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H J Safi

Publications and source records attributed to H J Safi.

At least 73 records · Page 4Linked to original sources
PubMed1994

Coronary artery bypass after substernal colon interposition for carcinoma of the esophagus.

A 70-year-old man presented with severe angina pectoris caused by critical stenosis of the left anterior descending coronary artery 11 years after mediastinal radiation therapy, esophagectomy and substernal colon interposition for squamous cell carcinoma of the esophagus. Coronary artery bypass was performed through a left thoracotomy using the left internal mammary artery with profound hypothermia. This uncommon approach to an unusual case is described here.

Aged↗
PubMed1994

A new technique for left renal cryopreservation.

Our technique for left renal cryopreservation seems to have promise for preventing renal failure after thoracoabdominal aortic aneurysm repair. Based on the evidence we have obtained with this limited study, we plan to continue using this technique with selected, high-risk patients.

Aortic Aneurysm, Abdominal↗
PubMed1993

Brain protection via cerebral retrograde perfusion during aortic arch aneurysm repair.

Eleven patients underwent resection and graft replacement of ascending and aortic arch aneurysms. Retrograde cerebral perfusion was used during the procedures to minimize cerebral ischemia. Retrograde cerebral perfusion (15 degrees to 24 degrees C) was administered through the superior vena cava. The mean cerebral ischemic time was .35 minutes (range, 11 to 71 minutes). Throughout retrograde cerebral perfusion, blood samples were drawn from the innominate and left carotid arteries at 1, 5, and every 10 minutes thereafter for analysis of arterial oxygen content, total creatine kinase level, and creatine kinase BB fraction. All patients survived. All except 1 awoke neurologically intact. In this patient, electroencephalogram and transcranial Doppler studies conducted before circulatory arrest were consistent with embolic phenomena. There was no significant difference between the current group's intraoperative electroencephalograms and those of a similar historical group. Postoperative complications included transient renal failure, myasthenia gravis, cholecystitis, premature atrial contractions, atrial fibrillation, and vocal cord paralysis. The creatine kinase BB fraction range was 1.8 to 13.4. The increase of total creatine kinase level was due to MM fraction. Retrograde cerebral perfusion during circulatory arrest is a valuable adjunct for protecting the brain. The creatine kinase BB band was not a good marker to detect brain injury. With continued use of this technique and accumulation of a larger series, we may better define the role of retrograde cerebral perfusion in brain protection.

Adult↗
PubMed1993

Deep hypothermia with circulatory arrest. Determinants of stroke and early mortality in 656 patients.

We have retrospectively evaluated our results after aortic surgery in adults using deep hypothermia with circulatory arrest to determine the patient predictors of early death and postoperative stroke by logistic regression analysis. Of the 656 patients operated on between July 7, 1979, and January 30, 1991, 43% (n = 283) were female, the median age of the patients was 64 years (range 10 to 88 years), 12% (n = 77) had acute dissection, 26% (n = 173) had previously undergone either cardiac or ascending aortic operations, and 13% (n = 85) had a history of cerebrovascular disease. Eighty-four patients underwent elephant trunk procedures. The median circulatory arrest time was 31 minutes (range 7 to 120 minutes). The univariable predictors of transient or permanent stroke, defined as clinical evidence of neurologic injury, either global or hemiparetic, which occurred in 44 patients (7%), were as follows (p < 0.05): increased age; a history of cerebrovascular disease; circulatory arrest time (7 to 29 minutes = 12/298 [4%], 30 to 44 minutes = 15/201 [7.5%], 45 to 59 minutes 9/84 [10.7%], 60 to 120 minutes 7/48 [14.6%]; cardiopulmonary bypass time; and concurrent descending thoracic aorta repair. The multivariably determined predictors were as follows (p < 0.05): a history of cerebrovascular disease; previous aortic surgery distal to the left subclavian artery; and cardiopulmonary bypass time. A history of aortic valve incompetence, however, was associated with a lower risk of stroke (adjusted odds ratio 0.42, p = 0.015). The multivariably determined predictors for increased risk of early death (p < 0.05), which occurred in 66 (10%) patients, were as follows: increased age; Marfan syndrome; concurrent distal aortic aneurysm; previous ascending aortic operation; cardiopulmonary bypass time; cardiac complications; renal complications; and stroke. In this study, the occurrence of stroke was observed to increase after 40 minutes of circulatory arrest; furthermore, the mortality rate increased markedly after 65 minutes of circulatory arrest. Thus the "safe" period for strokes not developing appeared to be limited to approximately 40 minutes. We conclude that deep hypothermia with circulatory arrest is a safe technique for the repair of complex aortic problems provided both the circulatory arrest and the cardiopulmonary bypass times are not excessive. In addition, the clinical characteristics of the patients are important determinants of stroke and death.

