Saphenectomy wound complications: fact or fiction.
Explore the source record for details and available documents.
Coronary Artery Bypass↗
Biomedical subjects
K B Allen
Publications and source records attributed to K B Allen.
Transmyocardial laser revascularization: surgical experience overview.
Transmyocardial revascularization (TMR) using holmium:yttrium-aluminium-garnet (YAG) and carbon dioxide lasers has been approved by the United States Food and Drug Administration for the treatment of medically refractory angina in patients without conventional options. In prospective, randomized trials, patients who received TMR experienced improved angina, better-event free survival, and reduction in cardiac-related rehospitalizations when compared to patients remaining on medical therapy alone. In addition, TMR as an adjunct to coronary artery bypass grafting (CABG) has resulted in improved clinical status for patients who would not be completely revascularized by CABG alone.
Angina Pectoris↗
Facile location of the saphenous vein during endoscopic vessel harvesting.
Endoscopic techniques are used more frequently to harvest the saphenous vein for cardiac and peripheral vascular procedures. To identify the saphenous vein through an initial small access incision can be difficult. We describe the use of a portable intraoperative ultrasound system to expeditiously identify the saphenous vein during endoscopic harvesting, particularly in obese patients.
Body Weight↗
Endoscopic and traditional saphenous vein harvest: a histologic comparison.
BACKGROUND: Vein trauma after saphenectomy by endoscopic or longitudinal techniques may influence the progression of medial and intimal hyperplasia and ultimately affect graft patency. This study compared the histologic characteristics of saphenous veins after endoscopic and longitudinal harvest. METHODS: One hundred seventy patients who underwent elective coronary artery bypass grafting had saphenectomy performed endoscopically (n = 88) or by a longitudinal incision (n = 82). Cross-sectional specimens from endoscopically (n = 151) and longitudinally (n = 158) harvested veins were submitted for hematoxylin-eosin, trichrome, and elastin staining. Blinded histologic evaluation involved graded analysis of endothelial, smooth muscle, and elastic lamina continuity in addition to medial and adventitial connective tissue uniformity. RESULTS: Regardless of harvest technique, endothelial, elastic lamina, and smooth muscle continuity as well as medial and adventitial connective tissue uniformity were not significantly different. CONCLUSIONS: Minor histologic alterations occur during saphenectomy, however, endoscopically and longitudinally harvested saphenous veins are histologically similar.
Endoscopy↗
Management of closed space infections associated with endoscopic vein harvest.
Wound complications are uncommon following endoscopic saphenous vein harvest. However, closed space infections within the endoscopic tunnel may occur and are difficult to manage. We describe the management of closed space infection in 3 patients and a method that allows drainage without unroofing the endoscopic tunnel.
Drainage↗
Transmyocardial laser revascularization combined with coronary artery bypass grafting: a multicenter, blinded, prospective, randomized, controlled trial.
OBJECTIVE: We sought to assess the safety and efficacy of transmyocardial revascularization combined with coronary artery bypass grafting in patients not amenable to complete revascularization by coronary bypass alone. METHODS: A total of 263 patients whose standard of care was coronary artery bypass grafting and who had one or more ischemic areas not amenable to bypass grafting were prospectively randomized to receive coronary bypass of suitable vessels plus transmyocardial revascularization to areas not graftable (n = 132) or coronary bypass alone with nongraftable areas left unrevascularized (n = 131). Group preoperative demographics and operative characteristics were similar. RESULTS: The operative mortality rate after coronary bypass/transmyocardial revascularization was 1.5% (2/132) versus 7.6% (10/131) after coronary bypass alone (P =.02). Patients undergoing both coronary bypass and transmyocardial revascularization required less postoperative inotropic support (30% vs 55%, P =.0001) and had a trend toward fewer insertions of intra-aortic balloon pumps (4% vs 8%, P =.13) than did patients having coronary bypass alone. Multivariable predictors of operative mortality were coronary artery bypass alone (odds ratio, 5.3; 95% confidence interval, 1.1-25.7; P =.04) and increased age (odds ratio, 1.1; 95% confidence interval, 1. 0-1.2; P =.03). One-year Kaplan-Meier survival (95% vs 89%, P =.05) and freedom from major adverse cardiac events defined as death or myocardial infarction (92% vs 86%, P =.09) favored the combination of coronary bypass and transmyocardial revascularization. Baseline to 12-month improvement in angina and exercise treadmill scores was similar between groups. CONCLUSIONS: In a prospective, randomized, multicenter trial, transmyocardial revascularization combined with coronary artery bypass grafting in patients not amenable to complete revascularization by coronary bypass alone was safe; however, angina relief and exercise treadmill improvement were indistinguishable between groups at 12 months of follow-up. Operative and 1-year survival benefits observed after adjunctive transmyocardial revascularization require confirmation by a larger validation study, which is ongoing.
