Search

with oxygen. This can be judged accurately enough if the total bag capacity is not more than about 2 litres. Stage 1?Preparation of the Bag.?The bag of oxygen is rebreathed until an increase is noted in the depth or rate of respiration. About 10 seconds' more rebreathing is encouraged and the first stage is terminated. Stage 2?Fine Adjustment.?After at least two minutes the prepared bag is rebreathed for 20 seconds and its Pco2 is measured. After a further two-minutes rest (about the time required to analyse the previous sample of gas), the 20-second rebreathing period is repeated. This procedure is continued until the bag Pco2 remains unaltered by the rebreathing. This value is taken as the mixed venous Pco2.

Four young men involved in high-speed car crashes developed cardiovascular trauma. Two patients had aortic aneurysms, one rupture of the mitral valve, and one ventricular septal defect; successful surgical correction was undertaken in all. The importance of considering the possibility of cardiovascular trauma in these circumstances is emphasized, and x-ray films (repeated if necessary) should be taken even when there are no external signs of trauma.

The current approach to treatment at St. Mary9s Hospital of dissecting aortic aneurysms uses a period of induced hypotension before aortography and consideration for surgical correction. There are 13 survivors of a series of 24 patients treated in this way.

I MPROVED care and management of the parturient have resulted in a gratifying reduction in the maternal mortality rate. This has been accomplished primarily by a marked decrease in deaths due to purely obstetrical causes, but those due to nonobstetrical factors have not demonstrated a similar improvement. This emphasizes the necessity of directing attention to the latter group. With increased knowledge and awareness, the obstetrician in cooperation with the internist has been able to decrease the maternal mortality due to cardiac disease, diabetes, and other complications responsive to modern therapeutic regimes. However, there are other nonobstetrical abnormalities which are almost’invariably fatal. This may be attributed largely to an almost universal ladk of suspicion of their presence in conjunction with pregnancy so that the true diagnosis is made too frequently at postmortem examination. Furthermore, there is little clinical consciousness of these entities in pregnancy since scant attention is given to them in obst,etrical teachingl-” and literature. This is unfortunate, since some of these are amenable to correction either before or during pregnancy. Greater awareness will lead to their earlier diagnosis and treatment with resultant improvement in maternal salvage. Aneurysms constitute one of these nonobstetrical abnormalities which have not received adequate attention despite the fact that rupture during pregnancy is associated with a maternal mortality varying from 40 to 100 per cent. Although rupture of an aneurysm most commonly occurs after the age of 40, it may happen during the childbearing period and complicate pregnancy. Furthermore, the various clinical pictures produced by ruptured aneurysms simulate more obvious obstetrical complications. As a result, the treatment instituted is generally not directed toward the actual defect. The purpose of this paper is to stimulate an awareness and develop a clinical consciousness of the coexistence of aneurysms of the arterial system and pregnancy, so that early and adequate therapy may be instituted. Hence, this publication will consider aneurysms of the aorta and its abdominal branches, and a companion paper will discuss cerebral aneurysms. This report is based upon 75 cases of aneurysm of the aorta and 50 cases of aneurysm involving the major branches of the abdominal aorta culled from the literature (Tables I to IV). Two additional cases of saccular aneurysm

There is no intent in this paper to review the entire subject of dissecting aneurysm, which has been fairly well covered in numerous articles. Most cases are treated by the internist. However, there is a surgical problem. It is in those patients with abdominal symptoms that the surgeon is confronted with a diagnostic dilemma. Presumably, one of four patients with dissecting aneurysm of the aorta may present signs and symptoms indicating an abdominal surgical emergency. All patients with hypertension who present evidence of an acute surgical condition of the abdomen of doubtful etiology should be suspected of having a dissecting aneurysm or aortic rupture. Two recent case reports have been added for illustration. Both patients entered the hospital within a few weeks of each other and their hospital course stimulated this paper.