Actuarial Analysis↗
PubMed1993

Experience with 1509 patients undergoing thoracoabdominal aortic operations.

PURPOSE: The purpose of this study was to retrospectively identify variables associated with early death and postoperative complications in patients undergoing thoracoabdominal aortic operations. METHODS: The data on 1509 patients who underwent 1679 thoracoabdominal aortic repairs between 1960 and 1991 were retrospectively reviewed. The median age was 66 years (range 1.5 years to 86 years), and aortic dissection was present in 276 (18%) patients. The extent of the first repair performed included 378 (25%) type I (proximal descending to upper abdominal aorta), 442 (29%) type II (proximal descending aorta to below the renal arteries), 343 (23%) type III (distal descending and abdominal aorta), and 346 (23%) type IV (most of the abdominal aorta). The median total aortic clamp time was 43 minutes. RESULTS: The 30-day survival rate was 92% (1386/1509) for the 30-year period. On multivariate analysis the preoperative and operative variables associated with death included (p < 0.05) increasing age, preoperative creatinine level, concurrent proximal aortic aneurysms, coronary artery disease, chronic lung disease, and total aortic clamp time. When the postoperative variables were also included in the stepwise logistic regression model, then in addition, cardiac complications, stroke, kidney failure, and gastrointestinal hemorrhage became significant (p < 0.05). The overall incidence of paraplegia or paraparesis was 16% (234/1509). By use of stepwise logistic regression analysis, the significant predictors (p < 0.05) of paraplegia or paraparesis developing were total aortic clamp time, extent of aorta repaired, aortic rupture, patient age, proximal aortic aneurysm, and history of renal dysfunction. Kidney failure (postoperative creatinine level > 3 mg/dl or dialysis) occurred in 18% (269/1509) of patients; dialysis was required in 9% (136/1509). Gastrointestinal complications manifested in 7% (101/1509) of patients. CONCLUSION: Although the survival rate has improved, paraplegia/paraparesis and kidney failure continue to be vexing problems that require further research.

Adolescent↗
PubMed1992

Composite valve graft replacement of the proximal aorta: comparison of techniques in 348 patients.

Composite valve graft replacement of the ascending aorta is being increasingly used, although it is not clear which technique, the Bentall, Cabrol, or button, is the best method for coronary artery ostial reattachment. We retrospectively analyzed our results with respect to these three techniques in 348 consecutive patients operated on between September 17, 1979, and January 29, 1991. Variables included aortic arch replacement in 88 patients (25%), need for deep hypothermia and circulatory arrest in 119 (34%), aortic dissection in 131 (38%), acute dissection in 34 (9.8%), reoperation in 79 (23%), and insertion of St. Jude prostheses in 270 (78%). The 30-day survival rate was 91% (316/348), the in-hospital survival rate was 90% (312/348), and the 30-day incidence of postoperative new transient (n = 6) and permanent (n = 6) stroke was 3% (12/348). The 30-day survival rates for each method were as follows: Cabrol, 92% (144/157); button, 91% (39/43); and Bentall, 91% (125/137). On stepwise multivariate logistic regression analysis with control for operative date and independent prognostic factors, operative technique was not an independent determinant of early mortality or stroke. On late follow-up, the Kaplan-Meier 5-year survival rate was 71% with no significant difference between the groups (3-year survival: Cabrol, 76%; Bentall, 79%; and button, 81%; p = 0.28). The 3-year freedom from reoperation was 95% (Cabrol, 97%; Bentall, 91%; and button, 100%; p = 0.17). We conclude that for patients undergoing reoperation or complicated repairs or when tension on the ostial anastomoses may occur, the Cabrol technique is preferable. If feasible, however, the button technique has better long-term results for both survival and rate of reoperation. An alternative technique is to use an interposition graft to reattach the left coronary artery and excise an aortic button for the right coronary artery reattachment. This has the advantages of technical ease in reattaching the left coronary artery, good results for reattachment of the right coronary artery, minimal tension on the anastomoses, and visualization of all anastomoses.

