Vein harvest: minimally invasive techniques and reduction in complications.

Revascularization of the coronary or lower extremity circulation ideally requires an autologous conduit. The saphenous vein is the most commonly used graft. Minimally invasive surgical techniques for harvesting of the greater saphenous vein (GSV) are gaining popularity. With better instruments, critical evaluation of techniques and longer follow-up of patients, the outcome of such vein harvesting is improving. An increasing number of authors are reporting a variety of techniques with reduction in wound complications compared to conventional surgery.

Primary aorto-duodenal fistula secondary to infected abdominal aortic aneurysms: the role of local debridement and extra-anatomic bypass.

Gastrointestinal bleeding secondary to spontaneous rupture of an infected abdominal aortic aneurysm into the duodenum is a rare and highly lethal clinical occurrence, representing roughly a third of all primary aortoduodenal fistulas. Diagnosis is problematic due to the subtleties in the clinical presentation and course, and surgical treatment is usually delayed, representing a challenge even for the experienced vascular surgeon. The overall mortality is over 30% and the operative approaches are still controversial. Two cases of ruptured infrarenal aortic aneurysms complicated with aortoduodenal fistula were recently treated at our institution. Bacterial aortitis was documented by arterial wall cultures positive for Klebsiella and Salmonella species respectively. The clinical courses and outcomes of the two patients (one survivor ) treated with retroperitoneal debridement and extra-anatomic bypass and a review of the modern surgical treatment are herein described.

Atherosclerotic aneurysm of the proximal subclavian artery: a case report.

Aneurysms of the upper extremities, and particularly the intrathoracic segment of the subclavian artery, are unusual. Surgical approach and timing of repair remain controversial. We successfully treated a case of a large proximal subclavian artery aneurysm, atherosclerotic in origin. In spite of the size, the symptoms were vague. The patient underwent partial resection of the lesion located in the proximal third of the right subclavian artery, and repair using 8 mm dacron interposition graft. She did well postoperatively and remains symptom free at 1 year. A discussion of this disorder with the relevant literature review is herein included.

Carotid endarterectomy in a vascular fellowship training program: good results with a consistent technique.

OBJECTIVE: To find out whether carotid endarterectomy performed by senior residents or vascular fellows in a vascular fellowship program with a uniform technical approach can give results equal to or better than the acceptable standard. DESIGN: A case study with follow-up ranging from 121 to 1369 days. SETTING: A university teaching hospital. PATIENTS: Two hundred and one consecutive patients operated on between May 1989 and June 1993. INTERVENTIONS: Isolated carotid endarterectomy. MAIN OUTCOME MEASURES: Neurologic findings, cardiovascular complications and local wound problems after carotid endarterectomy. RESULTS: There were no deaths, one permanent stroke and two significant deficits from which the patients fully recovered. CONCLUSIONS: Carotid endarterectomy can be performed by senior surgical residents and vascular fellows within a vascular fellowship program, with a perioperative stroke and death rate of less than 1% when a uniform approach is used.

Comparison of late pulmonary function after posterolateral and muscle-sparing thoracotomy.

Muscle-sparing thoracotomy incisions have received considerable recent attention. There have, however, been few clinical and functional comparisons between the various approaches. The present study assessed early clinical results and late pulmonary function changes in 79 patients undergoing pulmonary operations by posterolateral, limited lateral, or transverse axillary thoracotomy. With the exception of wound seromas in the limited lateral group, there was no difference in rates of death or complications. Patients with muscle-sparing incisions showed significantly better late preservation of forced vital capacity and flow during the midportion of the forced vital capacity but not of other pulmonary volumes and flows. We conclude that limited incisions may result in slightly better late pulmonary function, but that the differences are small and of no apparent clinical advantage in the average patient.