Abstract:

Abdominal aortic aneurysms (AAAs) are a major cause of illness and death in the United States and abroad. Along with progress in the surgical management of this condition, numerous advances have been made in understanding the pathogenesis of AAAs. Since the time of Scarpa (1804), AAA disease has been associated with, and attributed to, atherosclerotic vessel changes. Excluding patients with Marfan's Syndrome and Ehlers-Danlos type IV diseases, virtually all human AAA specimens contain some degree of atherosclerosis. However, atherosclerotic changes are associated with diverse arteriopathies (ie, aorto-occlusive disease versus AAAs). Over the last 2S years, considerable research has been performed comparing aneurysmal, occlusive, and normal aortae. AAA disease is a unique process with pathogenic mechanisms that may operate independently of atherosclerosis. In this chapter we discuss the incidence of AAA as well as its pathogenesis concerning genetics, molecular biology, biochemistry, and immunology.

Authors:

David C. Paik, M.D., Joseph F. Capella, M.D., M. David Tilson, M.D., Columbia University, St. Luke's Roosevelt Hospital Center, New York, NY

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Abstract:

The era of human heart transplantation began in 1967 by Dr. Christian Barnard in South Africa. Unfortunately, most patients died within the first year after transplantation from rejection or opportunistic infection, and the procedure was abandoned in all but a few centers. With the dedicated work of Dr. Norman Shumway from Stanford University, advances in immunosuppression and improved detection and management of rejection allowed heart transplantation to evolve from a laboratory curiosity into a clinical reality. Finally, with the introduction of the immunosuppressant, Cyclosporin A (CyA), in the 1980s the number of cardiac transplants being performed increased exponentially. Heart transplantation has entered the mainstream of surgical management of congestive heart failure and approximately 2000 procedures are performed annually in the United States and 3000 worldwide.

Authors:

Valluvan Jeevanadam, M.D., Temple University Hospital, Philadelphia, PA

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Abstract:

Cardiac valve replacement surgery has advanced considerably over the past 20 years with suitable choices of mechanical prostheses and bioprostheses as valvular substitutes. The extensive developments over the past three decades have been introduced to reduce or eliminate valve related complications, namely thromboembolism, anticoagulant related hemorrhage, and structural failure as well as to optimize hemodynamic performance. The mechanical prostheses have been developed to eliminate structural failure, to facilitate prevention of blood status and thrombus formation, to facilitate intraoperative leaflet positioning and to facilitate radiopacity for evaluation of prosthesis function. The biological valvular prostheses, namely porcine aortic or bovine pericardium, have been developed with tissue preservation, together with stent designs, that contribute to preservation of anatomical characteristics and biomechanical properties of the leaflets.

Authors:

W.R. Eric Jamieson, M.D., F.R.C.S. (C), University of British Columbia, Vancouver, Canada

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Abstract:

Vascular surgery has evolved considerably over the past 100 years from a specialty that offered patients only palliative procedures to treat significant vascular diseases to a field centered on the diagnosis and correction of vascular disorders. Aortic and peripheral artery aneurysms were once medical problems rarely diagnosed and frequently fatal. Diffuse, occlusive arterial disease secondary to atherosclerosis frequently resulted in limb gangrene or specific end-organ ischemia. Modern vascular therapy has dramatically reduced the incidence of primary limb amputations and significantly decreased the risk of fatal complication of arterial aneurysm rupture.

Authors:

Michael L. Marin, M.D., Frank J. Veith, M.D., Montefiore Medical Center, New York, NY., Juan C. Parodi, M.D., Instituto Cardiovascular de Buenos Aires, Argentina

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Abstract:

Angiography currently is the principle diagnostic test for evaluation of the vasculature. Though this invasive radiologic procedure demonstrates vascular anatomy and areas of narrowing and blockage, it does not define the specific cause of the occlusion. This limitation may inhibit the appropriate treatment of vascular disease. Recently, a variety of endovascular tools designed for the treatment of specific disorders have been developed, such as lytic therapy for thrombotic occlusions, lasers for fibrotic occlusions, and atherectomy catheters for calcific atherosclerotic occlusions. For effective use of these tools, the specific cause of a vascular lesion must be determined. Angioscopy can enhance the use of these innovative therapies by providing a real-time panoramic view of the lumen, which permits both the diagnosis of luminal irregularities and visual guidance of specific luminal therapy.

