Follow-up of renal and mesenteric artery revascularization with duplex ultrasonography

Objective

To evaluate the long-term anatomic results of renal revascularization procedures using duplex ultrasonography.

Design

A case series.

Setting

A university-affiliated hospital.

Patients

Twenty-five patients who had undergone renal percutaneous transluminal angioplasty (PTA) (18 arteries), renal bypass (10 arteries) and mesenteric bypass (6 arteries). The mean follow-up was 22 months (range from 3 to 48 months) for those who underwent renal PTA, 23 months (range from 1.5 to 70 months) for those who underwent renal bypass and 34 months (range from 8 to 144 months) for those who underwent mesenteric bypass.

Main Outcome Measures

Patency rates for the three procedures as assessed by duplex ultrasonography.

Results

Duplex ultrasonography demonstrated patency without stenosis after renal and mesenteric artery revascularization in 14 arteries subjected to renal PTA, 9 arteries subjected to renal bypass and 6 arteries subjected to mesenteric bypass. Three arteries that had renal PTA had recurrent vessel stenosis and one had occlusion. One artery that had renal bypass showed occlusion.

Conclusions

Renal PTA, renal bypass and mesenteric bypass are durable procedures at 2 years of follow-up, and duplex ultrasonography is a valuable method for assessing the patency of arteries after renal and mesenteric revascularization.     

Peritonsillar abscess after tonsillectomy: a review of the literature

INTRODUCTION

Peritonsillar abscess (PTA) is a common condition with a complicated aetiology. PTA after tonsillectomy is rare. This literature review of PTA in the absence of tonsil tissue aims to collate experience of these cases and examine the wider implications for understanding the aetiology of PTA formation.

METHODS

A structured literature review was performed using Ovid MEDLINE®. Keywords ‘quinsy’ or ‘peritonsillar abscess’ were combined with ‘tonsillectomy’.

RESULTS

The search resulted in 212 citations and the identification of 11 cases of PTA formation in the absence of tonsil tissue. The most common indication for tonsillectomy was recurrent tonsillitis or PTA. Nine patients had no interval peritonsillar infection (ie a peritonsillar infection after a tonsillectomy) prior to presenting with the PTA. The mean interval between tonsillectomy and PTA was 16 years. All patients were managed either by incision and drainage or by needle aspiration with or without antibiotics.

CONCLUSIONS

PTA in the absence of tonsil tissue is rare. Potential sources of infection include congenital branchial fistulas, Weber''s glands and dental disease. These alternatives should also be considered in patients presenting with PTA formation in the absence of concurrent tonsillitis and may influence management decisions.     

Acute compartment syndrome secondary to disruption of the perforating branch of the peroneal artery following an acute inversion injury to the ankle

INTRODUCTION

Although ankle sprain by inversion is common in daily practice, acute compartment syndrome following ankle inversion injury is unusual. Only a few cases of this uncommon entity have been reported.

PRESENTATION OF CASE

This report describes a case of acute compartment syndrome following severe inversion of an ankle injury secondary to disruption of the perforating branch of the peroneal artery 3 h after the trauma. Although emergent fasciotomy was performed, residual weakness of ankle dorsiflexion still presented six months after surgery.

DISCUSSION

To the best of our knowledge, this case is the third in literature on an acute compartment syndrome following severe inversion ankle injury secondary to disruption of the perforating branch of the peroneal artery.

CONCLUSION

This report underscores the importance of considering compartment syndrome when individual has an inversion ankle injury, even when no fracture exists.     

Reliability of MRI Findings of Peroneal Tendinopathy in Patients with Lateral Chronic Ankle Instability

Background

Patients with chronic lateral ankle instability also have peroneal tendinopathy often. However, preoperative MRIs of these patients are vague in many cases. Our study was performed to see the reliability of MRI findings of peroneal tendinopathy in patients with chronic lateral ankle instability.

Methods

MRI images for 82 patients who had chronic lateral ankle instability, and had received surgical treatment between March 2006 and November 2009 were compared with impressions from operating rooms. The mean age of patients was 36.4 years (range, 15 to 64 years), 82 ankles were studied, and patients with rheumatoid diseases were excluded from the study.

