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SURGICAL TECHNOLOGY INTERNATIONAL II.
$245.00 - Online Edition
Surgical Technology International II contains 66 peer-reviewed articles featuring the latest advances in surgical techniques and technologies.
1993 - ISBN: 0-9638866-0-6
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Cardiovascular Surgery
Current Use of Substitute Heart Valves
Denton A. Cooley, MD, Houston, Texas
Although repair of diseased heart valves became possible in the 1940s, replacement of such valves had to await the development and refinement of the heart-lung machine, as well as the advent of serviceable valve substitutes. Early investigators were hindered by the idea that alternative valves should closely resemble anatomic ones. Not until the early 1960s, with the introduction of caged- ball prostheses by Harken and Starr, did effective valve replacement become possible. Since that time, substitute heart valves have continued to evolve, and many improvements have been made in their design and fabrication. As of 1988, approximately 51,000 valves were being implanted annually in the United States.
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Cardiopulmonary Perfusion
Nancy L. Achorn, Ccp, Philip C. Crawford, Ccp, Merrill H. Bronstein, MD, San Francisco, California
Open heart surgery is one of the most highly technical of all modern medical techniques, and includes procedures such as coronary artery bypass grafting, cardiac valve repair or replacement, correction of congenital defects, resection of aneurysms, ablation of abnormal pathways of conduction, etc. It relies on the coordinated interaction of a heart surgeon, an anesthesiologist, several nurses and technicians, and a perfusionist. The first successful open heart surgery was performed in Philadelphia forty years ago by Dr. John Gibbon, Jr., whose wife, Mary, was his perfusionist. This historical landmark came after two decades of laboratory exploration and perfection of their extracorporeal circuit and its ability to sustain life. Perfusion, the technology which has evolved from those groundbreaking discoveries, controls, supports and maintains the circulation by application of extracorporeal devices. During open-heart surgery, perfusion (cardiopulmonary bypass - CPB) supplants the functions of the heart and lungs to provide the surgeon with a still, dry operating field. Today, this highly specialized role is performed by individuals conversant in a variety of scientific modalities working in close communication and cooperation with the surgeon. Perfusionists understand the anatomy, pathology, and physiology of the patient, while administering medications, anesthetics, blood, blood components and blood substitutes. Simultaneously, they operate a highly sophisticated electromechanical device to substitute for the human heart and lungs. Today's perfusionists know and utilize aspects of varied pursuits which include a functional comprehension of machines and motors, electronics and electrical safety, plastics and biocompatibility, drugs and pharmacology, blood and its components, hemodynamics and fluid dynamics, hypothermia and hyperthermia, gas exchange and metabolism, electrolytes and blood compatibility, anticoagulation and anesthesia. The logarithmic expansion in these unrelated fields of study have enhanced our ability to provide patient care.
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Heart Transplantation
G. Primo, MD, Brussels, Belgium
Since the first human heart transplantation performed by barnard on December 3, 1967, cardiac transplantation has now largely entered its third decade of clinical applicability. Up to the end of the seventies, the rather disappointing survival results mainly caused by the limited effectiveness of the immunosuppression therapy available at that time, maintained the clinical use of the procedure to a restricted number of no more than 20 to 30 patients each year world wide. The introduction in 1980 of Cyclosporine in the immunosuppression therapy has produced a tremendous improvement in the survival rate and has since promoted a spectacular resurgence of interest for heart transplantation which is presently a well established therapy for end stage congestive heart failure. Indeed, currently the real limiting factor of the treatment is the limited procurement of donor organs.
