Multiple Venous Aneurysms of the Saphenous Vein: Report of an Uncommon Case

Venous aneurysms are rare entities. They may cause serious complications like thrombosis or pulmonary embolism. An uncommon case of multiple large aneurysms of the saphenous vein of a forty-one-year old woman is reported. The literature is reviewed and etiology, potential complications, diagnosis, and treat ment are discussed.

Subclavian Steal Syndrome. Correction by Transthoracic or Extraanatomic Repair

Proximal subclavian artery stenosis may cause severe disturbances of cere bral blood supply well known as subclavian steal syndrome.

On the other hand subclavian artery stenosis may produce problems of the perfusion of the arm. But in the presence of a well established collateral circula tion with reversal flow in the ipsilateral vertebral artery the reduced perfusion of the arm in the presence of proximal subclavian artery stenosis seldom re quires operative treatment.

Anti-inflammatory and cartilage-protecting effects of an intra-articularly injected anti-TNF{alpha} single-chain Fv antibody (ESBA105) designed for local therapeutic use

OBJECTIVES

(1) To show that a single-chain Fv antibody (scFv) against tumour necrosis factor alpha (TNFalpha) (ESBA105) has efficacy comparable to a full length anti-TNFalpha IgG (infliximab); (2) to evaluate whether ESBA105 has all the properties required for the local treatment of arthritis; and (3) to investigate its discriminative tissue penetration properties.

METHODS

In vivo efficacy was measured in arthritis of the knee joint induced by the intra-articular injection of recombinant human TNFalpha (rhTNFalpha) in Lewis rats. Cartilage penetration of scFv (ESBA105) and full length IgG (infliximab) were studied in bovine cartilage specimens ex vivo. Tissue penetration, biodistribution and pharmacokinetics of ESBA105 were followed and compared after intra-articular and intravenous administration.

RESULTS

In cell culture, ESBA105 showed similar TNFalpha inhibitory potency to infliximab. In vivo, ESBA105 inhibited rhTNFalpha-induced synovial inflammation in rats with efficacy again comparable to infliximab. An 11-fold molar excess of ESBA105 over rhTNFalpha resulted in 90% inhibition of knee joint swelling, inflammatory infiltrates and proteoglycan loss from cartilage. In ex vivo studies of bovine cartilage, ESBA105 penetrated well into the cartilage whereas infliximab remained on the surface. In vivo, rapid penetration into the synovial tissue, cartilage and surrounding tissues was observed following intra-articular injection of [(125)I]-ESBA105 into the knee joint of rabbits.

CONCLUSIONS

ESBA105 potently inhibits inflammation and prevents cartilage damage triggered by TNFalpha. In contrast to a full length IgG, ESBA105 also penetrates into cartilage and can be expected to reverse the TNFalpha-induced catabolic state of articular cartilage in arthritides.

Photodynamic effects in vitro in fresh gynecologic tumors analyzed with a bioluminescence method

Photodynamic therapy (PDT) is a promising alternative method for clinical cancer treatment. In the present study, cells from four breast carcinomas, seven ovarian carcinomas of various stages of differentiation, and ascites from a diffuse metastatic tumor were treated by PDT in vitro. Tetra(m-hydroxyphenyl)-chlorin (m-THPC) was used as the photosensitizer. Surviving cell rate was evaluated by the ATP-Cell-Viability-Assay (ATP-CVA), which measures light production as an interaction of intracellular ATP with the luciferin-luciferase complex. The most effective PDT of the tumor cells was achieved at an m-THPC concentration of 0.2 microgram/ml following incubation of the cells with photosensitizer for 24 hours. PDT toxicity resulted in a cell survival rate of 1% to 42% compared to untreated control cells (survival rate of control = 100%). The inhibitor concentration IC50 of m-THPC was determined both in the dark (dark toxicity) and in combination with laser irradiation. IC50 was defined as the concentration of photosensitizer which caused 50% of cell death. The IC50 values were heterogeneous in all tumor specimens examined. IC50 values for dark toxicity were on average 0.14 microgram m-THPC/ml for primary ovarian carcinoma, 2.16 micrograms m-THPC ml for refractory ovarian carcinoma and 0.3 microgram m-THPC/ml for breast carcinoma. After PDT, average IC50 value for refractory ovarian carcinoma was 0.04 microgram m-THPC/ml, for primary ovarian carcinoma 0.05 microgram m-THPC/ml and for breast carcinoma 0.03 microgram m-THPC/ml. These data might indicate that clinical PDT of gynecological carcinoma requires individual treatment conditions to achieve optimal results.

