Annals of surgery
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Comparative Study
A clinical survey of aortobifemoral bypass using two inherently different graft types.
The performance of knitted Dacron and polytetrafluoroethylene (PTFE) bifurcated grafts are compared in this study of 312 patients at a single institution. Patients of the two graft groups were statistically well-matched in risk factors and degree of distal obstructive disease. Operating time needed to implant either graft was approximately equal. ⋯ Complications affected 13% of the patients of the Dacron group and 4% of the PTFE group. All six graft infections and all seven graft double-limb thromboses occurred in Dacron grafts. Anastomotic aneurysms, amputations, and late graft revisions occurred with greater frequency in patients with Dacron grafts.
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Comparative Study
Significant reductions in mortality for children with burn injuries through the use of prompt eschar excision.
During the past 19 years, mortality due to burn injuries has markedly declined for children at the Boston Unit of the Shriners Burns Institute (SBI), dropping from an average of 9% of SBI admissions during 1968-1970 to an average of 1% during 1981-1986. Detailed statistical analysis using logistic regression was necessary for determining whether this decline in mortality was explained by changes in patient characteristics, such as age or burn size, which are known to strongly influence the outcome of burn injuries. This dramatic decline in mortality during the past 19 years was not the result of change in the age of the patients or their burn sizes; rather, it may be attributed to improvements in burn care. ⋯ Dramatic improvement in survival occurred in patients with burns covering more than 50% of the body surface area. Since 1979, mortality has been essentially eliminated for patients with burn sizes less than 70% of the total body surface area (of 296 patients with burns covering 15-69% of the total body surface area, only two patients died). During the period 1979-1986, 29 of 37 patients (78%) survived an 80% or greater total body surface area thermal injury.
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The efficacy of routine screening coagulation tests was studied to identify occult coagulopathies in patients prior to elective general and vascular surgery procedures. The efficacy of screening tests was compared to that of indicated tests performed for predefined clinical indications, which were elicited by history and physical examination and a detailed coagulation history questionnaire. Tests were prothrombin time (PT), partial thromboplastin time (PTT), platelet count (PC), and bleeding time (BT). ⋯ Of the 605 indicated tests, 7.4% were abnormal, and all significant coagulopathies were found in this group. The study shows that preoperative screening tests for coagulopathies not suspected on the basis of detailed clinical information are unnecessary and should not be done. In the authors' institution 46% of screening coagulation tests could be eliminated.
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A retrospective analysis of all patients with traumatic thoracic aortic rupture (TAR) admitted to the hospital over a consecutive 10-year period was performed in order to define the incidence, morbidity, and mortality of associated cardiac contusion (CC) in patients with TAR. Of the 13 patients with TAR, eight (62%) had associated CC. All patients with CC had two or more of the following positive findings: abnormal ECG, elevated myocardial-band creatinine kinase levels, abnormal radionuclide angiography/left ventricular segmental wall motion studies, or cardiac damage seen at surgery and postmortem examination. ⋯ All patients with isolated TAR survived, whereas three of eight patients suffering combined TAR and CC died perioperatively, secondary to cardiac arrest. In patients with TAR, the presence of associated CC occurs with increased frequency, is associated with increased morbidity (cardiac arrest, ARDS), and results in increased operative mortality secondary to cardiac instability. A branch-chain decision tree (clinical algorithm) was developed as a means of improving management of patients with combined TAR and CC, including indications for preoperative pulmonary artery catheterization.
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Acute aortic dissection occurred in 18 patients who had previously diagnosed atherosclerotic aneurysms of the thoracic and/or abdominal aorta. These patients were reviewed to assess the clinical course when these two forms of aortic pathology coexist. Patients were grouped according to status of their atherosclerotic aneurysm (previously repaired vs. untreated) and the segments of the aorta effected by the acute spontaneous dissection. ⋯ In Group 3 patients, rupture occurred both at the atherosclerotic aneurysm (four patients) and at the site of the aortic intimal tear of the dissection (two patients) after AAA repair. The use of Magnetic Resonance Imaging (MRI) has proven to be highly accurate in delineating the nature and extent of pathology in recently encountered patients with complicated aortic disease. Coexistence of atherosclerotic aneurysm and acute dissection appears to increase the risk of aortic rupture, in both proximal and distal aortic segments.