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Progress on the Total Artificial Heart
Francisco A. Arabia, MD, Jack G. Copeland, MD, Richard G. Smith, Msee, Tucson, Arizona
The total artificial heart (tah) is a device that fully replaces the failing heart and provides control of the circulatory system. This device has been used to provide permanent support, however, its most important role is to serve as a bridge to cardiac transplantation. There are two of these devices available: the CardioWest C-70™ (Symbion,Jarvik J-7™) and the Penn State Heart. The TAH replaces the ventricles and is anastomosed to the respective atria andgreat vessels. It is constructed of segmental polyurethane and utilizes mechanical heart valves for inflow and outflow. It connects to a console via drive lines that pierce the skin. The TAH is pneumatically driven, and a personal computer monitors its function. Its advantages include control of the circulatory system, reversal of early organ failure, and early mobility of the patient. Its disadvantages include cost, and the complications of infection and thromboembolism. Further investigation of this deviceis required to developan optimal total artificial heart.
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High Speed Rotational Atherectomy in Coronary Artery Disease, Padma K. Raju, MD, Simon H. Stertzer, MD, Richard E. Shaw, PhD, Eugene Pomerantsev, MD, Robert Zipkin, MD, Richard K. Myler, MD, Mary Murphy, Ms, Rn., Daly City, California
Despite major advances in its diagnosis and management, coronary artery disease remains the major cause of death accounting for 45.3 percent of all deaths in the United States.One of the major milestones in the treatment of coronary artery disease has been the introdnction of non-surgical revascularization in the form of percutaneous transluminal coronary angioplasty by Andreas Gmentzig in 1977. In the early years, PTCA could only be performed in proximal, discrete, non-calcified lesions. Over the last decade, major advances in the catheter, balloon and guide wire technology as well as increased operator experience extended the benefits of PTCA to patients with more complex lesions and multivessel coronary artery disease. Although the initial impetus for the development of newer devices has been to address the problem of restenosis, they are proving to be useful in treating lesions that are inadequately treated or subject to increased incidence of complications. The high speed rotational atherectomy is a valuable addition with its ability to treat long, calcifiedlesions. This report will describe the technical aspects of the Rotablator®, the procedure of high speed rotational atherectomy and its clinical applications.
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New Laser and Angioscopic Technologies in Medicine
Warren S. Grundfest, MD, FACS, Los Angeles, California
The goal of this chapter is to describe the evolution and implementation of several new interventional technologies which expand the capabilities for less invasive coronary artery intervention. These technologies, including excimer laser angioplasty and angioscopy, are based on the use of new fiberoptics and laser technology. While the application of these technologies may appear unrelated, each specialty has borrowed technology and techniques from other disciplines to develop less invasive forms of therapy.
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Pulmonary Arteriovenous Malformations: Transcatheter Embolization
Yuri F. Neklasov, MD, St. Petersburg, Russia
The congenital abnormality of the pulmonary vessel's development, presented by a direct communication between pulmonary artery and pulmonary veins, has multiple pathomorphologic manifestations which lead, in turn, to a wide range of anomalies such as pulmonary arteriovenous malformations (PAVM), pulmonary arteriovenous aneurysms (PAVA), pulmonary arteriovenous fistulas, pulmonary angiomas, cavernous hemangiomas and pulmonary-hamartomas (Rozenstrauch et al. 1987: Burke et al. 1986).
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Intravascular Stents for the Treatment of Venous Obstruction
C. Venugopal, MD, Michael D. Dake, MD, Stanford, California
Intravascular stents were primarily designed for use in the arterial system, however, there are many venous disorders that may be effectively treated with these devices. Indeed, they have been placed throughout the venous system to treat venous obstruction. Stents have been used in superior vena cava syndrome, catheter induced stenoses of central veins; most commonly subclavian veins, and stenoses of arterio-venous fistulae to name a few common sites. Another major application of stents in the venous system has been in the creation of transjugular intrahepatic portosystemic shunts (TIPS) for the treatment of portal hypertension. There are reports of stents being used to treat obstructive hepatic venous webs (Budd-Chiari Syndrome), May-Thurner Syndrome, and even in the veins of the central nervous system. As experience and follow-up with stents increase, new venous applications will be reported.
