Carotid pseudoaneurysm is an uncommon but serious complication of carotid endarterectomy. A case is presented in which the lesion occurred four weeks after combined aortocoronary bypass and carotid endarterectomy without patch angioplasty. The English surgical literature concerning this lesion is reviewed and reported. Case ReportA seventy-one-year-old diabetic white male presented to Riverside Methodist Hospitals on August 5, 1985, with claudication. A loud left carotid bruit was appreciated. Arteriography demonstrated greater than 90 % stenosis of the left internal carotid artery (ICA) at its origin (Figures 1, 2) . The vessel was not aneurysmal. The right vertebral artery was occluded, but the carotid system was normal. Aortoiliac occlusive disease, including bilateral superficial femoral artery occlusions with good runoff, was demonstrated. Cardiac catheterization was performed after resting electrocardiography had demonstrated a remote inferior wall myocardial infarction, along with nonspecific ST changes. This showed a large circumflex lesion, nondominant RCA, and 60% LAD lesion. In view of his previous silent infarction he was judged a candidate for aortocoronary bypass and left carotid endarterectomy to precede repair of his aortoiliac and lower extremity disease.On August 12, 1985, the patient underwent left carotid endarterectomy followed by aortocoronary bypass. Findings included excellent left ICA backflow, although there was severe stenosis rather high in the internal carotid that prevented placement of a shunt distally. The at Monash University on June 22, 2015 ves.sagepub.com Downloaded from

The awareness of the diagnostic difficulty and the documented high mortality risk of perioperative myocardial infarction (PMI) has led to the wide use of work up to rule out PMI after major noncardiac operations. This has caused stable postoperative patients to be kept in monitored hospital beds for extended periods of time and to be subjected to additional tests. We hypothesized that the mortality of PMI is high and, therefore, the wide use of postoperative work up to identify these patients is justifiable. We performed the following study to prove our hypothesis. All patients in the recovery room after major noncardiac operations who underwent work up to rule out PMI were identified and followed. The PMI work up included care in an electronically monitored unit, physical assessment, continuous ECG monitoring, and three 12-lead electrocardiograms and cardiac enzymes obtained at six to eight hour intervals. Data collection included patient demographics; preoperative cardiac risk factors; incidence of intraoperative hypotension, hemorrhage and ECG changes; type of anesthesia and operative procedures and their durations; postoperative ECG and cardiac enzyme results; the incidence of PMI and patient outcome.Two hundred patients were studied; 85 males and 115 females. Their mean age was 62.9 years. Preexisting conditions included hypertension in 162 patients, peripheral arterial disease in 102, diabetes mellitus in 97, angina in 30, previous myocardial infarction in 41, and smoking in 107. Of 200 patients, 164 had an abnormal preoperative ECG. Vascular operations were performed in 104 patients, nonvascular abdominal operations in 48, and other operations in the remaining 48. Intraoperatively, hypotension occurred in 29 patients, blood loss of >500 ml in 25 and ECG changes in 10. There were no deaths. PMI occurred in 5/200 (2.5%) patients. Four had undergone vascular operations and one had had an abdominal operation. The mean age of the patients with PMI was 64.2 years. The duration of operation and blood loss were similar to those of patients without PMI. None of these patients developed cardiac failure or cardiogenic shock and none of them died. Conclusion:The incidence of PMI among patients undergoing noncardiac surgery is low and its mortality is negligible. Physicians should become more selective in the use of monitored beds and in the ordering of a work up to rule out PMI. Technology, Pauwelsstrasse. 30, D-52057, Aachen, Germany Aims: To study the relationship between myocardial release of cTnI and myocardial cell death as assessed by the amount of apoptosis and necrosis after cardiac surgery. Methods:Eighteen young pigs were operated on with standardized cardiopulmonary bypass (CPB). Release of cTnI in the cardiac lymph (CL), coronary sinus (CS), and arterial blood (A) was related to postoperative myocardial cell death by both necrosis and apoptosis. Apoptotic cells were detected by a TUNEL detection kit. Necrotic cells were counted by light microscopy. Results:In all animals, cTnI was significantly relea...

An interesting case of aortorenal bypass allowing discontinuation of renal dialysis is presented, along with a brief review of the literature. Case ReportA fifty-six-year-old white male was admitted with pulmonary edema. History included myocardial infarction three years prior to admission, hypertension treated for ten years, and diabetes mellitus requiring insulin for eighteen months. Renal failure was identified by an elevated BUN (156 mg/dl) and serum creatinine (13.2 mg/dl). The patient was begun on hemodialysis with consequent reduction of serum creatinine to 6.4 mg/dl. Renal ultrasonography gave normal findings. Percutaneous needle biopsy of the kidney revealed nonspecific changes of acute renal failure without widespread glomerular hyalinization. Abdominal aortography demonstrated bilateral total renal artery occlusions. There was very diminished opacification of the renal circulation from lumbar arterial collateral sources (Fig. 1). The right renal artery was occluded over a 2-cm length to its primary bifurcation. On the left the occlusion was less than 1 cm and was thought to be secondary to mural aortic plaque. The abdominal aorta was severely atherosclerotic with ulceration extending into the iliac system. The patient underwent bilateral aortoiliac and bilateral saphenous aortorenal bypass. Aortorenal anastomoses were end-side. Renal dialysis was required on two occasions after surgery but was discontinued by the eighth postoperative day. Serum creatinine was 3.1 mg/dl on discharge, with further declines to 1.7 two weeks later and to 1.4 at two months. The postoperative course to seventeen months has been uneventful.