[Surgical therapy of chronic traumatic aortic aneurysm]

Rupture of the aorta that usually occurs with major blunt trauma of the chest is associated with a high mortality, and only 2% of the patients survive long enough to develop a false aneurysm. Although symptom-free latent period is not rare, there is evidence of progression. Since 1970 we operated on 28 patients (24 male and 4 female, mean age 41.2 years) for chronic traumatic aneurysm of the descending aorta. A previous blunt trauma of the chest had certainly occurred in 23 cases (3 months to 20 years before) and was likely in 4 patients; in one young woman the aneurysm developed after percutaneous angioplasty of a coarctation. In 26 patients surgical repair consisted in a Dacron tube interposition, and in 2 cases patch repair was adequate. In 11 cases the "clamp and repair" technique was applied, while in 17 patients extracorporeal circulation was established to perform the reconstruction, two of these cases were operated with hypothermic circulatory arrest. Although there was no correlation between the occurrence of complications and the applied procedure, we lately turned to establish cardiopulmonary bypass in all cases with regard to a better control of the hemodynamics during clamping, the possibility of direct retransfusion of blood, and the option to extend the procedure, if necessary. In view of the facts, that traumatic thoracic aneurysms develop late complications in about 75% of the cases, and the morbidity in elective surgery is of a low figure, we conclude, that surgery of such lesions is mandatory, once the diagnosis has been established, and that an expectant attitude in the treatment is justified only in exceptional cases.

[Endoluminal therapy of infrarenal abdominal aortic aneurysms: a new interventional technique]

PURPOSE

With a series of 31 transluminal stent-graft procedures, we assessed the feasibility and clinical effectiveness of a new stent-graft for the treatment of infrarenal abdominal aortic aneurysms (AAAs).

METHODS

We treated the patients (male; mean age 71 years) with straight or bifurcated nitinol stents covered with woven dacron graft material for infrarenal eccentric saccular AAA (n = 4) or AAA involving the bifurcation and the common iliac arteries (n = 27). The 18-F delivery system was advanced via a surgical arteriotomy and the stent-graft was placed under fluoroscopic control. Follow-up period ranged from 8 days to 9 months.

RESULTS

The implantation of the stent-grafts was technically successful in 30/31 cases. Procedure-related complications were acute hepatic failure due to gastric bleeding in a patient with liver cirrhosis, graft occlusion due to emboli originating from the left atrium (n = 1), macro-embolisation (n = 3), local haematoma (n = 1) and av-fistula (n = 1) requiring surgery. A post-implantation syndrome with leukocytosis and elevated C-reactive protein was observed in all patients.

CONCLUSIONS

Endoluminal repair of infrarenal AAA with use of dacron covered nitinol stent-grafts is feasible, safe and clinically effective. However, careful long-term evaluation is necessary.

[Initial clinical experiences with endovascular stent-grafts for treatment of infrarenal abdominal aortic aneurysm]

With a series of 34 transluminal stent-graft procedures, we assessed the feasibility and clinical effectiveness of a new stent-graft for the treatment of infrarenal abdominal aortic aneurysms (AAAs). We treated 34 male patients (mean age 71 years) with straight of bifurcated nitinol stents covered with woven Dacron graft material for infrarenal excentric saccular AAA (n = 3) or AAA involving the bifurcation and the common iliac arteries (n = 31). The 18-F delivery system was advanced via a surgical arteriotomy and the stent-graft was placed under fluoroscopic control. Follow-up period ranged from 8 days to 13 months. The implantation of the stent-grafts was technically successful with exclusion of AAA in 31/34 cases (91%). In 2 patients, there was a persisting leak at the distal end of the endoprosthesis after treatment; in another, marked coiling of the external iliac artery impeded the delivery system to be advanced and consecutive rupture resulted in conversion to surgical repair. Other procedure-related complications were acute hepatic failure due to gastric bleeding in a patient with liver cirrhosis, graft occlusion due to emboli originating from the left atrium (n = 1), local hematoma (n = 1), and AV-fistula (n = 1) requiring surgery. A post-implantation syndrome with leucocytosis and elevated C-reactive protein was observed in all patients. Endoluminal repair of infrarenal AAA with use of Dacron covered nitinol stent-grafts is feasible, safe and clinically effective. However, careful long-term evaluation is necessary before it will become clinical practice.

Abdominal aortic aneurysms: preliminary technical and clinical results with transfemoral placement of endovascular self-expanding stent-grafts

PURPOSE

To evaluate treatment of infrarenal abdominal aortic aneurysm (AAA) with a new endoluminal stent-graft.

MATERIALS AND METHODS

In 26 male patients, straight or bifurcated nitinol stents covered with woven Dacron graft material were implanted to treat eccentric saccular AAA (n = 3) or AAA involving the bifurcation and common iliac arteries (n = 23), with follow-up from 8 days to 8 1/2 months.

RESULTS

Implantation was technically successful in all but one of the 26 (96%) patients (leak of the stent-graft for more than 3 months necessitated implantation of an additional covered stent). In seven of the 26 patients, minor residual perfusion persisted immediately after implantation, but complete thrombosis occurred within 7 days. Five procedure-related complications occurred: distal embolization (n = 2); local hematoma, which necessitated surgery (n = 1); acute hepatic failure due to gastric bleeding, in a patient with liver cirrhosis (n = 1); and stent-graft occlusion due to emboli originating from the left atrium (n = 1).

