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Biomedical subjects

George J Reul

Publications and source records attributed to George J Reul.

14 recordsLinked to original sources
PubMed2006

Myocardial thievery: the coronary-subclavian steal syndrome.

Coronary-subclavian steal syndrome entails the reversal of blood flow in a previously constructed internal mammary artery coronary conduit, which produces myocardial ischemia. The most frequent cause of the syndrome is atherosclerotic disease in the ipsilateral, proximal subclavian artery. Although coronary-subclavian steal was initially reported to be rare, the increasing documentation of this phenomenon and its potentially catastrophic consequences in recent series suggests that the incidence of the problem has been underreported and that its clinical impact has been underestimated. We review the causes and background of coronary-subclavian steal; methods of preventing, diagnosing, and treating it; and the potential influence of various treatment regimens on long-term survival and the likelihood of late adverse events in patients with coronary-subclavian steal syndrome.

Anticoagulants↗
PubMed2006

Combined endovascular and surgical treatment of infected carotid-carotid bypass graft.

PURPOSE: To present a complex case involving an infected carotid-carotid bypass graft that was successfully treated with a stent-graft and subsequent surgical removal of the infected graft. CASE REPORT: A 75-year-old woman presented with persistent purulent drainage of an infected and exposed carotid-carotid prosthetic bypass graft. Wound cultures revealed methicillin-resistant Staphylococcus aureus. She was treated with appropriate intravenous antibiotic therapy without improvement in wound drainage. Because of her comorbid conditions, a decision was made to pursue endovascular revascularization of her left and right common carotid arteries (CCA), with subsequent surgical removal of the infected prosthetic graft. The patient underwent balloon angioplasty; a 7x18-mm Omnilink stent was deployed in the innominate artery and a 7x18-mm Herculink stent in the ostial left CCA. During the same procedure, the carotid-carotid bypass graft was excluded with deployment of an 8x50-mm Viabahn stent-graft in the right CCA. Several days later, the infected and now thrombosed carotid-carotid bypass graft was surgically removed, and an area of adjacent muscle was used to patch the previously excluded connection of the bypass from the right CCA. A saphenous vein patch was used to repair the defect in the left CCA. Her postoperative course was uneventful. At 1 year, the clinical and duplex examinations revealed satisfactory wound healing and patent left and right CCAs. CONCLUSION: This case indicates that a combined endovascular and surgical approach may be a safe and effective option in the treatment of carotid-carotid bypass graft infection.

Aged↗
PubMed2005

Concomitant brachiocephalic and coronary artery disease: outcome and decision analysis.

BACKGROUND: In patients with coronary artery disease, concomitant brachiocephalic disease may affect outcome and influence decision making regarding operative staging, technique, and choice of conduit. METHODS: Eighty consecutive patients (mean age, 59.3 years; 60.0% male) with concomitant brachiocephalic and coronary artery disease were identified either before (group A, n = 48) or after (group B, n = 32) coronary artery bypass grafting. Patients who had symptomatic brachiocephalic and coronary artery disease before surgery underwent concomitant brachiocephalic reconstruction and coronary artery bypass grafting using either all-vein coronary conduits (n = 41) or vein-and-internal mammary artery conduits (n = 7). Patients who had coronary-subclavian steal syndrome after coronary artery bypass (group B, n = 32) underwent either surgical (n = 5) or endovascular (n = 27) brachiocephalic reconstruction only. RESULTS: All patients were asymptomatic after intervention. Operative mortality was 4.2% for group A and 3.1% for group B. The perioperative stroke rate was 2.1% for group A and 0% for group B. Actuarial 10-year freedom from specific events for group A was as follows: death 59.9 +/- 12.8%, brachiocephalic restenosis 100%, coronary-subclavian steal syndrome 100%, myocardial infarction 83.5 +/- 10.5%, stroke 82.1 +/- 9.9%, redo coronary artery bypass grafting 95.8 +/- 4.1%, other vascular operation 82.2 +/- 8.9%, and adverse cardiac outcome (death, redo coronary artery bypass grafting, or myocardial infarction) 52.9% +/- 13.2% (for patients with all-vein conduits) or 100% (for patients with vein-and-internal mammary artery conduits). At midterm follow-up (mean, 2.92 years), both the surgical and the endovascular treatment subgroups of group B had 100% brachiocephalic patency. CONCLUSIONS: Long-term results in a limited population support continued evaluation of concomitant brachiocephalic reconstruction and coronary artery bypass grafting with use of the internal mammary artery conduit in an attempt to improve late survival in patients with concomitant disease. The excellent midterm brachiocephalic patency after either surgical or endovascular treatment of patients with coronary-subclavian steal syndrome supports continued evaluation of both methods.