Results

Of the 82 cases, 26 were true positives, 38 true negatives, 13 false positives and 5 false negatives. Of 39 cases of peroneal tendinopathy diagnosed from MRI, 14 had peroneal tendon partial tears, 15 tenosynovitis, 3 dislocations, 17 low-lying muscle bellies, and 6 peroneus quartus muscles. Of 31 cases of peroneal tendinopathy observed in surgery 11 had peroneal tendon partial tears, 4 tenosynovitis, 5 dislocations, 12 low-lying muscle belliess, and 1 peroneus quartus muscle. Sensitivity and specificity of peroneal tendinopathy were 83.9% and 74.5%, respectively. Positive predictive value was 66.7%. Negative predictive value was 88.4%. Accuracy rate was 78.0%.

Conclusions

MRI is a useful diagnostic tool for detecting peroneal tendinopathy in patients with chronic lateral ankle instability. However, MRI is vague in many cases. Therefore, a thorough delicate physical examination and careful observation is needed.     

Incidental discovery of a long standing arteriovenous fistula after thrombectomy for acute lower limb ischaemia

INTRODUCTION

Arteriovenous fistula (AVF) is the abnormal connection between an artery and vein. Congenital AVF of the popliteal artery is very rare.

PRESENTATION OF CASE

89 year old lady presented with right acute lower limb ischaemia. She had unilateral chronic venous hypertensive change in the right leg. Femoral embolectomy was performed. Backflow was achieved. Arteriotomy was closed. The patient''s leg continued to deteriorate. She returned to theatre. On-table angiogram showed an occluded SFA. Thrombectomy was completed. SFA was patent but no blood flowed into the distal popliteal artery. A second on table angiogram revealed AVF between popliteal artery and vein. Dissection to the posterior aspect of the knee revealed the fistula. The vein was arterialized and enlarged. The AVF was ligated. Normal distal blood flow was achieved. Retrospectively we measured the leg lengths. Right leg was 3 cm longer than the left. The right leg circumference was 7 cm greater than the left. She reported chronic venous change from a young age. She did not report any history of trauma to the limb.

DISCUSSION

Popliteal artery to popliteal vein fistula is a rare. Trauma is the most common cause of popliteal AVF. Should the condition develop before closure of the epiphyses, there may be an increase in leg measurements.

CONCLUSION

We postulate that this case of AV fistula may be congenital due to discrepancy in leg measurements and unilateral chronic venous hypertensive change. Rarely persistent remnants of the embryonic sciatic artery can lead to arteriovenous anastomoses, which may be a possible aetiology.     

彩色多普勒超声诊断2型糖尿病患者下肢动脉病变

目的分析彩色多普勒超声用于诊断2型糖尿病患者下肢动脉病变的价值。方法对800例2型糖尿病患者的3组下肢动脉：胫前动脉（ATA）、胫后动脉（PTA）和足背动脉（DPA）行彩色多普勒超声检查,从管径、斑块及血流动力学方面进行比较。结果糖尿病患者下肢动脉出现斑块最多、狭窄最严重的是ATA远心端和DPA,PTA斑块相对较少,狭窄较轻。糖尿病包括糖尿病足双侧下肢动脉在管径、管腔最大狭窄率及血流动力学方面差异无统计学意义,病变程度相当。结论彩色多普勒超声在诊断糖尿病下肢动脉病变中具有重要价值,有助于了解血管狭窄程度及血流动力学方面的信息,指导临床治疗。     

Depression after CABG: a prospective study

Introduction

Depression during or shortly after hospitalization elevated two to three times the risk of mortality or nonfatal cardiac events, significantly increasing the morbidity and mortality of these patients.

Objective

To assess the impact of revascularization on symptoms of depression in patients with coronary artery disease.

Methods

A prospective cohort study of 57 patients of both sexes undergoing coronary artery bypass grafting between June 2010 and June 2011. We used the SF-36 to assess quality of life, and the Beck Depression Inventory to detect depressive symptoms, applied preoperatively and six months.

Results

The prevalence of patients aged 60-69 years was 22 patients (38.60%), 39 men (68.42%), 26 described themselves as mixed race (45.61%), 16 literate (28.07 %) and 30 married (52.63%). The beck depression inventory score demonstrated increased after revascularization: 15 patients mild (26.32%) at time zero to 17 (29.82%) after. And with moderate, seven patients (12.28%) before and 10 (17.54%) after. In the categories of individuals with decreased minimum degree of 32 (56.14%) to 28 (49.12%), and severe of three (5.26%) for two (3.51%) patients. Association was observed between beck depression inventory, gender, age, lifestyle, comorbidities and quality of life.

