Central nervous system injury after aortic operations: profits of amending old ways.
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Aortic Diseases↗
Biomedical subjects
L G Svensson
Publications and source records attributed to L G Svensson.
Elephant trunk reconstruction for aberrant right subclavian and aortic aneurysm.
Although an aberrant right subclavian artery is the most common abnormality of aortic arch development, it is an unusual entity to encounter during repair of thoracic aortic aneurysms. A case of an aberrant right subclavian artery requiring reattachment during repair of an ascending aorta, aortic arch, and descending thoracic aortic aneurysm is reported. We report using the modified elephant trunk technique for surgically managing the aneurysm and aberrant right subclavian artery.
Aged↗
Minimal-access "J" or "j" sternotomy for valvular, aortic, and coronary operations or reoperations.
For more complex aorta, valvular, and coronary operations or reoperations where the new minimal-access operations are difficult to apply, a "J" or "j" sternal incision from the first interspace or sternal notch into the right fourth intercostal space is a useful alternative. The approach has been used for aortic and mitral valve procedures, coronary artery bypass with or without cardiopulmonary bypass, aortic root rupture, atrial septal defect repair, hemiarch repair, maze procedure, and composite valve grafts, including reoperations and transannular mitral valve replacements in 30 patients without complication related to it.
Aorta↗
New and future approaches for spinal cord protection.
The major cause of spinal cord injury, during and after aortic surgery, is based on the occurrence of one or more of the three following events: (1) the duration and degree of ischemia;(2) failure to re-establish blood flow to the spinal cord after the repair; and (3) a biochemically mediated reperfusion injury. Clinically, this manifests either as permanent or reversible paraplegia or paraparesis, or a neurogenic bladder. For more than 40 years, numerous methods have been attempted to prevent paralysis, and some of the newer technical innovations include reducing the duration of ischemia, the use of newer centrifugal pump distal perfusion techniques, localized hypothermia, intrathecal maneuvers, pharmacological agents, angiography, somatosensory-evoked potential monitoring, spinal motor-evoked potential monitoring, hydrogen mapping, not resecting the posterior aortic wall, the use of stents, and a spectrum of various pharmacological agents to prevent reperfusion injury to the spinal cord. Some of these techniques and agent seem to be effective at reducing the risk of spinal cord injury.
Animals↗
Endarterectomy for calcified porcelain aorta associated with aortic valve stenosis.
BACKGROUND: A calcified porcelain aorta may complicate aortic valve insertion and require an alternative, more complex method for valve replacement. The reason for this is that sutures cannot be inserted through the calcific plates in the annulus and ascending aorta. METHODS: In 6 patients with an average age of 73.8 years (range, 65 to 81 years), we performed the simpler procedure of aortic endarterectomy of the calcific plates with the aortic valve replacement. We realized that there may be an increased risk of postoperative complications, particularly stroke. The calcific plates were fractured to allow debridement of the calcium. In addition, an end-arterectomy was performed of the left main coronary ostium in 2 patients, and 5 patients also had coronary artery bypass grafting performed. RESULTS: All 6 patients underwent successful operations without major complications. On follow-up, echocardiography or computed tomographic scans in 3 patients have not shown dilation of the ascending aorta. CONCLUSION: Endarterectomy of the aorta may be an option in the management of patients with calcification of the aorta.
Aged↗
Applications of statistical quality control to cardiac surgery.
BACKGROUND: Although originally developed for use in manufacturing statistical quality control techniques may be applicable to other frequently performed, standardized processes. METHODS: We employed statistical quality control charts (X- s, p, and u) to analyze perioperative morbidity and mortality and length of stay in 1,131 nonemergent, isolated, primary coronary bypass operations conducted within a 17-quarter time period. RESULTS: The incidence of the most common adverse outcomes, including death, myocardial infarction, stroke, and atrial fibrillation, appeared to follow the laws of statistical fluctuation and were in statistical control. Postoperative bleeding, leg-wound infection, and the summation of total and major complications were out of statistical control in the early quarters of the study period but showed progressive improvement, as did postoperative length of stay. CONCLUSIONS: The incidence of morbidity and mortality after primary, isolated, nonemergent coronary bypass operations may be described by standard models of statistical fluctuation. Statistical quality control may be a valuable method to analyze the variability of these adverse postoperative events over time, with the ultimate goal of reducing that variability and producing better outcomes.