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Techniques and Technology in Endovascular Surgery
Edward B. Diethrich, MD, Phoenix, Arizona
Today's vascular surgeons are no longer confined to the time-honored progressive triad of exercise, medication, and bypass surgery for the treatment of peripheral vascular disease. Our options have expanded to include primary therapy using thrombolysis, laser angioplasty, atherectomy, balloon dilation, and intravascular stents, most of these tecnological categories featuring several devices from which to select. Coupled with the concomitant development of intraluminal assessment and guidance technologies, namely, intravascular ultrasound (IVUS) and angioscopy, today's vascular specialists. can evaluate atherosclerotic disease with greatly enhanced accuracy, deriving far more specific information about an obstruction than was ever required for classical vascular reconstruction. In the end, this new specialty of endovascular surgery will provide results equal to those methods used in the past but with less invasiveness. All these options and a more complex diagnostic database require coordination if these new resources are to be used to their fullest advantage for maximal revascularization. It is now incumbent upon vascular surgeons to appreciate the strategies for selecting endovascular interventions based upon lesion pathology and desired outcome.
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Current Treatment and Prevention of Pulmonary Embolus With the Greenfield Filter, Lazar J Greenfield, MD, Mary C Proctor, Ms, Ann Arbor, Michigan
Anticoagulation is standard therapy for treatment of venous thromboembolic disease. However, in some cases it is unsafe or ineffective. Mechanical interruption of the inferior vena cava (IVC) with the Greenfield filter offers the best level of mechanical protection for these patients. Commonly accepted indications for filter insertion are listed in (FigureI). The original 24 F stainless steel Greenfield vena caval filter (SGF) has been in use for more than 20 years and a smaller 12 F titanium (TGF-MH) version has been approved for clinical use. The unique geometry of the six-legged conical design allows adequate flow within the IVC even when 70% of the cone is filled with thrombus (Figure 2). Each filter has demonstrated a high rate of caval patency and low rate of recurrent PE.
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Advances in Vascular Prosthetics: the Gore- Tex Eptfe Stretch Graft
Raju H. Gandhi, MD, Jock R. Wheeler, MD, Roger T. Gregory, MD, Norfolk, Virginia
Following introduction of the gore-tex stretch vascular graft in 1991, over 15,000 bifurcated and 35,000 straight grafts have been distributed (Figure 1). This novel graft, recommended for arterial and venous reconstruction, is touted to afford significantly superior handling characteristics, kink-resistance and conformability. In addition, the "stretch" feature is thought to confer ease of sizing and anastomotic accuracy. Whether this product of advanced polymer science represents a panacea in the field of vascular grafting or a mere addition to the host of less than ideal synthetic conduits remains to be discerned. The first human implantation of a stretch graft was conducted by one of the authors (R.T.G.) during aortic replacement at the Eastern Virginia Medical School (EVMS). A favorable experience has since been gained by utilization of the stretch graft during vascular reconstruction for aortoiliac, infrainguinal and visceral arterial disease. This review will present the intriguing history of synthetic graft development and recount our experience with the Gore-Tex stretch vascular graft.
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The Medial Visceral Rotation Approach To the Proximal Abdominal Aorta: How To Assemble and Use the Omni-Tract® Retractor System
Tammy K. Ramos, MD, and Ronald J. Stoney, MD, San Francisco, California
In the past decade, the standard of care for transfusion in major surgery has evolved in most modern hospitals to autotransfusion (AT) techniques. In several states, in fact, it has become a law of "informed consent". The surgeon must present the risks of homologous transfusion and discuss alternatives and options with the patient. Presently, three standard transfusion options are preoperative donation, intraoperative salvage, and postoperative salvage. This article will address aspects of the latter option - post-operative salvage. Present technology has made significant advances over older collection systems. The Haemolite® 2 is a compact, portable cell-saver well-suited for this purpose for reasons to be presented. Postoperative blood salvage is not a new concept. The Sorenson Device (Sorenson Research Co., Salt Lake City, UT) has been used extensively for many years to collect blood from mediastinal and chest tubes following cardiovascular and thoracic surgery. Similarly, the Soleotrans collection device [Solco-Basle, Rockland, Mass) has been used in vascular and ortIropedic cases for blood salvage. Other devices such as the Pleura-Vac and Auto-Vac share tire same features: collection of shed blood in low volume, filtration, and reinfusion without washing the RBC's. (Figure I) The omission of this processing step is the major difference in comparison with the Haemolite® 2 that separates the RBC's by centrifugal washing. (Figure 2) Presently this "washed vs unwashed" aspect is the source of controversy, which this article will attempt to clarify.
