Factors associated with recurrence of varicose veins after thermal ablation: results of the recurrent veins after thermal ablation study.

BACKGROUND: The goal of this retrospective cohort study (REVATA) was to determine the site, source, and contributory factors of varicose vein recurrence after radiofrequency (RF) and laser ablation. METHODS: Seven centers enrolled patients into the study over a 1-year period. All patients underwent previous thermal ablation of the great saphenous vein (GSV), small saphenous vein (SSV), or anterior accessory great saphenous vein (AAGSV). From a specific designed study tool, the etiology of recurrence was identified. RESULTS: 2,380 patients were evaluated during this time frame. A total of 164 patients had varicose vein recurrence at a median of 3 years. GSV ablation was the initial treatment in 159 patients (RF: 33, laser: 126, 52 of these patients had either SSV or AAGSV ablation concurrently). Total or partial GSV recanalization occurred in 47 patients. New AAGSV reflux occurred in 40 patients, and new SSV reflux occurred in 24 patients. Perforator pathology was present in 64% of patients. CONCLUSION: Recurrence of varicose veins occurred at a median of 3 years after procedure. The four most important factors associated with recurrent veins included perforating veins, recanalized GSV, new AAGSV reflux, and new SSV reflux in decreasing frequency. Patients who underwent RF treatment had a statistically higher rate of recanalization than those treated with laser.

Surgical management of esophageal perforation: role of esophageal conservation in delayed perforation.

Definitive repair of esophageal perforation is considered the preferred treatment for patients presenting early (<24 hours). However, the optimal management of delayed presentation (>24 hours) has not been well defined. This study examined the management of esophageal perforation and compared the outcomes of early versus delayed presentation. Records of patients admitted with the diagnosis of esophageal perforation were reviewed. Contrast studies were used to confirm the diagnosis in all cases. Patient demographics and outcome were analyzed to determine differences between early and delayed presentation. A total of 22 cases of esophageal perforation were identified (eight early vs 14 delayed presentations). Operative interventions included primary repair (four), reinforced repair (14) either with intercostal muscle or pleural flap, and a complete esophageal resection (one). Debridement and drainage without repair were done in two patients and a proximal intramural tear was treated with antibiotics and observation. Two patients died during hospitalization. All surviving patients had near-normal restoration of esophageal function. Follow-up at 3 years has shown minimal gastrointestinal problems. One patient required repeat esophageal dilatations and two patients underwent antireflux therapy. Esophageal repair should be considered in all cases of nonmalignant esophageal perforation and should not be influenced by the time of presentation.

Apico-aortic conduits in children with severe left ventricular outflow tract obstruction.

BACKGROUND: Infrequently, congenital heart defects are complicated by left ventricular outflow tract obstruction (LVOTO) not amenable to conventional reconstruction. Apico-aortic conduits provide a means of palliating such patients until definitive repair is possible. The purpose of this study was to review a single institution's current experience with apico-aortic conduits. METHODS: The medical records of pediatric patients receiving apico-aortic conduits were reviewed. Demographics, operative techniques, preoperative and postoperative physiologic variables, morbidity, mortality, and functional class were recorded. Off-pump and on-pump procedures were categorized for comparison. RESULTS: Ten cases of apico-aortic conduits for left ventricular outflow tract obstruction were identified. Indications included congenital aortic stenosis, aortic atresia, and subaortic stenosis. Six procedures were performed off-pump and four required median sternotomy with cardiopulmonary bypass as necessitated by concomitant procedures. There was one operative death. The remaining patients demonstrated hemodynamic improvements and are all alive to date. One patient required conduit valve replacement. All patients are in New York Heart Association classification I or II at the time of last follow-up. CONCLUSIONS: Apico-aortic conduits provide a safe and effective treatment alternative for select cases of left ventricular outflow tract obstruction. Off-pump techniques are feasible in the majority of cases. This valuable adjunct should be considered whenever conventional repair of left ventricular outflow tract obstruction is considered prohibitive.

The use of methylene blue as an extravascular surgical marker impairs vascular responses of human saphenous veins.

Methylene blue is occasionally applied to the adventitia of blood vessels during coronary artery bypass and other vascular procedures to assist in the orientation of the vessel. Inherent in this method is the assumption that extravascular application of methylene blue is innocuous with regard to vascular function. In the first part of this study, the in vitro vascular reactivity of methylene blue-labeled saphenous veins was compared with that of veins that were not marked with methylene blue. The vasoactive agents tested were designed to examine multiple pathways. They included potassium chloride, prostaglandin F2 alpha, phenylephrine, serotonin, angiotensin II, BHT-933 (alpha 2-adrenergic agonist), sodium nitroprusside, acetylcholine, isoproterenol, and verapamil. Compared with unmarked veins, those marked with methylene blue demonstrated a significant impairment of both vasoconstrictor and vasodilator function. These observations were made on a relatively small number of patients and could therefore be attributed to inherent differences between patients or surgical procedures. In the second part of this study, these variables were eliminated by dividing a single vein from one patient into three segments for a 45-minute exposure to external only methylene blue, internal and external methylene blue, or no methylene blue. The segments were then evaluated for vasoreactivity in vitro. Externally applied methylene blue reduced vasoconstriction regardless of the agonist. Further, both endothelium-dependent and -independent vasodilation was diminished by external methylene blue exposure. In veins exposed to methylene blue both internally and externally the results were similar but the magnitude of impairment greater. It is concluded that surgical marking of blood vessels with methylene blue has the potential to adversely affect vascular reactivity and therefore the use of alternative dyes should be considered.

Mechanical assistance for cardiogenic shock following cardiac surgery, myocardial infarction, and cardiac transplantation.

