Seminars in vascular surgery
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Besides renal failure and mesenteric infarction, spinal cord ischemia is the most dreaded complication after thoracoabdominal aortic surgery. Several techniques have been developed to improve neurologic outcome of these massive surgical procedures, including pharmacologic adjuncts, epidural cooling, distal aortic perfusion, cerebrospinal fluid drainage, and reattachment of segmental arteries. ⋯ The surgical protocol included left heart bypass and cerebrospinal fluid drainage, and MEP monitoring was applied to identify critical intercostal and lumbar arteries. Based on MEPs, the aggressive surgical approach resulted in a significant reduction of neurologic complications (2.3%).
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The management of acute massive pulmonary embolism (PE) constitutes a major clinical problem because of the associated derangement of hemodynamic and respiratory functions from obstruction to pulmonary blood flow. Despite advances in management with thrombolytic therapy or open embolectomy, the mortality rate remains high. To improve the chance of survival, catheter techniques that are capable of removing or fragmenting the clot have been developed. ⋯ The overall success rate is approximately 76%, with a mortality rate of 25%. Transvenous pulmonary embolectomy and thrombofragmentation are safe and effective techniques for treating patients with massive PE. The success of each of the techniques depends on a thorough understanding of the mechanism of action of each of the devices used and a facile catheterization technique.
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Thrombolytic therapy for pulmonary embolism can rapidly reverse right ventricular failure and reduce mortality and morbidity among appropriately selected patients. Individuals being considered for this treatment should be screened for potential major bleeding problems, which, if present, should lead to alternative management with catheter or surgical embolectomy. There is no ideal thrombolytic agent; nor have indications for thrombolysis been precisely defined. Available data indicate that patients with moderate or severe right ventricular dysfunction gain the most from this pharmacologic strategy.
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A new technique is described to approach the confluence of the subclavian vein and the internal jugular, as well as to expose the innominate vein from its origin to the superior vena cava. The operation accomplishes decompression of the subclavian vein and allows direct approach of the subclavian and the innominate veins. ⋯ Its reconstruction is explained in detail and achieves solid stability of the sternum and of the shoulder girdle. This approach also prevents deformity that other operations proposed in the past may cause.