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Monitoring Distal Extremity Perfusion With the Pulse Amplitude Monitor During Vascular Reconstruction
Thomas J. Fogarty, MD, Amitava Biswas, Ba, Stanford, California, Kenneth L. Serra, Ba, Boulder Colorado, George D. Herman, Bsme, Portola Valley, California
One problem in vascular surgery today is the effective monitoring of blood flow to distal extremities before, during, and after a surgical reconstruction. Current methods of blood flow assessment such as periodic pulse palpation, skin signs, Doppler sounds, and capillary refill are neither continuous nor objectively comparable. Because of the qualitative nature of these methods, it is difficult to compare measurements taken by different people at different times, making a quick and appropriate response to changing perfusion requirements difficult. In order to address these problems, a system has been designed to monitor and document pulse amplitudes non-invasively. A pulse amplitude monitor system (Figure 1) consists of a pulse sensor and a waveform monitor (Impra, Tempe, AZ). The sensor (Figure 2) contains a piezoelectric film which is used to detect the slight mechanical oscillations of the arterial wall beneath the skin surface. This film is mounted on a compressible foam block which isolates the vibrations and maintains constant force on the skin. The sensor is taped over a distal pulse, typically that of the dorsalis pedis.
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Postoperative Salvage: Technological Advance in the "Washed Vs Unwashed" Blood Controversy
Roy L. Tawes, MD, Gerald R. Sydorak, MD, Thomas B. Duvall, Burlingame, California
In the past decade, the standard of care for transfusion in major surgery has evolved in most modern hospitals to autotransfusion (AT) techniques. In several states, in fact, it has become a law of "informed consent". The surgeon must present the risks of homologous transfusion and discuss alternatives and options with the patient. Presently, three standard transfusion options are preoperative donation, intraoperative salvage, and postoperative salvage. This article will address aspects of the latter option - post-operative salvage. Present technology has made significant advances over older collection systems. The Haemolite® 2 is a compact, portable cell-saver well-suited for this purpose for reasons to be presented. Postoperative blood salvage is not a new concept. The Sorenson Device (Sorenson Research Co., Salt Lake City, UT) has been used extensively for many years to collect blood from mediastinal and chest tubes following cardiovascular and thoracic surgery. Similarly, the Soleotrans collection device (Solco-Basle, Rockland, Mass) has been used in vascular and orthopedic cases for blood salvage. Other devices such as the Pleura-Vac and Auto-Vac share tire same features: collection of shed blood in low volume, filtration, and reinfusion without washing the RBC's. (Figure 1) The omission of this processing step is the major difference in comparison with the Haemolite® 2 that separates the RBC's by centrifugal washing. (Figure 2) Presently this "washed vs unwashed" aspect is the source of controversy, which this article will attempt to clarify.
