Record 1 from database: MEDLINE Order full text for this document Title Admission surgery: the patient

with abdominal and thoracic trauma. Author Rupp M Address Source Todays OR Nurse, 1993 Jul-Aug, 15:4, 29-35 Abstract 1. Epidemiology may affect admission. It is essential to know what types of trauma patients are typically admitted, at what time of day, and on which day of the week. Within trauma systems, one of the major determinants of patient survival is the adequacy of surgical personnel and equipment resources. 2. Assessment of the abdominal and thoracic trauma patient is an active process, requiring constant curious attention. Due to the time-critical nature of these injuries, effective communication is paramount. There may be little or no documentation, and minimal verbal report, consisting of mechanism of injury and vital signs. A stable patient may rapidly deteriorate. 3. Injury severity and location are key in patients' mortality and morbidity. Outcomes for vascular injury surgeries depend on time lag, differences in surgeons' experience, associated injury, site of wounds, type of arterial lesions, and infection. Record 2 from database: MEDLINE Order full text for this document Title Bicycle trauma: a five-year experience. Author Yelon JA; Harrigan N; Evans JT Address Department of Surgery, Nassau County Medical Center, East Meadow, New York 11554. Source Am Surg, 1995 Mar, 61:3, 202-5 Abstract The medical records of 84 patients who were admitted to the hospital following injuries sustained during bicycle collisions (BC) between January 1986 and December 1991 were retrospectively reviewed. BC most commonly occurred during summer months in the afternoon and early evening. The average patient age was 21.3 years, with more men injured than women (83% vs 17%). Forty-four individuals were struck by a motor vehicle, 36 fell from their cycles, and two were struck by another cyclist. The average ISS for the group was 13.1. Fifteen per cent of the patients had a documented positive toxicology screen; all patients tested positive for ethanol, with an average blood alcohol level of 201 mg/dL. An additional 17% of patients had polychemical intoxication. Orthopedic injuries were the most commonly encountered (59.5%),

with lower extremity fractures being most common (52%). Neurologic injuries accounted for 35.7% of injuries, with closed head injuries being most common. Twenty-four patients sustained visceral injuries: 50% thoracic, 25% genitourinary, and 25% abdominal. Of the thoracic injuries, 83% had parenchymal lung injuries, and half had skeletal chest injury. No patient had a vascular lesion within the chest, owing to the minimal deceleration incurred during these injuries. The genitourinary injuries (n = 6) were all urethral injuries that occurred with ejections from the bicycle. No patient had any form of protective gear. The overall average length of stay was 9.15 days, with 30.9% requiring ICU admission. Although bicycling remains a popular recreational activity as well as mode of transportation, few locals mandate protective legislation.(ABSTRACT TRUNCATED AT 250 WORDS)

Record 3 from database: MEDLINE Order full text for this document Title [Increased association of cardiac and thoracic vascular lesions after closed trauma of the thorax] Author Pretre R; Murith N; Faidutti B Address Departement de Chirurgie, Hopital Cantonal Universitaire, Geneve, Suisse. Source Ann Chir, 1995, 49:9, 854-7 Abstract The association of a cardiac and a thoracic vascular lesion following blunt trauma seems real based on our experience and other published reports. Over the last 4 years, we have operated upon 3 patients with this association. The cardiac lesions included severe myocardial contusion (documented by electrocardiographic and enzymatic changes), a tear of the aortic valve, and occlusion of a coronary artery. The vascular lesions consisted in rupture of the aortic isthmus in 2 patients and traumatic pseudoaneurysm of the innominate artery. This association justifies a detailed cardiovascular evaluation in any case of severe cardiac or thoracic vascular lesion.

Record 4 from database: MEDLINE Order full text for this document Title Aortoventricular fistula secondary to blunt trauma: a case report and review of the literature. Author Siavelis HA; Marsan R; Marshall WJ; Maull K Address Department of Surgery, Loyola University Medical Center,

Maywood, Illinois 60153, USA. Source J Trauma, 1997 Oct, 43:4, 713-5 Abstract An aorto-right ventricular fistula secondary to nonpenetrating trauma is described. Review of the literature is reported. Ascending aortic injuries present as either traumatic pseudoaneurysms or, less commonly, as aortocardiac fistulas. Blunt cardiac injury is a frequent concomitant injury and contributes to the high mortality of this lesion. Prompt surgical intervention is required for survival.

Record 6 from database: MEDLINE Order full text for this document Title Blunt injury to the supra-aortic arteries. Author Prtre R; Chilcott M; Mrith N; Panos A Address Departement de Chirurgie, Hopital Cantonal Universitaire, Geneve, Switzerland. Source Br J Surg, 1997 May, 84:5, 603-9 Abstract BACKGROUND: Blunt trauma causing injury to the vessels of the aortic arch is uncommon but may be attended by serious consequences. Most surgeons will experience only an occasional case and will need to rely on published literature for guidance. METHODS: A Medline search over 1986-1995 was carried out using the following keywords: brachiocephalic trunk, common carotid artery and subclavian artery; injury was used as a subheading. RESULTS AND CONCLUSION: After the aortic isthmus, the innominate is the most commonly injured artery in the chest. Whatever the site of an arterial lesion, however, angiography is the diagnostic test of choice. Some vascular lesions are relatively benign and may be managed without operation; this form of management may also be appropriate if there is severe associated neurological injury. Otherwise, operation using an approach and technique suited to the site of the injury is advocated. Record 7 from database: MEDLINE Order full text for this document Title [Thoracic traumas and wounds in Libreville. Therapeutic aspects. Apropos of 106 cases] Author Ondo N'Dong F; Rabibinongo E; Ngo'o Ze S; Bellamy J; Mambana C; Diane C Address Service de Chirurgie Thoracique, Vasculaire et Viscrale, Fondation Jeanne Ebori, Libreville Gabon.

Source J Chir (Paris), 1993 Aug-Sep, 130:8-9, 367-70 Abstract 106 cases of trauma and chest wounds have been treated at the Jeanne Ebori Foundation from 1980 to 1990. They involved 90 men (85%) and 16 women (16%) with an average age of 35. The prevalent etiology was road accidents 55 (52%), followed by assaults 30 (28%). 22 blade wounds and 12 bullet wounds required coordinated surgical and intensive care at resuscitation. 19 pleuro-mediastinal spills, 8 intra-thoracic lesions with 6 vascular wounds and 1 heart wound. Surgical treatment required 13 immediate thoracotomies and in 3 cases with 1 associated laparotomy. We recorded 8 deaths (7%), 75 healings without consequences (71%) and 23 healings with consequences (22%). We noted the extreme gravity of the penetrating wounds especially bullet wounds, as well as that of the poly-traumatisms. This picture requires complex resuscitation management with surgical relays in a precarious respiratory context.

Record 8 from database: MEDLINE Order full text for this document Title Management of airway trauma. II: Combined injuries of the trachea and esophagus. Author Kelly JP; Webb WR; Moulder PV; Moustouakas NM; Lirtzman M Address Source Ann Thorac Surg, 1987 Feb, 43:2, 160-3 Abstract Twenty-four consecutive patients with combined injuries of the trachea and esophagus were operated on at the Tulane University Hospital and the Charity Hospital of New Orleans between 1967 and 1983. Only 3 of the injuries resulted from blunt trauma, and 1 of these patients had a total transection of both the trachea and esophagus; the remaining injuries were due to penetrating trauma (20 gunshot wounds; 1 stab wound). The combined lesions involved the cervical region in 20 patients and the thoracic esophagus and trachea or bronchus in 4. All patients underwent bronchoscopy; in recent years all have had esophagoscopy, because our experience indicates that esophagrams, which patients also underwent, have a high rate (12.5%) of false negative results. Operative techniques included a two-layer closure of all esophageal injuries, closure of the trachea with non-absorbable monofilament suture, and transthoracic or cervical drainage. Muscle flaps were used for suture line reinforcement. Associated operative procedures included tracheostomy (5), laparotomy (4), vascular procedures (5), neurologic procedures (2), and closed-tube thoracostomy (6). Five patients (21%) died in the perioperative period, 4 of 20 with combined cervical injuries, and 1 of the 4 with combined thoracic injuries. Deaths resulted from missed injuries to the esophagus (2 patients), a missed tracheal injury (1), associated vascular injury (1), and associated thoracoabdominal injury (1). Two patients