In 1930, two of us (J. E. M. and J. H. D.) presented before the American Heart Association a preliminary report1dealing with the major question of the prolongation of life as a result of treatment in 43 patients with aortic aneurysm, 90 with aortic insufficiency and 8 with various other forms of syphilitic heart disease. Because of limitations of space, it was not possible to discuss other than the one major issue, and consideration of other data was deferred. Meanwhile we have kept in touch with the patients originally reported on and have added others. In this paper, we offer a general consideration of the treatment of cardiovascular syphilis, based now on 53 patients with aortic aneurysm and 112 with aortic regurgitation. The 8 patients with syphilitic myocarditis, aortitis or angina pectoris included in the original paper have been left out of consideration, since the discussion at the

Three hundred sixty arterial injuries in 353 patients are reviewed. They covered a wide spectrum of injuries and included 36 aortic injuries and 19 cases of carotid truama. The mortality rate of 12% was in large part due to aortic injuries. Shock was the predominant cause of death. Infection was the most frequent non-fatal complication. Pulmonary complications were surprisingly uncommon. With methods and techniques discussed in the paper, 90% satisfactory end results were achieved. The amputation rate was 6% where extremity injuries were involved.

THE prognosis after rupture of an aneurysm of the A abdominal aorta has improved with recent advances in cardiovascular surgery,1 2 3 4 5 6 7 and it is therefore of vital importance to make an early diagnosis. Although the clinical signs and symptoms of this condition have been adequately described8 9 10 11 the diagnostic value of the plain film of the abdomen has not been given the attention that it deserves. This paper summarizes the pertinent x-ray findings in 20 cases of ruptured aneurysms proved at autopsy or surgery. The findings in 37 cases of intact aneurysms are included as controls. The great majority of abdominal aneurysms . . .

Fungal endocarditis is an uncommon complication of cardiac surgery. Candida endocarditis following open heart surgery was first reported by Koelle and Pastor (1956) and since then 24 cases have been recorded. Nineteen cases were reviewed by McConnell and Roberts (1967) and three cases of their own were added. Two more cases have been reported since, one by Newsome, Lea and Russell Rees (1967) and the other by Kahn, Kane and Dean (1968). The fungi isolated from these 24 cases were Candida albicans in 14, other Candida species in seven, Aspergillus in two and Paecilomyces in one (Uys et al., 1963). The first case of Aspergillus endocarditis following open heart surgery was reported by Newman and Cordell (1964). This paper presents a case of Aspergillus fumigatus endocarditis on an aortic valve homograft.

From the standpoint of surgical treatment, the vascular hypertension could be classified into three categories; namely, coarctation of the thoracic aorta, atypical thoraco-abdominal aortic coarctation and renovascular hypertension. In this paper, the surgical treatment of vascular hypertension based on a 20 year experience at the University Hospitals of Marburg, Cologne and currently of Munich are reported. Surgical therapy is most effective, if the relationship between the vascular or organ changes and the existing hypertension is clarified. Therefore, it is true that in the light of operative long term results the efforts should be directed to appropriate patient selection and adequate operative procedures.

Echocardiographic examination of the aortic valve cusps has proved useful in the differential diagnosis of left ventricular outflow tract lesions. This paper presents a previously undescribed motion pattern of the aortic valve in 3 patients with ruptured right coronary sinus of Valsalva aneurysm. The right coronary cusp opened normally with the onset of systole, but demonstrated abnormal early systolic closure, with reopening in late systole. The noncoronary cusp moved normally. Following surgical correction in one patient, this early systolic closure was no longer present. Echocardiographic patterns in patients with membranous subvalvular aortic stenosis, idiopathic hypertrophic subaortic stenosis, and congenital aortic stenosis are compared.

RUPTURE of an arteriosclerotic abdominal aneurysm into the inferior vena cava is unusual. The production of an aortocaval fistula by this means has rarely been emphasized and less frequently corrected. There are individual reports1 2 3 4 5 6 but on only 6 such patients in whom successful surgical treatment has been carried out. This paper is prompted by the diagnostic, as well as the technical implications raised in the successful management of 2 additional patients. Case Reports Case 1. L.L. (M.G.H. 860748), a 52-year-old man, was admitted to the private service of the Massachusetts General Hospital on July 7, 1961, because of shortness of . . .

Various hazards of external cardiac massage, such as rib fracture and bone-marrow emboli, are well known. This paper describes an unusual hazard, aortic aneurysm. The mechanism of production of this lesion differs in several respects from that of most closed-chest aortic lesions.

