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Biomedical subjects

J S Coselli

Publications and source records attributed to J S Coselli.

83 records · Page 5Linked to original sources
PubMed1984

Reevaluation of early evacuation of clotted hemothorax.

During an 181/2 year period, we encountered 14,300 patients with blunt or penetrating thoracic or thoracicoabdominal trauma. In 155 patients, residual clotted hemothorax or empyema developed later. Thirty-nine patients underwent early evacuation of clotted hemothorax with no mortality and an average hospital stay of only 10 days. When progression to empyema occurred, the mortality rate increased to 9.4 percent and the average hospital stay to 37.9 days. The most common related event in the development of empyema was concurrent injury to intraabdominal organs and the inevitable bacterial contamination of the thorax. In a small number of patients, tube thoracostomy drainage is inadequate and results in residual clotted hemothorax. Despite recent pleas for conservative, expectant management, it is our experience that early evacuation of clotted hemothorax is not only cost-effective, it is also associated with lower morbidity, lower mortality, and reduces the chance of development of empyema.

Abdominal Injuries↗
PubMed1983

Traumatic bronchobiliary fistula.

Bronchobiliary fistulae have very rarely been reported as a result of trauma. Herein, a case is reported and seven previous cases discussed. All were a result of thoraco-abdominal injuries and all had biliptysis. Early exploration via a transthoracic approach is recommended. This approach resulted in a shortened hospital stay and decreased morbidity.

Abdominal Injuries↗
PubMedDate not supplied

Treatment of acute aortic dissection involving the right coronary artery and aortic valve.

A complication of acute dissection of the ascending aorta is involvement of the aortic valve and right coronary artery. A case is presented in which the treatment of this lesion involved placement of a composite valve graft with reattachment of the left main coronary artery using a small Dacron tube graft and a saphenous vein bypass to the right coronary artery.

Acute Disease↗
PubMedDate not supplied

Bilateral external iliac artery injury from a single missile.

Bilateral vascular injuries either from penetrating or blunt trauma are rare. This report of a patient with injury to both external iliac arteries stresses the need for early operation in abdominal vascular trauma, the occasional need for groin incisions to obtain distal vascular control and the advantages of prosthetic replacement when extensive injuries are present in large vessels.

Adult↗
PubMedDate not supplied

Aortic root surgery in Marfan syndrome: current practice and evolving techniques.

BACKGROUND: Our current approach to aortic root disease in patients with Marfan syndrome is replacement with a composite valve graft, a technique with established excellent early and long-term results. The purpose of this report is to retrospectively review our results with aortic root replacement in Marfan patients and to discuss the status of several alternative techniques, chiefly aimed at eliminating the need for a mechanical valve, that are currently under investigation. PATIENTS AND METHODS: In patients with Marfan syndrome, we perform aortic root replacement for all ascending aortic dissections and significant annuloaortic ectasia or aortic valvular insufficiency. We reserve concomitant mitral valve surgery for those patients with clinically significant regurgitation. From February 1991 through July 1996, 45 patients with Marfan syndrome underwent aortic root replacement; 44 of the patients (97.8%) had composite valve grafts placed. Thirteen patients (28.9%) required concomitant graft replacement of the transverse aortic arch and four patients (8.9%) underwent concurrent mitral valve replacement. RESULTS: There were no intraoperative deaths, two early deaths (4.4%), and no postoperative strokes. No patient has developed evidence of an anastomotic pseudoaneurysm nor graft infection during follow-up. CONCLUSIONS: Composite valve graft replacement of the aortic root carries low morbidity and mortality, produces excellent long-term results, and currently remains the treatment of choice for proximal dissection or significant annulo-aortic ectasia in patients with Marfan syndrome. Alternative techniques are evolving; however, further long-term data demonstrating durability that compares favorably to established techniques will be required before recommending their routine use.

Adolescent↗
PubMedDate not supplied

Current status of thoracoabdominal aortic aneurysm repair in Marfan syndrome.

BACKGROUND: Patients with Marfan syndrome frequently develop aneurysms or dissections involving multiple segments of the aorta; graft replacement of multiple aortic segments prolongs survival. Indications for graft replacement of the thoracoabdominal aortic segment include impending rupture, ischemic complications from dissection, or an aortic diameter measuring 5.5 cm or more. We retrospectively reviewed our experience with 50 consecutive thoracoabdominal aortic aneurysm repairs in Marfan patients to evaluate the results of surgery using contemporary techniques. PATIENTS AND METHODS: From January 1986 through July 1996, 800 patients underwent graft replacement of thoracoabdominal aortic aneurysms. Fifty patients (6.3%) had Marfan syndrome. Aneurysms without dissection were present in nine (18%) of the Marfan patients. The remaining 41 patients (82%) had chronic dissection. Both chronic dissection and Crawford extent II aneurysms were more prevalent in patients with Marfan syndrome than in non-Marfan patients. Extensive thoracoabdominal aortic aneurysm repairs (extents I and II) were performed in 72% of Marfan patients; atriodistal bypass was used in 22 patients (44%). RESULTS: The 30-day survival rate was 96%. Renal failure requiring hemodialysis occurred in three patients (6%). Two patients (4%) had postoperative lower extremity neurological deficits. No patient receiving atriodistal bypass developed paraplegia or paraparesis, versus two patients (7.1%) among the 28 who did not. CONCLUSION: Patients with Marfan syndrome have a high prevalence of extent II aneurysms and associated dissection. Using contemporary surgical techniques, Marfan patients can undergo thoracoabdominal aortic aneurysm repair with low mortality and morbidity, despite the extensive nature of their disease.

