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Surgical Technology International I contains 66 peer-reviewed articles featuring the latest advances in surgical techniques and technologies.

 

1991 - ISBN 1 85745 020 5

 

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Introduction by Ben Eiseman MD, FACS

Sections

Cardiovascular Surgery

 

Impact of Technological Advances on Vascular Surgery in the 1990s
John J. Bergan MD FACS Hon FRCS (Eng), Clinical Professor of Surgery, University of California, San Diego; Uniformed Services University of The Health Sciences, Bethesda, Maryland; Scripps Memorial Hospital, La Jolla, California

01-135

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Abstract

'All change is a miracle to contemplate; but it is a miracle which is taking place every instant.' Henry David Thoreau, Walden, 1854. Progress in vascular surgery is fuelled by technology. Every advance in modern vascular surgery has been preceded by a technological development which, though apparently amazing, soon became a commonplace. Those who do not believe in change in vascular surgery or that technological advances described in this volume will have any place in the treatment of vascular disease, reflect an attitude described best by Lord Moynihan, then President of the Royal College of Surgeons of England. He said, 'surgery ... has now almost reached its limit...we can surely never hope to see the craft of surgery made much more perfect than it is today.' Changes which have occurred since that statement are a cascade of advances including antibiotics, anticoagulants, prostheses, sutures, needles, and a variety of scopes which have become as common as aseptic technique.

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The Vascular Laboratory in the 1990s

What's in and what's out
D. Preston Flanigan MD, Clinical Professor of Surgery, University of California School of Medicine, Irvine, California

01-139

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Abstract

The vascular laboratory as a recognised entity is, at best, only 15 years old. Many growing technologies were applied prior to this time, but it was not until the addition of Doppler ultrasound to the vascular surgeon's armamentarium that non-invasive diagnosis began to take hold. The vascular laboratory was necessary because angiography, which was felt to be the gold standard by many, was expensive, had the risk of potentially serious complications, and did not have the characteristics of a test which made it easily repeatable at frequent intervals. Most importantly, angiography was an anatomic evaluator and provided minimal information regarding function. Although pathologic anatomy and function are often related, the relationship is sufficiently weak to dictate the need for an accurate method of functional evaluation. This was the role of the early vascular laboratories. Today's vascular laboratory provides both functional and anatomic information. In some cases, the anatomic information is superior to that which can be obtained from angiography.

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Prosthetic Vascular Grafts
The state of the art in the 1990s

Richard F. Kempczinski MD, Professor of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio

01-144

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Abstract

During the early years of vascular prosthetic development (1940-1960), the characteristics of the ideal graft were gradually defined. In order to be clinically useful, a vascular graft must be readily available in a variety of sizes and lengths and be suitable for use throughout the body.

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The Future of Lasers in Endovascular Surgery
Rodney A. White MD, Chief, Vascular Surgery, Harbor-UCLA Medical Center; Associate Professor of Surgery, UCLA School of Medicine, Los Angeles, California

01-146

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Abstract

The potential for precise tissue ablation via a miniaturised delivery system (i.e. fibre optics) makes laser angioplasty a promising alternative for treatment of atherosclerotic occlusions which are not amenable to current forms of therapy. This is a particularly relevant consideration since the majority of developing angioplasty devices aside from balloons are difficult to miniaturise in a cost-effective manner. The utility of contemporary devices is restricted to stenotic or short occlusive lesions, with a high rate of early recurrence of lesions being a significant limiting factor in most locations. In order to address and resolve the current deficiencies and define the potential of lasers as an angioplasty device, it is first appropriate to overview the current status and define unresolved issues.

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Endovascular Techniques and Peripheral Vascular Surgery
Thomas J. Fogarty MD, Director of Vascular Surgery, Sequioa Hospital, Redwood City, California, George D. Hermann BSME, Engineering Manager, Fogarty Research, Portola Valley, California

01-150

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Abstract

Endovascular is an increasingly popular term that describes the use of catheter-based instruments to diagnose and treat vascular disease. Implicit in this terminology is its association with techniques that are less invasive to the patient than traditional surgical techniques. Endovascular techniques began in 1963 with the advent of the Fogarty arterial embolectomy catheter for removal of clotted blood from the peripheral arterial circulation. Shortly thereafter, radiologist Charles Dotter introduced the concept of arterial dilatation which was popularised a decade later by cardiologist Andreas Gruntzig with the use of a non-dispensible plastic balloon catheter. During the next two decades, endovascular techniques proliferated in the growing fields of interventional cardiology and interventional radiology, yet were embraced more slowly by the surgical community.

