A newly-approved carotid patch, derived from porcine small intestinal submucosa (SIS), is thought to allow functional tissue regeneration by acting as a biologic scaffold of extracellular matrix. We report three cases of asymptomatic pseudoaneurysm after SIS patch closure. At exploration there were intact suture lines, no growth from cultures, and central patch herniation. Histopathologic examination showed postendarterectomy neointima in the artery and disorganized collagen in the pseudoaneurysm. SIS patch remnants adjacent to macrophage infiltration and neovascularization indicated ongoing processes of degradation and synthesis. Imbalances between degradation and host tissue synthesis are problems that may unpredictably affect SIS patch integrity.

A 41 year old white female presented with upper respiratory distress and shortness of breath appeared on initial computed tomography (CT) scan to have a large left retroperitoneal mass with left renal vein extension including a mass up to the level of the atrium. This presentation suggested hypernephroma. She proved, however, to have an adrenal cortical carcinoma which displaced the kidney, exhibiting vascular invasion within the gland and non-adherent extension into the vena cava, atrium, common hepatic vein and left renal vein, where some adherence was present. This unusual tumor required extensive surgery for removal, including use of cardiopulmonary bypass, with good results.

A 34-year-old woman was referred for evaluation of a chest roentgenogram abnormality. The patient, a nonsmoker, was immunocompetent with no risk behavior for HIV. She reported a sudden cough that developed, followed by pain in her left anterior chest radiating to the shoulder. The cough was accompanied by subsequent development of bloody mucus. Her symptoms persisted for 1 week with no prior history of similar episodes.On physical examination, diminished breath sounds were auscultated over the left chest. Chest roentgenogram (Fig 1) demonstrated a large left upper lobe opacification with posterior displacement of the major fissure. Subsequent workup included computed tomographic imaging of the thorax (Fig 2) and a bronchoscopy, which did not provide the diagnosis. Due to the large size of the mass, a tissue biopsy was not pursued because it would not impact the plan for thoracotomy and resection.Fig 2View Large Image Figure ViewerDownload (PPT)The patient underwent a left thoracotomy, revealing a large, solid mass filling the hemithorax from hilum to apex. An intraoperative frozen section evaluation of the specimen suggested lymphoma. A pneumonectomy was performed. Several factors were judged to prohibit completion of a lesser operation (lobectomy and wedge resection). Calcific granulomatous disease involved the hilum and fissure, causing fusion of the two lobes. In addition, the primary lesion was considerable in size and was accompanied by a satellite nodule. In fact, resection of portions of the pericardium and left phrenic nerve were required in conjunction with resection of the specimen. Individual nodes from the inferior pulmonary ligament, aortico-pulmonary window, and paratracheal region were sampled.Pathologic evaluation of the specimen revealed it to be a large cell malignant lymphoma (B-cell, immunoblastic type), 14 cm in size (Fig 3; hematoxylin & eosin; 40×). A negative bronchial margin was confirmed. Calcification seen on the roentgenogram was found to represent an old histoplasma granuloma within an inferior hilar node. Remaining nodes showed mild lymphadenitis, but no evidence of malignancy. The tumor was determined to be stage IV by the Ann Arbor classification system.Fig 3View Large Image Figure ViewerDownload (PPT)The patient successfully completed eight cycles of “CHOP” (cyclophosphamide, doxorubicin, vincristine, and prednisone) chemotherapy and is in complete remission 5 years after the surgery. A 34-year-old woman was referred for evaluation of a chest roentgenogram abnormality. The patient, a nonsmoker, was immunocompetent with no risk behavior for HIV. She reported a sudden cough that developed, followed by pain in her left anterior chest radiating to the shoulder. The cough was accompanied by subsequent development of bloody mucus. Her symptoms persisted for 1 week with no prior history of similar episodes. On physical examination, diminished breath sounds were auscultated over the left chest. Chest roentgenogram (Fig 1) demonstrated a large left upper lobe opacification with posterior displacement of the major fissure. Subsequent workup included computed tomographic imaging of the thorax (Fig 2) and a bronchoscopy, which did not provide the diagnosis. Due to the large size of the mass, a tissue biopsy was not pursued because it would not impact the plan for thoracotomy and resection. The patient underwent a left thoracotomy, revealing a large, solid mass filling the hemithorax from hilum to apex. An intraoperative frozen section evaluation of the specimen suggested lymphoma. A pneumonectomy was performed. Several factors were judged to prohibit completion of a lesser operation (lobectomy and wedge resection). Calcific granulomatous disease involved the hilum and fissure, causing fusion of the two lobes. In addition, the primary lesion was considerable in size and was accompanied by a satellite nodule. In fact, resection of portions of the pericardium and left phrenic nerve were required in conjunction with resection of the specimen. Individual nodes from the inferior pulmonary ligament, aortico-pulmonary window, and paratracheal region were sampled. Pathologic evaluation of the specimen revealed it to be a large cell malignant lymphoma (B-cell, immunoblastic type), 14 cm in size (Fig 3; hematoxylin & eosin; 40×). A negative bronchial margin was confirmed. Calcification seen on the roentgenogram was found to represent an old histoplasma granuloma within an inferior hilar node. Remaining nodes showed mild lymphadenitis, but no evidence of malignancy. The tumor was determined to be stage IV by the Ann Arbor classification system. The patient successfully completed eight cycles of “CHOP” (cyclophosphamide, doxorubicin, vincristine, and prednisone) chemotherapy and is in complete remission 5 years after the surgery. Assistance in preparation of this article was provided by Michelle C. Zeiser, AA.

