Vascular

The development of open-heart surgery has been reviewed beginning with general body hypothermia and inflow stasis, then continuing with extracorporeal circulation by controlled cross-circulation. The successes with the latter technique stimulated rapid development of the simple disposable highly effective bubble oxygenator for extracorporeal circulation to permit correction of virtually all forms of congenital and acquired heart disease. For the few conditions not amenable to corrective procedures, heart replacement became a practical reality. The creation of chronic heart block in the early operations had a very deleterious effect upon survival until highly effective electrical pacing was developed.

Fifteen patients of mean age 65 years underwent simultaneous coronary artery bypass grafting and abdominal aortic aneurysm repair between 1988 and 1992. Of these 13 had coexistent angina and two had symptomless coronary artery disease detected by preoperative dipyridamole thallium scanning or exercise stress testing. All patients had significant coronary artery disease on coronary angiography. Coronary artery bypass grafting was performed first, with a median number of grafts of 4, a median aortic cross-clamp time of 39 min and a median bypass time of 74 min. Abdominal aortic aneurysm repair followed with a median aortic clamp time of 66 min. Six straight and nine bifurcated grafts were inserted. The median total operating time was 395 min. All patients were managed postoperatively in the cardiothoracic intensive care unit with a median duration of 5 days. The median total hospitalization was 14 days. One patient died of non-cardiac causes; hence the mortality rate was 6.7%. The authors' experience suggests that combined coronary artery bypass grafting and abdominal aortic aneurysm repair is feasible in carefully selected patients.

Between February 1991 and October 1991, vena cava filters made of Vascor (Toulon. France) were inserted into 51 patients. The male:female ratio was 29:22 and mean age 74 (range 45–94) years. Diagnosis of thrombophlebitis was established by venography in 48 patients (94%) and ultrasonography in three (6%). Thrombosis was unilateral in 49 patients and bilateral in two, involved the pelvic veins in 38 (75%) and the leg veins in 13 (25%). Of the 51 patients, 17 (33%) presented pulmonary emboli and 12 (24%) had waving supracrural clots. The Vascor umbrella filter is a two-stage stainless-steel device with attachment tabs for anchoring and centring. It can be placed either percutaneously using a 7-gauge French introducer via the jugular, subclavian or brachial vein or surgically. In the present series, placement was achieved percutaneously via the jugular vein, in 49 cases (96%) and surgically in two (4%). Postoperative and follow-up examinations included coagulation tests, Doppler ultrasonography and abdominal radiography. In the immediate postoperative period, one patient developed a pneumothorax which was treated by pleural drainage and five died from cancer within the first month after placement. There were no postoperative accidents and no patient had recurrent embolism. In three patients, the filter tilted 30° and in one caval thrombosis was identified. Follow-up examinations were performed in 46 patients, with a mean duration of 12 months. Ten patients have died. Caval thrombosis occurred in two patients (4%) but proximal migration of the filter and recurrence of pulmonary embolism have not been observed.

Five cases of cerebrovascular accident or transient ischaemia in young adults resulting from segmental mediolytic arteriopathy are reported. The aetiology of segmental mediolytic arteriopathy is unknown but the disorder is characterized by focal, non-inflammatory mucoid degeneration of the media of muscular, non-arteriosclerotic arteries, frequently involving cerebral intracranial or extracranial vessels. It is similar to Erdheim—Gsell's medionecrosis of the aorta and may occur in any muscular artery. The consequences are mostly fatal in cerebral arteries. Histological analysis of each case is described. Clinicians should be aware of the possibility of intramural haemorrhage and dissecting aneurysm as a result of mucoid degeneration of the arterial media in young adults with cerebrovascular accident.

Vibration white finger is a vasospastic disorder caused by long-term exposure to vibration tools. In an attempt to assess the extent of obliterative vessel disease in this disorder, hyperaemic hand blood flow was measured using technetium-labelled human albumin and a γ camera. This method quantitates blood flow in ml/100ml of tissue per min in addition to providing a perfusion image used to assess vessel disease. A perfusion score is then given to this image to reflect the extent of disease. The results of this study demonstrate that 78% of patients with vibration white finger had evidence of organic vessel disease. Moreover, patients with advanced disease tend to be bilaterally affected. The use of this simple method is advocated to aid in the diagnosis of vibration white finger; this may be particularly important for medicolegal purposes.

