Efficacy and cost-effectiveness of preoperative IABP in patients with ejection fraction of 0.25 or less.

BACKGROUND: The purposes of this study are to determine whether patients with severe left ventricular dysfunction benefit from prophylactic insertion of an intraaortic balloon pump and to evaluate its cost-effectiveness. METHODS: Between January 1991 and December 1995, 163 consecutive patients with a left ventricular ejection fraction of 0.25 or less underwent isolated coronary artery bypass grafting. An intraaortic balloon pump was inserted before operation in 37 patients (group A). The remaining 126 patients underwent operation without preoperative insertion of the device (group B). Preoperatively, 91.9% (34/37) of group A patients and 54.8% (69/126) of group B patients were in New York Heart Association functional class III or IV (p < 0.001). RESULTS: The 30-day mortality rate was 2.7% (1/37) and 11.9% (15/126) for groups A and B, respectively (p < 0.005). All deaths occurred in patients in functional class III or IV. In group B, 28 patients (22.2%) required an intraaortic balloon pump after cardiotomy for low cardiac output, 42.9% (12/28) of whom died. Median postoperative hospital stay was 9.9 days and 12.0 days, and mean hospital charges were $50,627 and $54,818 for survivors in groups A and B; respectively (p = not significant). CONCLUSIONS: Our experience suggests that patients with severe left ventricular dysfunction undergoing coronary artery bypass grafting may benefit from preoperative intraaortic balloon pump insertion, especially patients in functional class III or IV. This approach improved survival significantly, reduced hospital stay, and was more cost-effective.

Which is the graft of choice for the right coronary and posterior descending arteries? Comparison of the right internal mammary artery and the right gastroepiploic artery.

BACKGROUND: The graft of choice for the left anterior descending coronary artery is the left internal mammary artery because of superior long-term patency. However, controversy exists regarding the graft of choice for the right coronary artery and for the posterior descending branch. METHODS AND RESULTS: Two types of pedicled arterial grafts were used for the right coronary and the posterior descending arteries in patients undergoing coronary bypass surgery between January 1991 and September 1994. Group A comprised 114 patients with a right internal mammary artery (RIMA) graft, and group B consisted of 127 patients with an in situ right gastroepiploic artery (R-GEA) graft. Mean age was 56.9 years in group A and 63.3 years in group B; 7.9% (9 of 114) and 33.9% (43 of 127) were diabetics in groups A and B, respectively. Overall mortality was 2.6% (3 deaths) for group A and 3.9% (5 deaths) for group B (P = NS). However, the prevalence of perioperative myocardial infarction in the right coronary artery distribution was significantly higher for group A (5.3%, or 6 of 114) than for group B (0.8%, or 1 of 127; P < .05), and the reoperation rate for graft failure (from 0 to 12 months after surgery) was significantly higher for the RIMA (4.4%, or 5 of 114) than for the R-GEA (0%; P < .05). Also, the prevalence of deep sternal wound infection in diabetics was significantly higher in group A (22.2%, or 2 of 9) than in group B (4.6%, or 2 of 43; P < .05). CONCLUSIONS: Our preliminary results suggest that the failure rate of the RIMA graft is significantly higher, especially if used as a pedicled graft to the posterior descending artery. The risk of sternal wound complications is greater in diabetics if both internal mammary arteries are used for grafting. Therefore, the R-GEA graft is preferred in diabetics and whenever the posterior descending artery is the target vessel.

An algorithm for the surgical management of chronic abdominal aortic occlusion and occluded aortofemoral grafts.

An algorithm for the surgical management of chronic abdominal aortic occlusion is presented based upon experience of treating 60 consecutive patients. Of 33 patients with juxtarenal aortic occlusion, 17 underwent aortofemoral bypass (AFB), 10 descending thoracic aortofemoral (DTAF), 5 axillofemoral (AxF) bypass, and 1 ascending thoracic aortofemoral bypass. Of 11 patients with mid or distal aortic occlusion, 8 underwent AFB, 2 DTAF and 1 AxF. Of 16 patients with aortic graft occlusion, 1 underwent AFB, 10 DTAF and 5 AxF. Acceptable risk patients were selected for AFB (26). DTAF (22) was frequently preferred for patients with occluded aortic grafts or other hazardous intraabdominal pathology. AxF (11) was used for patients with severe cardiopulmonary risk, limited life expectancy from malignancy, or when emergency procedures were required for salvage of severely ischemic limbs in debilitated patients with chronic aortic occlusion. In the AFB, DTAF and AxF groups the perioperative mortality was 8%, 5% and 36% respectively, the late mortality was 15%, 36% and 45%, and the 5-year primary cumulative graft patency was 92%, 89% and 15%.