Adult↗
PubMed2005

Brachiocephalic reconstruction II: operative and endovascular management of single-vessel disease.

OBJECTIVE: Although the surgical management of brachiocephalic disease is well established, evolving endovascular techniques present new options for treatment. We explored the potential benefits and drawbacks of these interventions in terms of outcome. METHODS: From 1966 to 2004, 391 consecutive patients (43.7% male; mean age, 61.9 years) with single-vessel brachiocephalic disease were treated with either operative bypass (group A; n = 229) or percutaneous transluminal angioplasty and stenting (group B; n = 162). RESULTS: All patients were asymptomatic after surgery or endovascular intervention. Group A and group B had similar operative mortality (0.9% vs 0.6%) and stroke (1.3% vs 0%) rates. However, 5 years after the procedure, group A had significantly better freedom from graft or intervention failure (92.7% +/- 2.1%) than did group B (83.9% +/- 3.7%; P = .03, Kaplan-Meier analysis; P = .001, Cox regression analysis). At 10 years, group A had the following rates of actuarial freedom from specific events: death, 73.7% +/- 4.6%; myocardial infarction, 84.2% +/- 3.6%; stroke, 91.4% +/- 3.4%; graft failure, 88.1% +/- 3.3%; coronary revascularization, 69.8% +/- 5.1%; and other vascular operation, 70.7% +/- 4.6%. Endovascular intervention involved less initial cost (mean savings, $8787 per procedure), was less invasive, and did not necessitate general anesthesia. On satisfaction questionnaires, 96.5% of patients receiving an endovascular intervention and 95.1% of patients receiving operative bypass for single-vessel brachiocephalic disease subjectively rated their treatment as "good" or "very good." CONCLUSIONS: Operative bypass and endovascular intervention for single-vessel brachiocephalic disease are both associated with acceptably low operative morbidity and mortality. Operative bypass produces significantly better mid-term freedom from graft or intervention failure than endovascular intervention and produces excellent long-term freedom from failure. Endovascular intervention offers tangible benefits regarding cost, level of invasiveness, and subjective patient satisfaction. Undetermined are the differences between the procedures regarding long-term durability, patterns of failure, efficacy as an adjunct to coronary artery bypass grafting, need for anticoagulation, efficacy as treatment for complex (multivessel) disease, and long-term cost.

Adult↗
PubMed2005

Brachiocephalic reconstruction I: operative and long-term results for complex disease.

OBJECTIVES: Complex brachiocephalic disease involves multiple vessels and is frequently associated with multisystem atherosclerosis. We reviewed surgical outcome and examined the impact of this problem on decision making regarding operative staging, technique, and choice of conduit. METHODS: Between 1966 and 2000, 157 consecutive patients (mean age, 54.0 years; 48.4% male) with innominate artery or multivessel brachiocephalic disease underwent operative reconstruction using either a transthoracic approach (group A, n = 113) or a less invasive, extrathoracic approach (group B, n = 44). Reconstruction required multiple distal anastomoses in 70 patients (44.6%), concomitant coronary artery bypass grafting (CABG) in 37 patients (23.6%), and concomitant carotid endarterectomy (CEA) in 26 patients (16.6%). RESULTS: No significant differences were found between group A and group B when operative mortality (2.7% vs 2.3%) and stroke rates (2.7% vs 6.8%) were analyzed. However, 10 years after surgery, freedom from graft failure was significantly better in group A (94.4% +/- 4.4%) than in group B (60.3% +/- 13.4%) ( P = .002). Freedom from graft failure was adversely affected by nonaortic inflow ( P = .002) and axillo-axillary cervical grafts ( P = .0001). Mortality and stroke rates for subgroups having multiple distal anastomoses (2.9%, 2/70 and 4.3%, 3/70), concomitant CABG (5.4%, 2/37 and 0, 0/37), and concomitant CEA (3.8%, 1/26 and 3.8%, 1/26) were similar to those of other patients. For the entire patient group, 10-year rates of actuarial freedom from specific events were death, 68.8% +/- 6.0%; myocardial infarction, 86.7% +/- 4.5%; stroke, 87.0% +/- 4.4%; coronary revascularization, 88.0% +/- 3.6%, and other vascular operation, 79.9% +/- 4.4%. CONCLUSIONS: Transthoracic arch reconstruction for complex brachiocephalic disease can be done with acceptably low morbidity and mortality similar to those of a less invasive, extrathoracic approach. Furthermore, the transthoracic approach is associated with significantly better long-term freedom from graft failure, possibly because it preserves aortic inflow to the great vessels. Nonetheless, the high frequency of late events in this relatively young patient population reflects the presence of multisystem atherosclerosis and suggests the need for close follow-up and lifestyle modification.