Coronary Artery Bypass↗
Screening carotid ultrasonography and risk factors for stroke in coronary artery surgery patients.
BACKGROUND: The role of noninvasive carotid artery screening in relation to other clinical variables in identifying patients at increased risk of stroke after coronary artery bypass grafting was examined. METHODS: Preoperative, intraoperative, and postoperative clinical data were prospectively collected for 1,835 consecutive patients undergoing first-time isolated coronary artery bypass grafting between March 1990 and July 1995, 1,279 of whom had screening carotid ultrasonography. All patients with postoperative neurologic events were identified and reviewed in detail. Average patient age was 65.3 years (range, 33 to 92 years), and 9.3% (171 patients) had a prior permanent stroke or transient ischemic attack. Hospital and 30-day mortality was 2.2% (41 patients). Forty-five patients (2.5%) had a transient or permanent postoperative neurologic event. The data were analyzed by stepwise logistic regression to determine the independent predictors of both significant carotid stenosis and stroke. RESULTS: On multivariate analysis, the clinical predictors of significant carotid stenosis were age (p < 0.0001), diabetes (p = 0.0123), female sex (p = 0.0026), left main coronary stenosis greater than 60% (p < 0.0001), prior stroke or transient ischemic attack (p = 0.0008), peripheral vascular disease (p = 0.0001), prior vascular operation (p = 0.0068), and smoking (p < 0.0001). When all variables were evaluated for those patients who underwent noninvasive carotid artery screening, the independent predictors of postoperative neurologic event were prior stroke or transient ischemic attack (p < 0.0001), peripheral vascular disease (p = 0.0037), postinfarction angina pectoris (p = 0.0319), postoperative atrial fibrillation (p = 0.0014), carotid stenosis greater than 50% (p = 0.0029), cardiopulmonary bypass time (p = 0.0006), significant aortic atherosclerosis (p = 0.0054), postoperative amrinone or epinephrine use (p = 0.0054), and left ventricular ejection fraction less than 0.30 (p = 0.0744). CONCLUSIONS: The etiology of postoperative stroke is multifactorial. Selective use of carotid ultrasonography is of value in identifying patients who are at greater risk of postoperative stroke independent of other variables and should be considered before coronary artery bypass grafting, particularly in patients with a history of neurologic event or peripheral vascular disease.
Adult↗
Intraoperative identification of spinal cord blood supply during repairs of descending aorta and thoracoabdominal aorta.
OBJECTIVE: The aim was to intraoperatively identify the spinal cord blood supply and shorten the aortic crossclamp time. METHODS: A platinum electrode was placed intrathecally by lumbar puncture alongside the spinal cord. After the aorta was crossclamped, hydrogen in a saline solution was injected into the aorta and, if it was shown that the segment supplied the spinal cord and there were multiple arteries, then these were individually injected. The repair was performed by a sequential segmental method as described previously. RESULTS: Postoperatively, highly selective angiography was used to confirm that reattached intercostal arteries supplied the spinal cord. The technique was accurate in all patients. Five spinal cord perfusion patterns were noted: (1) direct, (2) collateral, (3) no direct supply from segment tested, (4) from atriofemoral bypass, and (5) occluded reattached intercostals. When no response was obtained or no further testing was required (n = 8), testing time was 4.2 minutes and crossclamp time 41.9 minutes. When multiple segmental arteries required further testing, the mean testing time was 10.4 minutes and crossclamp time 58.5 minutes, including reattachment of intercostal vessels (p = not significant). CONCLUSION: Preliminary findings indicate that this method is a safe research technique, can detect radicular arteries, and may reduce the time for aortic crossclamping if no vessels are identified as supplying the spinal cord.
