Vascular surgery最新文献

Fifteen cases who have had myocardial infarction with aneurysm formation or severe scarring of the left ventricle as a result of occlusion of left anterior descending coronary artery are presented. Bypass to left anterior descending coronary artery using internal mammary artery or saphenous vein was done in all of these patients. Ten of these had plication or excision of the left ventricular aneurysm. All of them survived the operation and are doing well. Early results in this series of patients indicate that left anterior descending coronary artery bypass in these patients is of great value by allowing perfusion to patent brances of left anterior descending coronary artery.

Eighty-six popliteal aneurysms in 52 patients have become limb threatening. Popliteal aneurysms should be sought for and when found elective replacement should be considered.

In order to learn about some possible reasons for the low proportion of women among the patients with aortocoronary bypass operation (12-20%) we have compared the prevalence of hypertension, hyperlipidemia, history of smoking and chest pain in 110 women and 813 men with this surgical intervention. In spite of the similar or even higher prevalence of abnormal risk factors, the women patients showed less extensive coronary artery impairment than the male patients indicating their higher tolerance of the risk factors and lesser need for the bypass operation.

A rather long and extensive experience with tissue reconstruction in patients with mitral valve disease, and a much less extensive one with oartic lesions, has convinced us of the superiority of the presented techniques of reconstruction, and of the preferability of fascia lata over all other tissues so far tried for this purpose. Despite an early increment of shrinkage of the order of about 30% of each linear measurement, late studies of fascia lata removed from reconstructed valves after several years (over five) indicate no loss of cellularity and no measurable loss of tissue strength or flexibility. Late calcification was not observed in any of our baboons, although it appears to be a consistent development in dogs. It has been seen in only one patient (after four years) to date. It is now believed that we can offer prolonged clinical benefit approaching actural "cure" to many of the younger patients who otherwise would have no recourse but to prosthetic palliation. It is true that recently Willen, Dubiel and Johansson (50, 51), Gersbach and Wegmann (52), and Senning and Rothlin (53) have demonstrated that repetitive deposits of fibrin upon the surfaces of fascia lata implanted within the cardiovascular chambers lead to progressive encapsulation with organizing connective tissue (scar). At some time period following surgery, closer to 10 years than to 5, degeneration of the fascia takes place, presumably due to "strangulation" by the organized exudate which interrupts the "normal" mechanism of its nutrition which is based upon diffusion from the flowing blood. The recent contributions of Sullivan, Harken and Gorlin (54), Weily and Genton (55), and Harker and Slicter (56) to our understanding of the role of the platelets in initiating such fibrinous deposition now provide us with a way to prevent such late degeneration of valves made of fascia lata. The regular administration of platelet dispersing agents (aspirin, Persantin, or inderol) in ordinary therapeutic dosage would seem to be completely protective. Undoubtedly, anticoagulant therapy would be equally effective. However, the permanent maintenance of a proper level of "anti-coagulation" such as is usually deemed necessary following implantation of a prosthetic heart valve is a heavy psychological and biological burden for a patient to bear. Many such individuals live precariously between the risks of thromboembolism and the risks of hemorrhage. Thromboembolism really only represents a farther point along the spectrum of the readiness of fibrin accumulation following initial platelet aggregation and deposition. Since frank thromboembolism appears "never" to follow intracardiac implantation of fascia lata, it would seem that platelet dispersive therapy sould suffice in such cases.

A patient with ventricular septal defect and pulmonary arterial hypertension (Eisenmenger's syndrome) associated with aortic coarctation with follow-up for 19 years, and with rupture of an aneurysmatic pulmonary artery is described. An incident of extreme fright with a possible transient systemic hypertension may have precipitated the dissection of the pulmonary arterial intima and the rupture.

Ten pairs of mongrel dogs had bilateral femoral artery reconstruction using the femoral veins from the other of each pair. Four grafts failed in the first two weeks and 16 grafts failed in pairs within two to four weeks of each other up to 15 months. Five dogs died with patent grafts between 15 and 42 months and five dogs were sacrificed at 42 months with patent grafts. Aneurysmal degeneration did not occur. Normal architecture of the vein was destroyed by fibrous replacement, but a few smooth muscle cells and adventitial elastic fibers persisted. Gross and microscopic mural thrombi were present in half the grafts indicating continued endothelial instability at 42 months. Osseous metaplasia was found in five grafts. Allogenic vein is an acceptable substitute when autogenous vein is lacking for femorotibial bypass and urgent femoropopliteal bypass.

50 consecutive patients undergone open heart surgery were analyzed regarding postoperative arrhythmias in the first postoperative 3 days. Disturbances of rhythm occurred in each case of our group, serious or not serious (100%). Ventricular premature beats were the most frequent type of arrhythmia in the first and second postoperative days (80%). Two cases expired postoperatively. In one of them complete atrioventricular block developed after double valvular replacements (mitral and tricuspid). The other died of low cardiac output syndrome. Etiology of the arrhythmias after open heart surgery is not clear in the absence of electrolyte and metabolic disturbances, digitalis intoxication and surgical trauma to the conduction system and coronary arteries. Low cardiac output syndrome, hypotension and hypoxia can also be blamed in the formation of these arrhythmias. Other factors such as the prolongation of anoxic arrest, irritation of the ventricular septum by valvular prostheses, cardiac irritation by thoracic tubes, psychologic trauma, halothane anesthesia and coronary arterial disease in the old age group may be the possible predisposing factors in these patients.