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Biomedical subjects

N R Hertzer

Publications and source records attributed to N R Hertzer.

At least 91 records · Page 5Linked to original sources
PubMed1985

Extracranial carotid aneurysms: report of six cases and review of the literature.

Ligation of atherosclerotic extracranial carotid aneurysms was described nearly 200 years ago, but resection and direct reconstruction of these unusual lesions currently are associated with less risk for perioperative neurologic complications as well as with durable late results. During an interval in which carotid endarterectomy was performed in over 1500 patients at The Cleveland Clinic, only six patients underwent surgical management of cervical carotid aneurysms. Aneurysm resection was performed in conjunction with reanastomosis of the internal carotid artery in two patients but required saphenous vein interposition grafts in four others. A temporary carotid shunt was employed routinely and was threaded through the harvested vein before its insertion whenever graft replacement was necessary. Although one vein graft required revision because of early thrombosis, no operative deaths or permanent strokes occurred in this small series. Each patient has remained asymptomatic throughout a maximum follow-up period of 6 years postoperatively.

Adult↗
PubMed1985

Coronary angiography in 506 patients with extracranial cerebrovascular disease.

Coronary angiography was performed during the evaluation of a prospective series of 506 patients (mean age, 65 years) presenting with extracranial cerebrovascular disease and previous neurologic symptoms (N = 288) or asymptomatic carotid bruits (N = 218). Severe, surgically correctable coronary artery disease was documented in 37% of patients suspected to have coronary artery disease by conventional clinical criteria, compared with 16% of those who were not. Severe inoperable coronary disease was present in 9.8% and 1.5% of these respective subsets and was especially common (14%) among diabetics. As the result of this investigation, an algorithm for perioperative cardiac screening has been developed in an attempt to reduce the eventual mortality caused by myocardial infarction in patients who require extracranial reconstruction.

Adult↗
PubMed1985

Vascular problems in urologic patients.

Intraoperative vascular surgical consultation may be necessary if venous or arterial injury occurs during transabdominal urologic operations. Loss of blood usually can be controlled by simple digital compression until the consultant arrives, but urologists should be familiar with the principles of vascular reconstruction. Adequate exposure of the injured segment is essential, and the repair of major vessels must preserve patency as well as provide hemostasis. In this regard, patch angioplasty is sometimes necessary, and formal replacement with autogenous or prosthetic grafts may rarely be required. Blunt arterial trauma can precipitate distal arterial embolization, a complication that usually is not suspected until the immediate postoperative period. Although salvage should be managed by a vascular surgeon, urologists must be alert for the early signs of acute extremity ischemia after extensive retraction has been used deep in the pelvis, particularly in elderly or atherosclerotic patients. Considering the established diagnostic accuracy of roentgenographic studies presently employed in the fields of urology and vascular surgery, preoperative planning should limit the number of urgent intraoperative consultations between members of these two specialties. Each may have valuable advice to offer the other concerning the treatment of unusual problems involving obstructive uropathy, aortic aneurysms, and occlusive arterial disease, and their cooperative effort is especially important in the management of renal revascularization.

Aortic Aneurysm↗
PubMed1985

Cumulative stroke and survival ten years after carotid endarterectomy.

With the life-table method, late stroke and survival data were calculated for 329 patients (mean age 59 years) followed a minimum of 10 years after carotid endarterectomy. The cumulative incidence of stroke was 24% at 10 years after operation, but only 10% of patients sustained strokes that clearly involved the ipsilateral cerebral hemisphere. Late strokes were most common (p less than or equal to 0.05) among hypertensive patients (31%), those with preoperative strokes (31%), and patients with recognized contralateral carotid stenosis (42%). Contralateral hemispheric strokes occurred in 36% of patients with uncorrected contralateral stenosis compared with 8% of those who had elective bilateral reconstruction (p = 0.09). Myocardial infarctions caused more late deaths (37%) than did strokes (15%), and 10-year survival after incidental myocardial revascularization (55%) was superior (p = 0.0001) to survival for patients with suspected but undocumented coronary disease (32%).

Actuarial Analysis↗
PubMed1985

External carotid revascularization: review of a ten-year experience.