Implantation of the distal aorta: a technique for preservation of pelvic blood flow in aortofemoral reconstruction.

We report our initial experience with a previously undescribed variation of aortofemoral bypass. This technique is an alternative to end-to-side aortic anastomosis for preservation of pelvic blood flow. It involves an end-to-end proximal aortic anastomosis with implantation of the distal aorta into the posterior wall of the bifurcation graft. This approach has been used selectively for nine patients. Seven patients operated on using this technique had bilateral external iliac artery disease preventing retrograde perfusion of the pelvis. We used this procedure in two other young patients to preserve large inferior mesenteric and distal aortic lumbar vessels proximal to common iliac artery occlusions. Mean follow-up has been 20 months. There have been no deaths and no major complications. This technique provides the hemodynamic benefit of a proximal end-to-end aortic anastomosis while maintaining patency of the distal aorta and its branches. Additional technical advantages may include better suture line protection from the duodenum and a decreased potential for graft limb kinking. These factors may ultimately result in superior long-term graft patency.

Abbreviated aortic insufficiency in aortic dissection caused by prolapse of the intimal flap.

Aortic insufficiency was identified in a patient with acute ascending aortic dissection. The aortic insufficiency was limited to the first half of diastole by prolapse of the intimal flap against the regurgitant orifice. This unusual pathophysiology was well demonstrated by two-dimensional and color flow Doppler echocardiography.

Descending thoracic aortobifemoral bypass for occluded abdominal aorta: retroperitoneal route without an abdominal incision.

Severe juxtarenal aortic disease and occluded aortic bifurcation grafts have prompted surgeons to seek alternative routes when reoperating. We have modified the descending thoracic aortobifemoral bypass procedure by drawing the graft through a retroperitoneal tunnel to the left groin, thereby eliminating the need for an abdominal incision. The lower thoracic area is exposed through a left anterolateral thoracotomy incision and each common femoral artery is exposed by vertical incisions in the groins. The right limb is drawn through a retrorectus tunnel to the right groin for the final anastomosis. Experience with this technique in 12 patients has demonstrated less risk of atheroemboli, less blood loss, shorter operating time, and a more rapid postoperative recovery, than is the case in reentering the abdomen for a secondary aortic procedure.

A review of morbidity and mortality in elderly patients undergoing pulmonary resection.

The morbidity and 30-day operative mortality were reviewed in the 43 patients 70 years of age or older who underwent pulmonary resection between June 1976 and May 1981. In addition to their surgical illness, many of these patients had pre-existing medical conditions including: coronary artery disease (8), hypertension (14), diabetes (4), and congestive heart failure (5). The mean preoperative 1 second forced expiratory volume (FEV1) was 1.7 liters and 17 patients had an FEV1 of less than 1.5 liters. The operative mortality was 2.3% (one patient), the average duration of postoperative hospital confinement was 9 days, and 39 of 42 (93%) of the patients were discharged within 2 weeks of their operation. There were 38 postoperative complications in 25 of the 42 survivors, most of which were minor and all of which were resolved. Problems included: air leak (13), atrial fibrillation or flutter (3), myocardial infarction (1), respiratory difficulties (9), hemorrhage (2), mental confusion (3), hyperpyrexia (3), difficult-to-manage diabetes (1), and social problems (3). Only two patients required prolonged mechanical ventilation. The low operative mortality, the short postoperative stay, and the minimal number of serious complications is contrasted with other published reports describing a high-operative mortality in elderly patients. The improvement may be related to recent advances in postoperative management and anesthetic techniques. These data suggest that advanced age is not a contraindication to curative pulmonary resection.

Objective criteria for the interpretation of carotid artery spectral analysis patterns.

