Successful Reoperations Research Articles

Rates and predictors of success and failure in repeat epilepsy surgery: A meta-analysis and systematic review.

Medically refractory epilepsy is a debilitating disorder that is particularly challenging to treat in patients who have already failed a surgical resection. Evidence regarding outcomes of further epilepsy surgery is limited to small case series and reviews. Therefore, our group performed the first quantitative meta-analysis of the literature from the past 30years to assess for rates and predictors of successful reoperations. A PubMed search was conducted for studies reporting outcomes of repeat epilepsy surgery. Studies were excluded if they reported fewer than five eligible patients or had average follow-ups < 1year, and patients were excluded from analysis if they received a nonresective intervention. Outcomes were stratified by each variable of interest, and quantitative meta-analysis was performed to generate odds ratios (ORs) and 95% confidence intervals (CIs). Seven hundred eighty-two patients who received repeat resective epilepsy surgery from 36 studies were included. Engel I outcome was observed in 47% (n=369) of patients. Significant predictors of seizure freedom included congruent over noncongruent electrophysiology data (OR = 3.6, 95% CI = 1.6-8.2), lesional over nonlesional epilepsy (OR = 3.2, 95% CI = 1.9-5.3), and surgical limitations over disease-related factors associated with failure of the first surgery (OR = 2.6, 95% CI = 1.3-5.3). Among patients with at least one of these predictors, seizure freedom was achieved in 58%. Conversely, the use of invasive monitoring was associated with worse outcome (OR = 0.4, 95% CI = 0.2-0.9). Temporal lobe over extratemporal/multilobe resection (OR = 1.5, 95% CI = 0.8-3.0) and abnormal over normal preoperative magnetic resonance imaging (OR = 1.9, 95% CI = 0.6-5.4) showed nonsignificant trends toward seizure freedom. This analysis supports considering further resection in patients with intractable epilepsy who continue to have debilitating seizures after an initial surgery, especially in the context of factors predictive of a favorable outcome.

Endovascular surgery for critical ischemia of lower extremities with suppurative-necrotic lesion of the feet

To improve treatment of patients with grade IV chronic ischemia of lower extremities via endovascular angioplasty combined with surgical methods for suppurative-necrotic lesions of the feet. 51 patients with grade IV chronic ischemia of lower extremities underwent endovascular interventions (balloon angioplasty, stenting). A total of 23 stents were deployed in 16 patients including 12 stents in superficial and common femoral arteries, 5 in popliteal artery, 6 in iliac artery. There were no stents in crural arteries. The most perspective artery for wound healing was preferred in case of revascularization below popliteal segment. Necrectomy was performed along with angioplasty in patients with suppurative-necrotic lesion of the feet followed by delayed reconstructive operations if it was necessary. Endovascular surgery for grade IV chronic ischemia of lower extremities was associated with good immediate results in most cases due to revascularization and organ-sparing interventions for suppurative lesions of the feet. Current endovascular methods allow to perform successful re-operations to restore blood flow in previously repaired arteries and implanted stents with restenosis or thrombosis.

Mo1467 Predictors of Successful Pelvic Reoperations in Colorectal Surgery: A Multivariate Analysis

Mo1467 Predictors of Successful Pelvic Reoperations in Colorectal Surgery: A Multivariate Analysis

Contemporary Management of Splanchnic and Renal Artery Aneurysms: Results of Endovascular Compared with Open Surgery from Two European Vascular Centers

