K Ala-Kulju’s research while affiliated with Helsinki University Central Hospital and other places

In a retrospective study, 210 autogenous femorotibial saphenous vein grafts inserted during the 15 years from 1967 to 1982 were followed-up for a mean period of 62.3 +/- 5.7 months. Seven patients, who had had eight grafts died in hospital. The remaining 202 grafts fell into three groups: (1) Sixty grafts in patients who received 325 mg of dipyridamole and 1.0 g of acetylsalicylic acid daily, starting on the second postoperative day and continuing for six months. (2) One hundred and two grafts in patients on no antithrombotic therapy. (3) Forty grafts in patients on warfarin therapy to maintain the prothrombin time (prothrombin-proconvertin method) within the therapeutic range (0.10 to 0.20). Medication was continued for six months. This group included more high-risk patients than the other two groups. The mean ages and the incidence of risk factors did not vary significantly between the groups. The patency rates in three groups at five years were 62.5%, 44.0% and 26.0% and at ten years 48.5%, 25.0% and 21.5% for the dipyridamole and acetylsalicylic acid, no therapy and warfarin groups, respectively. The limb salvage rates were 100%, 96% and 85% in the dipyridamole and acetylsalicylic acid, no therapy and warfarin groups respectively. Thus, the best results were seen in the aspirin/dipyridamole group.

The diagnostic features and operative results in 13 patients with subclavian artery aneurysms were analysed. Symptoms related to subclavian artery aneurysms were present in seven patients, whereas six patients were asymptomatic and the aneurysm was discovered incidentally on chest X-ray. Angiography was the most valuable diagnostic examination and was also necessary in planning the operation. A correct preoperative diagnosis was made in five of six patients with computed tomography. Resection of the aneurysm was performed in nine and aneurysmal exclusion in the latest four patients. Direct reconstruction was used in nine and in four cases an extra-anatomic carotico-subclavian bypass was performed. Postoperative complications arose in two symptomatic and in four asymptomatic patients (46%: two strokes, two wound infections demanding extirpation of the prosthesis in one patient, two pareses of the recurrent nerve and one postoperative haemorrhage). Operative mortality was one patient. Follow-up data was available for all patients for periods of 6 months to 14 years. The vascular graft was patent in all patients. The authors conclude that subclavian artery aneurysm must be included in the differential diagnosis of all obscure upper mediastinal masses as seen on the chest X-ray and examined with CT and angiography. Exclusion of the aneurysm with extra-anatomical reconstruction is technically easier and gives the same postoperative long-term results as resection of the aneurysm and direct reconstruction. A relatively high complication rate after operation on asymptomatic subclavian aneurysms indicates a need for re-evaluation of operative indications in asymptomatic patients.

Two cases of left ventricular (LV) pseudoaneurysm following mitral valve replacement (MVR) are presented. In one patient the false aneurysm developed after an initially successful correction of intraoperative left ventricular wall rupture while the other case resulted from an apparently uncomplicated MVR performed because of staphylococcal endocarditis. Both cases were detected by combined 2-dimensional and Doppler echocardiography. The operative treatment was similar in both patients. After extirpation of the old prosthesis, the orifice of the pseudoaneurysm was closed from inside the heart, either with a Dacron patch or using interrupted sutures supported by a teflon pledget. One of the patients died one month postoperatively but the other one recovered and is clinically well 6 months after repair. She has, however, a residual communication between the LV and the pseudoaneurysm.

We present a report of a 58-year-old male patient who suffered from Buerger's disease of the upper extremities verified by microscopy and angiography. Despite medical treatment and repeated thoracic sympathectomy he developed gangrene at the tip of his right thumb and index finger. Pedicled omentum was prepared through midline laparatomy, placed through subcostal incision to the subcutaneous space of the forearm and affected fingers. Rest pain disappeared by the fifth day after surgery. The omental pedicle was ligated six weeks post-operatively and the extremity mobilized. The thumb healed well. The index finger required amputation because of continuing infection. Five years postoperatively the patient has a good functioning hand in which the transferred omentum has retained its viability.

We have used polydioxanone (PDS) in 50 patients who underwent coronary artery bypass grafting. The anastomoses consisted of suturing an autologous vein graft to the coronary artery (122 operations), a vein graft to the aorta (63 operations) and the internal mammary artery to the coronary artery (33 operations). The recipient coronary artery was subjected to endarterectomy in 28 instances. The anastomoses proved to be reliable in the early postsurgical period; no bleeding was attributed to the PDS suture. Clinical follow-up for a maximum of two-and-half years, completed using control coronary angiograms in selected cases, demonstrated good results. The practical properties of PDS were evaluated to be at least as good as those of polypropylene. Experiments have clearly shown that small artery anastomoses heal more favourably after the use of absorbable sutures than after the use of nonabsorbable sutures. Because of this finding and on the basis of our clinical experience, we believe the application of PDS in coronary surgery should be recommended as an alternative treatment.

