Inferior vena cava interruption with the Hunter-Sessions balloon: eighteen years' experience in 191 cases.

Over a period of 18 years, 191 consecutive patients had interruption of the inferior vena cava with the Hunter-Sessions balloon for complications of deep venous thrombosis and pulmonary embolism. Causes of deep venous thrombosis and pulmonary embolism included the postoperative state (33%), cancer (32%), and stroke (11%). There were 93 females and 98 males; ages ranged from 17 to 90 years (average, 57 years). Indications for placement of the Hunter-Sessions balloon were as follows: contraindication to anticoagulants (33%), anticoagulant complications (24%), pulmonary embolism despite anticoagulants (45%), and others including inferior vena cava thrombus (12%). Sixty-eight percent had clinical phlebitis and 36% had positive venography results. Pulmonary embolism had occurred in 165 patients (86%). It was diagnosed by ventilation-perfusion scanning (75%), angiography (23%), or on clinical grounds (2%) in patients with confirmed deep venous thrombosis. At the time of the procedure 52% were in significant cardiopulmonary distress, and 10% were intubated and on respirators. Transjugular placement was done in 188 patients, and transfemoral placement was performed in three. All All tolerated inferior vena cava interruption. Thirty patients (15%) died while in the hospital an average of 21 days after balloon placement, which was unrelated to the deaths. Follow-up was 45 months. Ninety-four patients are dead, 95 are alive, and the status of two patients is unknown. Twenty-nine of 64 patients (45%) who died after they left the hospital died of cancer. At last follow-up, 75% of patients had legs free of edema and 25% had need for elastic stockings. No malfunction or migration has occurred with the device. No patient had a pulmonary embolism while in the hospital after insertion of the Hunter-Sessions balloon, and no patient died of pulmonary embolism. Late minor pulmonary embolism occurred in three patients.

Does choice of anesthetic agent significantly affect outcome after coronary artery surgery?

A prospective study of 1094 consecutive adult patients undergoing coronary revascularization was undertaken to determine the effect of anesthetic technique on outcome. Patients received one of five primary techniques: high-dose fentanyl (greater than 50 micrograms/kg), moderate-dose fentanyl (less than 50 micrograms/kg), sufentanil (3-8 micrograms/kg), diazepam (0.4-1 mg/kg) with ketamine (3-6 mg/kg) or halothane (0.5-2.5% inspired concentration after thiopental induction). Supplemental inhalation anesthesia (enflurane, halothane, or isoflurane) was used in 60% of cases where the primary technique was intravenous based. Patients in the above anesthetic groupings had similar perioperative demographic and risk classifications. The overall incidence of postoperative myocardial infarction, postoperative low cardiac output state, and in-hospital death were 4.1, 5.6, and 3.1%, respectively. There were no significant differences in the incidence of these occurrences or in the incidence of serious pulmonary, renal, or neurologic morbidity or length of ICU stay among primary anesthetic techniques nor among supplemental inhalation agent groups. Multivariate discriminant analysis of this data suggests that a multitude of factors are significantly more important than anesthetic technique as determinants of outcome after coronary artery surgery.

Effect of pulmonary artery catheterization on outcome in patients undergoing coronary artery surgery.

Previous studies have suggested that low-risk cardiac surgical patients may be safely managed without pulmonary artery catheterization (PAC). However, no prospective studies have determined whether PAC improves outcome in higher risk patients compared with that following central venous pressure (CVP) monitoring alone. The authors prospectively examined the incidence of and factors related to perioperative morbidity and mortality in 1094 consecutive patients undergoing coronary artery surgery managed with elective PAC (n = 537) or with CVP (n = 557). Perioperative risk factors and demographics that predict morbidity and mortality after cardiac surgery were used to quantify risk classification. Outcome was judged by length of ICU stay, occurrence of postoperative myocardial infarction, in-hospital death, major hemodynamic aberrations, and significant noncardiac systemic complications. No significant differences in any outcome variables were noted in any group of patients with similar quantitative risk classification managed with or without PAC, including those in the highest risk class. In addition, there were no significant differences in outcome among the 39 patients who would have been managed with CVP monitoring only, but who subsequently developed a clinical need for PAC based on the occurrence of serious hemodynamic events compared to patients who had PAC performed electively. This study suggests that PAC does not play a major role in influencing outcome after cardiac surgery, that even high-risk cardiac surgical patients may be safely managed without routine PAC, and that delaying PAC until a clinical need develops does not significantly alter outcome, but may have an important impact on cost savings.

