Successful aorto-circumflex coronary bypass grafting through left thoracotomy following aortic and mitral valve replacement

We report successful descending thoracic aorto-circumflex coronary artery bypass grafting using a saphenous vein graft through left thoracotomy in a 44-year-old female. The patient developed severe angina attack after aortic and mitral valve replacement. Coronary angiography showed 99% stenosis of the circumflex coronary artery. Under general anesthesia, left femoral vein to arterial partial cardiopulmonary bypass was performed via left 4 th intercostal space. Body temperature was lowered to 22 degrees centigrade, and spontaneous cardiac fibrillation occurred. After minimal exposure by pericardial dissection of the circumflex coronary artery, distal anastomosis and then proximal anastomosis at the descending thoracic aorta was carried out under cardiac fibrillation. This surgery was done with minimal intra-and postoperative bleeding. Postoperative course was very smooth, and the patient was discharged and leading a normal life for 6 months after surgery.     

Interventional coronary revascularization in a patient with chronic dissection of the ascending aorta

In a 74-year-old patient who had undergone coronary artery bypass grafting 8 years earlier, angiography was performed for recent onset of angina pectoris. Surprisingly, angiography revealed chronic dissection of the ascending aortic vessel with occlusion of a saphenous vein graft and partial thrombosis of the false lumen. Additionally, there was significant progression of coronary artery disease with new stenoses in both the ostium and body of the saphenous vein graft to the right coronary artery and a high grade left main coronary artery stenosis. Because any surgical intervention was refused by the patient, an interventional therapeutic strategy with percutaneous transluminal dilatation and stenting of both the bypass graft and the left main coronary artery was planned and successfully performed. This is the first report of a complex intervention and revascularization procedure carried out in a patient with type A aortic dissection. Thus, selected cases of chronic type A dissection my be amenable to interventional coronary revascularization in acute coronary syndromes.     

Axilloaxillary cardiopulmonary bypass: a practical alternative to femorofemoral bypass

BACKGROUND: Peripheral arterial and venous cannulation for cardiopulmonary bypass is used increasingly for patients undergoing minimally invasive cardiac operations, complex reoperations, or repair of aortic dissection or aneurysm, and for patients with extensive arteriosclerotic aortic disease in whom aortic cannulation is a prohibitive embolic risk. The common femoral artery and vein are most commonly used for peripheral cannulation, but these sites may be predisposed to complications, primarily because the femoral vessels are commonly involved with arteriosclerotic disease. We have recently begun to use the axillary artery and axillary vein as alternative cannulation sites, achieving full cardiopulmonary bypass, providing antegrade aortic flow, and avoiding many of the complications associated with other sites. METHODS: Seven patients with peripheral vascular or aortic disease, or both, prohibiting safe aortic or femoral cannulation underwent cardiopulmonary bypass through axillary artery and axillary vein cannulation, approached through a small single subclavicular incision. RESULTS: All patients were successfully cannulated and axilloaxillary cardiopulmonary bypass was possible without the need for additional cannulas. All axillary vessels were closed primarily without complication. CONCLUSION: For an expanding population of patients with peripheral vascular and aortic disease, axilloaxillary bypass is a safe and practical alternative to aortic or femoral cannulation.     

Effect of ethyl alcohol on maternal and fetal acid-base balance and cardiovascular status in chronic sheep preparations

Thirteen chronically catheterized pregnant sheep were given intravenous infusions of 10 per cent ethyl alcohol in 5 per cent dextrose solution (15 mg/kg over two hours). Samples of blood from maternal femoral artery, uterine vein, and fetal brachiocephalic artery were drawn at hourly intervals before, during and after the infusions. Plasma was analyzed for alcohol concentration, protein concentration, haematocrit, PCO2 and pH. Maternal and fetal arterial blood pressures were monitored continuously. There were no significant differences between maternal and fetal arterial blood alcohol levels at any sampling interval nor was there any difference in elimination constants. Alcohol infusion did not produce any significant change in plasma protein concentration, haematocrit, PCO2 and pH, and mean arterial blood pressure in either mother or fetus. However, both maternal and fetal heart rate increased significantly following alcohol infusion.     