Pseudocoarctation of the aorta is a rare anomaly. Until now, it has been considered to be a benign condition. The case presented in this paper was followed for 12 years, at which time a trilobulated aneurysm developed at the site of the aortic kink. To our knowledge, this is the first reported case of such a complication. A possible reason for the aneurysm formation is suggested and the differentiation of pseudocoarctation from true coarctation is briefly discussed.

Acute dissecting hematoma of the aortic wall is now potentially curable by surgery. 1 Without surgery more than one-third of persons so afflicted will die within 48 hours and about two-thirds within 10 days. 2 On the other hand, an exploratory operation may carry an even greater risk because of the many serious diseases which mimic this lesion clinically. What is urgently needed, therefore, is a safe procedure which can establish the diagnosis beyond question immediately after the onset of symptoms. This paper describes three instances of acute dissecting hematoma to show that venous angiocardiography is a safe procedure which supplies a diagnostic picture. A fourth case illustrates the angiocardiographic pattern of a combination of an aneurysm of the aorta and healed dissecting hematoma. Cases of Acute Dissecting Hematoma Case 1. —A 60-year-old Negro man was admitted to Temple University Hospital on March 31, 1957, because of persistent pain, which

ARTERIOSCLEROTIC aneurysms of the abdominal aorta present as serious a challenge to surgeons today as they have at any preceding time, although the reasons for this situation are different from those pertaining as recently as 15 years ago. Whereas in the past the details of operative technique successfully challenged the surgeon, the current methods of surgical treatment of vascular diseases are sufficiently refined to permit direct as well as indirect attacks on such aneurysms. Pressing problems remain that are no less urgently in need of settlement than are the purely technical ones. These have to do with indications for operation in abdominal aortic aneurysm, selection of the type of procedure to be used, and evaluation of the efficacy of the operative procedures under consideration in the alleviation of symptoms and the prolongation of life. This paper presents experience with the operative treatment used in 23 patients who had aneurysms of

LMOST FROM THE TIME of Roentgen's discovery, x-rays have been used for the detection of aortic disease. In 1931, P. D. White wrote that "Roentgenology continues to be the most important means of detection of aortic disease .... " but that it "is a crude method of diagnosis, deformity or calcification of the aorta being necessary before the roentgen ray picture appears abnormal. ''~ In 1929, dosSantos et alfl published the first description of a radiologic demonstration of the aorta by means of injection of opaque medium. These authors used a translumbar needle-puncture technique to show the abdominal aorta and its branches. Nine years later, Robb and Steinberg 3 showed that the aorta (as well as the great veins, the heart, and the central circulation) could be demonstrated satisfactorily by introduction of contrast medium into peripheral veins. That same year, Castellanos and Pereiras, 4 described retrograde brachial injection of contrast medium for opacification of the aorta. Farinas 5 was first to describe the use of a catheter for aortography. He reported, in 1941, the introduction of a catheter into the femoral artery by means of surgical exposure of the artery and puncture with a trochar, through which the catheter was passed and subsequently threaded into the abdominal aorta. Radner, 6 in 1948, described the use of a catheter technique for retrograde thoracic aortography, which he accomplished by passage of a catheter from the radial artery. Thus, during these two decades, the 1930s and 1940s, the basic methods still used for definitive roentgen evaluation of the aorta were developed. The succeeding two decades have seen remarkable expansion of these basic methods, along with their refinement. The development by Seldinger 7 of a simple percutaneous technique for introduction of the catheter has played a major role in making this roentgenologic method an important part of medical practice throughout much of the world. AORTOGRAPHIC TECHNIQUE A detailed description of aortographic technique will not be undertaken here; the reader is referred to textbooks 8'9 and papers cited in the references for such details. Nonetheless, a few general comments are in order. Since Seldinger's 7 description of a simple percutaneous method of insertion of a catheter into a peripheral artery, this technique and modifications of it have gained increasing popularity for all types of angiography throughout the

IN RECENT YEARS several case reports1-4of successful repair of an arteriovenous fistula between an atherosclerotic aneurysm of the abdominal aorta and the inferior vena cava have been published. In each instance the predominant clinical feature has been high-output cardiac failure. It is the purpose of this paper to record the first case of an arteriovenous fistula between an atherosclerotic abdominal aortic aneurysm and an anomalously placed retroaortic left renal vein. The predominant clinical features were quite different from those of aorto-vena caval fistula. In our patient, left flank and abdominal pain was severe and associated with a pulsating abdominal mass and continuous bruit over the left side of the abdomen and back. Resection of the aneurysm and closure of the opening in the left renal vein with preservation of its continuity and insertion of a bifurcating, crimped, knitted Dacron prosthesis led to healing of the lesion and a

