All-artery multigraft coronary artery bypass grafting with only internal thoracic arteries possible and safe: a randomized trial.

BACKGROUND: The internal thoracic artery (ITA) bypass to the left anterior descending coronary artery is of proven benefit in multigraft coronary artery bypass. Total ITA grafts, if reoperation is averted by avoiding saphenous vein grafts (SVGs), are attractive. The safety of the total ITA graft operation (all-ITA) is a concern. METHODS: A randomized trial of multiple-ITA bypass graftings with the use of bilateral sequential ITA without SVGs was performed. Control patients received 1 ITA plus SVG. Inclusion criteria were those used in the Coronary Artery Surgery Study, extended to age 76 years, and any angina class, except emergent. One hundred sixty-two patients were randomized (81 patients per group) from January 1, 1990, to December 31, 1994. RESULTS: Baseline traits were similar as were cross-clamp times, pump times, and number of arteries bypassed (average, 4.3 arteries). Patients who received multiple ITA grafts had no myocardial infarctions, per reference laboratory. One patient died, and 2 patients returned for bleeding. The ITA-SVG group had similar results. The all-ITA group experienced successful completion in 93% of cases. Complications did not differ from control patients. CONCLUSIONS: Early and 5-year outcomes were not different between the all-ITA group and the ITA with SVGs group. We believe experienced surgeons can safely extend the ITA to multibypass coronary artery bypass without use of SVG to achieve an all-ITA operation.

The problem of recurrent stenosis following carotid endarterectomy.

From 1977 to 1985, 306 consecutive patients underwent carotid endarterectomy by a single surgeon. The post-operative stroke and death rates were 1.3% and 2.6%. Of the 184 patients with follow-up duplex scanning, 24 (13%) had a recurrent stenosis of 50% or greater. Of 15 possible risk factors studied to assess a possible relationship with recurrent stenosis, four were definitely associated and a fifth probably implicated. The four definitely associated risk factors for recurrent stenosis were an age of 70 years or older (p = 0.0025), female gender (p = 0.0001), ulcerated lesions (p = 0.013), and asymptomatic lesions (p = 0.041). The fifth risk factor that may play a role (though not reaching statistical significance) was combined carotid endarterectomy and myocardial revascularization (p = 0.066). In these patients, we recommend using vein patch angioplasty to reduce the recurrence rate.

Prevention of pancreatic fistula by modified pancreaticojejunal anastomosis.

A major cause of morbidity after pancreatoduodenectomy is leakage from the pancreaticojejunal anastomosis. To prevent this complication, we have employed mucosal stripping from the proximal jejunum prior to end-to-end anastomosis in 19 patients with good results.

Combined carotid endarterectomy and myocardial revascularization.

From February 1971 through December 1987, 95 patients underwent combined carotid endarterectomy and myocardial revascularization. Mortality and postoperative stroke rates were 4 percent and 2 percent, respectively, for the 16-year experience. From 1980 to 1987, when 89 percent of patients had their operation, mortality and stroke rates were 1 percent and 2 percent, respectively. Follow-up carotid duplex scan in 41 patients revealed that 25 percent had more than 50 percent restenosis. Only two in this group were symptomatic. We conclude that the combined approach to concomitant carotid and coronary artery atherosclerosis can be done safely. Continued study with noninvasive testing is important to document restenosis rates.

Influence of estrogen receptors on survival and recurrence in patients with breast cancer without lymph node metastases.

A retrospective chart review was conducted to determine the prognostic effect of estrogen receptor (ER) protein in patients with node-negative operable breast cancer. One hundred nine patients with breast cancer whose tumors underwent ER analysis and whose lymph node negativity was established histologically were studied. Based on life-table analysis, the overall survival at six years was 92.7% for ER-positive patients, 95.3% for ER-negative patients, and 94.4% for ER-borderline patients. The disease-free survival was 83.3%, 92.8%, and 71.4%, respectively. Survival and disease-free survival were also correlated to menopausal status. The difference in survival was not statistically significant at six years. We conclude that in node-negative primary operable breast cancer, ER status should not be used as a discriminant for adjuvant treatment.

Enhanced streptokinase-induced thrombolysis using heparin in a rabbit model.

Heparin potentiation of clot lysis by streptokinase was studied in a rabbit model. Clot was initiated in the rabbit aorta with stasis and thrombin and allowed to naturally propagate proximally until stasis met flow. The clot was allowed to age for 1 h before assigning treatment. Fifteen rabbits (group I) were given streptokinase (10,000 IU/h) and 11 rabbits (group II) were given streptokinase (10,000 IU/h) plus sodium-heparin (120 IU/h). Thrombolytic therapy was continued for 5 h. Clot lysis averaged 30% in group I and 70% in group II. Ten of 11 rabbits in group II had more than 50% clot lysis, whereas only 4 of 15 in group I had this degree of lysis. One group II rabbit and four group I rabbits died prematurely; each was noted to have clot propagation at the time of death. While a trend for amelioration of hypofibrinogenemia was observed in the group receiving both streptokinase and heparin, this difference was not statistically significant. We conclude, in the animal model, that thrombolysis by a combination of heparin and streptokinase is more effective than streptokinase alone. Systemic effects are apparently no worse with the combination.

Primary hepatic leiomyosarcoma.

We describe a case of primary hepatic leiomyosarcoma and review the previous reports on this entity. We stress the histologic differentiation of this tumor from similar neoplasms and point out the need for aggressive resection in operable cases.