Introduction Splanchnic and renal artery aneurysms (SRAAs) are uncommon but potentially life-threatening in case of rupture. Whether these aneurysms are best treated by open repair or endovascular intervention is unknown. The aim of this retrospective study is to report the results of open and endovascular repairs in two European institutions over a fifteen-year period. We have reviewed the available literature published over the 10 last years. Methods All patients with SRAAs diagnosed from 1995 to 2010 in St Marys Hospital (London, UK) and Henri Mondor Hospital (Créteil, France) were reviewed. Preoperative clinical and anatomical data, operative management and outcomes were recorded from the charts and analyzed. Results 40 patients with 51 SRAAs were identified. There were 21 males and 19 females with a mean age of 57 ± 14.9 years. The aneurysms locations were: 14 (27%) renal, 11 (22%) splenic, 7 (14%) celiac trunk, 7 (14%) superior mesenteric artery, 4 (8%) hepatic, 4 (8%) pancreaticoduodenal arcades, 3 (6%) left gastric and 1 (2%) gastroduodenal. 4 patients presented with a ruptured SRAA. 17 SRAAs in 16 patients were treated by open repair, 15 in 15 patients were treated endoluminally and 17 (mean diameter: 18 mm, range: 8–75 mm) were managed conservatively. One patient with metastatic pulmonary cancer with two mycotic aneurysms of the superior mesenteric artery (75 mm) and celiac trunk (15 mm) was palliated. After endovascular treatment, the immediate technical success rate was 100%. There was no significant difference between open repair and endovascular patients in terms of 30-day post-operative mortality rate and peri-operative complications. No in-hospital death occurred in patients treated electively. Postoperatively, four patients (1 ruptured and 3 elective) suffered non-lethal mild to severe complication in the open repair group, as compared with one in the endovascular group ( p = .34). The mean length of stay was significantly higher after open repair as compared with endovascular repair (17 days, range: 8–56 days vs. 4 days, range: 2–6; p < .001). The mean follow-up time was 17.8 months (range: 0–143 months) after open repair, 15.8 months (range: 0–121 months) after endovascular treatment, and 24.8 (range: 3–64 months) for patient being managed conservatively. No late death related to the VAA occurred. In each group, 2 successful reoperations were deemed necessary. In the endovascular group, two patients presented a reperfusion of the aneurysmal sac at 6 and 24 months respectively. Conclusion No significant difference in term of 30-day mortality and post-operative complication rates could be identified between open repair and endovascular treatment in the present series. Endovascular treatment is a safe alternative to open repair but patients are exposed to the risk of aneurysmal reperfusion. This mandates careful long-term imaging follow up in patients treated endoluminally.

One-Stage Repair of Extensive Thoracic Aortic Aneurysm Using the Arch-First Technique and Bilateral Anterior Thoracotomy

One-Stage Repair of Extensive Thoracic Aortic Aneurysm Using the Arch-First Technique and Bilateral Anterior Thoracotomy

Causes of failure in the surgical treatment of primary hyperparathyroidism: lessons from 51 successful reoperations.

A review of 51 successful reoperations for persisting hypercalcaemia due to primary hyperparathyroidism shows that inadequate anatomical knowledge, inadequate surgical technique and unusual localizations of the parathyroids are the most frequent causes of failure of the primary operation. The majority of these failures are therefore preventable. There is a frequent need for cervical thymectomy in parathyroid surgery. Sternotomy is only very rarely necessary.

Intrathoracic Leaks Following Esophagectomy Are No Longer Associated With Increased Mortality

Assess outcomes following intrathoracic leaks after esophagectomy from 1970 to 2004 to evaluate the impact of evolving surgical and perioperative techniques on leak-associated mortality (LAM). An intrathoracic leak following esophagectomy has historically been considered a catastrophic event, with mortality as high as 71%. Concerns about this complication often affect choice of surgical approach for esophagectomy. A retrospective review of all esophagectomies for cancer from 1970 to 2004 (n = 1223) was performed. Outcomes following intrathoracic anastomoses (n = 621) were analyzed by era: historical 1970-1986 (n = 145) and modern 1987-2004 (n = 476). There was no difference in the frequency of leak between the time intervals (4.8% versus 6.3%, P = 0.5). Despite a significant increase in the use of preoperative chemoradiation (1% versus 42%, P < 0.001) in the historical versus modern era, the overall mortality decreased from 11% to 2.5% (P < 0.001). The LAM was markedly reduced from 43% to 3.3% (P = 0.016). Factors associated with LAM included failure to use enteral nutrition (HR 13.22, CI 1.8-96.8) and era in which the surgery was performed (HR 18.3, 1.9-180). Other differences included an increased proportion of successful reoperations for leak control (11/30 versus 0/7, P = 0.08) and use of reinforcing muscle flaps (7/11). In the modern era, perioperative mortality is not significantly different for patients with or without intrathoracic leaks (3.3% versus 2.5%, P = 0.55), nor is long-term survival (P = 0.16). Modern surgical management of intrathoracic leaks results in no increased mortality and has no impact on long-term survival. Clinical decisions regarding the use of intrathoracic anastomoses should not be affected by concerns of increased mortality from leak.