experienced cervical esophageal suture line leaks, both of which sealed with conservative therapy. Clinical follow-up showed good results in 90% of the patients who survived.(ABSTRACT TRUNCATED AT 250 WORDS) Record 9 from database: MEDLINE Order full text for this document Title Combined ascending aorta rupture and left main bronchus disruption from blunt chest trauma. Author Marzelle J; Nottin R; Dartevelle P; Gayet FL; Navajas M; Rojas Miranda A Address Thoracic Department, Marie-Lannelongue Hospital, Le Plessis Robinson, France. Source Ann Thorac Surg, 1989 May, 47:5, 769-71 Abstract After blunt chest trauma, early diagnosis of associated bronchial, vascular, and esophageal injuries must be attempted, as those lesions may be produced by the same mechanism. We report a case of successful management of associated bronchial transection and injury of the ascending aorta. Aortic repair required cardiopulmonary bypass and the use of prosthetic materials, although gross contamination of the mediastinum from the bronchial disruption is a theoretical contraindication to such a procedure. A separate approach to the vascular and airway injuries allowed successful management of both lesions. UNITED STATES

Record 10 from database: MEDLINE Order full text for this document Title Posttraumatic rupture of the thoracic aorta. Author Vloeberghs M; Duinslaeger M; Van den Brande P; Cham B; Welch W Address Department of Thoracic and Cardiovascular Surgery, Akademisch Ziekenhuis, Vrije Universiteit Brussel. Source Acta Chir Belg, 1988 Jan-Feb, 88:1, 33-8 Abstract Ten patients with traumatic lesions of the thoracic aorta were seen in a hospital. Most were victims of traffic accidents and presented severe associated lesions along with their vascular trauma. We found that the vascular injuries were clinically manifest in only a minority of patients. The remaining ruptures were discovered through

CT-scanning of the mediastinum or angiography. We believe that in every major trauma victim aortic lesions should be actively sought for by complimentary examinations to guarantee maximum survival of the patients. Record 11 from database: MEDLINE Order full text for this document Title The isolated posttraumatic aneurysm of the brachiocephalic artery after blunt thoracic contusion. Author Kraus TW; Paetz B; Richter GM; Allenberg JR Address Department for Surgery, University of Heidelberg, Germany. Source Ann Vasc Surg, 1993 May, 7:3, 275-81 Abstract Most supra-aortic aneurysms are localized in the extracranial carotid and subclavian artery. Aneurysms of the brachiocephalic artery (BCA) represent a rather rare finding. Chronic arteriosclerotic changes are responsible for the majority of cases. Posttraumatic BCA damage is only occasionally encountered, complete vascular dissection by perforating injuries being the dominant causative mechanism. Although isolated BCA trauma after blunt thoracic contusion is rare, brachiocephalic injury in association with aortic lesions seems to be the second most common site of vascular injury after the aorta. Cases of isolated blunt BCA trauma documented in the literature to date usually involved a complete avulsion of the artery from the aortic arch or complete rupture near the aortic origin. We present an isolated case of posttraumatic BCA aneurysm in a woman involved in a car accident who suffered blunt chest trauma with a subtotal, near circumferential vessel wall dissection of only the intima and media. Clinical features, diagnostic procedure, surgical treatment, and trauma mechanisms of postcontusional BCA lesions are described and discussed in reference to the literature.

Record 12 from database: MEDLINE Order full text for this document Title Cardiac damage in nonpenetrating chest injuries. Report of 5 cases. Author Glock Y; Massabuau P; Puel P Address Department of Cardio-Vascular Surgery, Hospital University Center of Rangueil, Toulouse, France. Source J Cardiovasc Surg (Torino), 1989 Jan-Feb, 30:1, 27-33 Abstract The Authors report 5 cases of cardiac injury after blunt chest trauma: (a) one right atrial disruption with acute tamponade treated successfully; (b) two left ventricular perforations with rib fractures:

one patient was exsanguinated and died, the other one presented a late subacute cardiac tamponade with successful operative repair; (c) one isolated traumatic tricuspid insufficiency which was well tolerated; (d) one atrio-inferior caval disruption with acute tamponade. Cardiac damage secondary to nonpenetrating chest trauma is uncommon but with the present modes of high speed transportation they are occurring with increasing frequency; correct management of cardiac ruptures depends upon rapid recognition of the injury and expeditious surgical repair. The occurrence of tricuspid valvular lesions alone as a result of nonpenetrating trauma is not common. Echocardiographic examination after blunt chest trauma is a useful diagnosis procedure. Record 13 from database: MEDLINE Order full text for this document Title Use of active shunt for surgical repair of intrapericardial inferior vena caval injury. Author Picard E; Marty An CH; Meunier JP; Frapier JM; Sguin JR; Mary H; Chaptal PA Address Thoracic and Cardiovascular Unit, Centre Hospitalier Universitaire, Hopital Arnaud de Villeneuve, Montpellier, France. Source Ann Thorac Surg, 1995 Apr, 59:4, 997-8 Abstract We report a case of intrapericardial inferior vena caval disruption due to goring by a bull, and we describe the surgical repair of this uncommon penetrating cardiac injury. Review of the literature indicates that, as with other penetrating cardiac injuries, this rare lesion requires aggressive treatment involving an emergency thoracotomy. The use of an atrial caval active shunt was necessary for successful surgical management, and therefore we conclude that surgical treatment of this lesion is comparable with surgical repair of hepatic veins and retrohepatic vena caval injuries incurred during blunt vascular trauma or penetrating abdominal injuries.

Record 14 from database: MEDLINE Order full text for this document Title Emergency arteriography in the assessment of penetrating trauma to the lower limbs. Author Jebara VA; Haddad SN; Ghossain MA; Nehm D; Aoun N; Tabet G; Ashoush R; Atallah NG; Boustany FN; Saade B; et al Address Department of Thoracic and Cardiovascular Surgery, Htel Dieu de France, St Joseph University Hospital, Beirut, Lebanon. Source

Angiology, 1991 Jul, 42:7, 527-32 Abstract One hundred emergency arteriographies (EA) were performed in 87 patients with lower limb trauma due to high-velocity missiles. Thirteen patients had bilateral injuries. In 79 cases, EA findings were positive and led to emergency surgery. In 76 cases an arterial injury was found and treated, a positive predictive value of 96% (76/79). In the other 3 cases, no arterial lesion was found (3 false positives). Among the 21 patients with normal findings from angiography, 10 had surgical exploration because of high clinical suspicion of vascular injury. Arterial injury was found in 2 cases (2 false negatives). In 8 patients, arteriography modified the surgical procedure. In the 11 remaining patients, clinical and echo Doppler follow-up results were normal, a negative predictive value of 90% (19/21). Sensitivity was 97%, specificity 86%, and accuracy 95%. These data show that arteriography in stable patients is a safe and accurate procedure. It permits avoidance of unnecessary surgical exploration in selected patients and helps modify the surgical procedure.