Conclusion

There was a high prevalence of elevated beck depression inventory scores, lowest scores of depressive symptoms among men and association between the improvement of quality of life scores and beck depression inventory.     

Triple coronary artery revascularization on the stabilized beating heart: initial experience

Objective

To decrease health costs and morbidity related to extracorporeal circulation, surgeons have modified the coronary artery bypass (CAB) technique so that it can be completed without the use of extra-corporeal circulation. This study summarizes initial experience with direct coronary artery revascularization on the beating heart using a coronary stabilizer.

Design

A case series.

Setting

The Montreal Heart Institute, a university-affiliated centre, specializing in the treatment of cardiac illnesses.

Patients

Ten patients underwent CAB by this technique. They presented with double or triple coronary artery disease with no intramyocardial, heavily calcified, diffused atheromatous coronary vessels, or left main coronary disease.

Intervention

CAB grafting in the beating heart. The anterior wall was grafted in all patients, the inferior wall in 7 and the posterior wall in 7.

Main outcome measures

Patient survival and graft patency.

Results

One patient died of multiple organ failure not related to the grafting technique itself, and 1 patient suffered a non-Q myocardial infarction. Early coronary angiography performed on 8 patients showed 100% graft patency, most with excellent distal runoff (21/22 grafts).

Conclusion

In patients with adequate anatomy, performance of CAB without extracorporeal circulation can achieve excellent early results provided there is appropriate mechanical stabilization of the beating heart.     

Epidemiology of coronary artery bypass grafting at the Hospital Beneficência Portuguesa,S?o Paulo

Introduction

The knowledge of the prevalence of risk factors and comorbidities, as well as the evolution and complications in patients undergoing coronary artery bypass graft allows comparison between institutions and evidence of changes in the profile of patients and postoperative evolution over time.

Objective

To profile (risk factors and comorbidities) and clinical outcome (complications) in patients undergoing coronary artery bypass graft in a national institution of great surgical volume.

Methods

A retrospective cohort study of patients undergoing coronary artery bypass graft in the hospital Beneficência Portuguesa de São Paulo, from July 2009 to July 2010.

Results

We included 3,010 patients, mean age of 62.2 years and 69.9% male. 83.8% of patients were hypertensive, 36.6% diabetic, 44.5% had dyslipidemia, 15.3% were smokers, 65.7% were overweight/obese, 29.3% had a family history of coronary heart disease. The expected mortality calculated by logistic EuroSCORE was 2.7%. The isolated CABG occurred in 89.3% and 11.9% surgery was performed without cardiopulmonary bypass. The most common complication was cardiac arrhythmia (18.7%), especially acute atrial fibrillation (14.3%). Pneumonia occurred in 6.2% of patients, acute renal failure in 4.4%, mediastinites in 2.1%, stroke in 1.8% and AMI in 1.2%. The in-hospital mortality was 5.4% and in isolated coronary artery bypass graft was 3.5%. The average hospital stay was 11 days with a median of eight days (3-244 days).

Conclusion

The profile of patients undergoing coronary artery bypass graft surgery in this study is similar to other published studies.     

Risk factors of atheromatous aorta in cardiovascular surgery

Objective

To determine the prevalence and profile of ascending aorta or aortic arch atheromatous disease in cardiovascular surgery patients, its risk factors and its prognostic implication early after surgery.

Methods

Between January 2007 and June 2011, 2042 consecutive adult patients were analyzed, with no exclusion criteria. Atheromatous aorta diagnosis was determined intraoperatively by surgeon palpation of the aorta. Determinants of atheromatous aorta, as well as its prognostic implication were studied by multivariate logistic regression.

Results

Prevalence of atheromatous aorta was 3.3% (68 patients). Determinants were age > 61 years (OR= 2.79; CI95%= 2.43 - 3.15; P<0.0001), coronary artery disease (OR=3.1; CI95%=2.8 - 3.44; P=0.002), hypertension (OR=2.26; CI95%=1.82 - 2.7; P=0.03) and peripheral vascular disease (OR=3.15; CI95%= 2.83 - 3.46; P=0.04). Atheromatous aorta was an independent predictor of postoperative cerebrovascular accident (OR=3.46; CI95%=3.18 - 3.76; P=0.01).