Aim of the study was to to demonstrate a useful solution to carotid angioplasty and stent complications. A 67 year old male had uncomplicated left carotid endarterectomies in 1985 and 1986. A left distal common carotid angioplasty and stent in 1999 was complicated by stenosis. In 2000 a left common carotid bypass from the lower common carotid to the distal internal carotid well above the stent was performed, yielding retrograde filling of the external carotid, distal antegrade filling of the internal carotid, and widely patent vessels in subsequent Doppler studies. He is currently doing well clinically with no recurrent stenosis. In conclusion a second redo carotid operation was deferred in favor of angioplasty and stent, which had complications. Despite prior operations the only difficulty with the reoperation was obtaining control of the distal internal carotid above the stent. The strategy demonstrated here will be useful to correct complications of carotid angioplasty and stenting.

AIM:To evaluate the prophylactic effect of diltiazem on the incidence of atrial arrhythmia (fibrillation and/or flutter) following coronary artery bypass grafting (CABG). Data were retrospectively gathered.METHODS:Patients undergoing elective CABG by one surgeon at one institution over a three-year period were considered for inclusion. Those selected were divided into 3 groups: A (patients placed on intravenous diltiazem intraoperatively, then converted to oral diltiazem upon initiation of oral intake); B (patients started on oral diltiazem upon initiation of oral intake without prior intravenous diltiazem); and C (patients receiving no diltiazem). A comparison of postoperative rates of atrial fibrillation was made between the 3 (demographically balanced) groups using logistic regression.RESULTS:Two hundred and eighty seven patients met inclusion criteria. The incidence of postoperative atrial fibrillation in the entire sample was 19.9% (57/287). Incidence of postoperative atrial fibrillation within each group was: A = 16.3% (22/135); B = 12.7% (7/55); C = 28.9% (28/97). Statistical significance was demonstrated for the following comparisons: A versus C (p = 0.0451) and B versus C (p = 0.0065). In an alternate model groups A and B were combined and compared to C (p = 0.0181).CONCLUSIONS:A lower incidence of atrial fibrillation following CABG was observed in patients treated prophylactically with diltiazem. Differences were statistically significant whether the drug was administered intravenously and orally (A) or only orally (B). Diltiazem, which has an established role in the management of atrial fibrillation, may prove to be well suited for prophylaxis due to low cost and relative safety.

Background: Improvements in replacement vessel harvesting techniques and antispasmodic agents since the 1970s have led to a resurgence of interest in the radial artery (RA) as a conduit for coronary revascularization.Methods: This randomized study compared the Ultra Cision Harmonic Scalpel(R) (HS) (Ethicon Endo-Surgery, Inc., Cincinnati, OH) and the cold steel scalpel (CSS) for harvesting radial arteries to be used in coronary artery bypass grafting (CABG) procedures. Men and non-pregnant women, aged 21 to 79 years, with myocardial ischemia or coronary stenosis who were scheduled to undergo coronary bypass were enrolled in the study.Results: Harvesting of the radial artery by the Harmonic Scalpel required a significantly lower number of clips to control bleeding. There was no significant difference between the times required to harvest the artery with either device. There were no complications, malfunctions, or serious adverse events associated with the use of either device.Conclusions: The Harmonic Scalpel provides excellent control of bleeding compared to the cold steel scalpel, and its use permits bleeding to be controlled without the need for potentially damaging electrocautery. No clinically significant adverse events were associated with the use of die Harmonic Scalpel.

