Superiority of aortic over femoral cannulation for cardiopulmonary bypass, with specific attention to lower extremity neuropathy.

The advantage of aortic cannulation over femoral cannulation in cardiopulmonary bypass has been well established in our experience. Over a four year period, we compared the incidence of complications of these two modalities in a large group of patients. Specific emphasis is placed on the lack of lower extremity neurological deficit and retrograde dissection in patients who underwent aortic cannulation.

Permanent transvenous balloon occlusion of the inferior vena cava: experience with 60 patients.

Traditional operations to obstruct the IVC are often unsatisfactory because the morbidity and mortality is appreciable: poor risk patients do not tolerate surgical and anesthetic trauma. Furthermore, if the patient is anticoagulated, an operation requires that such desirable treatment be stopped. Ten years ago a study was begun to develop a transvenous method of IVC occlusion in the awake anticoagulated patient. Animal studies were done prior to patient application. A technique was evolved wherein IVC interruption could be accomplished with a balloon bearing catheter inserted through the jugular vein. The balloon was positioned with venography and after inflation held in place by lateral pressure in the distensible IVC. The catheter was then removed, leaving the balloon in position. Balloon occlusion has been used in the management of 60 selected patients since 1970. Twenty-nine patients were simultaneously anticoagulated without complication. Very sick patients tolerated the procedure well. No patient experienced further pulmonary emboli. Nine hospital deaths occurred from a variety of causes, none related to the balloon catheter. Late follow-up shows that the occluding balloon gradually deflates in about 12 months. The remnant has remained stable in all patients, contained in a scar that permanently interrupts the IVC.

Abdominal aortic resection in thoracic dissection.

Dissection nearly always begins in the thorax, but it commonly extends into the abdominal aorta, which may become the focal point of the disease. We report five patients who illustrate the surgical management of this disease variant. Clinical manifestations included retroperitoneal rupture, expanding false aneurysm, and lower aortic occlusion. All patients had an aortic bifurcation graft, with reentry of the false lumen at the renal level. Two patients also had thoracic-aortic resection or plasty or both. Although one patient had thoracic aortic rupture at the five-year interval, these abdominal aortic resections provided effective palliation in all. This successful experience in managing complex dissections shows that when aortic dissection extends into the abdomen, resection of the distal aorta with a reentry procedure may be appropriate therapy.

Carotid body tumor: resection or reflection.

We have studied a series of 24 cases of carotid body tumor, comprising our total experience during the past two decades. Twelve patients had symptoms related to compression or invasion of the surrounding structures. Two patients had malignant changes, while three individuals had bilateral lesions. Thirteen patients underwent neck exploration for diagnosis or attempt at surgical removal of the tumor prior to admission to our institution. Definitive procedures in 24 cases resulted in one postoperative death, a rate of 4%. Internal carotid flow was preserved in every case. Intraluminal shunting was employed during the last decade, and no instance of cerebral damage was encountered. It is our intention to emphasize the importance of an accurate diagnosis by carotid angiography prior to surgical management. We also wish to encourage routine excision of these tumors as they are diagnosed, before they reach an enormous size.

Mitral insufficiency secondary to coronary heart disease.

Twenty-four patients were operated on for mitral regurgitation secondary to coronary heart disease. Their common features consisted of a history of myocardial infarction, congestive heart failure, coronary occlusive disease, left ventricular dysfunction, low cardiac output, pulmonary hypertension, and increased left ventricular end-diastolic pressure. Fourteen patients were in intractable congestive heart failure at the time of operation. The operative procedures employed consisted of aneurysmectomy in 4 patients; mitral valve replacement (MVR) in 7;MVR and revascularization in 4; MVR and aneurysmectomy in 5;MVR, revascularization, and partial ventricular resection in 3; and MVR with closure of ventricular septal perforation in 1 patient. Six patients died, a hospital mortality of 25%, and only 42% had good results. The degree of associated coronary artery disease and the status of the left ventricular myocardium were the most important prognostic factors.

Aortic insufficiency secondary to aortic root aneurysm or dissection.

Twenty-four patients with aortic regurgitation secondary to aortic root aneurysm (13 patients) or dissection (11 patients) were operated on, utilizing a variety of surgical procedures to cope with the varied pathological findings. These ranged from primary repair of the ascending aorta without any prostheses in patients with acute aortic dissection to replacement of the valve and the entire ascending aorta for aortic root aneurysm. In four patients with Marfan syndrome the right coronary artery was transplanted to the ascending aortic graft, allowing an extension of the graft to the valve anulus and excision of the entire aneurysmal aorta. The immediate and late results have been most encouraging.

Current surgical management of left ventricular aneurysm.

One hundred thirty-two patients with ventricular aneurysm had cardiac catheterization, coronary anglography, and ventriculography. More than 50 percent of the patients, in addition to aneurysmectomy, had other procedures consisting of revascularization, mitral valve replacement, and closure of ventricular septal performation. The overall mortality was 10 percent. Aneurysmectomy alone had a higher mortality (9 percent) when compared with combined resection of the aneurysm and coronary bypass (5.4 percent). During a six-month to 4-1/2-year follow-up (mean, 21 months), seven patients died, representing a late mortality of 6 percent. This study confirms the importance of complete cardiac evaluation in patients with ventricular aneurysm and shows that, in spite of extensive combined operative procedures required in more than 50 percent of the patients, the results are favorable.

Acute renal failure complicating ruptured abdominal aortic aneurysm.

Ruptured abdominal aortic aneurysm complicated by renal failure is associated with a mortality greater than 90%. Aggressive management, which included the early use of hemodialysis, was employed. Between 1970 and 1973, a total of 43 patients had surgery for proved ruptured abdominal aortic aneurysm. Fourteen patients developed acute and fixed renal failure. Nine of these 14 patients had undergone hemodialysis with treatments beginning as early as the second postoperative day and lasting as long as ten weeks. There were six survivors, with a hospital mortality of 33%. This represents an improvement in survival compared with our earlier experience where the mortality in this type of patient was 93%. Early use of hemodialysis in the postoperative management of patients with acute renal failure complicating ruptured abdominal aortic aneurysm is recommended.

Late thrombosis affecting one limb of aortic bifurcation graft.

Late unilateral limb thrombosis was encountered in 45 of 601 patients discharged from the hospital with functioning aortic bifurcation grafts, an incidence of 7.5%. It was invariably associated with clinical manifestations of arterial insufficiency to the affected limb more serious than those of the extremity prior to the initial operation. Although the specific cause could not be determined, it was usually due to either progression of the disease distal to the reconstructed segment or to certain compromises at the time of the first operation or both. Among several procedures employed, unilateral reconstruction of the thrombosed limb is the procedure of choice. The reoperation was successful in 75% of the patients.