A simple method to reduce ischemic time of the spinal cord in extensive thoracoabdominal aneurysm operations.

OBJECTIVE: Although the incidence of paraplegia from surgery of extensive thoracoabdominal aneurysms Crawford type I - Ill.could be reduced to about 10 % in more recent series, development of additional measures to avoid this disastrous complication seems worthwhile. One of of the major determinants of preventing ischemia is obviously keeping ischemic time of the spinal cord below 30'. In this regard, we introduced a surgical technique that allowed reperfusing the intercostal arteries within 30 min. METHODS: In a consecutive series 17 Patients with thoracoabdominal aneurysms (9 Crawford type II, 7 type I and one type III) underwent thoracoabdominal aortic replacement using either fem.-fem.-or left atrio-fem. bypass with selective perfusion of the visceral vessels. To keep the ischemic time of the spinal cord as short as possible, the first step of aortic replacement consisted of reattachement of the intercostal arteries of the segments Th 10-L 1 followed by immediate reperfusion via a side branch of the prostheses with the aid of the heart and lung machine. RESULTS: Mean ischemic time was 25 min. The mean number of reperfused intercostal arteries was five. One patient died of bleeding complications and could not be evaluated for paraplegia. There was no further hospital mortality. One patient developed paraplegia. With the exception of two patients, all had a very fast recovery and limited stay on the ICU. CONCLUSIONS: Compared to our former experience, we were able to reduce the incidence of paraplegia dramatically. Our observations to date strongly support the hypothesis that an ischemic period of less than 30' is fairly well tolerated by the spinal cord.

Results of and comments on the 2000 survey of the American Association of Academic Chief Residents in Radiology.

RATIONALE AND OBJECTIVES: The American Association of Academic Chief Residents in Radiology (A3CR2) annually surveys radiology residency programs on issues related to training. The objective is to highlight national similarities, differences, and trends to help programs establish standards and improve residency training. MATERIALS AND METHODS: Questionnaires were mailed to 180 accredited diagnostic radiology residency training programs in the United States. The survey covered the usual general topics and more specific topics considered every 4 years; for 2000 the latter were on-call issues and the chief residency year. RESULTS: Completed surveys were returned from 63 programs (35%). Important findings included increased caseload and call commitments, especially for smaller programs. Resident salaries appear to have increased more than the consumer price index. Nonemergent after-hour coverage and teleradiology are now a large part of the resident work practice. Women continue to be underrepresented, with a trend downward. Chief residents are more involved in organizing preparation for board examinations and have greater office facilities and more administrative duties. CONCLUSION: This survey provided useful insights. All levels of residency face increased workloads. On-call hours have not changed, but the work has intensified and the use of teleradiology has increased. Many programs have adopted a "night-float" system, and nonemergent after-hours coverage should be considered in any program evaluation. Continued vigilance and sustained efforts are required to ensure that radiology is considered as a specialty by both men and women. With increased demands on attending physicians' time, chief residents may need to take on more administrative responsibilities.

"The antero-axillary thoracotomy for operations of the distal aortic arch and the proximal descending aorta".

Antero-axillary thoracotomy in a 45 degrees position has become the most frequent approach for lung resection in our country. This approach also offers an ideal view of the aortic arch with the supraaortic vessels being closer to the incision site than in sternotomy or standard thoracotomy. We have therefore used this approach in our last 14 patients with lesions of the distal aortic arch and proximal descending aorta. Operative diagnoses included three arteriosclerotic aortic arch aneurysms, one post-traumatic aneurysm and two acute traumatic transections, as well as four acute type B dissections, three aneurysms after coarctation patch plasty and one recurrent stenosis after primary interposition of a vascular graft. Two patients died of sudden cardiac arrest on the 4th and 6th postoperative day, respectively, both following repair of a ruptured aneurysm. Except for recurrent laryngeal nerve palsy in six patients there were no further operations or morbidity. All operations were performed with the aid of left heart bypass. Induction of deep hypothermia and circulatory arrest, as is advocated for some of these lesions, was not required. This approach is especially useful in those cases where there is indecision as to whether a median sternotomy or a standard thoracotomy would provide the most optimal exposure.