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Biomedical subjects

H C Stansel

Publications and source records attributed to H C Stansel.

At least 19 recordsLinked to original sources
PubMed1990

Thirty-year follow-up of superior vena cava-pulmonary artery (Glenn) shunts.

The first superior vena cava-pulmonary artery shunt (Glenn shunt) in our series was performed in February 1958. From then through September 1988, 91 patients have undergone this procedure for a wide variety of congenital defects. We here report follow-up data available on all patients. Ages ranged from 2 days to 46 years (mean 6.8). Diagnoses were as follows: tricuspid atresia, 27; single ventricle, 22; tetralogy of Fallot, 14; D-transposition of the great arteries, ventricular septal defect, and pulmonary stenosis, 9; D-transposition, 5; Ebstein's anomaly, 4; pulmonary atresia + intact septum, 4; and others, 6. The hospital mortality rate was 7.7% (one death in the last 53 patients, 1.9%). Five deaths occurred in patients less than 6 months old. There were 20 late deaths (22%) with actuarial survival rates of 84% and 66% at 10 and 20 years, respectively. Pulmonary arteriovenous fistula formation was seen in 18 patients (19.7%), six of whom have undergone therapeutic embolization with improvement in saturation. The prevalence of pulmonary arteriovenous fistula increases with time after shunt. No long-term shunt thrombosis or stricture formation was seen. Fifty percent of shunts were still functioning at 20 years. Palliation was limited because of decrease in blood flow to the contralateral pulmonary artery, collaterals between the inferior and superior venae cavae, and pulmonary arteriovenous fistula formation. Improvement in saturation was obtained in eight otherwise inoperable patients by creation of a right axillary arteriovenous fistula up to 19 years after the Glenn shunt. Three patients had conversion of a Blalock-Taussig shunt to a Glenn shunt with improvement in congestive heart failure. Twenty-six patients have undergone a Fontan procedure with two deaths. Compared with the group having a Fontan procedure without a prior Glenn operation, there was no difference in early or late mortality. Thirty years after a Glenn shunt, the first patient in this series is working full time after having undergone a modified Fontan procedure in 1981. We conclude that the Glenn connection, usually with supplemental procedures to enhance oxygenation, has provided excellent physiologic palliation with low mortality up to 30 years with no late thrombosis or stricture formation. The incidence of pulmonary arteriovenous fistula increases with time and can be effectively treated with embolization. Physiologic repair after the Glenn shunt carries a low mortality. Although currently used infrequently, superior vena cava-pulmonary artery shunting remains a useful method of palliation in selected patients.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗
PubMed1983

Optimal methods of repair of descending thoracic aortic transection and aneurysms.

The method for optimal protection of the spinal cord and viscera during surgical repair of aneurysms and acute disruptions of the descending thoracic aorta is controversial. We reviewed our experience with 50 consecutive patients who underwent such repairs between January 1968 and April 1982 to determine the safest method of protection. Thirty-two had acute transections, 9 had ruptured aneurysms, 6 had false aneurysms, and three had atherosclerotic aneurysms. Extracorporeal circulation was used in 21 patients with an average cross-clamp time of 67 minutes, a Gott shunt was used in 26 with an average cross-clamp time of 74 minutes, and no shunt was used in 3 patients with cross-clamp times of 20, 24, and 50 minutes. Paraplegia was significantly reduced with both extracorporeal circulation and the heparin-bonded Gott shunt; however, the former method was associated with a high incidence of postoperative bleeding in conjunction with systemic heparinization, and this, in turn, contributed to a high mortality, particularly in patients with traumatic transection who often had associated severe injuries. We believe that the Gott shunt provides the best protection, particularly in the setting of a training program where a relatively small number of these operations are performed and cross-clamp times may be prolonged.

Adolescent↗
PubMed1983

Extraanatomical reconstruction for bilateral intrathoracic subclavian artery aneurysms.

Successful extraanatomical repair of bilateral intrathoracic arteriosclerotic subclavian artery aneurysms is reported. Rupture of the left subclavian aneurysm required emergency thoracotomy for proximal and distal ligation. The right subclavian aneurysm was repaired electively. Because of constraints resulting from the arterial anatomy (origin of aneurysm at innominate artery bifurcation), prior operation (coronary artery bypass grafting and repair of aneurysm of the sinus of Valsalva), and the patient's occupation (young, employed craftsman with dominant right hand), an extraanatomical reconstruction was devised to exclude the aneurysm and revascularize the head and arm. The reconstruction consisted of an external ilioaxillary Gore-Tex bypass graft in conjunction with an end-to-end distal subclavian to distal common carotid Gore-Tex graft. This is believed to represent the first reported successful repair of bilateral intrathoracic arteriosclerotic subclavian aneurysms, and the first application of this extraanatomical reconstruction.

