Journal of vascular surgery
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We have previously described a technique for intrathecal administration of papaverine and cerebrospinal fluid drainage to prevent paraplegia after aortic surgery. Herein we report the cerebrospinal fluid and hemodynamic alterations that occurred in 11 patients who had 30 mg of a specially prepared papaverine hydrochloride 10% dextrose solution injected before aortic cross-clamping and also had cerebrospinal fluid drainage. A mean of 26.6 ml (SD +/- 7.1 ml) was drained before and 34.6 ml (SD +/- 24.1 ml) was drained during aortic cross-clamping. ⋯ The administration of intrathecal papaverine had no significant effect on mean arterial pressure, systemic vascular resistance, cerebrospinal fluid pressure, nor the pH of cerebrospinal fluid. Neither were there any complications noted related to the technique. All the patients survived, and no new immediate postoperative paraparesis or paraplegia occurred.(ABSTRACT TRUNCATED AT 250 WORDS)
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We report seven cases of dissection of the abdominal aorta. Three patients had acute back pain, whereas four patients had more chronic courses. In six cases, as a result of the palpation of a pulsatile abdominal mass, clinical diagnosis was an atheromatous aneurysm. ⋯ Six patients with an infrarenal dissection were treated by replacement of the aorta with a Dacron prothesis, and one patient with an suprarenal dissection was treated conservatively. With a mean follow-up of 3 years, all patients were alive and free of symptoms. These results favor graft replacement in case of infrarenal aortic dissection and more selective surgical indications in suprarenal aortic dissection.
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During the past 2 decades 102 consecutive patients (77 men and 25 women) with multiple aortic aneurysms underwent 201 aortic reconstructions. These procedures (174 elective and 27 emergent) represented 3.4% of the 5837 aortic aneurysm operations performed. Seventy-five (30.9%) of the 243 aneurysms occurred in the infrarenal aorta, 65 occurred in the descending aorta (26.7%), 56 occurred in the thoracoabdominal aorta (23.0%), and 47 occurred in the ascending aorta or arch (19.3%). ⋯ Kaplan-Meier 5-year survival including perioperative deaths for all patients after the first operation was 76% and after the last operation 40%. We conclude that multiple aortic aneurysms can be safely managed, usually with staged repairs, and that long-term survival is probably. After the first aortic operation the presence of multiple aneurysms mandates close observation with timely surgical intervention.
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Real-time electrocardiographic monitoring for silent myocardial ischemia was performed on 200 patients undergoing peripheral vascular surgery to try to better define those at high risk of perioperative myocardial infarction. The patients were divided into those undergoing abdominal aortic aneurysm or lower extremity revascularization procedures (group I, n = 120) and those undergoing carotid artery endarterectomy (group II, n = 80). Silent ischemia was detected during the preoperative, intraoperative, or post-operative periods in 60.8% of group I and 67.5% of group II patients. ⋯ The results show that in both groups there was a significantly (p less than or equal to 0.05) greater total duration of perioperative ischemic time, total number of perioperative ischemic episodes, and total duration of perioperative ischemic time as a percent of total monitoring time in patients who suffered a perioperative myocardial infarction compared to those who did not. Multivariate logistic regression analysis of preoperative characteristics in all 200 patients showed the occurrence of preoperative silent myocardial ischemia and angina at rest to be the only significant predictors of perioperative myocardial infarction. Thus perioperative monitoring for silent myocardial ischemia might noninvasively identify those patients undergoing peripheral vascular surgery who are at increased risk for perioperative myocardial infarction, permitting implementation of timely preventive measures in selected patients.
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A retrospective review was undertaken of 127 lower extremity fasciotomies performed for compartment syndrome after acute ischemia and revascularization in 73 patients with vascular trauma and 49 patients with arterial occlusive disease. One hundred twelve (88%) fasciotomies were performed early (at the time revascularization); 15 (12%) were delayed because of late compartment syndrome diagnosis. Ninety-four (77%) patients had more than one accepted indication for fasciotomy. ⋯ Eighteen (15%) patients died of cardiopulmonary failure or multisystem failure or both, without fasciotomy-related problems. Open fasciotomy for compartment syndrome after acute lower extremity ischemia and revascularization was associated with an increased risk of minor wound morbidity. However, limb loss and death resulted from persistent ischemia and underlying systemic disease processes or injuries, but not from open fasciotomy wound complications.