. Factors favoring a good outcome of acute venous thrombosis were (1) no prior thrombotic disease, (2) localized thrombosis, and (3) prompt streptokinase therapy.

Streptokinase and Heparin in the Treatment of Pulmonary Embolism: A Randomized Comparison

Treatment with streptokinase followed by heparin was compared on a randomized basis with treatment with heparin alone in patients with acute pulmonary embolism. The diagnosis and results of treatment were established by pulmonary angiography. Fifteen patients received streptokinase and 16 received heparin alone. Complications included bleeding and pyrexia in both treatment groups and anaphylaxis in a patient receiving streptokinase. There were three deaths attributed to the disease its treatment. Patients in the strepto kinase group had significantly greater angiographic improvement (P = 0.0125) than those in the heparin group.

Occlusion of Coronary Arteries after Vein Bypass

The coronary arteries of 100 patients were radiographically visualized by selective injection of contrast material. Findings in the three main arteries (left anterior descending, right, and circumflex arteries) were analyzed before and after aortocoronary-saphenous vein graft surgery. Proximal coronary artery stenosis progressed to complete occlusion in almost half the patients on whose stenotic arteries a graft had been placed. The incidence was higher than that observed in nongrafted arteries during the “natural” course of the disease. The frequency of occlusion in grafted coronary arteries was higher in severely stenotic than in moderately stenotic arteries. The fact that the occlusion occurred more often with a patent graft than with a closed graft suggests a hemodynamic component in its pathogenesis. The study indicates that in many patients the prognosis must remain linked to patency of the bypass graft.

Spontaneous changes in left ventricular function between sequential studies

Abstract To evaluate day to day changes in left ventricular function, studies were performed in 17 patients in stable condition undergoing elective cardiac catheterizatlon and coronary arteriography on successive days. Seven patients had significant coronary artery disease, seven had significant valvular heart disease, two had both lesions, and one had no demonstrable heart disease. The group as a whole demonstrated no significant day to day changes in any measured parameter of left ventricular function …. The hematocrit decreased from 43.4 ± 4.3 to 41.5 ± 4.5 percent ( P The range of these day to day changes in the parameters of left ventricular function without therapeutic intervention must be considered when evaluating the effects of therapy. Since wall motion abnormalities were constant in site and showed little variation in extent, the effects of medical and surgical treatment on left ventricular asynergy can be assessed by sequential studies.

Percutaneous angiographic embolization: A procedure of increasing usefulness: Review of a decade of experience***

During the past decade percutaneous therapeutic vascular occlusion was performed on 152 occasions in 124 patients. The primary indication for vasoocclusive therapy was acute or recurrent bleeding. Upper gastrointestinal bleeding from arterial sources was controlled in 92 percent of patients and acute variceal bleeding in 83 percent. Renal embolization was performed for palliation of severe pain and hematuria from unresectable renal primary or secondary malignancies, to decrease blood loss and facilitate surgery in operable renal tumors, and for ablation of renal function to control chronic protein loss or severe hypertension. Our encouraging experience convinces us that transcatheter embolization is a useful, safe and effective procedure in selected patients. It seems certain that the technique of therapeutic embolization will be improved, its indications extended and its application become commonplace whenever angiographic skills and facilities exist.

Late Results Following Emergency Saphenous Vein Bypass Grafting For Unstable Angina

Fifty-five consecutive patients with intermittent resting chest pain persisting more than 24 hours after hospitalization and accompanied by ECG changes representative of ischemia were operated urgently more than one year ago. Recent cases with shorter follow-up are excluded. Twenty-eight patients had single grafts, 23 had double grafts, three had triple grafts, and one a quadruple graft. There were three operative deaths (5%) and one sudden late death (2%). There were six early Mls and three late Mls. Follow-up ranges from 12 to 52 months (mean 24 months) with nine patients followed for four years. Actuarial analysis indicates a projected survival rate of 93% three years postoperative. Twenty-three survivors are Functional Class (FC) I, 19 are FC II, and eight are FC III. Functional class could not be determined in one survivor. Thirty patients had postoperative angiography one week to 32 months postop. 35/51 grafts were patent. Only three patients had no patent grafts. There were no significant differences between mean preoperative and postoperative left ventricular end-diastolic pressures (assessed in 20 patients) or ejection fractions (assessed in ten patients). The extremely low mortality early and late postop (7%), the low incidence of Ml (16%), and the excellent functional results after extended follow-up indicate that emergency saphenous vein bypass grafting is an effective therapy for unstable angina.