Penetrating cardiac wounds: prospective study of factors influencing initial resuscitation.

A prospective study of 66 consecutive patients with cardiac wounds seen over a 27-month period is reported. No patient was excluded. Patients were stratified by injury mechanism and by physiologic scoring at admission using the cardiovascular-respiratory elements of the Trauma Score (CVRS). Admission cardiac rhythm was obtained in patients with a CVRS of 0 and a Glasgow Coma Scale (GCS) score of 3. Information concerning the anatomic extent of the cardiac wound, the presence or absence of tamponade, and the degree of injury to other structures was also collected prospectively. Seventy percent of the cardiac wounds were caused by gunshots. The probability of successful resuscitation was significantly related to mechanism of injury and physiologic condition on arrival. Among patients arriving with a CVRS of 0 and a GCS score of 3, survival correlated with cardiac rhythm. Pericardial tamponade did not prove to be an independent predictor of early survival. The presence of tamponade was statistically linked to the mechanism of injury. Transport by non-official conveyance was associated with a higher CVRS on arrival. Intoxication with alcohol or cocaine had no evident effect on resuscitation probability.

Management of penetrating neck injuries. The controversy surrounding zone II injuries.

Penetrating neck injuries present a difficult challenge in management, given the unique anatomy of the neck. Controversy surrounds the approach to zone II injuries; mandatory versus selective exploration. On the basis of an extensive literature review, the authors conclude that neither approach is obviously superior. A selective approach is safe in the asymptomatic and hemodynamically stable patient, provided that accurate invasive diagnostic means are immediately available. The mandatory approach is safe, reliable, and time tested. The greatest problem appears to be the accuracy of detection of cervical esophageal injuries: Radiologic evaluation may be inaccurate, rigid esophagoscopy carries a risk of perforation, and the injury may easily be overlooked during surgical exploration.

Free vascularized tissue transfer for limb salvage in peripheral vascular disease.

In patients with tissue necrosis, higher limb salvage rates can be accomplished with free tissue transfers performed by a vascular and plastic surgeon team. We treated 10 patients with severe ischemic soft tissue defects in their legs with radical debridement and free tissue transfer alone (two patients) or after revascularization (eight patients). Arteriography was performed to plan revascularization to evaluate bypass results, and to identify appropriate recipient vessels for free tissue transfer. Soft tissue defects treated with free tissue transfer included nonhealing amputation sites in five patients and proximal skin and muscle necrosis in the remaining patients, one of which resulted in an exposed in-situ graft in one leg. One patient underwent a distal bypass specifically to provide arterial inflow for free tissue transfer, whereas seven other patients received free tissue transfers following bypass due to persistently nonhealing wounds. The remaining two patients had diabetes mellitus with necrosis near a major joint with nonhealing amputation sites. Free tissue transfers were taken from the latissimus dorsi in six patients, and from the gracilis, rectus abdominis, rectus femoris, and scapula flaps in other patients. Recipient vessels for free tissue transfers were the external iliac artery (one patient), saphenous vein bypass grafts (two patients), popliteal artery (one patient), posterior tibial (three patients), and dorsalis pedis vessels (three patients). Eight of the 10 flaps were viable at follow-up (four months-six years), with a mean follow-up of 20 months. One patient underwent above-knee amputation 15 months after operation and one underwent below-knee amputation three years later due to central flap necrosis. The remainder achieved functional limb salvage allowing patients to resume ambulation. Vascular surgeons should consider free tissue transfer in patients with nonhealing soft tissue defects following optimal revascularization to further extend our ability to salvage the threatened limb.

The preoperative diagnosis of the ulcerated carotid atheroma.

