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Biomedical subjects

N R Hertzer

Publications and source records attributed to N R Hertzer.

At least 109 records · Page 6Linked to original sources
PubMed1982

Early patency of the carotid artery after endarterectomy: digital subtraction angiography after two hundred sixty-two operations.

During a 12-month period of study, 265 patients (mean age 65 years) underwent a total of 314 carotid endarterectomies for the management of previous transient cerebral ischemia (39%), prior stroke (10%), or severe asymptomatic carotid stenosis (51%). Five patients (1.6%) died within 30 days of operation, but only three deaths (1%) were related to carotid reconstruction. Six patients (1.9%) experienced postoperative strokes, including 1.6% of those with previous transient ischemia, 9.7% of those with prior strokes (P less than 0.02), and 0.6% of those with asymptomatic carotid stenosis before operation. Digital subtraction angiography (DSA) was performed during the same hospital admission following 262 procedures in a group of 214 patients, including all patients who had postoperative neurologic complications. Seven of these operations were limited to external carotid endarterectomy. The internal carotid artery was entirely normal in 239 (94%) of the remaining 255 DSA studies. The external carotid artery was normal on 238 (93%) of 255 DSA examinations, but was occluded on 12 (4.7%). A focal intimal defect corresponding to the apical arteriotomy suture was found in nine internal carotid arteries (3.6%), but these lesions did not appear to be hemodynamically significant. The internal carotid artery contained over 30% stenosis in two patients (0.8%) and was occluded in five (1.9%). Two of these five patients had neurologic complications, but four others with operative strokes had normal angiograms. Asymptomatic postoperative thrombosis of the internal carotid artery was documented in only three patients (1.2%).

Adult↗
PubMed1981

Postoperative stroke and late neurologic complications after carotid endarterectomy.

From 1969 through 1973, 335 consecutive patients (mean age, 60 years) underwent 390 carotid endarterectomies using hypercarbic general anesthesia and no carotid shunting. Early neurologic complications were most common among patients with previous neurologic symptoms and among those with subtotal stenosis or occlusion of the contralateral internal carotid artery. The introduction of routine carotid shunting without hypercarbia during a subsequent series of 626 procedures from 1974 through 1978 has been associated with significantly fewer operative strokes in comparable groups of patients. Complete follow-up information during a mean interval of 8.6 years is available for 95% of 325 operative survivors. Late completed strokes have occurred in 17% of patients but have involved the cerebral hemisphere on the side of previous carotid endarterectomy in only 7%. Of 93 operative survivors who had subtotal stenosis of the contralateral internal carotid artery, 45 underwent contralateral endarterectomy as an elective procedure and 48 did not. The late contralateral stroke rates for these two groups of patients were 4% and 16%, respectively, although these differences did not attain statistical significance. Forty-nine (78%) of 63 patients with contralateral internal carotid occlusion have had no late neurologic symptoms following unilateral carotid endarterectomy.

Adult↗
PubMed1981

Fatal myocardial infarction following carotid endarterectomy: three hundred thirty-five patients followed 6-11 years after operation.

Routine coronary angiography has been recommended to all patients undergoing carotid endarterectomy at the Cleveland Clinic since 1978. Patients found to have severe, correctable coronary artery disease (CAD) have been advised to undergo myocardial revascularization as a staged or combined procedure in conjunction with carotid endarterectomy in an attempt to reduce the incidence of fatal myocardial infarction during the postoperative period, and during the late follow-up interval. In order to provide an historic standard with which the results of this approach may eventually be compared, complete follow-up information has been obtained for 95% of 335 consecutive patients who underwent carotid endarterectomy between 1969 and 1973. Fatal myocardial infarction accounted for 60% of early deaths within 30 days of operation and occurred in 1.8% of the entire series. Among the patients who survived operation, the five-year mortality rate was 27%, and the 11-year mortality rate was 48%. Myocardial infarction caused 37% of the deaths that occurred within five years after operation and 38% of the deaths that have occurred within 11 years. Differences in the incidence of fatal myocardial infarction within five years after operation between a group of 116 patients who had no clinical evidence of CAD and a group of 209 patients suspected to have CAD attained statistical significance (p less than 0.1) despite the fact that 67 patients suspected to have CAD eventually underwent myocardial revascularization. Improvement in actuarial survival (p less than 0.05) and reduction in the late mortality rate (p less than 0.01) were statistically significant for the subset of patients with suspected CAD who had aortocoronary bypass graft procedures.

Adult↗
PubMed1981

Fatal myocardial infarction following lower extremity revascularization. Two hundred seventy-three patients followed six to eleven postoperative years.

Routine preoperative coronary angiography has been recommended to all patients scheduled for elective lower extremity revascularization at the Cleveland Clinic since 1978. Patients found to have severe, correctable coronary artery disease (CAD) have been advised to undergo myocardial revascularization prior to surgical management of lower extremity ischemia in an attempt to reduce the incidence of fatal postoperative myocardial infarction. In order to provide an historic standard with which the results of this approach may eventually be compared, complete follow-up information has been obtained for 95% of 273 consecutive patients who underwent lower extremity revascularization between 1969 and 1973. Fatal myocardial infarction accounted for 52% of early postoperative deaths and occurred in 3.3% of the entire series. Among the patients who survived operation, the five-year mortality rate was 20% and the 11-year mortality rate was 40%. Complications of CAD caused 50% of the deaths that occurred within five years postoperatively and 55% of the deaths that have occurred within 11 years. The incidence of fatal myocardial infarction within five years after operation among patients who had preoperatively evidence of CAD was statistically significant (p less than 0.01).

