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Background: Thoracoabdominal aortic aneurysm repair requires complex surgery. Clamping of the descending aorta during the operation results in organ malperfusion, ischemia, and in some cases, irreversible end-organ damage and death. Several methods for organ preservation during the operation evolved, resulting in decreased post-operative organ malfunction. Re-attachment of intercostal arteries, cerebrospinal fluid drainage, and temporary bypass of the clamped aorta and selective perfusion of the spinal cord, intestine, liver and kidneys are widely used during the operation., Objectives: To determine the impact of implementation of protective measures on the outcome of thoracoabdominal surgery over a decade., Methods: Between March 1993 and March 2003, 11 patients (age 41-80 years, average 60 years) underwent thoracoabdominal aortic aneurysm repair in our hospital. Different methods for organ preservation were used during the operation., Results: The early survival is 91%. One patient suffered from paraplegia and one from mild temporary paraparesis. Two patients died during the follow-up period (at 5 months from pneumonia and at 2 years from aortic arch rupture)., Conclusions: Implementation of all adjuncts to protect the organs dependent on aortic perfusion may eliminate the ischemic consequences of aortic clamping.

Coronary artery disease amenable to percutaneous interventions or coronary artery bypass grafting, and resectable lung cancer are major causes of morbidity and mortality. We present our experience in the treatment of 3 patients (men aged 64 and 66 and a woman of 77) who each had significant coronary artery disease and a resectable lung tumor. They underwent combined coronary artery bypass grafting and pulmonary lobectomy. We conclude from our experience and review of the literature that concomitant surgery in such cases is safe and effective, decreases suffering, and decreases the cost of 2 separate invasive procedures.

The optimal surgical treatment for concomitant carotid and coronary artery disease is controversial. Between 1991 and 1995 we performed 34 procedures for combined disease of the carotid and coronary arteries. The first 8 operations were carotid endarterectomies followed by coronary artery bypass grafting (staged procedure). The next 26 operations were performed during a single anesthesia (combined procedure). The patients were 28 men and 6 women, aged 58-81 years (mean 68). 80% were in functional class III or IV. In 40% ventricular function was moderately or severely reduced. There was an average of 3.6 grafts per patient, and in all except 3 patients the left internal thoracic artery was used as a conduit for coronary artery bypass grafting. 30% had symptomatic carotid stenosis; there was no perioperative mortality. In the staged procedure group, 2 patients had postoperative cardiac complications: in 1 acute coronary insufficiency and acute myocardial infarction in the other. 1 had postoperative, transient, amaurosis fugax. In the combined procedure group, 1 had a myocardial infarction and 1 a minor occipital stroke. During follow-up, 1 patient died 4 months after operation of myocardial infarction, and 1 had a minor stroke. The results suggest that the combined procedure is safe and carries low risk of both mortality and morbidity. Whenever cardiac disease is stable and there is no main coronary artery disease, a staged procedure should be considered. In any other situation we continue to perform the combined procedure.

Lung transplantation is now considered acceptable therapy for end-stage lung disease. Until recently therapy for emphysema was disappointing, but lung transplantation has brought new hope for those terminally ill with the disease. We present our early experience with single-lung transplantation in 5 men and 1 woman with emphysema, 40-61 years old. All recovered following surgery, with remarkable improvement in lung function and functional capacity. They are now 6-20 months post-transplantation, do not need oxygen supplementation and are able to perform their normal daily activities. Shortage of donor organs is the limiting factor for single-lung transplantation in these patients.

We have developed a technique for autotransfusion of shed mediastinal blood collected in the cardiotomy reservoir. Results in the first 50 consecutive patients in whom the system was employed were studied prospectively (group A) and were compared with those of the last 50 consecutive patients operated on before application of the new method (group B). The mean preoperative hematocrit (about 42%) and the total postoperative bleeding (about 11) were similar in both groups. Only 24 patients (48%) in group A required homologous blood transfusion, versus 43 (86%) in group B (p = 0.0001). This resulted in a 57% saving of blood units in group A (mean, 1.16 +/- 1.49 units per patient versus 2.72 +/- 1.99 in group B, p less than 0.0001). Foreign blood transfusion was thus avoided in 21 of the last 25 patients (84%) of group A. 7 days after operation, the mean hematocrit in group A was 30.9 +/- 4.3, compared with 33.0 +/- 3.8 in group B (p less than 0.001). Hemolytic jaundice occurred in 7 group B patients (14%) but in none in group A (p less than 0.01). A trend towards reduction in other complications was also demonstrated. We conclude that the use of foreign blood transfusions in those undergoing open heart surgery can be reduced significantly by this method, thus avoiding immediate transfusion reactions and minimizing the risks of late complications.