Coagulation monitoring in the surgical intensive care unit.

This article reviews the basic coagulation mechanism and how it has routinely been monitored. It points out some common perceptual pitfalls clinicians encounter when thinking about these tests. New horizons in perioperative hypocoagulability monitoring techniques are presented. Methods of evaluating and charting therapeutic progress for venous and arterial thrombotic diseases are also reviewed.

Extrapleural pneumonectomy for diffuse, malignant mesothelioma.

Extrapleural pneumonectomy for malignant mesothelioma is a radical procedure that entails en bloc removal of the parietal pleura, lung, pericardium, and diaphragm. Minimal tumor remains after this procedure; palliation and occasional long-term survival may be achieved in properly selected patients. Extrapleural pneumonectomy for diffuse, malignant mesothelioma was done in 33 patients (27 male and 6 female) with 18 procedures on the left side and 15 on the right. There was a history of exposure to asbestos in 16 (48%) of the patients. Histological classification revealed that 20 tumors were epithelial, 10 were mixed, and 3 were sarcomatous. Good palliation, defined as survival for 24 months with a return to fairly normal activities, was obtained in 8 patients (24%) and survival for 36 months was achieved in 5 patients. Three patients died of the disease at 59 months, 60 months, and 82 months. There were 3 operative deaths (9.1%), and serious postoperative complications occurred in 8 patients (24%). Postoperative adjunctive therapy consisting of chemotherapy or irradiation or both was given to approximately one-half of the patients. These findings indicate that extrapleural pneumonectomy for malignant mesothelioma can be done with an acceptable morbidity and mortality. Palliation is achieved in 24% of patients, and there may be an occasional long-term survivor.

Aortopulmonary fistula in a post-coarctation mycotic aneurysm.

A 21-year-old man presented with fever and septicemia resistant to antibiotic therapy. An unusual post-coarctation mycotic aortic aneurysm that had eroded into the left main stem bronchus was identified and replaced with a Dacron graft. A critical factor in achieving the satisfactory result was preparation of the femoral vessels for autotransfusion and possible cardiopulmonary bypass.

Management of penetrating wounds of the back and flank.

The results of a retrospective and prospective study of patients with penetrating wounds of the back and flank showed that physical examination alone was accurate in 72 and 83 per cent, respectively. The inaccuracy was primarily due to false-negative examinations. The most commonly injured organs were the liver and kidney. The presence of gross hematuria and intravenous pyelography proved to have an accuracy rate of 95 per cent in patients studied prospectively. Peritoneal lavage, although similarly accurate (95 per cent), was associated with a 10 per cent false-negative result when the wound was located in the back. Guidelines for the management of these patients include hospital admission, careful physical examination, urinalysis by dipstick and cell count, intravenous pyelography and peritoneal lavage. Initial hypotension usually is associated with visceral injury and is an indication for exploratory laparotomy. Strict adherence to these guidelines was associated with a negative exploration rate of less than 10 per cent and a decrease in the number of patients observed with visceral injury from 50 to 6 per cent.

Limited success of lumbar sympathectomy in the prevention of ischemic limb loss in diabetic patients.

The results of 93 consecutive lumbar sympathectomies performed over a five year period upon 54 patients with diabetes and 39 without diabetes were compared in terms of subsequent amputation using life table analysis methods. Cumulative success rates for avoiding amputation were significantly lower in those with diabetes as compared with rates for those without diabetes at five years and at most shorter six month intervals. Although there are a number of possible explanations for this difference, an important contributing factor may be the prior spontaneous denervation of diabetic blood vessels. The results demonstrate that better predictive indexes for lumbar sympathectomy are needed.