The "stable" ruptured abdominal aortic aneurysm gives a false sense of security.

BACKGROUND: Operative mortality for ruptured abdominal aortic aneurysms (rAAA) has not changed over the past 4 decades. Previous studies have attempted to identify preoperative risk factors that impact upon survival. METHOD: A retrospective review of 25 patients with rAAA treated during a 2-year period was performed. Patients were divided into groups based upon the presence (GpI), absence (GpIIa), or subsequent development of preoperative hypotension (GpIIb). Time intervals from initial presentation to arrival in the operating room (IP-OR), to cross clamp application (IP-XC), and from observed hypotension to cross clamp (HYPO-XC) were recorded. RESULTS: Average time intervals for IP-OR and IP-XC were significantly shorter for GpI compared with GpIIa and GpIIb. No difference in HYPO-XC was noted between GpI and GpIIb. Mortality was 33% for GpI, 25% for GpIIa, and 87.5% for GpIIb. CONCLUSIONS: Normal admission blood pressure led to a decreased sense of urgency, creating avoidable delays and missed opportunities for salvage.

Bilateral chylothorax following thoracic duct ligation: case report and review of the literature.

Bilateral chylothorax following thoracic duct injury is a rare occurrence. Since 1907 there have been only six reports in the literature of this potentially serious complication. We report a case of bilateral chylothorax following ligation of the cervical thoracic duct during a left subclavian to carotid artery transposition.

Current management of coexistent intra-abdominal pathology in patients with abdominal aortic aneurysms.

In conclusion, it can be seen that coexistent intra-abdominal pathology and aortic aneurysms demands an individualized approach to determine a treatment plan for a given patient. Life expectancy must be balanced against the risk of a complication developing in either the treated or untreated condition as well as the potential for increased morbidity associated with combined procedures. If combined procedures are performed, they must be undertaken only if the aneurysm resection has gone smoothly. Efforts must be directed at protecting the prosthetic graft from direct contamination that may accompany the secondary procedure. In general, the symptomatic lesion should be treated first. If both conditions are asymptomatic, the relative risks and benefits of treatment must be balanced against the probability that one or both of the conditions will become symptomatic.

Concomitants of asymptomatic retinal cholesterol emboli.

BACKGROUND AND PURPOSE: Asymptomatic retinal cholesterol emboli are sometimes encountered on ophthalmoscopic examination. They are associated with decreased survival, but their clinical significance is not fully known. We sought to determine which vascular risk factors are associated with such emboli. METHODS: We studied 70 consecutive men (55-84 years old) with asymptomatic retinal cholesterol emboli diagnosed in an eye clinic. Twenty-one men (57-78 years old) from the same eye clinic without retinal emboli or retinal ischemic events were randomly selected as control subjects. We determined vascular risk factors, presence of ischemic heart disease, and extracranial carotid artery disease. RESULTS: Patients had a higher prevalence of hypertension, smoked more, and had a higher prevalence of heterogeneous or echolucent carotid plaques on either side than did control subjects (p less than 0.001 for all three factors). Patients also had a higher prevalence of carotid artery stenosis greater than or equal to 50% on either side and a higher prevalence of ischemic heart disease than did control subjects, but these did not reach statistical significance (p = 0.06 and p = 0.08, respectively). CONCLUSIONS: Our findings suggest that hypertension and cigarette smoking may be important in the pathogenesis of asymptomatic retinal cholesterol emboli and that these emboli indicate systemic atherosclerosis rather than ipsilateral carotid artery stenosis.

Infrarenal aortic occlusion: does it threaten renal perfusion or function?

Proximal propagation of aortic thrombus with resultant impaired renal perfusion has been considered a significant risk of untreated infrarenal aortic occlusion. To investigate this question, we studied 52 patients surviving 1 year or more after surgical interruption of the infrarenal aorta in the course of treatment of aortic graft infection. Blood pressure, renal function, and renal artery anatomy were studied before and after aortic interruption. Preoperatively, 20 patients (38.4%) had treated hypertension, and 11 (21.2%) had impaired renal function (creatinine greater than 1.3 mg/dl). In 46 patients (88.4%) with angiography before aortic interruption, 31 (67.4%) had normal renal arteries, whereas 15 (32.6%) demonstrated renal artery stenosis of less than or equal to 50% (N = 10) or greater than 50% (N = 9). Concomitant renal revascularization (N = 3) or nephrectomy (N = 1) were rare. All patients were monitored after surgery for a mean period of 39.2 months. Thirty-three (63.5%) remain alive and well; 19 (36.5%) have died of causes not related (N = 15) or indirectly related (N = 4) to the original graft infection. Forty-eight patients (92.3%) had late assessment of their blood pressure (N = 44, mean follow-up of 31.0 months) and/or renal function (creatinine) (N = 42, mean follow-up of 26.1 months). Follow-up aortography in 21 patients (40.4%, mean interval of 27.7 months) demonstrated no instance of suprarenal propagation of aortic thrombus. During follow-up 41 patients (78.8%) had no change in either their blood pressure or serum creatinine. Seven patients (13.5%) developed worsening hypertension (N = 3) or a rising creatinine (N = 4).(ABSTRACT TRUNCATED AT 250 WORDS)

The immediate postoperative prosthesis (IPOP) in ischemia and septic amputations.

