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PubMedDate not supplied

Posterior limbal incision.

BACKGROUND: Sutureless cataract incisions should ideally remain sealed with increased intraocular pressure and be able to withstand increased external pressure to the posterior aspect. Cadaver eye studies have shown that meeting these criteria requires an internal corneal lip of at least 1.5 mm and a square wound. Scleral incisions can meet these criteria but sacrifice aesthetics and surgical efficiency. Clear corneal incisions provide aesthetics and surgical efficiency but not wound stability. An ideal incision would combined stability with aesthetics and efficiency. METHODS: We tested a posterior limbal incision to assess its stability, aesthetics, and efficiency. The incision originated at the posterior limbus within the conjunctiva, gaining about 1.0 mm in tunnel length over a clear corneal incision. This was enough to obtain a square profile for 3.0 x 3.0 mm wide incisions, while providing the aesthetics and surgical efficiency of a clear corneal incision. We compared a 3.0 x 2.0 mm posterior limbal with a 3.0 x 2.0 mm clear corneal incision. Each was tested in stepped, paracentesis, and hinged profiles. CONCLUSIONS: When compared with the clear corneal incision, the posterior limbal incision is equal in aesthetics and surgical efficiency, slightly superior in patient comfort, and far more stable.

Cataract Extraction↗

PubMed1997

Surgically induced astigmatism following a 4.0 mm sclerocorneal valve incision.

PURPOSE: To determine whether sutureless small incision cataract surgery reduces induced astigmatism over the long term. SETTING: University Eye Hospital, Vienna, Austria. METHODS: In a prospective study, we investigated surgically induced astigmatism in 63 cases of no-stitch, small incision cataract surgery with a 4.0 mm square sclerocorneal tunnel and implantation of a flexible intraocular lens. Follow-up was 4 to 5 years. Keratometry was measured with a Zeiss keratometer preoperatively and after 1 day, 1 week, 1, 3, and 9 months, and a median of 4.4 years. In 21 nonoperated eyes, we investigated the natural course of astigmatism over 5 years. RESULTS: The mean keratometric cylinder stabilized at 0.8 diopter (D) after 1 week and slightly decreased to 1.0 D after 4 to 5 years. Cravy's vector analysis showed an immediate against-the-rule (ATR) shift of -0.2 D that remained relatively stable until 9 months. Between 9 months and 4.4 years postoperatively, there was a statistically significant increase in ATR induced astigmatism from -0.2 to -0.5 D. The natural course of astigmatism in the nonoperated eyes showed an ATR shift of -0.1 D for the same period. CONCLUSION: The result show a small, though statistically significant amount of postoperatively induced astigmatism 4 to 5 years after no-stitch, small incision cataract surgery.

Aged↗

PubMed1997

Laser in situ keratomileusis to correct high myopia.

PURPOSE: To evaluate the effectiveness, predictability, and safety of laser in situ keratomileusis (LASIK) in 143 eyes with myopia from 8.00 to 20.00 diopters (D). SETTING: Alicante Institute of Ophthalmology, University of Alicante School of Medicine, Alicante, Spain. METHODS: This prospective study comprised 143 eyes (94 patients) that had LASIK with the Chiron Automated Corneal Shaper and the VISX 20/20 excimer laser using a multizone profile and a sutureless hinged corneal flap technique. RESULTS: Uncorrected visual acuity of 20/40 or better in 45.0% of eyes 3 months postoperatively and in 46.4% at 6 months. Best corrected visual acuity (BCVA) improved by 0.07 at 3 and 6 months and was stable after 3 months. Mean spherical equivalent was -13.19 diopters (D) +/- 2.89 (SD) preoperatively and +0.51 +/- 1.63 D at 3 months and +0.18 +/- 1.66 D at 6 months postoperatively. At 3 months, spherical equivalent was within 1.00 D of emmetropia in 57.5% of all eyes, 71.0% of eyes with a baseline refraction from -8.00 to -11.99 D (n = 59), 44.4% with a baseline refraction from -12.00 to -15.99 D (n = 54), and 53.0% of eyes with a baseline refraction from -16.00 to -20.00 D (n = 30). The respective 6 month percentages were 60.0, 72.4, 46.0, and 50.0%. The regression of effect was similar in all groups (approximately 0.50 D) between 1 and 3 months, although the high myopia group had further regression. Significant corneal steepening and an increase in corneal thickness occurred between 1 and 3 months. Flap thickness was always less than predicted with both the 130 microns plates, and achieved laser ablation was deeper than programmed. The relationships between postoperative refraction and preoperative keratometry and postoperative refraction and the difference in achieved versus programmed ablation were significant. Complications at 6 months included epithelial ingrowth, corneal flap melting, decentered ablation, and irregular astigmatism with loss of BCVA, although none was vision threatening. CONCLUSION: In this study, LASIK was effective and predictable in the correction of high myopia but was more accurate for myopia up to 12.00 D. Current surgical algorithms must be modified to improve predictability in higher corrections. Longer follow-up is necessary to evaluate long-term incidence of vision-threatening complications.