Long-term results of heart valve replacement with the Edwards Duromedics bileaflet prosthesis: A prospective ten-year clinical follow-up

Objective: The Edwards Duromedics valve (Baxter Healthcare Corp., Edwards Division, Santa Ana, Calif.) was designed with a self-irrigating hinge mechanism to reduce thromboembolic complications. After good initial clinical results, distribution was suspended in 1988 after reports of valve fracture after 20,000 valves had been implanted. The manufacturer conducted extensive studies to improve the Edwards Duromedics and reintroduced a modified version, which is available as Edwards Tekna. The purpose of the study was the evaluation of long-term results of the original Edwards Duromedics that might be important for the current version, the Edwards Tekna valve. Methods: A prospective clinical 10-year follow-up was performed of 508 patients who underwent valve replacement with the Edwards Duromedics valve in the aortic ( n = 268), mitral ( n = 183), and aortic and mitral ( n = 56) position. Results: The perioperative mortality rate was 6.9%; follow-up was 98% complete, comprising 3648 patient-years for a mean follow-up of 86 months (range: 33 to 144 months). The actuarial freedom from complications at the 10-year follow-up and the incidence rate (percent per patient-year) were as follows: late mortality rate, 69.2% ± 2.4% (3.5% per patient-year); thromboembolism, 90.7% ± 1.6% (0.96% per patient-year); anticoagulation-related hemorrhage, 87.7% ± 1.7% (1.34% per patient-year); prosthetic valve endocarditis, 96.7% ± 0.09% (0.38% per patient-year); valve-related mortality rate, 89.3% ± 1.6% (1.21% per patient-year); valve failure, 86.2% ± 1.85% (1.54% per patient-year); and valve-related morbidity and mortality rate, 71.1% ± 2.3% (3.2% per patient-year). Three leaflet escapes were observed (one lethal, two successful reoperations; 99.1% ± 0.05% freedom, 0.08% per patient-year). All patients functionally improved (86% in New York Heart Association classes I and II), and incidence of anemia was insignificant. Conclusions: These results confirm that the Edwards Duromedics valve shows excellent performance concerning thromboembolism, hemolysis, and functional improvement and will serve as a reference for the last version, the Edwards Tekna valve, where comparable long-term data are currently not available. (J Thorac Cardiovasc Surg 1998;115:1121-9)

Role of reoperation in recurrence of adrenal cortical carcinoma: Results from 188 cases collected in the Italian National Registry for Adrenal Cortical Carcinoma

Background. Recurrence of adrenal cortical carcinoma (ACC) after radical surgery is a common finding. Although successful reoperations have been reported with encouraging results, most published experiences are anecdotal and based on few cases. We report the results of surgical treatment for recurrent ACC in a multiinstitutional series. Methods. One hundred eighty-eight cases of ACC were collected in a national registry. A complete follow-up was obtained in 179 cases. At initial diagnosis 92 patients had local disease (stage I or II). One hundred seventy patients underwent surgical treatment, considered radical in 140; in this group, recurrent disease was observed in 52 cases (37%) after a mean disease-free interval of 21.7 months. Results. Adjuvant chemotherapy was ineffective in ameliorating the prognosis. The mean survival in 20 patients who underwent reoperation was significantly higher (15.85 ± 14.9 months) than in nonreoperated cases (3.2 ± 2.9 months). Five-year actuarial survival in reoperated patients is significantly better than in nonreoperated patients (49.7% versus 8.3%, respectively). Conclusions. Although the prognosis of this tumor is still poor, surgery is the only effective therapy; reoperation allows survival comparable to that observed in patients without recurrent disease. An aggressive strategy for recurrent ACC is advisable until prospective studies demonstrate a real effectiveness for chemotherapy.

