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Closure of Patent Ductus
CORRESPONDENCE
Closure of Patent Ductus To the Editor: Kron and associates recently described in The Annals a simple method of ductal obliteration in the premature infant using a single metal clip (Ann Thorac Surg 37:422, 1984). 1 too was attracted to this technique but I did have one awkward experience two years ago when a ductus was completely transected by application of the 5-mm-long Ethicon Ligaclip. Some ducts have thinner walls than others, and I am afraid there is considerable danger in clipping a thin-walled duct. Incidentally, the infant survived following suture repair of the divided ductus. A. R. C. Dobell, M.D.
Division of Cardiovascular and Thoracic Surgery The Montreal Children's Hospital 2300 Tupper Montreal, PQ, Canada H3H l P 3
Reply To the Editor: My associates and I were very interested in Dr. Dobell's account of a ductus being completely transected by application of a clip. It is ironic, but the reason we started using clips was because we had an experience with a premature infant in whom the ductus was completely transected by the ligature; this was repaired by the use of two clips. Since that time, we have used clips exclusively for the closure of the patent ductus. Any technique has inherent dangers, even in the best of hands. We make a considerable effort to leave as much tissue as possible undissected around the ductus just to avoid this complication. I believe certainly that there are some patients who present a risk of ductal injury even with careful use of the clip technique. As yet, we have encountered no injuries to the ductus caused by the use of clips, but we will always be concerned about this possibility. We thank Dr. Dobell for bringing this problem to our attention.
lrving L. Kron, M . D . Division of Thoracic and Cardiovascular Surgery Department of Surgery Box 181 University of Virginia Medical Center Charlottesville, V A 22908
Rebound Vasospasm after Coronary Bypass Grafting To the Editor: The report entitled "Rebound Vasospasm after Coronary Revascularization in Association with Calcium Antagonist Withdrawal'' by Engelman and associates (Ann Thorac Surg 37469, 1984)was interesting, and I am sure it reflects the experience of many cardiovascular surgeons in the era of calcium antagonist therapy. That these effects may be widely present in other vascular beds is not well understood. My colleague and I recently performed a femoroposterior tibial bypass graft with saphenous vein on a 63-year-old man with two gangrenous toes. He had been taking verapamil(80 292
mg orally four times a day) for several months for atrial arrhythmias. This medication was discontinued 24 hours before operation. During the procedure, the 3-mm posterior tibial artery became a I-mm "cord" as we began manipulation and anastomosis. Arteriography documented this intense vasospasm (Figure), which was not responsive to treatment with papaverine. Nifedipine was not administered. Verapamil therapy was initiated in the recovery room. The posterior tibial pulse was normal early in the postoperative period and remains normal six months after operation.
Douglas P. Grey, M.D. Division of Vascular Surgery Kaiser-Permanente Medical Group, Inc. 2200 O'Farrell St San Francisco, C A 94115
Reply To the Editor: Dr. Grey's letter describes a vascular reconstruction procedure in which profound posterior tibial artery spasm was associated with verapamil withdrawal. This is yet another example of how the preoperative cessation of a calcium antagonist can induce
Closure of Patent Ductus To the Editor: Kron and associates recently described in The Annals a simple method of ductal obliteration in the premature infant using a single metal clip (Ann Thorac Surg 37:422, 1984). 1 too was attracted to this technique but I did have one awkward experience two years ago when a ductus was completely transected by application of the 5-mm-long Ethicon Ligaclip. Some ducts have thinner walls than others, and I am afraid there is considerable danger in clipping a thin-walled duct. Incidentally, the infant survived following suture repair of the divided ductus. A. R. C. Dobell, M.D.
Division of Cardiovascular and Thoracic Surgery The Montreal Children's Hospital 2300 Tupper Montreal, PQ, Canada H3H l P 3
Reply To the Editor: My associates and I were very interested in Dr. Dobell's account of a ductus being completely transected by application of a clip. It is ironic, but the reason we started using clips was because we had an experience with a premature infant in whom the ductus was completely transected by the ligature; this was repaired by the use of two clips. Since that time, we have used clips exclusively for the closure of the patent ductus. Any technique has inherent dangers, even in the best of hands. We make a considerable effort to leave as much tissue as possible undissected around the ductus just to avoid this complication. I believe certainly that there are some patients who present a risk of ductal injury even with careful use of the clip technique. As yet, we have encountered no injuries to the ductus caused by the use of clips, but we will always be concerned about this possibility. We thank Dr. Dobell for bringing this problem to our attention.
lrving L. Kron, M . D . Division of Thoracic and Cardiovascular Surgery Department of Surgery Box 181 University of Virginia Medical Center Charlottesville, V A 22908
Rebound Vasospasm after Coronary Bypass Grafting To the Editor: The report entitled "Rebound Vasospasm after Coronary Revascularization in Association with Calcium Antagonist Withdrawal'' by Engelman and associates (Ann Thorac Surg 37469, 1984)was interesting, and I am sure it reflects the experience of many cardiovascular surgeons in the era of calcium antagonist therapy. That these effects may be widely present in other vascular beds is not well understood. My colleague and I recently performed a femoroposterior tibial bypass graft with saphenous vein on a 63-year-old man with two gangrenous toes. He had been taking verapamil(80 292
mg orally four times a day) for several months for atrial arrhythmias. This medication was discontinued 24 hours before operation. During the procedure, the 3-mm posterior tibial artery became a I-mm "cord" as we began manipulation and anastomosis. Arteriography documented this intense vasospasm (Figure), which was not responsive to treatment with papaverine. Nifedipine was not administered. Verapamil therapy was initiated in the recovery room. The posterior tibial pulse was normal early in the postoperative period and remains normal six months after operation.
Douglas P. Grey, M.D. Division of Vascular Surgery Kaiser-Permanente Medical Group, Inc. 2200 O'Farrell St San Francisco, C A 94115
Reply To the Editor: Dr. Grey's letter describes a vascular reconstruction procedure in which profound posterior tibial artery spasm was associated with verapamil withdrawal. This is yet another example of how the preoperative cessation of a calcium antagonist can induce