Adult↗

PubMed1997

Unpreserved lidocaine to control discomfort during cataract surgery using topical anesthesia.

PURPOSE: To determine whether intraoperative unpreserved lidocaine further decrease discomfort or pain during sutureless small incision cataract surgery and intraocular lens (IOL) implantation under topical anesthesia. SETTING: Outpatient ambulatory surgical center. METHODS: In this prospective controlled study, comparable eligible patients were randomized to receive 0.1 cc unpreserved lidocaine 1% or 0.1 cc balanced salt solution (BSS) (control group) in double-masked fashion. Study drugs were injected intracamerally 1 minute before phacoemulsification. A predefined uniform pain/discomfort scale was used for assessment during phacoemulsification and IOL insertion. A secondary study using a 0.5 cc dose was also performed. RESULTS: Twenty-six percent in the control group and 9% in the lidocaine group had discomfort pain scores of 2 or more; 10% in the BSS group felt increased pressure or pain during phacoemulsification. In the lidocaine group, discomfort was felt mainly during IOL insertion, possibly as a result of wound manipulation. During phacoemulsification, no patient in the lidocaine group reported pain; 2% felt increased pressure during phacoemulsification. A dose increase to 0.5 cc reduced any intraocular sensation to 3% in the lidocaine group. No patient in either group had significant cell loss or adverse events. CONCLUSION: Intraoperative lidocaine is safe and effective in controlling intraoperative discomfort.

Aged↗

PubMedDate not supplied

Corneal topographic changes after frown and straight sclerocorneal incisions.

PURPOSE: To compare the corneal topographic changes following cataract surgery with two types of sclerocorneal tunnel incisions for implantation of 6.0 mm optic poly(methyl methacrylate) intraocular lenses. SETTING: University Eye Hospital, Vienna, Austria. METHODS: This prospective, unmasked, and unrandomized study comprised 48 otherwise healthy eyes scheduled for cataract surgery. A 4.5 mm sutureless frown incision was made in 22 eyes and a 6.0 mm straight sclerocorneal incision with a horizontal 10-0 nylon infinity suture in 26 eyes. Preoperatively and 1 week and 1 and 3 months postoperatively, corneal topography was recorded by the TMS-1 computer-assisted videokeratoscope (Computed Anatomy, Inc.). The data were evaluated by batch-by-batch analyses of the paired differences between the records. The significance of topographic changes was calculated by paired Wilcoxon tests; group comparisons were made using Wilcoxon tests. RESULTS: In both groups, horizontal steepening and lower corneal flattening were consistently 0.4 diopter (D). Upper peripheral corneal flattening at 1 week and 1 and 3 months postoperatively was 0.7, 0.7, and 0.7 D, respectively, in the straight-incision group and 0.7, 0.4, and 0.3 D, respectively, in the frown-incision group. Vertical flattening and horizontal steepening were significant in both groups (P < .01). Group comparisons revealed significant differences in only 15 of 225 areas (P < .05). CONCLUSION: There were no major differences between the two incision groups in surgically induced topographic changes.

Aged↗

PubMed1998

Nucleus fragmentation in a scleral pocket for small incision extracapsular cataract extraction.

We present a technique for planned manual extracapsular cataract extraction (ECCE) incorporating a modification of mini-nuc ECCE in which the scleral tunnel is made wide enough to allow a nucleus of any size to settle in the tunnel. A 5.0 mm, inverted-V chevron incision is used in which the exposed part of the nucleus lodged in the scleral pocket can be manually picked and fragmented until it is small enough to be removed through the incision. The chevron incision is flexible enough to allow a medium-sized nucleus to be extracted without fragmentation and implantation of a rigid 6.0 mm poly(methyl methacrylate) lens. Vector analysis of preoperative and 3 month postoperative keratometric results in 30 patients showed that the surgically induced vector was 0.54 diopter (D) +/- 0.58 (SD). Mean reduction in astigmatism was 0.08 +/- 0.39 D. The sutureless technique is fast and safe, allows a nucleus of any size to be extracted through a constant size 5.0 mm incision, and results in minimal postoperative astigmatism.

