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Acute dissection of the ascending aorta as a late complication of coronary artery bypass grafting has been rarely reported. We report a case of a 61 year-old man in whom acute dissection of the ascending aorta developed 2 years after coronary artery bypass grafting. The ascending aorta was replaced with a Dacron graft, and an island of the aortic wall, on which previous proximal anastomoses had been placed, was implanted into the Dacron graft successfully.

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We report a case of a 60-year-old woman who underwent emergency surgical repair of a ruptured pseudoaneurysm of the left ventricle 10 days after acute myocardial infarction. The repair consisted of oversewing the rupture (2 cm long) on the posterior wall under cardiopulmonary bypass. The patient made a satisfactory recovery.

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PURPOSE: This study reports our experience with thiopental sodium (Pentothal) cerebral protection, without intraluminal shunting, during carotid endarterectomy. Only those complications that occurred during surgery or within 30 days of operation have been addressed. METHOD: A prospective, unselected, consecutive series of 621 carotid endarterectomies was done during a 7-year period, with electroencephalography-monitored, high-dose Pentothal for cerebral protection. RESULTS: Five ischemic strokes (0.8%), completion of two strokes-in-evolution (0.3%) and four strokes caused by cerebral hemorrhage (0.6%) occurred in 11 patients in the perioperative (30-day) period, for a combined cerebral morbidity-mortality rate of 1.7%. Four reversible ischemic neurologic deficits (0.6%) and two transient ischemic attacks (0.3%) in six patients produced a transient deficit rate of 0.9%. Symptomatic coronary artery disease coexisted in 37% of the patients but resulted in only five acute myocardial infarctions (0.7%), one of which was fatal (0.1%). Other perioperative complications in 10 patients (1.5%) were associated with the operative procedure. There were no complications directly attributable to the high-dose Pentothal. Prospective data collection has allowed definition of the disease and cause of all cerebral complications. CONCLUSION: The complications in this series have been related to surgical and clinical management problems rather than failure of cerebral protection. Cerebral protection with high-dose Pentothal under electroencephalographic control has been effective and complication free.

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The need for reoperation caused by recurrence of coronary artery disease is becoming increasingly common. Although reoperation is more difficult and time-consuming, with careful surgical technique it can be carried out with the same mortality as that described by many units for primary coronary artery bypass grafting (1.2-2.0%). In the 172 patients described here, who had coronary artery reoperations between 1981 and 1990, there were two in-hospital deaths (1.2%). There were three postoperative bleeds which required return to theatre. No patient suffered a postoperative neurological deficit or postoperative myocardial infarction. These reoperations comprised 6.9% of the 2497 coronary artery operations carried out in the same period. Follow-up disclosed eight late deaths, from five-62 months after operation; all survivors claim to be symptomatically improved. Consideration should be given to the potential problems of reoperation when carrying out primary myocardial revascularisation.

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Confirming the diagnosis of acute transection of the descending aorta can be problematic. Unnecessary patient movement and time delay are often associated with conventional investigations. We describe a patient in whom such an injury was clearly and quickly defined at the bedside by transesophageal echocardiography.

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The coexistence of coronary and carotid arterial disease in the same patient requires that particular measures be undertaken to avoid the risks of myocardial infarction and stroke. The last 50 patients requiring operations on both subsystems and with no mortality and minimal morbidity are reported. A method for the management is described, to allow discrimination between those patients needing a combined coronary-carotid procedure and those in whom the operations should be staged. The application of this protocol to the last 1732 patients who presented with coronary and/or carotid artery disease has resulted in all overall mortality of 0.63% and morbidity of 0.17%.

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Between January 1978 and August 1985, 1500 patients underwent coronary artery bypass grafting by one surgical team, with a total mortality of 0.46% (seven patients). All these patients were suffering from class 3 or class 4 angina and more than half (54%) had evidence of preoperative infarction. The achievement of minimal mortality and morbidity is the immediate aim of surgery; a continuing long-term improvement in symptoms and life expectancy is the ultimate goal. Every physician should be aware of the risks of the invasive treatment of coronary artery disease either by bypass grafting or by angioplasty.