Record 15 from database: MEDLINE Order full text for this document Title Posttraumatic left ventricular pseudoaneurysm due to intramyocardial dissecting hematoma. Author Maselli D; Micalizzi E; Pizio R; Audo A; De Gasperis C Address Department of Cardiac Surgery, Ospedale Maggiore della Carita, Novara, Italy. Source Ann Thorac Surg, 1997 Sep, 64:3, 830-1 Abstract A left ventricular aneurysm can develop in patients sustaining blunt chest injury. This condition has been attributed to myocardial contusion or to a direct vascular lesion leading to myocardial necrosis. We report the case of a pseudoaneurysm resulting from myocardial dissection beginning from a small tear in the endocardial wall. Successful surgical exclusion of the pseudoaneurysm by endoaneurysmal patch closure of the communications between the aneurysm and the left ventricular cavity is described. Record 16 from database: MEDLINE Order full text for this document Title Traumatic tear of the basilar artery associated with vertebral column injuries. Author Sato Y; Kondo T; Ohshima T Address Department of Legal Medicine, Kanazawa University Faculty of Medicine, Japan. Source

Am J Forensic Med Pathol, 1997 Jun, 18:2, 129-34 Abstract An unusual case of traumatic basal subarachnoid hemorrhage (SAH) due to a mechanical tear of the basilar artery is reported. A 70-year-old man who had been suffering from cerebrovascular dementia was found dead in a ditch. Externally, subcutaneous hemorrhage with abrasions was observed on the left side of the forehead, face, and lower jaw, together with small contusions in the left superciliary arch. Internally, a 3-mm-long transversal tear of the basilar artery was observed, and dislocations of both C6-C7 and T1-T2 as well as a small fracture of the processus spinosus of C5 were found. No pathological vascular lesions such as aneurysms and vasculitis, other than arteriosclerosis, were observed in the vertebral-basilar system. Ethanol was not detected in the intracardiac blood or in the urine. These findings indicate that when the man fell into the ditch, severe hyperextension occurred as a result of minor blunt forces to the face, and that the traumatic tear of the basilar artery was mechanically caused by overstretching due to hyperextension of the head. It is also suggested that due to his advanced age the muscle tone of the neck might have declined, impairing its defense action, and that head hyperextension might, therefore, occur rather more readily under such conditions.

Record 17 from database: MEDLINE Order full text for this document Title [Vascular injuries of the limbs. Evaluation of 106 lesions in 76 patients] Author Leguerrier A; Lebeau G; Leveque JM; Rosat P; Rioux C; Logeais Y Address Source J Chir (Paris), 1986 Feb, 123:2, 108-16 Abstract A total of 106 lesions due to vascular injuries (noniatrogenic) to limbs were treated in 81 patients at the CHR, Rennes (Cardiovascular and Thoracic Unit) between 1970 and 1983. Analysis of data allowed a profile of arterial lesions (type and location) to be retraced, and demonstrated the high frequency of associated lesions, these varying in distribution according to whether the upper limbs (major seriousness of neurologic sequelae) or lower limbs (very high incidence of osteoarticular lesions) were involved. Among the "immutable" severity factors (related to the injury) emphasis has to be placed on "contending or crush injuries", widely displaced lesions, extensive arterial dilacerations (middle segments of limbs) and multiple vascular lesions. This study focused attention mainly on the tactical and technical factors allowing improvement in the always reserved prognosis of these lesions. Firstly, by maximum reduction in the duration of ischemia by early diagnosis (to avoid referral to a "second hand") and by judicious indication for angiography (conducted preferably in the operation room and if necessary repeated after vascular repair surgery). Secondly, by

repair of lesions in conformity with well established rules and principles: bone stabilization initially, formal venous repair surgery for large venous trunks, preferably "conservative" surgery of arterial vessels to ensure a perfect result initially (any recovery operation results in a very high incidence of failures).

Record 18 from database: MEDLINE Order full text for this document Title Transthoracic repair of innominate and common carotid artery disease: immediate and long-term outcome for 100 consecutive surgical reconstructions. Author Berguer R; Morasch MD; Kline RA Address Division of Vascular Surgery, Wayne State University/Detroit Medical Center, Harper Hospital, MI 48201, USA. Source J Vasc Surg, 1998 Jan, 27:1, 34-41; discussion 42 Abstract PURPOSE: This is a review of 100 consecutive supraaortic trunk reconstructions (SAT) performed over 16 years. METHODS: There were eight innominate endarterectomies and 92 bypass procedures based on the thoracic aorta (n = 86) or proximal innominate artery (n = 6) in 98 patients 24 to 79 years of age. Indications included cerebrovascular ischemia in 83 and upper extremity ischemia in four. Thirteen patients were asymptomatic. An innominate lesion was bypassed in 78 cases. The left common carotid and left subclavian arteries required reconstruction in 38 and nine patients, respectively. Multiple trunks were reconstructed by direct bypass grafting in 35. Approach was via median sternotomy in 92, partial sternotomy in six, and left thoracotomy in two. Seven patients underwent concomitant cardiac surgery. RESULTS: Eight deaths and eight nonfatal strokes occurred, for a combined stroke/death rate of 16%. The operative mortality rate was 6% for SAT and 29% for SAT/cardiac operations. Perioperative complications included two asymptomatic graft occlusions, three nonfatal myocardial infarctions, seven significant pulmonary complications, three sternal wound infections, and one recurrent laryngeal nerve injury. Follow-up ranged from 1 to 184 months (mean, 51 +/- 4.8 months). Eight patients were lost to follow-up. Twenty-one late deaths occurred. Two SATs required late revision. The cumulative primary patency rates at 5 and 10 years were 94% +/- 3% and 88% +/- 6%, respectively. The stroke-free survival rates at 5 and 10 years were 87% +/- 4% and 81% +/- 7%, respectively. Patients who survived beyond 30 days had a median stroke-free life expectancy of 10 years, 7 months (SE, 6%). CONCLUSIONS: Direct reconstruction of complex symptomatic SAT lesions can be performed with acceptable death/stroke rates and with long-term patient benefit. Asymptomatic lesions in patients who have significant concomitant conditions should be managed with a less-morbid cervical or endovascular approach, even if long-term outcome of the latter is

inferior.

Record 19 from database: MEDLINE Order full text for this document Title [Angiographic detection of vascular lesions following injury to the brachiocephalic branch of the aortic arch] Author Platzbecker H; Khler K Address Source Radiol Diagn (Berl), 1985, 26:6, 767-74 Abstract Abstract unavailable online.

Record 20 from database: MEDLINE Order full text for this document Title [Traumatic ruptures of the thoracic aorta] Author Vollmar JF; Kogel H; Cyba-Altunbay S; Kunz R Address Abteilung fr Thorax- und Gefsschirurgie des Klinikums der Universitt Ulm. Source Langenbecks Arch Chir, 1987, 371:2, 71-84 Abstract 1) Traumatic rupture of the thoracic aorta is most frequently caused by a traffic accident with deceleration. Approximately 80% of these patients die immediately. In 29 patients (1973-1986) reaching surgical treatment, all aortic lesions were located at the aortic isthmus (28 covered and 1 free rupture). 25 (86%) of them had serious associated injuries of the head, other thoracic or intraabdominal organs and/or the extremities. A seat belt could not prevent the deceleration injury of the aorta but reduced associated injuries of the head and the intraabdominal organs. 2) The widely accepted surgical rule that every diagnosed traumatic aortic rupture should have an immediate surgical repair is no longer acceptable. In all patients with a clinically and angiographically stable covered rupture of the aorta with serious associated injuries and symptoms of shock the surgical treatment of the aortic lesion should be undertaken with delayed emergency after some hours or several days. This changed surgical concept is based both on the rarity of secondary free rupture of the aortic lesion and on the chance to stabilize the circulatory condition by a primary shock treatment including the surgical elimination of other sources of blood loss. The group with such a delayed aortic vascular repair (n = 12) showed a remarkably improved outcome with reduced operative mortality and reduced risk of paraplegia

