Hypertension and tachyarrhythmias arising during an operative procedure are rarely caused by an unsuspected pheochromocytoma. However, when this tumor becomes clinically manifest under general anesthesia during a procedure for an unrelated condition, the mortality is high. An unusual case of a patient who developed episodes of catastrophic hypertension and tachyarrhythmias while undergoing a coronary artery bypass procedure is described. The subject of undiagnosed pheochromocytoma becoming clinically manifest under general anesthesia is discussed with a pertinent review of the literature.

This paper presents an unusual case of an individual with myocardial ischemia, angina pectoris, and myocardial infarction who also had an anaphylactic reaction to angiographic dye. The coronary bypass operation was guided by the use of intraoperative coronary reactive hyperemia assessed by Doppler ultrasound. The patient has had a good response to the operation without additional angina or difficulties.

From November, 1980, to May 1985, 699 patients have undergone percutaneous transluminal coronary angioplasty of 784 lesions at our institutions. Simultaneous surgical standby was available on all cases. One hundred twenty-four patients (18%) underwent immediate myocardial revascularization; 45 (6%) were operated on because the lesion could not be dilated. Seventy-nine patients (11%) underwent immediate operation for an acute complication of angioplasty: coronary occlusion in 45, dissection in 29, coronary perforation in three, and atrial perforation in one. Fourteen patients (18%) required cardiopulmonary resuscitation en route to the operating room, and 10 patients (20%) had insertion of an intra-aortic balloon pump in the cardiac catheterization laboratory. The average time from complication to reperfusion was 87 minutes, ranging from 40 to 165 minutes. An average of 2.0 grafts per patient (ranging from one to five grafts per patient) were performed. Of those 79 patients who underwent operation for an acute complication, one died (1.3%), 31 patients (39%) had a myocardial infarction according to enzyme criteria (creatine kinase-myocardial band greater than 40 IU), and 17 patients (22%) had new Q waves on the electrocardiogram. Good results are related to minimizing the time the myocardium is ischemic. No patient in whom reperfusion was begun in less than 75 minutes had a Q wave infarction or a creatine kinase-myocardial band level greater than 40 IU. Simultaneous surgical standby is the only method allowing immediate access to surgical facilities. A standby team of eight persons and equipment were immediately available for emergency bypass grafting for an average of 3.6 hours (range 1.3 to 5.4 hours per angioplasty attempt). The patient charges for this simultaneous standby were $632.00 per angioplasty attempt, or $442,278.00 for the entire series. The actual cost of the standby was over $1,700.00 per attempt totaling $1,188,843.00 for the 699 patients. This underestimation of the cost of surgical standby has occurred in other series, because little mention has been made of this cost in the published reports on the cost effectiveness of angioplasty. In terms of time demands, over 2,500 hours were spent by surgeons standing by for the 699 attempts. Simultaneous surgical standby is the most effective means of limiting the time the myocardium is ischemic after an angioplasty complication. However, this method is costly, necessitating more of a financial and time commitment than generally anticipated. Future studies of the cost effectiveness of angioplasty should include the cost of surgical standby with accurate per-patient cost accountability.

Eleven patients with left atrial myxoma in a ten-year period were reviewed. They ranged from 16 to 69 years old. Eight patients were female. All tumors were located in the left atrium; one patient had multiple tumors. The main clinical presentation was congestive heart failure seen in eight patients. Ten patients had a correct pre-operative diagnosis. Echocardiography confirmed the diagnosis in seven patients, angiocardiography in two and cardiac catheterization in one. All tumors were successfully removed with the aid of cardiopulmonary bypass and using a right atriotomy and trans-septal approach. Two patients underwent concomitant saphenous vein aortocoronary bypass. There were no operative deaths. Excision of the tumor resulted in marked symptomatic improvement. There have been no recurrences. A review of the pertinent literature is presented.

ARTERIOVENOUS (A-V) FISTULAS between the renal artery and vein are being recognized with increasing frequency. The increased use of diagnostic percutaneous renal biopsy and use of diagnostic arteriography coupled with high urban violence rates are the primary responsible factors. The first intrarenal fistula was reported by Vorela’ in 1928. The earliest symptomatic cases were treated by nephrectomy. Advances in vascular surg+al techniques and interventional radiology have altered the management of such fistulas. The aim of current therapy is to preserve most or all of the functioning kidney on the involved side. Our recent experience in dealing with a patient with a large renal A-V fistula, causing progressive congestive heart failure and angina pectoris, prompted a review of the etiology, diagnosis, and management of this disease.

