Sepp Weimann

Isolated iliac artery aneurysms

Clinical and diagnostic data were collected from 22 men with iliac artery aneurysms treated surgically over a period of 22 years. Their ages ranged from 47 to 80 years (mean 64.0). Eight patients had multiple aneurysms. Thirty isolated iliac artery aneurysms were detected, 20 aneurysms (66.6%) located on the right and 10 (33.3%) on the left side. Twenty-six aneurysms were found in the common iliac artery (86.6%). Fifteen patients were symptomatic (68.2%); rupture occurred in five patients (22.7%), three of whom were initially asymptomatic. Thirteen of 17 patients whose aneurysms did not rupture had a palpable mass (76.4%), and three had bruits in the area of the aneurysm. All 22 patients were subjected to operative procedures. Seventeen patients operated upon electively survived, whereas only three patients who were operated upon after rupture survived. Graft interposition was the most common procedure. All 20 patients who survived after the operation were followed. Two died of myocardial infarction three and five years later, one of cancer six years later, and one of an unknown cause eight years after operation. Iliac artery aneurysms are extremely rare; their diagnosis is very difficult. The mortality rate is two times higher than in aortic aneurysms, once the diagnosis has been established. Therefore elective resection and arterial reconstruction are recommended.

Direct subclavian—carotid anastomosis for the subclavian steal syndrome

Between 1984 and 1986, 38 patients--25 males and 13 females--underwent treatment for proximal subclavian arteriosclerotic lesions. All of these patients presented with symptoms of the subclavian steal syndrome and 13 (34.2%) had additional claudication of the arm. Preoperative angiography showed distal filling of the subclavian artery via retrograde flow in the vertebral artery. 31 patients (81.5%) had total occlusion of the proximal subclavian artery and 7 (18.5%) presented with severe stenosis. 34 of these lesions were on the left (89.5%) and 4 on the right side (10.5%). Complete cerebral angiography was performed in each patient with emphasis on visualisation of the carotid bifurcation and selective opacification of the aortic arch vessels if indicated. Doppler ultrasound flow measurement in the vertebral artery yielded the basic data which were then used for comparative postoperative evaluation. The operation was performed under general anaesthesia and heparinisation. A shunt was not required while performing the direct end-to-side anastomosis between the transected subclavian and the common carotid artery. Arteriosclerotic plaques in the distal stump of the transected subclavian artery and occasionally the origin of the vertebral artery were dealt with by simple eversion endarterectomy. There was no operative mortality; the postoperative complication rate was 13.1% including palsy of the recurrent nerve in 3 patients, a lymphatic cyst of the neck in one patient and bleeding requiring re-exploration in another. Occlusion of the reconstructed artery or neurologic deficit did not occur. Post operatively all patients were treated with platelet inhibitors. The average follow-up period was 13 months, when the reconstructed arteries were found to be patent in 37 patients (97.4%).(ABSTRACT TRUNCATED AT 250 WORDS)

Graft replacement of post-traumatic thoracic aortic aneurysm: results without bypass or shunting.

From 1986 to 1991 13 cases of post-traumatic thoracic aneurysm were treated at our department. All patients had apparent thoracic injury at the time of trauma, and their mean age was 35 years. The mean time between trauma and operation was 3 years and six patients were asymptomatic. In all patients the diagnosis was made by computed tomography and angiography and all post-traumatic thoracic aneurysms were located at the aortic isthmus. No spinal cord protection by bypass or shunting was used during surgery and the clamp-and-repair method with a mean clamping time of 38 min was used in all 13 patients. No renal or neurological complications were observed postoperatively and there were no hospital deaths. The data of 202 patients who had been operated upon for post-traumatic thoracic aneurysms since 1981 have been reviewed with regard to the relationship between spinal cord protection and the incidence of postoperative paraplegia. Different methods of spinal cord protection were used in 121 patients resulting in paraplegia rate of 1.6%. In 81 patients the clamp-and-repair method was used and no case of paraplegia was observed in this group.

Traumatic Renal Artery Occlusion: Is Late Reconstruction Advisable?

We report a case of traumatic renal artery occlusion treated successfully by reconstruction several years after the injury. Hypertension resulted in diagnostic investigation by means of excretory urography, computerized tomography, angiography and perfusion scintigraphy. Treatment consisted of a thin-walled polytetrafluoroethylene (Gore-Tex) bypass between the aorta and left renal artery near the hilus. When the patient was discharged from the hospital the creatinine level was normal and blood pressure was 180/90.

Local Fibrinolysis and Perfusion in the Treatment of Priapism of the Corpora Cavernosa and Corpus Spongiosum

A 69-year-old patient was referred with priapism of the corpora cavernosa and the corpus spongiosum. Blood aspiration, irrigation with heparin-saline solution and metaraminol injections proved unsuccessful. Surgical intervention was inadvisable in view of delayed coagulation. Complete detumescence was achieved after intracorporeal perfusion with streptokinase.

Carotid occlusion caused by seat belt trauma

Surgical reconstruction should be considered in patients showing episodes of transient cerebral ischaemia or progressive neurological deterioration secondary to carotid arterial injuries proved by arteriography. Even complete thrombosis of the internal carotid artery may be managed successfully, if thrombectomy and intimal repair are undertaken within some hours after the onset of neurological symptoms. Unger reported a mortality rate of 21% following carotid arterial trauma, 34% of the patients improved if they underwent surgical repair, whereas only 14% of the patients improved if they had ligation or were not treated surgically. Statistical data have shown that both shock and coma are bad prognostic omens and patients presenting with these signs have less than a 50% chance leaving the hospital alive and well, even if they receive optimum emergency management. Although coma has been suggested as a contraindication to carotid repair, review of the literature has shown the data to be too limited to warrant such a conclusion.