Summary In recent years a rather unusual form of aortitis of obscure origin has been observed in African children and adolescents. The term ‘idiopathic aortitis’ has been used in the literature to describe this lesion. In the present paper, the aetiology, clinical and pathological features of the condition are briefly described and the radiological findings considered in some detail. The various arteriographic changes which may be demonstrated by aortography are illustrated. The relationship between this obscure type of aortitis in young Africans and classical Takayashu's syndrome is uncertain. The main features of the 2 conditions are tabulated to indicate some of their similarities and differences.

This paper contains a brief review of the cases, published earlier, of aneurysms of the sinuses of Valsalva, and a case is reported in which the diagnosis was made before rupture of the aneurysm by means of thoracic aortography. No reports are to be found in the literature of the diagnosis of unruptured aortic sinus aneurysms and of the associated clinical findings. Roentgenograms, aortograms and catheterization findings are included.

SUMMARY The paper describes a case of dissecting aortic aneurysm which had ruptured into the left pulmonary artery. The horse presented with atrial fibrillation and peripheral oedema. The condition is compared with reports of a similar syndrome in man. RESUME L'auteur decrit un cas de formation puis de rupture d'aneurysme aortique dans l'artere pulmonaire gauche. Le cheval montrait une fibrillation auriculaire et un oedeme peripherique. Ce cas est comparea des cas semblables rapportes chez l'homme. ZUSAMMENFASSUNG Dieser Artikel beschreibt einen Fall von Aneurysma dissecans der Aorta, das in die linke Pulmonalarterie hinein rupturierte. Das Pferd wies Vorhofflattern und periphere Oedeme auf. Der Zustand wird verglichen mit Berichten uber ein ahnliches Syndrom beim Menschen.

HORSESHOE KIDNEY, in combination with an abdominal aortic aneurysm, is a rare and challenging problem in management. In the following case, surgery was deferred 5 yr before our treatment owing to the complexities of these combined pathologies. This paper deals with the detailed care of a patient while reviewing the salient features of diagnosis and treatment for abdominal aortic aneurysm in conjunction with horseshoe kidney. In a careful review of the literature, we were able to find only two cases with the above pathology so reported. Report of a Case In 1957 a 48-yr-old male was admitted to another hospital complaining of chest pain radiating down the left arm. An electrocardiogram (EKG) revealed ischemic changes which subsequently reverted to normal. Physical examination revealed a pulsating mass in his abdomen. A translumbar aortogram demonstrated an abdominal aortic aneurysm. Surgery was contemplated but abandoned when intravenous pyelography revealed a horseshoe kidney overlying

RECENT advances in the surgical treatment of dissecting aneurysm of the thoracic aorta, based on resection and graft replacement of a segment of aorta including the intimal tear, have made preoperative identification of the site of the tear an extremely important part of the evaluation of patients with this disease.1 , 2 The purpose of this paper is to discuss the roentgenologic findings in dissecting aneurysm, with particular reference to recognition of the intimal tear. Material During the four-year period between October, 1961, and September, 1965, 24 patients with aortic dissection demonstrated angiographically have been seen at the Massachusetts General Hospital. The . . .

ANEURYSMS of the aortic sinus (of Valsalva) are rare. Jones and Langley,1 in their classic paper, reviewed the literature in 1949 and reported a total of 43 cases proved by autopsy and added 4 of their own. Of these, 25 were of congenital origin; the remainder were acquired. In 1951 Venning2 described 3 additional cases. Falholt and Thomsen,3 in 1953, reported a case with a congenital aneurysm of the right aortic sinus diagnosed by retrograde aortography, and totaled the number of congenital cases in the literature as 34. Another autopsy was recorded recently by Basabe, Hojman and Rosemblit.4 Fifteen cases . . .