Coronary Artery Bypass↗
Risk factors for leg wound complications following endoscopic versus traditional saphenous vein harvesting.
BACKGROUND: Risk factors for leg wound complications following traditional saphenectomy have included: obesity, diabetes, female gender, anemia, age, and peripheral vascular disease. Use of an endoscopic saphenectomy technique may modify the risk factor profile associated with a traditional longitudinal incision. METHODS: From September 1996 to May 1999, 276 consecutive patients who underwent elective isolated coronary artery bypass grafting performed by a single surgeon (K.B.A.) had their greater saphenous vein harvested endoscopically. During the period from January 1999 to May 1999, the surgical records of 643 patients who underwent the same operation and had a traditional longitudinal saphenectomy were reviewed for postoperative leg wound complications. Group demographics were similar regarding preoperative risk stratification and traditionally identified wound complication risk factors (diabetes, gender, obesity, preoperative anemia, and peripheral vascular disease). Leg wound complications were defined as: hematoma, dehiscence, cellulitis, necrosis, or abscess requiring dressing changes, antibiotics and/or debridement prior to complete epithelialization. Follow-up was 100% at six weeks. RESULTS: Leg wound complications following endoscopic harvest occurred in 3% (9/276) of patients versus 17% (110/643) of traditional harvest patients (p < 0.0001). No univariate risk factors for wound complications were associated with endoscopic saphenectomy. Univariate predictors of wound complications following traditional saphenectomy included: diabetes (p = 0.001), obesity (p = 0.0005), and female gender (p = 0.005). Multivariable risk factors for leg wound complications following saphenectomy were traditional harvest technique (OR 7.56, CI 3.8-17.2, p < 0.0001), diabetes (OR 2.10, CI 1.4-3.2, p = 0.0006) and obesity (OR 1.82, CI 1.2-2.8, p = 0.007). CONCLUSIONS: Traditional longitudinal saphenectomy is a multivariable risk factor for development of leg wound complications. Endoscopic saphenectomy modifies the risk factor profile for wound complications and should be the standard of care, particularly for obese and/or diabetic patients who require venous conduit during coronary artery bypass grafting.
Aged↗
Comparison of transmyocardial revascularization with medical therapy in patients with refractory angina.