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Will Angiosocopy Replace Operative Arteriography in the 1990s?
Cornelius Olcott IV MD, Associate Clinical Professor of Surgery, Stanford University School of Medicine, Palo Alto, California

01-055

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Abstract

Vascular surgeons have always been concerned with the intra-operative assessment of their reconstructions. Failure of vascular reconstructions in the early post-operative period is most commonly a result of a technical error at the time of surgery. Hence, any technique which aids the vascular surgeon in evaluating his reconstruction and in preventing technical errors will be beneficial to both the surgeon and their patient. Traditionally, intra-operative arteriography has been the 'gold standard' for evaluating vascular surgical procedures.

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Reperfusion Syndrome
Malcolm O. Perry MD, Professor of Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee

01-158

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Abstract

The interruption of blood flow causing ischemia is usually the result of an intrinsic obstruction of major arteries by clots. Emboli that originate in the heart are the main cause of such obstructions, and patients who have had myocardial infarcts or have stenosis of the mitral valve or arrhythmias such as atrial fibrillation are susceptible to the development of clots within the heart which can lead to distal thromboembolism. Another common cause of arterial obstruction is the formation of clots in an area of narrowing caused by arteriosclerosis.

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Steps to Technical Expertise in Carotid Endarterectomy
Wesley S. Moore MD, Professor of Surgery, Section of Vascular Surgery, UCLA Center for the Health Sciences, Los Angeles, California

01-163

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Abstract

Carotid endarterectomy is a prophylactic operation that is designed to prevent strokes related to atherosclerotic plaques in the carotid bifurcation. Once a plaque is safely removed, a major potential cause for stroke in that patient is eliminated. However, the operation itself carries two major risks: death and stroke. These risks are related to patient selection and technical expertise in the performance of the operation. This chapter will focus upon those aspects of surgical technique, when properly applied, that can minimise the risks of surgical complication and thus permit the operation to achieve its highest potential of stroke prevention.

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A Technique of Carotid Endarterectomy and Carotid Shunting
Toshio Inahara MD, Department of Surgery, St Vincent Hospital and Medical Center, Portland, Oregon, John C. Mayberry MD, Department of Surgery, St Vincent Hospital and Medical Center, Portland, Oregon
Dipankar Mukherjee MD, Department of Surgery, St Vincent Hospital and Medical Center, Portland, Oregon

01-168

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Abstract

With the advent of carotid arterial operations, concerns of interruption of cerebral perfusion and ischemic injury loomed as the major deterrent. The physiologic basis for cerebral protection is to diminish its oxygen requirement by chemical or hypothermic means or to continue its adequate arterial perfusion. The first successful carotid reconstruction resecting an internal carotid stenosis with anastomosis of the patent external carotid to the distal internal carotid artery was performed by Carrea of Argentina in 1951. Preoperatively, ascorbic acid and phenobarbital was given but its rationale was not explained.

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Refinements in the Techniques of Venous Surgery
Norman L. Browse MD, FRCS, Professor of Surgery, St. Thomas' Hospital, London, UK

01-171

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Abstract

The surgery of venous disease falls into two distinct categories, the removal of malfunctioning unsightly superficial veins and the restoration of the function of the deep veins by repairing or replacing valves or bypassing obstructions. During the past decade surgical advances have mainly been concerned with the refinement of techniques to reduce the cost of surgery and its outward and visible manifestation - the scars, rather than the introduction of new principles or objectives.

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Popliteal Vein Valve Transplantation for Deep Venous Valvular Incompetence
Thomas F. O'Donnell Jr. MD, Division of Vascular Surgery, New England Medical Center Hospitals, Tufts University School of Medicine, Boston, MA, Harold J. Welch MD, Division of Vascular Surgery, New England Medical Center Hospitals, Tufts University School of Medicine, Boston, MA

01-173

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Abstract

Interest in deep venous reconstruction for severe chronic venous insufficiency (CVI) is burgeoning. Vein valve transplantation for deep venous valvular incompetence, an indirect method for correcting deep venous valvular incompetence achieves its physiologic benefits by placing a normal functioning valve harvested from the upper extremity into the deep system. By contrast, other authors in this volume have presented alternative forms of deep venous valvular reconstruction where the valve mechanism itself is directly repaired or a local segment of vein containing a functioning valve from the same anatomic area, such as the saphenous or profunda, is transposed into the deep venous circuit. Several factors influence the role of deep venous valvular surgery and its frequency. For example, the incidence of deep venous involvement in patients with advanced stage II or frank ulceration (stage III) is variable and depends upon patient selection process.

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Venous Valvuloplasty
Robert L. Kistner MD, Straub Clinic, Honolulu, Hawaii

01-181

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Abstract

The technical feasibility of surgical correction of abnormal venous valves is now established. In times past, it was generally thought that surgery inside the veins would be fraught with a virtual certainty of failure due to thrombosis of the vein. This has turned out to be not true. In 1968 the first venous valvuloplasty was done and since then hundreds more have been reported from surgeons in America and Europe with a very rare incidence of post-operative thrombosis. The operation is done today by any vascular surgeon who has taken the time to study the details of technique that are necessary to achieve a successful repair.