(47% vs. 25% respectively 35% vs. ca. 10%). None of these patients with a delay up to 17 days for vascular repair developed a secondary free aortic rupture. Up to recently this risk has been obviously overestimated on the basis of earlier studies in the sixties. 3) The immediate repair of the aortic rupture with its high operative mortality and high rate of ischemic paraplegia can be restricted to a few exceptional cases with a secondary free rupture in the hospital. The transvenous DSA is the best approach for an early diagnosis and for the surgical decision to perform vascular repair immediately or with delay. Record 21 from database: MEDLINE Order full text for this document Title Diagnosis and management of traumatic aorto-right ventricular fistulas. Author Samuels LE; Kaufman MS; Rodriguez Vega J; Morris RJ; Brockman SK Address Department of Cardiothoracic Surgery, Allegheny University Hospital, Philadelphia, Pennsylvania 19102, USA. Source Ann Thorac Surg, 1998 Jan, 65:1, 288-92 Abstract BACKGROUND: Traumatic aorto-right ventricular (Ao-RV) fistulas are rare lesions that result in congestive heart failure if left untreated. Early diagnosis and prompt surgical intervention are required to avoid the natural outcome of cardiac decompensation. METHODS: All cases of traumatic Ao-RV fistula described in the English literature since 1958 were reviewed. The clinical presentation, methods of diagnosis, and treatment strategies were assessed to determine the pathophysiology, natural history, and outcome of surgical intervention. RESULTS: Forty cases of traumatic Ao-RV fistulas were described in the English literature. There were 39 men and 1 woman, with a mean age of 28.3 years (range, 15 to 50 years). Twenty-two (55%) patients had isolated Ao-RV fistulas. Fourteen (35%) had Ao-RV fistulas with aortic insufficiency. Definitive surgical repair was performed in 38 patients. The associated aortic valve injuries were managed with repair techniques or replacement with prosthetic devices. The surgical outcomes in all patients were satisfactory. CONCLUSIONS: The pathophysiology and natural history of Ao-RV fistulas involves the development of congestive heart failure. Traumatic aortic insufficiency frequently is associated with this disorder. Early diagnosis and prompt treatment are necessary to avoid the natural outcome of cardiac decompensation. Definitive repair should be performed with the aid of cardiopulmonary bypass during the same hospitalization. Record 22 from database: MEDLINE Order full text for this document Title Reconstruction of radiation-induced chest wall lesions.

Author Samuels L; Granick MS; Ramasastry S; Solomon MP; Hurwitz D Address Department of Plastic Surgery, Medical College of Pennsylvania, Philadelphia. Source Ann Plast Surg, 1993 Nov, 31:5, 399-405 Abstract Radiation-related ulcers of the chest wall provide a great challenge to reconstructive surgeons because of the necessity of protecting the underlying vital structures and the difficulty in repairing irradiated tissues. To evaluate the efficacy of treatment, 24 patients who underwent reconstruction of radiation related ulcers of the chest wall were retrospectively reviewed. A variety of muscle and musculocutaneous flaps as well as omentum and microvascular tissue transfers were used to reconstruct these defects. The defects in the chest wall arose from spontaneous breakdown of irradiated tissue, tumor recurrence, or nonhealing after surgical procedures performed in the irradiated field. Our treatment protocol consisted of aggressive debridement of all affected tissues including skeletal tissues when necessary. The application of a tension free closure using a flap was then performed. Skeletal support was provided in three reconstructions. There were no mortalities, the morbidity rate was 29% (six minor, one major complication), and the mean hospital stay was 10.9 days. None of the patients required prolonged ventilator support. In all but 2 patients, who were left with small chronic granulating nonhealing wounds, complete wound healing was achieved. We conclude that chest wall reconstruction of radiation-related ulcers can be achieved with minimal morbidity in an acceptable period of inpatient hospital care using a variety of vascularized tissue transfers.

Record 23 from database: MEDLINE Order full text for this document Title Radiation-related wounds of the chest wall. Author Granick MS; Larson DL; Solomon MP Address Department of Plastic and Reconstructive Surgery, Medical College of Wisconsin, Milwaukee. Source Clin Plast Surg, 1993 Jul, 20:3, 559-71 Abstract Irradiation-associated chest wall lesions pose a significant health hazard to the patient. The principles of management include (1) biopsy of any open wounds to rule out the recurrence or persistence of tumor, (2) aggressive debridement of all offending tissues, and (3) reconstruction with well-vascularized flap tissue. Numerous questions arise regarding the practical management of these patients. The controversies that have arisen during our management of more

than 100 of these patients have been discussed. It is appropriate to perform reconstruction following nonhealing of a superficial ulcer or immediately following the excision of a full-thickness chest wall defect. Hyperbaric oxygen can serve as a useful adjunct. It is rarely necessary to use a prosthetic material for the purpose of chest wall stabilization during the reconstruction of full-thickness defects. Paradoxic chest wall movement in the postoperative period does not significantly affect pulmonary function tests and is generally a transient problem. Subtotal excisions are frequently necessary. As long as all of the necrotic or tumor-bearing tissue has been fully removed, these wounds can be expected to heal in most instances by placing vascularized tissue into the defect. Operative sites in previously irradiated chest wall tissue can be expected to heal if proper and careful surgical technique is employed. Nevertheless, there is a risk of wound breakdown following any surgery in irradiated tissue. Finally, we believe it is appropriate to proceed with aesthetic recontouring of chest wall deformities associated with irradiation exposure. Record 24 from database: MEDLINE Order full text for this document Title Intraoperative catheter thrombolysis as an adjunct to surgical revascularisation for infrainguinal limb-threatening ischaemia. Author Knaus J; Ris HB; Do D; Stirnemann P Address Department of Thoracic and Cardiovascular Surgery, University of Berne, Switzerland. Source Eur J Vasc Surg, 1993 Sep, 7:5, 507-12 Abstract The objective of this study was to assess the benefits of intraoperative thrombolysis (IOL) on patients with acute leg ischaemia. This study was conducted in the Department of Cardiovascular Surgery, Inselspital, Berne, Switzerland. IOL was prospectively assessed in 25 patients with infrainguinal limb-threatening ischaemia due to acute thrombosis of atherosclerotic lesions and aneurysms (44%), occluded grafts (32%), arterial injuries (12%), delayed embolism (8%) and trash foot (8%). Three hundred and seventy-five thousand units of urokinase were delivered over 30 min with inflow occlusion to the profunda femoral artery in 8%, to the calf arteries via exposed trifurcation in 88% and to the pedal arch via exposed posterior tibial artery at the ankle in 8% of the patients. This was followed by graft thrombectomy in 24%, femoropopliteal bypass in 60%, intraoperative percutaneous transluminal angioplasty in 12% and vein patch angioplasty in 16%. Chief outcome measures were: postoperative morbidity; mortality; patency and limb salvage up to a maximum of 2 years. Postoperative bleeding complications occurred in two patients (8%) and consisted of two wound haematomas. Four patients died within 30 days after IOL, but no death could be attributed to IOL. All remaining patients were followed with a mean follow-up time of 10.9 months. The patency and limb salvage rate

remained stable at 71 and 86% after 6 and 2 months, respectively. Conclusions were that IOL followed by surgical inflow restoration is a straightforward procedure for limb-threatening ischaemia with rewarding results regarding side effects, patency and limb salvage. Record 25 from database: MEDLINE Order full text for this document Title [Spontaneous spinal epidural hematoma: case report] Author Nakamura H; Tominaga T; Satoh S; Kousyu K; Yoshimoto T Address Department of Neurosurgery, Tohoku University, School of Medicine. Source No Shinkei Geka, 1997 Apr, 25:4, 379-83 Abstract We report a case of spontaneous spinal epidural hematoma (SSEH) at the upper thoracic level which accompanied an epidural vascular lesion demonstrated by histological examination. A 62-year-old male was referred to our department, because of sudden onslaught of back pain, progressive paraparesis, and sensory disturbance below the dermatome of Th8. He had no history of a tendency to bleed, anticoagulant therapy, or trauma. There was no abnormality in the laboratory data. MRI revealed that an epidural mass at the level of dorsal T1 and T2 was compressing the spinal cord. Multilevel spondylotic change and thickened yellow ligament were also noted. Sixteen hours after the onset, we performed laminectomy at T1 and T2 and evacuated the epidural hematoma. An unusual vascular-net like tissue was found on the dura mater after removal of the hematoma. Postoperatively, neurological symptoms disappeared within three weeks. Histological appearance of the vascular tissue was a cluster of vessels containing a dilated vein with partially thin wall due to lack of elastic and collagen fibers. In reviewing the literature, there are several reports describing vascular lesions, such as cavernous angioma and AVM, as possible etiologies of SSEH. In the present case, long lasting compression of the posterior epidural venous plexus by the thick yellow ligament might have resulted in formation of an abnormal vein which ultimately caused bleeding.