Aneurysm↗
PubMed1982

Failure of autogenous reversed saphenous vein femoropopliteal grafting: pathophysiology and prevention.

As part of a study of various clinical, pathologic, and hemodynamic factors on both short- and long-term patency of autogenous reversed saphenous vein femoropopliteal bypass grafts, an early and recent series of patients from Yale University School of Medicine is compared with four other index series. Review and comparison reveals a well-recognized pattern of graft failure that occurs in three definable periods. The closure rate differs between periods and among series and allows a delineation of the responsible factors. Improvement in long-term cumulative patency rate depends on an understanding of the factors responsible for vein graft failure and the methods for their elimination or control.

Aged↗
PubMed1982

Factors affecting performance and thromboembolism after porcine xenograft cardiac valve replacement.

Long-term durability and the need for anticoagulation in conjunction with the use of porcine valves remain questionable. We analyzed valve dysfunction and thromboembolism in 325 adult (older than 20 years) and 31 pediatric survivors who received 407 porcine xenograft valves from June, 1974, to September, 1980 (46% of all valve replacements). Valves at risk in the adults were 216 aortic, 138 mitral, and 22 tricuspid; in children, 14 aortic, eight mitral, seven pulmonary, and two tricuspid. Mean follow-up was 38 (9 to 85) months. Twenty-seven valved conduits also were followed up for 9 to 85 (mean 52) months. Two late deaths in children resulted from dysfunction and another from endocarditis. One late death in an adult was caused by embolism. The other 36 deaths in the entire group were not valve related. Dysfunction requiring reoperation at 12 to 37 months occurred in eight of 325 adults (six mitral, one aortic, and one tricuspid). Dysfunction was due to recurrent endocarditis in six and to primary tissue failure in two (both older than 35 years of age); all survived reoperation. However, in children, severe dysfunction due to primary tissue failure occurred in seven (23%) cardiac valves, necessitating replacement at 21 to 48 months, and three of 27 conduits had to be replaced at 39 to 70 months. Thromboembolism occurred in six adults with mitral xenografts but none with aortic or tricuspid valve. Four of the patients with thromboemboli (one of whom died) were among 16 who had atrial fibrillation and no warfarin, but aspirin and persantine (11.7%/patient-year) and two were among 14 with sinus rhythm on no medication. No thromboembolism occurred in patients with mitral xenografts who were in sinus rhythm and receiving antiplatelet agents or in those with atrial fibrillation receiving warfarin. This experience indicates a high incidence of relatively early failure of porcine xenograft cardiac valves in children and young adults but excellent medium and long-term performance in older adults, in whom severe dysfunction occurred mainly with recurrent endocarditis. Thromboembolism occurred primarily in patients with mitral replacement especially with atrial fibrillation and no anticoagulants.

Adult↗
PubMed1982

The closure index: prediction of long-term patency of femoropopliteal vein grafts.

Of 227 reversed saphenous vein femoropopliteal graft procedures performed between January 1, 1974, and December 31, 1978 limbs (72 patients) and postoperative angiograms (37% of total) were reviewed to assess the influence of graft diameter, length, and runoff on patency rates. Patient characteristics were as follows: mean age was 64 years; 73% were men; 22% were diabetics; and 68% had ischemia as the indication. Patients were followed from 26 to 86 months (mean 52 months). Patency of grafts was assessed by physical examination or arteriography and evaluated by the life-table method. Postoperative angiograms were reviewed, and the diameter and length of the vein graft, as well as the diameter and number of runoff vessels, were noted. These variables were then related by the closure index (CI). Limbs were stratified into three groups: group I--CI less than equal to 50, 51 limbs; group II--50 less than CI less than 100, 22 limbs; and group III--CI greater than equal to 100, 12 limbs. Cumulative patency rates at 3 and 5 years, respectively, were as follows; total group, 60.6% and 52.3%; group I, 71.1% and 59.6%; group II, 47.7% and 47.7%; and group III, 15.6% at 3 years. Many factors cause graft failure. Between 30 days and 5 years, thrombosis of the graft is promoted by stasis. Low-flow velocity is most often associated with a "mismatch" of graft diameter and length to runoff. Patients with a CI of 50 or lower have a 72% chance of prolonged graft patency, but in those with a CI of 100 or higher, graft failure within 1 year is to be expected. The CI enables the surgeon to predict the likelihood of long-term patency of femoropopliteal grafts.

Aged↗
PubMed1981

Patch reconstruction of the right ventricular outflow tract with pulmonary valve insertion.

