Biomedical subjects
Publications and source records attributed to M J Mack.
A case is presented of left main coronary artery stenosis in a patient with significant comorbidities who was successfully managed with minimally invasive direct coronary artery bypass as protection before percutaneous transluminal coronary angioplasty. This "hybrid" approach for the management of a high-risk patient led to a favorable outcome.
BACKGROUND: There is increasing interest in performing minimally invasive coronary artery bypass grafting. To evaluate the current level of acceptance and utility of this procedure a survey of 162 cardiothoracic surgeons was conducted. RESULTS: Currently only 16% of surveyed surgeons performed more than 10 minimally invasive coronary artery bypass grafting procedures. Most were less than 55 years old and in private practice. The majority predicted that it will be indicated in less than 25% of coronary artery bypass grafting cases and considered minimally invasive coronary artery bypass grafting a modification of existing techniques rather than investigational. Most believed exposure and stabilization of the coronary arteries on the beating heart to be the most challenging part and expressed concern with quality of the anastomosis. CONCLUSIONS: We conclude that minimally invasive coronary artery bypass grafting is rapidly gaining acceptance in younger surgeons as techniques are improved. Despite concerns with adequacy of anastomosis the procedure is not considered investigational and follow-up is not rigorous.
BACKGROUND: The role of nonanatomic wedge resection in the management of stage I (T1 N0 M0) non-small-cell lung cancer continues to be debated against the present gold standard of care--anatomic lobectomy. METHODS: We analyzed the results of 219 consecutive patients with pathologic stage I (T1 N0 M0) non-small-cell lung cancer who underwent open wedge resection (n = 42), video-assisted wedge resection (n = 60), and lobectomy (n = 117) to assess morbidity, recurrence, and survival differences between these approaches. RESULTS: There were no differences among the three groups with regard to histologic tumor type. Analysis demonstrated the wedge resection groups to be significantly older and to have reduced pulmonary function despite a higher incidence of treatment for chronic obstructive pulmonary disease when compared with patients having lobectomy. The mean hospital stay was significantly less in the wedge resection groups. There were no operative deaths among patients having wedge resection; however, a 3% operative mortality occurred among patients having lobectomy (p = 0.20). Kaplan-Meier survival curves were nearly identical at 1 year (open wedge resection, 94%; video-assisted wedge resection, 95%; lobectomy, 91%). At 5 years survival was 58% for patients having open wedge resection, 65% for those having video-assisted wedge resection, and 70% for those having lobectomy. Log rank testing demonstrated significant differences between the survival curves during the 5-year period of study (p = 0.02). This difference was a result of a significantly greater non-cancer-related death rate by 5 years among patients having wedge resection (38% vs 18% for those having lobectomy; p = 0.014). CONCLUSION: Wedge resection, done by open thoracotomy or video-assisted techniques, appears to be a viable "compromise" surgical treatment of stage I (T1 N0 M0) non-small-cell lung cancer for patients with cardiopulmonary physiologic impairment. Because of the increased risk for local recurrence, anatomic lobectomy remains the surgical treatment of choice for patients with stage I non-small-cell lung cancer who have adequate physiologic reserve.
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BACKGROUND: Standard options for the invasive management of proximal disease of the left anterior descending coronary artery include coronary artery bypass grafting with a left internal mammary artery and percutaneous transluminal coronary angioplasty. METHODS: We describe a surgical technique for bypass of the left anterior descending coronary artery with a left internal mammary artery without median sternotomy and without cardiopulmonary bypass. Thoracoscopy is used to harvest the internal mammary artery, whereas the mammary-coronary artery anastomosis is performed under direct vision through a limited anterior thoracotomy. RESULTS: We have performed this procedure successfully in 3 patients with minimal morbidity and shortened hospital stay. Average operative time was 3 hours and postoperative hospital stay averaged less than 48 hours. CONCLUSION: Although experience is limited and follow-up is very short, with further experience, this less invasive surgical technique may become a viable option for the management of proximal left anterior descending disease.