Adult↗

PubMed1998

Topical anesthesia: Proxymetacaine versus Amethocaine for clear corneal phacoemulsification.

PURPOSE: To evaluate the use of proparacaine (Proxymetacaine) versus tetracaine (Amethocaine) as the topical anesthetic agent for phacoemulsification cataract surgery using a 3.5 mm clear corneal sutureless incision. SETTING: Harold Wood Hospital, Romford, Essex, United Kingdom. METHODS: This prospective study comprised 40 randomly selected patients. Twenty were given Proxymetacaine and 20, Amethocaine. The level of discomfort experienced during delivery of the topical anesthetic agent and during and immediately after surgery was measured using a pain score. During surgery, topical anesthesia was supplemented by intracameral lignocaine 1%. RESULTS: Patients given Proxymetacaine experienced no stinging sensation during its administration; those given Amethocaine reported varying degrees of discomfort. The difference between groups was statistically significant (P < .01). There was no difference between groups in the amount of discomfort experienced intraoperatively or postoperatively. CONCLUSION: Proxymetacaine is the topical analgesic of choice for phacoemulsification because it produced no discomfort on administration yet had the same analgesic properties as Amethocaine.

Analgesia↗

PubMed1998

Visual recovery after phacoemulsification using topical anesthesia.

PURPOSE: To assess the speed of visual function recovery after phacoemulsification using topical anesthesia. SETTING: Department of Ophthalmology, Royal United Hospital, Bath, United Kingdom. METHODS: Twenty consecutive patients having routine sutureless clear corneal phacoemulsification with implantation of a Staar foldable intraocular lens were recruited in a prospective study. Visual acuity was assessed using a LogMAR chart and contrast sensitivity using a Pelli-Robson chart 1, 2, 4, and 16 hours postoperatively. A final examination and refraction were performed at 1 week. RESULTS: Although return of visual acuity was slow during the first 2 hours, the mean LogMAR acuity had improved to 0.425 (Snellen equivalent 6/15) by 4 hours and 0.165 (Snellen equivalent of 6/9.5) by 16 hours. There was no postoperative ptosis or diplopia. CONCLUSION: The absence of diplopia and rapid return of visual function with a mean acuity of 6/15 by 4 hours suggest that early patient discharge is relatively safe.

Aged↗

PubMed1998

Staar Collamer posterior chamber phakic intraocular lens to correct myopia and hyperopia.

PURPOSE: To evaluate the efficacy, safety, stability, and predictability of implanting a collagen polymer (Staar Collamer), posterior chamber phakic intraocular lens (IOL) to correct myopia and hyperopia. SETTING: Centre for Advanced Refractive Eye Surgery at the BMI Alexandra Hospital, Cheadle, Manchester, United Kingdom. METHODS: A Staar Collamer posterior chamber phakic IOL was implanted in 25 eyes of 14 patients with a mean age of 37.9 years (range 20 to 50 years). Seven patients were men and seven, women. Sixteen were myopic and 9, hyperopic. Before treatment, each patient had a thorough evaluation including refractive, general, ocular, and social and personal histories. The examination included visual acuity, refraction, tonometry, topography, biometry, biomicroscopy, pupil size in dim illumination, and posterior segment evaluation by a vitreoretinal specialist. Patients were informed about the surgical process and expected outcome, their own expectations were discussed, and their consent to surgery was obtained. Surgical implantation was performed through a less than 3.0 mm clear corneal sutureless incision using brief general anesthesia on a day-case surgical basis. RESULTS: At 3 months postoperatively, all eyes had a significant increase in uncorrected visual acuity, allowing all but two patients (three eyes) to manage most activities without spectacles. Adjustment by incisional corneal surgery was planned for undercorrected myopic eyes (n = 3). Pupil block glaucoma and pigment deposits occurred in one patient each. CONCLUSION: In this short-term study, the posterior chamber phakic IOL was predictable, safe, and efficacious in the correction of myopic and hyperopic refractive errors, with good refractive stability. Long-term follow-up is required to validate that the absence of significant complications in most patients is a lasting phenomenon.

Adult↗

PubMed1998

Simplified anesthesia technique for scleral tunnel phacoemulsification.