This is a case report of management of a delayed mycotic superior mesenteric artery aneurysm occurring in a patient 2 years after aortic valve replacement for endocarditis. A chronic ulcer history, anticoagulation therapy, episodic gastrointestinal bleeding associated with negative gastrointestinal series, and gastritis seen at endoscopy delayed the ultimate diagnosis. An episode of massive hemorrhage precipitated angiography with subsequent surgical confirmation of the diagnosis. Management included debridement and extirpation of the major part of the aneurysm, Doppler assessment of the inadequacy of collateral mesenteric arterial blood flow, and restoration of flow with a bypassing saphenous vein graft segment. Although this technique of reconstruction has been suggested, we can find no other report of such a similar case among the few reported surgical successes with superior mesenteric artery mycotic aneurysm.

Coronary reserve in patients with supravalvular aortic stenosis may be limited by coronary artery ostial obstruction or left ventricular hypertrophy. To assess the relative effect of these two factors on coronary reserve, seven patients with supravalvular aortic stenosis were studied intraoperatively before and after repair. Six patients who underwent elective cardiac surgery for conditions that did not involve the left ventricle or the left anterior ascending coronary artery served as controls (control group 1). Four patients were studied before and after cardiopulmonary bypass to determine if cardiopulmonary bypass altered coronary reserve in normal vessels perfusing normal ventricle (control group 2). Using a pulsed Doppler probe to determine coronary velocity, coronary reactive hyperemia was induced in the left anterior descending coronary artery (patients with supravalvular aortic stenosis and group 1 controls) or right ventricular branches of the right coronary artery (group 2 controls) during maximal coronary dilation produced by a 20-second coronary occlusion. All patients with supravalvular aortic stenosis underwent patch aortoplasty to relieve left coronary artery ostial obstruction and outflow tract obstruction; three patients also underwent aortic valvotomy and one patient also underwent valve replacement. Coronary reactive hyperemia was calculated as the ratio of peak to resting velocity. This ratio was 5.0 +/- 0.6 (mean +/- SEM) preoperatively and 3.6 +/- 0.3 postoperatively in control group 2. Thus, coronary reserve was only modestly reduced after cardiopulmonary bypass. Before repair, the ratio of peak to resting velocity was markedly reduced in patients with supravalvular aortic stenosis compared with control group 1 (1.8 +/- 0.3 vs 4.9 +/- 0.5, p less than 0.05) and did not change after repair (1.7 +/- 0.2), even though the aortic gradient was reduced (80 +/- 14 vs 38 +/- 6 mm Hg, p less than 0.05) and real or potential coronary ostial obstruction was eliminated by the operation. Because coronary reserve did not improve after surgery in patients with supravalvular aortic stenosis, we conclude that left ventricular hypertrophy is probably the primary determinant of decreased coronary reserve in these patients.

One hundred seventy-five patients underwent elective aortofemoral bypass during the years from 1976 to 1979. One hundred eighteen of these patients received a knitted double velour prosthesis (Microvel) and the remainder received standard knitted Dacron. All patients had been followed for a minimum of 12 months. Early graft thrombosis occurred in three limbs, and these were restored by reoperation for 100 per cent patency at discharge from the hospital. The operative mortality was three patients (1.7%). Complications included myocardial infarction (three/one death), renal failure (one/one death), respiratory failure (one/one death), cerebrovascular accident (four), and superficial wound infection (five). Late complications were infrequent, but included seven graft limb occlusions in six patients (3.4%), and one graft infection, one ureteral obstruction, and one false aneurysm. Among the 256 symptomatic extremities, claudication was completely relieved in 199 (78%) and substantially improved in an additional 48 (18.5%). Hemodynamic assessment with arm/ankle or arm/high thigh indices improved in parallel with symptomatic relief. Thus, only nine (3.5%) symptomatic extremities failed to improve with the proximal reconstruction, requiring distal reconstruction or amputation. The authors remain advocates of aortofemoral grafting with end-to-end proximal anastomosis and hooding of the distal anastomosis over the profunda origin for most aortoiliac occlusive diseases. Our recent experience with double velour graft and this technique have been very satisfactory.

We tested double-velour Dacron, expanded polytetrafluoroethylene, gluteraldehyde-preserved human umbilical vein, and spiral composite autogenous vein against the standard of autogenous vein as segmental replacements in canine femoral veins. Technical adequacy of venous anastomoses was assessed by immediate postoperative venography. Continuous patency was assessed by venography at 3, 7, 21, and 42 days. None of the synthetic or other tissue grafts were comparable to autogenous vein in terms of early and continuous patency. Spiral vein composites had significantly better continuous patency when compared to synthetic or preserved tissue grafts. Recanalization was seen with both spiral composite autogenous vein and double-velour Dacron, but was not observed with expanded polytetrafluoroethylene or preserved umbilical vein. We conclude that: (1) these newer synthetic and preserved tissue grafts are unsatisfactory for use in the venous system, particularly in low-flow, small diameter sites and (2) spiral composites offer a simple method of constructing vein grafts of any chosen diameter which can be successful in even low-velocity flow, small diameter sites particularly when appropriately sized unmodified autogenous vein is not available.