Authors:

Joseph I. Zarge, M.D., John V. White, M.D., Temple University School of Medicine, Philadelphia, PA

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Abstract:

As has been the case in many fields in medicine, noninvasive vascular testing techniques originated in research projects to provide more exact definition of normal and abnormal physiology. Early tests were cumbersome to perform, due in part to the lack of dedicated equipment. The introduction of Doppler ultrasound technology in the late 1960s expanded the horizon for vascular testing. By the early 1970s, vascular testing had moved out of the research laboratory into the clinical arena. Dedicated noninvasive laboratories were established within hospital settings as well as part of office practices. The addition of duplex scanning greatly enhanced the capability of noninvasive laboratories and contributed further to growth of noninvasive testing. By the end of the decade, the vascular laboratories were well established across the country. The 1980s saw a great increase in the number of vascular laboratories, as well as the number of tests performed. There appeared to be unrestricted potential for growth and, unfortunately, increasing examples of abuse were encountered. As could be expected, excesses did not remain unchallenged and increasing restrictions were placed on the vascular laboratories, primarily in the areas of payment policy and levels of reimbursement.

Authors:

J. Dennis Baker, M.D., University of California School of Medicine, Los Angeles, CA

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Abstract:

Each new technique for achieving and clarifying the diagnosis of arterial disease has stimulated an effort to establish its value as a tool for guiding surgical intervention. Noninvasive studies such as oculoplethysmography (OPG), phonoangiography, Doppler ultrasound spectral analysis, B-scan ultrasound, duplex ultrasound, computed tomographic (CT) scanning, magnetic resonance imaging (MRI), and transcranial Doppler have been seductive because these tools require no invasion of the. body or the artery of interest and are, therefore, eminently safe.

Authors:

W. Robert Felix, Jr., M.D., Chestnut Hill Medical Center, Chestnut Hill, MA, Harvard Medical School, Boston, MA

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Abstract:

Chronic venous insufficiency has been known as a distinct pathologic entity at least since the time of Hippocrates, yet many pathologic features of this common ailment remain obscure. A recent resurgence of investigative effort in chronic venous insufficiency has occurred, spurred by the development of valve reconstruction surgery. The advent of newer diagnostic devices and techniques such as duplex scan and air plethysmography allow for a more detailed examination of the venous system than was possible previously.

Authors:

Seshadri Raju, M.D., University of Mississippi Medical Center, Jackson, MS

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Abstract:

Thromboembolism from a venous source continues to be of clinical significance with an annual incidence of 300,000 to 600,000 cases. These episodes of pulmonary embolism result in at least 50,000 deaths per year despite the use of effective prophylaxis and availability of noninvasive techniques to establish early diagnosis and treatment of thrombotic events. The main treatment modality continues to be effective anticoagulation, but this treatment may fail to control thromboembolism in 5% to 10% of patients, and anticoagulants have been associated with a mortality rate of up to 15%

Authors:

Ali F. AbuRahma, M.D., Yancy S. Short, M.D., West Virginia University, Charleston Area Medical Center, Charlston, WV

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Abstract:

Although blood transfusion has helped make major vascular surgery possible, it has done so at a potential cost to our patients. Allogeneic red cell transfusions subject patients to the risks of transfusion reactions, disease transmission, and immunomodulation. These risks can be avoided in the majority of our patients through a better understanding of transfusion practices and the use of multiple alternatives to allogeneic blood.

Authors:

Richard K. Spence, M.D., Umur Atabek, M.D., Cooper Hospital/UMC, Robert Wood Johnson Medical School at Camden, NJ

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