The AMA alternative to medical liability litigation: pros, cons, and fatal flaws.

The AMA proposal for an administrative scheme to replace professional liability litigation has many positive features. It abolishes jury trial and allows administrative determination of fault, representation by appointed lawyers, and limited recovery but for a wider range of injuries during treatment. Attractive as these provisions may seem to medical providers, several of them are radical enough to ensure rejection by the courts as unconstitutional. The "total package" approach to professional liability reform is less promising than concentration on the introduction of a few key items of proven or probable efficacy. Medical providers should concentrate their limited resources on tort reform providing for "caps" on noneconomic damages (pain and suffering), an absolute statute of limitations, reversal of the collateral sources (double recovery) rule, limitations on attorneys' fees, and periodic payments, rather than lump sums, for large awards. The new TMA proposal for neurological birth injuries is discussed briefly.

Localized pericardial flap to prevent tension on left internal mammary artery grafts.

Tension on a left internal mammary artery graft may be caused by the medial edge of the left lung. A localized pericardial flap may be used to prevent this problem while still allowing adequate pulmonary expansion.

EKG guided placement of subclavian CVP catheters using J-wire.

In an attempt to improve the accuracy of central venous pressure (CVP) catheter tip location, 84 consecutive cardiac surgery patients in sinus rhythm were studied prospectively with respect to subclavian insertion of a CVP catheter using a guidewire technique. The presence of cardiac arrhythmia was used as an index of right atrial (RA) location of the guidewire tip, before threading the catheter over the guidewire. Correct catheter tip location (superior vena cava [SVC] or RA) was achieved in 100% of patients (N = 78) with premature atrial contractions (PACs) related to guidewire insertion. This fell to 50% (N = 4) if no arrhythmias were noted from the guidewire. Ventricular arrhythmias were noted in two of 84 patients (2.4%). Other problems related to the use of this technique are discussed.

Acute and chronic stimulation thresholds of intramyocardial screw-in pacemaker electrodes.

Two screw-in intramyocardial electrodes were inserted in the left ventricle of each of 6 mongrel dogs, and the electrical characteristics were studied over a six-month period. The unipolar lead configuration had consistently better threshold and sensing values than the bipolar configuration during this period. Peaking between implantation and 3 weeks later, mean lead thresholds increased significantly (unipolar, 0.4 to 8.2 mu J; bipolar, 0.6 to 10.2 mu J) while R wave amplitude decreased (unipolar, 16.6 to 8.5 mv; bipolar, 10.6 to 5.8 mv). Mean chronic values for stimulation thresholds were as follows: unipolar, 2.6 mu J, and bipolar, 3.1 mu J. Mean values for the R wave amplitude were as follows: unipolar, 10.6 mv, and bipolar, 7.2 mv. Analysis of the results indicated that with certain exceptions, the optimum system has 2 intramyocardial electrodes, 1 in unipolar configuration and 1 "reserve." In general, adequate values at implantation are a stimulation threshold of 1.4 mu J (e.g., 1.1 v at 500 ohms and 0.6 msec pulse width) and an R wave amplitude of 5 mv.

Fibromuscular disease of carotid arteries: long term results of graduated internal dilatation.

From 1967 to 1979, 25 patients (pts) were operated on for fibromuscular disease (FMD) of the internal carotid artery (ICA). Eleven patients (44%) had transient weakness of an extremity, 4 had amaurosis fugax and 6 (24%) had an asymptomatic carotid bruit. Bilateral carotid arteriography showed significant stenotic lesions in 23 pts (92%) (bilateral in 10), arterial dissection in 1, and severe associated atherosclerosis with ICA endarterectomy and graduated internal dilatation (GID) (9 bilateral); 2 underwent GID with ICA endarterectomy and patch graft: 1 pt had tube graft replacement of the ICA. There was no operative mortality. One pt had a stroke during operation after tube graft replacement of the ICA. Of the 19 pts followed for 2 to 12 years (mean 7.3 years), 2 had late recurrence of mild symptoms. One pt required GID of the contralateral ICA recurrence of symptoms 4 years postoperatively. Graduated internal dilatation of fibromuscular disease of the internal carotid artery can produce long term relief of symptoms; recurrence is rare.

Resection of abdominal aortic aneurysm in the presence of horseshoe kidney.

We report four cases of abdominal aortic aneurysm associated with horseshoe kidney. These cases illustrate the factors that determine the ease of resection in this situation: whether the isthmus of the kidney is parenchymatous or thin and fibrous; the presence or absence of anomalous renal arteries; and the origin of the arterial supply of the renal isthmus. Although the technical challenges involved in aneurysm resection in the presence of horseshoe kidney are significant, these cases illustrate that standard resection and replacement of the aneurysm with a prosthetic graft usually should be possible.