From January, 1982, to October, 1986, 33 patients were treated with either the Pierce-Donachy prosthetic ventricle or the Bio-Medicus ventricular assist device for cardiogenic shock following a cardiac operation, myocardial infarction, or cardiac transplantation. Twenty-five patients required the assistance for postcardiotomy shock and 8, for a variety of conditions including myocardial infarction shock and myocarditis, and as a bridge to cardiac transplantation. Complications were frequent and usually secondary to prolonged cardiopulmonary bypass. Results were poorest in the group with postcardiotomy shock. Earlier application of an assist device could lead to more frequent survival and avoidance of the detrimental effects of prolonged extracorporeal circulation.

Mechanical assistance for biventricular failure following coronary bypass operation and heart transplantation.

From September 1983 to March 1985, five patients who could not be weaned from extracorporeal circulation or who deteriorated in the recovery room have been treated with biventricular mechanical support using two vortex pumps, standard cannulas and tubing. One patient was supported for six hours following heart transplantation and acute graft failure until another donor heart could be found. Intraaortic balloon pumping was utilized in each patient to augment the circulation and produce pulsatile flow. Four of the five patients were weaned from the device. Only one patient is currently a long-term survivor. Although long-term survival has been low, the ability of the myocardium to recover was impressive and warrants the efforts at assisting the heart in biventricular failure.

Multiple coronary bypass grafting: current mortality and morbidity.

Although coronary artery bypass surgery has become increasingly popular in recent years, recent critical reports have cast doubt on its efficacy in certain groups of patients. Our report reviews a recent experience with multiple coronary bypass grafting for triple vessel disease. From March 1976 to October 1978, 276 patients received from three to nine coronary bypass grafts. Combined procedures including valve replacement and ventricular aneurysmectomy are included. There were two operative deaths (30 days) for a 0.7% operative mortality. Eleven patients (4%) sustained a perioperative infarction. Other nonfatal operative complications are reviewed. The overall safety and low morbidity allow us to recommend coronary bypass surgery to certain controversial subsets of patients, ie, those with high-grade double and triple vessel disease with stable angina.

A prospective evaluation of the pulsatile assist device.

Conversion of roller pump flow to pulsatile flow by the pulsatile assist device (PAD) is said to result in improved myocardial preservation and a decrease in the incidence of perioperative myocardial infarction. The clinical advantages of the PAD were evaluated in a prospective randomized study of 100 consecutive coronary artery bypass operations. Serial electrocardiograms, creatine phosphokinase isoenzyme studies, and myocardial scans with technetium-labeled pyrophosphate failed to demonstrate any signficiant difference between patients with the PAD and those receiving nonpulsatile flow. Plasma hemoglobin levels were significantly higher in the PAD group indicating increased blood trauma. Other potential disadvantages of the PAD are discussed. Based on this study, we see few advantages of the PAD in routine coronary bypass operations.

Celestin tube intubation for advanced esophageal carcinoma.

Nine patients with advanced esophageal carcinoma underwent intubation with Celestin tubes between July 1973 and May 1975. Our indications for intubation were inability to swallow liquids or handle secretions and tracheoesophageal fistula resulting from advanced carcinoma involving the esophagus. Eight patients received adequate palliation; one died of continuing aspiration from a tracheoesophageal fistula. Major complications were noted in two survivors. The operative technic is discussed in detail.

A comparison between propranolol and hypothermia in preventing ischemic contracture of the left ventricle (stone heart).

Ischemic contracture of the left ventricle ("stone heart") was studied utilizing a previously described stone heart model. Our studies suggest that beta-adrenergic blockade is not quantitatively as important as hypothermia in protecting ischemic myocardium. On the basis of reduced fibrillatory activity and a slight protective effect shown by electron microscopy, it would appear that combining propranolol with hypothermia may be superior to either used singly.

Bronchogenic cysts: problems in diagnosis and management.

Bronchogenic cysts usually are easily recognized and treated. On occasion they can present problems in diagnosis or management. We have experienced four such cases. A two month old infant whose cyst drained transbronchially during induction of anesthesia; a nine month old infant with preoperative respiratory obstructive signs; an adult with preoperative respiratory obstruction and acute severe respiratory distress during positioning for thoracotomy; and a newborn with an opacified hemithorax associated with retained fetal pulmonary fluid. Awareness of these unusual problems with bronchogenic cysts allows for promt and accurate management and avoids delays and possible complications.

Strut fracture in De Bakey valve. Successful reoperation and valve replacement.

Strut fracture in a De Bakey aortic valve is reported. The theoretical disadvantage of a Pyrolite carbon--coated ball and titanium struts is mentioned. Periodic cinefluoroscopy is recommended in all patients with a De Bakey aortic valve to avoid the complications associated with strut wear or fracture.

A simple and effective left ventricular vent tube.

We have devised a simple, cheap, left ventricular vent that is relatively free from malfunction. It has further use in that it serves as a means of cooling the endocardium when hypothermic techniques are utilized.

Pulmonary sequestration. A broad spectrum of bronchopulmonary foregut abnormalities.

We believe the broad clinical, embryological, and radiological spectrum of pulmonary sequestration has not been adequately emphasized. In order to gain clearer understanding of these foregut abnormalities, all cases from the files of three Army Medical Centers were reviewed. Thirty-two patients, the largest single series in the literature, met the criteria for a diagnosis of bronchopulmonary sequestration. Clinical manifestations varied from no symptoms to recurrent pulmonary infection, hemoptysis, and intrapleural hemorrhage. The presence of symptoms strongly correlated (23/32) with air-containing cystic sequestrations. The embryological and radiological spectra as well as appropriate operative therapy are reviewed.