Bioassay in vivo for circulating vasoactive agents after renal artery constriction in dogs

We used the gracilis muscle vascular bed to bioassay blood from the two renal veins, vena cava, and aorta continuously for the presence of vasoactive agents before and for 45 minutes after partial occlusion of the left renal artery in dogs. Compared to comparable blood samples from control dogs, left renal venous, vena caval, and aortic blood, but not right renal venous blood, from dogs with renal artery constriction developed vasoconstrictor activity. This was associated with increased renin concentration in plasma from the left renal vein and the vena cava and an increase in systemic arterial pressure. In dogs pretreated with indomethacin, blood from the right renal vein also showed vasoconstrictor activity. Pretreatment with antirenin serum abolished all of the differences between control and experimental dogs. These findings suggest that during acute unilateral renal artery constriction the constricted kidney releases renin and the contralateral kidney releases prostaglandins in sufficient quantity to produce systemic vascular effects.     

Bronchogenic carcinoma associated with right aortic arch and postaortic left brachiocephalic vein--report of a case

61-year-old male was admitted to our hospital for surgical treatment of bronchogenic squamous cell carcinoma arising from left B8. The patient had right aortic arch with aberrant left subclavian artery and postaortic left brachiocephalic vein. Intraoperatively, left ligamentum arteriorsus forming vascular ring between the left subclavian artery and the pulmonary artery was found, however the ligamentum arteriorsus was not divided because no symptom of esophago-tracheal compression was observed. The left brachiocephalic vein was located between the ascending aorta and the arterial ligament. The lower lobe of the left lung was resected, and lymph nodes in the left side of the mediastinum were dissected easily because the aortic arch was positioned on the other side. Preoperative assessment of the type of branching and the course of arteries and veins is important for safe operation.     

Acute type A aortic dissection with leg ischemia

The incidence of lower extremity ischemia secondary to acute aortic dissection is relatively low, however, the presenting symptoms are variable in term of severity. We report here in two cases of such circumstances who were successively differently treated. Case one was a 60 years old male presented with severe left leg pain. Even after the initiation of cardiopulmonary bypass, the leg ischemia did not improve, therefore selective leg perfusion was additionally performed through direct left femoral artery cannulation. The surgery toward dissection was completed by mean of simultaneous graft replacement of ascending aorta and aortic arch. The leg ischemia after the aortic procedure however had persisted, femorofemoral bypass was created to relieve the mal-perfusion. Case two was a 37 years old male admitted with severe left leg pain associated with sensory-motor nerve dysfunction with muscle rigidity. In this particular patient, femoro-femoral bypass was firstly reconstructed as the mean of leg salvage procedure. After we learned there was no serious reperfusion symptom manifested, we performed radical surgery toward the aorta. We believe that the decision making of surgical treatment for acute type A dissection complicated with the presence of lower extremity ischemia is based on the severeness of mal-perfusion.     

Perforation and localized dissection of the left common iliac artery during the modified Bentall procedure: a case report

We performed the modified Bentall procedure for annuloaortic ectasia in a 41-year-old man with Marfan's syndrome. Approximately 15 minutes after initiation of cardiopulmonary bypass with an arterial delivery via the left common femoral artery, perfusion volume gradually decreased and the abdomen of the patient was distended. Retrograde dissection was strongly suggested. Perforation and localized dissection of the left common iliac artery were recognized. Following repair of the lesion, the modified Bentall operation was carried out. Postoperative course was uneventful. The patient has been well for 22 months after the operation.     

