Improved technique for closure of median sternotomy incision. Mersilene tapes versus standard wire closure.

A continuous series of 2,135 cardiac surgical procedures performed with a median sternotomy is reviewed. Standard closure with steel wire was used in 1,650 patients, and a new technique with Mersilene tape was used with 485. The rate of sternal dehiscence was 2.4% among those having wire closure, and there were no instances of dehiscence among the 485 patients with Mersilene tape closure (a statistically significant difference at p less than 0.005). The method was quick and easy to perform and highly effective in establishing firm and permanent approximation of the sternum. Presence of factors associated with increased risk of postoperative sternal dehiscence did not affect the outcome when Mersilene tape was used. We highly recommend this technique in all median sternotomy incisions.

Inadvertant atrial fixation of a Swan-Ganz catheter by suture and a method for its percutaneous removal.

A patient with type I dissection of the thoracic aorta inadvertently had a Swan-Ganz catheter sutured to the right atrium during surgical repair of the dissection. A method for its removal using percutaneous passage of a No. 15 scalpel blade is described. The hazards of Swan-Ganz catheters are explored, and the changing roles of nonsurgical interventional procedures are discussed.

Foregut cysts of the mediastinum. Results in 20 consecutive surgically treated cases.

Mediastinal cysts of foregut origin represent an important diagnostic group. Classified according to their anomalous embryonic origins, they include bronchogenic, esophageal, enteric, and nonspecific cysts. A series of 20 consecutive surgically treated cases from the thoracic surgical service of a large medical center is reported, all successfully resolved without mortality. Described are 12 bronchogenic, four enterogenous, and four nonspecific cysts, occurring in a variety of thoracic locations. Close attention to symptomatology reveals a wide range of manifestations, from total absence of symptoms to life-threatening respiratory distress. Definitive diagnosis was accomplished in some cases by means of noninvasive radiologic techniques, while angiography, bronchoscopy, and esophagoscopy were also useful in selected instances. Operative therapy consisted of complete excision if possible or partial excision if adhesion to intrathoracic bodies had occurred.

Aortocoronary Gore-Tex graft: 18-month patency.

Despite widespread success with Gore-Tex (polytetrafluoroethylene) vascular grafts in peripheral artery operations, very little use has been made of this material in aortocoronary bypasses. We present the case of a 61-year-old woman with a 6-month history of angina who was found to have no suitable saphenous vein available at operation and who therefore underwent Gore-Tex bypass grafting to the right coronary artery. Coronary angiograms made 6 months and 18 months postoperatively showed patency of the 6 mm Gore-Tex replacement graft as well as the internal mammary artery placed to the left anterior descending coronary artery. Although frequent follow-up and close observation are recommended in patients with aortocoronary Gore-Tex grafting, the unique design of this material has made it the best alternative for synthetic coronary bypass conduit in the absence of the saphenous veins, particularly when these veins are found to be inadequate only at the time of operation.

Percutaneous transluminal dilation of aortocoronary saphenous vein bypass grafts.

To evaluate the efficacy of percutaneous transluminal angioplasty as a possible alternative to repeated open heart surgery for symptomatic aortocoronary saphenous vein graft stenoses, the procedure was initiated at Shadyside Hospital in January 1978. Percutaneous transluminal angioplasty has been used in nine aortocoronary graft stenoses and 11 native coronary artery stenoses. Of the nine grafts, eight (88 percent) were successfully dilated, including three that had been totally closed as visualized by angiography. Of the 11 coronary dilations, only four (36 percent) resulted in improved flow. The more favorable results experienced with the graft dilations was thought to be due to the nature of the occlusive processes affecting these grafts. The fibrous intimal proliferative disease that is found in most grafts is easily compressible, while the nature of the disease in the coronary arteries is not so readily predictable. Better instrumentation and careful evaluation before and after angioplasty will improve the results and extend the indications for coronary artery and saphenous vein graft transluminal angioplasty.

Percutaneous transluminal angioplasty in the management of occlusive disease involving the coronary arteries and saphenous vein bypass grafts: preliminary results.

Since January, 1978, we have evaluated 18 patients in whom segmental occlusive disease of the aorta-coronary saphenous vein graft or the native coronary circulation was present. The significantly occluded vessels were restored to relatively normal circulation by means of percutaneous transluminal dilatation in 10 of these patients, with technical failures in seven patients and the occurrence of a thrombosis during the procedure in one other. Successful dilatation occurred in six of the seven patients with saphenous vein graft stenosis. Percutaneous transluminal angioplasty of the native coronary arteries in 11 patients resulted in five successful dilatations. All dilatation procedures are performed with the use of local anesthesia with an open-heart team standing by. In the event of technical failure or incipient thrombosis with developing infarction, the patient is transferred for immediate bypass. On the basis of these early results, we have developed guidelines of the indications for percutaneous transluminal dilatation of the coronary arteries and their saphenous vein grafts. The need for improved instrumentation to broaden these guidelines is discussed. Case histories of five patients are presented, and a summary table for all 18 patients is also provided. Certain inherent complications are discussed, but our preliminary results are encouraging, particularly with regard to stenoses of saphenous vein bypass grafts.

Concomitant prophylactic inferior vena caval clipping.

Fatal pulmonary embolism is a common complication of any major surgery, especially in high risk patients. Experimental work in animals showed definite impairment of myocardial function after inferior vena caval ligation, but no changes after clipping. During the last four years, we have used concomitant vena caval clipping as a prophylactic measure in major abdominal vascular procedures. No added mortality or morbidity has occurred because of clipping per se and no deaths were due to pulmonary embolism. We recommend concomitant prophylactic clipping as an adjunctive procedure for all laparotomy patients who are prone to pulmonary embolism.

Aorto-coronary graft for dissected coronary artery.

A 46-year-old woman while undergoing selective coronary cine angiogram dissected her coronary artery. She was managed by heparin therapy followed by urgent aorto-coronary artery saphenous vein graft with no consequences.

Incidence and prevention of pulmonary embolism after coronary artery surgery.

Pulmonary embolism is one of the common complications of aortocoronary artery graft surgery. During one year period, 22 patients had documented evidence of pulmonary embolism out of 231 patients who were operated. There were four deaths and all confirmed by autopsy. Clinical signs of phlebitis were absent in many cases of pulmonary embolism. Elastic stockings were not effective to prevent phlebitis. Heparin did not prevent deaths in all four patients. Heparin therapy and aggressive caval interruption by Modin-Uddin umbrella has eliminated deaths in the last 450 cases.