Brachial artery rupture due to an exostosis: brief report.
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Adult↗
Biomedical subjects
R Suy
Publications and source records attributed to R Suy.
Percutaneous transluminal angioplasty of the subclavian artery: early and late results.
Percutaneous transluminal angioplasty of 23 subclavian arteries was attempted in 22 patients. Dilatation was successful in 3 of 4 right subclavian artery stenoses and 18 of 19 left subclavian artery stenoses. The primary clinical indication was posterior fossa ischemia in 11 patients, upper limb ischemia in 14 and both symptoms in 6. In 2 patients, dilatation of an asymptomatic high-degree left subclavian artery stenosis was performed before coronary artery bypass surgery using the internal mammary artery. Eighteen patients on follow-up over 6-60 months (mean 25 months) are free of symptoms with equivalent systolic blood pressures in both arms. Three patients showed relapse of the stenosis after 8, 12, and 15 months; one was successfully treated with a second dilatation. Complications consisted of an occlusion at the left axillary artery puncture site and a distal embolus to a finger artery. Percutaneous transluminal angioplasty appears safe and efficient therapy for subclavian artery stenoses with excellent short- and long-term results.
Aged↗
Intraoperative angioplasty.
Of 768 angioplasties performed in our institute, 42 procedures (5%) in 39 patients were performed by a radiologist in the operating room in combination with vascular surgery; 15 ilial, 20 femoral, 5 tibial, 1 renal, and 1 brachiocephalic artery stenoses were treated. Immediate and late successes, as well as the complication rates, were comparable to those of the percutaneous approach. The main reasons for the intraoperative approach were absence of arterial pulsations, ulcerative lesions at the puncture site with risk of peripheral embolisation, and the opportunity of a surgical arteriotomy offering access to an otherwise unreachable stenotic artery. The advantages of intraoperative dilatation in combination with surgery over simple operation are the reduction of operative morbidity and mortality, shortening of the operative time, and improved results by reassuring the in- or outflow of the operated territory. The main disadvantages are the limited fluoroscopic field and the limited mobility of the fluoroscopy device.
Angioplasty, Balloon↗
Obturator bypass: a sixteen year experience with 55 cases.
Fifty-five obturator bypasses were performed over a 16 year period for limb salvage. The indications for the choice of this technique included arterial infection, aneurysm formation or soft tissue skin loss at the groin (26 patients), and extensive atherosclerotic disease of the iliofemoral vessels, precluding their use for inflow or outflow (27 patients). There were five perioperative deaths and the five-year patency rate was 37%. Long-term results after above-knee reconstruction substantially exceeded those for below-knee anastomoses (three year patency rates of 71% and 45% respectively). Due to its morbidity and mortality the decision to perform an obturator bypass should be based upon sound indications such as deep infection at the groin, or extensive multilevel arterial disease. Its usefulness in extensive multilevel arterial disease is not demonstrated.
Adult↗
Extensive disobliteration of the aorto-iliac and common femoral arteries using the LeVeen plaque cracker.
In 1978 LeVeen et al. described an original technique for extended aortobifemoral disobliteration using a retroperitoneal approach. This technique was introduced to Europe by Widdershoven and Willekens in 1977 and was adopted in Belgium by Suy and Nevelsteen in 1982 and in Spain by Cuesta and Bengoechea in 1984. A group of 228 patients treated by the LeVeen's method from 1982 to 1987 were followed-up for a mean of 21 months (1-54). Disabling claudication (66%) or more advanced ischaemia (34%) was the indication for treatment. An aorto-bifemoral endarterectomy was performed in 124 patients. Aorto-biiliac endarterectomy in 39, unilateral aortofemoral endarterectomy with a contralateral aorto-iliac endarterectomy in 17 and unilateral iliofemoral endarterectomy in 48 cases. There were seven postoperative deaths (3%) and an early thrombectomy had to be performed in 8 patients. There were 14 late deaths. Occlusion occurred in 11 patients giving a 3-year-patency rate of 97%. There were no late complications related to the technique. It is concluded that disobliteration using the LeVeen technique compares well with prosthetic grafting. Since this method does not require the use of foreign material the patient is protected from the complications sometimes seen after the insertion of prosthetic grafts.