In the presence of ipsilateral internal carotid artery (ICA) occlusion, external carotid artery (ECA) revascularization can improve cerebral perfusion or eliminate an embolic source. From 1974 through 1984, 37 patients at The Cleveland Clinic underwent 42 ECA reconstructions; autologous patch angioplasty and intraluminal shunting were used when feasible. Thirty procedures were limited to primary ECA revascularization, whereas 12 extended procedures were performed as reoperations after previous ECA endarterectomy or required complementary subclavian or intracranial bypass. There were no early postoperative deaths nor neurologic morbidity in the limited group, but one death, four ipsilateral hemispheric strokes, and one retinal embolism occurred in the extended group. Ten patients have died during a follow-up interval of 1 to 72 months (mean 27 months). Five late deaths were caused by myocardial infarction, only one of which was complicated by a contralateral stroke. Two additional strokes have occurred; one involved the ipsilateral and one the contralateral cerebral hemisphere. Five other patients experienced recurrent cerebral or ocular ischemic symptoms. In conclusion, extended ECA reconstruction is associated with a higher operative risk than limited revascularization. Late follow-up is necessary to detect those patients who may eventually require additional management of recurrent cerebrovascular symptoms or incidental coronary artery disease.

Aged↗
PubMed1985

The early results of vascular surgery in patients 75 years of age and older: an analysis of 3259 cases.

The population in the United States older than 75 years of age will double by the year 2000. The computerized registry of The Cleveland Vascular Society includes 19,990 vascular procedures, which have been divided into two groups. Group A consists of 16,731 operations performed on patients younger than 75 years of age and group B consists of 3259 procedures performed on patients older than 75 years of age. The overall operative mortality rate in group A was 4.4% (736 of 16,731). In subsets of group B the mortality rates were: age 75 to 79 years, 11.3% (210 of 1862), age 80 to 84 years, 13.4% (125 of 932), age 85 to 89 years, 18.0% (68 of 376), and age 90 to 98 years, 28.1% (25 of 89). In carotid endarterectomy there were no significant differences in the stroke and operative mortality rates when groups A and B were compared. Group A stroke rate was 1.8% (94 of 5220), operative mortality rate was 1.5% (77 of 5220); group B stroke rate was 2.2% (17 of 782) and the mortality rate was 2.3% (18 of 782). For aortic reconstructions group A mortality rate was 7.1% (276 of 3905); group B operative mortality rate was 24.1% (148 of 615) (p less than 0.001). In femoropopliteal reconstructions group A operative mortality rate was 2.2% (55 of 2377) and group B mortality rate was 6.7% (38 of 571) (p less than 0.0001). For lower extremity thromboembolectomy group A operative mortality rate was 14.3% (113 of 789) and the mortality rate for group B was 28.4% (196 of 689) (p less than 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1984

Natural history of periprosthetic air on computerized axial tomographic examination of the abdomen following abdominal aortic aneurysm repair.

The presence of periprosthetic gas on computerized axial tomography (CT) of the abdomen following abdominal aortic reconstruction has been proposed to be a reliable indicator of prosthetic graft infection, a complication that requires intervention entailing significant mortality and morbidity. To evaluate the reliability of this finding in the early postoperative period, prosthetic grafts in 26 patients undergoing elective aneurysm repair were evaluated with postoperative CT examinations. Serial scans were obtained at mean intervals of 3, 7, and 52 days postoperatively. The presence or absence of periprosthetic air on CT scan was noted, and the results were correlated with aneurysm size as determined by preoperative ultrasound examination of the abdominal aorta or by measurements made during operation. Mean aneurysm size was 6.1 cm (range 4.5 to 10.6 cm). Periprosthetic air was demonstrated in 17 (65%) of the 26 patients studied within 1 week postoperatively. Patients with aneurysms larger than 6.0 cm were more likely to demonstrate periprosthetic air then those with smaller aneurysms (chi 2 = 5.024, p = 0.025). All patients found to have periprosthetic air had spontaneous resolution by late CT scanning obtained a mean of 52 days postoperatively (range 21 to 85 days). One patient died in the early postoperative period and two did not return for late scans. Only one patient demonstrated periprosthetic air as late as the thirty-second postoperative day, and this air had resolved by the seventieth postoperative day.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1984

Coronary artery disease in peripheral vascular patients. A classification of 1000 coronary angiograms and results of surgical management.