CONCLUSION

Exclusion of AAA from circulation was feasible, safe, and clinically effective with the new stent-graft.

Growth of "new" coronary vascular structures by angiogenetic growth factors

The efficacy of the human angiogenetic heparin-binding growth factor I (HBGF-I) to initiate site-directed growth of new blood vessels from the aorta into the myocardium was studied. First, manipulated Escherichia coli bacteria, which had received the human mRNA-transcript for HBGF I into their genetic material, were cultivated. The growth factor derived was purified using heparin-Sepharose affinity chromatography. The separation and characterization of biologically active alpha- and beta-chains was carried out using high pressure liquid chromatography (HPLC) of dialyzed and lyophilized samples from the heparin-Sepharose column. One microgram HBGF I (alpha-ECGF) was bound to polytetrafluoroethylene (PTFE) sponges, precoated with collagen type I, and implanted between the aorta and the myocardium of the left ventricle in experimental rats. Twelve growth factor implants in the experimental group were compared to six controls receiving uncoated PTFE sponges for 9 weeks. Digitized computed angiography showed new blood vessels between the aorta and the myocardium in 11 of the 12 experimental animals, and retrograde coronary perfusion by these "new" vascular structures could be seen. Histology showed no specific structures in the control group (without HBGF I). In the experimental group (with HBGF I) individual vessels with highly differentiated endothelial and smooth muscle cell layers were evident. Our experiments proved the feasibility of induced, site-directed angiogenesis. It is possible to initiate in vivo growth of new "coronary" vascular structures between the aorta and the myocardium.

Diltiazem provides anti-ischemic and anti-arrhythmic protection in patients undergoing coronary bypass grafting

In 91 patients undergoing elective coronary bypass grafting, the anti-ischemic and anti-arrhythmic efficacy of a 24-hour infusion of either the calcium antagonist diltiazem (0.1 mg/kg per h, n = 44) or nitroglycerin (1 micrograms/kg per min, n = 47) were compared. Myocardial ischemia was diagnosed by Holter monitoring and the repeated assessment of 12-lead ECG and serum enzyme levels and defined as a transient ischemic event, transient coronary spasm or myocardial infarction. The two groups did not differ with respect to preoperative and operative data. Postoperatively, the average heart rate and pulse pressure rate were significantly lower in the diltiazem group. The incidence of postoperative atrial fibrillation (4.5 vs 19.1%, P < 0.01), transient coronary spasm (2.3 vs 11.4%, P < 0.05) and myocardial infarction (4.5 vs 8.5%, not significant) and the frequency of ventricular premature couplets/h (12.1 +/- 4.5 vs 18.1 +/- 5.1, P < 0.05) and ventricular runs/h (2.5 +/- 0.8 vs 6.5 +/- 2.8, P < 0.05) were lower in the diltiazem as compared to the nitroglycerin group. In addition, diltiazem-treated patients had significantly lower postoperative peak values of creatine kinase-MB (19.3 +/- 11.6 vs 29.3 +/- 20.6, P < 0.05). In conclusion, perioperative infusion of diltiazem is effective in reducing the incidence and extent of arrhythmias and myocardial ischemia in patients undergoing elective coronary bypass grafting as compared to patients receiving nitroglycerin.

[Accusation of malpractice in cardiovascular surgery]

The reproach of malpractice in cardio vascular surgery seems to be up to now quite seldom in comparison with other While in cardiac surgery the acknowledgement was found extremely seldom in vascular surgery acknowledgement of malpractice reproach must be expected in about 50%. In cardiac surgery mainly new neurological deficits are content of malpractice reproach; in vascular surgery artery injuries and surgical procedures to correct varicose veins are most often involved. In order to prevent or to minimise those malpractice reproaches an optimal communication between the surgeon and the patient, an extensive informed consent and a very strict medical indication for surgery are imperative.

Imaging in cardiac mass lesions

In 26 patients with cardiac mass lesions confirmed by surgery, diagnostic imaging was performed preoperatively by means of two-dimensional echocardiography (26 patients), angiography (12 patients), correlative computed tomography (CT, 8 patients), and magnetic resonance imaging (MRI, 3 patients). Two-dimensional echocardiography correctly identified the cardiac masses in all patients. Angiography missed two of 12 cardiac masses; CT missed one of eight. MRI identified three of three cardiac masses. Although the sensitivity of two-dimensional echocardiography was high (100%), all methods lacked specificity. None of the methods allowed differentiation between myxoma (n = 13) and thrombus (n = 7). Malignancy of the lesions was successfully predicted by noninvasive imaging methods in all six patients. However, CT and MRI provided additional information concerning cardiac mural infiltration, pericardial involvement, and extracardiac tumor extension, and should be integrated within a preoperative imaging strategy. Thus two-dimensional echocardiography is the method of choice for primary assessment of patients with suspected cardiac masses. Further preoperative imaging by CT or MRI can be limited to patients with malignancies suspected on the grounds of pericardial effusion or other clinical results.