Unusual presentation of bronchogenic carcinoma: case report and review of the literature.

Although blood spread of pulmonary malignancy presumably occurs through microembolization, frank embolization of tumor fragments is uncommon. The first reported case of bronchogenic carcinoma appearing as a peripheral arterial embolus is described. The patient, a 64-year-old female, had acute ischemia of the left leg secondary to tumor embolism to the left profunda femoris and popliteal arteries. Shortly after embolectomy, she suffered atelectasis of the whole left lung from an epitheloid carcinoma in the left main bronchus. Twenty-eight cases of frank tumor embolism to the arterial tree occurring during the course of a noncardiac malignancy have been reported. None, however, occurred as an initial event. Pulmonary metastasis in patients with advanced malignancy was the source of the arterial emboli in 45% (13/29) of reported cases, but bronchogenic carcinoma was the original cell type in 38% (11/29) of cases. In general, arterial tumor embolism is a complication of advanced malignancy usually originating from one of multiple pulmonary metastases. This first case report of tumor embolism to a lower extremity occurring as the initial event in the clinical course of a bronchogenic carcinoma serves to emphasize the protein manifestations of malignant disease.

Clinical experience with the Smeloff-Cutter prosthesis: 1- to 12-year follow-up.

To determine the long-term results of aortic valve replacement with the Smeloff-Cutter prosthesis, the fate of 358 of 459 (78%) consecutive patients was determined 1 to 12 years postoperatively. There were 319 male patients (70%). Mean age at operation was 57 years (range, 15 to 84 years). Aortic stenosis was the dominant lesion in 267 patients (58%) and aortic regurgitation in 133 patients (29%). Fifty-nine patients (13%) had both aortic stenosis and regurgitation. In addition to aortic valve replacement, 93 patients (20%) had coronary artery bypass, 30 (6.5%) had mitral commissurotomy, 23 (5%) had mitral valve replacement, and 41 (9%) had other procedures. Preoperative status by New York Heart Association Functional Class was: Class I, 3 (1%); Class II, 39 (8%); Class III, 148 (32%); and Class IV, 269 (59%). Operative (30-day) mortality was 8.5% (39 out of 459). Functional improvement was obtained in all postoperative survivors: 345 (82%), Class I; 63 (15%), Class II; and 12 (3%), Class III. A perivalvular leak developed in 6 patients (1%) and subacute bacterial endocarditis in five (1%). Actuarial long-term survival was 80% at 5 years and 71% at 8 years. Thromboembolism occurred in 34 patients (9.5%). The incidence of thromboembolism per 100 patient-years for patients receiving no anticoagulants was 5.4; antiplatelet agents, 2.9; and Coumadin (sodium warfarin), 2.6. Major thromboembolism was uncommon in patients on a regimen of sodium warfarin but major morbidity from bleeding was significant.

Late results of reconstructive surgery for renovascular disease.

In order to determine the late results of reconstructive surgery for renovascular disease, a review was made of a series of 505 consecutive patients who underwent operation over a 20-year period. There were 257 males (50.9%) with an age range of 3-80 years. Renal artery bypass grafts were used in 75.4% (471/625) and thromboendarterectomy and/or patch angioplasty in 15.0% (94/625) of reconstructions. Associated vascular procedures were performed in 38.0% (186/489) of patients. Operative mortality (30-day) was 1.8% (9/489) overall, and 4.8% (9/186) with associated procedures but there was no operative mortality in 303 consecutive isolated renal artery reconstructions. The blood pressure was normal or improved in 65% of patients at a mean follow-up interval of 49.3 months, range 1-240 months. The best response rate was obtained in younger patients with isolated renal lesions. Linear regression analysis showed age at operation to be the most important determinant of blood pressure response (p < 0.003) with the presence or absence of diffuse atherosclerosis as another but less powerful determinant of responsiveness (p < 0.07). Crude 15-year survival was 70% (340/489). The overall five- and ten-year actuarial survival probabilities were 80 and 62% respectively. The most common causes of death were myocardial infarction, stroke, and cancer. Cox regression analysis for variables influencing survival indicated that age at operation (p < 0.001), sex (p < 0.01) and the presence or absence of fibromuscular disease (p < 0.002) were the major determinants of late survival with persistent severe hypertension exerting an important but lesser influence. The results of this study indicate that about two-thirds of patients will experience long-term relief of hypertension after operation and that the best long-term survival and blood pressure relief will be obtained in patients less than 50 years of age. Because hypertension in females is better tolerated, younger, male patients appear to have the most to gain from successful renovascular reconstruction.

Surgical treatment of renovascular hypertension. Long-term follow-up of 216 patients up to 20 years.