A case is presented of abdominal aortic aneurysm infected with salmonella enteritidis, maintaining septicaemia. Immediate surgery became necessary because of imminent rupture of the aneurysm. The infected thrombus within the aneurysmal sac was debrided, with irrigation of antibiotic solution, and in situ aorto-iliac reconstruction was carried out. A prolonged course of ciprofloxacine and a short course of vancomycin were administered. Recovery was uneventful. The infection parameters are normal 6 months postoperatively and CT-scan shows no signs of periprosthetic infection. The relevant literature concerning the surgical procedures for mycotic aneurysms is reviewed.

The results of 305 femorotibial bypass grafts performed in 246 patients are presented. Of these operations 246 were primary and 58 secondary or tertiary. A total of 66 diabetic patients were in the series. An autogenous saphenous vein graft was employed in 196 primary operations, the other grafts used being PTFE, human umbilical cord vein graft, venous allograft and knitted dacron velour graft. Hospital mortality was 8 patients (2.6%), while late mortality was 73 patients, 39 of them having had patent grafts. There were 89 (29.2%) immediate or early hospital failures. Two-hundred-sixteen grafts were followed for a mean observation time of 62.3 +/- 5.7 months. The cumulative patencies were analyzed using the life-table method. One, five, and ten year overall patencies for saphenous vein grafts as indicated by claudication were 73%, 53% and 35%, respectively. In rest pain, the patency rates were 62%, 46% and 40% at similar intervals. In impending gangrene the patencies were 43%, 35% and 20%, respectively. The patencies for arterial substitutes were generally poor, i.e., 35% and 15% at one and five years. None of the graft substitutes were followed for up to ten years. Diabetic patients had a significantly lower patency rate than nondiabetics (p = 0.002). The impact was remarkable if impending gangrene co-existed. In all these situations the early graft failure ensued. Both the run-off and inflow status affected the patency rates. This was significantly lower (p = 0.001) when only one distal branch was visualized in angiography.

From 1967 to 1982, 305 femoral tibial bypasses were performed. Of these 180 (59%) were performed on limb salvage indication. A reversed autogenous saphenous vein was used in 134 instances, among 46 vein substitutes there were 15 vein allografts, 13 human umbilical cord vein grafts, 12 PTFE grafts and six dacron grafts. Hospital mortality was six patients. An additional 37 patients died during the follow-up period. The patency rates for saphenous vein bypass grafts were 62.5%, 48%, and 25% at one, five, and ten years, respectively, and 33% and 25% at one and five years, respectively, for the vascular substitutes. The mean +/- SD follow-up time was 62.27 +/- 5.7 months. During the early postoperative period 23 legs (12.7%) had to be amputated. During the follow-up period an additional 14 legs (7.8%) were lost giving a limb salvage rate of 79.5%.

In 1966-1986, two men and four women (mean age 47.5 years) underwent surgery for primary sternal tumour. Three of the tumours were benign (two condromata, one osteochondroma) and three were malignant (two chrondrosarcomata, one reticulum cell sarcoma). Inflammatory or degenerative lesions impeded differential diagnosis in three additional cases (without tumour). The tumours were treated with radical resection of the affected part of the sternum, including the relevant attached structures. Marlex-mesh reconstruction of the defect was necessary in four cases. There was no operative mortality. One Marlex graft became infected. At follow-up (average 11.1 years, range 9.0-14.7 years), five patients were alive without recurrence of tumour and the sixth had died of unrelated cause.

Arterial complications of thoracic outlet syndrome (TOS) were surgically treated in 11 patients (12 limbs) and venous complications in five (6 limbs). Arteriography showed total occlusion or significant stenosis of the subclavian artery in eight patients (bilateral in 1), with complicating peripheral thrombosis in three. Two patients had unilateral subclavian artery aneurysm: One was the patient with bilateral subclavian occlusion, and the other also had brachial artery embolism. Yet another patient had brachial thrombosis. Treatment included reconstructive surgery (3 limbs), thoracic sympathectomy (3) or decompression alone (6). Of the five patients with venous TOS complications, four were found at phlebography to have subclavian thrombosis and one had significant bilateral subclavian obstruction. Treatment was transaxillary first-rib resection (4 cases) or division of soft-tissue bands and hypertrophied anterior scalene muscle (1 case). After follow-up averaging 9 years, eight of the nine survivors in the arterial group were working and seven were asymptomatic. All five in the venous group were working and only two had slight, strain-related symptoms. Impaired arterial flow in TOS can usually be managed with decompression, but direct surgery (bypass or thrombectomy) or thoracic sympathectomy is required in cases with severe ischemia with proximal occlusion and after resection of a subclavian aneurysm or in cases with unilateral Raynaud's phenomenon or thrombosis of small arteries. For venous symptoms decompression alone suffices.