Adult↗
PubMed2004

Iatrogenic left subclavian artery-to-left brachiocephalic vein fistula: successful repair without a sternotomy.

Subclavian vein catheterization can result in arteriovenous fistula formation--a rare complication that will eventually lead to heart failure if left untreated. The world medical literature describes several subclavian artery-to-subclavian vein fistulas and 2 subclavian artery-to-brachiocephalic vein fistulas, both on the right side. To our knowledge, there have been no reports of an iatrogenic left subclavian artery-to-left brachiocephalic vein fistula. We report a case in which this complication occurred after unsuccessful transvenous pacemaker placement. We treated the fistula with a simple surgical technique that avoided the need for a sternotomy. Although stenting is typically the procedure of choice for such fistulas, our technique is useful when stenting is not indicated.

Aged↗
PubMed2002

Outcome after simultaneous abdominal aortic aneurysm repair and aortocoronary bypass.

Myocardial infarction remains the leading cause of early and late death after abdominal aortic aneurysm (AAA) repair. Myocardial revascularization is staged either before or concomitant with AAA resection, but results are far from uniform. We retrospectively analyzed our experience with patients who underwent concomitant AAA resection and aortocoronary bypass (ACB) to examine the factors affecting early morbidity/mortality and early results. Forty-two patients (all men; mean age, 67.2 years) underwent simultaneous ACB grafting and AAA repair between 1975 and 1998. All were managed postoperatively in the cardiothoracic intensive care unit (mean stay, 6.1 days). The mean total hospital stay was 17.2 days. Two died in the early postoperative period (4.8%): 1 of sustained myocardial failure following a third ACB, and 1 of coagulopathy after concomitant ACB, aortic valve replacement, and AAA. One patient developed a nonfatal MI on postoperative day 3. The incidence of wound and bleeding complications was higher for patients undergoing both ACB and AAA repair than for patients undergoing AAA resection alone. On follow-up (mean, 10 years; range, 7 months to 15 years), only 2 of 10 late deaths were due to cardiovascular causes. We believe that concomitant myocardial revascularization is warranted in select patients requiring elective or urgent AAA resection in order to decrease perioperative risk and improve late survival. Cardiac failure or ischemia during aortic surgery can be prevented by proper perfusion with or without cardiopulmonary bypass. In patients undergoing simultaneous procedures, the increased risk is related to the severity of the vascular and coronary artery disease and not to the combined operations.

Aged↗
PubMed2002

Coronary obstruction by a calcific pericardial ring.

We report the unique case of a 62-year-old man whose left anterior descending artery was intermittently obstructed by a heavily calcified pericardial ring. This is a rare case in which a coronary artery has been compressed because of constrictive pericarditis.

Calcinosis↗
PubMed2002

Aortic stent-graft infection due to a presumed aortoenteric fistula.