The influence of obesity on perioperative morbidity: retrospective study of 502 aortocoronary bypass operations

The incidence of perioperative complications after coronary artery surgery was investigated by a retrospective study of all 502 patients undergoing coronary artery bypass graft (CABG) surgery in our Department between January 1st and December 31st of last year (1990). Furthermore, the influence of obesity on the early results of surgery was assessed and the effect of preoperative weight reduction on perioperative complication rates examined. Obese patients had a greater incidence of left-stem coronary artery stenosis (p less than 0.001), hyperlipidaemia (p less than 0.05), hypertension (p less than 0.05), diabetes mellitus (p less than 0.02), and were in general younger at the time of operation (57.9 +/- 8.4 vs. 60.8 +/- 8.5 years). There were no differences in the surgery performed and in operative mortality, but there were some in perioperative morbidity. Obese patients had higher rates of infection (p less than 0.02), sternal dehiscence (p less than 0.02), arrhythmias (p less than 0.02) and myocardial infarction (p less than 0.02). No significant differences were identified in obese patients with or without preoperative weight reduction, although there was a trend of better postoperative recovery and results in patients having undergone preoperative weight reduction. Analysis of our results demonstrated obesity to be an independent risk factor for perioperative complications, hospital morbidity, and length of hospitalization.

Added hospital stay due to wound infections following cardiac surgery

To determine the prolongation of hospital stay due to postoperative wound infections following cardiac surgery, a prospective cohort study was performed by matching multiple control patients without infection to each infected patient (= case). Out of 22 cases, no patient died. No case had to be excluded from the matching process because of a lack of suitable control patients. The maximum number of controls per case was 10. The mean added stay was 12.2 days constituting a considerable prolongation of stay due to wound infection in cardiac surgery.

Isolation of the membranes from secretory organelles (trichocysts) of Paramecium tetraurelia

We present for the first time a method for isolation of the membranes of extrusive organelles (trichocysts) from sterile culture of different strains of Paramecium tetraurelia. First, trichocysts are isolated according to a new method (Glas-Albrecht, R. and Plattner, H. (1990) Eur. J. Cell Biol. 53, 164-172) with high purity and yield. Then the organelles are subjected to osmotic swelling. Since trichocysts then easily 'decondense' and entangle membranes, these cannot be isolated directly by centrifugation, but only by passage through a filter and subsequent centrifugation. Purity of membrane fractions is analysed by electron microscopy and SDS-PAGE, combined with silver staining or, after biotinylation, by avidin-peroxidase labelling. Molecular masses resolved in our gels are in a range from less than or equal to 15 to greater than or equal to 105 kDa. Main bands obtained with nd9-28 degrees C trichocyst membranes (most bands also being common to wild type trichocysts) are of about 16.5, 19-21, 27-29, 33-34, 44-45 (strong), 47-48 (strong), 57, 61, 65 (strong), 68-71, 75, 81, 94-95 (strong), 104 and greater than or equal to 110 kDa, from a total of approx. 23 bands resolved. There is no remarkable occurrence of dominant protein bands from trichocyst contents ('trichynins'), though these might represent up to 10(3)-times more of the total trichocyst proteins. The ratio of phospholipid/protein is approx. 0.2 mg/mg. The methodology developed might also be valuable for the isolation of extrusome membranes from some other protozoan species.

Reduction of the risk of surgery for abdominal aortic aneurysms by extended coronary diagnostics and therapy

The morbidity and mortality in the surgery of abdominal aortic aneurysms are essentially determined by the coronary risk profile of the patient. Preoperative coronary artery diagnostics with the potential consequence of a coronary revascularization as procedure before the aneurysmectomy seems to be mandatory to decrease the risk of treatment. Out of 223 patients treated at our institution for abdominal aortic aneurysm, 68 (30.5%) had to undergo extended cardiological diagnostic procedures, and 37 (16.6%) needed a coronary angiography; in 23 patients (10.3%) myocardial revascularization was performed prior to the aneurysmectomy. Since routinely performing this thorough investigation of the coronary risks, the mortality of surgery for aortic aneurysm has been clearly reduced.