In an attempt to reduce early and late mortality caused by myocardial infarction, coronary angiography was performed in 1000 patients (mean age, 64 years) under consideration for elective peripheral vascular reconstruction since 1978. Those found to have severe, surgically correctable coronary artery disease (CAD) were advised to undergo myocardial revascularization (CABG), usually preceding other vascular procedures. The primary vascular diagnosis was abdominal aortic aneurysm (AAA) in 263 patients (mean age, 67 years), cerebrovascular disease (CVD) in 295 (mean age, 64 years), and lower extremity ischemia (ASO) in 381 (mean age, 61 years). Severe correctable CAD was identified in 25% of the entire series (AAA, 31%; CVD, 26%; and ASO, 21%). Surgical CAD was documented in 34% of patients suspected to have CAD by clinical criteria (AAA, 44%; CVD, 33%; and ASO, 30%) and in 14% of those without previous indications of CAD (AAA, 18%; CVD, 17%; and ASO, 8%). Cardiac procedures (216 CABG) were performed in 226 patients (AAA, 30%; CVD, 22%; and ASO, 19%), with 12 (5.3%) postoperative deaths. A total of 796 patients underwent 1066 peripheral vascular operations with an early mortality of 2.0% (AAA, 3.4%; ASO, 1.9%; and CVD, 0.3%), but only one death (0.8%) occurred in the group of 130 patients having preliminary CABG. The overall operative mortality for 1292 cardiac and peripheral vascular procedures was 2.6%.

Age Factors↗
PubMed1984

Incidental asymptomatic carotid bruits in patients scheduled for peripheral vascular reconstruction: results of cerebral and coronary angiography.

From 1978 to 1982 routine preoperative coronary angiography was performed in a series of 1000 patients under consideration for elective peripheral vascular reconstruction, including 295 who were selected primarily because of recognized extracranial cerebrovascular disease. Incidental asymptomatic carotid bruits were discovered in 144 (20%) of the remaining 705 patients who primarily were scheduled for such procedures as aortic replacement, lower extremity revascularization, or visceral artery bypass, and 139 of these 144 patients underwent cerebral angiography as well as cardiac catheterization. Carotid stenosis exceeding 50% of lumen diameter was documented by biplanar angiography in 39 (58%) of 67 patients with unilateral bruits and in 54 (75%) of 72 patients with bilateral bruits (p = 0.0471), and greater than 75% stenosis was present in 42% and 46% of these subsets, respectively. Cardiac catheterization revealed severe, surgically correctable coronary artery disease (CAD) in 29% of patients with incidental carotid bruits and in 24% of those without bruits, as well as in 32% of patients who had documented carotid stenosis and in 22% of those who did not. Although these differences were not statistically valid, the incidence of severe, correctable CAD was significantly higher among patients suspected to have CAD by standard clinical criteria (33% to 38%) than among those who were not (13%), irrespective of whether carotid bruits were present (p = 0.0021) or absent (p = 3.48 X 10(-9). Prophylactic carotid endarterectomy was performed in 54 patients (bilateral in nine), with one death (1.6%) and one postoperative stroke. In addition, 153 patients underwent elective myocardial revascularization in an attempt to reduce subsequent surgical risk and enhance late survival, with an early mortality rate of 5.2%. Only three strokes (0.4%) occurred after a total of 714 other peripheral vascular procedures in this series, and the overall operative mortality rate was 2.7%. While this study does not resolve the controversy concerning the management of incidental asymptomatic carotid bruits in patients scheduled for other operations, it provides new perspective regarding synchronous carotid and coronary disease and confirms the low risk for subsequent stroke and death after appropriate carotid and coronary reconstruction.

Aged↗
PubMed1984

The risk of vascular surgery in a metropolitan community. With observations on surgeon experience and hospital size.