A simplified anesthesia technique for sutureless scleral tunnel, small incision, one-port phacoemulsification is described. Step 1: Mild intravenous sedation is achieved with 1 mg of midazolam and 10 mg of propofol. Step 2: A tetracaine- or preservative-free-lidocaine-soaked Weck cell sponge is applied to the superior bulbar conjunctiva and the superior episcleral tissue for localized anesthesia. Step 3: Preservative-free lidocaine 1%, 0.75 cc, is injected into the anterior chamber for intraocular anesthesia. This technique can be used in the presence of all types of cataracts, requires about 10 seconds to complete, and can be used with all phacoemulsification techniques. Results of the technique in a study population are reported.

Adult↗

PubMed1998

Surgically induced astigmatism with superior and temporal incisions in cases of with-the-rule preoperative astigmatism.

PURPOSE: To evaluate surgically induced astigmatism (SIA), postoperative astigmatism, and uncorrected visual acuity (UCVA) after cataract surgery with superior corneal, superior scleral, and temporal corneal 4.0 mm sutureless incisions in cases of preoperative with-the-rule (WTR) astigmatism. SETTING: Hopital des Quinze-Vingts, Paris, France. METHODS: This prospective evaluation included patients having phacoemulsification with foldable lens implantation through a 4.0 mm incision. Patients with preoperative WTR astigmatism were randomly assigned to 1 of 3 incisions: superior corneal (Group 1), superior scleral (Group 2), or temporal corneal (Group 3). All patients had autokeratometry preoperatively and postoperatively (1 day, 1 week, 1 month, 1 year). Surgically induced astigmatism using the vector method, postoperative astigmatism, and UCVA (patients whose spherical equivalent was with +/- 1 diopter) were evaluated. RESULTS: Ninety patients were included in the study; there were 30 in each incision group. One year postoperatively, Group 1 had 1.52 diopters (D) of SIA and 1.36 D of postoperative astigmatism; 53.5% of patients had a UCVA of 20/32 or better, Group 2 had 0.69 D of SIA (P < .05) and 0.67 D of postoperative astigmatism (P < .05); 82.7% of patients had a UCVA of 20/32 or better (P < .05). Group 3 had 0.69 D (P > .05), 0.98 D (P < .05), and 79.3% (P > .05), respectively. CONCLUSIONS: In this study, the superior corneal incision produced significant SIA, leading to high postoperative astigmatism and poor UCVA. The scleral and temporal incisions produced minimal SIA and good UCVA.

Aged↗

PubMed1999

Phacoemulsification of white hypermature cataract.

PURPOSE: To evaluate the safety of phacoemulsification of white hypermature cataract, which is common in developing countries. SETTING: Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India. METHODS: In a teaching hospital setting, a prospective evaluation of phacoemulsification in 25 eyes of 25 consecutive patients with hypermature cataract was done. Patients with good pupil dilation, optimal endothelial cell count, and disease-free ocular and systemic status were included. High magnification, sodium hyaluronate, and a Utrata capsulorhexis forceps were used to perform continuous curvilinear capsulorhexis (CCC). The stop and chop technique was used for nuclear emulsification. A 5.5 mm optic allpoly(methyl methacrylate) intraocular lens (IOL) was implanted, and wound closure was sutureless. RESULTS: Successful CCC was performed in 23 of 25 cases. In 2 cases, the CCC edge extended toward the periphery and a Vannas scissors was used to achieve an even cut. No complications were seen during nuclear emulsification and IOL implantation. Eighty percent of the patients had a visual acuity of 20/40 or better on the first postoperative day. Five patients had significant corneal edema that resolved within 1 week in all cases. CONCLUSION: Phacoemulsification was successfully and safely performed in appropriately selected patients with white hypermature cataract.

Aged↗

PubMed2000

Induced corneal astigmatism using an asymmetric corneoscleral tunnel and a large-optic intraocular lens.