OBJECTIVE: The efficacy of video-assisted thoracic surgery for thymectomy with myasthenia gravis has not been examined. METHODS: Thirty-three consecutive patients underwent total thymectomy by video-assisted techniques between 1992 and 1995. There were 13 male and 20 female patients with a mean age of 38.42 +/- 16.88 years (range 9 to 84 years). The procedures were performed by either a right (n = 11) or left (n = 22) thoracoscopic approach and all anterior mediastinal tissue was removed. RESULTS: There was no perioperative mortality or long-term morbidity. One patient required conversion of the video-assisted technique to a lateral thoracotomy. All patients except one were extubated immediately. The mean hospital stay was 4.12 +/- 6.07 days (range 1 to 37 days) with a median of 3 days. Mean follow-up is 23.39 +/- 11.72 months (range 4 to 47 months). Clinical improvement was seen in 87.9% (29/33): one of two patients (50%) in stage I, 17 of 19 (89.4%) in stage IIA, eight of nine (88.8%) in stage IIB, and three of three (100%) in stage III. Metaanalysis of these results compared with results in nine published series in which other techniques were used showed no difference in clinical improvement after thymectomy between series. CONCLUSION: We conclude that video-assisted thymectomy is as effective as the traditional open surgical approaches for performance of thymectomy in the management of patients with myasthenia gravis. In addition, the improved cosmesis of the video-assisted approach ideally will lead to earlier thymectomy in patients with myasthenia gravis.
OBJECTIVE: The objective of this study was to identify the utility of "keyhole" thoracotomy approaches to single vessel coronary artery bypass surgery. SUMMARY BACKGROUND DATA: Although minimally invasive surgery is efficacious in a wide variety of surgical disciplines, it has been slow to emerge in cardiac surgery. Among 49 selected patients, the authors have used a left anterior keyhole thoracotomy (6 cm in length) combined with complete dissection of the eternal mammary artery (IMA) pedicle under thoracoscopic guidance or directly through the keyhole incision to accomplish IMA coronary artery bypass grafting (CABG) to the left anterior descending (LAD) coronary artery circulation or to the right coronary artery (RCA). METHODS: Keyhole CABG was accomplished in 46 of 49 patients in which this approach was attempted. All patients had significant (> 70%) obstruction of a dominant coronary artery that had failed or that was inappropriate for endovascular catheter treatment (percutaneous transluminal coronary angioplasty or stenting). Forty-four of the 49 patients had proximal LAD and 5 had proximal RCA stenoses. The mean age of the patients (35 men and 14 women) was 61 years, and their median New York Heart Association anginal class was III. The mean left ventricular ejection fraction was 42%. Femoral cardiopulmonary bypass support was used in 9 (19%) of 46 patients successfully managed with the keyhole procedure. Short-acting beta-blockade was used in the majority of patients (38 of 46) to reduce heart rate and the vigor of cardiac contraction. RESULTS: As 49 patients have survived operation, which averaged 248 minutes in duration. Median, postoperative endotracheal intubation time for keyhole patients was 6 hours with 25 of 46 patients being extubated before leaving the operating room. The median hospital stay was 4.3 days. Conversion to sternotomy was required in three patients to accomplish bypass because of inadequate internal mammary conduits or acute cardiovascular decompensation during an attempted off-bypass keyhole procedure Postoperative complications were limited to respiratory difficulty in three patients and the development of a deep wound infection in one patient. Nine (19%) of 46 patients received postoperative transfusion. There have been no intraoperative or postoperative infarctions, and angina has been controlled in all but one patient who subsequently had an IMA-RCA anastomotic stenosis managed successfully with percutaneous transluminal coronary angioplasty. CONCLUSIONS: These early results with keyhole CABG are encouraging. As experience broadens, keyhole CABG may become a reasonable alternative to repeated endovascular interventions or sternotomy approaches to recalcitrant single-vessel coronary arterial disease involving the proximal LAD or RCA.