Angiography↗
Timing of surgery after acute myocardial infarction.
OBJECTIVE: We wished to determine if timing of surgery, when other co-morbid variables are controlled, influenced outcome after operations for acute myocardial infarction. DESIGN: Between 3/20/1990 and 6/17/1994, data was prospectively collected on 338 patients undergoing operation for either evolving infarcts (n=73) or up to 21 days after infarction (mean 7.9 days). SETTING: Tertiary hospital referral center. PATIENTS: Infarction was diagnosed by CK enzymes or EKG Q-waves preoperatively in 338 patients undergoing surgery. The mean age of the patients was 66.1 years (SD+/-10.5 years), 76 had emergency operations immediately after catheterization (50 following PTCA complications), 223 had urgent operations, and 39 were elective. INTERVENTIONS: Seventy-three had preoperative ballon pumps, and 259 had one or more mammary artery bypasses with a mean of 3.27 (SD+/-1.0) distal anastomoses. RESULTS: In-hospital and 30-day survival rate was 95.6% (323/338). Of the 73 variables evaluated by step-wise logistic regression analysis, the multivariate independent preoperative predictors of death were: aortic valve regurgitation, chronic pulmonary disease, preoperative diuretic administration, preoperative balloon pump, preoperative inotropes, and the need for additional concomitant noncardiac surgery. Including the operative variables, the predictors were: preoperative balloon pump, preoperative inotropes, the presence of left main stenosis, preoperative renal failure, chronic pulmonary disease, valve disease, ischemic arrhythmia, pump perfusion time, valve surgery, and homologous blood transfusion volume required. When the postoperative variables were included, the predictors were: preoperative inotropes, postoperative balloon pump, postoperative epinephrine, postoperative permanent stroke, and postoperative acute renal failure. The time between infarction and operation was not an independent prediction (p>0.4) in any of the logistic regression models. CONCLUSION: Early operation after acute infarction is not in itself a risk factor, rather comorbid disease and preoperative hemodynamic status determine outcome after surgery.
Hemodynamics↗
Prospective evaluation of minimal blood use for ascending aorta and aortic arch operations.
The feasibility, safety, and impact on postoperative hospital stay of performing ascending aorta and aortic arch operations without homologous blood transfusions have not been evaluated. Sixty consecutive patients, 38 (63%) of whom also had aortic valve replacements and 17 (28%) of whom also had coronary artery bypass grafting, were evaluated for participation in blood conservation measures. Of the 45 who were able to use blood conservation techniques, 87% (39/45) required no intraoperative and 69% (31/45) required no in-hospital homologous blood transfusions. The 30-day survival rate was 98.3% (59/60), and no patient sustained a new stroke, neurologic cognitive deficit, or infection. Multivariate analysis of the 60 patients showed that the predictors of in-hospital homologous transfusion were (p < 0.05) age, cardiopulmonary bypass time, and postoperative chest tube drainage. Preoperative autologous blood donation was associated with a significantly lower risk of homologous transfusion (p = 0.0006). Indeed, patients participating in blood conservation techniques had a significantly (p < 0.05) lower incidence of homologous transfusions, required less intraoperative shed blood washing, were extubated earlier, gained less weight, had shorter hospital stays, and were discharged in a better dyspnea functional class. Most major elective cardiovascular operations on the ascending aorta and aortic arch can be safely performed without homologous transfusions.
Aged↗
Transvenous versus transthoracic cardioverter-defibrillator implantation. A comparative analysis of morbidity, mortality, and survival.
The hypothesis that transvenous implantation of a cardioverter-defibrillator is associated with less morbidity than use of a transthoracic approach was investigated in a retrospective series of 146 patients. None of these patients had concomitant heart procedures, and the preoperative characteristics of the two groups were similar. When analyzed by actual technique used (transvenous, 57 patients; transthoracic, 89 patients) and by the intention-to-treat method (transvenous, 65 patients, 8 of whom actually underwent thoracotomy; thoracotomy, 81 patients), transvenous implantation was associated with a lower incidence of postoperative respiratory complications and atrial fibrillation. Total cardiac mortality and freedom from sudden cardiac death in the transvenous and transthoracic groups were comparable at 2 years.
