The management of infected abdominal aortic grafts and graft-enteric fistulas

Seven cases of infected aortic grafts or aorto-enteric fistulas following resection of an abdominal aortic aneurysm are reviewed. All cases were treated with axillo-femoral bypass and graft removal. Patients had recurrent fever, chills, and abdominal pain (5 patients), or massive gastrointestinal hemorrhage (2 patients). The two patients with massive gastrointestinal hemorrhage died. Three of the 5 long-term survivors had a recurrence of the retroperitoneal abscess after graft removal; one of these died. One axillo-femoral bypass graft required early thrombectomy. There have been no subsequent problems with any of the grafts in the 2.5 to 4 year followup period. Axillo-femoral bypass immediately before graft removal is the treatment of choice for infected or fistulous aortic grafts. Any delay in graft removal after the onset of symptoms should be avoided.

Post-traumatic aneurysms of the thoracic aorta

Nineteen patients with histologically proved post-traumatic aneurysm of the thoracic aorta were reviewed. Only seven aneurysms were detected at the time of hospitalization for trauma. Eight of 12 patients with chronic aneurysms either became symptomatic or showed enlargment during a period of observation. Surgical excision was the recommended method of therapy.

Ultrastructure of the cardiac muscle of early human embryo

In order to compare the ultrastructural difference between cardiac myocytes of the 54 day gestational age and that of the 114 day gestational age, the human fetal hearts were studied by means of electron microscopy. In the 54 day heart, although the nexus was developed already, contractile elements were immature and there was no close association between myofibril and mitochondria, and also sarcoplasmic reticulum was not accomplished. On the contrary, in the 114 day heart, the contractile elements, mitochondria and sarcoplasmic reticulum were partially developed fairly well in myocytes.

Studies on trypsin inhibitor in barley. I. Purification and some properties

To clarify the properties and functions of a trypsin inhibitor from Japanese barley in comparison with the inhibitor from Pirkka barley, an inhibitor was isolated from the barley Hordeum distichum L var. emend Lamark by extraction with 1% NaCl, ammonium sulfate fractionation and repeated chromatography on DEAE-cellulose and CM-cellulose. The final purified preparation of the inhibitor was found to be homogeneous by both chromatographic and electrophoretic analysis. The inhibitor was thermostable and was stable over the broad pH range from 2 to 11. No inhibition was observed by heavy metal ions and many reagents at 10(-2) M, except that p-chloromercuribenzoate caused a 69% loss of activity. The inhibitor was subjected to isoelectric focusing at pH 7.51 and its molecular weight was calculated to be 14,200+/-900 by polyacrylamide gel electrophoresis in the presence of sodium dodecyl sulfate. The apparent dissociation constant for the complex between the inhibitor and trypsin[EC 3.4.21.4] was 1.64 X 10(-7)M with casein as a substrate. One microgram of purified inhibitor inhibited 1.5 mug of pure trypsin in the hydrolysis of alpha-N-benzoyl-DL-arginine-p-nitroanilide. By chemical modification of arginyl residues in the inhibitor with 1,2-cyclohexanedione, the inhibitor was shown to be an arginine inhibitor. The inhibitor contained relatively many basic amino acids and few half cystines as compared with Pirkka barley trypsin inhibitor.

Acute prolonged renal arterial infarction. Return of function after thromboendarterectomy

This report describes a case of complete occlusion of the right renal artery. Arteriography and intravenous pyelography demonstrated no kidney function. The occlusion was treated by endarterectomy, and eleven days later another intravenous pyelogram revealed that renal function had been restored. A review of the literature also suggests that acute occlusion (caused by embolism) or chronic occlusion (caused by atherosclerosis) should be treated surgically to perserve renal function, reserving nephrectomy only if that should fail.

Traumatic right coronary arterial-right atrial fistula

A healthy 25 year old man presented with a machinery murmur and a history of a penetrating thoracic injury. Hemodynamic and angiographic evaluation demonstrated a fistula from the right coronary artery to the right atrium that was later successfully repaired. This case and similar reported cases indicate that fistula formation is a late complication of penetrating thoracic injuries. The onset of the murmur occurs with enlargement of the fistula and typically is delayed for several weeks to months after the initial injury.

Coronary artery surgery for recurrent ventricular arrhythmias in patients with variant angina

Two patients with Prinzmetal's variant angina had recurrent episodes of resting chest pain, ST segment elevation, QRS widening, ventricular tachycardia, and ventricular fibrillation. These eqisodes were unresponsive to medical therapy including lidocaine, procaine amide, and quinidine sulfate. Coronary arteriography revealed severe obstructive coronary artery disease, involving more than one coronary artery, in both patients. Aorticocoronary saphenous vein grafts were utilized to bypass significant disease in each patient. In one patient blood flow through the grafts was measured at 90 and 65 ml per minute, respectively, at operation and patent grafts were demonstrated six months postoperatively. Neither patient has had recurrence of chest pain or evidence of ventricular tachycardia at one year or 2 1/2 years postoperatively. Postoperative resting and maximal exercise ECG's are normal. Coronary artery surgery may be an effective method of therapy for ischemic ventricular tachycardia when medical therapy fails.

Hemolytic anemia due to progressive enlargement of silastic ball component of aortic prosthesis

The patient described developed hemolytic anemia following insertion of a Starr-Edwards aortic valve prosthesis. No diastolic murmur was heard and no insufficiency was detected. The hemolytic anemia was progressively more severe and uncompensated despite various medical measures.

The anemia was characterized by fragmented erythrocytes in the peripheral blood, reticulocytosis, elevation of plasma heme pigments augmented by exercise, increased fecal urobilinogen, and iron loss in the urine. Studies of chromium-51-tagged erythrocytes indicated an extracorpuscular mechanism of hemolysis.

At reoperation the ball component of the prosthesis was found to be enlarged and obstructing blood flow. Chemical analysis of the ball showed significant cholesterol and lipid deposits. The hemolysis disappeared after the prosthesis was replaced with a homograft valve. Ferrokinetic studies showed rapid plasma clearance and incorporation into circulating erythrocytes. Triglycerides were elevated during the period of hemolysis. Red cell membrane lipids were normal.