BACKGROUND: Transmyocardial revascularization involves the creation of channels in the myocardium with a laser to relieve angina. We compared the safety and efficacy of transmyocardial revascularization performed with a holmium laser with those of medical therapy in patients with refractory class IV angina (according to the criteria of the Canadian Cardiovascular Society). METHODS: In a prospective study conducted between March 1996 and July 1998 at 18 centers, 275 patients with medically refractory class IV angina and coronary disease that could not be treated with percutaneous or surgical revascularization were randomly assigned to receive transmyocardial revascularization followed by continued medical therapy (132 patients) or medical therapy alone (143 patients). RESULTS: After one year of follow-up, 76 percent of the patients who had undergone transmyocardial revascularization had improvement in angina (a reduction of two or more classes), as compared with 32 percent of the patients who received medical therapy alone (P<0.001). Kaplan-Meier survival estimates at one year (based on an intention-to-treat analysis) were similar for the patients assigned to undergo transmyocardial revascularization and those assigned to receive medical therapy alone (84 percent and 89 percent, respectively; P=0.23). At one year, the patients in the transmyocardial-revascularization group had a significantly higher rate of survival free of cardiac events (54 percent, vs. 31 percent in the medical-therapy group; P<0.001), a significantly higher rate of freedom from treatment failure (73 percent vs. 47 percent, P<0.001), and a significantly higher rate of freedom from cardiac-related rehospitalization (61 percent vs. 33 percent, P<0.001). Exercise tolerance and quality-of-life scores were also significantly higher in the transmyocardial-revascularization group than in the medical-therapy group (exercise tolerance, 5.0 MET [metabolic equivalent] vs. 3.9 MET; P=0.05); quality-of-life score, 21 vs. 12; P=0.003). However, there were no differences in myocardial perfusion between the two groups, as assessed by thallium scanning. CONCLUSIONS: Patients with refractory angina who underwent transmyocardial revascularization and received continued medical therapy, as compared with similar patients who received medical therapy alone, had a significantly better outcome with respect to improvement in angina, survival free of cardiac events, freedom from treatment failure, and freedom from cardiac-related rehospitalization.
Aged↗
Cardiac sympathetic denervation after transmyocardial laser revascularization.
BACKGROUND: Transmyocardial laser revascularization (TMR) has been shown to improve refractory angina not amenable to conventional coronary interventions. However, the mechanism of action remains controversial, because improved myocardial perfusion has not been consistently demonstrated. We hypothesized that TMR relieves angina by causing myocardial sympathetic denervation. METHODS AND RESULTS: PET imaging of resting and stress myocardial perfusion with [13N]ammonia (NH3) and of sympathetic innervation with [11C]hydroxyephedrine (HED) was performed before and after TMR in 8 patients with class IV angina ineligible for CABG or PTCA. A mean of 50+/-11 channels were created in the left ventricle (LV) with a holmium:YAG laser. A semiautomated program was used to determine NH3 uptake and HED retention in the LV. Perfusion and innervation defects were defined as the percentage of LV with tracer uptake or retention >2 SD below normal mean values. All patients experienced improvement in their angina by 2.4+/-0.5 angina classes after surgery, P=0.008. Sympathetic innervation defects exceeded resting perfusion defects in all patients before TMR (34.6+/-27.3% for HED versus 9.4+/-10.8% for NH3, P=0.008). TMR did not significantly affect resting or stress myocardial perfusion but increased the extent of sympathetic denervation in 6 of 8 patients by 27.5+/-15.9%, P=0.03. In the remaining 2 patients, both sympathetic denervation and stress perfusion defects decreased after surgery. CONCLUSIONS: TMR causes decreased myocardial HED uptake in most patients without significant change in resting or stress myocardial perfusion, suggesting that the improvement in angina may be at least in part due to sympathetic denervation.
Aged↗
Pericardial effusion: subxiphoid pericardiostomy versus percutaneous catheter drainage.
BACKGROUND: Optimal management of cardiac tamponade resulting from pericardial effusion remains controversial. METHODS: Cardiac tamponade in 117 patients was treated with either subxiphoid pericardiostomy (n = 94) or percutaneous catheter drainage (n = 23). Percutaneous catheter drainage was used for patients with hemodynamic instability that precluded subxiphoid pericardiostomy. Effusions were malignant in 75 (64%) of 117 patients and benign in 42 (36%) of 117. RESULTS: Subxiphoid pericardiostomy had no operative deaths and a complication rate of 1.1% (1 of 94). In contrast, percutaneous drainage had significantly (p < 0.05) higher mortality and complication rates of 4% (1 of 23) and 17% (4 of 23), respectively. Patients with an underlying malignancy had a median survival of 2.2 months, with a 1-year actuarial survival rate of 13.8%. In comparison, patients with benign disease had a median survival of 42.8 months and a 1-, 2-, and 4-year actuarial survival rate of 79%, 73%, and 49%, respectively (p < 0.05). Effusions recurred in 1 (1.1%) of 94 patients after subxiphoid pericardiostomy compared with 7 (30.4%) of 23 patients with percutaneous drainage (p < 0.0001). CONCLUSIONS: Benign and malignant pericardial tamponade can be safely and effectively managed with subxiphoid pericardiostomy. Percutaneous catheter drainage should be reserved for patients with hemodynamic instability.
