Diagnosis and treatment of blunt cardiac rupture.

Blunt cardiac rupture is rare, but when it does occur it is almost immediately fatal. In patients surviving the initial insult, the overall mortality rate is 60%-90%. Patients typically present with either cardiac tamponade or massive hemothorax. We report a case of blunt cardiac rupture in a young male who had prolonged transfer time with survival. He presented with an intact pericardium and cardiac tamponade. In stable patients, the diagnosis can be confirmed with emergent echocardiography prior to operative intervention. If unstable, then subxiphoid pericardial window is both diagnostic and therapeutic. The repair is approached via either a left anterior thoracotomy or median sternotomy. The incision is usually dictated by the physiologic status of the patient at presentation. We conclude that patients with blunt cardiac rupture can be saved, especially those with vital signs are still strong when treatment is begun. Early diagnosis is the key to survival for patient with this rare condition.

Laparoscopy-associated mesenteric vascular events: description of an evolving clinical syndrome.

Over the past few years, several cases of acute mesenteric ischemic events following laparoscopy have appeared in the literature. To date, no formal description of this phenomenon has been provided. In this article, we summarize and analyze the features of the five reported cases to date as well as a sixth case encountered at our institution. The probable cause of this complication involves changes in splanchnic hemodynamics related to elevated intra-abdominal pressure. A review of the relevant literature is provided.

Cross-filling of circle of Willis and carotid stenosis by angiography, duplex ultrasound, and oculopneumoplethysmography.

PURPOSE: To evaluate the filling of the Circle of Willis on preoperative arteriograms and to correlate this observation with the results of oculopneumoplethysmography (OPG) and severity of carotid stenosis as determined by duplex ultrasonography and angiography. PATIENTS AND METHODS: Ninety-five patients underwent OPG, duplex ultrasonography, and selective carotid and vertebral arteriography. RESULTS: In all, 45 (88%) patients with a positive OPG had interhemispheric cross-filling of the middle cerebral artery and anterior cerebral artery from a contralateral carotid injection in contrast with 10 (23%) patients with a negative OPG (P < 0.001). Of patients with carotid stenosis > or = 80% on duplex ultrasound, 39 (91%) had cross-filling from a contralateral carotid injection in contrast with 16 (31%) patients with < 80% stenosis (P < 0.001). Of patients with carotid stenosis > or = 80% on arteriogram, 37 (90%) had cross-filling from a contralateral carotid injection in contrast with 18 (33%) patients with < 80% stenosis (P < 0.001). CONCLUSION: These data suggest that the Circle of Willis is frequently incompetent as a collateral pathway and that arteriographic cross-filling is not a reliable index of this pathway. Patients with a positive OPG and corresponding carotid stenosis are likely to have a physiologically incompetent collateral pathway. Perhaps these patients should undergo surgery, even if the stenosis is less than 80%.

Laparoscopic staging laparotomy with intra-abdominal manipulation.

We describe a method for performing laparoscopic staging laparotomy. We believe this minimally invasive approach can ease the transition between purely open and laparoscopic surgery, and it is applicable to a variety of intra-abdominal problems. The results are comparable to those of a standard staging laparotomy, with improvement in access morbidity and decreased hospitalization time.

The risk of ligation of the left renal vein in resection of the abdominal aortic aneurysm.

The left renal vein can be ligated during aortic operation to attain better access to the perirenal aorta. This maneuver has been considered safe, with a low incidence of postoperative renal complications. This study was done to evaluate the risk of left renal vein ligation and its influence on renal function in patients with elective resection of abdominal aortic aneurysms. The records of 332 patients undergoing elective repair of abdominal aortic aneurysms during a five year period were reviewed. The clinical and operative data of patients who had left renal vein ligation and those who did not were similar. Left renal vein ligation was not associated with an increased mortality rate but was strongly associated with an increase in serum creatinine level and a clinical diagnosis of postoperative azotemia. Nine of 13 patients who had left renal vein ligation had postoperative azotemia compared with 21 of 319 patients without left renal vein ligation (p less than 0.001). The mean change of preoperative and postoperative creatinine value was an increase of 1.92 milligrams per deciliter in patients with left renal vein ligation in contrast with 0.26 milligram per deciliter in patients without ligation (p less than 0.00075). Thus, ligation of the left renal vein increases the risk of postoperative renal complications and its use should be selective.

Factors affecting survival of patients with ruptured abdominal aortic aneurysm in a West Virginia community.

The hospital records for patients treated for ruptured abdominal aortic aneurysms in southern West Virginia during a recent five year period were reviewed. The over-all mortality rate was 62 per cent. Patients with intraperitoneal rupture had a higher mortality rate (97 per cent) than patients with retroperitoneal rupture (25 per cent). Patients at increased risk were more than 80 years of age, presented with syncope, experienced a short duration of symptoms before seeking medical attention, had preoperative systolic blood pressure levels of less than 90 millimeters of mercury and had a preoperative hemoglobin level of less than 8. Other factors associated with death were a delay in beginning surgical treatment, a larger total blood loss and amount of blood transfused. The results of multivariate analysis demonstrated that preoperative blood pressure, preoperative hemoglobin, presence of syncope and the amount of blood loss were, in large part, reflections of the type of rupture and had only slight independent relationship to mortality. The most effective method of preventing fatal outcome is elective resection of the aneurysms before rupture occurs.