Closed-chest cardiopulmonary bypass and cardioplegia: basis for less invasive cardiac surgery

BACKGROUND: We developed a method of closed-chest cardiopulmonary bypass to arrest and protect the heart with cardioplegic solution. This method was used in 54 dogs and the results were retrospectively analyzed. METHODS: Bypass cannulas were placed in the right femoral vessels. A balloon occlusion catheter was passed via the left femoral artery and positioned in the ascending aorta. A pulmonary artery vent was placed via the jugular vein. In 17 of the dogs retrograde cardioplegia was provided with a percutaneous coronary sinus catheter. RESULTS: Cardiopulmonary bypass time was 111 +/- 27 minutes (mean +/- standard deviation) and cardiac arrest time was 66 +/- 21 minutes. Preoperative cardiac outputs were 2.9 +/- 0.70 L/min and postoperative outputs were 2.9 +/- 0.65 L/min (p = not significant). Twenty-one-French and 23F femoral arterial cannulas that allowed coaxial placement of the ascending aortic balloon catheter were tested in 3 male calves. Line pressures were higher, but not clinically limiting, with the balloon catheter placed coaxially. CONCLUSIONS: Adequate cardiopulmonary bypass and cardioplegia can be achieved in the dog without opening the chest, facilitating less invasive cardiac operations. A human clinical trial is in progress.     

Two cases of the retroaortic left renal vein and a morphogenetic consideration of the anomalous vein

The left renal vein rarely passing behind the abdominal aorta is called "the retroaortic left renal vein". We encountered two cases of the retroaortic left renal vein during the student course of dissection at Iwate Medical University School of Medicine in the years 1986-1997. The incidence of the retroaortic left renal vein was calculated at 2/266 or 0.75%. We observed and recorded the two cases of the retroaortic left renal vein by photographs and line drawings. Then, to consider the morphogenesis of the anomalous vein, we studied 16 cases of the renal collar (the circumaortic renal venous ring) from 149 bodies. Moreover, we observed and recorded the relations between the left renal vein and the lumbar veins in 19 bodies dissected in 1996. Results were compared with those of the reports by some different authors and conclusions were as follows. 1. The incidence of the retroaortic left renal vein is estimated approximately at 0.75%. 2. The retroaortic left renal vein is derived from the renal collar (circumaortic renal venous ring) at an embryonic stage and is completed by the regression and disappearance of the ventral (preaortic) limb and the persistence of the dorsal (postaortic) limb at a later stage. The ventral limb originates from the anastomosis between the subcardinal veins and the dorsal limb originates from the anastomosis between the supracardinal veins (external vertebral venous plexus). The left lumbar veins drain into the inferior vena cava by using the intersupracardinal anastomosis (external vertebral venous plexus). The dorsal limb and the left lumbar veins are considered to use a same venous route passing dorsal to the abdominal aorta. Indeed, in the 16 cases of the renal collar studied, the dorsal limb use the left second lumbar vein in 7 cases, the third lumbar vein in 6 cases, the fourth lumbar vein in 1 case, both the second and the third lumbar veins in 1 case and unknown lumbar vein in 1 case. Moreover, in the two cases of the retroaortic left renal vein the dorsal limb use the third lumbar vein. 3. The retroaortic left renal vein of our cases leaves the renal hilus behind the renal artery (usually in front of the artery) at the level of the intervertebral disc between the second and the third lumbar vertebrae (just one verteral body lower than usual) and flows into the inferior vena cava by using the left third lumbar vein. The reason why ventral (normal) route of the left renal vein disappear may be that the vein leaves the renal hilus at the lower level and the more dorsal position than usual.     

Improved psychological well-being, quality of life, and health practices in moderately overweight women participating in a 12-week structured weight loss program