Aorta, Abdominal↗
The value of ejection fraction as a predictor of early and late survival following aortocoronary bypass surgery in patients with moderate to severe depression of the left ventricular function.
Predictability analysis of early and late survival of coronary bypass patients with reduced left ventricular function was performed using stepwise logistic regression based on preoperative and operative data. The total perioperative mortality was 3.4% and the total actuarial survival of the whole group at 42 months was 87.7%. Thirty preoperative and operative parameters of 149 patients were entered into a first mathematical model. Four parameters were selected as a consequence: ejection fraction, anginal class, obesity, septal infarct. A prediction model based on these parameters, gave a correct prediction of the operative outcome in 99.3% of the patients. However due to the only five perioperative deaths, this model should be interpreted with caution. The accuracy of ejection fraction alone was 97.3%, the sensitivity was 100% but the specificity was only 20%. The same parameters of 97 patients were entered into a second mathematical model. Four parameters were selected in this case: ejection fraction, NYHA functional classification, septal infarct, anterior infarct. A second prediction model, based on these parameters, gave a correct prediction of the late outcome at 24 months in 93.8% of the patients. The accuracy of the discrimination on the basis of ejection fraction alone was 89.7%, its sensitivity was 96.5% but its specificity was only 41.7%. Ejection fraction was the best predictor out of the studied variables but due to its low specificity not good enough as a sole parameter.
Adult↗
Complete occlusion of the main left coronary artery. A clinical study.
Between 1975 and 1985, 12 patients with complete occlusion of the main left coronary artery (MLCA) were seen. The historical, clinical, biochemical, radiological, electrocardiographic, angiographical, surgical and follow-up findings were analyzed. Eight of the 12 patients presented on admission an unstable clinical situation. A normal ECG at rest was found in only 3 patients. Exercise testing elicited definite electrocardiographic changes in 5 of 6 cases. Coronary atherosclerosis was the cause of occlusion in 11 patients; in 1 patient the underlying disease process remained unclear. Significant lesions of the right coronary artery (RCA) were found in 9 and of the left anterior descending (LAD) or circonflex (CFLX) artery in 6 patients. Global and/or regional left ventricular dysfunction at rest was present in 10 patients. Angiographically visible collateral circulation was found in all patients but its extent was variable. All patients underwent bypass surgery. There were 1 operative and 2 late deaths.
Adult↗
Emergency coronary bypass grafting for evolving myocardial infarction. Effects on infarct size and left ventricular function.
Emergency aorta-coronary bypass grafting was performed early in the course of evolving myocardial infarction in 48 patients. The time interval between the onset of symptoms and reperfusion was 169 +/- 80 minutes. Quantitative assessment of postoperative thallium 201 myocardial scans in 19 patients revealed a significant salvage of myocardium after surgical reperfusion: The size of the residual infarction was less than 50% of that in a matched, medically treated, prospective control group (n = 39) (p less than 0.05). Postoperative equilibrium-gated radionuclide blood pool studies (technetium 99m) showed an enhanced recovery of regional and global ejection fraction after operation as compared to after medical treatment (p less than 0.05). Ultrastructural evaluation of biopsy specimens obtained during the operation delineated subendocardial necrosis in the majority of cases (72%), but subepicardial necrosis was found in only 6% of instances. Q-wave abnormalities were observed on the postoperative electrocardiogram in 50% of cases. Operative mortality was 0% in low-risk patients (i.e., hemodynamically stable condition, n = 26) and 18% in high-risk patients (i.e., cardiogenic shock including total electromechanical dysfunction, n = 22). Survival rate at 18 months was 92% +/- 4%, and 95% +/- 4% of the survivors were event free. It is concluded that early surgical reperfusion of evolving myocardial infarction limits infarct size significantly, enhances functional recovery, and may be a lifesaving operation in patients having cardiogenic shock associated with unsuccessful resuscitation.