Record 26 from database: MEDLINE Order full text for this document Title Arterial injuries. Review of 12 years experience with 32 patients. Author Baadsgaard SE; Svendsen F; Bille S; Egeblad K Address Department of Thoracic and Vascular Surgery, Aalborg Sygehus, Denmark. Source J Cardiovasc Surg (Torino), 1991 Jul-Aug, 32:4, 468-71 Abstract

Thirty-two patients with 41 injured arteries were operated upon during a period of 12 years. Three quarters were men, and the median age was 33 years. Accompanying lesions were seen in 87.5% of the patients. Nearly half the lesions were related to blunt trauma. Occupational accidents constituted the largest group. The diagnosis was made on clinical grounds in most cases. The median time lapse from trauma to operation was 5 hours. The principles of treatment were those that are generally accepted. No patients died, the amputation rate was 12.5%. Median follow-up was 8 months. A successful arterial reconstruction contributed to a good functional result. Postreconstruction thrombosis of arteries were found to occur within the first hours or days after reconstruction. Late thrombosis was rare and the overall long-time patency was 61.4%. Patency of repair of upper limb small vessels was 54.5%.

Record 27 from database: MEDLINE Order full text for this document Title [Thoracic trauma with injuries of the thoracic spine] Author Hasse J; Morscher E Address Abteilung Lungenchirurgie, Chirurgischen Universittsklinik Freiburg. Source Radiologe, 1987 Sep, 27:9, 398-401 Abstract From a major series of surgically treated patients with fractures and fracture dislocations of the thoracic spine 4 cases are presented exhibiting different trauma mechanisms and presenting with a variety of associated acute and chronic intrathoracic lesions. Surgical stabilisation and treatment of additional intrathoracic injury (vascular, lymphatic duct, empyema, posttraumatic fibrothorax) necessitated a transpleural approach, effective for the spine as well. Diagnostic radiology was restricted to minimal requirements due to urgency and/or difficulties of exposure.

Record 28 from database: MEDLINE Order full text for this document Title [Air bags influence the pattern of injury in severe thoracic trauma] Author Pillgram Larsen J; Geiran O Address Thoraxkirurgisk avdeling, Ulleval sykehus, Oslo. Source Tidsskr Nor Laegeforen, 1997 Jun, 117:17, 2437-9 Abstract Severe intrathoracic cardiovascular injuries were found in three patients who were drivers of cars involved in head on collisions

causing air bags to be released. A 32 year old male had not worn a seat belt, while a 39 year old female was restrained by a seat belt. The male patient suffered an intimal lesion of the brachiocephalic artery. Extensive soft tissue haematomas were seen subcutaneously and retrosternally. The female suffered a rupture of the aortic isthmus and a dislocated pelvic fracture. Vascular repair was performed in both patients. The female died after two months without having regained consciousness. The third patient, a 47 year old male, had not worn a seat belt. He lost his pulse within minutes. Midline emergency thoracotomy showed a complete rupture of the right atrium. An air bag protects against injuries caused by hitting internal parts of the vehicle. It does not necessarily protect against deceleration trauma in high speed collisions.

Record 29 from database: MEDLINE Order full text for this document Title [Supracoeliac aortic clamping. Technique and indication in traumatic abdominal pathology] Author Leschi JP; Coggia M; Goau Brissonnire O; Patel JC Address Service de Chirurgie generale, digestive et vasculaire, Hopital Ambroise-Pare, Boulogne. Source Presse Med, 1994 Jul, 23:25, 1163-5 Abstract Supracoeliac occlusion of the aorta was performed in two patients with visceral and vascular lesions due to blunt abdominal trauma. In both cases, aortic occlusion was required due to peroperative hypovolaemic shock. The first case was a 30-year-old man hospitalized for blunt thoracic and abdominal trauma. Haemodynamic parameters were unstable at admission with initial blood pressure at 85/45 mmHg. Physical examination indicated a haemoperitonium which was confirmed echographically. At laparotomy, among other injuries, the right supra-hepatologic vein and two posterior veins draining the segment VII were severed. Despite suture and haemostatic procedures, hypovolaemic shock occurred with systolic pressure at 40 mmHg. In the second case, haemoperitonium was also confirmed echographically in a 28-year-old man hospitalized for blunt frontal abdominal trauma. Blood pressure was 70/45 mmHg at admission and emergency laparotomy revealed major avulsion of the left lobe of the liver and lesions to the sub-renal vena cava and the left renal vein in addition to major injury to the pancreas and the stomach. While the supra-coeliac aorta was being prepared, persistent bleeding led to shock with a systolic pressure of 45 mmHg. In both cases, the supracoeliac artery was clamped, for 30 and 35 minutes respectively, making it possible to re-establish satisfactory haemodynamic conditions and allowing favourable outcome. These observations demonstrate that per-operative occlusion of the supracoeliac aorta performed as a salvage manoeuvre in cases of hypovolaemic shock can be an effective means of re-establishing a

precarious haemodynamic situation. The technique is simple and rapid and few complications have been reported. Record 30 from database: MEDLINE Order full text for this document Title Spontaneous spinal epidural hematoma: findings at MR imaging and clinical correlation. Author Holts S; Heiling M; Lnntoft M Address Department of Radiology, University Hospital, Lund, Sweden. Source Radiology, 1996 May, 199:2, 409-13 Abstract PURPOSE: To evaluate radiologic findings and clinical data in patients with spontaneous spinal epidural hematoma (SSEH). MATERIALS AND METHODS: Thirteen patients (10 men aged 28-71 years; three women aged 40-65 years) with SSEH from 1986 to 1995 underwent magnetic resonance (MR) imaging; six also underwent spinal angiography. Patients with minor trauma, anticoagulant therapy, increased bleeding tendency, or vascular lesions were included. RESULTS: The incidence was estimated to be 0.1 patients per 100,000 patients per year. On MR images, the hematoma was in the anterior (n=8) or posterior (n=4) epidural space or both (n=1). The most common location was the upper thoracic region. T1-weighted images were most useful owing to the pathognomonic signal shift from isointensity with the cord in the early period to hyperintensity in the intermediate stage. Five patients had minor trauma, and four were receiving anticoagulant therapy. CONCLUSION: A rough estimation of the incidence of SSEH is provided,and the results confirm the previously described association with minor trauma and anticoagulant therapy and low frequency of arteriovenous malformations.

Record 31 from database: MEDLINE Order full text for this document Title Subclavian artery aneurysm associated with absence of the ipsilateral internal carotid artery. Author Mikami C; Suzuki M; Komoda K; Kubo N; Kuroda K; Ogawa A; Okudaira Y Address Department of Neurosurgery, Iwate Medical University, Morioka, Japan. Source Neurol Res, 1996 Apr, 18:2, 140-4 Abstract A 48-year-old male presented with a rare subclavian artery aneurysm associated with absence of the ipsilateral internal carotid

artery. The aneurysm was resected and replaced with a Gore Tex artificial graft. Computed tomography, angiography and cerebral blood flow findings suggest that defect of the right internal carotid artery occurred in the developmental stage. There was no past history of trauma, nor histological evidence of inflammatory or sclerotic changes in the aneurysmal wall. The two vascular lesions may have been influenced by a synchronous causative factor in his developmental stage.