Aged↗
Replacement of entire aorta from aortic valve to bifurcation during one operation.
A 68-year-old patient presented with an extensive aortic aneurysm extending from the aortic valve to the aortic bifurcation associated with severe continuous pain, dysphagia, and hoarseness. Because of the risk of impending rupture and an "elephant trunk" procedure not being an option, the entire aorta from the aortic valve to the aortic bifurcation was replaced during one operation using deep hypothermia with circulatory arrest and retrograde perfusion of the brain through the jugular veins. Seven months after the operation the patient walks more than 3 km a day and lives a normal life. The operative repair is presented.
Aged↗
Management of acute aortic dissection associated with coarctation by a single operation.
Acute aortic dissection associated with significant coarctation of the aorta is a difficult problem to manage operatively. A patient is presented who had both a bypass graft from the ascending aorta to the abdominal aorta and insertion of a composite valve graft in one operation to solve the problem.
Adult↗
Influence of segmental arteries, extent, and atriofemoral bypass on postoperative paraplegia after thoracoabdominal aortic operations.
PURPOSE: The purpose of this article was to study the influence of either reattachment or oversewing of patient segmental intercostal or lumbar arteries, extent of aneurysm, and atriofemoral bypass on the incidence of postoperative paraplegia/paraparesis in patients at high risk with type I or II thoracoabdominal aneurysms. METHODS: Data were prospectively collected on 99 patients undergoing type I or II thoracoabdominal aneurysm repairs, including exact extent of repair and whether atriofemoral bypass ws used. Patency of intercostal arteries from T3 to T12 and lumbar arteries from L1 to L4 were checked by intraoperative inspection. If the arteries were patent, note was taken of whether they were reattached to the new aortic prosthesis. Postoperative neurologic motor function was graded daily for the first 5 days, and the worst score in the first 30 postoperative days (POD) was used for analysis. RESULTS: Ninety-five of 99 (96%) patients were 30-day survivors. By POD 30, 31 of 98 (32%) patients had had a neurologic deficit. There was no difference in the incidence of deficits according to whether lumbar or intercostal arteries were reattached, ignoring the effect of patency of the arteries. Of greater importance, however, was whether patent segmental arteries were oversewn at specific levels. Thus, for patients who had one or more arteries at T11, T12, or L1 oversewn (often because they could not be reattached), a deficit developed in 11 of 23 (48%) patients versus 20 of 75 (27%) patients who did not have patent arteries or had all patient arteries reattached (p = 0.05, odds ratio = 2.5). More specifically, if all arteries at this level were oversewn, a neurologic deficit developed in 63% of patients versus 23% if all their arteries were reattached (p = 0.01). Reattachment of patent arteries at individual levels from T7 to L4 showed a trend toward a lower risk of deficits but did not reach statistical significance. On multivariate analysis, atriofemoral bypass was associated with a lower risk of paralysis (p = 0.068), and significantly so when controlled for age (p = 0.0329, odds ratio 0.287). Subgrouping of extent type I thoracoabdominal aneurysms resulted in an incidence of paralysis of 14% (3/22) for subgroup A and 23% (5 of 22) for subgroup B compared with 43% (23 of 55) for type II thoracoabdominal aneurysms (type I [8 of 44 18%], versus type II [p = 0.0097]). CONCLUSION: Patients with no or few patent segmental arteries in the aortic segment being replaced have a lower risk of neurologic deficits, compared with those with patent arteries. Every effort should be made to reattach all arteries at T11, T12, and L1 and, when possible within the constraints of technical feasibility and time, also those from T7 to L4. Preoperative angiography or intraoperative hydrogen testing may better identify the arteries that need to be reattached. When feasible, atriofemoral bypass appears to be protective, particularly when sequential clamping and segmental repairs can be performed.
