Magnetic resonance imaging angiography in patency evaluation of bronchial artery revascularization grafts

In this report we present our experience of non-invasive magnetic resonance imaging (MR) angiography and selective catheter angiography in assessing the patency of bronchial artery revascularization grafts after an en bloc double-lung and heart-lung transplantation. We studied 8 patients who had undergone pulmonary transplantation with direct bronchial artery revascularization. Catheter angiography was performed 10 days to 63 months postoperatively. MR angiography was performed within 24 h of the catheter procedure and the results were compared with the findings from catheter angiography. Catheter angiography showed the bronchial revascularization graft to be patent in 6 patients and occluded in 2. At MR angiography, the patency of bronchial artery revascularization grafts was reliably identified in 7 of the 8 patients. One patient had inadequate image quality because of void artefacts caused by haemostatic clips. It is concluded that MR angiography is a reliable method for assessing the patency of bronchial artery revascularization grafts.     

Magnetic Resonance Imaging Angiography in Patency Evaluation of Bronchial Artery Revascularization Grafts

In this report we present our experience of non-invasive magnetic resonance imaging (MR) angiography and selective catheter angiography in assessing the patency of bronchial artery revascularization grafts after an en bloc double-lung and heart-lung transplantation. We studied 8 patients who had undergone pulmonary transplantation with direct bronchial artery revascularization. Catheter angiography was performed 10 days to 63 months postoperatively. MR angiography was performed within 24 h of the catheter procedure and the results were compared with the findings from catheter angiography. Catheter angiography showed the bronchial revascularization graft to be patent in 6 patients and occluded in 2. At MR angiography, the patency of bronchial artery revascularization grafts was reliably identified in 7 of the 8 patients. One patient had inadequate image quality because of void artefacts caused by haemostatic clips. It is concluded that MR angiography is a reliable method for assessing the patency of bronchial artery revascularization grafts.     

Reconstructive surgery of the bronchi in inflammatory lesions

"Reconstructive bronchial surgery" and "parenchyma-preserving operation" are terms which define the surgical purpose of restoring patency of the bronchial system or avoiding non-patency. This is beyond the limits of bronchoplasty. Inflammatory lesions are rare as reasons for reconstructive surgery. This indication applied to merely 13 of 120 of the author's patients who underwent reconstructive operations on their tracheobronchial system. Tuberculous aetiology was predominant. Bronchoplastic measures, therefore, were associated with lobectomy in almost all cases. Parenchyma-preserving operations may yield lasting success with minor complications even in cases of inflammatory processes, provided that indications were carefully established and operations performed with subtle techniques.     

Anterior rectus fascia back cut: a new modification to relieve the pressure in fascial closure of the superior pedicle of a transverse rectus abdominis myocutaneous flap

The maintenance of vascular patency is one of the key points to be considered after a pedicled transverse rectus abdominis myocutaneous (TRAM) flap has been raised and when closing the anterior rectus fascia to avoid a hernia. In this study we describe a new approach to closing the most superior part of the fascia to help insure vascular patency. Forty patients who had their breasts reconstructed with TRAM flaps made up the study group. The new back cut technique was used in 25 patients. Of the remaining 15 patients, four required early revision on the day of operation for severe venous congestion or ischaemia. None of the patients who had the back cut technique required early revision. We found the back cut technique to be safe and easy, and we think that it can reduce the incidence of flap ischaemia and still achieve tight fascial closure.     

Extra-anatomic bypass grafting in the lower extremity

Between January 1975 and December 1980, 104 extra-anatomic bypasses were performed on 102 patients. Of these, there were 81 femorofemoral bypasses on 80 patients and 23 axillofemoral bypasses on 22 patients. Those who underwent femorofemoral grafting were divided into three groups: group 1 - 18 patients who had undergone previous aortofemoral bypass grafting with occlusion of one limb of the graft, group 2 - 17 patients who were considered to be at high risk and group 3 - 45 patients who could have tolerated a conventional reconstructive procedure. Our results indicate that the cumulative patency rate of the femorofemoral bypass at the end of 1 year and 5 years is good and that this operation is an excellent first choice procedure in cases of unilateral iliac disease, to relieve severe ischemia or disabling claudication, whether the patient is a poor or good operative risk. On the other hand, axillofemoral grafting has a lower patency rate and should be reserved for high-risk patients and for the relief of severe ischemia only.     