[Prolongation of hospital stay by nosocomial pneumonia and wound infection]

From June 1988 to September 1989, a prospective survey comprising a total of 1183 patients in a university hospital was carried out to ascertain the additional length of stay in intensive care units because of nosocomial pneumonia associated with artificial ventilation (418 patients, 296 men, 122 women, mean age 48.8 +/- 21 years, ventilated for more than 24 h) or by postoperative wound infections (765 patients, 501 men, 264 women, mean age 60 +/- 11 years, after operations on the large bowel, heart or biliary tract). Each patient with a nosocomial infection was matched against a variable number of control patients (for cases of pneumonia a maximum of 6, for wound infections a maximum of 10) without nosocomial infection. Pneumonia developed in 100 (23.9%) of artificially ventilated patients, and 46 of these patients together with 101 controls were entered into the matching procedure. 24 patients with pneumonia had to be excluded from analysis because no controls could be found for them, and also 30 patients who died while in the intensive care unit. 49 (6.4%) of the surgical patients contracted postoperative wound infections. 43 of them, together with 210 controls, were entered into the matching procedure. Among patients with pneumonia the average additional duration of stay was 11.5 days, and among patients with post-operative wound infections it was 13.9 days. The results confirm that nosocomial infections contribute substantially to prolongation of hospital stay and hence to the costs.

Traumatic herniation of the heart into the right pleura

This case report summarizes our experience with a 19-year-old male patient who suffered a blunt chest trauma during a traffic accident. On admission no serious injuries could be detected, but 12 hours later displacement of the heart to the right side combined with sudden cardiac failure appeared. Emergency operation showed a right-sided rupture of the pericardium with complete herniation of the heart into the right pleural cavity and consequent strangulation by the pericardial margin.

Coronary artery disease in a patient with a congenital pericardial defect

This case report summarizes our experience with a 43 year old male patient with congenital pericardial defect, involving the left ventricular part of the pericardium, and additionally 2-vessel coronary-artery disease in the absence of any coronary risk factors. This patient underwent coronary-artery bypass grafting. Intraoperatively the heart was found to be rotated and herniated into the left pleural cavity, strangulated by the remaining pericardium causing a bridle stricture of the right as well as the left margin of the heart, with a subsequent local narrowing of the ventricle in these areas. Furthermore, assessment of the coronary arteries at operation by external palpation showed the location of an RCA- and LAD-stenosis to match exactly with the stricture area.

Reduction of blood transfusion requirement in open heart surgery by administration of high doses of aprotinin--preliminary results

Reduction of homologous blood requirement in cardiac surgery is of increasing interest and may be achieved by various technical and pharmacological means. High-dose aprotinin (about 840 mg, equivalent to 6 million Kallikrein inactivator units), a serine proteinase inhibitor, was administered during open heart surgery to 60 patients refusing homologous blood transfusions or suspected to have an increased risk of bleeding. As a significant decrease in donor blood requirement could be observed, a prospective, randomised double blind study in 80 male patients undergoing primary coronary surgery with high-dose aprotinin administration was performed. Mean blood loss was reduced by 45.9% (652 ml in the treated vs 1204 ml in the untreated group, p less than 0.01) and the mean amount transfused was decreased by 74.2% (242 ml vs 937 ml, p less than 0.01). No homologous blood was needed in 57.9% of the aprotinin-treated patients and in 31.6% of patients not treated with aprotinin.

[Surgical indications in asymptomatic internal carotid artery stenosis and in relation to heart surgery interventions]

In the last 30 years, carotid endarterectomy has been employed on a wide-spread basis with the intention of providing surgical prophylaxis of stroke. Currently, however, there is no evidence available from prospective, randomized comparative studies indicating a clear superiority of surgical treatment versus medical treatment with respect to stroke prophylaxis or improvement in survival. Based on recent publications with sufficiently large patient populations, operative mortality appears to be about 1% and the rate of perioperative stroke about 3.4%. In those with symptomatic internal carotid stenosis, without surgery there is a 5% yearly risk of cerebral infarction such that carotid endarterectomy possibly appears warranted. In contrast, in association with asymptomatic internal carotid stenosis, that is, in the absence of any symptoms indicative of cerebral hypoperfusion, based on several recent prospective studies, the yearly rate of cerebral infarction is 1 to 2% and, consequently, less than that of the prophylactic surgical intervention. Additionally, carotid endarterectomy does not render complete protection against stroke and the follow-up curves for the respective treatments do not differ meaningfully, even during longterm observation. Accordingly, for asymptomatic internal carotid stenosis, the indication for surgery has not been clearly established. Among those with asymptomatic carotid stenosis, there may be a subgroup of individuals with high-grade luminal obstruction or multiple vessel disease, who according to several studies, appear to be at a higher risk of subsequent complications even though this has not yet been confirmed by prospective, randomized studies.(ABSTRACT TRUNCATED AT 250 WORDS)

Concentrations of flucloxacillin in heart valves and subcutaneous and muscle tissues of patients undergoing open-heart surgery

Thirty-seven patients were given a single, 2-g intravenous bolus injection of flucloxacillin prior to open-heart surgery. Within 12 h, flucloxacillin concentrations in serum and heart valves declined from 125.2 to 4.4 micrograms/ml and from 16.5 to 3.7 micrograms/g, respectively. Concentrations in subcutaneous tissue and muscle were almost identical, declining from 14.7 or 14.2 micrograms/g to undetectable levels after 8 to 10 h.

