William H. Brown

The cell-saver and autologous transfusion: An underutilized resource in vascular surgery

The vascular surgeons best resource for blood transfusion is the patients own blood. It is readily available for recycling, already precisely typed and crossmatched, and without the risk of transfusion-related diseases such as hepatitis and AIDS. The relative ease, safety, and cost-effectiveness of autologous blood transfusions, intraoperative autotransfusions, and postoperative autotransfusions has been shown in our hospital experience with 320 cases and in the literature. We predict that autologous donor blood and autotransfusion will soon be widely accepted and utilized as the best and safest method of blood replacement.

Coagulopathy associated with peritoneovenous shunting

Le Veen shunts successfully alleviated ascites in 19 of 24 patients (79 percent). Clinical clotting typical of disseminated intravenous coagulation occurred in nine of these patients (37 percent) and was fatal in seven (78 percent). Laboratory findings suggesting disseminated intravenous clotting were present in five other patients (21 percent) but were not associated with troublesome bleeding. Coagulopathy was reversed in 7 of 14 patients (50 percent), if the shunt was ligated and supportive measures were taken early in the postoperative course. Failure to recognize or take immediate action resulted in progressive disseminated intravenous clotting associated with a mortality of 50 percent (7 of 14 patients).

Value of postoperative heparin therapy in peripheral arterial thromboembolism

The experience with 359 patients with arterial thromboembolism from 1963 to 1982 has been reported. Combined operative and anticoagulant therapy appears the most beneficial form of treatment. Treatment with heparin after catheter embolectomy was associated with a decrease in mortality (7.6 percent), number of amputations (5 percent), and recurrent emboli (6 percent). Serious wound complications occurred less frequently than anticipated (8 percent). We advocate prompt arteriography and revascularization procedures to ensure long-term limb function after initial embolectomy for salvage, if the result is less than optimal or expected. Postoperative heparin seems to buy time in marginal cases, enabling secondary operations to ensure a satisfactory outcome in most patients.

Management of deep venous thrombosis and pulmonary embolism during pregnancy.

Despite venous stasis and a hypercoagulable state during pregnancy, the reported incidences of deep venous thrombosis and pulmonary embolism are remarkably low, about 1 in 2,000 and 1 in 10,000 cases, respectively. Mortality from antepartum thromboembolism has been reported in about 15 percent of untreated patients and less than 1 percent of treated patients. Adequate anticoagulant therapy significantly reduces maternal mortality and decreases postpartum morbidity. The proper anticoagulant agent for use during pregnancy has been widely debated. Coumarin compounds pass through the placenta and into the fetus. Hemorrhagic complications in the fetus are uncommon if prothrombin times are carefully controlled and if the drug is discontinued before delivery. However, coumarin during the first trimester has the teratogenic hazard of producing chondrodysplasia punctata. Heparin, in contrast, does not cross the placental barrier and is considered more effective treatment for deep venous thrombosis; however, long-term intravenous administration during pregnancy has been considered both impractical and possibly hazardous due to the risk of osteoporosis after 6 months of therapy. In our study, a combined regimen of intravenous and subcutaneous heparin was used successfully in four women with deep venous thrombosis. One patient who had recurrent embolization while on adequate intravenous heparin underwent vena caval clipping and had an uneventful Cesarian section at term with a normal infant. Another patient also underwent Caesarian section with a normal infant, while the other two women had normal vaginal deliveries at term. Miniheparin therapy was continued for 3 months postpartum, followed by long-term aspirin and Ascriptin therapy. Carefully controlled heparin therapy in a pregnant woman with deep venous thrombosis both safe and beneficial for mother and fetus.