Actuarial Analysis↗
The human umbilical vein graft in below-knee femoropopliteal and femorotibial surgery: an eight year experience.
The authors present a series of 175 femoropopliteal (below-knee) and 65 femorotibial reconstructions with the human umbilical vein (HUV) graft performed over an eight year period. With a mean follow-up of 36.7 months (range one month to 84 months) the early patency rate of 89% decreased to 54% after five years. Long-term patency was found to be primarily related to the location of the distal anastomosis and the quality of the outflow, showing a statistically significant decrease after repeat revascularization. Early thrombosis, even in the absence of a technical failure and late aneurysmal degeneration remain the major problems associated with the use of the HUV graft. It is therefore recommended that these reconstructions be preserved for patients with advanced ischemia or a limited life-expectancy.
Adult↗
A biochemical and ultrastructural study on myocardial changes during aorto-coronary bypass surgery: St. Thomas Hospital cardioplegia versus intermittent aortic cross-clamping at 34 and 25 degrees C.
The changes induced by continuous aortic cross-clamping in combination with multidose ice-cold St. Thomas Hospital cardioplegia (myocardial temperature below 16 degrees C), or intermittent aortic cross-clamping at 34 or 25 degrees C were evaluated in a randomized study on 72 patients undergoing extensive aorto-coronary bypass surgery. The cumulative release of heart-specific enzymes was very small and no marked ultrastructural changes in mitochondria of both the subepi- and the subendocardial layer of the left ventricular free wall occurred. No differences between the three operation techniques could be observed on the basis of the above-mentioned parameters. Myocardial ATP and glycogen contents were decreased in post-ischaemic tissue in both the normothermic and hypothermic intermittent aortic cross-clamp groups. This decrease was associated with a release of lactate and inorganic phosphate during the repetitive periods of reperfusion. No change in myocardial ATP and glycogen content could be observed in the cardioplegia-treated hearts. St. Thomas Hospital cardioplegia is obviously most effective in preventing changes in myocardial metabolism such as reduction of ATP and carbohydrate stores during the reversible phase of ischaemic insult.
Adenosine Triphosphate↗
How predictable is the postoperative work resumption after aortocoronary bypass surgery?
The number of aortocoronary bypass procedures increased at the Cardiovascular Surgery Department of the University Hospital in Leuven (Belgium) from 12 patients in 1971 to 650 patients in 1983. A similar evolution took place in the other existing Belgian cardiovascular centers and new departments were created to fill this need. The financial burden of the direct hospital costs of these procedures on the National Health Care program is considerable. The postoperative work-resumption will restore the patient's social dignity, it can increase the patient's personal income and thus decrease the indirect costs such as workmen's compensation; it will therefore improve the cost effectiveness of coronary surgery so that it can be offered to the numerous patients who need it for their survival or for the improvement of their quality of life. Studies about the employment status before and after aortocoronary surgery, as published from other centers, can not be projected on the Belgian situation due to the difference in population cohorts, laws regulating the working conditions, the national unemployment ratio and disability compensations. With this in mind, a study of the preoperative and postoperative employment and its predictability was undertaken.
Adult↗
Redo coronary surgery.
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Angina Pectoris↗
Nifedipine as an adjunct to St. Thomas' Hospital cardioplegia. A double-blind, placebo-controlled, randomized clinical trial.
