Just as the recent progress in heart surgery has occurred parallel to the improvements in the techniques of anaesthesia, so have the newer procedures in peripheral vascular surgery been helped by the development of new types and methods of administration of anticoagulant drugs in the post-operative period. At least this has been our experience in the Vascular Diseases Service of the ' Lila Hidalgo' Hospital where the basic material for this study was gathered.In connection with this study, we have available for study the material from 24 patients, upon whom reconstructive arterial operations were performed: I8 of these were thromboendarterectomies, 2 were autogenous vein grafts and 4 were arterial homografts. We regard the result as good when the arteries remained patent, and consider the result bad when bleeding or postoperative thrombosis occurred; yet we wish to point out that in connection with this study we have intentionally ignored some other factors of no less importance, such as: selection of patients suitable for the operation and the type of operation to be performed.At first we did not use anticoagulants in the immediate post-operative period, and based this on the following points:I. To avoid the danger of the possible complications of this therapy, especially haemorrhage.2. As soon as the blood flow is restored,, the circulation speed increases to a rate fast enough to avoid the danger of thrombosis.This led us to rely upon the maintenance of an adequate blood pressure and to the employment of intravenous spasmolitics (Eupaverine).occlusions: one with a good result, but in the other two the artery thrombosed again at the site of the operation, which made us to think that increased circulation speed was not enough to prevent this complication.Thus it occurred to us that the administration of anticoagulants might have an important place in the management of these patients in the postoperative period. It was only left to be proved what type of anticoagulant would be adequate and how to administer it. Our first step was to associate heparin with anticoagulants of a prolonged action. In the postoperative period we administered intravenously heparin every four hours subsequent to the operation until coumarin anticoagulants administered several hours before the operation took the prothrombin time to adequate levels, at which point we discontinued heparin. This procedure was carried out in two cases, one of them with Tromexan, and the other one with intravenous Warfarin at I.5 mg./kg. weight. In both patients the results were disastrous due to repeated haemorrhages, even with sub-therapeutic prothrombin levels, and one patient died as a result.It seemed possible that these coumarin anticoagulants, independent of their anti-prothrombin action and due to their capilatoxic action, had produced a diffuse haemorrhage tendency difficult to control, which made us decide that their use was counterindicated at least within the immediate post-operative period.Thereafter we decided to administer only heparin, which we...
Thromboendarterectomy as described in 1947 by Joao Cid Dos Santos consists of the extirpation of a thrombus together with a portion of the endothelium. The advisability of this operation is based on the demonstration of the existence of a cleavage plane on the internal elastic lamina level, together with the possibility of administering anticoagulants later on, in order to avoid a new thrombosis on the operated segment. This is in accordance with the result of a previous arteriographic study permitting the demonstration of the segmentary character of the obstruction.This study points out our experience with the operation at the Vascular Diseases Service of the Lila Hidalgo Hospital and is intended to put forth the two factors that, in our judgement, greatly influenced the results obtained; i.e., patient selection and postoperative anticoagulant therapy. MATERIALIn each of our patients there was a history of a chronic ischemia syndrome, in which intermittent claudication was the chief complaint. Fifty per cent showed, in addition, trophic lesions of an ulcerative type or preexisting gangrene. In each of them, pre-and postoperative studies of the oscillometric readings and arteriograms (for the topographic diagnosis of lesions) were made, because only those patients with segmental lesions between the aorta-iliac bifurcation and the popliteal bifurcation were considered suitable for the operation. In some instances of iliac occlusion (figs. 1 and 2) the arteriographic study was completed by injecting the dye into the femoral artery-after previous dissection and puncturing of same-in the now of and against circulation to check the distal circulatory condition and the lower limit of the obstruction.Clinical and electrocardiographic checks were conducted to verify the cardiac status in order to discard the possibility of operation in patients with severe lesions, or take the necessary precautions in connection with the type of anesthesia and medication. TECHNIQUE . The first patients were treated according to the technique of continuous incisions along the length of the obstructed segment of Reboul,i which practice was abandoned promptly because it prolongs the operation. Thereafter the preferred technique was that of Joao Cid Dos Santosl 3 relative to discontinuous incisions.Once the cleavage plane was found and the thrombus dissected with the endothelium, the latter was cut obliquely on the level of the distal end, to avoid the necessity of fixing the thrombus with U-sutures according to the Kunlin and Leriche technique in order to prevent dissecting hematoma.Frequent irrigations were made of the operative area with 10 mg per cent of heparin solution, closing the arteriotomy with everting continuous suture made with Deknatel 5-0 silk. On our recent patients who had femoral occlusion, we successfully performed the Cannon and Barker2 technique.In the majority of our patients, especially those with iliac occlusion, we perform a lumbar sympathectomy, which, while increasing the velocity of circulation in the endarterecto...
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