Raphael Walden

Percutaneous transluminal angioplasty. A suggested method for analysis of clinical, arteriographic, and hemodynamic factors affecting the results of treatment.

Sixty-nine percutaneous transluminal angioplasties (PTAs) were performed in the iliac and the femoral arteries of 54 patients. The main factors that might affect the results were reviewed: associated diseases, severity of ischemic symptoms, location and type of lesions (stenosis or occlusion and their length), and presence of disease distal to the site dilated. The vascular status of the patients in our series was more severe than in most others. Improvement at follow-up (average 15 months) was maintained in 74% of 66 radiographically successful PTAs. Poor runoff was the only factor found to affect the outcome deleteriously. Intra-arterial pressure measurements performed during the procedure and vascular laboratory studies were most valuable in assessing immediate and long-term results. Wide variations in results of PTA published in the literature are due to differences in methods of selection, evaluation, and reporting. A plea is made for future presentations of PTA series in an analyzable and comparable way, including and correlating all relevant variables as in the model suggested by the present study.

Damage control for abdominal trauma.

The damage control concept represents an extension of modern trauma resuscitation into the operating room. This surgical concept has found its most versatile and important use in severe abdominal trauma. The two critical concerns during damage control laparotomy are achieving hemostasis and preventing uncontrolled spillage of intestinal contents or urine. All else is secondary, and contrary to the traditional sequence of abdominal surgery, it is also deliberately disregarded. The common denominator of the many techniques presented in this article for a bail-out laparotomy is the need for a rapid decision, creative improvisation, and awareness that the outcome is determined by the patients physiologic envelope and not by anatomic integrity, which can be achieved at reoperation.

Surgical resource utilization in urban terrorist bombing: a computer simulation.

BACKGROUND The objective of this study was to analyze the utilization of surgical staff and facilities during an urban terrorist bombing incident. METHODS A discrete-event computer model of the emergency room and related hospital facilities was constructed and implemented, based on cumulated data from 12 urban terrorist bombing incidents in Israel. RESULTS The simulation predicts that the admitting capacity of the hospital depends primarily on the number of available surgeons and defines an optimal staff profile for surgeons, residents, and trauma nurses. The major bottlenecks in the flow of critical casualties are the shock rooms and the computed tomographic scanner but not the operating rooms. The simulation also defines the number of reinforcement staff needed to treat noncritical casualties and shows that radiology is the major obstacle to the flow of these patients. CONCLUSION Computer simulation is an important new tool for the optimization of surgical service elements for a multiple-casualty situation.

Hypothermic circulatory arrest for thoracic aneurysmectomy through left-sided thoractomy

PURPOSE In an attempt to clarify the role of hypothermic circulatory arrest (HCA) in the management of complex aortic aneurysms operated on through the left thoracotomy, our technique of HCA and outcome were reviewed. METHODS During a 21-month period, 15 (17%) of 87 aneurysms of the descending thoracic or thoracoabdominal aorta were operated on by HCA. Eleven patients had chronic aortic dissections (four type A and seven type B), two patients had atherosclerotic aneurysms, and one each had congenital or infected postoperative aneurysms. The use of HCA was planned before surgery in 14 patients. Indications included proximal aortic disease in 12 patients, making either clamping of the transverse aortic arch unsafe (eight patients) or necessitating replacement of the arch with a graft (four patients). Preoperative decision to use HCA was made in two additional patients, one with a ruptured aneurysm and another patient for spinal cord and visceral protection because of anticipated prolonged ischemia as a result of reoperation. Intraoperative technical difficulties prompted the use of HCA in only one patient. Deep hypothermia (15 degrees to 24 degrees C) was induced through partial cardiopulmonary bypass. Left-sided heart venting was necessary in five patients. Aortic replacement was limited to the descending thoracic aorta in five patients, whereas it involved the thoracoabdominal aorta in 10 patients. Four patients had associated replacement of the aortic arch. RESULTS Three patients died (one of a ruptured aneurysm) during surgery or early after surgery (two of bleeding and one of left ventricular failure). All other patients awoke neurologically intact, but one patient had delayed onset of paraplegia. Another patient died 4 days after surgery of rupture of the ascending aorta. Eleven patients were perioperative survivors without significant morbidity. CONCLUSIONS Hypothermic circulatory arrest is a valuable adjunct in the management of complex aortic aneurysms through left-sided thoracotomy. Its results warrant consideration of its selective use for spinal cord/visceral protection.

Stenotic Coiling and Kinking of the Internal Carotid Artery

Between January 1979 and December 1991, 174 of a total of 2304 carotid reconstructions (7.5%) were performed in 166 patients for stenotic coiling or kinking of the internal carotid artery. There was a 1.4 male predominance and the mean age of the patients was 66.3 ± 9.6 years (range 38 to 91 years). Seventeen patients (9.8%) were asymptomatic, 54 (31%) were symptomatic because of a previous stroke, and 103 (59.2%) had had transient ischemic attacks. The symptoms were hemispheric in 108 (62.1%) cases, ocular in 19 (10.9%), and vertebrobasilar in 30 (17.2%). The stenotic coiling or kinking was isolated in 35 (20.1%) cases and associated with other lesions of the internal carotid artery in 139 (79.9%). These included 119 atherosclerotic stenoses, 14 aneurysms, and six stenotic lesions due to fibromuscular dysplasia. Angioplasty of the carotid bifurcation was performed in 102 (58.6%) patients, associated with endarterectomy in 84 (48.3%) cases and with dilatation of dysplastic lesions in six (3.5%) cases. A bypass graft and resection and anastomosis of the carotid artery were performed in 36 (20.7%) patients each. There were four postoperative deaths (2.3%): two were due to neurologic causes, one to heart disease, and one to complications of an associated surgical procedure. Five patients (2.9%) had postoperative strokes and eight (4.6%) had transient ischemic attacks. At postoperative follow-up investigations four (2.3%) patients had carotid occlusions and 10 (5.7%) had morphologic abnormalities. At 5 years, actuarial survival was 80.97 ± 8.8%, patency was 96.12 ± 2.95%, and the ipsilateral stroke-free rate was 93.12 ± 4.49%. Treatment of stenotic coiling or kinking of the internal carotid artery yields satisfactory results, comparable to those of endarterectomy, for isolated atherosclerotic carotid stenoses and is effective in the prevention of ipsilateral ischemic stroke.