The first objective of this study was to confirm that 4 days of head-down tilt (HDT) were sufficient to induce orthostatic intolerance, and to check if 4 days of physical confinement may also induce orthostatic intolerance. Evidence of orthostatic intolerance during tilt-up tests was obtained from blood pressure and clinical criteria. The second objective was to quantify the arterial and venous changes associated with orthostatic intolerance and to check whether abnormal responses to the tilt test and lower body negative pressure (LBNP) may occur in the absence of blood pressure or clinical signs of orthostatic intolerance. The cerebral and lower limb arterial blood flow and vascular resistance, the flow redistribution between these two areas, and the femoral vein distension were assessed during tilt-up and LBNP by ultrasound. Eight subjects were given 4 days of HDT and, 1 month later, 4 days of physical confinement. Tilt and LBNP test were performed pre- and post-HDT and confinement. Orthostatic intolerance was significantly more frequent after HDT (63%) than after confinement (25%, P < 0.001). Cerebral haemodynamic responses to tilt-up and LBNP tests were similar pre- and post-HDT or confinement. Conversely, during both tilt and LBNP tests the femoral vascular resistances increased less (P < 0.002), and the femoral blood flow reduced less (P < 0.001) after HDT than before HDT or after confinement. The cerebral to femoral blood flow ratio increased less after HDT than before (P < 0.002) but remained unchanged before and after confinement. This ratio was significantly more disturbed in the subjects who did not complete the tilt test. The femoral superficial vein was more distended during post-HDT LBNP than pre-HDT or after confinement (P < 0.01). In conclusion, 4 days of HDT were enough to alter the lower limb arterial vasoconstriction and venous distensibility during tilt-up and LBNP, which reduced the flow redistribution in favour of the brain in all HDT subjects. Confinement did not alter significantly the haemodynamic responses to orthostatic tests. The cerebral to femoral blood flow ratio measured during LBNP was the best predictor of orthostatic intolerance.     

Magnetic susceptibility studies on PrxY1-xBa2Cu3O7- delta single crystals in the insulating regime

During the dissection of the neck region of a 56 year old female cadaver an artery was found branching from the thyrocervical trunk as a fourth branch and entering the aortic arch on its superior posterior aspect between the brachiocephalic trunk and the left common carotid artery. Selective angiography revealed that this artery branched into several arterioles at its junction on the superior aspect of the aortic arch between the brachiocephalic trunk and the left common carotid artery. No similar structure could be found in the literature. Evaluation of this phenomenon according to our knowledge of the development of human arterial networks, it was concluded that the artery might be a persistent intersegmental artery, or an enlarged nutrient artery (vas vasorum) to the aortic arch.     

Utilization of self-expandable prosthesis (stent) introduced through the femoral artery for treatment of dissection of the descending aorta

PURPOSE: We present four cases of dissection of the thoracic descending aorta that underwent treatment with an auto expandable dácron-covered stent. METHODS: The stent was deployed through the femoral artery in the hemodynamic laboratory after sedation, local anesthesia in both inguinal areas and systemic heparinization. The catheter with the stent was introduced through a cutdown in the left femoral artery until the area in the thoracic aorta with the previously diagnosed tear. RESULTS: The stent was expanded with immediate occlusion of the false lumen. The whole procedure took 90 minutes and the patients were discharged without complications. CONCLUSION: Stent utilization is an important step to improve treatment results in type B aortic dissection.     

Long-term effects of ventilation tubes for persistent otitis media with effusion in children

OBJECTIVE: To analyze the clinical and scintigraphic features in four postoperative patients with lower limb edema. DESIGN: Four case reports are presented, and causes of increased lymphatic flow are discussed. MATERIAL AND METHODS: Filtered 99mTc-sulfur colloid (0.1 mL; 20 MBq) was administered by subcutaneous injection into the second web space of each foot. Sequential local (inguinal) and whole-body imaging was performed periodically up to 24 hours after the injections. The patients were three women who were 40, 51, and 86 years of age and an 81-year-old man. RESULTS: Each patient had unilateral lower extremity swelling and had recently undergone an ipsilateral lower limb operation. One female patient had previously undergone proximal femoral vein ligation, and another female patient had venous insufficiency demonstrated by Doppler ultrasonography. The male patient had a history of severe arterial insufficiency, and the remaining female patient had no venous or arterial abnormalities. On lymphoscintigraphy, all patients showed increased lymphatic flow in the edematous lower limb. Only the male patient also demonstrated abnormal dermal backflow pattern. CONCLUSION: Increased lymphatic flow most likely is a normal response to lower limb edema in the presence of normal peripheral lymphatic structures. In the four described cases, a recent lower limb surgical procedure may have resulted in disturbance of normal proximal lymphatic channels. The role of sympathetic innervation of the peripheral lymphatic system is a potential factor determining lymphatic response to trauma or surgical intervention. Increased flow on lymphoscintigraphy may not necessarily represent normal flow, especially if other scintigraphic features of abnormal lymphatic function-such as dermal backflow pattern-are present.     