Adult↗
Aortic dissection and aortic aneurysm surgery.
During the last year, the role of noninvasive studies for aortic dissection--magnetic resonance imaging, computed tomography scanning, and transesophageal echocardiography--has become better defined. Both magnetic resonance imaging and transesophageal echocardiography are highly accurate in detecting aortic dissection. On transesophageal echocardiographic imaging of the ascending aorta, artifacts may be present that mimic an intimal flap (septum). These linear echo densities have characteristic features which distinguish them from a true intimal flap (septum). Their recognition is critical in avoiding false positive transesophageal echocardiography findings. The general consensus on operations for ascending aorta and aortic arch dissection is that patients should be operated upon immediately. Controversy still remains, however, as to whether the aortic arch needs replacement at the time of the ascending and proximal aortic arch repair. Most authors agree that deep hypothermia with circulatory arrest is the preferable technique for acute aortic dissection repair and for surgery on the aortic arch in adults. Retrograde perfusion of the jugular veins is an added advantage. For acute aortic dissection involving the descending thoracic or thoracoabdominal aorta, evidence continues to accumulate that initial medical therapy with beta-blockers and antihypertensives is the preferable mode of treatment unless complications requiring surgery arise. Percutaneous techniques are increasingly being described, including fenestration of the aortic dissection septum, stenting of the aorta or aortic branches, and insertion of intraluminal aortic tube grafts. The safety of surgery on the thoracoabdominal aorta and on the descending thoracic aorta, including the prevention of complications, is reviewed.
Adolescent↗
Cardiopulmonary bypass in patients with previously completed stroke.
It has been assumed that patients with neurological residua after a completed stroke are at increased risk of neurological complications associated with cardiac operations requiring cardiopulmonary bypass. To evaluate these assumptions, we reviewed retrospectively 1,163 consecutive patients undergoing cardiac operations with cardiopulmonary bypass. Among these 1,163 patients were 43 patients having a previously completed stroke with neurological residua, but without clinically significant extracranial carotid artery disease. Forty-one underwent coronary artery bypass grafting; of these, 1 required concomitant aortic valve replacement, 1 had mitral valve replacement, and 1 had aortic valve replacement. There was one death in this group of 43 patients, due to massive pulmonary embolism. Only 1 of these 43 patients experienced new neurological symptoms after operation, which would appear to indicate that patients with a previous, completed stroke may not be at increased risk of neurological complications from cardiac operations requiring cardiopulmonary bypass.
Aged↗
Brain protection via cerebral retrograde perfusion during aortic arch aneurysm repair.
Eleven patients underwent resection and graft replacement of ascending and aortic arch aneurysms. Retrograde cerebral perfusion was used during the procedures to minimize cerebral ischemia. Retrograde cerebral perfusion (15 degrees to 24 degrees C) was administered through the superior vena cava. The mean cerebral ischemic time was .35 minutes (range, 11 to 71 minutes). Throughout retrograde cerebral perfusion, blood samples were drawn from the innominate and left carotid arteries at 1, 5, and every 10 minutes thereafter for analysis of arterial oxygen content, total creatine kinase level, and creatine kinase BB fraction. All patients survived. All except 1 awoke neurologically intact. In this patient, electroencephalogram and transcranial Doppler studies conducted before circulatory arrest were consistent with embolic phenomena. There was no significant difference between the current group's intraoperative electroencephalograms and those of a similar historical group. Postoperative complications included transient renal failure, myasthenia gravis, cholecystitis, premature atrial contractions, atrial fibrillation, and vocal cord paralysis. The creatine kinase BB fraction range was 1.8 to 13.4. The increase of total creatine kinase level was due to MM fraction. Retrograde cerebral perfusion during circulatory arrest is a valuable adjunct for protecting the brain. The creatine kinase BB band was not a good marker to detect brain injury. With continued use of this technique and accumulation of a larger series, we may better define the role of retrograde cerebral perfusion in brain protection.
Adult↗