Adult↗
PubMedDate not supplied

Individual strategies of hemostasis for thoracic aortic surgery.

The problem of altered hemostasis remains a major challenge during thoracic aortic surgery. Bleeding is associated with a marked increase in morbidity and mortality. The hemostatic derangements are caused by multiple interrelated factors including interference with the vascular integrity, extensive surgical dissection, transient need for complete inhibition of the normal coagulation process, large blood products and fluid requirements, hemodilution, hypothermia, extensive ischemia and reperfusion, activation of systemic inflammatory responses, interference with fibrinolysis, and the use of extracorporeal circulation systems. Acquired coagulopathy must be specifically diagnosed and treated. Platelet deficiencies, both qualitative and quantitative, are the most predictable and consistent disturbance in the hemostatic function and the most common cause of intraoperative and postoperative bleeding. Precise surgical technique is essential to prevent blood loss. Topical agents should not be used for and cannot correct imperfections in surgical technique. Nonspecific measurements that are useful to decrease intraoperative blood loss include strict control of blood pressure and hemodynamic status, the induction of mild controlled hypotension, and the reversal of hypothermia. Rewarming may produce clear procoagulant effects by improving the efficacy of platelets and clotting factors. Platelet dysfunction can be reduced by several pharmacological interventions including acid aminocaproic, desmopressin and aprotinin; however, efficacy and safety are still being established. The most important factorS regarding safety in thoracic aortic surgery are a secure suture line and the experience of the surgical and anesthesiology teams.

Aortic Dissection↗
PubMedDate not supplied

Natural history of descending and thoracoabdominal aortic aneurysms.

Data on the natural history of descending and thoracoabdominal aneurysms are limited to a few studies. They demonstrated that, independent from the different mechanisms of injury and degeneration affecting the structural integrity of the aortic wall, the biologic fate of all aneurysms is progressive enlargement and rupture. Laminated thrombus and calcification do not prevent this process. The natural history is markedly influenced by size, location, symptoms, and etiology of thoracic aneurysms. They may develop symptoms related to mechanical compression of adjacent structures, but more frequently they are asymptomatic until rupture occurs. Usually, aortic rupture causes death by exsanguination and shock before bleeding can be controlled. Occasionally, rupture can be contained by the parietal pleura or occur towards the mediastinum, esophagus, pulmonary parenchyma, or bronchi. Untreated aneurysms will cause death in the majority of patients because of rupture. Recent data evaluating smaller and asymptomatic thoracic aneurysms with CT scan support nonoperative management and close follow-up of descending and thoracoabdominal aortic aneurysms only when the diameter is less than 5 cm. Patients with Marfan syndrome may be operated upon with smaller aneurysms. Independent of etiology, operative repair is the most effective means to alter the otherwise malignant course of descending and thoracoabdominal aortic aneurysms. The role of endovascular repair of these aneurysms remains to be established; however, it may represent an alternative to treat thoracic aneurysmal disease in very high risk patients.

Aortic Dissection↗
PubMedDate not supplied

Experience with retrograde cerebral perfusion during proximal aortic surgery in 290 patients.

BACKGROUND: We currently routinely use profound hypothermic circulatory arrest (PHCA) with retrograde cerebral perfusion (RCP) during repair of proximal aortic dissection and aneurysms involving the transverse aortic arch. Experimental data regarding the efficacy of RCP are conflicting. We retrospectively reviewed our experience with proximal aortic surgery to compare the results of PHCA performed with and without RCP. PATIENTS AND METHODS: From January 1987 through July 1996, 590 patients underwent ascending or transverse aortic arch operations. Of the 479 patients who required PHCA, RCP was utilized in 290 (60.5%). The patients who did not receive RCP had a higher prevalence of preexisting cerebrovascular disease, diabetes, and aortic dissection than those who did. RESULTS: Overall 30-day and in-hospital mortality rates were 7.9% (38/479) and 8.8% (42/479), respectively; six (1.3%) intraoperative deaths were excluded from the analysis regarding neurologic complications. There were 19 strokes (4.0%). Comparing the patients who had RCP with those who did not, 30-day mortality rates were 3.4% (10/290) vs. 14.8% (28/189, p < 0.001), in-hospital mortality rates were 3.4% (10/290) vs. 16.9% (32/189, p < 0.001), and stroke rates were 2.4% (7/289) vs. 6.5% (12/184, p < 0.05), respectively. CONCLUSIONS: Patients who had RCP during PHCA had lower mortality and stroke rates than those who did not. Although the higher prevalence of cerebrovascular disease, diabetes, and dissection in the latter group may have contributed to these differences, the clinical results confirm the safety and potential benefits of RCP, further supporting its use during proximal aortic surgery requiring circulatory arrest.

Adolescent↗