Primary Abdominal Aortic Dissection

Aortic dissection originating in the abdominal aorta is a rare condition and can originate above or below the renal arteries. Acute dissection of the abdominal aorta may present with back pain in the absence of a pulsatile abdominal mass in a patient with systemic hypertension. Although the diagnosis of aortic dissection can be confirmed by ultrasound or CT, precise visualisation of the intimal defect together with the site of entry can only be achieved by angiography. In acute dissection, rupture or obstruction of major branches may require immediate vascular surgical intervention.

Intraoperative Kalorimetrie bei Aortengabelrekonstruktion

ZusammenfassungVeränderungen des Stoffwechsels sollten mit der indirekten Kalorimetrie unter Routinebedingungen bei Aortengabelrekonstruktionen untersucht werden. Elf männliche Patienten wurden in totaler intravenöser Anästhesie (TIVA) mit dem Servoventilator 900 D ohne Lachgase mit FiO2 0,5 beatmet. Kalorimetriert wurde mit einem Deltatrac® (Datex). Zur Auswertung wurden folgende Meßpunkte herangezogen: 5 min nach Intubation, 5 min vor Aorten-Klemme = Referenzwert, bei Klemmen; 5, 10, 15 min nach Öffnen; 1, 5, 10 min nach Öffnen und bei Operationsende. Zur statistischen Berechnung wurde der Student-t-Test für gepaarte Werte verwendet. Die Aortenklemmung führt zu einem Abfall von V˙O2 (90% des Ausgangswertes) und V˙CO2 (75% des Ausgangswertes) (Abb. 1, 2, 3). Das Öffnen der Klemme führt bei jedem Bein zu einem signifikanten Anstieg von V˙O2 (118%); Die CO2-Produktion steigt etwas langsamer, ist jedoch für das 1. Bein ebenfalls signifikant (90%). Auffallend ist eine kontinuierliche Abnahme des respiratorischen Quotienten von (MP1) 0,98±0,11 bis zu 0,75±0,06 bei OP-Ende. Das dichte Nicht-Rückatmungssystem des Servo-Ventilators 900 D ermöglicht mit dem Deltatrac eine zuverläßliche, rasche und nicht invasive Messung von V˙O2 und V˙CO2, wenn kein Lachgas verwendet wird und FiO2<0,6 ist. Der Abfall des RQ von Narkose-Beginn bis OP-Ende uß als Zeichen einer vermehrten Fettverbrennung angesehen werden.AbstractOxygen uptake (V˙O2) and carbon dioxide elimination (V˙CO2) can be measured with an indirect calorimeter; this method is well established in routine monitoring of ICU patients to evaluate metabolic state as a reflection of stress. In various experimental studies it was demonstrated that anaesthetics can influence whole-body metabolism. The purpose of this study was to examine whether indirect calorimetry can be used intraoperatively during routine anaesthesia and whether presumable changes in metabolism can be detected immediately. Abdominal aortic cross-clamping changes circulation, nutritional supply of the lower extremities and thus V˙O2 and V˙CO2. We therefore used this operation for our study. Method. Eleven patients, mean age 64 years, undergoing reconstruction of the aortic bifurcation, were studied. After premedication with piritramid and atropine, total intravenous anaesthesia (TIVA) was performed with fentanyl and midazolam after an induction with thiopental. Patients were ventilated with a Servo-Ventilator 900 D and a constant FiO2 of 0.5, without N2O. Routine monitoring consisted of ECG, pulsoximetry, CVP and continuous AP. V˙O2 and V˙CO2 were measured with a Deltatrac® (Datex), and data were registered every minute. For statistical evaluation we used a Wilcoxon-Ranksum test for matched pairs, p<0.05 was considered significant. Data from specific time (5 min after intubation, 5 min before clamping; 5, 10 and 15 min after clamping, before declamping and 5 and 10 min after declamping and at the end of surgery) were calculated. In addition to absolute values, we compared the measured V˙O2 and V˙CO2 to baseline (5 min before clamping=MP2). Results. Mean operating time was 139 min±37; aortic cross-clamping time for the first extremity was 38 min and 55 min for the second. As expected, there was a significant decrease in V˙O2 (90% of baseline) and V˙CO2 (75% of baseline) during aortic cross-clamping. After declamping V˙O2 again rose to 110% of baseline, or to 103% for the second limb. V˙CO2 increased to only 90% and 82%, respectively. At the end of surgery V˙O2 reached baseline, whereas V˙CO2 remains at 83%. The respiratory quotient V˙CO2: V˙O2 was markedly reduced from 0.95±0.156 to 0.73±0.06 during surgery. The Deltatrac® showed every change in V˙O2 without delay; changes in V˙CO2 seem to occur somewhat retarded. Discussion. Aortic cross-clamping leads to a marked decrease in V˙O2 and V˙CO2 reflecting the temporary reduction in whole-body metabolism. Declamping results in a compensatory rise, especially in V˙O2. V˙CO2 seems to increase less after declamping, perhaps due to the CO2 pool of the organism or to a change in metabolism from carbohydrate to mainly fat oxidation.The results of this study demonstrate that indirect calorimetry can easily be performed during anaesthesia and surgery. Preconditions are a non-rebreathing system without airleak, constant FiO2<0.6 and no use of nitrous oxide.