Comparison of axillounifemoral and axillobifemoral bypass operations

Routine use of axillobifemoral (ABF) bypass has been advocated because this operation is thought to achieve better patency than the axillounifemoral (AUF) procedure. In 5 years we performed 34 AUF and 22 ABF bypass operations for limb salvage in high-risk patients using 6 mm polytetrafluoroethylene grafts. Five-year cumulative life table patency rates for AUF bypasses were 71% with reoperation (secondary patency) and 44% without reoperation (primary patency). These values were not significantly different (p greater than 0.5) from those for ABF bypasses (77% and 50%, respectively). Five-year limb salvage results (AUF 73%; ABF 89%) were also not significantly different (p greater than 0.1). Correlation of arterial outflow characteristics with graft patency revealed that 78% of the patients who never had graft occlusion had occluded superficial femoral arteries (SFA) demonstrated at the first operation, while 79% of the patients who experienced graft closure had comparable SFA occlusions. Our aggressive approach to graft thrombosis included angiographic study of the inflow arterial system. This revealed that 16% of the failed grafts were associated with hemodynamically significant stenosis of the donor subclavian artery. Our results indicate that AUF bypass is the procedure of choice for unilateral limb ischemia in high-risk patients who require an axillary source and that patency of the SFA does not affect outcome. These results also emphasize the need to obtain angiographic evaluation of the inflow system.     

Experience with Ultraflex expandable metallic stents in the management of endobronchial pathology

BACKGROUND: Experience with Ultraflex expandable metallic stents (Micro-invasive, Boston Scientific, Watertown, MA) in the management of endobronchial pathologies leading to airway compromise is reported. METHODS: Between January 1999 and August 2000, twenty-eight expandable metallic stents were inserted into 25 patients (7 men and 18 women; median age, 65 years) who presented with respiratory distress. Each patient had comorbid medical conditions or end-stage malignancy that precluded formal surgical repair. Seventeen patients had intrinsic airway obstruction, 5 had extrinsic compression, 2 had a tracheal tear, and 1 had a tracheoesophageal fistula. Stents were inserted through a bronchoscope under direct vision. Eighteen patients received tracheal stents alone (1 of these patients received two tracheal stents), and 5 patients received bronchial stents only. Two patients received a tracheal and a bronchial stent. Twenty-one stents were covered and seven were uncovered. RESULTS: All patients had successful stents with restoration of airway patency and closure of tracheal defects. One patient developed a respiratory infection early after the operation. Follow-up bronchoscopy confirmed satisfactory stent position in each patient. Late complications included sputum retention, halitosis, and granulation tissue formation. CONCLUSIONS: Ultraflex expandable metallic stents should be considered in the management of airway compromise in selected patients for whom formal surgical repair is inappropriate or contraindicated.     

The choice of operation for bronchial carcinoids

In a review of the literature, 1,392 patients with bronchial carcinoids were found. Of these, there were 313 patients for whom individual data with regard to type of operation, follow-up period, and outcome were given. Actuarial curves for proportions of patients who had not died of the disease or who had not undergone reoperation for residual disease were constructed for each type of operation. The prognosis up to 20 years after surgical treatment for bronchial carcinoids is excellent. For 15 to 20 years postoperatively, the prognosis after a lobectomy is excellent and after a pneumonectomy, slightly worse. The prognosis after a lung parenchyma-saving operation (wedge or segmental resection and bronchoplastic procedures) is similar to that after a lobectomy up to 7 years postoperatively. After that, the proportion of disease-free patients declines precipitously. At 20 years the difference in comparison with a lobectomy is statistically significant for both wedge or segmental resections and bronchoplastic procedures. Parenchyma-saving operations cannot therefore be said to be radical. A policy for decision-making at the operating table is formulated.     

Surgical treatment of pulmonary echinococcosis

Operation with the use of a laser for resection of the external fibrous capsule with re-expansion of the remaining cavity in patients with echinococcosis of the lungs is more effective than operation by capitonnage of the cavity. The main advantages of laser operations were the absence of closed cavities, deformities of bronchi, atelectasic areas of tissue around the fibrous cavity, and disorders of capillary blood flow and bronchial patency. All this allowed poor results of the operation and fatal outcomes in the main group of patients to be avoided.     

Association between the number of vascular operation on the lower limbs and long term survival.