PURPOSE: To report a case of late stent-graft infection with aortoenteric fistula. CASE REPORT: A 76-year-old Colombian man received an AneuRx stent-graft for a 5.5-cm infrarenal AAA. The aneurysm sac progressively shrank until 22 months postoperatively, when an increase in diameter was noted on magnetic resonance imaging without evidence of endoleak or air in the sac. Two months prior, the patient had developed fever and an elevated white blood cell count; he underwent a 6-week course of intravenous antibiotics. Shortly thereafter, the fever recurred, along with progressive weight loss, which prompted admission. The computed tomographic scan showed no evidence of endoleak, but gas collection was seen anteriorly in the sac; aspirated material was positive for a variety of organisms. At surgery 23 months after stent-graft implantation, pronounced inflammatory reaction and scarring were seen around the graft in conjunction with evidence of a healed duodenal perforation, suggestive of an aortoenteric fistula. The excised stent-graft was intact; no deterioration was seen. The patient had a protracted recovery but has been afebrile and asymptomatic >1 year after stent-graft explantation CONCLUSIONS: Close surveillance after endovascular AAA repair is essential to detect late leaks, secondary migration, endotension, structural failure, and infection with or without aortoenteric fistula.

Aged↗
PubMed2002

Hypercoagulable state leading to paraplegia in a middle-aged man.

A 37-year-old man presented with an unusual thrombotic disorder characterized by acute paraplegia and the absence of palpable pulses due to extensive arterial thrombosis of the aorta and its distal branches. The patient had an extremely complicated course that necessitated multiple revascularization procedures over a 1.5-year period. This case is unusual not only because of its complexity but also because of the patient's relatively young age, his lack of risk factors for vascular disease, and the presence of a neurologic deficit that improved when circulation was restored. More unusual, however, is the fact that all diagnoses were excluded except for a high lipoprotein(a) level. To our knowledge, this is the 1st reported case in which aortic thrombosis has been related to hypercoagulability.

Acute Disease↗
PubMed2002

Interrupted aortic arch in an adult single-stage extra-anatomic repair.

Interrupted aortic arch is a rare congenital malformation of the aortic arch that occurs in 3 per million live births. Defined as a loss of luminal continuity between the ascending and descending portions of the aorta, this anomaly entails a very poor prognosis without surgical treatment. To our knowledge, the world medical literature contains only 12 reports of isolated interrupted aortic arch diagnosed in adults. Nine of these patients underwent successful surgical repair, but 1 died during the early postoperative period. We describe a 10th successful surgical repair, which involved a 42-year-old woman who had an asymptomatic type B interrupted aortic arch (characterized by interruption between the left subclavian and left carotid arteries). We performed a single-stage extra-anatomic repair by placing a 16-mm extra-anatomic Dacron graft between the ascending and descending portions of the thoracic aorta and by interposing a 7-mm extra-anatomic Dacron graft between the 16-mm graft and the left subclavian artery. The patient recovered uneventfully and continued to do well 6 months later.

Adult↗
PubMed2002

Surgical treatment of coronary artery anomalies: report of a 37 1/2-year experience at the Texas Heart Institute.

The surgical treatment of coronary artery anomalies continues to evolve. The most common coronary artery anomalies requiring surgical intervention include coronary artery fistulae, anomalous pulmonary origins of the coronary arteries, and anomalous aortic origins of the coronary arteries. The choice of surgical intervention for each type of coronary anomaly depends on several anatomic, physiologic, and patient-dependent variables. As surgical techniques have progressed, outcomes have continued to improve, however, controversy still exists about many aspects of the proper management of patients who have these coronary artery anomalies. We reviewed the surgical treatment of 178 patients who underwent surgery for the above-mentioned types of coronary artery anomalies at the Texas Heart Institute from December 1963 through June 2001. On the basis of this experience, we discuss historical aspects of the early treatment of these anomalies and describe their present-day management.

Adolescent↗
PubMed2002

Rare chronic gastric volvulus associated with left atrial and mediastinal compression.

We report a case of chronic gastric volvulus associated with left atrial compression in a 75-year-old woman who presented with chest pain, shortness of breath, and hypotension after elective hemiarthroplasty of the left hip. The patient's medical history included a paraesophageal hernia and gastric volvulus diagnosed in 1997 but left untreated. The present diagnosis of gastric volvulus was made on the basis of a chest radiograph and subsequent computed tomography. Echocardiography showed the volvulus compressing the left atrium. Surgery to repair the defect was successful, and there were no operative or postoperative complications. A review of the world medical literature revealed that gastric volvulus is rarely reported to cause hemodynamic compromise or compression of the heart and mediastinal structures.

Aged↗