Video-assisted thoracic surgery (VATS) has assumed greater importance in the management of pleural disease. Since 1990, we have performed VATS procedures to manage a variety of pathologic pleural processes in 306 patients. The 99 patients with complex empyemas or hemothoraces are the focus of this report. Seventy-six patients with complex empyemas (including 26 chronic) were approached with VATS after inadequate chest tube drainage. The causes associated with the thoracic empyemas were parapneumonic collections in 47, after hemothorax in 8, infected sympathetic effusions associated with intra-abdominal sepsis in 6, postresectional in 5, prolonged bronchopleural fistula following spontaneous pneumothorax in 4, chronic drainage of malignant pleural effusions in 4, and chronic drainage of pleural effusion in 2 patients undergoing chemotherapy. Ages ranged from 14 to 78 years. Sixty-three patients (83%) were treated with thoracoscopic drainage +/- decortication alone. Thirteen patients (17%) required subsequent thoracotomy for decortication, including 12 of the 26 (46%) chronic empyemas known to be greater than 3 weeks old. Chest tubes were removed 3.3 +/- 2.9 days postoperatively in 67 patients; 9 patients (12%) were sent home with empyema tubes. Postoperative hospital stay for these patients with empyema averaged 7.4 +/- 7.2 days. There were five deaths, all related to progressive sepsis from associated pneumonia (6.6%). Twenty-three patients underwent thoracoscopic evacuation of hemothoraces that resulted following open heart surgery in 6, thoracic trauma in 7, were iatrogenic in 7, and bleeding into malignant effusions in 3. All were successfully treated by thoracoscopic drainage and pleural debridement alone. Chest tubes were removed 2.8 +/- 0.5 days postoperatively and hospital stay averaged 4.3 +/- 1.9 days. There were no complications; one patient with a hemothrax (after heart transplant) died of unrelated causes. In our experience, VATS has been highly successful in the early management of empyemas and hemothoraces. Conversion to open thoracotomy must always be anticipated, especially when approaching chronic empyemas.
STUDY DESIGN: This report is a preliminary description of the efficacy of video-assisted thoracoscopic surgery in thoracic spinal procedures that otherwise require open thoracotomy. OBJECTIVE: This report sought to describe the efficacy of video-assisted thoracoscopic surgery in thoracic spinal procedures that otherwise require open thoracotomy. SUMMARY OF BACKGROUND DATA: In a landmark study that compared video-assisted thoracoscopic surgery for peripheral lung lesions with thoracotomy, video-assisted thoracoscopic surgery reduced postoperative pain, improved early shoulder girdle function, and shortened hospital stay. METHODS: Video-assisted thoracoscopic surgery was performed in 12 thoracic spinal patients (herniated nucleus pulposus, infection, tumor, or spinal deformity) and is described in detail in this report. RESULTS: Video-assisted thoracoscopic surgery in thoracic spinal surgery resulted in little postoperative pain, short intensive care unit and hospital stays, and little or no morbidity. In the short follow-up period, there was no post-thoracotomy pain syndrome nor neurologic sequelae in these patients. Operative time decreased dramatically as experience was gained with the procedure. CONCLUSION: Given consistently improving surgical skills, a number of thoracic spinal procedures using video-assisted thoracoscopic surgery, including thoracic discectomy, internal rib thoracoplasty, anterior osteotomy, corpectomy, and fusion, can be performed safely with no additional surgical time or risk to the patient.
Standard anterior approach to the thoracic spine is by a posterolateral thoracotomy. Because of the morbidity associated with this incision, video-assisted thoracic surgery (VATS) has been used as a less invasive approach for many intrathoracic disease processes. We have applied VATS for anterior access to the thoracic spine. From April 1991 to September 1994, 95 patients underwent thoracic spine procedures using thoracoscopy as the sole method of anterior approach. Procedures performed include discectomy for herniation (n = 57), multilevel discectomy for correction of spinal deformity (27), corpectomy (9), and drainage of intervertebral disc space abscess (2). All levels of the thoracic spine from the T2-T3 level to the T12-L1 interspace were approached. Forty-four procedures were performed through the left side of the chest and 41 through the right. The planned procedure was accomplished by VATS in all but 1 patient who required conversion to an open procedure because of scarring from a previous spine procedure. Mean operative time was 2 hours 24 minutes (range, 45 minutes to 5 hours 10 minutes). Average chest tube duration was 1.4 days, and mean length of stay was 4.82 days (range, 2 to 21 days). Complications included intercostal neuralgia (6), atelectasis (5), excessive epidural blood loss (2,500 mL; 2) and temporary paraparesis in a scoliosis patient related to operative positioning. We conclude that VATS offers a new, less morbid anterior approach to the thoracic spine. Although there is a significant learning period, most procedures requiring an anterior access can be performed safely by this technique. The VATS approach mandates an expanded role for the thoracic surgeon in operative spine disease.