The duplex scanner (imager + pulsed Doppler) in combination with a fast Fourier transform spectrum analyzer has been used to identify areas of arterial narrowing. To evaluate its effectiveness in the detection of clinically significant carotid stenosis, 1 previously described and 2 original objective parameters were applied to the real time sound frequency tracings from 157 carotid arteries that also had angiograms available to determine the presence and degree of stenotic involvement. There was a statistically significant difference between the means of the test scores of the group of vessels with high grade narrowing (greater than or equal to 60%) and those with less than 40% stenosis for all 3 criteria. Of major clinical interest were our 2 parameters, the 3-point diastolic internal carotid frequency total and the internal-to-common carotid spectral area ratio, both of which showed considerable promise as predictors of stenotic disease. For each test, 40/46 (87%) of the test scores of the arteries with 50% or greater narrowing fell outside 2 standard deviations (95% confidence level) of the means of the vessels with less than 50% stenosis. A previously reported parameter, the internal-to-common carotid peak systolic frequency ratio, was notably less discriminant in this regard.

Evaluation of the peak frequency ratio (PFR) measurement in the detection of internal carotid artery stenosis.

The peak frequency ratio (PFR) between the internal carotid and common carotid artery Fast Fourier Transform Spectral Analysis patterns has been used to identify patients with internal carotid artery stenosis. To evaluate further the accuracy of the PFR, we applied it to the spectral analysis data from 396 vessels whose sound signals were obtained with a Duplex scanner (pulsed Doppler) and 246 arteries whose audible flow data were generated by a continuous-wave Doppler. The pulse Doppler with spectral analysis (PD/SA) correctly identified 221/254 (87%) of the vessels with less than 50% angiographic stenosis, 81/100 (81%) of the arteries with 50-99% stenosis, and 35/42 (83%) of the totally occluded internal carotid vessels for an overall accuracy of 85%. The continuous-wave Doppler with spectral analysis (CW/SA) did well in two categories but had an unacceptably high 47% false-negative rate for arteries with 50-99% stenosis. The PFR when applied to PD/SA test results is a useful parameter in screening patients with suspected internal carotid artery stenosis.

A quantitative method for the evaluation of spectral analysis patterns in carotid artery stenosis.

Duplex scanning in conjunction with Fast Fourier Transform Spectral Analysis offers a means of identifying stenotic internal carotid arteries, but few quantitative algorithms for interpretation of the spectral analysis patterns have been described. We first developed two objective parameters for analyzing carotid artery spectral analysis patterns which included a total of three peak frequencies in diastole and a ratio of spectral pattern areas between the internal and common carotid vessels. We then devised a formula for interpretation of the test results based on a computerized, best-fit, step-wise, discriminate analysis performed on 196 angiographically studied carotid vessels. This formula was then prospectively applied to 154 other carotid arteries with independently interpreted angiograms. 103/109 (94%) of the carotid arteries with less than 50% angiographic stenosis were correctly identified as were 40/50 (89%) of the vessels with 50% or more narrowing. Combining these groups with 16/17 (94%) properly classified total occlusions resulted in an overall accuracy rate of 93%. Application of the formula to smaller subgroups also showed significant differences in the formula means as they related to the degree of angiographic stenosis. Duplex scanning in conjunction with spectral analysis offers a reliable screening test for the evaluation of patients with suspected carotid artery stenosis.

Comparison of oculoplethysmography/carotid phonoangiography with duplex scan/spectral analysis in the detection of carotid artery stenosis.

The accuracy of the duplex scan with spectral analysis (DS/SA) in predicting the presence of arteriographic carotid stenosis was compared to that of oculoplethysmography/carotid phonoangiography (OPG/CPA) in 234 vessels from 117 patients who had had both non-invasive studies in addition to independently interpreted arteriograms. The DS/SA with 212/234 (91%) overall correct responses was superior to the OPG/CPA which properly classified 181/234 (77%) of the vessels (p less than .01). Of major clinical impact was the superiority of the DS/SA (p less than .001) in identifying the 72 vessels with 50-99% stenosis. The OPG/CPA had a discouraging 39/72 (54%) false-negative rate in this group whereas the DS/SA missed only 9/72 (12%) of these arteries. Of those 39 incorrect responses for the OPG/CPA, 26/39 (67%) were in patients with a 50% or greater stenosis on the contralateral side. This is a recognized area of weakness for that test. Based on the results of this study, we have abandoned the use of the OPG/CPA in the evaluation of patients with suspected carotid stenosis and rely solely on the duplex scan with spectral analysis.

Comparison of reactive hyperemia and treadmill tests in the evaluation of peripheral vascular disease.