Plasma levels of main granulocyte components during cardiopulmonary bypass

Plasma levels of granulocyte lactoferrin, myeloperoxidase, and elastase in alpha 1-proteinase inhibitor complex were compared with C3a and C5a levels in 10 patients undergoing cardiopulmonary bypass. At the end of the operation, plasma levels of lactoferrin increased from 97.0 +/- 22.8 to 1257 +/- 139.8 ng/ml, myeloperoxidase increased from 37.1 +/- 4.3 to 170.9 +/- 34.9 ng/ml, and elastase in alpha-proteinase inhibitor complex rose from 89.4 +/- 7.4 to 437.8 +/- 97.3 ng/ml. There was also a significant anaphylatoxin formation. To investigate the relationship between complement and granulocyte activation, patients undergoing cardiopulmonary bypass received the calcium channel blocker nifedipine (orally and intravenously) and the antiplatelet drug dipyridamole. The continuous infusion of nifedipine (5.91 +/- 0.53 micrograms/kg body weight per hour) caused significantly lower levels of elastase in alpha-proteinase inhibitor complex and lactoferrin but not anaphylatoxin. Dipyridamole was without effect on complement and granulocyte activation during cardiopulmonary bypass. Our data demonstrate inhibition of granulocyte activation during cardiopulmonary bypass by continuous infusion of nifedipine, even in the presence of complement activation.

Transcranial Doppler ultrasonography during cardiopulmonary bypass in patients with severe carotid stenosis or occlusion

Blood flow velocity of the middle cerebral artery was monitored during cardiopulmonary bypass procedures by means of transcranial Doppler ultrasonography. Our investigation was carried out in a group of 16 patients with severe carotid stenosis or occlusion and in a control group of 42 patients with no or stenosis of less than 50% local diameter reduction. After onset of cardiopulmonary bypass, both groups showed a short unstable phase followed by increased blood flow velocity (10% increase ipsilateral to the obstruction, 27% increase in the control group). Just before rewarming, blood flow velocity was still comparable to (control group -3%) or higher than (ipsilateral to obstructions +14%) prebypass values. Analysis of three patients with postoperative diffuse encephalopathy did not reveal reduced blood flow during cardiopulmonary bypass as a relevant factor. Two of the three showed luxury perfusion. Reduced perfusion due to carotid obstruction was not observed during cardiopulmonary bypass and therefore cannot be considered a significant risk factor for the development of intraoperative stroke.

[Early postoperative control of internal thoracic artery-coronary artery anastomoses using intra-arterial DSA]

Early postoperative angiographic control is important for prognosis and medical therapy for patients undergoing coronary bypass surgery. Grafts from the internal mammary artery had been shown to be superior to venous bypasses for anastomoses to the left anterior descending coronary artery. Thus, the need for angiographic demonstration of graft patency and function is increasing. We report on the angiographic analyses of 73 patients after left internal mammary artery (LIMA) bypass surgery by filling of the graft via retrograde injection of contrast medium into the left brachial artery. In all cases the bypass, anastomosis and downstream vessel were clearly visualised. No complications or side effects were observed.

Significance of early angiographic follow-up after internal thoracic artery anastomosis in coronary surgery

The authors report about the radiological checking of the patency of the internal thoracic artery transplant in 75 patients with coronary artery disease, using intraarterial DSA in the early postoperative phase (between 6th and 8th postoperative day). The left or the right brachial artery was punctated and the contrast medium was injected at a dosage of 50 ml in counter-current. Only one angiogram series per patient was necessary to appraise the anastomosis and the perfusion of the bypass applied. In 5 patients a stenosis and in 4 patients an occlusion of the transplant could to be diagnosed. Early postoperative angiography enables quality control. In case of occlusion reoperation may be indicated.

Nonreversed saphenous vein grafts in coronary surgery

The nonreversed saphenous venous graft in coronary surgery gives better match of diameters at the aortic as well as at the coronary anastomosis. The destruction of the valves is necessary and special valvulotomes are used. This preliminary report of a new technique in coronary surgery must be followed by long term results.

[Cardiovascular operations in patients with perioperative reduced kidney function]

Acute renal failure (ARF) following cardiovascular surgery represents a serious complication in view of the multimorbidity in such patients. 8 out of 16 patients with ARF requiring hemodialysis after cardiac surgery died; the degree of preoperative renal insufficiency could not be recognized as predisposing factor. 17 out of 21 patients with ARF following aortic vascular surgery died; the severity of the preoperative disease seems to be of prognostic value. Open heart surgery had to be performed in 9 patients out of the chronic dialysis program; perioperative complications did not occur, suggesting that cardiovascular operations can be performed without increased risk in this patient group.

