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Deaths Following Cardiac Surgery and Invasive Interventions
Published in Mary N. Sheppard, Practical Cardiovascular Pathology, 2022
The most common is poor cardiac function which results from embolism and/or anoxia, hypoperfusion, exacerbation of pre-existing disease, iatrogenic factors and stress. This leads to multi-organ failure with cerebral anoxia, acute renal tubular necrosis, acute pancreatitis and adrenal cortical infarction. Systemic and coronary emboli may occur. Embolized material includes thrombi, fat, bone marrow, air, calcium, atheroma, talc, silicone, platelets and other debris from the perfusion apparatus. Hypoperfusion can lead to cerebral infarction or ischaemic damage to the bowel, without thrombosis or emboli present in these organs. Prolonged bypass can lead to consumption coagulopathy and haemorrhage from cannulation sites. Saphenous vein graft failure is most common within 30 days of operation and is dependent on several factors including vein size and excessive length, distal runoff and slow flow, and hypercoagulability and thrombosis. Alternatively, arterial grafts such as the LIMA and radial arterial grafts remain patent longer and have patency rates exceeding 90% at 10 years.
Facilitated coronary interventions: Adjuncts to balloon dilatation
Published in John Edward Boland, David W. M. Muller, Interventional Cardiology and Cardiac Catheterisation, 2019
Several passive filters have been designed as alternatives to the balloon occlusion systems.57–59 They have the apparent advantages of allowing perfusion during distal protection, and perhaps, of limiting arterial trauma during the time the device is in position. Each system consists of a retractable membrane that has a series of 50, 100, or 200 µm diameter holes. Atheromatous debris has been retrieved from coronary, renal and carotid arteries and from saphenous vein grafts during a variety of interventions. It has become clear that even routine, apparently uncomplicated coronary balloon angioplasty procedures can lead to embolisation of atheromatous debris. Whether this results in myocardial injury and an adverse long-term outcome remains controversial.52 Although current guidelines give a class 1 recommendation (level of evidence B) to the use of embolic protection devices in saphenous vein graft interventions, recent data have been somewhat conflicting with some studies suggesting a benefit to distal protection,60 and others suggesting no benefit.61,62 A recent meta-analysis of distal protection in the setting of acute myocardial infarction also showed that although TIMI 3 flow and myocardial blush scores were better in the distal protection group, no significant difference was apparent in major adverse events.63
Metastatic Neck Disease
Published in John C Watkinson, Raymond W Clarke, Terry M Jones, Vinidh Paleri, Nicholas White, Tim Woolford, Head & Neck Surgery Plastic Surgery, 2018
The plan to resect the carotid should always be a pre-operative decision and almost never should a situation arise where this is contemplated for the first time peri-operatively. Pre-operative work up is essential to plan the resection. Balloon occlusion of the artery with single photon emission computer tomography (SPECT) is performed to prognosticate the possibility of neurological deficit following resection. If the test shows adequate cross-flow and does not cause symptoms, there is a lesser need to shunt the artery during resection. If the cross-flow is inadequate, the internal carotid artery should be shunted for the duration of the resection. In all cases, we recommend reconstruction of the artery using an appropriate graft to reduce chances of neurological complications. Most studies report using the saphenous vein graft (Figure 18.9). Intra-operative ligation without reconstruction is fraught with a high risk of complications owing to the haemodynamic instability that can occur. This is likely even in those patients who demonstrate good cross-flow and a stump pressure of more than 70 mmHg.
Device profile of the VEST for external support of SVG Coronary artery bypass grafting: historical development, current status, and future directions
Published in Expert Review of Medical Devices, 2021
Three clinical trials investigated the use of the eSVS mesh. Schoettler et al. randomized left circumflex versus right coronary stenting in 25 patients undergoing coronary bypass surgery [35]. At 9 months postoperatively the patency rate of mesh-supported grafts was 27.8% while that of unsupported vein grafts was 85.7%. Genoni and coworkers examined the use of the eSVS mesh in right-sided coronary grafts in 20 patients undergoing off pump CABG [36]. In this study, intraoperative transit time flow measurements and computed tomographic angiography at 5 days were performed to assess early patency. A total of 22 venous grafts were performed; overall patency was 95% and thus, eSVS application did not compromise early saphenous vein graft patency. In the largest cohort studied, Emery and colleagues conducted a multicenter trial in 90 patients whereby a mesh-supported saphenous vein graft was randomized to either the right or the circumflex circulation and an unsupported graft was used to the opposite territory [37]. The primary endpoint included angiographic patency at the 9–12 month postoperative window. Seventy-three (82%) of patients returned for angiography; overall patency was 49% for the treated vessels versus 81% for unstented grafts.
Blunt injury of popliteal artery
Published in Acta Chirurgica Belgica, 2019
Jui-Tsung Chang, Chih-Yuan Lin, Yi-Ting Tsai, Yi-Chang Lin
An 18-year-old teenager was immediately brought to the emergency department after falling from a motorcycle. Upon arrival, the patient was alert in consciousness and complained about right knee pain and leg numbness. On physical examination, there was ecchymosis on the right popliteal region (Figure 1) and the range of motion in right knee was normal. The pulsation of right dorsalis pedis artery was weak but no neurological deficit of both legs was found. The computerized tomographic angiography of lower limbs disclosed total occlusion of the right popliteal artery with patent collateral perfusion and distal runoff in right lower leg (Figure 2). Emergent vascular exploration showed one segmental arterial transection with an intramural hematoma (Figure 3). Then, the patient underwent reconstruction with great saphenous vein graft and experienced reperfusion injury after the operation.
The predictive role of modified TIMI risk index in patients with ST-segment elevation myocardial infarction
Published in Acta Cardiologica, 2019
Adnan Kaya, Muhammed Keskin, Tolga Sinan Güvenç, Mustafa Adem Tatlısu, Osman Kayapınar
The main findings of this study can be summarised as: i) There is a gradual increase in both in-hospital and long-term mortality with increasing mTRI categories. ii) Patients with a mTRI more than 60 have a high risk for mortality despite revascularisation and should be followed-up closely. iii) Patients with a higher mTRI had similar revascularisation rates with those with lower mTRI groups, but stent implantation rate is significantly lower in this group. A higher incidence of saphenous vein graft occlusion and presence of 3-vessels disease deserving surgical revascularisation might have led to this situation. iv) Discriminative capacity of mTRI was moderate to good for both in-hospital and long-term mortality, and across all the subgroups except patients aged less than 65 years. v) Discriminative capacity of mTRI is higher than TRI for both in-hospital mortality and long-term mortality, with the discriminative capacity of the latter is poor for the majority of subgroups analysed.