Adult↗
PubMed1981

External carotid endarterectomy.

External carotid endarterectomy may be useful in the management of selected patients who have internal carotid occlusion, persistent neurologic symptoms and additional atheromatous ulceration or stenosis within the carotid bifurcation. The procedure should be associated with a low risk for intraoperative stroke and a reasonable likelihood for symptomatic improvement. If symptoms are not completely corrected by external carotid endarterectomy, superficial temporal artery-to-middle cerebral artery bypass may be performed with greater confidence in a successful hemodynamic result.

Aged↗
PubMed1980

Blunt carotid artery trauma: report of two cases and review of the literature.

Blunt carotid artery trauma is uncommon but has been associated with severe, permanent neurologic deficits in 42% and mortality in 30% of 96 patients previously reported in the English literature. Since neurologic symptoms characteristically develop only after a latent interval and since physical evidence of significant cervical trauma often is absent, diagnosis of nonpenetrating carotid injuries with the use of arteriography usually is delayed until the appearance of obvious, frequently irreversible neurologic complications. Carotid injuries should be suspected in patients who develop monoplegia or hemiplegia following blunt craniocervical trauma, particularly if computerized tomography excludes the presence of intracranial hemorrhage. The cumulative results of a collected series of 96 patients suggest that early surgical correction of blunt carotid injuries is appropriate for patients with transient episodes of cerebral ischemia, strokes in evolution, or mild completed neurologic deficits.

Adolescent↗
PubMed1980

Fatal myocardial infarction following abdominal aortic aneurysm resection. Three hundred forty-three patients followed 6--11 years postoperatively.

Routine preoperative coronary angiography has been recommended to all patients scheduled for elective abdominal aortic aneurysm resection at the Cleveland Clinic since 1978. Patients found to have severe, correctable coronary artery disease (CAD) have been advised to undergo myocardial revascularization prior to aneurysm resection in an attempt to reduce the incidence of fatal postoperative myocardial infarction. In order to provide an historic standard with which the results of this approach may eventually be compared, complete follow-up information has been obtained for 96% of 343 consecutive patients who underwent abdominal aortic aneurysm resection between 1969 and 1973. Fatal myocardial infraction accounted for 37% of early postoperative deaths and occurred in 6% of the entire series. Among the patients who survived operation, the five-year mortality rate was 31% and the 11-year mortality rate was 52%. Complications of CAD caused 39% of the deaths that occurred within five years after operation and 41% of the deaths that occurred within 11 years. The late incidence of fatal myocardial infarction among patients who had preoperative evidence of CAD was statistically significant (p < 0.05).

Aged↗
PubMed1980

A retrospective comparison of the use of shunts during carotid endarterectomy.

In this report, compared in retrospect is the incidence of intraoperative stroke among 152 operations performed under hypercarbic general anesthesia without carotid artery shunting, 260 operations performed under both hypercarbia and normocarbia anesthesia with selective shunting based upon internal carotid artery back pressure and 366 operations performed under normocarbia anesthesia with routine carotid artery shunting. Chi-square analysis determined that routine carotid shunting was associated with a significant reduction in the incidence of intraoperative stroke among patients with previous transient ischemic attacks. In addition, both routine shunting and selective shunting, depending upon internal carotid artery back pressure, reduced the incidence of intraoperative stroke among patients with subtotal stenosis of the contralateral internal carotid artery. Considering the safety, simplicity and wide availability of Silastic carotid artery shunts, their routine use during carotid endarterectomy appears advisable in preference to more elaborate and expensive methods of intraoperative cerebral protection.

Anesthesia↗
PubMed1980

A prospective study of the incidence of injury to the cranial nerves during carotid endarterectomy.

In order to determine the incidence of cranial nerve injury during carotid endarterectomy, preoperative and postoperative otolaryngologic examinations were performed in a prospective series of 240 operations. Thirty patients experienced a total of 38 cranial nerve injuries, involving the recurrent laryngeal nerve in 14, the hypoglossal nerve in 13, the marginal mandibular nerve in six and the superior laryngeal nerve in five. Postoperative dysfunction affected one cranial nerve in 25 patients, two nerves in four and three nerves in one patient. Most cranial nerve injuries were asymptomatic or mild in severity, resolved in one to 12 months and probably were caused by intraoperative retraction.

Arteriosclerosis↗
PubMed1980

Influence of distal arterial occlusive disease on prognosis following aortobifemoral bypass.