From 1978 through 1981 complete perioperative information concerning a total of 10,189 peripheral vascular procedures performed in northeastern Ohio was recorded in the computer registry of The Cleveland Vascular Society. This report is an analysis of mortality and morbidity rates for all 5686 operations involving carotid endarterectomy (N = 2646), lower extremity revascularization (N = 1987), and abdominal aortic aneurysm resection (N = 1053). The operative mortality rate was 1.2% for carotid reconstruction, 2.8% for femoropopliteal or distal bypass, 3.5% for aortofemoral revascularization, and 11.9% for aortic aneurysm resection (elective operations 6.5%; emergency operations 32.9%). Postoperative strokes occurred after endarterectomy in 2.7% of patients having preoperative neurologic symptoms and in 2.0% of those with asymptomatic carotid stenosis. Lower extremity amputation was unavoidable in 1.5% of patients after aortofemoral reconstruction and in 6.0% after femoropopliteal or distal bypass. Statistical testing indicated that the operative mortality rate was not related to the respective size of the 27 hospitals involved in the survey. The relative annual experience of the 29 participating surgeons significantly influenced only the mortality rate of elective aneurysm resection and the amputation rate after femoropopliteal or distal revascularization. This study suggests that the results of major arterial reconstruction in metropolitan areas may be expected to be comparable to those of published series if the responsible surgeons are specifically trained and maintain an active interest in the field of vascular surgery.

Aorta, Abdominal↗
PubMed1983

Intraoperative autotransfusion during abdominal aortic reconstruction.

Intraoperative autotransfusion by a continuous-flow centrifuge system was used during more than 300 abdominal aortic reconstructions at the Cleveland Clinic since May 1979. Fifty consecutive patients undergoing such operations were studied prospectively. Volumes of blood lost, salvaged, and transfused during each operation were tabulated. Autologous autotransfused blood was compared with homologous bank blood with respect to oxygen-carrying capacity, coagulation factors, microaggregate levels, red cell mass, pH, and free hemoglobin concentration. Chromium-51 red cell survival studies were performed in autotransfused blood in random patients and in control subjects. Renal, hepatic, and coagulation functions were determined during the first postoperative week. Each patient received a mean volume of 1,203 ml of autotransfused blood and 1,682 ml of bank blood to replace a mean operative blood loss of 2,386 ml. Red blood cell survival of both salvaged autologous and unshed autologous blood in the control group was nearly identical. Salvaged blood had superior oxygen-carrying capacity, a lower microaggregate level, and better buffering capacity than bank blood. Although transient elevations in liver function values and free hemoglobin levels were noted, no clinically important aberration of coagulation, hepatic, or renal function was demonstrated.

Aged↗
PubMed1983

Teflon reinforcement of an uninterrupted aortic anastomosis.

In the experience of the author, Teflon reinforcement of an uninterrupted aortic anastomosis has proved to be a rapid and reliable method to avoid excessive blood loss during reconstruction of the abdominal aorta with a prosthetic arterial graft. This approach has been especially appropriate when the aorta is too calcified or flimsy to permit a conventional, continuous suture technique.

Aorta, Abdominal↗
PubMed1983

Combined myocardial revascularization and carotid endarterectomy. Operative and late results in 331 patients.

Simultaneous coronary artery bypass and carotid endarterectomy were performed in 331 patients (mean age 61 years) at the Cleveland Clinic from 1973 through 1981. Of these, 195 (59%) had Functional Class III-IV angina pectoris, 308 (93%) had multiple-vessel coronary artery disease (CAD), 68 (21%) had over 50% stenosis of the left main coronary artery, and 185 (56%) had either segmental or diffuse impairment of left ventricular function. Asymptomatic carotid stenosis was documented in 173 patients (52%), and the remaining 158 had experienced either previous transient cerebral ischemia (38%) or completed strokes (10%). Single aorta-coronary grafts were placed in 59 patients (18%), double grafts in 131 (40%), and three or more grafts in 141 (42%). Nineteen patients (5.7%) died postoperatively in the hospital. Neurologic deficits occurred in 30 patients (9.0%) and produced permanent functional impairment in 15 (4.5%). Late results have been obtained for 312 operative survivors at a mean postoperative interval of 38 months. Thirty-eight patients (12%) have died, but the 5 year life-table survival rate of the study group was identical to that of the normal population aged 61 years. Significant differences in cumulative 5 year survival rates were identified among diabetic patients (p less than 0.025) and among those receiving single rather than double (p less than .005) or multiple (p less than .01) coronary grafts. Although 18 patients (5.8%) have had late strokes, only five (1.6%) of these strokes have involved the cerebral hemisphere on the same side as combined carotid endarterectomy.