Acute surgical intervention for complications of percutaneous transluminal angioplasty

Since 1979, percutaneous transluminal angioplasty (PTA) resulting in an overall improvement of 80.3% has been performed in 4380 patients with occlusive atheroma of the lower extremities. Complications requiring immediate surgical treatment occurred in 123 (2.8%) of the cases, consisting of occlusion (16%), dissection (13%), perforation (10%), embolisation (15%) and haematoma at the puncture track (69%). Of the group treated surgically, 18 (14.6%) patients underwent amputation of a lower limb. Since 1980 348 percutaneous transluminal coronary angioplasties (PTCAs) have been performed for coronary artery disease. In 15 cases (4.3%) emergency coronary bypass surgery was necessary because of complications encountered with PTCA. Two patients died and perioperative myocardial infarction occurred in 7 (subendocardial-3: transmural-4). In spite of a low complication rate and good results from PTA and PCTA acute surgical intervention for complications carries a significant operative morbidity and mortality. We conclude that selection for PTA and PTCA has to involve vascular and cardiac surgeons, their presence being mandatory at institutions in which therapeutic radiological procedures are undertaken.

Penetration of ceftazidime into heart valves and subcutaneous and muscle tissue of patients undergoing open-heart surgery

Patients undergoing open-heart surgery were given an intravenous bolus injection of 2 g of ceftazidime as a single dose over a period of 5 min. Within 12 h, ceftazidime concentrations in serum declined from 55.8 to 3.9 mg/liter. Subcutaneous tissue concentrations of the drug decreased from 21.0 to 2.7 micrograms/g, and muscle concentrations decreased from 34.5 to 2.5 micrograms/g. Ceftazidime concentrations in cardiac valvular tissue were even higher than those in muscle or fat, declining from 37.4 to 6.3 micrograms/g within 10 h.

Computerised tomography after abdominal aortic aneurysm repair

CT scan early after AAA resection and graft implantation enables the detection of local complications such as extensive haematomas around the implanted graft (25 cases), gas bubbles (7 cases) fluid collections, inflammatory infiltration in the tissue around the graft and compression of organs in the neighbourhood (1 case) to be detected. The possibility of detecting these complications as early as possible allows effective treatment. The addition of CT guided needle biopsy to allow culture of suspicious material makes this a very useful technique. For these reasons routine postoperative CT scanning after aortic aneurysm surgery is recommended.

Pharmacokinetics of vancomycin in serum and tissue of patients undergoing open-heart surgery

Penetration of vancomycin into serum, heart valves, subcutaneous tissue and muscle was determined in 33 adult patients undergoing open-heart surgery. Each patient received 15 mg/kg vancomycin as a 30-min intravenous infusion preoperatively. Within 6 h vancomycin plasma concentrations declined from 28.9 to 4.2 mg/l. Vancomycin concentrations decreased in subcutaneous tissue slowly and varied in muscle between 1.2 and 3.2 mg/kg, in subcutaneous tissue between 1.3 and 4.4 mg/kg and in heart valves between 2.3 and 4.2 mg/kg. Vancomycin concentrations in heart valves are high enough to inhibit most oxacillin-resistant Staphylococcus aureus, and coagulase-negative staphylococci causing postoperative wound infections and endocarditis.

Vascular tumor in the heart

A rare case of a vascular tumor originating from the uterus growing up in the inferior vena cava into the right heart with clinical signs of tricuspid insufficiency is reported. Although this vascular tumor primarily showed no signs of malignancy, consequent re-evaluation seems to be necessary in order to detect possible tumor recurrence in time.

Determination of aortic valve orifice area in aortic valve stenosis by two-dimensional transesophageal echocardiography

Two-dimensional transesophageal echocardiography was used to measure aortic valve orifice area in 24 patients with aortic valve stenosis (AS) and 15 patients without aortic valve disease. Using transesophageal echocardiography, orifice area could be measured in 20 of 24 patients with AS. With transthoracic echocardiography, orifice area could be determined in only 2 of 24 patients. In patients with AS, orifice area determined by transesophageal echocardiography was 0.75 +/- 0.34 cm2 and that calculated with Gorlin's formula was 0.75 +/- 0.32 cm2. In normal aortic valves, orifice area was 3.9 +/- 1.2 cm2 by transesophageal echocardiography. A good correlation was demonstrated between aortic valve orifice area determined using transesophageal echocardiography and calculated orifice area using Gorlin's formula in patients with AS: r = 0.92, standard error of estimate = 0.14 cm2. The absolute difference between orifice area measured with both methods ranged from 0.0 to 0.4 cm2 (mean 0.09 +/- 0.1). In 4 patients orifice area could not be determined with transesophageal echocardiography. The orifice could not be identified in 2 patients because an appropriate cross-sectional view of the aortic valve could not be achieved and in 2 patients with pinhole stenosis (aortic valve orifice area 0.3 cm2). These data show that aortic valve orifice area can be measured reliably using 2-dimensional transesophageal echocardiography.