Conclusion

Although infrequent, the presence of atheromatous aorta is associated with advanced age, hypertension, coronary artery disease and peripheral vascular disease. In those patients, a more detailed preoperative and intraoperative assessment of the aorta is justified, due to greater risk of postoperative cerebrovascular accident.     

Proximal fibula resection in the treatment of bone tumours

Background and objectives

We present a large study of patients with proximal fibula resection. Moreover we describe a new classification system for tumour resection of the proximal fibula independent of the tumour differentiation.

Methods

In 57 patients the functional and clinical outcomes were evaluated. The follow-up ranged between six months and 22.2 years (median 7.2 years). The indication for surgery was benign tumours in ten cases and malignant tumours in 47 cases. In 13 of 45 patients, where a resection of the lateral ligament complex was done, knee instability occurred. In 32 patients a resection of the peroneal nerve with resulting peroneal palsy was necessary.

Results

Patients with peroneal resection had significantly worse functional outcome than patients without peroneal resection. An ankle foot orthosis was tolerated well by these patients. Three of four patients with pathological tibia fracture had local radiation therapy. There was no higher risk of tibia fracture in patients with partial tibial resection.

Conclusions

Resection of tumours in the proximal fibula can cause knee instability, peroneal palsy and in cases of local radiation therapy, a higher risk of delayed wound healing and fracture. Despite the risks of proximal fibula resection, good functional results can be achieved.     

Comparison of weight loss achieved after laparoscopic adjustable gastric banding between Afro-Caribbean,Caucasian and South Asian adult female patients in a London bariatric centre

Introduction

It has been shown that following laparoscopic adjustable gastric banding (LAGB) procedures, Afro-Caribbeans achieve poorer weight loss compared with Caucasians. The reasons for this are multifactorial. However, studies have been based on mainly female patients from the US and none to date have been from the UK. Furthermore, South Asians have not previously been compared. The aim of this study was to compare excess weight loss percentage (%EWL) outcomes up to five years following LAGB in Afro-Caribbean, Caucasian and South Asian females in a London-based teaching hospital.

Methods

An analysis was carried out of prospectively collected data of female patients aged ≥16 years of Afro-Caribbean, Caucasian or South Asian origin who underwent LAGB between October 2000 and December 2011. Data included demographics, co-morbidities and anthropometrics.

Results

Overall, 596 females underwent LAGB; 316 Caucasians (53.0%), 64 Afro-Caribbeans (10.8%) and 27 South Asians (4.5%) formed the majority of those who disclosed ethnicities. Age and initial body mass index (BMI) were comparable between Afro-Caribbeans and Caucasians (mean BMI: 47.3kg/m² [standard deviation [SD]: 7.5kg/m², range: 37.0–78.3kg/m²] vs 45.8kg/m² [SD: 7.1kg/m², range: 24.7–79.8kg/m²], p=0.225). A non-significant trend suggested less %EWL in Afro-Caribbeans than in Caucasians at 6 months, and at 1, 2, 3, 4 and 5 years (21.4% vs 24.4%, p=0.26; 27.4% vs 31.3%, p=0.27; 33.0% vs 36.8%, p=0.15; 39.0% vs 45.8%, p=0.14; 34.2% vs 45.3%, p=0.16; 37.1% vs 47.6%, p=0.67). South Asians and Caucasians had a similar age and preoperative BMI (mean BMI: 43.6kg/m² [range: 32.5–59.1kg/m²] vs 45.8kg/m² [range: 24.7–79.8kg/m²], p=0.08). The %EWL was greatest at three and four years among South Asians although numbers were small (n=4 and n=3 respectively).

Conclusions

A non-significant trend suggests poorer weight loss outcomes in Afro-Caribbeans compared with Caucasians in our cohort. Discussion of realistic weight loss outcomes as well as enhanced follow-up and dietary modifications are required for Afro-Caribbean patients. Low numbers prevent definitive conclusions regarding South Asians. Multicentre studies across England are required to better define any differences between ethnicities.     

Limited adequacy of thyroid cancer patient follow-up at a Canadian tertiary care centre

Background

We sought to evaluate the adequacy of follow-up of thyroid cancer patients at a Canadian centre.

Methods

We mailed a survey to the family physicians of thyroid cancer patients and analyzed the findings relative to follow-up guidelines published by the American Thyroid Association (ATA). Statistical significance between early and late follow-up patterns was analyzed using the χ² test.