Although pulmonary regurgitation is generally well tolerated, reconstruction of the right ventricular outflow tract and insertion of a pulmonary valve are indicated in some patients. This procedure was performed in 12 patients, ages 1 1/2-17 years (mean 10 years). Seven had tetralogy of Fallot; of these, one underwent primary repair with Glenn shunt takedown and six underwent repeat operations after previous repairs. Of these six, the major indication for reoperation was right ventricular outflow tract obstruction in four, tricuspid and pulmonary regurgitation in one, and a residual ventricular septal defect and patent shunt in one. Three had absent pulmonary valve syndrome and two had pulmonary atresia. There were no early complications or deaths in this series during a mean follow-up of 28 months. Repeat cardiac catheterization was performed in eight patients and revealed that the preoperative right ventricular-pulmonary artery gradient was reduced from 58 +/- 25 mm Hg to 11.6 +/- 7 mm Hg at rest postoperatively and was located at the level of the valve. This gradient increased with exercise or isoproterenol infusion to 31 +/- 9 mm Hg. Our experience suggests that right ventricular outflow tract reconstruction with porcine valve insertion can be safely performed with good hemodynamic results. This technique allows insertion of a larger porcine valve and avoids kinking and compression of a conduit behind the sternum.

Adolescent↗
PubMed1980

Differences in results for aneurysm vs occlusive disease after bifurcation grafts: results of 100 elective grafts.

To compare abdomonal aortic surgery for aneurysmal (AAA) vs occlusive (OCC) disease, 50 consecutive cases of elective bifurcation grafts for AAA and 50 consecutive cases for OCC disease were analyzed. The mean age of the AAA patients was a decade greater than the OCC patients, and they had more associated diseases. Only six AAA patients were women, while women predominated in the OCC group. Only three AAA patients were claudicants and none had rest pain. About one third of the OCC group had distal disease, and 14 had rest pain. Operative mortality was 4% (two deaths in each group). The survival of the grafted AAA patients was almost equal to normal expectancy. There were no late thromboses of grafts in the AAA group, while there were five late failures in the OCC group. The OCC group underwent significantly more frequent reoperative surgery during the follow-up period. The numerous differences in the two population groups apparent in this study provide a basis for questioning the concept that aneurysms are caused by atherosclerosis.

Adult↗
PubMed1980

Early extubation following pediatric cardiothoracic operation: a viable alternative.

A protocol is presented that facilitates early extubation following pediatric cardiothoracic operations. A total of 197 consecutive patients were managed according to this protocol. Fifty percent of the patients were less than 3 years old. Cardiopulmonary bypass was required in 113 (57%) of the surgical procedures. Extubation immediately following the surgical procedure was accomplished in 142 (72%) of the patients. Pulmonary complications occurred in 8 of these 142 patients (6%) and in 10 (18%) of the 55 patients requiring postoperative mechanical ventilation. Of the patients having early extubation, 5 (4%) required reintubation. One death in this group was unrelated to pulmonary function. There were 16 deaths among the 55 patients managed with mechanical ventilation. Carefully conducted early extubation provided specific advantages over routine postoperative mechanical ventilation. Modern techniques of anesthesia and surgical repair of congenital heart disease can decrease the requirement for postoperative mechanical ventilation and the potential for related complications.

Age Factors↗
PubMed1979

Obturator canal bypass grafts for septic lesions of the femoral artery.

Infection of the femoral artery results in false aneurysm formation and hemorrhage unless appropriate reconstructive measures are taken. We reviewed ten such cases managed by obturator canal bypass with autogenous saphenous vein. The graft maintained viability of the extremity in every case in the early postoperative period. One death occurred related to cardiac disease, and there was one late failure. This experience confirms the usefulness of the obturator canal as a method for bypass of the infected femoral artery.

Adolescent↗
PubMed1979

Simplified splanchnic artery revascularization using extra-anatomic bypass grafts: a report of ten cases.

Revascularization of the superior mesenteric artery or renal artery is frequently complicated by concomitant atherosclerotic disease in the adjacent aorta. In ten patients, extra-anatomic saphenous vein bypass grafts to the splanchnic vessels were constructed and inflow was obtained from the external iliac artery. All patients recovered without complication and have had functioning grafts on follow-up arteriography. This extra-anatomic bypass provides a simple method for splanchnic artery revascularization.

Aged↗
PubMed1979

Surgical principles and polytetrafluoroethylene.

This report describes a 24-month follow-up in 100 consecutive polytetrafluoroethylene (PTFE) arterial grafts. Although initial results were superb, a continued follow-up has showed extremely high closure rates for femoropopliteal and femorotibial grafts. The primary reason for this high attrition rate is thought to be stasis. We believe that PTFE is clearly the best synthetic arterial replacement available, but the material does not approach the autogenous saphenous vein in terms of long-term patency. Therefore, in spite of its many advantages, we do not recommend the elective use of PTFE for peripheral small-vessel bypass.

Bioprosthesis↗