The cardioprotective effect of the addition of the slow calcium-channel blocker nifedipine to cardioplegic solution was tested in two double-blind placebo controlled randomized studies. The first study included 24 patients undergoing aortic-coronary bypass grafting, and the second included 24 patients undergoing aortic valve replacement. Nifedipine at a dose of 200 micrograms/L or placebo was added to St. Thomas' Hospital cardioplegic solution. The following markers of ischemia were used: adenosine triphosphate and its catabolites, creatine phosphate and inorganic phosphate, determined in transmural left ventricular biopsy specimens taken before, at the end of, and after aortic cross-clamping; hemodynamic recovery 15 minutes after cessation of cardiopulmonary bypass; clinical outcome in terms of the incidence of arrhythmias, low cardiac output, positive inotropic support immediately after operation, and follow-up at 15 months. The main difference between the two studies was that myocardial temperature during cross-clamping remained constant at 14 degrees C in coronary bypass grafting but increased to 25 degrees C in valve operations despite the application of the same amounts of cardioplegic solutions. This lower temperature resulted in better preservation of high-energy phosphates in coronary bypass operations as compared to the placebo group having valve replacement operations. According to analysis of variance, a drug effect could be demonstrated only in the aortic valve replacement study: Accumulation of breakdown products of the adenine nucleotide pool was less in the nifedipine group than in the placebo group (p less than 0.05). Adenosine triphosphate decreased only to 84% in the nifedipine group and to 72% in the placebo group. Despite this adenosine triphosphate-sparing effect, weaning from cardiopulmonary bypass was more difficult in the nifedipine group. Left ventricular stroke work index 15 minutes after bypass was decreased to 72% of the prebypass value in the nifedipine group (t test, p less than 0.01) and only to 86% in the placebo group (p = NS). In contrast, after the patients were admitted to the intensive care unit, the incidence of low cardiac output tended to be lower in the nifedipine group than in the placebo group: 33% versus 58% (p = NS). In conclusion, ischemia-induced degradation of nucleotides as it occurs when myocardial cooling is inadequate can be prevented by the addition of nifedipine to the St. Thomas' Hospital cardioplegic solution. This effect, however, is not associated with an improved clinical outcome.
Adult↗
[Sciatic artery or persistent axial artery. Apropos of 2 rare variants].
Arteriography in two patients showed a persistent sciatic artery, in one case complete and the other case incomplete, associated with a persistent superficial femoral artery. One case was complicated by the presence of an aneurysm. Embryology, pathology, clinical aspects and surgical repercussions are discussed, and emphasis placed on the need for preoperative angiography to detect this embryologic variant requiring another surgical attitude.
Aged↗
Emergency bypass surgery: late effects on size of infarction and ventricular function.
Using thallium myocardial scintigraphy and radionuclide ventriculography, we assessed size of infarction and left ventricular function at late follow-up (greater than 2 months) in 13 patients who underwent emergency coronary artery bypass surgery (ECABS) during evolving myocardial infarction and in 26 controls who received conventional treatment for acute infarction. Thallium scans were quantitatively analyzed. The thallium defect, expressed as a numerical value in arbitrary units, was smaller after early revascularization (within 4 hr of the onset of symptoms, n = 10) than in the controls: 397 +/- 232 vs 2779 +/- 972 for anterior infarction (p less than .001) and 475 +/- 511 vs 1454 +/- 960 for inferior infarction (p less than .05). The patients undergoing revascularization late (4 to 5 hr after the onset of symptoms, n = 3) had thallium defects comparable to those in the controls. Regional ejection fraction of the involved left ventricular segment was higher after early revascularization (41 +/- 9% vs 21 +/- 8% for anterior infarction, p less than .005; 67 +/- 14% vs 51 +/- 11% for inferior infarction, p less than .01). Global ejection fraction was higher after early revascularization in patients with anterior infarction (57 +/- 10% vs 37 +/- 9%, p less than 0.02), but not in those with inferior infarction (60 +/- 11% vs 54 +/- 8%, p greater than .05). After late revascularization, regional and global ejection fraction were comparable to those in controls. In selected patients, early reperfusion of acutely ischemic myocardium by ECABS can limit size of infarction and preserve left ventricular function, but time constraints may be severe.
Adult↗
Platelet survival in patients with angiographically diseased and normal coronary arteries.