Decreased erythrocyte Na+,K(+)-ATPase activity associated with cellular potassium loss in extremely low birth weight infants with nonoliguric hyperkalemia

To determine whether a shift of potassium ions from the intracellular space to the extracellular space accounts, in part, for the hyperkalemia seen in extremely low birth weight infants, we examined potassium concentration in serum and erythrocytes from extremely low birth weight infants with hyperkalemia (n = 12) or with normokalemia (n = 27). In addition, to determine whether the shift of potassium was associated with low sodium-potassium-adenosinetriphosphatase (Na+,K(+)-ATPase) activity, we studied the activity of ATPase in the last 16 infants enrolled in the study. Fluid intake and output were measured during the first 3 days of life. Infants were considered to have hyperkalemia if the serum potassium concentration was 6.8 mmol/L or greater. Blood was obtained daily for intracellular sodium and potassium levels by means of lysis of erythrocytes. The remaining erythrocyte membranes were frozen and analyzed for Na+,K(+)-ATPase activity. There were significantly lower intracellular potassium/serum potassium ratios in the infants with hyperkalemia for each day of the 3-day study (p < 0.001). In the hyperkalemic group, there was lower Na+,K(+)-ATPase activity than in the infants with normokalemia (p = 0.006). Low Na+,K(+)-ATPase activity was associated with lower intracellular potassium/serum potassium ratios (p = 0.006), higher serum potassium values (p = 0.02), and lower intracellular potassium concentration (p = 0.009). The urinary data demonstrated that there was no difference in glomerulotubular balance between the two groups. We conclude that nonoliguric hyperkalemia in extremely low birth weight infants may be due, in part, to a shift of potassium from the intracellular space to the extracellular space associated with a decrease in Na+,K(+)-ATPase activity.     

Arg-7 mutant X wild-type crosses in Chlamydomonas reinhardi: study of the enzyme produced in diploid strains

The concentration of prostaglandin (PG) F-2alpha in ovarian arterial blood was compared to that in aortic and carotid blood at different stages of the ovine oestrous cycle, and its concentration measured in the ovarian artery following the infusion of radioactive PGF-2alpha to the uterine vein. In all cases the concentration of PGF-2alpha increased during passage through the ovarian artery, and the increase was proportional to the log of the concentration in the uterine vein. No such change was observed in the concentration of progesterone in the ovarian artery or of PGF in the uterine artery. It was concluded that PGF-2alpha can be and is normally transferred from the uterine vein to the ovarian artery. These results are compatible with the hypothesis that PGF-2alpha of uterine origin is the normal luteolytic agent in the sheep.     

Coronary obstruction secondary to direct cannulation

Four patients are reported with obstruction of the proximal left main coronary artery that developed following prosthetic replacement of the aortic valve. Angina pectoris and ventricular arrhythmias were the presenting clinical manifestations. Anterior descending coronary artery bypass was used in 3 of the patients and vein patch angioplasty in the fourth. One patient died in the hospital. The 3 survivors achieved reflief from angina and ventricular arrhythmias. One patient died from nephropathy 2 1/2 years later. Two patients remained asymptomatic 1 1/2 and 3 years later, respectively. This review emphasizes the need for prompt coronary angiography in patients experiencing angina pectoris after aortic valve replacement, and it shows that coronary revascularization can be performed with satisfactory results.     

Early outcome of in situ femorotibial reconstruction among patients with diabetes alone versus diabetes and end-stage renal failure: analysis of 83 limbs