OBJECTIVE: To investigate to what extent the need for more than one vascular operation for chronic lower limb ischaemia was associated with relative long term survival. DESIGN: Retrospective observational study. SETTING: University hospital, Norway. SUBJECTS: 1574 patients (29% women) operated on for chronic lower limb arterial insufficiency. Of these 447 needed at least one further operation for progressive limb ischaemia. MAIN OUTCOME MEASURES: Long term survival estimated by the Kaplan-Meier method. The expected survival was calculated from mortality tables issued by the Norwegian Central Bureau of Statistics. RESULTS: The 10-year survival rate was 46% for the patients operated on once and 24% for the patients who had two or more operations. The expected survival rates were 57% and 52%, respectively. Both categories of patients had significantly shorter long term survival than a demographically-matched population. The long term survival of patients operated on twice or more was significantly less than that of those who needed only one operation. CONCLUSION: There is an association between the need for more than one vascular operation and long-term survival. Atherosclerotic disease among these patients seems to be more aggressive.     

Quality of survival in patients with surgically treated bronchial carcinoma.

Quality of survival was studied in 69 surgically treated bronchial carcinoma patients (25% of a total 273 patients in an unselected epidemiological sample). The Carlens vitagram index was used. The quality of survival in patients cured by pulmonary resection was excellent. It was poor in patients who underwent resection and subsequently died, and especially in patients who had non-resectional thoracotomies. The patients who were operated on and later died did not have a better quality of survival than non-surgically treated patients in the same stage. Thus pulmonary resection has no palliative effect in bronchial carcinoma patients who are not cured. The possible benefit of "removing the tumour burden" in patients treated with operation alone can, therefore, be dismissed. The only aim of the operation at present must be to cure.     

Utility of femorofemoral bypass. Comparison of results with indications for operation

Sixty-eight patients underwent femorofemoral bypass (FFB) at the University of Louisville Affiliated Hospitals over a 9-year period from 1980 to 1989. There were patients with acute ischemia requiring emergency operation, those with chronic ischemia following failed aortic reconstruction, good-risk patients with chronic ischemia who had FFB as the procedure of choice, and poor-risk patients who were unsuitable for other procedures. Patients operated on for acute ischemia had a significant number of infectious complications, with five of eight graft failures in this group due to infection. Primary patency rates were similar in all groups, with a 5-year primary patency of 42 per cent. Overall operative mortality was 4.4 per cent. Satisfactory limb salvage rates (75%) suggest that FFB is an acceptable option for providing inflow in patients with acute ischemia or for patients with a failed previous vascular prosthesis. FFB provides adequate inflow in poor-risk patients not suitable for aortic reconstruction, but patency rates do not warrant its use as a procedure of choice in good-risk patients.     

THE SIGNIFICANCE OF DONOR LEG DISTAL RUNOFF IN FEMOROFEMORAL BYPASS GRAFTING

Background: The aim of this study is to determine if femorofemoral bypass grafting is an effective operation for unilateral iliac occlusive disease, and to assess for factors that may predict a poorer outcome. A retrospective review was conducted of cases identified from a prospective audit database. Methods: Information was obtained from the clinical notes of 97 patients who had 100 femorofemoral bypass graft operations. All living patients were invited for assessment which included colour duplex sonography of the graft and measurement of the ankle brachial index. Results: Using life-table analysis, the five-year graft secondary patency for claudicants was 79% and for those with critical ischaemia 78%. Five-year survival for claudicants was 65% and for those with critical ischaemia, 38%. Poor distal runoff in the infrapopliteal arteries of the donor limb adversely affected graft patency. Graft survival was not affected by the indication for operation, by donor or recipient superficial femoral artery patency, or by the need for endarterectomy, pre-operative angioplasty or the graft material. Conclusions: Femorofemoral bypass grafting is the procedure of choice for all patients who require surgical intervention for unilateral iliac occlusion and donor limb distal runoff may be an important determinant of graft patency.     

Surgical Treatment of Cancer of the Thoracic Esophagus in Association With a Major Pulmonary Operation

Background: Pulmonary complications have been a major cause of mortality after operations for cancer of the thoracic esophagus. Although the risk involved in esophagectomy associated with a major pulmonary operation is expected to be high, it has seldom been evaluated on the basis of clinical experience.

Study Design: Of 408 patients who underwent esophagectomy, 8 had previously undergone major pulmonary operation (7 for tuberculosis and 1 for pulmonary cancer) and 10 underwent concurrent major pulmonary resection (7 for pulmonary invasion of esophageal cancer, 2 for synchronous pulmonary cancer, 1 for extensive bronchiectasia). All patients underwent systematic lymph node dissection for esophageal cancer, except one patient with mucosal cancer. To prevent postoperative complications, the operative approach and dissection procedures for esophageal cancer were modified according to the associated pulmonary operation and the extent of cancer invasion. All thoracotomies for esophagectomy were performed on the same side as the major pulmonary operation. Additional median sternotomy was performed when necessary. In the most recent 8 patients who underwent major pulmonary resection concurrent with esophagectomy, the bronchial stump was covered with a pedicle flap.