Record 32 from database: MEDLINE Order full text for this document Title Traumatic chest lesions in patients with severe head trauma: a comparative study with computed tomography and conventional chest roentgenograms. Author Karaaslan T; Meuli R; Androux R; Duvoisin B; Hessler C; Schnyder P Address Department of Radiology, University Hospital, CHUV, Lausanne, Switzerland. Source J Trauma, 1995 Dec, 39:6, 1081-6 Abstract In patients with severe craniocerebral trauma, who need a continuous positive-pressure breathing, the detection of pulmonary and mediastinal traumatic lesions, especially pneumothorax, may alter the management. The aim of this study is to evaluate the efficiency and accuracy of conventional supine chest roentgenograms to detect the associated traumatic chest lesions in severe craniocerebral trauma and to compare their value as a diagnostic method for the identification of unsuspected lesions with a limited chest computed tomographic (CT) examination. Forty-seven consecutive patients with severe craniocerebral trauma underwent head CT and a prospective limited CT examination of the thorax in the same session. Nine patients (19.1%) presented a pneumothorax, bilateral in one case. Six pneumothoraces (60%) were identified both on conventional chest roentgenograms and CT, whereas in four cases (40%), the lesion was only detectable on CT. The CT study also showed 31 areas of pulmonary parenchymal contusions in 19 subjects (40%), whereas the conventional chest roentgenograms demonstrated 17 areas of contusions in 11 (23%) subjects. One thoracic aorta and one right diaphragm rupture were detected on CT study. On the conventional chest roentgenograms the mediastinal vascular injury was overlooked, whereas the right diaphragmatic rupture was highly suspected. The limited chest CT examination supplied additional information in 30% of patients. In 12.7% of patients, this information was clinically significant enough to alter the management. In patients with severe craniocerebral trauma evaluation of associated chest trauma by a supplementary limited chest CT, examination provides more and precise information about the size and severity of mediastinal and pulmonary lesions with a superior detectability of pneumothorax.

Record 33 from database: MEDLINE Order full text for this document Title [Peripheral vascular injuries in polytrauma] Author Richter A; Silbernik D; Oestreich K; Karaorman M; Storz LW Address Chirurgische Klinik, Klinikum Mannheim, Fakultat fur klinische Medizin der Universitat Heidelberg. Source Unfallchirurg, 1995 Sep, 98:9, 464-7 Abstract Between 1972 und 1993 a total of 68 patients were treated at the Department of Surgery of the University Clinic of Mannheim for peripheral vascular injury resulting from multiple trauma. The average age of these patients was 31.3 years, and most of them were male (88.2%; n = 60). The injured vessels were localized evenly in all the extremities: 31 patients (45.5%) presented with arterial damage of the upper extremity, and 37 (54.5%) showed lesions along the femoro-popliteal arteries. The most frequent location of injured vessels in the multiply traumatized patient was the popliteal artery (n = 18, 26.5%), the distal part of the superficial femoral artery (n = 12, 17.6%), the brachial artery (n = 14, 20.6%) and the axillary artery (n = 10, 14.6%). The dominant cause, of trauma was road traffic accidents (72%), and 20 patients (29%) acquired their vascular injuries as motorcyclists. There were also 13 occupational accidents (19%) involving vascular injuries. In addition to a vascular trauma 34 patients (50%) had complicated fractures, and a further 34 patients (50%) had multiple fractures: 12 (17.6%) had head and brain damage, 5 (7.3%) had blunt abdominal trauma and 6 (8.8%) had blunt thoracic injury. The general amputation rate was 2.9% (n = 2). One patient died on the table of a torn off subclavian artery combined with multiple other injuries. Paresis of the plexus is a particular problem after vascular lesions of the upper extremity: in 22 patients (71%) paresis of the plexus persisted after successful vascular reconstruction (follow-up period between 3 months and 16 years, median time 3.45 years).(ABSTRACT TRUNCATED AT 250 WORDS) Record 34 from database: MEDLINE Order full text for this document Title Endovascular approaches for traumatic arterial lesions. Author Ohki T; Veith FJ; Marin ML; Cynamon J; Sanchez LA Address Department of Surgery, Montefiore Medical Center, University Hospital, Albert Einstein College of Medicine, New York, NY 10467, USA. Source Semin Vasc Surg, 1997 Dec, 10:4, 272-85

Abstract Vascular injuries caused by blunt or penetrating trauma can be challenging to diagnose and treat, particularly when they involve central vessels. Endovascular treatment for vascular trauma includes the placement of embolization coils and intravascular stents and the employment of stented grafts. The use of stented grafts appears to be associated with decreased blood loss, a less invasive insertion procedure, reduced requirements for anesthesia, and a limited need for an extensive dissection in a traumatized field. These advantages are especially important in patients with central arteriovenous fistulas or false aneurysms, particularly those who are critically ill from other coexisting injuries or medical comorbidities. In these circumstances, the use of stented grafts already appears justified to treat traumatic central arterial lesions. Endovascular grafts are important tools for the treatment of vascular trauma, and they should be included in the armamentarium of the vascular surgeon. Record 35 from database: MEDLINE Order full text for this document Title [Therapy of acute traumatic vascular injuries using covered stents] Author Krmer S; Grich J; Rilinger N; Lutz P; Brambs HJ; Kunze V; Steudel A; Scharrer Pamler R Address Abteilung fur Diagnostische Radiologie, Universitatsklinik Ulm. Source Rofo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr, 1997 Nov, 167:5, 496-500 Abstract PURPOSE: Evaluation of percutaneously implanted covered stents in acute vascular bleeding as therapeutic alternative to conventional surgical treatment. MATERIALS AND METHODS: 8 patients aged 26 to 83 years with acute vascular lesions caused by traumas, and subsequent haemorrhage, were transferred to our department. Because of general inoperability or difficult surgical access, interdisciplinary evaluation favoured an interventional treatment. In 6 patients stents could be placed percutaneously to the aorta, subclavian and iliac arteries. In one case we had to implant three stents into the thoracic aorta. RESULTS: In 7 interventionally treated patients the stents could be placed exactly on the lesions (88%). The bleeding could be stopped immediately in 6 cases (75%). In one patient we had to implant successfully two more stents in reintervention (12%). In another patient the available prosthesis was too short, so that the patient had to be referred to the OR for surgical treatment (12%). There were no complications during the treatment. CONCLUSION: First results in the use of covered stents as interventional treatment of acute vascular lesions are encouraging and may represent a possible alternative to surgical therapy in locally limited bleedings, presupposing that all different types and sizes of industrially produced covered stents are available. Further investigations to compare surgical and interventional techniques are warranted.

Record 36 from database: MEDLINE Order full text for this document Title Applications of digital subtraction angiography in cardiovascular diagnosis. Author Myerowitz PD; Swanson DK; Turnipseed WD Address Source Surg Clin North Am, 1985 Jun, 65:3, 423-37 Abstract Both intravenous and intra-arterial DSA have widespread applications in the field of cardiovascular diagnosis. The definition of carotid artery stenosis or severe peripheral vascular disease in the patient undergoing coronary artery bypass surgery might dictate the need for simultaneous carotid and coronary artery surgery or demonstrate the best route for insertion of an intra-aortic balloon. DSA also might find further application in the definition of thoracic aortic dissection, thoracic aortic trauma, and coarctation of the thoracic aorta, as well as in showing the adequacy of repair of thoracic coarctation in patients who remain hypertensive postoperatively. Left ventricular imaging using intravenous or intraventricular injections of contrast material provides an accurate method of calculating ejection fraction and an excellent picture of left ventricular wall motion. In addition, because smaller amounts of contrast material may be used for intraventricular infections, patients with renal failure or severe impairment of the left ventricle might fare better with the reduced contrast load. Multiple ventriculograms can be performed following interventions such as pacing or exercise to allow a more adequate definition of left ventricular performance. Intravenous DSA still has not achieved satisfactory visualization of the coronary arteries or coronary artery bypass grafts. However, aortic root injections of contrast material can provide adequate definition of these structures and has been recommended as a screening technique for coronary disease in patients undergoing arteriography for other vascular disease. Current work on the development of DSA techniques for the quantitation of coronary artery blood flow and myocardial perfusion is quite promising. Accurate, reproducible measurement of coronary artery blood flow, patterns of myocardial perfusion, and areas of myocardium supplied by specific coronary vessels with obstructions may soon provide physiologic information about anatomically defined coronary artery disease. A variety of congenital heart defects have been defined by intravenous DSA. Shunt lesions such as atrial septal defects, ventricular septal defects, and patent ductus arteriosus have been defined anatomically, and the severity of their shunts has been estimated by placing windows of interest over the various cardiac chambers. It is possible that certain congenital malformations might be studied adequately by intravenous DSA, eliminating the need for cardiac catheterization.(ABSTRACT TRUNCATED AT 400 WORDS) Record 37 from database: MEDLINE