PURPOSE: Both end-stage renal disease and diabetes have been demonstrated to have a negative effect on the outcome of infrainguinal arterial reconstruction, primarily because of increased perioperative morbidity and wound complications. This study was undertaken to determine whether the combination of these comorbid factors affects the outcome of distal arterial reconstruction. METHODS: Eighty-three distal lower extremity arterial bypasses originating from the femoral artery and terminating at the peroneal, anterior, or posterior tibial artery were performed on 76 patients over a 5-year period at a tertiary care medical center. Autogenous greater saphenous vein was used as the bypass conduit in all instances. Combined inflow and composite vein procedures were excluded. RESULTS: There was one perioperative death, for a mortality rate of 1.2%. The diabetes mellitus (DM) plus end-stage renal disease (DM+ESRD) cohort displayed a significantly lower 1-year primary patency rate compared with the diabetes mellitus cohort, 53% versus 82% (p < 0.02). However, the limb salvage rate for the DM+ESRD and DM cohorts during the same time interval were not significantly different, 63% versus 84% (p < 0.06). The 52% 1-year survival rate for the DM+ESRD cohort was strikingly lower than the 90% 1-year survival rate for the DM cohort (p < 0.002). CONCLUSION: Despite the use of the optimal autogenous conduit, the combination of diabetes and end-stage renal disease can be expected to significantly decrease primary graft patency without affecting limb salvage. The greatest effect of these comorbid factors is on patient survival.     

Sympathetic blockade of isolated rat hindlimbs by intra-arterial guanethidine: the effect on blood flow and arterial-venous shunting

In order to improve the understanding of the role of sympathetic nerve degeneration in reimplantation failure, the hindlimbs of eight rats (Group I) underwent near-complete amputation. The soft tissues of the hindlimb were transected at the proximal thigh with the femoral artery, vein and femur left intact. The femoral vessels were clamped and guanethidine was infused into a branch of the femoral artery of the right leg of each animal, while saline was injected into the left leg. The clamps were removed after 15 minutes. A baseline preoperative injection of radiolabeled microspheres was made, and subsequent injections at 6, 12, 18, and 24 hours postoperation. Twelve rats (Group II) were then used to assess the amount of arterial-venous shunting preoperatively (n = 6) and at 18 hours postoperation (n = 6), by venous sampling. Blood flow to both limbs increased postoperation, but there was significantly more flow in the guanethidine treated limb at 18 and 24 hours postoperation. The amount of shunting was approximately 50% in both limbs at 18 hours, as compared to 10% preoperation. These results highlight the potential benefit of guanethidine and other sympathetic blocking agents in reimplantation to increase blood flow, decrease tissue ischemia and increase anastomotic patency rates. They also suggest that sympathetic nerve degeneration did not affect the volume of arterial-venous shunting in this model, but the difference in blood flow was likely due to arteriolar vasospasm. Further study is needed to elucidate the clinical significance of sympathetic nerve degeneration in reimplantation failure.     

Surgical treatment of noniatrogenic trauma of the femoral arteries

Trauma to the femoral arteries corresponds to 30 percent of all arterial traumas. The authors reviewed 74 patients with noniatrogenic trauma of the femoral arteries treated from January 1991 to December 1993. Ages ranged from 11 to 50 years, with a mean of 24. Seventy-one patients were male and three female. Fifty-two patients (70.2 percent) were white, 20 (27 percent) were black and two (2.8 percent) were Asian. Trauma due to firearms had the highest incidence, with 61 cases (82.4 percent). Absence of pulse was the most frequent clinical symptom (62.5 percent). Severe ischemia, with risk of loss of limb, was found in 66.2 percent of the cases. The superficial femoral artery was impaired in 77 percent of the cases. A preoperative arteriography was performed on only five patients, victims of multiple penetrating trauma or an asymptomatic penetrating wound along a vessel passage. In six cases, arterial and venous ligature was the chosen procedure. In three cases, a primary arterial anantomosis was performed. Simple arterriorraphy was feasible in one patient. In 64 of the patients, a venous graft was undertaken using a segment of the inverted great saphenous vein withdrawn from the other lower limb. Fasciotomoy was used in 32 patients (43.2 percent), all of whom exhibited pasting of the lower limb muscles at admission. One patient died during the immediate postoperative period as the result of multiple organ failure caused by polytraumatism. Preservation of the limb was attained in 72 patients (97.3 percent) Severe, previously-incurred ischemia was responsible for the only two amputations, aggravated by an exceedingly long delay between the time of injury and surgery. One of these patients, in addition to severe ischemia, had extensive injuries to the soft tissues. We conclude that trauma of the femoral arteries, attended while the limb still maintains its vitality, has a positive clinical outcome with a high rate of limb preservation. Mortality usually results from injury to other organs.