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Retroperitoneal Approach To the Aorta
Thomas F. O'donnell, Jr., MD, Boston, Massachusetts
Most historians feel that history is cyclical and, indeed, circular. The retroperitoneal approach for aortic level surgery emphasizes this phenomenon. Although there has been a great deal of interest in this "new" method, it is truly an old approach. Sir Astley Cooper ligated a high lying iliac artery aneurysm through this approach in the early 1800's, while DuBost reported resection of an abdominal aortic an aneurysm with a homograft replacement achieved through this approach in 1952. In 1963, Rob reviewed 500 of his patients who underwent the retroperitoneal approach for aortic surgery and enthusiastically advocated this approach, because of its lower morbidity and mortality. Unfortunately little hard data accompanied this paper. Ten years later, a large series of 90 patients who underwent aortoiliac reconstruction was reviewed by Helsby, et al. 1975. In this series he employed a long left paramedian incision to achieve this retroperitoneal exposure of the aorta. A low, 3%, mortality was reported. More recently, Melvin Williams at Johns Hopkins reawakened interest in the retroperitoneal approach when he described a 4% operative mortality accompanying difficult aortic reconstruction. He favored medial rotation of the left kidney so that the aorta could be approached posteriorly. His seminal report of an exceedingly low mortality and morbidity, despite complex aortic anatomy influenced the readoption of this approach by several surgeons. Influenced by his results we adopted the retroperitoneal approach for high risk AAA while Leather and Sicard subsequently reported large series of aortoiliac reconstruction and aneurysms done through this approach. These series were associated with a relatively low mortality and shortened hospital stay (Table 1).
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Vascular Imaging: Overview Where Is This Technology Leading? What's the Best Bet for the Future?
Rodney A. White, MD, Marco Scoccianti, MD, Torrance, California
New and exciting vascular imaging technologies are assuming increasingly important roles in the management of vascular disease. Non-invasive modalities such as computerized tomography, magnetic resonance imaging and duplex ultrasound supplement the information obtained by invasive techniques including angiography, angioscopy and intraluminal ultrasound. This paper outlines the modern and developing vascular imaging techniques that are rapidly becoming integral components of advanced diagnostic systems as well as therapeutic devices.
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Hemodialysis Access Techniques
Donald D. Bell, MD, Long Beach, California
Progression in hemodialysis technology and vascular access techniques has led to many patients remaining on chronic hemodialysis for significantly greater periods of time. The surgically constructed arteriovenous fistula at the wrist, mid-forearm, or antecubital fossa presents the most ideal and long-term angioaccess. Adequate radial or brachial arterial flow is mandatory for success, and moderate to large sized patent superficial arm veins are even more critical for immediate and long-term patency. A properly selected and constructed fistula has primary patency rates often exceeding five and ten years. Only 15 percent of the chronic renal failure population are candidates for arteriovenous fistula (autogenous) angioaccess. This percentage is significantly lower in the acutely ill hospitalized individuals who become semiurgent hemodialysis candidates. Resultantly, arteriovenous placement of a non-autogenous expanded PTFE graft has become the modern day mainstay for long-term chronic access construction.
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Ultrasound Guided Balloon Angioplasty
Bruce J Brener, MDi Scott R. Cluley, MD, Victor Parsonnet, MD, Michelle Ferrara-Ryan, Bs, Richard Schoenfeld, MD, Andrew Novick, MD, Dave Vilkomerson, PhD, Newark, New Jersey, Larry Hollier, MD, New Orleans, Louisiana
A modified angioplasty catheter has been developed which can be guided into position with duplex ultrasound. This reduces the risks of ionizing radiation and contrast agents and uses a modality familiar to the vascular surgeon. This catheter was tested successfully in a canine model for safety, accuracy and therapeutic efficacy. Following FDA approval, clinical trials in humans were initiated. This paper describes the preliminary results with use of this device in humans.
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Intraoperative Transesophageal Echocardiography
Susan Adler, MD, Gordon Curry, MD, Michael M. Jewett, Rd, Ms, Burlingame, California
A methodical, basic intraoperative transesophageal exam can be performed quickly by anesthesiologists trained in transesophageal echocardiography. This provides a wealth of information with minimal invasiveness that is useful for the anesthesiologist, surgeon, and internist involved in the patient's care. Transesophageal echocardiography (TEE) is particularly valuable in the intraoperative monitoring of ventricular volume, ischemia and evaluation of valve morphology. And, as TEE imaging improves it is rapidly replacing aortography as the gold standard in the rapid evaluation of aortic dissection.
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