Arteriographic criteria were used to classify 376 consecutive patients who underwent aortobifemoral bypass for aortoiliac occlusive arterial disease between 1967 and 1977. Group A (126 patients, 34%) had isolated aortoiliofemoral disease, group B (156 patients, 41%) had associated femoropopliteal disease, and group C (94 patients, 25%) had associated femoropopliteal and tibioperoneal disease. Ischemic rest pain or tissue necrosis was the indication for operation in 13% of patients in group A, 30% of those in group B (P < 0.01), and 45% of those in group C (P < 0.001). The overall operative mortality rate was 5.6%, and differences in operative mortality among the three groups had no statistical significance. Fatal postoperative myocardial infarctions occurred in 4.5% of the entire series and accounted for 17 (81%) of 21 postoperative deaths. Late follow-up information for 3 to 13 postoperative years (mean, 6.3 years) was available for 337 (95%) of 355 operative survivors. Subsequent femoropopliteal or femorotibial bypass was necessary for 8% of patients in group A, 13% of those in group B, and 19% of those in group C (P < 0.05), but the presence of distal occlusive disease was not associated with meaningful differences in cumulative aortofemoral limb patency or major amputation. The late mortality rate was 28% for group A, 33% for group B, and 41% for group C. Myocardial infarctions were responsible for 46% of all late deaths and occurred in 11% of patients in group A, 15% of those in group B, and 20% of those in group C. The mortality rate (P < 0.01) and the incidence of fatal myocardial infarction (P < 0.02) within five postoperative years were statistically significant in group C.

Adult↗
PubMed1979

Routine coronary angiography prior to elective aortic reconstruction: results of selective myocardial revascularization in patients with peripheral vascular disease.

Routine coronary angiography to determine the prevalence of severe coronary artery disease (CAD) has been recommended to all patients under consideration for elective peripheral vascular reconstruction at the Cleveland (Ohio) Clinic since April 1978. Those found to have severe, correctable CAD have been advised to undergo myocardial revascularization prior to performance of elective peripheral vascular operations. Forty-one of the 68 patients with abdominal aortic aneurysms (AAA) and 26 of the 71 patients with aortoiliac occlusive arterial disease (AI) had clinical evidence of CAD; coronary angiography demonstrated severe, correctable CAD in 23 patients with AAA and in 14 patients with AI. Twenty-seven patients with AAA and 45 patients with AI had no clinical evidence of CAD; severe, correctable CAD was found in six patients with AAA and in six patients with AI. Ninety-six patients, including 26 who had staged cardiac procedures performed, have had elective aortic reconstruction, with one operative death.

Adult↗
PubMed1979

Recurrent stenosis after carotid endarterectomy.

Thirteen of 1,250 patients required a second operation for recurrent stenosis following carotid endarterectomy performed at the Cleveland Clinic between 1958 and 1978. Two other patients underwent reoperation because of recurrent stenosis following primary operations at other institutions. Thirteen of the 15 patients experienced neurologic symptoms caused by recurent stenosis, while two patients remained asymptomatic. Atherosclerosis was responsible for recurrent stenosis in 12 patients and appeared to be related to hypercholesterolemia. Three of the patients had myointimal fibroplasia. Eleven of the 16 reoperations for recurrent stenosis of the carotid artery consisted of carotid endarterectomy with vein patch angioplasty. Three patients had carotid endarterectomy with closure of the primary arteriotomy. One patient with occlusion of the internal carotid artery underwent endarterectomy of the external carotid artery because of amaurosis fugax, and a saphenous vein interposition graft was used to replace a previous Dacron graft in one patient with anastomotic stenosis. One patient had a stroke during reoperation manifest as multiple retinal emboli. Fourteen patients have remained asymptomatic from one to 70 months following reoperation. One patient with occlusion of the contralateral internal carotid artery has experienced persistent vertebrobasilar symptoms.

Age Factors↗
PubMed1979

Intraoperative hemodilution during elective vascular reconstruction.

Intraoperative hemodilution and retransfusion were used for blood replacement in 30 patients who underwent elective reconstruction of the abdominal aorta, thoracic aorta or femoropopliteal segment. During each operation, 1,000 to 2,000 milliliters of autologous blood were collected through an arterial cannula during induction of anesthesia and the initial stages of operative exposure. Each volume of shed blood was replaced with 1.5 volumes of colloid and crystalloid solutions to maintain a stable intravascular volume despite transient low hematocrit values--mean, 25.8 +/- 2.1 per cent--during the period of maximum blood loss in the surgical field. Collected blood was stored in standard citrate-phosphate-dextrose disposable units and was reinfused at the conclusion of the vascular procedure. Swan-Ganz pulmonary artery catheters were inserted in an initial study group of 15 patients. Serial blood hematocrit and coagulation studies and hemodynamic parameters were measured or calculated before and after induction of anesthesia, during hemodilution, after reinfusion of autologous blood and 24 hours after operation. Improvement in cardiac output and reduction in peripheral vascular resistance maintained adequate systemic oxygen transport during hemodilution. Transient dilution of coagulation factors was documented by abnormal prothrombin and partial thromboplastin times, but serious bleeding tendencies did not occur. Twenty-one of the 30 patients received no homologous blood. Considering the entire series of 30 patients, each required only 0.46 +/- 0.87, S.D., unit of homologous blood during operation and the postoperative period.

Adult↗