Order full text for this document Title Monocyte/macrophage accumulation and smooth muscle cell phenotypes in early atherosclerotic lesions of human aorta. Author Babaev VR; Bobryshev YV; Sukhova GK; Kasantseva IA Address Human Morphology Institute, Russian Academy of Medical Sciences, Moscow. Source Atherosclerosis, 1993 May, 100:2, 237-48 Abstract In a search for early atherosclerotic lesions, we have investigated grossly normal areas of human thoracic aortas taken at autopsy from 40 trauma victims aged from 3 to 40 years. Two areas of aorta were compared: lesion predisposed to atherosclerosis (LP) area localized on the dorsal aspect of the vessel along the row of intercostal branching sites, and lesion resistant (LR) area located on the ventral aspect of the vessel. Accumulation of apolipoprotein B (apo B) was found in LP aortic area of each child older than 6 years. Similar retention of apo B in LR area appeared only in aortas of teenagers. The apo B staining increased with age in both areas tested but was usually of a greater extent in LP area than in LR area. Typical smooth muscle cells (SMCs) and a few monocytes/macrophages (Mn/Mph) were revealed in the intimal layer of all aortas examined. The number of Mn/Mph dramatically increased in LP areas of individuals over 17 years. Quantitative study of double stained sections has shown a 2- to 6-fold enhanced number of Mn/Mph in LP area compared with LR aortic area of 10 men over 21 years. Focal infiltration of Mn/Mph in aortas of young adults occurred without endothelial denudation. In addition, some intimal SMCs in LP area of 12 aortas out of 29 expressed desmin and contained well-developed endoplasmic reticulum, while such cells were seldom detected in LP area of the vessels. Thus, focal accumulation of apo B with subsequent Mn/Mph infiltration and SMC phenotypic modulation in LP aortic area of young adults may be causally involved in fatty streak and atherosclerotic plaque formation.

Record 38 from database: MEDLINE Order full text for this document Title [Diagnostic problems of multiple trauma and technical means] Author Durandeau A Address Service d'orthopdie-traumatologie A, Hpital Pellegrin, Bordeaux. Source Chirurgie, 1990, 116:8-9, 627-31; discussion 631-2 Abstract Multiple trauma requires immediate and combined resuscitation and surgery. For resuscitation, the neurological condition must be assessed prior to any sedation, as well as the respiratory and

hemodynamic condition, in order to carry out first aid (tubing, ventilation, infusion...). The surgeon who is present must contribute in the quick clinical assessment of the lesions, perform temporary hemostasis as well as hemostatic and anti-infectious dressing, find out associated vascular complications and possible injuries to the spine and cord. Various blood samples must be taken before setting up the venous pathways (peripheral and central), and the various parameters will be followed up. Thoracic aspiration will sometimes be essential for better ventilation. Radiographs of the chest and of the pelvis will be taken with the injured person on the stretcher, without displacing him/her. The rest of the assessment will be performed only when the person with multiple trauma has been resuscitated and is hemodynamically stable, and it will include various radiographs, ultrasound and CT studies, and even angiograms, of the skeleton and of the cranial contents, of the thorax and of the abdomen. However, all these explorations are somewhat time-consuming, and involve a risk of neurological, hemodynamic or ventilatory aggravation. Therefore they must be organized into a hierarchy, and only those that are essential will be performed to avoid delaying the treatment. Neither must the effectiveness of resuscitation be too reassuring, as the morbidity of the lesions increases with the number of units of transfused blood. The vital prognosis is often worsened when a lesion is not recognized or when complications occur. Record 39 from database: MEDLINE Order full text for this document Title [Video-assisted thoracoscopic surgery] Author Jancovici R; Pons F; Conan J; Natali F; Vaylet F Address Service de Chirurgie thoracique, Hopital du Val de Grace, Paris. Source Rev Pneumol Clin, 1994, 50:1, 15-20 Abstract Since the team at the Laennec hospital first performed an extra-pleural thoracoscopy in 1990, a certain number of thoracic surgery units have started using this new technique. Video-assisted thoracoscopy is an absolutely revolutionary technique allowing an intrapleural approach to the mediastinum and to the pulmonary parenchyma without a thoracotomy. It requires a sophisticated technical set up including a video camera, direct or angular optics, and a video screen. The patient is placed in the same position as for a thoracotomy. For the pneumothorax and dystropic bullae, Video assisted thoracoscopic surgery has been largely shown to be the superior technique. The pleura is treated by avivement or sometimes by pleurectomy. Pulmonary biopsies are often taken. Preoperative computed tomography with methylene blue injection is often required for the exeresis of peripheral parenchymatous sub-pleural nodules and sometimes a small fishhook has to be placed within the tumour. Inversely, segmentectomies or lobectomies are rarely performed. There is a certain amount of risk involved in closed chest vascular dissections, and the question of carcinologic rigour has to be raised.

Tumours of the mediastinum, both cystic and solid tumours, are relatively easy to approach by dissection using video assisted thoracoscopy. Finally, this technique offers new possibilities for staging bronchial cancers, the treatment of broncho-pleural fistulas, and more recently for non operated chest trauma. This new technique is of great importance for the thoracic surgeon, although an evaluation of long-term results are still required.

Record 40 from database: MEDLINE Order full text for this document Title Abdominal aortic aneurysm and dissection after blunt trauma. Author Kysola K; Jrvinen A Address Department of Thoracic and Cardiovascular Surgery, University Central Hospital, Helsinki, Finland. Source J Cardiovasc Surg (Torino), 1987 Nov-Dec, 28:6, 737-9 Abstract A case of abdominal aortic aneurysm and dissection after blunt trauma is presented. Unlike traumatic lesions of the thoracic aorta, this condition seems to be extremely rare, and may therefore deserve publication. Conservative surgery (resection of the dissected intimal flaps, closure of the aortotomy with a Blalock-type vascular suture) gave good early and late (6 years follow-up) results.

Record 41 from database: MEDLINE Order full text for this document Title Postoperative chylothorax in children: differences between vascular and traumatic origin. Author Le Coultre C; Oberhnsli I; Mossaz A; Bugmann P; Faidutti B; Belli DC Address Clinique Universitaire de Chirurgie Pdiatrique et de Pdiatrie, Geneva, Switzerland. Source J Pediatr Surg, 1991 May, 26:5, 519-23 Abstract Twenty-four children with postoperative chylothorax were encountered among 1,264 consecutive thoracic operations over a 7-year period and form the basis of this study. Chylothorax was caused by direct lesion to the thoracic duct or lymphatic vessels in 17 patients and was associated with superior vena cava (SVC) obstruction in seven. Of the latter, five had bilateral chylothorax. Chylothoraces secondary to venous hypertension and thrombosis have a longer interval between operation and diagnosis compared with direct trauma as well as a longer duration and larger volume of