A retrospective analysis of the medical records of 17 consecutive patients undergoing lower extremity amputation and Immediate Postoperative Prosthesis (IPOP) placement for infectious complications of unreconstructable arterial insufficiency was performed. Significant soft tissue infection was present in 13 patients and osteomyelitis in four. The mean patient age was 59.4 years and 13 of 17 patients were diabetic. Fourteen patients underwent below knee and three underwent above knee amputations. Seven patients had undergone previous arterial reconstruction. Thirteen patients had previous ipsilateral amputations, five of which were open guillotine amputations performed between 3 and 7 days prior to definitive surgery. Four individuals (24%) required early removal of the IPOP, two due to patient noncompliance and two due to stump healing complications. Thirteen patients (76%) were successfully treated with IPOP and went on to achieve independent gait within 3 weeks of their definitive amputation.

Isovolemic hemodilution: correlations of mitochondrial and myocardial performance.

Subsarcolemmal (SS) and interfibrillar (IF) cardiac mitochondrial respiratory activities were examined under conditions of isovolemic hemodilution in rats. Experimental animals (mean Hct, 21%) had significantly higher cardiac indices than controls (mean Hct, 41.5%) 18 hours following isovolemic hemodilution with 0.9% NaCl. A 40% increase in cardiac output was associated with a significant increase in the respiratory control index (RCI) of the IF mitochondria. This increase in IF RCI occurred as a result of a significant decline in the ADP-independent (State 4) respiratory rate. These data demonstrate the ability of cardiac mitochondria to respond to increased myocardial demand by increasing mitochondrial efficiency and support the concept of subspecialized populations of mitochondria within the myocardial cell.

Subpopulations of human heart mitochondria.

Anatomically and biochemically distinct populations of cardiac mitochondria have been isolated from a number of animal species. The physiologic differences between subsarcolemmal (SS) and interfibrillar (IF) mitochondria, coupled with their different location within the cytomatrix, have led to speculation about possible specificities of function within the myocardial cell. To date, these two mitochondrial subpopulations have not been demonstrated in human cardiac tissue. Subsarcolemmal and interfibrillar cardiac mitochondria were isolated from papillary muscle removed from five patients undergoing mitral valve replacement surgery. Mitochondrial respiratory activity was determined polarographically. IF mitochondria had significantly higher state 3 (ADP-dependent) rates of respiration then SS mitochondria (116.7 +/- 7.1 versus 86.5 +/- 8.3 ng atoms or oxygen per minute per milligram mitochondrial protein; P less than 0.05 [mean +/- SE]). These data agree with similar studies performed in other animal species and support the concept of distinct subpopulations of mitochondria within the human myocardial cell.

Mitochondrial and myocardial performance. Response to ischemia and reperfusion.

The relationships between cardiac bioenergy metabolism and myocardial function were examined in a model of global myocardial ischemia and reperfusion. The respiratory activity of distinct populations of subsarcolemmal and interfibrillar mitochondria was correlated with max dP/dt (an index of myocardial contractility with respect to time). Max dP/dt was significantly reduced to 27% of the preischemic value following two hours of cardioplegia-protected, warm, global, ischemia in dogs during the cardiopulmonary bypass period. Reperfusion resulted in improved myocardial function such that by 60 minutes of reperfusion, max dP/dt returned to baseline. Significant declines in both state 3 respiratory rates and respiratory control indexes for subsarcolemmal and interfibrillar mitochondria were noted following the ischemic interval. Mitochondrial function similarly returned to baseline values following 60 minutes of reperfusion. These data demonstrate a close association between mitochondrial and myocardial activity.

Subpopulations of skeletal muscle mitochondria: response to ischemia.

The respiratory activity of distinct populations of subsarcolemmal (SS) and interfibrillar (IF) skeletal muscle mitochondria was studied in rat hindlimb muscle subjected to 30 min of global ischemia at 37 C. State 3 (ADP-dependent) and state 4 (ADP-independent) rates of respiration were determined polarographically using glutamate as the substrate, in order to calculate the respiratory control index (RCI). The RCI is the ratio of state 3 to state 4 respirations and is a sensitive indicator of mitochondrial coupling. An approximately 20 per cent decline in RCI was noted in the SS mitochondria following 30 min of warm ischemia. This decrease was a direct result of a significant decline in the state 3 respiratory rates. IF RCIs following the ischemic interval were not different from control. These data support the concept of separate populations of mitochondria within the skeletal muscle cell and demonstrate a specific injury pattern in the response to ischemia.

Experimental myocardial ischemia. Differential injury of mitochondrial subpopulations.

Distinct populations of subsarcolemmal (SS) and inter-fibrillar (IF) rat cardiac mitochondria were studied following 15 and 30 minutes of warm and cold global ischemia. The respiratory control index, state 3, state 4, adenosine diphosphate-oxygen ratio, and specific enzyme activities of these mitochondrial populations were examined. The subsarcolemmar and IF mitochondria were both severely uncoupled and inhibited by warm ischemia. However, IF mitochondria had a higher RCI at each ischemic interval. In cold ischemia, IF mitochondria were not injured compared with control specimens. Subsarcolemmar mitochondria showed a trend towards a lower RCI that was statistically significant at 30 minutes with succinate as a substrate. These data implicate a differential injury of ischemia on the compartmentalized bioenergy metabolism of the myocardial cell.

[Results of treatment in cases with bilateral retinoblastoma (author's transl)]. / Behandlungsergebnisse bei beiderseitigem Retinoblastom.

Immediate and late results of treatment in 132 cases with bilateral retinoblastoma (the children were aged between two months and six years) were analyzed. Combined treatment comprised enucleation of the more affected eye, further chemotherapy, X-ray treatment and photocoagulation. Cytostatic compounds used were "TET" (analogous to "TEM") and "Prospidin". Of the treated children, 44.8% are alive; the period of observation ranged from seven to 16 years.