Adolescent↗
PubMed1992

Doppler echocardiographic evaluation of pseudoaneurysms complicating composite grafts of the ascending aorta.

BACKGROUND: Pseudoaneurysms of the ascending aorta is a rare and serious complication after composite graft surgery for combined disorders of the aortic valve and ascending aorta. METHODS AND RESULTS: Echocardiographic and Doppler findings are described in eight patients (seven men, one woman; mean age, 45 +/- 12 years) with documented pseudoaneurysm of the ascending aorta and are compared with those by aortography and at surgery. The diameter of the ascending aorta ranged from 6 to 14 cm. Pseudoaneurysm was diagnosed by echocardiography in seven cases (six transthoracic, one transesophageal), by aortography in five, and by both methods in all patients. All three patients not diagnosed by aortography had a single dehiscence at the aortic annulus anastomosis. Five patients had more than one site of origin of the pseudoaneurysm. Periannular dehiscence (n = 7) was identified by color flow Doppler in six cases and by aortography in only one, and coronary artery dehiscence (n = 6) was detected by echocardiography in three and by aortography in two arteries. Of the three patients with distal graft dehiscence, one was identified by aortography and none by echocardiography. In cases of dehiscence at the aortic annulus, continuous wave Doppler further supported the diagnosis by demonstrating two distinct jets, one through the prosthetic valve and another with higher velocity through the communication. CONCLUSIONS: Echocardiography with Doppler can diagnose the presence of pseudoaneurysms complicating composite grafts and identify their proximal sites of origin. Furthermore, it complements aortography in the overall evaluation of patients with suspected pseudoaneurysm, particularly in those with single dehiscence of the graft at the aortic annulus anastomosis.

Adult↗
PubMed1992

Thoracoabdominal aortic aneurysms associated with celiac, superior mesenteric, and renal artery occlusive disease: methods and analysis of results in 271 patients.

Two hundred seventy-one of 1509 patients who underwent thoracoabdominal aortic repairs had either celiac or superior mesenteric or renal artery occlusive disease. These latter patients were treated by endarterectomy or bypass between June 20, 1960 and Jan. 10, 1991. After 1987, the 30-day survival rate was 93% (79 of 85) compared with 90% (245 of 271) before 1988. Multivariate predictors of death were age, postoperative reoperation for bleeding, and cardiac complications (p less than 0.05). Renal complications (13% dialysis, 35 of 271) were associated with preoperative renal dysfunction, elevated preoperative serum creatinine level, urine clearance time of dye, extent of the aorta replaced, coagulopathy, and paraplegia or paraparesis (p less than 0.05). The incidence of postoperative renal dysfunction was reduced by renal artery endarterectomy (p less than 0.05). On univariate analysis the risk of renal failure was reduced by renal artery perfusion with cold Ringer's lactate solution (p less than 0.05). Gastrointestinal complications (9%, 25 of 271) were associated with a history of peptic ulcer disease on multivariate analysis (p less than 0.05). The Kaplan-Meier 5-year survival rates for patients with and without occlusive disease were 53% and 60%, respectively, and at 10 years 37% and 30%, respectively (p = 0.08). We conclude that endarterectomy or bypass of occlusive visceral disease reduces the risk of renal failure after thoracoabdominal aortic aneurysm repairs, does not decrease early or late survival, and does not increase the risk of gastrointestinal complications.

Aged↗
PubMed1992

Surgery for acute dissection of ascending aorta. Should the arch be included?

