Ketonen P

Management of Arteriosclerotic Aneurysms of the Innominate and Subclavian Arteries

Two patients with innominate artery aneurysm and four with subclavian artery aneurysm are presented. Resection of the aneurysm and reconstruction of the vascular continuity were performed in all cases. No patient died in association with surgery. The complications included paralysis of the recurrent laryngeal nerve in one patient and postoperative infection of the vascular prosthesis, necessitating removal of the graft, in another. Because of the absence of surgical mortality and the acceptable complication rate, surgical resection of these aneurysms is recommended.

Surgical experience with simultaneous bilateral carotid endarterectomies

Eighty patients who had undergone bilateral carotid endarterectomy at the same operation were reviewed. All operative procedures were performed under general anaesthesia and during systemic heparinization and in all but six cases by using internal shunt. There were three deaths related to the operation representing 3.8% hospital mortality. Transient neurological deficits were noted in four patients (5% incidence) and permanent neurological deficits in four patients (also 5% incidence). A 100% late follow-up after an average period of 48 months revealed that 85.7% of the long-term survivors were functionally normal or improved. There were ten late deaths with heart disease accounting for 50% and stroke 30%.

Traumatic rupture of the thoracic aorta.

During the years 1961-78, 17 patients with traumatic rupture of the aorta underwent surgery at the Department of Thoracic and Cardiovascular Surgery, University Central Hospital, Helsinki. Nine of the cases were acute ruptures and 8 were chronic aneurysms. All cases were confirmed by pre-operative aortography. Rupture was located in each case in the proximal descending thoracic aorta just distal to the left subclavian artery. Surgical repair was made by using a left-side bypass in all cases but one, in which the operation time was so short that no organ protection was needed. The absence of paraplegias and kidney lesions demonstrated the adequacy of organ protection. Two of the three operative deaths were probably related to the systemic heparinization during left-side bypass which, by causing exacerbation of the cerebral bleeding, could have led to death. The possibility that these two deaths could have been avoided by using the new heparin-bonded, non-thrombogenic shunts, which obviate the need for generalized heparinization, is discussed. Operation is also recommended in chronic cases and should be performed as soon as an aneurysm has been diagnosed.

The effect of autotransplantation of the lung on pulmonary vascular resistance.

Re-implantation of the left lung was performed on 25 mongrel dogs to study the immediate haemodynamic changes in the re-implanted lung. During the experiments the animals were ventilated with pure oxygen to exclude hypoxia which is known to increase the pulmonary vascular resistance. The measurements were made under thoracotomy. The re-implantation had no effect on the aortic, central venous, pulmonary arterial or venous pressures. A significant increase was noted in the vascular resistance of the re-implanted lung. This was seen when the critical stenosis of the left pulmonary artery was determined immediately before and after the auto-transplantation. An elevation of about 10% was noted in the critical stenosis. It was concluded that the auto-transplantation caused an increase in the pulmonary vascular resistance, which did not depend on the hypoxia of the transplanted lung.

Valve Replacement for Bacterial Endocarditis

During the 10-year period 1970-79, 88 patients underwent valve replacement for complications of bacterial endocarditis. The mean age of the patients was 42 (15-60) years. There were 64 men and 22 women. Thirty-three patients had a history of rheumatic fever. In 11 cases the murmur was heard already in childhood. In 44 cases (50%) no heart disease was diagnosed before the onset of symptoms of bacterial endocarditis. Strepto- and staphylococci were the most common organisms found in culture. In 12 cases a dental and in 12 a respiratory tract infection preceded the endocarditis. In 51 cases, however, the origin of the infection remained unestablished. Intractable heart failure and embolizations were most common indications for operation. Only 9 patients underwent operation in the acute phase. Aortic valve replacement (AVR) was performed in 58 cases, mitral valve replacement (MVR) in 19, both AVR and MVR in 6, AVR and aneurysm of sinus Valsalva repair in 3 cases, AVR and repair of VSD in one and AVR combined with myocardial revascularization and replacement of the ascending aorta for aneurysm in one case. The early mortality was 9 patients (10%) and late mortality 9 patients. During follow-up times of up to 10 years, 7 patients experienced embolic complications. They recovered uneventfully. One valve prosthesis was replaced because of thrombosis and another due to paraprosthetic leak. Two patients had a late recurrent bacterial endocarditis 5 and 8 years postoperatively. They were treated conservatively and recovered. It was concluded that after valve replacement for bacterial endocarditis, the risk of recurrent infection is relatively low and that results approaching those for elective valve replacement can be achieved.