Difficult Complications After Hip Joint Replacement

Dislocation after hip replacement occurs at an overall incidence of 2% to 3% and has significant cost and morbidity implications. Statistically increased incidence is observed in females and in the elderly, and after reoperation procedures. Specific causes include cup malrotation, trochanteric migration, and decreased femoral offset. Head size, leg length, and postoperative mobilization have not proven to be causative factors, but the posterior exposure statistically and consistently is associated with increased instability. Extended acetabular walls do lessen the incidence of dislocation in the primary but even more significantly in the revision procedure. Early (< 3 months) dislocations successfully are treated by 4 to 8 weeks of immobilization in 60% to 70% of instances. The most successful reoperations are those in which the specific cause of the dislocation has been defined. The success rate is approximately 80% for cup reorientation and trochanteric advancement. Nonspecific or ill defined causes are managed successfully by surgical intervention in only approximately 50% of cases. With extensive soft tissue compromise, limited experience with certain salvage options include the bipolar implant with a reported success rate of approximately 80%. Captive articular designs also seem to be successful in approximately 70% of instances but with relatively short term followup and lingering concerns regarding the long term integrity of the fixation.

Institutional experience with a protocol of early primary repair of double-outlet right ventricle

Our institution has adopted a protocol of primary repair for all patients with double-outlet right ventricle. Since May 1989, 24 consecutive neonates and infants with double-outlet right ventricle and atrioventricular concordance (median age, 4 months) underwent anatomic biventricular repair. One patient (4%) received prior pulmonary artery banding but was still repaired as a neonate at 22 days of age. Twelve patients had a subaortic ventricular septal defect (VSD), 5 patients a subpulmonary VSD, 3 patients doubly committed VSD, and 4 patients a noncommitted VSD. Sixty-nine of 72 associated lesions were repaired simultaneously. Four types of repairs were used: intraventricular rerouting in 16 patients, arterial switch operation with VSD closure into the pulmonary artery in 4 patients, Rastelli-type repair with extracardiac conduit in 3 patients, and the Damus-Kaye-Stansel repair with concomitant repair of aortic arch obstruction in 1 patient. Ventricular septal defect enlargement was necessary in 15 patients. Repair of subpulmonary stenosis and of subaortic stenosis was carried out in 13 and 4 patients, respectively. Three patients underwent simultaneous repair of aortic arch obstruction with no mortality. Two of the patients with noncommitted VSD had simultaneous repair of complete atrioventricular canal and repair of severe pulmonary venous obstruction. The perioperative mortality was 8% (2 patients, and there was one late death (4%). Two patients (9%) underwent early successful reoperations (5 and 8 weeks postoperatively). The two reoperations were for residual VSD (1 patient) and severe mitral regurgitation (1 patient). All 21 survivors are alive at a mean follow-up of 40 months (range, 7 months to 6 years). The estimated 5-year actuarial survival is 88%, with no deaths after 2 months postoperatively. Ninety-five percent of long-term survivors have no restriction of physical activities because of cardiac status and are receiving no cardiac medications. An institutional protocol of early anatomic biventricular repair of double-outlet right ventricle in infants and neonates achieves excellent survival, making palliative operations unnecessary. Associated lesions should be repaired simultaneously. The complexity of these malformations requires a highly individualized and flexible surgical approach.

Supravalvar mitral stenosis: risk factors for recurrence or death after resection.