chylous drainage. Treatment was entirely nonoperative in 16 patients and operative in 8. Nonoperative treatment consisted of pleural needle aspiration or suction drainage in association with a medium chain triglyceride (MCT) diet (n = 11) or total parenteral nutrition (TPN) after failure of MCT (n = 5). Direct operation on the thoracic duct was performed in 5 patients, four had pleurodesis, and 2 had pleuroperitoneal shunts inserted. All patients were cured of their chylothorax and there were no deaths. Patients with major vein thrombosis were the most difficult to treat. On the basis of this experience, we suggest a step-by-step approach: (1) insertion of chest tube after 3 to 4 pleural punctures; (2) 1-week trial of MCT diet, with intravenous support to correct protein losses; (3) TPN if chylothorax increases or persists with large volumes; (4) Doppler echocardiography or phlebography to rule out obstruction of major thoracic veins; and (5) insertion of TPN line in inferior vena cava in case of such obstruction; and (6) direct surgical approach to the thoracic duct after 4 weeks of unsuccessful nonoperative treatment.(ABSTRACT TRUNCATED AT 250 WORDS) Record 42 from database: MEDLINE Order full text for this document Title [Spontaneous spinal epidural hematoma diagnosed by MRI: a case report] Author Kanai M; Egashira M; Murata T; Iwai Y; Seki M Address Department of Neurosurgery, Murata Hospital. Source No Shinkei Geka, 1989 Nov, 17:11, 1073-6 Abstract Appropriate diagnostic procedure for spinal epidural hematomas has not been established yet. The authors reported a case of spontaneous epidural hematomas at the thoracic level, in which correct diagnosis was made with MRI and good results were obtained by surgery. A 63-year-old female experienced a severe back pain which appeared suddenly during a walk and was followed by motor weakness in both legs deteriorating quickly to paraplegia. The patient had no history of hypertension, trauma or bleeding tendency. The laboratory data were normal. On admission, neurological examination revealed flaccid paraplegia, total sensory loss below the level of Th 6 and urinary and fecal incontinence. Myelograms showed incomplete block at the Th 6 level and postmyelographic CT scan showed an isodense mass, which was suspected to be an epidural tumor located behind the spinal cord. Emergent MRI confirmed an epidural hematoma as a high intensity area extending from Th 3 through Th 11. Sixty-five hours after onset, laminectomy of Th 4 through Th 11 and the evacuation of epidural hematoma were performed without identification of the origin of the bleeding. Neither vascular malformation nor tumor was recognized during operation. Neither was it noticed on histological examination. The patient made favorable progress after the surgery. During the first two weeks in the postoperative period, she regained muscle strength enough to do standing exercise, and satisfactory improvement was made in sensory function including urination and

defecation. We emphasize that MRI is indispensable to make a differential diagnosis of thoracic lesions. In the reported case, a correct diagnosis was made with MRI, and an extremely good result was obtained by an emergency operation.

Record 43 from database: MEDLINE Order full text for this document Title Port-Access coronary artery bypass grafting with the use of cardiopulmonary bypass and cardioplegic arrest. Author Reichenspurner H; Gulielmos V; Wunderlich J; Dangel M; Wagner FM; Pompili MF; Stevens JH; Ludwig J; Daniel WG; Schler S Address Cardiovascular Institute, University Hospital Carl Gustav Carus, Dresden, Germany. Source Ann Thorac Surg, 1998 Feb, 65:2, 413-9 Abstract BACKGROUND: To reduce surgical trauma, we performed minimally invasive Port-Access (Heartport Inc, Redwood City, CA) coronary artery bypass grafting with cardiopulmonary bypass and cardioplegic arrest. METHODS: Thirty-six men and 6 women with a median age of 59 years (range, 31 to 75 years) and isolated lesions of the left anterior descending branch of the coronary artery underwent Port-Access coronary artery bypass grafting. A small (6to 9-cm) incision was made parasternally on top of the fourth rib. The left internal thoracic (mammary) artery was dissected and taken down through the minithoracotomy either alone or using an additional thoracoscopic approach. Cardiopulmonary bypass was instituted through femoral cannulation, and an additional endoarterial balloon catheter (Heartport Inc) was introduced into the ascending aorta for aortic occlusion, aortic root venting, and the delivery of cold antegrade crystalloid cardioplegia. After cardioplegic arrest, the left internal mammary artery was anastomosed to the left anterior descending artery under direct vision. RESULTS: The median left internal mammary artery takedown time was 49.5 +/- 21.9 minutes, the duration of cardiopulmonary bypass was 59.5 +/- 32.8 minutes, the aortic occlusion time was 28.5 +/- 7.9 minutes, the intensive care unit stay was 1.0 +/- 3.2 days, and the total hospital stay was 5.0 +/- 2.5 days. Intraoperative angiograms were done in the first 10 patients and showed patent left internal mammary artery grafts without anastomotic complications in all cases. Two arterial dissections, including one aortic dissection, were observed in patients with preexisting peripheral vascular disease. The other complications were minor. All but 1 patient recovered well, with no major limitations in their daily activities. CONCLUSIONS: Using this minimally invasive method, sternotomy-related complications can be avoided, the hospital stay can be reduced, and a safe coronary artery bypass grafting procedure can be performed with the advantage of cardiopulmonary bypass and cardioplegic arrest as are used routinely in conventional coronary artery operations.

Record 44 from database: MEDLINE Order full text for this document Title Our experience with Palmaz-Schatz coronary stent. Author Kaul U; Agarwal R; Sharma S; Jain P; Goswami KC; Wasir HS Address Cardiac Thoracic Centre, AIIMS, New Delhi. Source Indian Heart J, 1994 Nov, 46:6, 291-6 Abstract Between September 1993 and August 1994 we have implanted Palmaz-Schatz coronary stents in 44 patients. Twenty eight patients presented with stable angina and 16 with unstable angina. Stenting was carried out for denovo, focal lesions in large coronary arteries (n = 27), significant dissection during PTCA with acute threatened closure (n = 9), suboptimal results (n = 5), restenosis after PTCA (n = 2) and saphenous vein graft stenosis (n = 1). Successful delivery of the stent was achieved in 43 cases. Percent diameter stenosis was reduced from 77 +/- 11% to 10 +/- 8% and minimal luminal diameter increased from 1.08 +/- 0.28 mm to 2.92 +/- 0.39 mm. There was 1 death due to left main dissection secondary to guiding catheter trauma in a patient taken up for bail out stenting. Vascular/bleeding complications occurred in 3 patients (6.7%). There was no instance of acute or subacute stent thrombosis. Forty patients are symptom free. Eighteen patients underwent six month angiography. Restenosis (> 50% diameter reduction) was seen in 2 and a new lesion distal to stent occurred in 1 case. All have been successfully redilated. A high rate of successful delivery of the Palmaz-Schatz coronary stent can be achieved in a wide spectrum of patients with very few complications. Long term results are very gratifying and encouraging.

Record 45 from database: MEDLINE Order full text for this document Title Transthoracic exposure for anterior spinal surgery. Author McElvein RB; Nasca RJ; Dunham WK; Zorn GL Jr Address Division of Cardiothoracic Surgery, University of Alabama, Birmingham 35294. Source Ann Thorac Surg, 1988 Mar, 45:3, 278-83 Abstract The anterior approach to the vertebral column is used to treat fractures, spinal deformities, and destructive lesions secondary to

tumor or infection. The thoracic surgeon, working with orthopedic surgeons and neurosurgeons, is uniquely qualified to provide surgical exposure expediently and assist in postoperative care. Forty-five patients with spinal deformities secondary to trauma (18 patients), congenital anomalies (16 patients), neoplastic disease (7 patients), and inflammation (4 patients) were treated by a transthoracic (37 patients) or thoracoabdominal (10 patients) anterior approach to the vertebral column. Two patients had subsequent operations. Free and vascularized rib grafts were used for stabilization and fusion with good results and few complications (8 patients). These results indicate that interspecialty cooperation results in expedient surgical exposure and good postoperative care.

Record 46 from database: MEDLINE Order full text for this document Title Conservative treatment of paraplegia following acute trauma in a patient with tuberculous kyphosis: case report and review of the literature. Author Chan KM; Leung PC Address Source Paraplegia, 1985 Jun, 23:3, 187-91 Abstract This is the third known reported case in the medical literature of complete paraplegia following acute trauma in a patient with tuberculous kyphosis. Early clinical evidence of neurological recovery and the absence of a radiological fresh lesion are important indications for conservative treatment. The patient made a complete recovery. The mechanism of injury is probably both mechanical and vascular.