[Acute and delayed aortocoronary bypass operations following transluminal angioplasty]

Since 1980 348 PTCAs and 1288 CABs were performed at our institution (relation 1:4). In 15 cases (4.3%) emergency CAB was necessary because of complications encountered with PTCA. Two patients died, i.e. a mortality rate of 43.3% out of the emergency CABs or 0.6% out of the PTCA group; in 46.6% myocardial infarction occurred. In the same period 12 patients received CAB because of unsuccessful PTCA after a mean time of 4.6 months without increased operative morbidity. Interdisciplinary indication and experience, operation permanence and temporary coronary perfusion may decrease the complication rate.

[Value of transvenous caval occlusion surgery in view of the complications]

180 vena cava filters (9 23 mm and 120 28 mm Mobin-Uddin and 51 Kimray-Greenfield filters) were implanted from 1970 till December 1985. Technical problems prevented insertion in 5 cases with each filter. With the Mobin-Uddin filter misplacement occurred in 5 cases (3.8%); in two patients embolisation of the 23 mm filter into the pulmonary artery, once with lethal outcome, developed. One perforation of the right ventricle during insertion was successfully treated. Recurrent embolism was found in 3.8% with Mobin-Uddin (M-U) filters, none with Greenfield (K-G) filters. Filter-related operative mortality rate was 3.1% and 0% respectively.

[Surgical indications in penetrating aneurysm of the abdominal aorta in advanced age]

Leaking abdominal aortic aneurysms must be considered as acute symptomatic aneurysms. Mainly in the very old patient the natural course of the disease is very doubtful. Therefore surgical repair seems to be necessary in nearly all cases. Special operative techniques such as tube resection as well as inlay technique are able to reduce the operative risk. Pharmacological control of blood pressure during surgery is as necessary as postoperative intensive care treatment.

[Diagnosis of thoracic aortic aneurysms and dissections using transesophageal echocardiography]

Transesophageal echocardiography was performed in 25 patients with the clinical suspicion of an aneurysm or dissection of the thoracic aorta. The results obtained were compared to those of conventional transthoracic echocardiography. An aortic dissection was found in 11 patients, an aortic aneurysm in 9 patients, and an aneurysm of the left subclavian artery, an abscess of the aortic ring and a perforated aortic sinus in one patient each. In 2 patients no abnormalities of the thoracic aorta could be found. The intimal flap was detected in 11 patients with transesophageal imaging and in 9 patients with the transthoracic approach. Aortic dissection was suspected in another 5 patients with transthoracic echocardiography which could be excluded by transesophageal echocardiography. In 13 patients (52%) imaging of the descending thoracic aorta was not possible with transthoracic echocardiography but in all patients it was possible from the transesophageal approach. Transesophageal echocardiography seems to be a useful diagnostic approach when diseases of the thoracic aorta were clinically suspected.

Cystic adventitial degeneration as a cause of dynamic stenosis of the popliteal artery: a case report

Cystic adventitial degeneration, which is generally localized in the popliteal artery, leads to a dynamic, exercise-dependent flow inhibition. The cysts of the adventitia, which increase in size with exercise, cause an increasing degree of stenosis which can be completely reversed after a longer period if rest. Angiographic presentation may therefore be misleading. Functional examination with Doppler sonography is able to identify the obstruction in such cases. Resection of the involved vessel and restoration of flow by interposition of a vein graft is the therapy of first choice.

Concentrations of mezlocillin in the serum, heart valves, muscle and subcutaneous tissue of patients undergoing open-heart surgery

4 g mezlocillin as a five-minute intravenous bolus were given preoperatively to 31 adult patients undergoing open-heart surgery. Mezlocillin serum levels declined from 42.8 mg/l at 1-2 h after injection to less than 1 mg/l at 6-8 h after application. Concentrations in muscle and subcutaneous tissue varied between 18 micrograms/g and less than 1 microgram/g. Mezlocillin levels in heart valves were higher than those in muscle and subcutaneous tissue, thus suggesting rapid diffusion of mezlocillin.

[Intra-arterial DSA for control of aortocoronary bypass--an alternative to coronary angiography]

Intraarterial DSA is a suitable method for early postoperative control of coronary artery bypass grafts. Small quantities of contrast media with low iodine content are injected into the aortic root. Investigations can be carried out with a routine fluoroscopic and digital equipment; additional cine-technique and analogue memory disc are not necessary. At an image rate of 3/s the bypass anastomoses can be exactly visualized in 75%, whereas diagnostic information was not sufficient in only 4% of all cases. The use of modern F-5-catheters and the nonselective injection make this method a less invasive alternative to coronary angiography. It is particularly useful in evaluation of short- and long-term results.