During a period of 20 years, 216 patients between the ages of 19 and 76 years underwent renal artery reconstruction for correction of renovascular hypertension. Reconstruction was bilateral in 18% of the patients. A transperitoneal approach was used in all cases. The most commonly used reconstructions were aortoneal bypass in 43% of the patients, thromboendarterectomy with primary closure or patch in 26%, and nephrectomy in 11%. There were 13 late nephrectomies. There was no operative mortality. Postoperatively, blood pressure was normal in 85% of the patients, improved in 11% and unchanged in 2%. Follow-up was one to 20 years. Actuarial survival at five years was 93%, at ten years 80%, and at 20 years 70%. Normal blood pressure was present at five years in 81% of the survivors, at ten years in 77%, and at 15 years in 74%. The results indicate the excellent long-term results of renovascular reconstruction for renovascular hypertension in appropriate patients.

Renal artery aneurysm. Long-term relief of renovascular hypertension by in situ operative correction.

Renal artery aneurysm is an uncommon cause of renovascular hypertension. Nephrectomy or, more recently ex vivo arterial reconstruction have been recommended as the treatment of choice. In contrast, we advocate in situ repair of the aneurysm and any associated lesions. Twenty-five hypertensive patients with 30 renal artery aneurysms were treated by tangential aneurysmectomy with primary arteriorrhaphy, saphenous vein patch angioplasty, or bypass graft. Nephrectomy was performed in two patients, one for a ruptured aneurysm. There was no operative mortality. Follow-up was obtained on all patients six months to 19 years after operation. Hypertension was relieved immediately and in the long-term in the majority of survivors. We believe these results indicate that despite the presence of severe renovascular disease, the affected kidney can be preserved and hypertension successfully relieved by a direct surgical approach without recourse to either nephrectomy or ex vivo reconstruction.

Prevention of distal embolism during arterial reconstruction.

Distal embolization of fragmented laminated thrombus and atheroma producing peripheral ischemia or gangrene is an underemphasized complication of arterial reconstruction. A set of techniques has been developed to minimize this important complication. To assess their effectiveness, the incidence of distal embolism in patients undergoing resection of abdominal aortic aneurysm with and without the use of these techniques was studied. In the 434 patients who underwent elective resection of abdominal aneurysm, measures to prevent distal embolism were used in all cases. The incidence of distal embolism was only 0.23 per cent (1 of 434), in contrast to reported incidences of up to 11 per cent. In the 21 patients who underwent emergency resection of ruptured aneurysm, these techniques were not used due to the need for early proximal control for resuscitation; distal embolism of atheromatous material occurred in 2 cases, an incidence of 9 per cent. The application of these techniques to other peripheral vascular procedures has resulted in similar low rates of postoperative distal ischemia.

Treatment of postradiation stricuture of the rectum by the modified Duhamel procedure.

Benign rectosigmoid stenosis secondary to pelvic radiation presents a difficult problem in management and is usually treated by permanent colostomy with its attendant discomfort and inconvenience. Other approaches include low anterior resection or even transsacral resection of the affected area of rectosigmoid, but they involve risk to rectal, bladder, and sexual function. The Martin modification of the Duhamel procedure is specifically designed to avoid these problems and was used successfully in the present case for treatment of rectosigmoid stenosis. The patient has been followed up 8 years and reports normal sensation and function of bladder and rectum and no disturbance of sexual function.

Improved results of operation for ruptured abdominal aortic aneurysms.

Of 1,393 consecutive patients operated on for aneurysm of the abdominal aorta between 1964 and 1978, 61 consecutive patients had undergone emergency operation for ruptured abdominal aortic aneurysm, for an incidence of 4.4% (61 of 1,393). There were 57 men and four women; their mean age was 77.5 years, with a range of 49 to 93 years. In 21 patients the diagnosis of aneurysm had been known from 1 day to 5 years prior to rupture. Hypotension (less than 100 mm Hg systolic) was present in 27.9% of patients (17 of 61) on admission to hospital and prior to operation in a total of 44.3% patients (27 of 61). Operation was begun in eight patients with an initially unrecordable blood pressure. The perioperative mortality rate (30 day) was 14.8% (nine of 61). The two factors most influencing survival were age [no patient younger than 60 years died vs. 40% of patients (four of 10) older than 80 years] and the magnitude of blood loss (survivors lost a total of 4,513 ml vs. 8,500 ml in those who died). Thus the most common cause of death was myocardial infarction (six of eight) in elderly patients, secondary to poorly tolerated severe hypovolemia. The results of this study suggest the need for avoidance of technical problems during operations, earlier referral of patients with known abdominal aortic aneurysms, especially the elderly, and early diagnosis with immediate operation for ruptured aneurysms.