The systolic ankle pressure response to thigh cuff occlusion (reactive hyperemia test) was compared with a similar measurement after treadmill exercise in 48 limbs of 24 normal volunteers. The reactive hyperemia test was then performed on 26 legs in 16 patients with clinical evidence of arterial disease of the leg and abnormal treadmill tests (mean decrease 39 +/- 24 percent). No decrease in pressure occurred in normal subjects after exercise. All control subjects demonstrated a decrease in pressure after thigh cuff occlusion (34 +/- 7.9 percent). The percent pressure decrease during reactive hyperemia in the abnormal group was significantly lower (49.7 +/- 19 percent; p less than 0.001). There was a high correlation between the percent decrease in pressure during reactive hyperemia and the decrease after exercise in the claudicants (r = 0.69; p less than 0.001). However, the percent pressure decrease in 13 of the 26 abnormal patients fell within 2 standard deviations of the reactive hyperemia control group mean. The range of the pressure decreases in these 13 patients, 16 to 48 percent, was shared by 47 of the 48 normal subjects. The findings in this study are inconsistent with those in previously published reports and suggest that reactive hyperemia testing cannot be used interchangeably with the treadmill exercise test.

Thoracotomy in patients over age seventy years: ten-year experience.

Recent reports have demonstrated satisfactory long-term survival following pulmonary resection in the elderly. However, the high operative risk commonly cited in patients over 70 years of age has led some authors to conclude that advanced age is a contraindication to pulmonary resection. During 1969 to 1978, 218 thoracotomies were performed in patients over the age of 70 years. Operations performed include 175 pulmonary resections and 43 miscellaneous thoracic surgical procedures. Primary or metastatic cancer was the indication for 174 operations (pulmonary resection, 150 cases; exploration and biopsy, 16 cases; pleurectomy, eight cases). One hundred thirty-seven patients (63%) had a benign course, whereas 74 patients experienced a total of 83 complications. Minor complications of atrial fibrillation, air leaks persisting for 7 to 14 days, and successfully managed retention of secretions were seen in 34 patients (16%). Nonfatal major complications were predominantly cardiac and respiratory in nature and occurred in 40 patients (18%). The overall hospital mortality was 3% (seven patients). Lung-sparing procedures were utilized whenever possible among the 150 patients undergoing pulmonary resection for carcinoma (sleeve lobectomy, 13 cases; segmental resection, 52 cases; wedge resection, 12 cases). The hospital mortality of 4% among these 150 patients was significantly lower (p < 0.001) than the 17% mortality among 308 elderly patients compiled from five series reported by other centers between 1973 and 1978. Long-term follow-up was obtained in 129 of the 139 (93%) available patients surviving pulmonary resection for cancer. The overall 5 year survival rate is 27%, ranging from 13% for patients having pneumonectomy to 42% for those having segmental resection.

Unusual presentations of abdominal aortic aneurysms.

A review of the records of 100 consecutive patients undergoing surgical repair of abdominal aortic aneurysms disclosed two individuals who presented in a fashion sufficiently rare as to warrant detailed discussion. The first had concomitant rupture and thrombosis manifested by lower extremity paraplegia and anesthesia, and the second had documented DIC in conjunction with a stable aneurysm. The latter completely resolved with heparin and subsequent surgical repair. Each of these presentations has had documentation in the surgical literature in less than five instances, and both case histories are given, followed by a review of the literature and theories as to the underlying pathophysiology.

Oculoplethysmography/carotid phonoangiography: its value as a screening test in patients with suspected carotid artery stenosis.

A review of 291 carotid arteries that were subjected to both oculoplethysmography/carotid phonoangiography (OPG/CPA) and arteriography showed that although 84% of the vessels that were narrowed less than 40% were properly categorized by the noninvasive test, there was poor grading ability for lesions 40% or greater, and an unacceptably high (40%) false-negative rate for marked carotid stenoses. This has been confirmed by others. Analysis of a 15-item questionnaire that was returned by 12 clinicians showed an unwarranted reliance on the OPG/CPA as a screening test in those patients without transient ischemic attacks. A large majority of responding physicians favored endarterectomy in asymptomatic patients with lesions greater than 70%, and the use of OPG/CPA prevented a substantial number of affected individuals from undergoing angiography and subsequent corrective surgery.

Intrapleural haemorrhage complicating pulmonary arteriovenous fistula.

Rupture of a pulmonary arteriovenous fistula caused intrapleural haemorrhage in a young woman with hereditary haemorrhagic telangiectasia and multiple bilateral fistulas. Bleeding was limited and exsanguination was probably prevented by pleural adhesions. Treatment included decortication, excision of the bleeding fistula, and prophylactic sclerosis of the opposite pleural space.