The experience is reported with 50 vertebral fistulas treated by the authors in a joint radiological and surgical team. Of the 28 fistulas that were traumatic, 18 occurred after incidental iatrogenic puncture, and 22 were spontaneous, of which four presented in patients displaying angiographic features of fibromuscular dysplasia. Eleven patients were operated on and 33 had endovascular treatment. In nine patients who were either symptom-free or in poor health, no treatment was advised. The fistula was occluded in 38 (93%) of the treated patients, and the vertebral artery patency was preserved in 32 (78%). A total of 224 published cases were reviewed: 152 were traumatic, most after a penetrating injury; 72 were spontaneous, with three age peaks (at 7.26 and 52 years). Treatment has evolved considerably and endovascular occlusion is now the treatment of choice, surgery being reserved for specific indications.

Some 1257 patients who had undergone revascularization procedures for unilateral iliac occlusions were reviewed retrospectively. A total of 824 patients were operated upon using conventional operations, 165 patients had femorofemoral bypass and 268 were treated using endovascular surgery techniques. Revascularization was performed through an extraperitoneal approach by means of iliac thromboendarterectomy (560) or iliac femoral bypass (264) if there was a total occlusion of either the common or external iliac artery (group 1). A femorofemoral crossover bypass was inserted when the operative risk was considered to be high (group 2). Endovascular procedures (percutaneous transluminal angioplasty 234, laser percutaneous transluminal angioplasty 11, stenting 22, atherectomy one) were used in recent years to treat stenoses or occlusions of 3 cm or less (group 3). The indications for operation were severe claudication in 79.7% in group 1 and 92.6% in group 3, whereas in group 2 66.7% of patients presented with symptoms of more advanced ischaemia. The immediate patency rate was 97.0% after extraperitoneal reconstructive surgery. 96.9% in the femorofemoral group and 92.1% in patients having an endovascular procedure. The operative mortality rate was 0.7, 4.2 and 0.3% for groups 1–3. respectively. The 5-year patency rate, analysed by the life-table method, was 77.9% in group 1, 75.3% in group 2 and 73.7% in group 3 (P= n.s., log rank test) The different revascularization techniques were chosen on the basis of the type of disease present and the patient's general condition. All procedures appeared to be effective when correctly selected.

The protective effect of a one-shot infusion of a range of low-temperature hypothermic solutions against spinal cord ischaemia was investigated. Forty rabbits were allocated into five groups each of eight animals. The abdominal aorta of each rabbit was clamped distal to the left renal artery, and also occluded for 30 min above the iliac bifurcation with an inflated 50-gauge French balloon catheter. Ringer's solution with lactate was infused through the catheter port distal to the balloon, at various temperatures (group I, uninfused control; group II, 33°C; group III, 23°C; group IV. 13°C; and group V. 3°C). The neurological status of the hind limbs was assessed on the second postoperative day using the criteria of Tarlov. A further eight rabbits underwent laminectomy at L2 or L3. Temperature probes were inserted into the spinal cord and the cord temperature monitored continuously during infusion in four rabbits from each of groups I and V. Spastic paraplegia occurred in five rabbits in group I, three in group II, and two in group III. Four rabbits in groups II and III, seven in group IV and all eight in group V showed complete recovery of neurological function. The infusion of 3°C solution achieved significantly lower spinal cord temperatures in group V after aortic clamping, compared with the temperatures in group I (P< 0.001–0.005). It was concluded that protection against spinal cord ischaemia and prevention of postoperative paraplegia are promoted as the temperature of the hypothermic infusion solution is lowered.

Vascular complications of Behçet's disease particularly affect the venous system. Arterial lesions include thrombosis and aneurysms. There are few reports of aortic involvement, usually of the abdominal aorta. Aortic arch involvement has not been reported previously. A patient with Behçet's disease who developed an aortic aneurysm involving the ascending aorta to the hiatus with massive incompetence of the aortic valve is described.

