S. Mattila

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.

Chemodectoma of the lung.

A case of pulmonary chemodectoma is presented. To date, five lung tumours regarded as chemodectoma have been reported in the literature. An asymptomatic woman, aged 49 years, had in the anterior segment of the right upper lobe a coin lesion, which was treated by segmental resection. Histologically the tumour fulfilled the criteria of chemodectoma.

Local anaesthesia in carotid surgery. A prospective study of 111 endarterectomies in 100 patients

A prospective study was carried out on 100 patients consecutively undergoing carotid endarterectomy in local anaesthesia, in order to evaluate the usefulness of clinical signs in awake patients for monitoring of cerebral function and to determine the need for internal shunt in carotid surgery. The indications for operations were transient ischemic attacks in 67 patients and major or minor stroke in 24 (16 with persistent neurologic deficit). In nine asymptomatic patients the endarterectomy was prophylactic, following detection of bruit and angiographic stenosis. Bilateral stenosis was present in 47 patients, including 13 with total occlusion of the contralateral vessel, and 60 patients had significant vertebral artery stenosis. The carotid artery was first tentatively occluded and, if this was well tolerated for 5 min, endarterectomy was done without an internal shunt. Neurologic deficit signs during the trial occlusion necessitated such shunt in 16 patients with pressure in the internal carotid stump ranging from 0 to 40 (mean 22.4) mmHg. On the other hand, 11 additional patients with stump pressure less than 35 mmHg tolerated the trial occlusion well, underwent carotid endarterectomy without internal shunt and had no deficit symptoms during or after operation. One patient died postoperatively. Hemiparesis appeared in two more patients, but resolved completely in one and gave only minor sequelae in the other. These complications were related to the preoperative condition (stroke) and the postoperative residual pressure gradient. It is concluded that trial occlusion of the carotid artery and observation of the awake patient provide reliable information on the need for an internal shunt during carotid endarterectomy.

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%.

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.

Hypothermia and circulatory arrest in reconstruction of aortic arch. A report of nine cases.

From 1982 until October 1985 we operated 9 cases of aortic aneurysm involving the transverse aortic arch (5 male and 4 female, from 26 to 69 years). Two patients had an acute dissecting aortic aneurysm, the others had an aneurysm of the aortic arch involving also the ascending aorta in 5 cases and the descending aorta in 1. Three patients underwent aortic valve replacement and implantation of coronary orifices. Two patients had previously had AVR. The operation was carried out under cardiopulmonary by-pass. After obtaining 25 degrees C hypothermia the bypass was discontinued and the cerebral vessels were cannulated from inside of the opened aneurysm and perfused at a flow rate of 250 ml/min. The myocardium was protected by cold cardioplegia and topical cooling. During total circulatory arrest the distal aortic arch anastomoses were completed in 28-56 minutes. Then the by-pass was restarted and the rest of the operation was carried out as usual. One patient with an acute dissecting aortic aneurysm died on the 2 post-operative day due to brain damage and rupture of abdominal aorta. The other patients recovered well. There were no permanent neurological or myocardial complications. Three patients had a transient renal failure, one needing dialysis. The 8 survivors have done well 4-46 months after the operation.

Effects of lovastatin on high-density lipoprotein subfractions in hypercholesterolemic patients with peripheral vascular disease.

The effects of lovastatin treatment on high-density lipoprotein subfractions (HDL2 and HDL 3) were investigated in 34 patients with severe peripheral vascular disease and type IIa or type IIb hyperlipoproteinemia by use of a density gradient ultracentrifugation method. Lovastatin therapy caused greater percentage changes in HDL2 than in HDL3. In HDL2 the increases of cholesterol, total lipid, apolipoprotein AI (apoAI) and apoliproprotein AII (apoAII) concentrations were 23% (p < 0.05), 28% (p < 0.01), 24% (p < 0.01) and 11 % (p < 0.01), respectively, in subjects with the type IIa phenotype. In patients with the type IIb phenotype the corresponding increases were 42% (p < 0.01), 44% (p < 0.01), 38% (p < 0.01) and 21% (p < 0.05), respectively. The apoAI/apoAII weight ratio in HDL2 rose by 11% and by 13% in type IIa and type IIb patients, respectively. The present results suggest that during lovastatin treatment the slight increase in serum HDL-cholesterol concentration was due, not to cholesterol enrichment by high-density lipoproteins, but more probably to an increase of the number of HDL particles. The observed changes were more pronounced in type IIb than in type IIa patients.

Surgical Treatment of Nondissecting Aneurysms of the Descending Thoracic Aorta

Between 1966 and 1981, 58 patients underwent operation for nondissecting aneurysm of the descending thoracic aorta at the University Central Hospital in Helsinki. The cause of the aneurysm was atherosclerotic in 38 cases. Nine aneurysms were post-traumatic and 11 had developed after correction of aortic coarctation with a Dacron patch. Rupture of the aneurysm with hypotension and haemothorax were present on admission in three patients (5.2%). Six operations were performed without use of shunt or bypass. In the other patients the circulation to the spinal cord and viscera was protected during the aortic resection and reconstruction. Left atrial-to-femoral artery bypass was used in 43 patients, femoral vein-to-femoral artery bypass in five, heparinized TDMAC shunt in three patients and total perfusion in one case. Transient paraparesis and irreversible paraplegia each occurred in one case in which some form of circulatory protection had been used. In the latter patient there was aneurysm rupture and hypotension on admission to hospital, and resection (greater than 10 cm) was done with TDMAC shunt. The patient died postoperatively of pulmonary complications. The total operative mortality was 12.1%. The mortality in the follow-up period (range 1-14 years, mean 5 years) was 13.8%. The conclusion from the study was that, when adequate technique of aneurysm resection is combined with shunt or bypass, an acceptable operative mortality and low incidence of paraplegia are obtainable.

Pulmonary Arteriovenous Fistulas

During the 20-year-period 1959-78, 7 patients with pulmonary arteriovenous fistula were treated at the Department of Thoracic and Cardiovascular Surgery. There were 5 men and 2 women, with a mean age of 26 (14-47) years. Cyanosis with elevated haematocrit was present in 4, dyspnoea in 4, neurological signs in 3 (including one brain abscess and one hemiplegia). Systolic hum was audible in 3 cases. Three patients had the hereditary type of the disease (Rendu-Osler-Weber) with telangiectasiae also elsewhere in the body. The calculated right-to-left shunt varied from 14 to 56 per cent of the cardiac output. The treatment was lobectomy in all cases (4 upper lobe, one middle lobe and 2 lower lobe resections). The patient with a brain abscess underwent craniotomy prior to lobectomy and developed epilepsy necessitating anticonvulsive treatment. The other patients had an uneventful recovery with relief of the symptoms. During the follow-up time (2-20 years), one patient (with hemiplegia) died of myocardial infarction 10 years after the operation. The others were doing well. It is concluded that the safest way to treat a pulmonary arteriovenous fistula is to operate as soon as it has been detected in order to prevent the complications so often associated with the disease.