Thirty-day and 1-, 5-, 10-, and 20-year overall survivorships among 82 patients undergoing replacement of the ascending aorta with or without the arch for acute aortic dissection between 1968 and May 1989 were 79%, 66%, 56%, 46%, and 30%, respectively. The multivariably determined risk factors for death were the inclusion of the arch in the replacement, the year of the operation, the predissection New York Heart Association functional class, diabetes, and concomitant coronary artery bypass grafting. The current 30-day survivorship predicted by the multivariable equation when the operation involves only the ascending aorta is 97%, and the 10- and 20-year predicted survivorships are 61% and 39%, respectively. When the current era the replacement involves the arch as well as the ascending aorta, the predicted 30-day survivorship is 84%, and the 10- and 20-year ones are 48% and 31%. In 1990 sixteen additional patients (one hospital death) underwent ascending aortic replacement, and six (no hospital deaths) ascending aorta and arch replacement. The predictions for 1990 from the multivariable equation were similar to these actual experiences (Ps for differences were 0.6 and 0.4). Seventy percent of surviving patients with DeBakey type I dissection were free of a second aortic operation for aneurysmal dilation of the distal false channel, but this occurred in none of nine patients in whom an intimal tear in the transverse arch was included in the resection.

Acute Disease↗
PubMed1992

Thoracoabdominal aortic aneurysm associated with umbilical artery catheterization: case report and review of the literature.

Aneurysms in infants and children are rare and are usually associated with cardiovascular malformations or connective tissue disorders. A new subgroup of patients has become recognized over the past two decades--those with aneurysms associated with umbilical artery catheterization. Critically ill newborns who have required umbilical artery catheterization and have developed sepsis, usually staphylococcal, are at risk for the development of mycotic aneurysm disease of the aorta or its major branches or both. Since first described in 1970, 34 cases have been reported in the literature, 14 involving the descending thoracic aorta, 10 the abdominal aorta, 6 the iliac arteries, and 4 either the thoracoabdominal aorta or multiple aneurysms involving both the thoracic and abdominal aorta. This report presents a case we recently treated of a 15-month-old-boy with a large thoracoabdominal aortic aneurysm and aneurysms of the infrarenal abdominal aorta and proximal right common iliac artery. It includes a review of the recent literature to analyze pathogenesis, clinical manifestations, and to formulate methods of treatment.

Aorta, Abdominal↗
PubMed1991

Cefamandole levels during thoracoabdominal aortic aneurysm surgery.

The pharmacokinetics of prophylactic antibodies may differ in cardiac and aortic aneurysm surgery for at least two reasons: aortic aneurysm surgery generally entails a greater blood volume loss and replacement, and aortic aneurysm surgery usually does not require extracorporeal cardiopulmonary bypass. We prospectively studied two different cefamandole dosing regimens in patients undergoing aortic aneurysm surgery (phase 1, 1 gm intravenously at the induction of anesthesia; phase 2, 2 gm intravenously at the induction of anesthesia followed by 1 gm intravenously every 2 hours during surgery). In phase 1 and 2 plasma levels were measured at the time of skin incision, aortic cross-clamping, aortic unclamping, and skin closure. In phase 2 cefamandole elimination in urine and cell-saver effluent was also determined. An adequate plasma level of 10 micrograms/ml was maintained in only 4 of 14 patients in phase 1, but in 10 of 10 patients in phase 2. Cefamandole loss in cell-saver effluent was 136 +/- 100 mg, which was 13% of the measured renally excreted amount. As has been previously shown in cardiac surgery, a cefamandole prophylactic antibiotic regimen of 2 gm intravenously at the induction of anesthesia followed by 1 gm every 2 hours during surgery provides a dependable and practical dosing regimen in patients undergoing aortic aneurysm surgery.

Aged↗
PubMed1991

Ruptured aneurysm of the descending thoracic and thoracoabdominal aorta. Analysis according to size and treatment.