To assess the medium term outcome in infants and children after surgical resection of supravalvar mitral stenosis with special reference to risk factors for mortality or recurrence of supravalvar mitral stenosis. No detailed follow up has been previously reported in this uncommon condition. Prospective cross sectional clinical and echocardiographic follow up. Paediatric cardiothoracic unit. 23 consecutive children (14 male, nine female, mean age 3 years 2 months at surgery) who underwent resection of supravalvar mitral stenosis between 1978 and 1993. Follow up was for a mean of 58 months (range 0.5-167) after resection of supravalvar mitral stenosis. Four patients developed recurrent supravalvar mitral stenosis: this has not been reported previously. This was recognised 14-108 months after resection and confirmed at repeat operation. Three of these patients had successful reoperations but one died. Five other patients died. On multivariate analysis the only variable associated with survival free of recurrent supravalvar mitral stenosis was older age (18 months or more) at time of surgery (hazard ratio 0.17, 95% confidence interval (CI) 0.03 to 0.95, P < 0.05). Five year actuarial survival free of recurrent obstruction when supravalvar mitral stenosis was resected at age less than 18 months was only 39% (95% CI 9 to 69%) compared with 73% (95% CI 24 to 93%) in older patients. Supravalvar mitral stenosis is part of a spectrum of obstructive lesions affecting the left heart. Recurrent supravalvar mitral stenosis can develop after surgical resection. The prognosis in those who require resection within the first 18 months of life is poor: mortality is high, as is the risk of recurrent supravalvar mitral stenosis in survivors, probably because of continuing turbulent flow across a small left ventricular inflow tract.

Cemented Total Knee Arthroplasty for Gonarthrosis in Patients 55 Years Old or Younger

The results of 68 cemented total knee arthroplasties (TKAs) in 50 patients with gonarthrosis who were 55 years old or younger at the time of surgery were reviewed. These patients were operated on between 1979 and 1987 and were followed for an average of 6.2 years. The average age of the patients was 50 years. Patients were evaluated by the Hospital for Special Surgery knee score. The average preoperative score was 53, and the average follow-up score was 90. Overall, 55 TKAs were rated as excellent and 13 as good. Using the knee rating score advocated by the Knee Society, the average postoperative score was 92 for pain and 84 for function. There were four successful reoperations for patellar component loosening, all in metal-backed patellae. The femoral and tibial components in these patients were intact, and at the follow-up period, two knees were rated as excellent and two as good. Detailed roentgenographic evaluation demonstrated that 20% of tibial components had radiolucencies in at least one zone on the anteroposterior roentgenogram and in 11% on the lateral roentgenogram. Femoral radiolucencies occurred in only 2% of knees. Patellar radiolucencies in one or more zones occurred in 20% of knees that had not had patellar revision. No complete or progressive radiolucencies at the bone-cement interface were noted for any component, and no components were considered to be roentgenographically loose. Cemented TKAs can achieve excellent long-term results in patients younger than 55 years old with gonarthrosis of the knee. These results compare with those obtained in published reports on older age groups.(ABSTRACT TRUNCATED AT 250 WORDS)

The use of high-resolution ultrasound to locate parathyroid tumors during reoperations for primary hyperparathyroidism.