Platelets may contribute to the pathogenesis of atherosclerosis and to the complications of coronary artery disease. Therefore, platelet kinetics were studied in 69 patients with angiographically documented coronary artery disease and in 16 patients with a normal coronary angiogram. Platelet survival time was calculated from the decay of radioactivity after injection of 51Cr-labeled autologous platelets. None of the mathematical models used was able to discriminate between the two patients groups. No correlation existed between survival time and extent of the arterial disease. Patients with a high serum cholesterol did not exhibit an enhanced platelet consumption. Thus, these studies do not support the idea that turnover is enhanced in patients with coronary artery disease as compared to those with normal coronary arteries.
Angiography↗
Multivariate analysis of angiographic, histologic, and electrocardiographic data in patients with coronary heart disease.
In 61 consecutive patients undergoing aortocoronary bypass grafting, angiographic and electrocardiographic (ECG) changes were studied. Histologic delineation of myocardium was obtained by analysis of transmural biopsy specimens acquired at the time of surgery. The use of principal-component analysis revealed three definite groups of patients. Group I comprised patients with histologic findings associated with severe left anterior descending coronary artery (LAD) stenosis, without abnormal wall motion or ejection fraction. ECG abnormalities were limited to ST changes. Group II comprised patients with severe myocardial cell degeneration with only modest fibrosis associated with severe LAD stenosis and severely impaired wall motion. The incidence of infarction on the ECG was low. Group III patients had important myocardial cell degeneration with severe fibrosis associated with severe LAD stenosis, severely depressed wall motion, and significantly impaired ejection fraction. In this group there was a high incidence of infarction apparent on the ECG. Postoperative follow-up (24 months) showed a total survival of 94.4% in group I, 92.8% in group II, and only 72.7% in group III. This identification of subtypes of coronary artery disease seems to be helpful in estimating patient prognosis after coronary surgery.
Adult↗
Intermittent aortic cross-clamping versus St. Thomas' Hospital cardioplegia in extensive aorta-coronary bypass grafting. A randomized clinical study.
Myocardial preservation was assessed in 72 patients undergoing extensive myocardial revascularization. The patients were allocated at random to three surgical techniques: Group 1, intermittent aortic cross-clamping at 32 degrees C; Group 2, intermittent aortic cross-clamping at 25 degrees C; and Group 3, St. Thomas' Hospital cardioplegia. As intraoperative markers of ischemic damage, adenosine triphosphate, creatine phosphate, and glycogen contents were determined in transmural left ventricular biopsy specimens taken at the beginning and at the end of cardiopulmonary bypass. Ultrastructure was studied in a similar pair of biopsy specimens. Release of myocardium-specific creatine kinase isoenzyme was determined intraoperatively and postoperatively. Functional recovery was assessed before and after weaning from cardiopulmonary bypass. The incidence of low cardiac output, myocardial infarction, and rhythm disturbances was compared between groups. Finally, actuarial survival and event-free curves were studied after 18 months' follow-up. The results show a better preservation of high-energy phosphates, glycogen, and ultrastructure in the cardioplegia group as compared to the two cross-clamp groups. However, severe myocardial damage was never observed. Release of MB creatine kinase isoenzyme was the same in all three groups. Functional recovery of the hearts immediately after cessation of cardiopulmonary bypass was better in the cardioplegia group, but the incidence of rhythm disturbances (atrioventricular conduction problems) was higher in the cardioplegia group than in the other two groups (p less than 0.05). Clinical outcome in terms of incidence of perioperative infarction, survival, and event-free follow-up was not different between groups. It is concluded that both techniques (aortic cross-clamping at 32 degrees C or 25 degrees C and St. Thomas' Hospital cardioplegia) offer good myocardial protection in extensive aorta-coronary bypass operations. St. Thomas' cardioplegia, however, in contrast to intermittent aortic cross-clamping, prevents the onset of ischemia-induced deterioration of cardiac metabolism, i.e., destruction of the adenine nucleotide pool.
Adenosine Triphosphate↗