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New Devices and Techniques for Thrombectomy of Arteries and Grafts
Thomas J. Fogarty MD, Director of Cardiovascular Surgery, Sequoia Hospital, Redwood City, California, Michelle Y. Monfort, Biomedical Design Engineer, Fogarty Research, Portola Valley, California

01-185

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Abstract

An arterial embolus is an obstructive segment of material which travels along the bloodstream until lodging in an artery which is too small in diameter to permit its passage. The embolus will halt flow of oxygenating blood to all tissue beyond the point of obstruction. Blood distal to the obstruction will stagnate and thrombose - or clot in place, effectively propagating the obstructive material along the artery. Arterial embolism poses a threat to both life and limb and prior to the mid-1960s was difficult for surgeons to treat because there was no simple and effective means to remove the embolus and associated distal thrombus.

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Angioplasty of the Completely Occluded Coronary Vessel
Norberto S. Schechtman MD, Interventional Cardiologist, North Miami Beach, Florida, Joseph Rosenblum DO, Consultant in Cardiovascular Research, San Francisco Heart Institute, San Francisco, California
Richard E. Shaw PhD, Director of Research and Operations, San Francisco Heart Institute, San Francisco, California, Richard K. Myler MD, Executive Director, San Francisco Heart Institute and Clinical Professor of Medicine, UCSF, San Francisco, California, Simon H. Stertzer MD, Director of Medical Research, San Francisco Heart Institute and Associate Professor of Medicine, UCSF, San Francisco, California

01-191

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Abstract

Over the past 12 years, the development and widespread use of new interventional techniques has widened the indications for the use of percutaneous transluminal coronary angioplasty (PTCA) in the treatment of totally occluded coronary arteries. In the early reports of the National Heart Lung and Blood Institute (NHLBI) Registry investigators recommended that angioplasty should not be attempted in coronary total occlusions. However, with improvements in operator skills, advanced catheter technology, and most notably, with the development of steerable guidewire systems, angioplasty is now being used to treat totally occluded arteries in an increasing number of patients.

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The Selection of Cardiac Pacing Systems
Nora Goldschlager MD, FACC, Professor of Clinical Medicine, UCSF School of Medicine and Director, Coronary Care Unit, San Francisco General Hospital, San Francisco, California

01-197

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Abstract

Once the decision has been made to implant a permanent pacing system for the management of symptomatic bradycardias, a clinical assessment of the patient's physiological needs must be made together with a systematic determination of the pacemaker features that can best meet those needs. The primary clinical objectives should be the restoration and maintenance of optimal cardiac function, so as to enable the patient to be as active as possible. Unless the clinical goals are clearly defined and the physiological consequences of various pacemaker features understood, the implanted system may not fully benefit the patient, or may even exacerbate the patient's symptoms. Clinical assessment usually includes an ambulatory electrocardiogram to document the occurrence, frequency, and type of tachycardia, and an exercise test to assess the presence of 'chronotropic incompetence,' defined as inability to increase heart rate in response to increased metabolic need.

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Current Pacemaker Therapy
Surgical consideration involving leads and lead placement

Thomas J. O'Connell MD, Seton Medical Center, Daly City, California

01-202

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Abstract

The implantable pacemaker, like the telephone, has evolved from a rather straightforward device, which offered virtually no choice to its early users, to a highly complex system embodying a number of choices, many of which must be made at the outset because they affect the performance of the system throughout its lifetime. The most important of these choices, is, of course, selection of the mode of pacing and its relationship to the underlying arrythmia. These considerations are discussed in considerable detail in Dr Nora Goldschlager's article on electrophysiology, and will not be repeated. The focus of this discussion will be on surgical techniques of implantation, particularly as related to the evolution of the modern lead system.

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Implantable Cardioverter Defibrillators
The state of the art

Sanjeev Saksena MD, FACC, Warren, New Jersey

01-2006

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Abstract

Implantable devices are now being routinely used for the treatment of patients with malignant ventricular tachyarrhythmias. This technology became an approved clinical therapy in the United States in 1985. The prototype implantable cardioverterdefibrillator ICD was developed in the 1970s and investigated in the 1980s. Since its approval in 1985 for general clinical application, ICDs are being increasingly used in patients with life-threatening ventricular tachyarrhythmias based upon a number of clinical trials undertaken in North America and western Europe.