Cardiac Tamponade↗
Transmyocardial revascularization in patients with refractory, unstable angina.
BACKGROUND: Previous reports of transmyocardial revascularization (TMR) indicate a significant mortality in patients with refractory, unstable angina. We hypothesized that TMR with a holmium laser would result in significant angina relief with acceptable mortality in this patient population. METHODS AND RESULTS: Patients were defined as unstable if they were unweanable from intravenous antianginal medications or were too unstable for a persantine thallium scan. Patients had a left ventricular ejection fraction (LVEF) of > 25% and were not amenable to CABG or PTCA. Before treatment, all patients had class IV angina. TMR was performed in 85 patients, with a mean of 35 +/- 11 transmural laser channels. Mean age was 63 +/- 10 years. Mean LVEF was 48 +/- 11%. Of these patients, 79% were men. Prior CABG and/or PTCA had been performed in 87% of patients, and 72% of patients had a history of prior MI. Operative mortality was 12% (10 of 85). There were 2 deaths between discharge and 3 months after surgery and 7 late deaths from 6 to 12 months after surgery. Twelve-month mortality was 22.4% (19 of 85). At 3 months, 86% of patients had class II angina or better. At 6 and 12 months, 77% and 75% of patients, respectively, had class II angina or better. Mean angina class at 6 and 12 months' follow-up was 1.5 +/- 1.1 and 1.6 +/- 1.3, respectively. CONCLUSIONS: In patients with refractory unstable angina, TMR with a holmium laser provided significant angina relief. Moreover, 30-day operative mortality and 12-month mortality were acceptable, especially given this subset of unstable patients with refractory angina.
Aged↗
Endoscopic versus traditional saphenous vein harvesting: a prospective, randomized trial.
BACKGROUND: Saphenous vein harvested with a traditional longitudinal technique often results in leg wound complications. An alternative endoscopic harvest technique may decrease these complications. METHODS: One hundred twelve patients scheduled for elective coronary artery bypass grafting were prospectively randomized to have vein harvested using either an endoscopic (group A, n = 54) or traditional technique (group B, n = 58). Groups A and B, respectively, were similar with regard to length of vein harvested (41 +/- 8 cm versus 40 +/- 14 cm), bypasses done (4.1 +/- 1.1 versus 4.2 +/- 1.4), age, preoperative risk stratification, and risks for wound complication (diabetes, sex, obesity, preoperative anemia, hypoalbuminemia, and peripheral vascular disease). RESULTS: Leg wound complications were significantly (p < or = 0.02) reduced in group A (4% [2 of 51] versus 19% [11 of 58]). Univariate analysis identified traditional incision (p < or = 0.02) and diabetes (p < or = 0.05) as wound complication risk factors. Multiple logistic regression analysis identified only the traditional harvest technique as a risk factor for leg wound complications with no significant interaction between harvest technique and any preoperative risk factor (p < or = 0.03). Harvest rate (0.9 +/- 0.4 cm/min versus 1.2 +/- 0.5 cm/min) was slower for group A (p < or = 0.02) and conversion from endoscopic to a traditional harvest occurred in 5.6% (3 of 54) of patients. CONCLUSIONS: In a prospective, randomized trial, saphenous vein harvested endoscopically was associated with fewer wound complications than the traditional longitudinal method.