PURPOSE: To prospectively evaluate the induction of corneal astigmatism using an asymmetric corneoscleral tunnel incision (J-incision) to implant large-optic (7.0 mm) intraocular lenses (IOLs). SETTING: Department of Ophthalmology, University of Bonn, Germany. METHODS: Thirty-five patients had sutureless phacoemulsification with implantation of a 7.0 mm poly(methyl methacrylate) posterior chamber IOL using an inverse J-shaped asymmetric tunnel incision. The corneal astigmatism was measured by corneal keratometry and topography preoperatively and 1 day and 1 and 3 months postoperatively. Induced astigmatism was calculated by vector analysis. RESULTS: Mean induced changes in the corneal radii measured by keratometry were 0.17 mm +/- 0.14 (SD) on the first postoperative day, 0.18 +/- 0.14 mm after 1 month, and 0.17 +/- 0.14 mm after 3 months. Mean postoperative induced astigmatism measured by corneal topography was 1.08 +/- 0.66 diopters (D), 0.89 +/- 0.78 D, and 0.85 +/- 0.70 D, respectively. No signs of wound instability were detected. CONCLUSION: An asymmetric corneoscleral incision was suitable for implantation of large-optic IOLs, resulting in immediate stability of the induced cylindrical power in the central 3.0 mm zone as measured by keratometry. A reduction in induced corneal astigmatism can be achieved using this technique versus using symmetrical wound constructions and large-optic IOLs.

Aged↗

PubMed2000

One year follow-up of astigmatism after 4.0 mm temporal clear corneal and superior scleral incisions.

PURPOSE: To compare the effect of 2 contemporary sutureless cataract surgery incisions on corneal astigmatism 1 year after surgery. SETTING: Outpatient Clinic, Department of Ophthalmology, Vejle Hospital, Denmark. METHODS: Sixty-nine patients who had cataract surgery in 1997 with a 4.0 mm temporal clear corneal (n = 32) or superior scleral (n = 37) incision were examined 1 year postoperatively. Surgically induced astigmatism was analyzed by vector analysis, vector decomposition, and polar values using preoperative and postoperative keratometric readings. RESULTS: Vector analysis revealed a slightly lower median induced cylinder in the clear corneal patients; 0.41 diopter (D) (95% confidence limits [CL] 0.24 to 0.67 D) versus 0.61 D (95% CL 0.49 to 0.73 D) (P < .05). Decomposition of the induced cylinder (against the rule/total) showed statistically significant differences in the direction of the cylinder; 0.21 (95% CL 0.03 to 0.41) versus 0.90 (95% CL 0.82 to 0.95) (P < .00001). The directional difference was confirmed by polar values. CONCLUSION: Both incisions induced low and comparable amounts of astigmatism. The directional differences were modest. Findings in previous studies of a poor outcome after clear corneal incisions were not confirmed in this long-term follow-up.

Aged↗

PubMed2000

Intraocular pressure after small incision cataract surgery with Healon5 and Viscoat.

PURPOSE: To evaluate the effect of Healon5 (sodium hyaluronate) and Viscoat (sodium chondroitin sulfate-sodium hyaluronate) on intraocular pressure (IOP) after bilateral small incision cataract surgery. SETTING: Department of Ophthalmology, University of Vienna, Vienna, Austria. METHODS: This prospective randomized study comprised 70 eyes of 35 consecutive patients with age-related cataract in both eyes scheduled for bilateral small incision cataract surgery. The patients were randomly assigned to receive Healon5 or Viscoat during cataract surgery in the first eye. The second eye received the other viscoelastic substance. Cataract surgery was performed in an identical fashion in both eyes, with a temporal 3.5 mm sutureless posterior limbal incision, phacoemulsification, and implantation of a foldable silicone intraocular lens. The IOP was measured preoperatively and 6 hours, 20 to 24 hours, and 1 week postoperatively. RESULTS: At 6 hours after surgery, the mean IOP increased by 5.2 mm Hg +/- 5.3 (SD) in the Healon5 group (P < .0001) and by 10.1 +/- 8.7 mm Hg in the Viscoat group (P < .0001). The increase was significantly higher in the Viscoat group than in the Healon5 group (P = .0016). Intraocular pressure spikes of 30 mm Hg or more occurred in 2 eyes in the Healon5 group and in 10 eyes in the Viscoat group (P = .0112). Twenty to 24 hours and 1 week postoperatively, the mean IOP in the 2 groups was not statistically different. CONCLUSIONS: Viscoat caused a significantly higher IOP increase and significantly more IOP spikes than Healon5 in the early period after small incision cataract surgery.

Aged↗

PubMed2003

Evaluation of a novel 2 mm internal diameter stainless steel saphenous vein to coronary artery connector: laboratory studies of on-pump and off-pump revascularization.