Non-traumatic arterial aneurysms in childhood are very uncommon and are usually associated with inflammatory or degenerative conditions. A case of idiopathic true aneurysm occurring in one popliteal artery of a 14-year-old girl is described. Geniculate artery branches arose from the sac and histological examination confirmed that it was a true aneurysm. Successful treatment by the insertion of a reversed vein graft was confirmed by follow-up years after the operation.

In order to determine the tightness of the pulmonary artery band, Doppler echocardiography is used to assess mitral valve flow velocity, which is an indirect indicator of pulmonary blood flow. The band is tightened until the velocity decreases to 70% of the original maximal level. Additional adjustment of the constriction is then made to obtain reasonable arterial oxygen saturation, heart rate and ventricular contractility. Using this method, 12 consecutive patients underwent pulmonary artery banding with satisfactory results. This technique is simple but useful in obtaining optimum constriction of the pulmonary artery in congenital heart disease with excessive pulmonary blood flow.

Atrial fibrillation following coronary artery surgery is common, especially in elderly patients but despite numerous studies its pathophysiological basis is still incompletely understood. It is usually benign and self-limiting, but may be associated with haemodynamic compromise, prolonged hospitalization and embolic stroke. No risk factors (apart from age and preoperative (β-blocker withdrawal) have been shown to be associated with its occurrence. Conventional treatment is usually effective but no prophylactic regime has been identified. Until such a regime is found the incidence of atrial fibrillation following myocardial revascularization may only be reduced by continuing treatment in patients on β-blockers in the preoperative period and re-establishing this therapy after surgery.

Leakage around the coronary ostia continues to be the major complication of composite graft replacement of the ascending aorta and aortic valve. To reinforce coronary anastomosis and reduce the operating time, a new modification of the Bentall operation was developed. This procedure involves dissecting full-thickness coronary buttons while leaving the epicardium on the aortic wall and complete wrap of the composite graft by the tailored aortic wall (Carrel patch and inclusion technique). Since March 1983, this approach has been performed in 12 patients (group A) and other Bentall-type operations in 22 (group B). Time affected by haemostasis was 28min less in group A than in B (P = 0.23). Blood loss and blood transfusion during surgery and hospitalization were significantly lower in group A than B. Significantly less leakage occurred in group A than in B. On the basis of these short-term results, the Carrel patch and inclusion technique is considered to be an accurate time- and blood-saving procedure.

Of a total of 133 patients who underwent heart transplantation, 16(12%) had pericardial and mediastinal complications. Non-infectious pericardial complications, pericardial effusion and constriction were noted in ten patients, and infectious pericarditis or mediastinitis in six. Cardiac echocardiography, catheterization and magnetic resonance imaging were useful in assessing these problems. All patients underwent surgical treatment, pericardial drainage, pericardectomy or muscle flap closure. Twelve (75%) of these 16 patients are long-term survivors. In conclusion, pericardial and mediastinal complications are common after heart transplantation, and aggressive surgical treatment is most often effective in their control.

Silent ischaemia, defined as ST-depression ≥ 1 mm without chest pain, was found on exercise testing in 22 (10.7%) of 206 patients who underwent aortocoronary bypass surgery in the period from March 1983 to November 1985. Exercise testing was performed 4.9 (range 3.6–6.7) years after operation on an electrically braked bicycle. Sixteen of the 22 patients were free from chest pain, while the remaining six had slight to moderate angina pectoris on exercise. Coronary angiography was performed in 21 patients with silent ischaemia; one of the 22 patients died before this investigation. Some 13 patients had one or more occluded grafts, one a new stenosis in a native vessel and five incomplete myocardial revascularization. For the remaining two patients, no aetiology for the ischaemia was found, and revascularization appeared to be complete. Before surgery, 13 patients had three-vessel disease, six two-vessel disease and three one-vessel disease. At follow-up, two patients had three-vessel disease, ten two-vessel disease and seven one-vessel disease. The value of identifying patients with silent ischaemia after aortocoronary bypass surgery with regard to life expectancy and quality is controversial. Subsets of patients, namely, those with main-stem stenosis and three-vessel disease, may benefit from secondary operation. Identification of these patients may therefore be of clinical importance.