The effects of femoral artery infusion of saline or prostaglandin E1 (PGE1) on femoral artery flow, mean arterial pressure, peripheral venous pressure, femoral bed vascular resistance, venous capacitance, and capillary filtration during femoral vein occlusion (FVO) were determined in the dog. FVO during femoral artery infusion of saline decreased femoral artery flow and concomitantly increased peripheral venous pressure, femoral bed vascular resistance, and capillary filtration. Intraarterial infusion of PGE1 (3.8–5.6 ng/kg/min) during FVO attenuated the decrease in femoral artery flow and increase in femoral bed vascular resistance. The administration of PGE1 augmented the increases in peripheral venous pressure and capillary filtration associated with FVO. Hindlimb venous capacitance was also increased by the intraarterial administration of PGE1 during FVO. These results suggest that PGE1 may be a useful agent in diminishing limb ischemia associated with major venous hypertension.

The cerebrovascular Doppler examination (CDE) and oculopneumoplethysmography (OPG-Gee) were compared in a single population group with no statistically significant difference found between the 2 studies. There appeared to be an advantage to combinant testing, for when the results of the 2 studies were concordant there was an accuracy of 94% and a false negative rate of 8%. Clinical correlation was available in 96% of the patients, providing adequate evidence to support the adjuvant role of non-invasive screening in the evaluation of symptomatic individuals. The percentage of false negative studies and the incidence of ulcerative disease make a diagnostic role impractical at present. For the asymptomatic individual, the diagnostic role of non-invasive screening seems justified. The false negative studies in the present series were confined to those vessels with 50-70% stenoses, which are difficult to assess angiographically and may be better characterized by hemodynamic evaluations.

Injuries to major vessels during combat have been associated with high mortality and morbidity, despite optimal triage and management. Eighty-two vena caval injuries from the Vietnam Vascular Registry (VVR) series have been studied. The nature of the wounding agents, location of wounds, and associated injuries have been documented and are contrasted with those of recent civilian series. Seventy-eight abdominal vena caval injuries were associated with mortality in 18 (23%), in whom 56 underwent repair of the injury and 15 had ligation of the inferior vena cava. This is the largest series reported of war-related vena caval injuries, and therapeutic alternatives and general recommendations derived from this review are presented.

Previous reports of continuous-wave Doppler imaging have combined that technique with periorbital Doppler studies. In the present report, 75 patients with findings suggestive of cerebrovascular insufficiency were evaluated using continuous-wave Doppler imaging, oculopneumoplethysmography (OPG-G) and the cerebrovascular Doppler examination (CDE). Each test was interpreted independently. Doppler imaging had an overall accuracy of 85%, with a 68% accuracy in identifying 50-70% stenoses and a 69% accuracy in identifying high-grade stenoses (greater than 70%) and occlusion. OPG-G had an overall accuracy of 85%, with a 55% sensitivity for 50-70% stenoses and an 89% sensitivity for high-grade stenoses and occlusion. The CDE had an overall accuracy of 84% and a 50% sensitivity for stenoses of 50-70% and an 88% sensitivity for high-grade stenoses and occlusion. As an independent technique, continuous-wave Doppler imaging achieves an overall accuracy comparable to that of OPG-G or the CDE. Its sensitivity to high-grade stenosis and occlusion, however, is less than that of the other techniques. Since CDE and OPG-G had a 94% sensitivity to carotid occlusion and a combined sensitivity to high-grade stenoses and occlusion of 88% and 89%, respectively, their combined use with Doppler imaging offers sensitivity to and differentiation of stenoses from occlusion.

There noninvasive techniques used in the evaluation of carotid occlusive disease were compared in the same population group. The cerebrovascular Doppler examination (CDE) had an accuracy rate of 89%, oculopneumoplethysmography (OPG-Gee) an accuracy rate of 94%, and supraorbital photoplethysmography (SOPPG) an accuracy rate of 86%. With the combined use of the CDE and the OPG-Gee, the accuracy rate increased to 96% when the results were concordant, and the false-negative rate dropped to 3%. The data would suggest that the combined use of the CDE and the OPG-Gee offers an advantage over either technique used individually.

The early (30-day) dislodgment rate of standard-use flange-tipped and of tined endocardial electrodes was compared in a randomized prospective clinical trial. Four of 16 (25%) of the flange-tipped leads and none of the 18 tined leads dislodged within 30 days of implantation (p = 0.01). We believe that the tined electrode represents a major improvement in electrode design and is clearly superior to the flange-tipped electrode in reducing the incidence of early dislodgment.