Results

Our survey response rate was 56.2% (91 of 162). The time from operation ranged from 1.24–7.13 (mean 3.96) years, and 87.9% of patients had undergone a physical exam within the previous year. Only 37.4% and 14% of patients had a serum thyroglobulin measurement within 6 and between 6 and 12 months before the survey, respectively. Thyroid simulating hormone (TSH) levels were measured within the prior 6 months in 67% of patients and between 6 and 12 months in 13.2%. The TSH levels were suppressed (< 0.1 μIU/L) in 24.2% of patients, 0.1–2 μIU/L in 44% and greater than 2 μIU/L in 17.6%. Ultrasonography was the most common imaging test performed.

Conclusion

There is significant variation in the follow-up patterns of patients with thyroid cancer, and there is considerable deviation from current ATA guidelines.     

Graft pathology at the time of harvest: impact on long-term survival

Objective

This study aims to present the graft pathology at the time of harvest and its impact on long-term survival.

Methods

The remnants of the bypass grafts from 66 consecutive patients with coronary artery disease receiving a coronary artery bypass grafting were investigated pathologically, and pertinent predictive risk factors and survival were analyzed.

Results

Medial degenerative changes with or without intimal proliferation were present in 36.8%, 37.8% and 35.6% of left internal mammary artery (IMA), radial artery and saphenous vein grafts. There were 2 (3.0%) hospital deaths and 9 (14.1%) late deaths. Multinomial logistic regression revealed left IMA pathological changes, dyslipidemia, history of percutaneous transluminal coronary angioplasty/stent deployment and Y-graft were significant predictive risk factors negatively influencing the patients’ long-term survival. Kaplan-Meier survival analysis revealed that the long-term survival of patients with left IMA pathological changes were significantly reduced compared with those without (74.1% vs. 91.4%, P=0.002); whereas no differences were noted in long-term survivals between patients with and without pathological changes of the radial arterial or saphenous vein grafts.

Conclusion

Pathological changes may be seen in the bypass graft at the time of harvest. The subtle ultrastructural modifications and the expressions of vascular tone regulators might be responsible for late graft patency. The pathological changes of the left IMA at the time of harvest rather than those of the radial artery or saphenous vein graft affect significantly longterm survival. Non-traumatic maneuver of left IMA harvest, well-controlled dyslipidemia and avoidance of using composite grafts can be helpful in maintaining the architecture of the grafts.     

Predictors of stroke in patients undergoing cardiac surgery

Objective

To determine the risk factors related to the development of stroke in patients undergoing cardiac surgery.

Methods

A historical cohort study. We included 4626 patients aged > 18 years who underwent coronary artery bypass surgery, heart valve replacement surgery alone or heart valve surgery combined with coronary artery bypass grafting between January 1996 and December 2011. The relationship between risk predictors and stroke was assessed by logistic regression model with a significance level of 0.05.

Results

The incidence of stroke was 3% in the overall sample. After logistic regression, the following risk predictors for stroke were found: age 50-65 years (OR=2.11 - 95% CI 1.05-4.23 - P=0.036) and age >66 years (OR=3.22 - 95% CI 1.6-6.47 - P=0.001), urgent and emergency surgery (OR=2.03 - 95% CI 1.20-3.45 - P=0.008), aortic valve disease (OR=2.32 - 95% CI 1.18-4.56 - P=0.014), history of atrial fibrillation (OR=1.88 - 95% CI 1.05-3.34 - P=0.032), peripheral artery disease (OR=1.81 - 95% CI 1.13-2.92 - P=0.014), history of cerebrovascular disease (OR=3.42 - 95% CI 2.19-5.35 - P<0.001) and cardiopulmonary bypass time > 110 minutes (OR=1.71 - 95% CI 1.16-2.53 - P=0.007). Mortality was 31.9% in the stroke group and 8.5% in the control group (OR=5.06 - 95% CI 3.5-7.33 - P<0.001).

Conclusion

The study identified the following risk predictors for stroke after cardiac surgery: age, urgent and emergency surgery, aortic valve disease, history of atrial fibrillation, peripheral artery disease, history of cerebrovascular disease and cardiopulmonary bypass time > 110 minutes.     

Impact of Cardiovascular Interventions on the Quality of Life in the Elderly

INTRODUCTION

The elderly population is growing rapidly. Political and socio-economic changes led to the demographic transition in this population with the highest number of surgeries and as well as many comorbidities.

OBJECTIVE

To evaluate the impact of cardiovascular intervention on quality of life of elderly patients after three and six months.