Previously suggested risk factors for operative mortality in reoperative coronary artery bypass grafting are contradictory. Therefore, we analyzed our data of 622 patients who underwent reoperative bypass grafting from January 1986 through June 1993. Among these patients, 258 had saphenous vein grafts alone and 364 had internal mammary artery grafting, including unilateral (342 patients) and bilateral (22 patients) mammary artery grafting with or without additional saphenous vein grafting. Overall operative mortality was 11.4% for reoperation compared with only 3.6% for primary bypass grafting during the same time frame. To determine risk factors for mortality and the influence of internal mammary artery grafting on the outcome, we analyzed 82 variables (31 preoperative, 17 intraoperative, and 34 postoperative) by univariate analysis. Significant variables or the variables having a trend (p < 0.2) to be associated with the mortality were included in stepwise multiple logistic regression analyses. Two regression analyses were separately performed. Regression 1 only included preoperative and intraoperative variables whereas regression 2 included postoperative variables as well. The logistic regressions demonstrate that preoperative variables (low ejection fraction [p = 0.0002], old age [p = 0.003], female gender [p = 0.011], and history of arrhythmia [p = 0.023]), intraoperative variables (emergency operation [p = 0.0001] and long perfusion time [p = 0.0001]), and postoperative variables (complications) are independently associated with higher mortality. Unlike previously described results, aortic crossclamp time, route of cardioplegia, use of internal mammary artery, number of grafts, and year of operation are not associated with operative mortality. The identification of these risk factors may have important implications in further improvement of the results of reoperative coronary artery bypass grafting.
Video-assisted thoracic surgery has been widely used in the treatment of spontaneous pneumothorax despite a paucity of data regarding the relative safety and long-term efficacy for this procedure. We reviewed 113 consecutive patients (68 male and 45 female patients, aged 15 to 92 years, mean 35.1) who underwent 121 video-assisted thoracic surgical procedures during 119 hospitalizations from 1991 through 1993. Recurrent ipsilateral pneumothorax was the most frequent indication for surgery and occurred in 77 patients (65%). The most common method of management was stapling of an identified bleb in the lung, which was undertaken in 105 (87%) patients. No operative deaths occurred. Complications included an air leak lasting longer than 5 days in 10 (8%) patients, two of whom required second procedures for definitive management. No episodes of postoperative bleeding or empyema occurred. The postoperative stay ranged from 1 day to 39 days (median 3 days, average 4.3 days) and 99 patients (84%) were discharged within 5 days. Mean follow-up was 13.1 months and ranged from 1 to 34 months. Eleven patients (10%) were lost to follow-up. Ipsilateral pneumothorax recurred after five of 121 procedures (4.1%). Twelve perioperative parameters (age, gender, race, smoking history, site of pneumothorax, severity of pneumothorax, operative indications, number of blebs, site of blebs, bleb ablation, method of pleurodesis, and prolonged postoperative air leak) were entered into univariate and multivariate analysis to identify significant independent predictors of recurrence. The only independent predictor of recurrence was the failure to identify and ablate a bleb at operation, which resulted in a 23% recurrence rate versus a 1.8% rate in those with ablated blebs (p < 0.001). These data suggest that video-assisted thoracic surgery is a viable alternative to thoracotomy for the treatment of recurrent spontaneous pneumothorax. It results in a short hospital stay, low morbidity, high patient acceptance, and a low rate of recurrence.
Video-assisted thoracic surgery has been adopted by some thoracic surgeons as the preferred approach over thoracotomy for many benign and malignant diseases of the chest. However, little concrete evidence exists to support this technique as the superior approach. This randomized study was carried out to define the advantages of video-assisted lobectomy over muscle-sparing thoracotomy and lobectomy. Sixty-one patients with presumed clinical stage I non-small-cell lung cancer were entered into the study. Each patient was randomized to muscle-sparing thoracotomy and lobectomy or video-assisted lobectomy. Six patients were excluded from the study either because final pathologic results revealed nonmalignant disease (3 patients) or because an attempted video-assisted lobectomy was converted to a thoracotomy. This left 30 patients in the thoracotomy group and 25 patients in the video-assisted group. No significant differences existed between the two groups in operating time, intraoperative blood loss, duration of chest tube drainage, or length of hospital stay. Significantly more postoperative complications occurred in the thoracotomy group (p < 0.5), the majority of which were prolonged air leaks. Return to work time was not an issue because the majority of the patients were either retired or not working at the time of the operation. Only three patients had persistent postthoracotomy pain (thoracotomy, n = 2; video-assisted lobectomy, n = 1). We conclude that video-assisted lobectomy was not associated with a significant decrease in duration of chest tube drainage, length of hospital stay, postthoracotomy pain, or, in this group of patients, a faster recovery time and return to work. Video-assisted lobectomy continues to expose the patient to the risk of a major pulmonary resection being done in an essentially closed chest. These results illustrate the need for critical evaluation of video-assisted thoracic surgery before the procedure is accepted as a superior approach based on presumed and thus far unproved advantages.