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Seventy patients who underwent a total of 77 consecutive carotid endarterectomies were given thiopentone (mean dose 19 mg/kg) under EEG control for cerebral protection during the period of carotid clamping. This technique was used instead of elective insertion of a temporary bypass shunt in response to adverse EEG changes occurring after clamping. The EEG was monitored continuously throughout operation. The EEG burst-suppression pattern with electrically inactive periods of 30-60 seconds was taken as indicating a depth of barbiturate anaesthesia adequate to provide brain protection. Patients exhibited a drop in blood pressure during barbiturate administration: in most the pressure recovered spontaneously but in twenty operations metaraminol was needed to re-establish an adequate pressure before clamping. No adverse cardiological effects were associated with the administration of thiopentone or metaraminol. There was no mortality and no neurological morbidity in this series.

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The effects of coronary artery bypass grafting (CABG) on ventricular performance and long-term clinical status were studied in 18 consecutive patients with disabling angina pectoris and severely depressed left ventricular (LV) performance (ejection fraction [EF] 27 +/- 9%). All patients survived CABG, although 1 patient had a perioperative myocardial infarction. There was no change in LVEF at rest, 29 +/- 12%, in the other 17 patients. However, LVEF during peak exercise increased from 22 +/- 7% to 27 +/- 14% (p less than 0.05). The 17 patients were separated into 2 groups: those who increased their peak exercise LVEF by at least 10% (group A, 8 patients) and those who increased it by less than 10% (group B, 9 patients). Preoperatively, patients in group A had a higher LVEF at rest (p less than 0.001) and smaller end-systolic and end-diastolic volumes at rest (p less than 0.001) and during exercise (p less than 0.005). Preoperatively, the LVEF in group A decreased with exercise, from 36 +/- 4% to 27 +/- 5% (p less than 0.01), but was unchanged in group B (19 +/- 3% vs 17 +/- 4%, difference not significant). After CABG, patients in group A had a smaller increase in end-systolic volume with exercise than those in group B (13 +/- 7 vs 34 +/- 22 ml/m2, p less than 0.05), but the changes in end-diastolic volume with exercise were not significantly different. At 27 +/- 5 months after CABG, 5 of 8 patients in group A were asymptomatic.(ABSTRACT TRUNCATED AT 250 WORDS)

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A rare case of saccular aneurysm of the right internal carotid artery is presented. The patient was asymptomatic, and the aneurysm was discovered incidentally at examination after a fall. The diagnosis was confirmed angiographically, and the aneurysm was surgically excised with end-to-end anastomosis of the artery.

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The role of surgery in the treatment of extracranial cerebrovascular disease is essentially a prophylactic one but it should be borne in mind that apart from preventing stroke, such procedures will or should eliminate symptoms. The authors believe that every patient suffering from cerebrovascular insufficiency should be thoroughly evaluated for extracranial cerebrovascular occlusive disease and that arteriograms should be performed on all patients who could be expected to be candidates for surgery. The various indications for surgery have been discussed. The authors believe that people who have severe bilateral disease and who are of an advanced age are probably in a higher risk group. They also believe that surgery should not be offered to people who have a complete stroke and who are in semi-coma or coma, no matter how rapidly they may be transferred to the operating theatre. The authors firmly believe that intra-operative E.E.G. monitoring is an important adjunct to the safe surgical treatment of lesions of the carotid bifurcation, not only to indicate when shunting is necessary but also to indicate how well that shunt is functioning. In spite of the frequent presence of associated heart disease, hypertension and other vascular lesions, operation can be offered with confidence to suitable candidates. Elimination of symptoms can be expected in over 90% of cases. Only one patient has suffered a stroke since leaving hospital and this occurred because of occlusion in his internal carotid artery which was not operated on. Apart from patient selection, the factors which have contributed to the authors' low morbidity and mortality have been the use of intra-operative E.E.G. monitoring, intra-operative heparinisation and the availability of excellent angiographic studies.

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