Acute intermittent postoperative block of mechanical prostheses is a rare and life-threatening complication; its incidence and treatment are not well defined. Between January 1975 and June 1991, 2839 mechanical prostheses were implanted using the same technique: mattress suture for mitral valve replacement and simple suture for aortic valve replacement. Prosthetic block occurred in eight patients: four following mitral valve replacement and four after aortic valve replacement. The blocked prosthesis was always a tilting disc valve (five Sorin, two Björk—Shiley and one Medtronic). The event occurred over a time interval of 6–48h (mean(s.d.) 17.3 (15.6)h). All patients having mitral valve replacement needed emergency prosthetic replacement. In aortic valve replacement, reoperation was necessary in two patients; the disc block disappeared in the others. All patients are alive with a follow-up ranging between 3 and 168 (mean 32.5) months. No structural failure was found in explanted prostheses leading to a diagnosis of extrinsic block. The overall incidence of this complication was 0.28% (eight of 2839); 0.24% (four of 1645) for mitral valve replacement and 0.33% (four of 1194) for aortic valve replacement respectively (n.s.). It was exclusively related to tilting disc valves (0.44%; eight of 1830) versus ball and bileaflets valve (0 of 1009). In mitral valve replacement reoperation on patients is mandatory; in aortic valve replacement patients the left ventricular pressure itself can overcome the prosthetic block. Attention should be paid to valve excision and suture technique as tilting disc prostheses are more vulnerable to extrinsic block. Furthermore, their use is contraindicated in redo operations and mitral valve replacement with total or partial preservation of mitral apparatus.

From May 1990 to August 1993, 100 patients underwent aortic valve replacement using the stentless porcine aortic valve. There were 69 males and 31 females. The mean age was 36 (range 11–76) years. Of 70 patients under 40 years of age, 20 were less than 20 years old. Indications included rheumatic heart sequelae in 55 patients (first valve replacement), prosthetic failure in 20, endocarditis in 13, congenital aortic bicuspid valve in four, degenerative disease in four and senile calcified aortic valves in four. Twenty patients had aortic annular related pathology. There were 15 associated surgical procedures. Forty-three patients required aortic root enlargement. There were approximately equal numbers of patients in New York Heart Association (NYHA) functional classes III and IV. The hospital mortality rate was 6%; 14 patients who experienced hospital morbidity had a full recovery. Two late reoperations were performed in patients with primary valve endocarditis; their recovery was uneventful. Four late deaths were not valve related. Comparative echo Doppler analysis before and after operation demonstrated good improvement of left ventricular function in nearly all patients. The valve was competent in 96% of patients and the remainder displayed minor jets without haemodynamic significance. The valve coaptation was stable in all patients. Use of the stentless porcine aortic valve in this first 100 patients has provided excellent clinical results with a follow-up of 41 months. Further follow-up and close observation will be required to analyse the outcome of this new valve and procedure with time.

A 70-year-old man presented with severe angina pectoris caused by critical stenosis of the left anterior descending coronary artery 11 years after mediastinal radiation therapy, esophagectomy and substernal colon interposition for squamous cell carcinoma of the esophagus. Coronary artery bypass was performed through a left thoracotomy using the left internal mammary artery with profound hypothermia. This uncommon approach to an unusual case is described here.

The case of a 13-year-old boy with a tricuspid valve myxoma and coronary artery occlusion and aneurysms suspected to be caused by Kawasaki's disease is presented. Simultaneous extirpation of the myxoma and coronary artery bypass grafting to the left anterior descending artery using the left internal mammary artery was performed. His postoperative course was satisfactory. Coronary artery bypass grafting in a child is also discussed.

Cardiac sarcoid is a disease of young adults. Arrhythmias or sudden death may be the first manifestation of cardiac sarcoidosis. Consideration for cardiac sarcoid should be given to all young patients with arrhythmias, heart failure, or episodes of sudden death. Surgical intervention may be warranted in patients with symptomatic cardiac sarcoid because of poor response to current medical therapy.

Papillary fibroelastoma is rare but one of the most common benign primary cardiac tumors after myxoma. This lesion may be associated with embolization, angina and sudden death. The incidental finding of a small pedunculated papillary fibroelastoma arising from the atrial septum detected by transesophageal two-dimensional echocardiography (TEE) in a patient undergoing coronary artery bypass grafting is reported. The advantage of TEE in diagnosing intracardiac tumors is also described.