METHODS

Analytical prospective cohort study with elderly between 60 and 80 years of age, of both sexes, with a diagnosis of coronary artery disease and underwent cardiovascular intervention during the period June 2010 to June 2011. Data were collected by individual interviews in the pre and postoperative periods (after three and six months) by telephone. We used the SF-36 to analyse quality of life in order to assess the physical and mental health of the study population.

RESULTS

Of the 44 individuals evaluated, 59.1% were men, 75% in the range of 65 to 74 years, 38.6% were white and 38.6% were black, 31.8% were uneducated, 43.2% were married and 68.2% had less than a minimum wage. Prevailed patients: non-diabetics (68.2%), non-obese (81.8%), hypertensive (84.1%), non-alcoholic and non-smokers (68.2% and 61.4%, respectively). A significant increase in the average of the SF-36 scores between pre and post-surgical periods (three and six months) for the domains: functional capacity, pain, general health, vitality and emotional aspect.

CONCLUSION

The elderly population undergoing intervention may have cardiovascular benefits and improvements of quality of life. Physical fitness improvement measures can be taken to resume that capability.     

Anatomical study of terminal peroneal artery perforators and their clinical applications

Introduction:

Peroneal artery gives off plenty of perforators that pass through fascial septum to supply skin and tenosynovium of peroneal muscles.

Aim:

The aim of this study was to study the anatomical basis of perforators from terminal part of peroneal artery axiality and to make use of this knowledge in reconstructing defects of posterior heel with the advantage of reducing the morbidity of conventional flaps.

Materials and Methods:

Our study was conducted at Department of Plastic surgery, Madras Medical College and Rajiv Gandhi Government General Hospital, India. We have carried out eleven cadaver dissections (from six cadavers-four fresh cadavers and two preserved cadavers) and delineated all septocutaneous and septosynovial perforators of distal peroneal axis and studied their relation with short saphenous vein (SSV) and sural nerve. Using this anatomical knowledge we have fashioned perforator based flaps in 13 patients (three propeller, four V-Y advancement, six tenosynovial flaps) for reconstruction of defects over tendo achilles and pericalcaneal region.

Results:

In all cases, SSV and sural nerve were preserved and donor site was closed primarily. No total flap loss was noted.

Conclusion:

Perforator based flaps from distal most part of peroneal artery provide a good and reliable method for reconstruction of pericalcaneal and tendo achilles region defects with preservation of SSV and sural nerve. It also avoids contour deformity of the grafted donor site of the classical lateral calcaneal artery axial flap.KEY WORDS: Terminal peroneal artery, lateral calcaneal artery, perforator-based flaps, peroneal tenosynovial sheath, propeller, V-Y advancement     

Atrioventricular block in coronary artery bypass surgery: perioperative predictors and impact on mortality

Introduction

Disturbances of the cardiac conduction system are frequent in the postoperative period of coronary artery bypass surgery. They are mostly reversible and associated with some injury of the conduction tissue, caused by the ischemic heart disease itself or by perioperative factors.

Objective

Primary: investigate the association between perioperative factors and the emergence of atrioventricular block in the postoperative period of coronary artery bypass surgery. Secondary: determine the need for temporary pacing and of a permanent pacemaker in the postoperative period of coronary artery bypass surgery and the impact on hospital stay and hospital mortality.

Methods

Analysis of a retrospective cohort of patients submitted to coronary artery bypass surgery from the database of the Postoperative Heart Surgery Unit of the Sao Lucas Hospital of the Pontifical Catholic University of Rio Grande do Sul, using the logistic regression method.

Results

In the period from January 1996 to December 2012, 3532 coronary artery bypass surgery were carried out. Two hundred and eighty-eight (8.15% of the total sample) patients had atrioventricular block during the postoperative period of coronary artery bypass surgery, requiring temporary pacing. Eight of those who had atrioventricular block progressed to implantation of a permanent pacemaker (0.23% of the total sample). Multivariate analysis revealed a significant association of atrioventricular block with age above 60 years (OR=2.34; CI 95% 1.75-3.12; P<0.0001), female gender (OR=1.37; CI 95% 1.06-1.77; P=0.015), chronic kidney disease (OR=2.05; CI 95% 1.49-2.81; P<0.0001), atrial fibrillation (OR=2.06; CI 95% 1.16-3.66; P=0.014), functional class III and IV of the New York Heart Association (OR=1.43; CI 95% 1.03-1.98; P=0.031), perioperative acute myocardial infarction (OR=1.70; CI 95% 1.26-2.29; P<0.0001) and with the use of the intra-aortic balloon in the postoperative period of coronary artery bypass surgery (OR=1.92; CI 95% 1.21-3.05; P=0.006). The presence of atrioventricular block resulted in a significant increase in mortality (17.9% vs. 7.3% in those who did not develop atrioventricular block) (OR=2.09; CI 95% 1.46-2.99; P<0.0001) and a longer hospital stay (12.75 days x 10.53 days for those who didn''t develop atrioventricular block) (OR=1.01; CI 95% 1.00-1.02; P=0.01).