Arteriography and carotid duplex imaging accurately quantify the degree of stenosis caused by carotid atheroma. Since arteriography is inconsistent in identifying carotid ulceration, and controversy exists regarding the diagnostic accuracy of carotid B-mode imaging, a prospective study was performed comparing the two techniques to 126 carotid endarterectomy specimens. Sixty percent (76/126) of specimens contained ulcers. The diagnostic sensitivity for B-mode imaging and arteriography was 47% (36/76) and 53% (40/76), respectively (p = NS). Importantly, the degree of stenosis caused by the plaque significantly affected diagnostic sensitivities. B-mode sensitivity was 77% (10/13) in plaques less than or equal to 50% and 41% (26/63) for plaques greater than 50% (p = 0.03). Arteriography likewise detected 77% (10/13) of ulcers in plaques less than or equal to 50% stenosis and 48% (30/63) in plaques with greater than 50% stenosis (p = 0.07). In patients with focal symptoms, 100% (10/10) of plaques with less than or equal to 50% stenosis contained ulcers, whereas in plaques with greater than 50% stenosis 63% (36/57) contained ulcers (p = 0.02). These data indicate that the diagnostic sensitivity for carotid ulceration is not significantly different between B-mode carotid imaging and arteriography. Since most B-mode errors occur with high-grade stenoses this short-coming is unlikely to adversely affect patient care. Previous studies investigating the ability of carotid B-mode imaging to detect ulceration failed to address quantitative aspects of the carotid plaque. These data appear to resolve the previously existing controversy.

Intraoperative intra-arterial thrombolytic therapy for salvage of limbs in patients with distal arterial thrombosis.

Acute arterial embolic or thrombotic occlusion of the runoff vessels is associated with an incomplete operative thromboembolectomy and an unacceptably high rate of amputation. This report presents a six year analysis of the use of intraoperative intra-arterial thrombolytic therapy, evaluating 38 patients who presented with impending loss of limb because of an acute occlusion of the runoff vessels. All of the patients had extensive thrombosis of a distal vessel and a complete distal thromboembolectomy was not possible. Fourteen patients received infusion of streptokinase, maximum dose of 50,000 units; 26 received urokinase (UK), maximum dose of 150,000 units, and two underwent an isolated limb perfusion technique using one million units of UK. Thirty-four lower and four upper extremities were treated. Twenty-eight of 38 patients had successful revascularization procedures that resulted in salvage of the limbs, and ten of the 38 underwent an extensive amputation. In 18 of the 28 who were successfully revascularized, lysis was clearly obtained, which contributed to the ultimate success; in ten of the 28, it was unclear whether or not lysis significantly contributed to salvage of the limbs. Although four of the 38 died within 30 days postoperatively and one patient had a hemorrhagic complication, neither the deaths nor the complication could be attributed to a lytic agent. There was no evidence of systemic thrombolysis in these patients. Intraoperative intra-arterial thrombolytic therapy administered by the slow bolus injection technique is safe. It can be an important adjunct to mechanical thromboembolectomy and bypass procedures in patients with limb-threatening ischemia caused by thrombosis of the distal part of the vessel. The isolated limb perfusion technique using high dose UK is particularly valuable in acute, small vessel, multiarterial occlusion. Intraoperative intra-arterial infusion of thrombolytic agents may make the difference between salvage or amputation of the limb without causing additional risk for the patient.

Postnephrectomy pseudoaneurysm with arteriovenous fistula.

Sonography detected a paraaortic pulsatile tubular mass in a patient 10 years after "stump" nephrectomy, which was subsequently confirmed as a renal artery-renal vein fistula by computed tomography, angiography, and laparotomy.

Esophagogastric anastomosis.

Sixty-one consecutive patients underwent an end to side esophagogastric anastomosis combined with plication of the stomach around the distal part of the esophagus. No instance of free leakage occurred. Heartburn and regurgitation have been uncommon in this series of patients.

Traumatic aneurysms of the superficial temporal artery.

Three cases of false aneurysms of the superficial temporal artery are reported. Most of these injuries are caused by trauma, frequently sports injuries, more rarely congenital or arteriosclerotic. Diagnosis is made by observation of a mass, usually pulsatile, in the distribution of this artery. Patients who present with a history of injury and a mass over the course of the superficial temporal artery should be suspected of having false aneurysm of the superficial temporal artery. Surgery is indicated to reduce the risk of hemorrhage from subsequent head trauma, to relieve headaches, and for any cosmetic defects.