Acute rupture was confirmed at operation in 117 patients treated for descending thoracic or thoracoabdominal aortic aneurysm. Descending thoracic (n = 80) aortic rupture occurred into lung or esophagus in 8, the pleural cavity in 49, and the mediastinum in 23. Upper abdominal aortic (n = 37) rupture occurred into peritoneal cavity in 3 and into retroperitoneal tissues in 34. Aneurysmal size (range, 5 to 17 cm; median, 8 cm) could be determined retrospectively in 86 patients; 59 (74%) descending thoracic and 27 (73%) abdominal aorta. Size (external diameter) in the former was 8 (14%), 5 to 6 cm; 21 (36%), 6 to 8 cm; 23 (39%), 8 to 10 cm; and 7 (12%) greater than 10 cm. Size at the abdominal site was similar. Thus size was not greater than 10 cm in 52 (88%) (range, 5 to 10 cm), which contradicts opinions that thoracic aneurysms rupture only when size exceeds 10 cm. Twenty-nine patients (25%) were hypotensive (systolic blood pressure less than 100 mmHg), of whom 16 (55%) had cardiac arrest before operation. Associated conditions included advanced age (greater than or equal to 75 years) in 26 (22%), coronary artery disease in 41 (35%), chronic obstructive pulmonary disease in 46 (39%), renal insufficiency in 25 (21%), and cardiovascular disease in 22 (18%). The overall early survival rate (30-day) was 89 of 117 patients (76%); 69% in patients with hypotension, 56% of patients with cardiac arrest, 88% in good-risk patients. Five-year (Kaplan-Meier) survival was 28%. Because elective operation is associated with 92% survival, this should be considered before rupture when aneurysm is 5 cm or larger in good-risk patients, in patients with symptomatic aneurysms, and in most patients with larger aneurysms.

Adolescent↗
PubMed1991

A prospective study of respiratory failure after high-risk surgery on the thoracoabdominal aorta.

From June 1960 to September 1990, 1414 patients underwent repair of thoracoabdominal aortic aneurysms, of whom 112 (8%) had pulmonary complications requiring respiratory support with tracheostomy; subsequently 45 (40%) died in the hospital. We determined by stepwise logistic regression analysis, in a prospective study of high-risk type I and II thoracoabdominal aortic aneurysms repairs, the independent predictors of respiratory failure, defined as respiratory ventilation exceeding 48 hours after operation. In 98 patients studied, 38 (39%) were women, 60 (61%) were men, 54 (55%) had type II thoracoabdominal aortic aneurysms, 34 (35%) had aortic dissection, 19 (19%) were nonsmokers, 40 (41%) exsmokers, and 39 (40%) active smokers. Before operation, 55 (56%) had chronic pulmonary disease with respiratory failure developing in 58% (p = 0.0005 versus no chronic pulmonary disease, 10/43, 23%), and of the 26 patients in the lower quarter of forced expiratory volume (1 sec) (FEV1 less than or equal to 1.45 L) respiratory failure developed in 61% (p = 0.035). In-hospital survival was 98% and 83% (p = 0.008), respectively, and cumulative survival at 6 months by Kaplan-Meier analysis was 96% and 80% (p = 0.004, log-rank test), respectively, for patients without respiratory failure (N = 56/98, 57%) and with respiratory failure (N = 42/98, 43%). On univariate analysis, the following were associated with respiratory failure (p less than 0.05): FEV1, FEV1% predicted, FVC, FEF25, FEF25% predicted, FEF25-75, FEF25-75% predicted, PaCO2 Pao2, symptoms, smoking history, chronic pulmonary disease, cryoprecipitate volume, postoperative neuromuscular deficit, cardiac complications, reoperation for bleeding, renal complication, stress ulceration, postoperative creatinine level, postoperative dialysis, and postoperative encephalopathy. The independent predictors of respiratory failure were (p less than 0.05): chronic pulmonary disease, smoking history, cardiac and renal complications. In patients with chronic pulmonary disease, the only independent predictor was FEF25 (p = 0.030). These observations may be of value in selecting patients for elective operation.

Adult↗
PubMed1991

A prospective randomized study of cerebrospinal fluid drainage to prevent paraplegia after high-risk surgery on the thoracoabdominal aorta.

This article is concerned with the study of the effect of several variables, principally that of cerebrospinal fluid drainage, on the incidence of neurologic deficit in a prospective randomized series of patients with extensive aneurysms of the descending thoracic and abdominal aorta (thoracoabdominal type I and II). Forty-six patients had cerebrospinal fluid drainage, and 52 were controls, with a total of 98 available for study. Cerebrospinal fluid pressure was continuously monitored in the former group and pressure maintained less than or equal to 10 mm Hg in 20, less than or equal to 15 mm Hg in 20, and greater than 15 mm Hg in 6 patients during period of aortic clamping. The method of treatment including reattachment of intercostal and lumbar arteries (p = 0.2), temporary atriofemoral bypass during aortic occlusion (p = 0.3), and spinal fluid drainage (p = 0.8) were not statistically significant in reducing the incidence of neurologic deficits. Thus cerebrospinal fluid drainage as we used it, was not beneficial in preventing paraplegia. On appropriate statistical analysis we found that the only significant predictor of delayed deficits was postoperative hypotension (p = 0.006).