Aneurysms of the sinuses of Valsalva are rare and when uncomplicated produce few clinical, roentgenographic, and electrocardiographic findings. Associated congenital lesions are frequently of interest, but the complications of these aneurysms, which produce a wide variety of changes, make them of medical interest. This paper reports 2 cases with roentgen changes which are seen much more frequently in other types of heart disease. Case I: A 54-year-old colored male was admitted to Duke University Hospital on May 1, 1955, because of severe, oppressive, nonradiating substernal pain. He had had a similar attack in March 1955, which was treated at another hospital as an acute coronary occlusion. He gave a two-year history of exertional dyspnea and angina, mild orthopnea, and occasional nocturnal dyspnea. More recently he had suffered mild pitting ankle edema and wheezing, and had coughed up foamy, pink sputum. The past medical history and systemic review were noncontributory. The patient specifically denied ev...

THE MANAGEMENT of sepsis has always been a preoccupation of the surgeon. With the development of vascular reconstructive surgery and its necessary reliance upon plastic prosthetic materials, the implications of wound infection are grave and can often result in the death of the patient. It is the purpose of this paper to examine this problem and to suggest means of management and prevention. University of Michigan Experience Between 1953 and 1966, at the University of Michigan affiliated hospitals, 890 aortic bypasses and aortic aneurysmectomies were performed. This represents a large group of patients, all requiring the use of plastic prostheses, and is the only vascular reconstructive procedure considered here. There were 12 infections involving the prosthesis, an incidence of 1.34%. Other authors have recorded a similar incidence varying from 1.1% to 6.0%. 1-5 The prosthetic material used was knitted Teflon in nine patients and woven Teflon in three. Operative indications

DIVERTICULA of the aortic arch are rare congenital anomalies found as a component of vascular rings in infants. They may occur with either a right or a left aortic arch and represent persistence of the contralateral dorsal aortic root1 (Fig. 1). There are several reports concerning their diagnosis in adults by means of routine roentgenographic studies of the chest.1 2 3 4 5 6 However, angiographic studies of such patients have rarely been reported. The purpose of this paper is to describe 4 patients, each referred for the evaluation of a mediastinal mass, in whom angiography demonstrated the presence of an aortic diverticulum. One of . . .

IN a previous paper the literature was reviewed, and an unsuccessful attempt at surgical repair of a ruptured abdominal aneurysm occurring in a patient with Marfan's syndrome was reported.† The cas...

The study of the termination of aortic aneurysms is always of interest. Rupture is one of the occasional methods that lead to the death of the patient. A very unusual and noteworthy variety of this method is rupture into the superior vena cava. In this paper I add two cases and discuss the more salient points of diagnosis. It is interesting as the literature runs to note that the cases are bunched, the report of one case being quickly followed by several others. The clinical notes with postmortem findings (made by Dr. Edwin F. Hirsch) of the first case are given in detail. The report of the second case is meager in details but accurate in its statements. The illustrations were made from the specimens, which are now preserved in the pathologic museum of Northwestern University. REPORT OF CASES Case 1. —A widow, aged 52, previously in good health, awaking

Aneurysm of the renal artery is a rare clinical and pathologic entity. Medical literature contains reports of only 74 cases. The first account of a case of "renal" aneurysm was published by Dr. Daniel Nebel1in 1719. For two and a quarter centuries this well known case of Nebel's has been incorrectly translated and misquoted. The patient was not a physician and did not have a renal aneurysm but suffered from an aortic aneurysm. Many of the earlier papers reveal incomplete case reports and do not warrant a clinical or pathologic diagnosis of renal aneurysm. Keen2in 1900 and Morris,3also in 1900, were the first to write more extensively on the subject. Summarizing articles were published by Vogeler4in 1922, Conroy5in 1923 and Gerard6in 1930. Mathe7in 1932 wrote an excellent review of the subject and tabulated 55 cases from

During the past few years excisional therapy of aortic aneurysms has been firmly established as the treatment of choice. The hazards of aortic aneurysms are well recognized. Thoracic aneurysms may cause unbearable pain from root compression and vertebral erosion. They may obstruct adjacent structures, such as trachea, bronchi, and esophagus. Abdominal aneurysms may also cause root pain. They sometimes bring about gastrointestinal dysfunction, and they may result in obstruction of the ureters or vesicle neck. The greatest hazard of aortic aneurysms, however, is rupture, and it is the threat of rupture which provides the single most compelling reason for advocating surgical treatment. When this complication occurs the patient is almost sure to die unless definitive surgery is carried out immediately. That prompt operation offers hope under such circumstances has been pointed out recently in an editorial by Gerbode.1 It is the purpose of this paper to illustrate the potentialities

Excerpt The subject of this paper, cardiovascular syphilis, offers an interesting example of a tendency to search for the new while at times forgetting the old teachings. Aortic aneurysm appears af...