Although the inferior epigastric artery has been used as an alternative arterial graft for coronary artery bypass grafting, little is known about the contractile and relaxation characteristics of this artery. This study was designed to compare the pharmacologic reactivity of the two arterial conduits--the inferior epigastric artery and the internal mammary artery. Forty-one inferior epigastric artery ring segments from eight patients undergoing coronary grafting and 62 internal mammary artery ring segments were set up in organ baths under physiologic pressure. The contractility was determined from the contraction induced by the depolarizing agent potassium and receptor-mediated vasoconstrictor agents, norepinephrine, U46619, and endothelin-1. Endothelium-dependent relaxation was induced by the calcium ionophore A23187, a non-receptor agonist for endothelium-derived relaxing factor, and acetylcholine, a receptor agonist for endothelium-derived relaxing factor. Glyceryl trinitrate was used to study endothelium-independent relaxation. The maximal response (either contraction or relaxation) and the effective concentration causing 50% of the maximal response for these two arteries were compared. There was no difference (p > 0.05) either in the maximal contraction force (5.30 +/- 0.87 versus 4.76 +/- 0.89 gm for potassium, 5.13 +/- 0.67 versus 4.47 +/- 1.15 gm for norepinephrine, 8.04 +/- 1.23 versus 6.23 +/- 0.99 gm for U46619, and 4.88 +/- 0.69 versus 5.57 +/- 0.93 for endothelin-1 (n = 6 to 10 for each vasoconstrictor) or in the maximal relaxation induced by glyceryl trinitrate (86.46% versus 92.98%, n = 6) or by acetylcholine (20.72% versus 45.51%, n = 5) between the inferior epigastric artery and internal mammary artery. The effective concentration causing half maximal response to all vasoconstrictors and vasodilators was similar between the two arteries (p > 0.05). However, A23187 induced significantly less relaxation in the inferior epigastric artery (38.42 +/- 15.49%, n = 6) than in the internal mammary artery (71.89 +/- 7.17%, n = 9, p < 0.05). We conclude that contractility, endothelium-independent relaxation, and receptor-mediated endothelium-dependent relaxation are similar in the inferior epigastric artery and the internal mammary artery. However, the endothelium of this arterial graft has less ability to respond to the non-receptor-mediated endothelium-derived relaxing factor stimulant. The influence of this difference on the prevalence of atherosclerosis and long-term patency rate in the inferior epigastric artery remains to be studied.
BACKGROUND: The malignant potential of indeterminate solitary pulmonary nodules (SPN) mandates accurate diagnostic management. METHODS: 613 patients undergoing either computed tomographic lung biopsy (CT-Bx) (n = 312) or thoracoscopic excisional biopsy (Thor-Bx) (n = 301) for the diagnosis of SPN were evaluated for relative accuracy, complications, and effect on clinical treatment. RESULTS: CT-Bx identified a malignant diagnosis (Dx) in 201 (64%) of 312 patients; 85 (42%) underwent operations. A total of 116 patients (58%) with synchronous cancer (n = 16), impaired physiologic condition, or unresectable lesions (n = 100) were not operated. Surgical treatment was deferred for 20 patients (6%) with a "specific benign" Dx and 44 physiologically impaired patients with "nonspecific benign" CT-Bx. Forty-seven patients with "nonspecific benign" Dx underwent operation. Thirty-two (68%) lesions were malignant (4 metastatic, 28 primary cancer). CT-Bx accuracy was 86% for malignant and 79 (71%) of 111) for benign lesions. Surgery was still required for 132 (82%) of 163 patients with resectable lesions. Complications occurred in 24% of patients. A specific benign or malignant Dx was obtained in 292 (96%) of 301 patients undergoing Thor-Bx. Conversion to thoracotomy for lobectomy occurred in 38 (21%) of 179 patients with lung cancer. One hundred forty-one patients with lung cancer and impaired physiologic condition and all patients with metastatic (n = 44) and benign lesions (n = 78) had thoracoscopic resection alone. Complications occurred in 22% of patients. CONCLUSIONS: Limited accuracy for benign Dx with CT-Bx requires surgical biopsy for patients with SPN with adequate physiologic reserve. Thor-Bx is a safe and accurate minimally invasive surgical approach to resectable peripheral SPN.