Early diagnosis and survival of ruptured abdominal aortic aneurysms.

The hospital records of patients treated with ruptured abdominal aortic aneurysm in a recent 5-year period were reviewed to collect data on factors which may be associated with mortality. Overall mortality was 62%. Patients with intraperitoneal rupture had a higher mortality (97%) than patients with retroperitoneal rupture (25%). Patients at increased risk were older than 80 years, presented with syncope, experienced a short duration of symptoms prior to emergency department (ED) arrival, had initial systolic blood pressure less than 90 mm Hg, and/or initial hemoglobin level less than eight on arrival at the ED and delay in beginning surgery. Multivariate analysis demonstrated preoperative blood pressure, preoperative hemoglobin, presence of syncope, and the amount of blood transfused were largely reflections of the type of rupture and had only slight independent relationship to mortality. The authors concluded that treating emergency physicians and surgeons have little control over the most important risk factors for mortality after aneurysm rupture, but may improve the prognosis by expediting diagnosis in the ED and surgical therapy.

Elective resection of 332 abdominal aortic aneurysms in a southern West Virginia community during a recent five-year period.

This study analyzed 33 variables that might potentially affect outcome in a series of 332 consecutive elective abdominal aortic aneurysm repairs in a southern West Virginia community. One of the interesting features of this series was that the repairs were done by 22 surgeons with varying degrees of experience. The mortality and complication rates were compared for various potential risk factors by both univariant methods (chi 2, Fisher's exact, and Student t tests) and multivariant methods of analysis. Our early mortality (2.1%) and postoperative complication rates were consistent with those of other series. With multiple linear regression models, five factors were selected as significant independent risk factors associated with an increasing number of postoperative complications: the number of blood transfusions (p less than 0.0001), left renal vein ligation (p less than 0.0001), the presence of greater than 50% renal artery stenosis (p = 0.0012), the lesser experience of the surgeon (p = 0.0203), and the history of prior cardiac catheterization (p = 0.0245). The only factor statistically correlated with mortality rate was an increased number of postoperative complications (p less than 0.0001). Neither postoperative complications nor mortality rate was found to be significant and independently influenced by other demographic, clinical, or operative factors. It is tempting to speculate that surgeons with less experience might be well served to refer patients with significant renal artery stenosis and coronary artery disease. Our mortality and complication rates were not increased by performing preoperative angiography and therefore prudent surgeons may find this helpful in selecting patients for safer repair.

Paradoxical embolism: an underestimated entity. A plea for comprehensive work-up.

UNLABELLED: Forty-one cases of arterial embolism were reviewed. The work-up included M + 2D echocardiography in 29 patients (71%), arteriography in 22 (54%), both echocardiography and arteriography in 19 (46%), and abdominal aortic ultrasound in 18 (43%). The sources of emboli were probable cardiac (8 = 20%)--mural cardiac thrombus detected by echocardiogram; possible cardiac (12 = 29%)--arrhythmias or other cardiac pathology detected without mural thrombus; probable arterio-arterial (7 = 17%)--proximal arterial thrombus detected; probable paradoxical embolism (2 = 5%)--fulfills the Johnson criteria with cardiac defect and right-to-left shunt detected by contrast echo in one patient and cardiac catheterization in the other; possible paradoxical embolism (3 = 7%)--meets two of three Johnson criteria without evidence of other source; and unknown source (9 = 22%)--conventional work-up negative or incomplete. Five of nine patients (56%) less than 50 years old had probable or possible paradoxical embolism, while in two patients (22%), the origin was unknown. CONCLUSION: (1) A significant proportion of patients with an arterial embolus are discharged with the source of emboli unknown, (2) paradoxical embolism must be considered and contrast saline or transesophageal echocardiogram should be done in patients under 50 years old.

Edema after femoropopliteal bypass surgery: lymphatic and venous theories of causation.

Edema of a lower extremity after femoropopliteal bypass surgery is a common problem. To study the causes of this phenomenon we evaluated 72 patients before and after surgery with noninvasive venous testing and venography. We also obtained postoperative lymphangiograms of a sample of 16 patients, eight with and eight without postoperative edema. Patients were sequentially assigned to one of four treatment groups: group A, a lymphatic-preserving inguinal dissection with conventional popliteal dissection; group B, a lymphatic-preserving popliteal dissection with conventional inguinal dissection; group C, lymphatic-preserving inguinal and popliteal dissections; group D, conventional inguinal and popliteal dissections. Twenty-nine (40%) of the 72 patients had postoperative edema. A similar proportion of patients with edema had deep venous thrombosis as patients without edema (3/29 [10%] vs 3/43 [7%], respectively). Patients in group D showed the highest incidence of edema, 17/20 or 85%, a rate significantly higher than the rates in the other three groups (p less than 0.001). Results of lymphangiograms were normal in six of the eight patients without edema (the other two had slight disruption), whereas they showed severe lymphatic disruption in all eight patients with edema. No association was found between edema and type of graft used or severity of preoperative symptoms. This study indicates that deep venous thrombosis is not an important cause of edema that occurs after bypass surgery and that intraoperative lymphatic disruption probably causes most cases of this complication.