Iatrogenic complications in surgery. Five years' experience in general and vascular surgery in a University Hospital.

Advances in medicine that have led to more sophisticated methods of diagnosing, treating and monitoring patients take an ever increasing toll in iatrogenic complications.1–3 It may be argued that the net effect is an improvement in care, but it is self-evident that minimizing iatrogenic complications will increase the benefit to the patients of the ever increasing complex methods of treatment. Iatrogenic complications tend to be sporadic and varied in nature, and are difficult to study as a group. Psychological and medicolegal problems add to this difficulty. However, if the incidence of iatrogenic complications is to be decreased, a concerted effort has to be made to study them. This report deals with such an effort.

Gangrene of toes with normal peripheral pulses.

Ten patients with pregangrenous and gangrenous changes of the toes in the presence of normal peripheral pulses are described. In the absence of diabetes this is an uncommon condition and is only rarely reported upon in the literature. Four patients had non occlusive artcriosclerotic changes in large arteries; three suffered from thrombocytosis and one from polycythemia vera; one patient had a monoclonal gamopathy and one was exposed to cold three months before the onset of gangrene. None of these patients smoked regularly.Severe pain usually preceded the gangrene. The process did not progress proximally in any patients, and in those who underwent toe amputations the healing was uneventful. Vasodilators and low-molecular dextran were not effective. Lumbar sympathectomy was performed in three patients, also with no effect on the course of the disease. Treatment of hematological disorders gave relief in three patients. Proximal arteriosclerotic changes should be corrected if possible to eliminate a source of emboli. In two patients anti-platelet aggregation agents provided relief. Toe amputation should be conservative and performed when definite demarcation appears between necrotic and viable tissue. This condition has a benign prognosis.

Mitochondrial function and tissue vitality: bench-to-bedside real-time optical monitoring system

BACKGROUND The involvement of mitochondria in pathological states, such as neurodegenerative diseases, sepsis, stroke, and cancer, are well documented. Monitoring of nicotinamide adenine dinucleotide (NADH) fluorescence in vivo as an intracellular oxygen indicator was established in 1950 to 1970 by Britton Chance and collaborators. We use a multiparametric monitoring system enabling assessment of tissue vitality. In order to use this technology in clinical practice, the commercial developed device, the CritiView (CRV), is tested in animal models as well as in patients. METHODS AND RESULTS The new CRV enables the optical monitoring of four different parameters, representing the energy balance of various tissues in vivo. Mitochondrial NADH is measured by surface fluorometry/reflectometry. In addition, tissue microcirculatory blood flow, tissue reflectance and oxygenation are measured as well. The device is tested both in vitro and in vivo in a small animal model and in preliminary clinical trials in patients undergoing vascular or open heart surgery. In patients, the monitoring is started immediately after the insertion of a three-way Foley catheter (urine collection) to the patient and is stopped when the patient is discharged from the operating room. The results show that monitoring the urethral wall vitality provides information in correlation to the surgical procedure performed.

Percutaneous transluminal aortic angioplasty: Early and late results

Percutaneous transluminal angioplasty of the infrarenal abdominal aorta (13 patients) and its bifurcation (15 patients) was performed in 28 patients with a total of 32 dilatation procedures. The group consisted of 16 female and 12 male patients and initial successful dilatation was achieved in all Recurrence within 1 month requiring bypass surgery occurred in 1 patient. Three patients were lost to follow-up. Long-term follow-up in the remaining 24 patients ranged from 1 to 9 years with a mean of 4.5 years. During the follow-up period, repeat angioplasty of the original stenosis was performed in 3 patients and another patient underwent dilatation of a new lesion which developed in the aorta. According to clinical and noninvasive studies, these 4 patients, as well as the other 20, have maintained patency of the treated lesions and are symptom free. No immediate complications requiring surgery occurred. We conclude that angioplasty is the initial treatment of choice in focal lesions of the distal abdominal aorta and its bifurcation.

Distribution and symmetry of arteriosclerotic lesions of the lower extremities: an arteriographic study of 200 limbs.

Lower-extremity arteriograms of 100 candidates for vascular surgery were reviewed. All the arteries in the 200 limbs were visualized and graded as normal, irregular, stenotic, or occluded. The occurrence of hemodynamically significant disease (stenosis or occlusion) was markedly different in various arteries: iliac—37%, common femoral—9%, superficial femoral—58%, deep femoral—19%, popliteal—17.5%, tibialis anterior—27.5%, tibialis posterior—28.5%, and peroneal—16.5%. A remarkable symmetry was observed between the two lower limbs. In 53–76% of contralateral vessels the arteriographic picture was identical. When one degree of difference in arteriosclerotic involvement was allowed, the symmetry increased to 80–96%.