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A prospective study was undertaken during the past 3 years to investigate the effectiveness of thoracoscopic corpectomy--endoscopic removal of the vertebral body in 15 cases (8 for pathologic fractures for tumors, 5 for traumatic fractures and 2 for infections). The average age of the patients was 53.2 years (range 28-85 years). The vertebral levels of corpectomy ranged from T3 to L1. The mean operating time was 211 min (range 83-450 min) and the mean estimated blood loss was 890 ml (range 150-2,800 ml). The postoperative morbidity appeared to be more favorable than with open thoracotomy [Alband OW, Corkill G. Thoracic disk herniation: treatment and prognosis. Spine 1979; 4:41-6; Landreneau RJ, Hazelrigg SR, Mack NJ. Postoperative pain-related morbidity: video-assisted thoracic surgery versus thoracotomy. Ann Thorac Surg (in press); McAfee PC. Complications of anterior approaches to the thoracolumbar spine: emphasis on Kaneda instrumentation. Clin Orthop 1994;306:110-9; McAfee PC, Bohlman HH, Yuan HA. Anterior decompression of traumatic thoracolumbar fractures with incomplete neurological deficit using a retroperitoneal approach. J Bone Joint Surg [Am] 1985;67: 89-104; Regan JJ, Mack MJ, Picetti GD, Guyer RD, Hochschuler SH, Rashbaum RF. A comparison of video-assisted thoracoscopic surgery (VATS) with open thoracotomy in thoracic spinal surgery. Today's Ther Trends 1994;11: 203-18.] because the mean chest tube duration was 1.22 days (range 1-3 days), the mean length of time in the intensive care unit was 2 days (range 1-4 days), and the mean length of total hospitalization was 6.5 days (range 2-12 days). Overall, the ability to visualize the anterior surface of the dura during corpectomy was better endoscopically than with open thoracotomy techniques--improved magnification, the ability of the operative assistant to see and therefore suction more efficiently, and the perspective of visualization was improved. It was possible to place the 30 degrees angled endoscope within the defect left by the resected vertebral body and look directly posteriorly at the dura, visualizing the epidural vessels and dural pulsations at close range. The limiting factor in wide application of the technique is the absence of a commercially available internal fixation system that can be applied endoscopically.
From January 1986 through June 1992, 512 elderly patients (70 years and older) underwent internal mammary artery grafting (IMAG). The operative mortality in these patients was 7.62% (39 of 512), which was significantly higher than that (1.97% [60 of 3,047]; p < 0.0001) in younger patients (under 70 years old). To investigate the risk factors in the elderly, the data from the 512 patients were evaluated by univariate analysis and multiple logistic regression. Of 53 variables analyzed, nine preoperative variables (age, smoking history, congestive heart failure, myocardial infarction, New York Heart Association functional class, ejection fraction, left main artery disease, stenosis of the left anterior descending artery, and reoperation), three intraoperative variables (emergency operation, bilateral IMAG, and right IMAG), and nine postoperative variables were significantly associated with the higher mortality (p < 0.05). In particular, the operative mortality was significantly higher in the patients undergoing right IMAG (21.62% [8 of 37]) than that in patients only undergoing left IMAG (6.53% [31 of 475]; p < 0.004). The significant preoperative and intraoperative variables and the variables that have a tendency for correlation (p < 0.2) to mortality were included in a stepwise multiple logistic regression. The regression analysis demonstrated that right IMAG, reoperation, history of myocardial infarction, age, left main artery disease, history of smoking, and postoperative complications are the risk factors for the elderly undergoing IMAG. Therefore, particular care should be taken in those patients scheduled to undergo IMAG. The role of right IMAG in the elderly should be further clarified before universal acceptance of the technique in these patients.