This study was designed to determine the prevalence of Chlamydia pneumoniae in carotid artery plaques. Although there have been numerous studies evaluating coronary plaques for this bacterium fewer studies have assessed noncoronary vasculature. In addition we wished to evaluate whether correlation exists between the presence of C, pneumoniae in carotid plaques and established risk factors for atherosclerosis. Sixty intact carotid artery plaques removed during surgery (carotid endarterectomy) were formalin-fixed and paraffin-embedded according to conventional techniques. These samples were evaluated by polymerase chain reaction analysis to detect presence of C. pneumoniae DNA, Results were tabulated and compared against established risk factors for atherosclerosis: diabetes, hypertension, hyperlipidemia, age, and smoking. Forty-two (70.0%) of the 60 plaques that were evaluated tested positive for the presence of C. pneumoniae DNA by polymerase chain reaction analysis. In the sample defined as being from heavy smokers (greater than 15-pack-year history) 33 (94.3%) of 35 plaques tested positive whereas two (5.7%) tested negative. This correlation demonstrated statistical significance (P = 1.36 x 10(-6), two-tailed Fisher exact test). Presence of C. pneumoniae in carotid plaques demonstrated no statistically significant correlation with diabetes, hypertension, or hyperlipidemia. Age as a risk factor was examined but not statistically evaluated because of the narrow range within our patient sample. Analysis of the data reveals that C. pneumoniae is present in large numbers of atheromatous plaques as is consistent with emerging data. What is interesting though is that 33 (94.3%) of the 35 smokers had plaques that tested positive for the bacterium as opposed to only nine (36.0%) of the 25 nonsmokers. Identification of specific populations exhibiting a high prevalence of C. pneumoniae may serve to focus future studies. Ongoing investigation will seek to determine whether C. pneumoniae plays an active role in the pathogenesis of atherosclerosis.

BACKGROUND:The efficacy of carotid endarterectomy in patients with asymptomatic carotid stenosis has not been confirmed in randomized clinical trials, despite the widespread use of operative intervention in such patients.METHODS:We conducted a multicenter clinical trial at 11 Veterans Affairs medical centers to determine the effect of carotid endarterectomy on the combined incidence of transient ischemic attack, transient monocular blindness, and stroke. We studied 444 men with asymptomatic carotid stenosis shown arteriographically to reduce the diameter of the arterial lumen by 50 percent or more. The patients were randomly assigned to optimal medical treatment including antiplatelet medication (aspirin) plus carotid endarterectomy (the surgical group; 211 patients) or optimal medical treatment alone (the medical group; 233 patients). All the patients at each center were followed independently by a vascular surgeon and a neurologist for a mean of 47.9 months.RESULTS:The combined incidence of ipsilateral neurologic events was 8.0 percent in the surgical group and 20.6 percent in the medical group (P < 0.001), giving a relative risk (for the surgical group vs. the medical group) of 0.38 (95 percent confidence interval, 0.22 to 0.67). The incidence of ipsilateral stroke alone was 4.7 percent in the surgical group and 9.4 percent in the medical group. An analysis of stroke and death combined within the first 30 postoperative days showed no significant differences. Nor were there significant differences between groups in an analysis of all strokes and deaths (surgical, 41.2 percent; medical, 44.2 percent; relative risk, 0.92; 95 percent confidence interval, 0.69 to 1.22). Overall mortality, including postoperative deaths, was primarily due to coronary atherosclerosis.CONCLUSIONS:Carotid endarterectomy reduced the overall incidence of ipsilateral neurologic events in a selected group of male patients with asymptomatic carotid stenosis. We did not find a significant influence of carotid endarterectomy on the combined incidence of stroke and death, but because of the size of our sample, a modest effect could not be excluded.

To assess the safety and efficacy of concomitant pulmonary resection and cardiac operation requiring cardiopulmonary bypass, the records of 19 patients were reviewed. Eighteen patients (94.7%) presented with cardiac symptoms and were found to have pulmonary pathology of indeterminate etiology. Pulmonary resections were performed through a median sternotomy in all but 1 patient, who underwent posterolateral thoracotomy and right middle lobectomy after repositioning because dense adhesions prevented adequate dissection through the initial incision. A total of 24 resections were performed. Sixteen (66.7%) were performed on cardiopulmonary bypass. Six wedge resections (25.0%) were performed before bypass. Two lobectomies (8.3%) were performed after infusion of protamine sulfate. Nine patients (47.4%) had benign pathology, 7 (36.8%) had primary carcinoma, and 3 (15.8%) had metastatic disease. Bleeding complications occurred in 15.8% of patients (3/19). There was 1 perioperative death (5.3%), which was due to adult respiratory distress syndrome after intraoperative hemorrhage followed lobectomy for bullous disease. Another patient required lateral extension of the sternotomy during an episode of exsanguinating intraparenchymal pulmonary hemorrhage, which resulted in lobectomy, as well as costochondral and sternal osteomyelitis. A third patient required exploration for bleeding at the staple line. Postoperative complications occurred in 7 patients (36.8%) and were predominantly respiratory (5/7, 71.4%) (p = 0.006). The median postoperative hospitalization was 15 days. Although comparison of patients who underwent pulmonary resection during bypass with those who had resection either before heparinization or after protamine infusion showed no significant difference with respect to age, incidence of malignancy, operation performed, complications, postoperative hospitalization, or survival, this was probably due to the small number of patients in the study. Survival correlated only with the diagnosis of malignancy (p = 0.042). Pulmonary resection performed on cardiopulmonary bypass leads to excessive bleeding and pulmonary complications and perhaps to excessive hospitalization. If concomitant correction of both cardiac and pulmonary conditions must be performed, pulmonary resection should be accomplished after reversal of anticoagulation to prevent excessive bleeding.