Results: Of the 18 patients who underwent pulmonary operation, postoperative complications developed in 13 of the 18 object patients, but none was fatal. The 3-year survival rate was 45%. All deaths were caused by esophageal cancer or another cancer.

Conclusions: Aggressive esophagectomy associated with major pulmonary operation is not contraindicated in patients with fair risk conditions. The operative procedures for esophagectomy should be appropriately modified to minimize the effect of the associated pulmonary operation. Special care should be taken with respect to the approach for mediastinal dissection and closure of the bronchial stump.     

Total Arterial Revascularization of the Heart using both Mammary Arteries and the Right Gastroepiploic Artery

From April 1988 to April 1989, nine patients (seven men and two women) with coronary three-vessel disease and disabling angina underwent elective myocardial revascularization. None of the patients had available veins because of previous bypass procedures (three) or extensive varicosis (six). On standard cardiopulmonary bypass and cardioplegic arrest the right and the left mammary arteries (RIMA, LIMA) and the right gastroepiploic artery (RGEA) were anastomosed each to a major coronary branch (none of them as free graft) in each patient. All patients survived the operation but one, who died 2 weeks after the operation of a bilateral pneumonia. Autopsy revealed patent anastomoses. One patient had to be reexplored for bleeding. Two patients required temporary inotropic support. There was no perioperative myocardial infarction. All survivors were discharged home in an average of 18.7 days after the operation, are free from angina, and all have negative stress tests (mean follow-up 7.7 months) but one with severe coronary atherosclerosis who experiences slight exertional angina despite good patency of the grafts. Five patients were recatheterized after a mean interval of 5.4 months after operation revealing in all cases patent anastomoses. Total revascularization of the heart with arterial grafts is feasible, safe, and it could become the method of choice if patency persists in the long run.     

Comparison of surgical procedures for vascular and airway anastomoses that utilize a modified non-suture external cuff technique for experimental lung transplantation in rats.

BACKGROUND: Lung transplantation in rats is technically difficult and results may vary. The non-suture cuff technique (non-suture [NS]), which involves using a cuff for anastomoses of vessels and airways, is commonly utilized to perform transplant procedures. However, the standard bronchial cuff may occlude the lumen, resulting in diminished graft survival. In contrast, the non-suture cuff technique for vascular anastomoses with bronchial suturing (bronchial suture [BS]), although more technically difficult, is known to have prolonged bronchial patency. We developed a "modified" NS technique that uses a larger and longer cuff for anastomoses and compared the efficacy of this procedure to the BS technique for lung transplantation. METHODS: The BS procedure was performed in 146 transplant procedures. The modified NS procedure, which uses a larger cuff than the standard NS procedure, was performed in 113 procedures. RESULTS: Although total ischemic times were comparable, the total operation time in the NS group was significantly shorter than in the BS group (p < 0.0001). Bronchial leakage occurred in 9.6% of BS group patients and 0% of NS group patients. Survival rates were comparable between groups. Although the BS technique is widely acknowledged to provide prolonged patency of bronchial anastomosis, graft survival in the NS group was observed up 17 months post-transplant. CONCLUSIONS: These data show that the NS technique, which is less technically difficult, results in shorter operative times compared with the BS procedure, and results in durable anastomoses of lung grafts.     

Factors affecting patency of internal thoracic artery graft: clinical and angiographic study in 1434 symptomatic patients operated between 1982 and 2002.