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Intra-operative Coronary Angioscopy
Sharon B. Siegel MD, San Francisco Heart Institute, Seton Medical Center, Daly City, California, Geoffrey H. White MD, Prince Alfred Hospital, Sydney, Australia

01-210

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Abstract

A goal of this article is to demonstrate how easily angioscopy can be incorporated into coronary artery bypass grafting. Intra-operative angioscopy has been used in a number of applications including prebypass arterial evaluation, inspection of the interior of the vein graft, examination of graft to coronary anastomoses and outflow. And adjunctive guidance during adjunctive revascularisation procedures. Despite promising initial trials of the use of intraoperative angioscopy, this technology has not been widely adopted because of perceived demanding technique, excessive effort required, and potential complications. Moreover, the possible benefits of the additional information gained during cardiac surgery operations have thus far only been partially demonstrated.

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Advances in Paedriatric Cardiac Surgery
Kevin Turley MD, Chief, Paediatric Cardiovascular Surgery, California Pacific Medical Center, San Francisco, California

01-218

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Abstract

Treatment of congenital cardiac disease has been marked in the recent decade by a movement towards treatment in early infancy, the development of techniques of radical palliation for conditions previously inoperable and the emergence of transplantation as a viable alternative.

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Left Ventricular Assist Device
Michael K. Wood MD, Peninsula Hospital Medical Center, Burlingame, California

01-221

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Abstract

Left ventricular assist device (LVADs) have been used with increasing frequency since the late 1980s. Technology has improved these devices to make them less thrombogenic and has decreased their size to allow greater application. By definition, the LVAD only assists or supports the pumping function of the left ventricle, unlike cardiopulmonary bypass which provides total circulatory and pulmonary function. LVADs support the circulation for hours to days and occasionally for weeks when the left and/or right ventricle has failed and is therefore unable to sustain the circulation. The hope is that by temporarily supporting the circulation, ventricular function will return. In other instances, LVAD type devices (also known as prosthetic ventricles) are used to 'bridge' the time until a suitable heart donor can be located for transplantation.

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Intervention in the Late Stages of Congestive Heart Failure
Prospects in the 1990s

J. Donald Hill MD, Department of Cardiovascular Surgery, California Pacific Medical Center, San Francisco, California, G. James Avery II MD
Department of Cardiovascular Surgery, California Pacific Medical Center, San Francisco, California, Nina E. Topic RN MS, Department of Cardiovascular Surgery, California Pacific Medical Center, San Francisco, California

01-224

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Abstract

The human heart is a brilliant example of biological engineering. Its four engineering components, when properly integrated, is a marvel of a rugged, high performance, self regulating biological pump. The components of the heart are conduction system (rate control), coronary circulation (fuel supply), valves (directional flow) and muscle (power and force). The breakdown of any component part and failure of proper system integration leads to reduced pumping performance and appearance of clinical symptoms. Effective treatment exits for the failure of three of these components - valve repair and/or replacement; coronary artery bypass, angioplasty or pharmacologic intervention; and pacemakers and drugs for conduction problems.

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Dynamic Cardiomyoplasty
Ignacio Y. Christlieb MD, Allegheny General Hospital, Allegheny-Singer Research Institute and the Medical College of Pennsylvania, Pittsburgh, PA, George J. Magovern MD, Allegheny General Hospital, Allegheny-Singer Research Institute and the Medical College of Pennsylvania, Pittsburgh, PA, James A. Magovern MD, Allegheny General Hospital, Allegheny-Singer Research Institute and the Medical College of Pennsylvania, Pittsburgh, PA

01-231

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Abstract

On January 8, 1985, Carpentier and his cardiovascular surgery group at the Broussais Hospital were the first to replace diseased human myocardium with a stimulated latissimus dorsi muscle flap. A few months later, Magovern and co-workers at Allegheny General Hospital in Pittsburgh were the first to repair a large left ventricular aneurysm with a latissimus dorsi cardiomyoplasty. Over the past six years, approximately 120 patients have undergone the operation throughout the world.

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Transmyocardial Revascularisation by CO2 Laser
John R. Crew MD FACS, San Francisco Heart Institute, Seton Medical Center, Daly City, California

01-236

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Abstract

Anatomical channels connecting the left ventricular chamber to the myocardial sinusoids supplying the left ventricle with oxygenated blood in the human heart were described by Dr Wearn in 1933. He microscopically confirmed these communicating vessels or tiny clusters of arteries by gelatin filling. The second type of these channels was located at the end of the vessels almost as though woven into the fabric of the muscular fibres. These irregular shaped blood vessels were called myocardial sinusoids. Three other early investigators described connecting channels. The first was Adrian Christian Thebesius, a Dutch physician in 1708 who described connections from the atrium the coronary veins which were called Thebesian veins. The second was the American physiologist F H Pratt who, in 1898, perfused blood though the ventricle alone in a cat, keeping it alive for more than an hour. Finally, the historical work of R T Grant who in 1926 reported that a congenitally deformed heart in a child had connecting cavities with the surrounding veins and arteries.

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