Surgical experience in descending thoracic aneurysmectomy with and without adjuncts to avoid ischemia.

Over the past twelve years, surgical treatment of descending thoracic aneurysms has been performed in 360 patients. Three different operative strategies were employed during resection to provide distal aortic perfusion by temporary bypass (Group 1, 75 patients) or shunt (Group 2, 22 patients) or to simplify the operative procedure with aortic cross-clamping alone (Group 3, 263 patients). The surgical results were determined primarily by patient-related and disease-related variables. Advanced age (older than 70 years), atherosclerotic cause, and emergency operation significantly increased the risks of early mortality and morbidity. The incidence of death (11.7%), paraplegia (6.5%), or renal failure (6%) was not reduced by the use of adjunctive perfusion, and bleeding complications increased significantly in Groups 1 and 2. Spinal cord injury was increased significantly by emergency operations, cross-clamp times exceeding 30 minutes, and extensive aneurysms (p less than 0.05). The risk of renal failure was increased by advanced age and atherosclerotic cause (p less than 0.05). With an experienced surgical team, the primary risks of descending thoracic aneurysmectomy are not influenced by the method of adjunctive perfusion, but are determined by patient factors such as the nature and extent of the aneurysm.

The surgical treatment of aortopulmonary window.

From 1956 through July 1981, 15 patients, ranging in age from 9 days to 20 years, underwent surgical correction of aortopulmonary (AP) window. Surface hypothermia and venous inflow occlusion were used in the first patient. In four patients, the technique for closure of AP window was similar to that for patent ductus arteriosus: in one, the AP window was ligated; and in three, clamping, division and suture were performed. Cardiopulmonary bypass was used in ten patients. In five patients, division and primary closure were done. In five, a patch was used to close the defect by using the transaortic and/or pulmonary approach. Associated cardiovascular anomalies were repaired concomitantly in four of seven patients. Two patients died during the immediate postoperative period; both were infants and had serious associated cardiovascular anomalies. One patient died from increased pulmonary vascular resistance and right heart failure 1 year after replacement of the tricuspid valve. Of 12 patients who survived the operation, 11 had excellent results. For the surgical treatment of patients with AP window, we stress the safety and ease afforded by extracorporeal circulation and a preference for the transaortic approach and fabric patch closure.

Azygography in the pre-treatment evaluation of oesophageal carcinoma.

Azygography is a useful technique for the pre-operative detection of unresectability of oesophageal malignancies. Invarison of the azygos vein by oesophageal carcinoma occurs because of the anatomic proximity of the thoracic oesophagus and the azygos vein. Azygography may be performed by either intraosseous injection of a rib or by direct retrograde catheterization. Complete obstruction of the azygos vein indicates that an oesophageal carcinoma is unresectable if no other intrathoracic disease is evident.