Age Factors↗
Transmyocardial revascularization utilizing a holmium:YAG laser.
OBJECTIVE: To evaluate the efficacy of transmyocardial revascularization performed on patients with refractory class IV or unstable angina with a holmium:yttrium-aluminum-garnet laser. METHODS: Transmyocardial revascularization with a holmium:yttrium-aluminum-garnet laser was performed in 42 patients with refractory angina who were not candidates for percutaneous transluminal coronary angioplasty or coronary artery bypass grafting. Patients had either Canadian Heart Association class IV angina (n = 23) or unstable angina (n = 19) and were unable to be weaned from intravenous nitroglycerin. Preoperative thallium studies identified the extent and location of reversible ischemia. Operative exposure was via a limited left anterior thoracotomy. An average of 45+/-11 laser channels were created with a mean operative time of 106+/-38 min. RESULTS: Perioperative mortality was 12% (5/42) with no late deaths. Complications included ventricular 7.1% (3/42) and atrial 4.7% (2/42) arrhythmias, reoperation for chest-wall hemorrhage 2% (1/42), and respiratory failure requiring reintubation 2% (1/42). Intra-aortic balloon pump placement was required in 12% (5/42). The mean postoperative length of stay was 5.5+/-4.9 (1-25) days. Mean follow-up on 100% of patients is 5.4+/-3.0 (1-12) months. At 3 (n = 33) and 6 (n = 21) months follow-up the mean angina class was 1.5+/-0.1 (P < 0.002) and 1.1+/-0.1 (P < 0.001), respectively. CONCLUSIONS: Transmyocardial revascularization utilizing a holmium:yttrium-aluminum-garnet laser resulted in a significant reduction in angina class and was beneficial in patients with refractory angina untreatable by conventional methods.
Angina Pectoris↗
Endoscopic saphenous vein harvesting.
Although the use of arterial conduit has decreased the amount of saphenous vein required for routine coronary artery bypass grafting, the saphenous vein as a bypass conduit remains an essential component of most practices. We describe the technique of endoscopic vein harvest that, in our initial experience with 30 patients, has improved patient satisfaction and decreased the complications associated with traditional harvest techniques.
Aged↗
Minimally invasive versus conventional reoperative coronary artery bypass.
BACKGROUND: Conventional reoperative (redo) coronary artery bypass grafting (CABG) is associated with significant morbidity. This retrospective study compared perioperative outcomes of conventional single-vessel redo CABG versus redo CABG done by a minimally invasive technique. METHODS: Group A consisted of 23 consecutive patients from September 1995 to July 1996 who underwent single vessel redo CABG of the left anterior descending artery with the left internal mammary artery using a limited anterior thoracotomy without cardiopulmonary bypass; group B consisted of 12 consecutive patients from November 1984 to July 1994 who underwent the same procedure using a median sternotomy with cardiopulmonary bypass. The two groups were similar with regard to age, sex, preoperative ejection fraction, and risk stratification. RESULTS: Mortality, cerebrovascular accidents, myocardial infarctions, and reoperations for bleeding were not significantly different between the groups. However, the patients in group A had significant reductions in atrial fibrillation, time to extubation, transfusions required, and length of cardiac recovery and hospital stay. With a mean of 12 +/- 6 months of follow-up, 87% of the patients in group A (20 of 23) are alive and asymptomatic. Actuarial survival rates for the patients in group B at 1, 2, and 10 years are 83%, 83%, and 72%, respectively. CONCLUSIONS: Minimally invasive single-vessel redo CABG can be performed safely and may reduce the morbidity associated with conventional single-vessel redo CABG.
Actuarial Analysis↗
An evaluation of the 1993-94 Bangladesh Demographic and Health Survey within the Matlab area.
Explore the source record for details and available documents.
Asia↗
Transaortic video-assisted excision of a left ventricular papillary fibroelastoma.
Explore the source record for details and available documents.
Cardiomyopathies↗