Conclusions

In most cases, atrioventricular block in the postoperative period of coronary artery bypass surgery is transient and associated with several perioperative factors: age above 60 years, female sex, chronic kidney disease, atrial fibrillation, New York Heart Association functional class III or IV, perioperative acute myocardial infarction and use of an intra-aortic balloon. Its occurrence prolongs hospitalization and, above all, doubles the risk of mortality.     

Comparative analysis of the patency of the internal thoracic artery in the CABG of left anterior descending artery: 6-month postoperative coronary CT angiography evaluation

Objective

To assess the patency of the pedicled right internal thoracic artery with an anteroaortic course and compare it to the patency of the left internal thoracic artery , in anastomosis to the left anterior descending artery in coronary artery bypass grafting by using coronary CT angiography at 6 months postoperatively.

Methods

Between December 2008 and December 2011, 100 patients were selected to undergo a prospective coronary artery bypass grafting procedure without cardiopulmonary bypass. The patients were randomly divided by a computer-generated list into Group-1 (G-1) and Group-2 (G-2), comprising 50 patients each, the technique used was known at the beginning of the surgery. In G-1, coronary artery bypass grafting was performed using the left internal thoracic artery for the left anterior descending and the free right internal thoracic artery for the circumflex, and in G-2, coronary artery bypass grafting was performed using the right internal thoracic artery pedicled to the left anterior descending and the left internal thoracic artery pedicled to the circumflex territory.

Results

The groups were similar with regard to the preoperative clinical data. A male predominance of 75.6% and 88% was observed in G-1 and G-2, respectively. Five patients migrated from G-1 to G-2 because of atheromatous disease in the ascending aorta. The average number of distal anastomoses was 3.48 (SD=0.72) in G-1 and 3.20 (SD=0.76) in G-2. Coronary CT angiography in 96 re-evaluated patients showed that all ITAs, right or left, used in situ for the left anterior descending were patent. There were no deaths in either group.

Conclusion

Coronary artery bypass grafting surgery involving anastomosis of the anteroaortic right internal thoracic artery to the left anterior descending artery has an outcome similar to that obtained using the left internal thoracic artery for the same coronary site.     

Lower extremity free flaps: a review

Objective

To identify factors related to free-flap coverage of lower extremity fractures that are linked to a negative outcome.

Design

A chart review.

Setting

A large microsurgical referral centre.

Patients

From 1981 to 1989, the records of all patients who underwent free-tissue transfer to the lower extremity with more than 1 year of follow-up were selected. From this was drawn a subgroup of 49 patients (mean age, 36 years) who had tibial fractures (55% were motor vehicle injuries) and in almost all cases established soft-tissue or bony defects. They formed the study group.

Intervention

Free-flap transfer.

Outcome Measures

Factors that might be associated with free-flap failure: mechanism of injury, grade of tibial fracture, history of smoking, diabetes, peripheral vascular disease, ischemic heart disease, vascular compromise in the leg preoperatively, recipient artery used, type of anastomosis, and hypertension or hypotension intraoperatively.

Results

Type IIIB tibial fractures were the most frequent (67%) and carried a significantly (p = 0.02) higher risk of free-flap failure than other types of fracture. Patients underwent a mean of four procedures before referral for free-tissue transfer. The mean time from injury to flap coverage was 1006 days. Stable, long-term coverage of the free flaps was achieved in 78% of patients. Wound breakdown was most often caused by recurrent osteomyelitis (65%). Seventy-four percent of the fractures healed. The amputation rate was 10%. Four patients required repeat free-flap transfer for limb salvage.

Conclusion

Only the grade of tibial fracture could be significantly related to postoperative free-flap failure.