The impact of newer and more expensive technologies upon the cost of cardiac surgery is a growing concern. It has been suggested that membrane oxygenators of a variety of types have differenct characteristics which may affect patient outcome and the postoperative course and thus the cost of care. Three hundred and sixteen patients were prospectively randomized to one of three membrane oxygenators (MO) to examine the impact upon postoperative care charges. There were no differences between groups in a variety of preoperative variables. There was a trend (not statistically significant) toward lower ventilator time, respiratory care related charges and intensive care unit stay and thus total postoperative care charges associated with the sue of rolled silicone sheet MO compared with microporous polypropylene hollow fiber or microporous polypropylene folded sheet MO. Design-related advantages and disadvantages were noted by perfusionists depending upon the type of surgical procedure performed. Studies examining the impact of high cost technology upon patient care will be required as concerns about the overall cost of medical care grow.

Increasing numbers of interventional radiologic procedures, often with large arterial catheters, have led to increasing total numbers of complications. Pseudoaneurysm is not an infrequent complication. It is often difficult to differentiate pseudoaneurysm clinically from hematoma. In the past, we have used gray scale duplex scanning to aid in this differentiation. We have recently found color Doppler scanning to allow quicker, easier, and more accurate diagnosis. Color Doppler imaging also can often demonstrate the track between the artery and the aneurysm.

Two hundred twenty-one consecutive adult cardiac surgical patients were examined prospectively for nutritional protein state, acute phase protein response, and delayed hypersensitivity reaction in an attempt to identify patients at high risk for the development of sternal wound infection, which occurred in 6 patients (2.7%). There was no significant correlation between preoperative nutritional protein concentrations (retinol-binding protein, prealbumin, and transferrin) and acute phase protein levels (C-reactive protein, alpha 1-acid glycoprotein, and complements B and C3), nor a statistically significant relationship between nutritional state or acute phase protein response and the development of sternal infection. Preoperative complement C3 levels were elevated, however, in 80.0% of those in whom sternal infections developed compared with 30.6% of those with well-healed wounds. Similarly, postoperative concentrations of alpha 1-acid glycoprotein were elevated in 80.0% of those in whom sternal infections developed compared with 28.6% of those with well-healed wounds. There was no correlation between delayed hypersensitivity and the risk of sternal infection, nor between preoperative nutritional protein and acute phase protein values. Seventy-three percent of patients were anergic on postoperative day 2. Stepwise logistic regression showed that age, body weight, preoperative intensive care unit stay, repeat median sternotomy, internal mammary artery grafting, postoperative hemorrhage, and postoperative cardiac arrest correlated with the development of sternal infection, whereas transfusion requirement, reexploration for bleeding, and the operation performed did not. We conclude that routine delayed hypersensitivity testing is of no value in predicting high-risk cardiac surgical patients when the anergy battery is placed on the preoperative day. Although statistically insignificant, possibly due to the small number of patients in whom sternal infection developed in this study (type II error), a larger study might find preoperative complement C3 and post-operative alpha 1-acid glycoprotein levels to be predictive of patients at risk for the development of sternal wound infection. The final logistic model for the predicted risk 2%) of sternal wound infection is: PREDSWC = exp(EQ)/1 + exp(EQ) where EQ = (0.38 x age) + (0.24 x weight) + (5.42 x preop ICU) + (4.39 x redo) + (7.14 x IMA) + (4.49 x hemorrhage) + (8.81 x arrest) - 62.72, and where preop ICU, redo, hemorrhage, and arrest are defined as yes (1) or no (0), IMA-is defined as 0, 1, or 2, age is in years, and weight is in kilograms.

Sclerosing mediastinitis is an uncommon disease associated with a multiplicity of clinical syndromes. The cause of this disorder is probably an abnormal fibroproliferative response to an inflammatory stimulus, most commonly a granulomatous infection secondary to Histoplasma capsulatum. The pathophysiology of this disease is predicated on the encasement of mediastinal vital organ structures within a dense fibrotic mass. This mass appears to emanate from an invasive chronic inflammatory process causing erosion as well as external compression of these structures. The following case reports illustrate the diversity of this disease entity, representing a patient population from the Ohio River Valley, endemic for histoplasmosis. The purpose of this report is to elucidate the various clinical manifestations of sclerosing mediastinitis and to correlate the pathologic process with a rational approach to treatment.