Aortic Dissection↗
PubMed1990

Treatment of postoperative infection of ascending aorta and transverse aortic arch, including use of viable omentum and muscle flaps.

Postoperative infection of the ascending aorta and aortic arch in 40 patients was treated by antibiotic therapy alone (4 patients) or by operation and lifelong suppressive antibiotic therapy (36 patients). Complications of infection included antibiotic-resistant infection, infected false aneurysm, rupture of suture line, aortocutaneous fistulas, aortic-right ventricular fistulas, arterial embolus, aortic valve insufficiency, aortobronchial fistula, mediastinal abscess, and chest wall problems. These were treated by a variety of operations including composite valve-graft replacement, graft replacement, patch-graft closure of false aneurysm, simple suture of disrupted suture lines and false aneurysm, and debridement of mediastinum and chest wall. The area of reconstruction was covered, and mediastinal dead space was reduced by mobilization of viable tissue, including local tissue and distant structures such as flaps of muscle and omentum. Thirty-three patients (83%) were early survivors, and 28 patients (70%) were alive and well at last follow-up 4 months to 6.5 years after operation.

Adult↗
PubMed1990

Diffuse aneurysmal disease (chronic aortic dissection, Marfan, and mega aorta syndromes) and multiple aneurysm. Treatment by subtotal and total aortic replacement emphasizing the elephant trunk operation.

The life expectancy of patients with aortic aneurysm is significantly prolonged by graft replacement therapy. Regardless, a significant predictor of late death is complications of either residual aortic aneurysmal disease or the development of additional aortic aneurysm. This paper reviews a personal experience in the treatment of 4170 patients with aneurysmal disease of either dissection or medial degenerative origin, indicating that multiple segment involvement was or became present in 1262 (30%) patients, 463 (67%) of 694 patients with dissection, and 799 (23%) of 3476 patients without dissection. Regardless of etiology, multiple involvement varied with the location of the presenting involved segment, i.e., ascending aorta (38%), ascending and arch (70%), descending thoracic aorta (73%), and abdominal aorta (26%). This study was limited in detail to 811 patients who had ascending and ascending and aortic arch replacement for aneurysm. These patients were divided into 3 subgroups: (1) 524 patients with no distal disease; (2) 135 patients with distal disease treated by subtotal replacement in 82 and total replacement in 53; and (3) 152 patients with distal disease not treated. The 5-year survival rate from the time of first operation, including early death from operation was 75% in group 1, 65% in group 2, and 39% in group 3. The causes of death in group 3 patients were aneurysmal rupture and/or associated disease. It is concluded that initial total aortic study and regular postoperative monitoring with computed tomographic scanning is indicated to detect extensive disease or recurrence of disease and that aggressive replacement is indicated except in patients with associated disease that does not permit operation.

Adolescent↗
PubMed1990

Dissection of the aorta and dissecting aortic aneurysms. Improving early and long-term surgical results.

We report the improving surgical results in a consecutive series of 690 patients referred to one of us (E.S.C.) for aortic dissection between December 1956 and September 1989, a substantial portion of whom had dissection as a complication of either previous aortic (n = 113, 16) or previous cardiac (n = 54, 8%) operation. Our initial operation of choice in patients requiring multiple operations in this group of 690 patients was based on the most life-threatening or symptomatic aortic segment involved, which was ascending aorta and/or aortic arch (Asc/Arch) in 301 (44%) patients, descending thoracic aorta (Desc) in 195 (28%) patients, and thoracoabdominal aorta (TaA) in 194 (28%) patients. As detailed below, considerable improvement occurred in the 30-day survival rates over time, particularly for acute dissection: [table; see text] The independent determinants of both early and long-term mortality were identified. Independent determinants of late fatal rupture, reoperation, and neuromuscular dysfunction for distal dissectors were also identified. In our experience, continued aggressive surgical intervention for aortic dissection with modern operative techniques has resulted in markedly improved 30-day operative survival (approaching 95% including those patients with acute dissection) and significant improvement in late results.

Acute Disease↗