AbstractIn a previous report we compared intraoperative ultrasound (IOUS) to preoperative ultrasound (US) in 25 consecutive patients undergoing reoperations for primary hyperparathyroidism. We demonstrated the superior effectiveness of IOUS to image abnormal parathyroid glands compared to US, and a 50% reduction in operative time resulting from this superior imaging capability. The present study extends these comparisons of preoperative imaging techniques to include computed tomography (CT) and technetium/thallium scintigraphy (Tc/Tl) in an updated series of 39 patients undergoing reoperative parathyroid surgery.All 39 patients underwent successful reoperations for either parathyroid adenoma (34 patients), parathyroid hyperplasia (4 patients), or parathyroid carcinoma (1 patient). IOUS was more effective than preoperative US, CT scan, or Tc/Tl scintigraphy in imaging 41 abnormal glands in these 39 patients. IOUS was not dependent on size or anatomic location of an abnormal gland for successful imaging. Abnormal glands in unusual locations, such as intrathyroidal adenomas or undescended adenomas, were imaged accurately with IOUS. Multiglandular disease was detected by IOUS, with correct imaging of 3 hyperplastic glands in a single patient; no other imaging technique was able to identify more than 1 abnormal gland in any patient. No imaging study (including IOUS restricted to the neck alone) was able to identify accurately a mediastinal parathyroid adenoma (1 patient).A clinical decision analysis revealed that IOUS had the highest sensitivity and positive predictive value of any imaging study. IOUS is thus a tool to be used by the surgeon in reoperations for parathyroid disease to facilitate dissection and identification of abnormal glands. When positive, IOUS can help the surgeon proceed quickly and easily to the location of abnormal tissue.

A Tri-Institutional Comparison of Tissue and Mechanical Valves using a Patient-Oriented Definition of “Treatment Failure”

Selection of valve type for predominant usage is obscured by limiting the analysis to prosthesis-related rather than patient-oriented failure modes. In this report, “treatment failure” is defined as a valve-related death or permanent patient disability; successful reoperations are excluded, and emboli with permanent residua are included. Results with the Starr-Edwards Silastic ball valve (Oregon) and the Hancock (Stanford) and Carpentier-Edwards (Vancouver) porcine valves are compared using this new definition of treatment failure.

Durability of endarterectomy and antegrade grafts in the treatment of chronic visceral ischemia

Several techniques have been used to revascularize the visceral circulation. Although initially successful, these repairs often have a significant rate of late occlusion. To determine the durability of transaortic endarterectomy (TEA) and antegrade aortovisceral grafting, we reviewed the last 67 consecutive patients operated on at the University of California, San Francisco for chronic visceral ischemia. The patients were principally middle-aged (mean, 59 years) women (76%) with atherosclerotic disease involving at least two major visceral arteries. Forty-seven patients underwent TEA; 22 patients had associated renal endarterectomy, and 15 patients had simultaneous aortic reconstructions. Twenty patients had an aortovisceral antegrade bypass placed as their only reconstruction. Two of these had concomitant aortic reconstructions. There were five perioperative deaths. Of the 62 patients available for follow-up, 60 patients who had a total of 111 major visceral branch repairs have been followed up for 6 months to 14 years (mean, 4.4 years). Four patients (7%) have had recurrent visceral ischemia. Two patients had recurrent symptoms and have been asymptomatic for nearly 5 and 6 years, respectively, after successful reoperations. Two patients had intestinal infarction and died as a result. Thirty-four patients have had follow-up aortography that showed 58 widely patent reconstructions, two asymptomatic single-vessel stenoses, and one asymptomatic occlusion. TEA and antegrade visceral bypass provided long-term relief of symptoms and prevented visceral gangrene in 56 of 60 patients (93%). The prolonged patency of these reconstructions is attributed to the following: (1) They originate from undiseased or endarterectomized aorta, (2) they provide optimal, nonturbulent flow, and (3) they avoid the inherent technical pitfalls of retrograde grafting.

Durability of endarterectomy and antegrade grafts in the treatment of chronic visceral ischemia.

