L. Michael Graver

Giant aneurysm of saphenous vein graft to coronary artery compressing the right atrium

Aneurysm of reverse aortocoronary saphenous vein graft is a known complication of coronary artery bypass grafting. In this report we present a case of a 60-year-old man who presented 12 years after coronary artery bypass grafting with a giant graft aneurysm of the reverse aortocoronary saphenous vein graft to the right coronary artery, compressing the right atrium. Spiral computed tomography was used to identify the aneurysm measuring 7 x 6 x 7 cm. We also reviewed the English-language literature and found reports of 50 patients with similar aneurysms of which 30 (61%) were identified as true aneurysms and 17 (33%) were identified as pseudoaneurysms. Three patients could not be identified into either group. We reviewed the presenting symptoms, diagnostic tools, and treatment options for this rare entity. An understanding of the pathophysiology of reverse aortocoronary saphenous vein graft aneurysm is important to prevent the possibility of aneurysm rupture, embolization, myocardial infarction, or death.

The Risks and Benefits of Thrombolytic Therapy in Acute Aortic and Mitral Prosthetic Valve Dysfunction: Report of a Case and Review of the Literature

A patient with acute thrombosis of a St. Jude mitral prosthesis was treated with streptokinase with initial success. Subsequent recurrent thrombosis and embolism prompted operative revision. Because the use of thrombolytic agents in this setting is somewhat controversial, we searched the literature for all reports of aortic or mitral prosthetic valve dysfunction treated this way. The cases of 58 patients treated 62 times were reviewed for efficacy of therapy and morbidity. Thrombolytic therapy may be useful in patients with prosthetic valve thrombosis causing critical hemodynamic compromise. It is frequently the only treatment needed. Further, it may help reduce operative risk for those patients in whom complete resolution is not possible. The incidence of systemic embolism is 18%, however, neurological events are usually limited and transient.

Speech and Swallowing Rehabilitation Following Devastating Caustic Ingestion: Techniques and Indicators for Success

Caustic material ingestion, either accidental or intentional, may result in tissue and organ destruction leading to a wide range of complications, including loss of speech and the ability to eat. The esophagus can be reconstructed successfully, but reopening the larynx and upper airway poses a significant therapeutic dilemma. External reconstruction may put the neoesophagus at risk. Loss of the normal swallowing mechanism and the protective supraglottic structures often results in fatal aspiration.

Is there a role for routine mediastinoscopy in patients with peripheral T1 lung cancers

BACKGROUND The role of surgical staging of patients with non-small cell lung cancer (NSCLC) continues to evolve. This report describes our findings utilizing routine cervical mediastinoscopy in the evaluation of peripheral T1 (<3 cm) lung tumors. METHODS Retrospectively 30 patients with peripheral T1 lesions and CT scans negative for pathologic adenopathy were identified over a 3-year period. Cervical mediastinoscopy was performed prior to VATS/thoracotomy during the same operative session. RESULTS Mediastinoscopy was performed in 29 of 30 patients. For patients with malignancy (27 of 30), 3 of 27 (11%) had mediastinoscopy positive for malignancy and no further resection performed. Overall the subgroup of patients with bronchogenic carcinomas had positive mediastinal involvement identified in 5 of 24 (21%) after mediastinoscopy or complete resection. CONCLUSION A significant number of patients with small peripheral lung cancers harbor radiographically occult lymph node involvement. Mediastinoscopy facilitates identification of patients with regionally advanced disease prior to resection, allowing neoadjuvant therapy and avoiding unnecessary resections.

Carbon dioxide embolism during minimally invasive vein harvesting

Gas embolism is a known complication of minimal access procedures in which carbon dioxide insufflation is used. We report a case of significant venous and right heart gas embolization, which occurred during performance of routine minimally invasive vein harvesting. This was manifest by hemodynamic deterioration secondary to transmission by a patent foramen ovale into the left heart and coronary circulation. Techniques to predict, diagnose, and prevent this rare but potentially fatal complication of minimally invasive vein harvesting are suggested.

Occlusion of left coronary artery ostium by an aortic valve cusp

Congenital anomalies of the aortic valve can be associated with other cardiac anomalies. In this report, we present a patient with an aortic valve anomaly associated with occlusion of left coronary ostia. In addition, we reviewed the literature and found 10 similar cases. Although compatible with life, this anomaly can lead to significant symptoms. Preoperative diagnosis as well as proper therapeutic planning should be tailored to correct valvular competence and restore coronary blood flow.

Routine Myocardial Revascularization with the Radial Artery: A Multicenter Experience

Abstract Background: Current literature documents use of the radial artery (RA) for myocardial revascularization only as an alternative conduit in cases where the saphenous veins have been previously harvested or are unsuitable for use. Large‐scale routine clinical use of the RA as the conduit of choice has not been reported. Methods: This prospective study evaluated the harvest of the RA from 933 patients and the subsequent use of the conduit as a preferred coronary artery bypass graft second only to the left internal thoracic artery in 930 of these patients. Results: Unilateral RA harvest was performed in 786 patients and 147 patients had bilateral RA harvest. A total of 1080 RAs were harvested; 214 (19.8%) originated from the dominant forearm. There was a mean of 3.30 ± 0.93 grafts per patient of which 2.43 ± 0.83 were arterial grafts. The mean number of RA grafts was 1.43 ± 0.53. Operative mortality was 2.3% with none due to the RA graft(s). There was no ischemia nor motor dysfunction in the operated hands. Thirty‐two (3.4%) patients experienced transient thenar dysesthesia that resolved in 1 day to 6 weeks. Conclusions: Our results demonstrate that routine total or near total arterial myocardial revascularization may be achieved safely and effectively with the use of one or both RAs in conjunction with the internal thoracic artery.

Exchange Transfusion Before Cardiopulmonary Bypass in Sickle Cell Disease

Cardiac operations in patients with sickle cell disease present the surgical team with many challenges. We describe a method of complete intraoperative exchange transfusion in the operating room that reduces the hemoglobin S (Hb S) level to less than 5%, without preoperative exchange transfusions. Plasma and platelet fractions separated intraoperatively from the patients native red cell mass were used, in addition to hemoconcentration while on cardiopulmonary bypass, to effectively reduce the red cell and clotting factor transfusion requirements after the procedure. The technique is useful in reducing transfusion requirements, avoiding cardiovascular stress associated with exchange transfusion before the operation, and can be used in urgent situations.

Use of the variable-length intraluminal sutureless graft

From August 1987 to May 1988 we treated 4 patients with acute ascending aortic dissections with a variable-length intraluminal aortic prosthesis. This operation uses profound hypothermic circulatory arrest and represents a refinement of existing techniques. There was no mortality, and morbidity was minimal. Modifications of this technique can be used in performing proximal aortic root reconstruction with a composite valved conduit. The use of a variable-length intraluminal prosthesis and hypothermic circulatory arrest is illustrated. This is a safe and useful technique in select cases of acute ascending aortic dissection.