Thoraxchirurgie, vaskulare Chirurgie最新文献

The experience with the Ionescu-Shiley pericardial xenograft used for heart valve replacement over a period of 7 years has demonstrated, in both the aortic and atrioventricular position, excellent long term clinical and haemodynamic results. There were very few valve related complications and none occurred with valves manufactured since May 1976 by Shiley Laboratories. The long term durability of the glutaraldehyde stabilised pericardial xenografts was demonstrated by a rigorous and complete clinical follow-up as well as by histological and haemodynamic investigations. Valve thrombosis or calcification have not been encountered in this series. The embolic rate has been very low in both the aortic and mitral positions in the absence of long term anticoagulant treatment. The superior haemodynamic performance of this valve, even in very small sizes, represents an additional advantage and makes it particularly suitable for use in patients with narrow aortic root and in children. The very good results obtained with the pericardial xenograft fully justify its continued clinical use in the aortic, mitral and tricuspid positions.

Six patients with traumatic flail chest underwent surgical stabilization using a procedure introduced by Brunner, Hoffmeister and Koncz (2). Compared with internal stabilization by intermittend positive pressure respiration (IPPR), there are some advantages: Time of artificial respiration is shortened, early mobilization is possible, nursing is easier. The procedure is simple to do and is indicated in those patients, in whom longterm artificial respiration is not necessary for other reasons.

A method for stabilization of flail chest is described. A row of pericostal chromic catgut sutures is placed from the pleural surface using a probe as ligature carrier.

45 pulmonary embolectomies have been carried out successfully, 10 by Trendelenburg's procedure, 35 with extracorporeal circulation. The latter method gives satisfactory results (34 survivals out of 36 attempts since 1970) and appears to be the procedure of choice. Any pulmonary trauma should be avoided at operation; embolectomy is done by intra-vascular suction. The hemodynamic status was always abnormal: 5 initial cardiac arrests, 20 cases of severe shock (9 demonstrating cardiac arrest on the operating table) and 11 cases with less severe shock. In 9 cases cyanosis, respiratory distress and signs of acute cor pulmonale were the clinical features of the massive embolus. In 9 patients the operation was performed after an unsuccessful trial of thrombolysis. Preoperative pulmonary angiography could be performed in 30 cases and always showed extensive pulmonary vascular obstruction of 60 to 95 per cent. These data are important for diagnosis and for assessment of the prognosis. Despite of present medical treatment with fibrinolytics, surgery is still advisable in the treatment of massive pulmonary embolism. The indications are moribund patients, those in whom thrombolysis is contraindicated or unsuccessful and those with massive pulmonary obstruction (greater than 60 per cent). In this latter subset thrombolytic therapy carries a high level of mortality.

Comparative study of 2,168 revascularizations and 221 limb amputations at the surgical hospital of Fürth/Bavaria (1970--1977). The lethality rate after arterial reconstructions in older patients, depending on the type of revascularization, was 3.3 per cent up to 21.1 per cent, being considerably lower than after amputation after which 42.5 per cent of the patients died. Therefore vascular surgery should be considered at an early stage of the disease in older patients with problems of circulation, particularly before any limb amputation.

In 12 mongrel dogs tracheal defects of different size were covered by bovine xenografts. The grafts were subjected to electronmicroscopic examination 2 to 19 months after implantation. Following the ingrowht of fibroblasts and capillaries a basal membrane is formed on the side of the previous graft lumen. After 4 to 5 months this membrane is covered from the tracheal margins by microvillous cells. After 8 months ciliated epithelia and goblet cells are developed by cell metaplasia. Although the graft becomes revitalized and integrated into the tracheal wall, the layer of ciliated epithelia is interrupted by less differentiated cells. The possible causes for this phenomenon are discussed. Thus bovine xenograft used for the repair of tracheal defects has the following advantages: total revitalization, no shrinkage, less prone to infection and formations of ciliated epithelia.

In 16 mongrel dogs bovine xenografts of 4 to 12 cm of length were used for arterial replacement. The grafts were removed after 30 minutes and up to 13 months for electronmicroscopic examination. The graft was shown to be significantly thrombogenic during the first six weeks after implantation. After 8 to 10 weeks an increasing revitalization of the graft is found starting from the ends of the canine artery. A cover of endothelial cells is formed in the graft lumen. The graft wall is enforced by formation of collagen and elastic fibers originating from capillaries and fibroblasts. Revitalization of the graft is limited to a rim of 2 to 3,5 cm next to the anastomoses with the canine artery. The remaining graft segment shows revitalization only on the outside wall. Degenerative changes take place in the inner layer of the graft with time passing.

Between 1973 and 1977 we performed 106 venous thrombectomies. 100 of these cases showed occlusion in the ilio-femoral area and 6 in the axillary area. The postoperative mortality was 2 per cent in pelvic thrombosis and 0 per cent in the Paget-von-Schroetter-Syndrome. Fatal pulmonary embolism did not occur. Seventy per cent of patients were free of complaints 6 months postoperatively. Best results were achieved by early operation. The Paget-von-Schroetter-Syndrome is frequently caused by a thoracic outlet syndrome. Therefore, the first rib has to be removed during the second operation in order to prevent recurrence.

A collective of 56 female and 54 male patients between 15 and 78 years were operated to prevent pulmonary embolism. 27 umbrella filters and 83 vena cava clips were implanted. Postoperative mortality was 15 per cent after umbrella filter implantation as compared to 0 per cent after clip application. 35 clip and 9 filter implantations were followed up by cavographic examination. Venograms were classified in three types according to caval patency. A significantly higher number of complications were observed after filter implantation. On the basis of a flow physics hypothesis an explanation is suggested for the liability to caval thrombosis after filter implantation. An evaluation of both operative methods and their indications is given.