In 1930 Moore and Danglade 1a published an article on the treatment of cardiovascular syphilis. They together with Reisinger 1b followed this in 1932 with a similar article. These articles were particularly valuable because, with the use of various self-explanatory charts, they detailed the facts which many older clinicians had failed to record in the analysis of the effects of specific treatment on cardiovascular syphilis. Inasmuch as there have been published only five other papers in which similar data have been recorded, 2 it seemed to the San Francisco Heart Committee and to me that a compilation of statistics made from the records of the various San Francisco hospitals according to the excellent chart forms originated by Moore and his co-workers would be an interesting contribution. The following statistics have been assembled with the courteous cooperation of the Medical Department of the Stanford University Hospitals, the University of California Hospital

THIS PAPER describes the successful excision of a massive aneurysm of the abdominal aorta and common iliac arteries in a patient 89 years of age. The size of the aneurysm and the advanced age of the patient have prompted this report. Report of a Case An 89-year-old male (born Dec. 8, 1870) was admitted to the Baltimore City Hospitals in May, 1960, because of progressive pain for 6 months in the right lower extremity. The pain, a shooting and stabbing one along the posterior thigh and leg, was worsened by standing or walking. The patient's health had been excellent. He was a vigorous man and prior to the onset of his present illness had walked 1 to 2 miles daily. There was no history of previous operations or serious illnesses. On physical examination the patient appeared younger than his stated age. The blood pressure was 162/104 mm. Hg. Scattered basilar

Advances in the field of vascular surgery are due mainly to developments in the use of vascular grafts. Preserved homografts have been discarded by many people because of the occurrence of late degeneration, causing rupture of the grafts. Synthetic prostheses, especially those made out of Dacron or Teflon, are now the choice for blood vessel substitutes. It has been nearly eight years since plastic prostheses were first used in vascular surgery, and various complications relating to its use, either early or late, have been reported in the literature. Recently, we had an unpleasant experience with a Dacron graft. Severe, fatal bleeding occurred through the graft postoperatively and was believed due to the activated fibrinolysis. It is the purpose of this paper to report a grave complication relating to the use of synthetic vascular prostheses and to describe an analytical study of the effects of fibrinolysis upon plastic prosthesis. Report of

Seven dogs (5 females and 2 males), with ages varying between 5 and 10 years’s old, showing pneumic osteo-arthropathy were studied. This condition was caused as follows: one by esophagic parasitic nodule (Spirocerca lupi) and aortic aneurysm; one by bronchogenic carcinoma with lung metastasis; another by lung metastasis from ovary digerminoma; two by lung metastasis from mammary adenocarcinoma and two esophagic sarcomas, the former being polymorphic and the latter osteogenic, both originated from parasitic granlomn (Spirocerca lupi). X-rays were taken and after that the animals were submitted to post mortem examination. Six related radiographic figures are shown in the paper.

SACCULAR aneurysms of the abnormal aorta occur infrequently and when they do, they are difficult to distinguish in diagnosis from such conditions as carcinoma of the stomach and hydronephrosis. Three cases are described in this paper of saccular abdominal aneurysms with unusual manifestations. The first one closely simulated a bleeding peptic ulcer; the second one caused renal failure, and the third was recognizable clinically as a ruptured abdominal aneurysm, although an electrocardiogram suggested an anterior coronary occlusion. The incidence varies in the recorded series of cases of this condition. Osler 1 (1905) reported only 16 cases among 1,800 ward admissions at Johns Hopkins Hospital. Bryant 2 (1903), in a review of the autopsy material at Guy's Hospital for 50 years, found 325 aneurysms of the abdominal aorta. Earlier writers, Nixon 3 (1911), and even some recent authors (Kampmeier, 4 1944; Scott, 5 1944; Pratt-Thomas, 6 1944) stress syphilis as the predominant etiological factor. Estes 7 (1950) found