OBJECTIVE: A second generation, 'easy-load', 2 mm internal diameter (ID), stainless steel, distal anastomotic device has been developed, and design improvements facilitate rapid connector loading with minimal magnification. The reduced size should allow application to most distal coronary vessels currently grafted. This technology may be useful in off-pump and minimally invasive surgical approaches to coronary revascularization. METHODS: Two distinct models were used to evaluate the distal connector. In the first model, a single saphenous vein graft (SVG)-to-LAD procedure (n=18) was used to evaluate long-term patency of the 2 mm ID, stainless steel, distal connector in a chronic canine model. Cardiopulmonary bypass was initiated through an anterolateral thoracotomy. Aortosaphenous vein anastomoses were created using suture. In the second model, an acute off-pump feasibility study of SVG-to-LAD bypass fashioned with both proximal and distal connectors (n=15) was conducted. Aortosaphenous vein anastomoses were performed using a FDA approved vascular connector. Device loading and deployment times, graft blood flow following native LAD ligation, and device-related complications were compared. In the chronic model, the grafts were examined by angiography and gross and microscopic examination at animal sacrifice. RESULTS: All 33 animals survived the procedures. All grafts were widely patent after a minimum 30 (n=8), 90 (n=5), and 180 days (n=5) in the chronic model. Distal graft loading and deployment times, graft blood flow rates, and device-related complications were similar in both procedures. In the off-pump feasibility study, total grafting time including loading and deployment was 10:54+/-2:54 min. CONCLUSIONS: Sutureless SVG-to-coronary artery bypass is feasible, rapid, and reproducible with on- and off-pump surgical techniques using a 2 mm ID, stainless steel, distal connector. In this model, early graft patency was 100% with either procedure, and grafts performed on-pump were widely patent at 30, 90, and 180 days. Few device-related complications occurred, each easily managed without compromising graft integrity, and the incidence of events was similar whether on- or off-pump techniques were employed. This or similar technologies may become an important addition to the management of coronary artery disease, particularly in off-pump or minimally invasive approaches.

Anastomosis, Surgical↗

PubMed1997

Experimental gluing of the bronchial stump after pneumonectomy in rats.

OBJECTIVE: The objective of this experimental study was to evaluate the usefulness of gelatin-resorcinol-dialdehyde adhesive in sutureless closure of bronchial stumps. METHODS: In 40 male Wistar rats bronchial stumps after left-sided pneumonectomy were closed by gluing with gelatin-resorcinol-dialdehyde adhesive. For macroscopic and microscopic examination four animals were sacrificed on postoperative days 2, 7 and 14 each, 14 animals on postoperative days 28 and 120 each. RESULTS: On macroscopic examination the gelatin-resorcinol-dialdehyde adhesive proved in all cases effective in tight bronchial stump closure. The adhesive did not cause local infection or necrosis of the bronchial stump nor other intrathoracic inflammatory complications. All animals survived and made an uncomplicated postoperative recovery. Microscopic examination revealed that the gelatin-resorcinol-dialdehyde adhesive initially evoked an acute inflammatory response with polymorphonuclear neutrophils predominating. After an intermediate stage characterized by a granulomatous reaction and resorption of the adhesive by multinucleated giant cells, 120 days postoperatively the bronchial stumps at the sites of previous gluing showed a regular fibrous scar tissue without inflammatory cells. CONCLUSION: The gelatin-resorcinol-dialdehyde adhesive showed effective in closing bronchial stumps after pneumonectomy in rats. The clinical extrapolation of this effect to thoracic surgical patients is uncertain at this time.

Animals↗

PubMed2003

Neurologic outcomes after coronary artery bypass grafting with and without cardiopulmonary bypass.

Neurologic injury, in the form of either stroke or more subtle neurocognitive impairment, is a frequent and potentially devastating complication of coronary artery bypass grafting (CABG). The etiology of CABG-associated neurologic injury is likely multifactorial, with the phenomena of cerebral hypoperfusion and embolism being the major contributors. Several perioperative strategies have been developed in an effort to reduce the incidence of CABG-associated neurologic complications. Hypothermic cerebral perfusion, alpha stat acid-base management, and slow patient rewarming have been shown by several investigators to minimize adverse neurologic sequelae associated with the use of cardiopulmonary bypass. Performing CABG without cardiopulmonary bypass (off-pump CABG), meanwhile, has been shown to reduce the risk of perioperative stroke, especially in high-risk patients such as the elderly. Whether off-pump CABG reduces the incidence of less severe neurocognitive impairment has not yet been clearly established and merits further investigation in the form of large, multicenter, randomized trials. Other technical innovations, such as the use of sutureless and clampless aortic anastomotic devices, also may be able to further minimize the neurologic complications associated with CABG.

Brain↗