Adult↗
PubMed1983

Complications of abdominal aortic reconstruction. An analysis of perioperative risk factors in 557 patients.

From 1974 through 1978, 557 patients (mean age: 63 years) underwent Dacron graft replacement of the abdominal aorta at the Cleveland Clinic. Postoperative complications occurred in 110 patients (20%), with mortality rates of 5.1% for those having intact aortic aneurysms, 26% for those with ruptured aneurysms, and 2.3% for those with aortoiliac occlusive disease. Myocardial infarction was the most common cause of postoperative death, affecting 3.1% of the entire series, but all 87 patients who had previously required myocardial revascularization survived subsequent aortic procedures (p less than 0.01). As defined in this investigation, temporary renal failure (7.0%) or pulmonary insufficiency (5.9%) were encountered more frequently than were other complications, but each of these was the singular cause of death in only 0.2% of all patients. Several risk factors significantly influenced postoperative mortality, (p less than 0.01), including age over 60 years, suspected coronary artery disease, serum creatinine greater than 2.0 mg/dl, complementary renal artery revascularization, and aneurysm rupture. In addition, intraoperative blood loss had a statistically valid correlation with postoperative mortality (p less than 0.01), myocardial infarction (p less than 0.010, renal failure (p less than 0.001), and pulmonary insufficiency (p less than 0.001).

Adult↗
PubMed1982

Routine surgical management of brachial artery occlusion after cardiac catheterization.

From 1965 through 1980, 1,108 patients (1.5%) underwent thrombectomy and local arterial reconstruction because of brachial artery occlusion after a total of 73,750 cardiac catheterization procedures performed at the Cleveland Clinic. In a study group of 100 consecutive patients, 91 had simple arteriotomy revision and nine had segmental arterial resection with either axial reanastomosis or a saphenous vein interposition graft. Thirteen patients sustained early recurrent thrombosis after limited arteriotomy revisions, and 11 of these had successful reoperations. Ninety-eight patients were discharged from the hospital with normal distal pulses and no ischemic symptoms. Statistical analysis indicated that women were more likely than men to experience early recurrent thrombosis, and that late ischemic symptoms were most common among women and among those who required reoperations at the time of initial treatment.

Adult↗
PubMed1982

Brachiocephalic arterial reconstruction.

From 1965 through 1980, 51 men and 49 women (mean age: 55 years) underwent transthoracic or extrathoracic revascularization of the innominate, common carotid, subclavian, or vertebral arteries. Preoperative symptoms were limited to the vertebrobasilar syndrome in 29 patients, to hemispheric neurologic or monocular visual events in 19, and to upper extremity ischemia in 13. Multiple symptoms were present in 27 other patients, and 12 patients were asymptomatic before operation. Median sternotomy was performed for correction of innominate, common carotid, or subclavian lesions in 34 patients, including six simultaneous brachiocephalic and cardiac procedures, with five operative deaths (14.7%). Extrathoracic reconstruction, such as carotosubclavian and axilloaxillary bypass or vertebral endarterectomy and reimplantation, was employed in 66 patients, with two operative strokes but no mortality (p less than .01). Late results were obtained from two to 189 months after operation (mean: 52 months). Considering their original symptoms, 82 patients have been classified as asymptomatic or improved, nine as unchanged, and nine others, including those who had operative complications, as worse. Twelve patients have eventually sustained either transient cerebral ischemia (six) or strokes (six), most of which were unrelated to eight documented late operative failures. In addition to 20 patients who required combined brachiocephalic and carotid bifurcation reconstruction, 27 additional carotid endarterectomies have at some time been necessary for patients having extensive cerebrovascular disease. Twenty patients have died during the follow-up interval, including eight with myocardial infarctions, but only one with a fatal stroke.

Adult↗