Several techniques have been used to revascularize the visceral circulation. Although initially successful, these repairs often have a significant rate of late occlusion. To determine the durability of transaortic endarterectomy (TEA) and antegrade aortovisceral grafting, we reviewed the last 67 consecutive patients operated on at the University of California, San Francisco for chronic visceral ischemia. The patients were principally middle-aged (mean, 59 years) women (76%) with atherosclerotic disease involving at least two major visceral arteries. Forty-seven patients underwent TEA; 22 patients had associated renal endarterectomy, and 15 patients had simultaneous aortic reconstructions. Twenty patients had an aortovisceral antegrade bypass placed as their only reconstruction. Two of these had concomitant aortic reconstructions. There were five perioperative deaths. Of the 62 patients available for follow-up, 60 patients who had a total of 111 major visceral branch repairs have been followed up for 6 months to 14 years (mean, 4.4 years). Four patients (7%) have had recurrent visceral ischemia. Two patients had recurrent symptoms and have been asymptomatic for nearly 5 and 6 years, respectively, after successful reoperations. Two patients had intestinal infarction and died as a result. Thirty-four patients have had follow-up aortography that showed 58 widely patent reconstructions, two asymptomatic single-vessel stenoses, and one asymptomatic occlusion. TEA and antegrade visceral bypass provided long-term relief of symptoms and prevented visceral gangrene in 56 of 60 patients (93%). The prolonged patency of these reconstructions is attributed to the following: They originate from undiseased or endarterectomized aorta, they provide optimal, nonturbulent flow, and they avoid the inherent technical pitfalls of retrograde grafting.

Unusual Sequelae of Colon Interposition for Esophageal Reconstruction: Late Obstruction Requiring Reoperation

Colon interposition has become a favored technique for esophageal reconstruction. Late morbidity is generally related either to technical problems associated with the procedure or to the development of new disorders in the transposed segment. Two patients are discussed who were seen with obstruction of colon interposition grafts ten and five years after esophageal reconstruction. In the first patient, a volvulus of the interposed colon associated with a chronically narrowed area distal to the looped segment resulted in obstruction. In the second patient, the redundant intrathoracic segment of the colon interposition became kinked at the diaphragmatic hiatus leading to dilatation and incomplete emptying. Both patients underwent successful reoperations and are doing well 10 and 12 months later. The causes and possible prevention of these and other late complications of colon interposition are discussed.

Routine Surgical Management of Brachial Artery Occlusion After Cardiac Catheterization

From 1965 through 1980, 1,108 patients (1.5%) underwent thrombectomy and local arterial reconstruction because of brachial artery occlusion after a total of 73,750 cardiac catheterization procedures performed at the Cleveland Clinic. In a study group of 100 consecutive patients, 91 had simple arteriotomy revision and nine had segmental arterial resection with either axial reanastomosis or a saphenous vein interposition graft. Thirteen patients sustained early recurrent thrombosis after limited arteriotomy revisions, and 11 of these had successful reoperations. Ninety-eight patients were discharged from the hospital with normal distal pulses and no ischemic symptoms. Statistical analysis indicated that women were more likely than men to experience early recurrent thrombosis, and that late ischemic symptoms were most common among women and among those who required reoperations at the time of initial treatment.

Operative experience with infective endocarditis

Thirty-two consecutive patients undergoing operative procedures at the Harbor-UCLA Medical Center from 1972 through 1977 for complications of infective endocarditis involving 38 valves were reviewed. Eighteen subjects using intravenously injected drugs were compared to 14 non-drug users. The drug users were found to have endocarditis superimposed on more normal native valves (86 percent of valves versus 56 percent), to have more gram-negative, fungal, and mixed infections (39 versus 0 percent), to require operation more often for resistant organisms or macroemboli (33 versus 0 percent), to require operation more often during active endocarditis (78 versus 43 percent), and to have more frequent periannular extension of aortic infection (57 percent of aortic valves versus 18 percent). The operative procedures included 26 single valve replacements (20 aortic and six mitral), five double valve replacements (aortic and mitral), and did not differ significantly between the two groups except for two partial tricuspid valve excisions in the drug group. The 30 day mortality rate was 6 percent in drug users and 7 percent in non-drug users, although more complications occurred in the drug group, including three successful reoperations for perivalvular problems. The late mortality rate was higher in drug users (39 versus 7 percent), with five of seven late deaths related to continued intravenous drug use. Early operative intervention for uncontrolled complications of infective endocarditis resulted in a low operative mortality rate even in drug users with severe endocarditis.