OBJECTIVE: The purpose is to define factors influencing long-term patency of the internal thoracic artery (ITA) to optimize the operative strategy. METHODS: 1482 left internal thoracic artery (LITA) and 636 right internal thoracic artery (RITA) symptom-directed angiograms were studied in 1434 patients. Data were prospectively collected from patients who had primary coronary artery bypass surgery during the period 1982-2002. The mean age of patients was 59 years; 85% were male. The mean period from operation to re-angiogram was 80 months. LITA was grafted to left anterior descending coronary artery (LAD) in 82% of cases, RITA to right coronary artery (RCA) in 40% and circumflex artery in 35% of cases. Graft failure was defined as > or =80% stenosis. RESULTS: 96.3% of LITA and 88.1% of RITA grafts were patent. No patient variables were significantly associated with graft patency (age, gender, diabetes, hypertension, LVEF, NYHA, AMI). Target coronary artery was associated with patency of both LITA and RITA grafts with maximum patency when grafted to LAD (P = 0.02) RITA had the worst patency to RCA, patency for the left system was identical to LITA. Proximal anastomosis to aorta (free RITA) had significantly better patency when compared with in situ RITA to RCA system (P = 0.005) while similar patency when grafted to left system. ITA diameter and target artery diameter were not associated with graft patency. Recent operations had better RITA patency (P = 0.03). The interval from operation to angiogram was not associated with ITA patency (96% patency for LITA and 88% patency for RITA, remained stable when studied at <1, 1-4, 5-9, 10-14 and >15 years). CONCLUSIONS: Even in a patient cohort that had adverse symptoms, excellent LITA and RITA patency was achieved which almost remained constant through all time intervals studied.     

Late patency of the left internal thoracic artery graft in patients with and without previous successful percutaneous transluminal coronary angioplasty

The aim of this study was to compare early and late graft patency in patients with and without previous successful PTCA. Of the 70 patients who received both early and late follow-up angiography, 13 patients who had received successful PTCA at the left anterior descending coronary artery (LAD) before CABG (group I) and 31 patients who had not received preoperative PTCA in any vessel (group II) were retrospectively reviewed. There were no significant differences in patient characteristics including major coronary risk factors. The mean duration between the operation and control angiography was 35+/-23 months in group I and 36+/-19 months in group II (P=0.90). Occlusions of the LITA graft were observed in four patients of group I and in four patients of group II. Cumulative patencies of the LITA graft were 54% in group I and 83% in group II (P=0.12). The late patency rate of the LITA graft bypassed to the LAD in patients that received previous successful PTCA in the coronary artery tended to be lower than in patients without previous PTCA. This result should be confirmed by further prospective studies.     

Crossover femoral-popliteal and femoral-tibial bypass

Crossover femoral-popliteal or femoral-tibial bypass has been employed as an alternative extra-anatomic bypass in 3 patients who had occlusion of an iliac artery with subsequent occlusion of the ipsilateral femoral artery with patency of either a popliteal or tibial artery and a patency of the contralateral common femoral artery. Each patient had a contraindication to a more conventional type of procedure. All procedures were performed with reinforced PTFE grafts. All grafts have remained patent for 6 months to 3 years. This operation should be considered as an alternative extra-anatomic reconstructive procedure in patients with the appropriate anatomy and who are not candidates for more standard types of vascular reconstruction.     

The effects of aspirin, dipyridamole and warfarin in femorodistal reconstruction: long-term results

This study was done to evaluate the effect of aspirin (ASA), dipyridamole (DIP), and warfarin on 406 patients who had femoropopliteal-tibial operations with saphenous vein (SV), umbilical vein (UV), polytetrafluoroethylene (PTFE) and Dacron (DuPont, Wilmington, DE). Above-knee bypasses were performed in 181 patients: 77 were taking ASA and DIP at the time of operation, 41 were placed on postoperative "low-dose" warfarin, whereas 63 did not receive adjunctive medications. Late patency demonstrated no significant difference among the groups based on graft material used (SV 71%, UV 68%, PTFE 66%, and Dacron 65%) (P less than .25). Below-knee femoro-popliteal bypasses were performed in 183 patients: 82 were taking ASA and DIP at the time of operation, 40 were placed on warfarin postoperatively and no medications were given to 41 patients. Late patency rates (39 months) demonstrated that SV (62%) was superior to UV (51%), PTFE (30%), and Dacron (18%) (P less than .01). Femorotibial-peroneal bypasses were done in 42 patients: 13 patients were taking ASA and DIP at operation, 21 were placed on warfarin postoperatively and 8 received no medication. SV late patency (33 months) was again superior (43%) to UV (31%); no PTFE or Dacron grafts functioned after 24 months. Patients who took warfarin and ASA had the best early (16 months) patency results. Above-knee prosthetic grafts achieved late patency rates similar to SV while reducing operative time, shortening recuperation, and sparing the saphenous vein for use in the coronary or infrapopliteal vessels. In below-knee bypasses SV was superior to prosthetic grafts, with or without the use of ASA and DIP or warfarin.(ABSTRACT TRUNCATED AT 250 WORDS)