Blood Flow into the Autotransplanted Canine Lung after Administration of Sympathomimetic Drugs

The vascular responses of the autotransplanted lung to noradrenaline, isoprenaline and tyramine were studied on anaesthetized mongrel dogs, which had undergone left lung autotransplantation 2 to 27 months previously. The responses were estimated by measuring the distribution of pulmonary blood flow between the intact and autotransplanted lung before and after the drug administration.Noradrenaline shifted slightly the blood flow towards ths autotransplanted left lung. Isoprenaline tended to change the blood flow in the opposite direction, but the average change was not statistically significant. Tyramine did not modify the distribution of the blood flow. The doses given produced profound changes in the aortic pressure and pulse rate, suggesting that the weak responses of the pulmonary circulation were not due to too small doses. Thus, the autotransplanted lung and the intact lung differed very little in their responses to sympathomimetic drugs.

Surgical Treatment of Acute Superior Vena Caval Syndrome: A Report of Two Cases

The syndrome caused by the acute obstruction of the superior vena cava with central nervous system symptoms as well as with symptoms related to the oedema of the upper respiratory tract is often very severe and fatal to the patient. Conservative treatment is usually of no help, and consequently the palliative reconstruction of the superior vena cava may be indicated. Two cases of acute superior vena caval syndrome with reconstruction of the superior vena cava are presented. In the first case, when a malignant mediastinal tumour (Hodgkins) was removed, a segment of the superior vena cava and the anonymous vein had to be removed. Following this operation acute superior vena caval syndrome developed and another operation was performed in which the superior vena cava was reconstructed with a Dacron prosthesis. Radiological examination of the superior vena cava 28 months postoperatively showed the prosthesis patent and the patient was free from symptoms. 51 months after the operation the patient was still asymptomatic. In the second case the obstruction of the superior vena cava was caused by anaplastic carcinoma of the upper lobe of the right lung. The acutely obstructed superior vena cava was reconstructed with a Dacron prosthesis. 9 months postoperatively the superior vena caval syndrome recurred and two months later the patient died of lung cancer. In both cases good palliation of the obstruction of the superior vena cava was obtained.

HISTOLOGICAL FINDINGS AFTER EXPERIMENTBL PULMONARY AUTOTRANSPLANTATION

Left lung autotransplantation was performed on 50 mongrel dogs to study histological changes in the autografted lung. Five samples were taken from both the central and peripheral parts of each lung of 17 postoperative failures and of three long-term survivors, which were sacrificed 3 weeks, 2 and 15 months postoperatively. The normal histological procedures were carried out by fixation with neutral formalin. Sections were stained with haematoxylin—eosin and van Gieson stains. Iron staining was performed in cases with marked pigmentation. None of the autografted lungs showed a completely healthy appearance. In 5 cases bilateral bronchopneumonia was found. Focal areas of inflammation were found in 7 additional cases. The autografted lung was more susceptible to infection than the contralateral. This was assumed to be due to denervation of the autografted lung and the abolition of the cough reflex and retention of bronchial secretions on the operated side. Different amounts of bleeding were seen in about hal...

THE PERIPHERAL LUNG PULSE AND BRONCHIAL CIRCULATION

The recording of the peripheral lung pulse by cinedensigraphy has been used to an increasing extent in the study of the regional pulmonary perfusion. The intensity of pulsation, expressed as pulsation index, has been used as synonymous with the blood flow and psr-fusion. Nothing, however, is known about the contribution of the bronchial circulation to the form and amplitude of the cinedensigraphic pulse. The purpose of the present study was to clarify this experimentally. The bronchial vessels of the right lungs of ten mongrel dogs were divided and the cinedensigraphic pulses of both lungs were recorded before and after severance of the vessels. It was noted that the pulmonary parenchymal pulsation did not show any significant change in form or amplitude after interruption of the bronchial circulation. Therefore the cinedensigraphic pulse, reflecting the intensity of the pulmonary arterial blood flow, is unaffected by the bronchial circulation.