Faculty Bibliography

Sixty-eight patients with extracavitary arterial prosthetic graft (EAPG) infections were managed over the past 15 years. We have developed a modified classification and management plan to treat EAPG infections. Based on the depth of the infection, patency of graft, and degree of graft involvement, the infection was treated with graft preservation or total graft excision and revascularization. This management plan resulted in a mortality rate of 10% (7 of 68) and a limb loss rate of 11% (7 of 61 threatened limbs in survivors). Wounds healed and remained healed after long-term follow-up in 82% of patients. Routine total excision of infected EAPGs is unnecessary and may result in a higher complication rate compared with selective graft preservation. $$:

PURPOSE: The purpose of this report was to determine differences in presentation, bacteriology, management, and outcome of early (EGIs) versus late extracavitary arterial graft infections (LGIs). METHODS: Between July 1, 1979, and June 30, 1994, we treated 141 patients with infected extracavitary arterial grafts (112 prosthetic, 29 vein) with selective partial or complete graft preservation. RESULTS: A total of 99 (70%) EGIs (< 2 months) and 42 (30%) LGIs (4 to 96 months) were involved. The hospital mortality rate was 14% (20 of 141), and the amputation rate in survivors was 13% (16 of 121). No significant difference in mortality (16% [16 of 99] vs 10% (4 of 42]) or limb loss (16% [13 of 83] vs 8% [3 of 38]) was seen between EGIs and LGIs, respectively (p > 0.05). Patients with EGIs were as likely to have a disrupted anastomosis (17% [17 of 99] vs 21% [9 of 42]) or systemic sepsis (4% [4 of 99] vs 4% [2 of 42]) as patients with LGIs, respectively (p > 0.05). Patients with EGIs were more likely to have patent, intact grafts and to be treated by complete graft preservation (61% [61 of 99] vs 26% [11 of 42]) (p = 0.0001). In comparison, patients with LGIs were more likely to have occluded grafts and to require subtotal graft excision (48% [20 of 42] vs 18% [18 of 99]) (p = 0.0001). Surviving patients with EGIs treated by complete graft preservation were more likely to have successful healing of their wounds after long-term follow-up (average 3 years) than patients with LGIs (79% [41 of 52] vs 40% [4 of 10], respectively) (p = 0.03). The pathogens cultured from wounds of EGIs versus LGIs were pure gram-positive bacteria in 49 (49%) versus 19 (46%), pure gram-negatives in 18 (18%) versus 11 (26%), and both types in 33 (33%) versus 12 (28%) (p > 0.05). CONCLUSION: Complete graft preservation can be attempted more frequently and is more likely to be successful in EGIs than in LGIs. No difference in bacteriology was seen between the two groups. Graft-preserving treatment can be successful but should only be cautiously attempted in patients with late extracavitary arterial graft infections

Purpose: The purpose of this study was to identify high-risk populations for severe carotid artery disease (SCD) and neurologic events (NE) after nonemergency isolated coronary artery bypass graft procedures (CABG). Methods: Between February 1989 and July 1992, 387 patients underwent preoperative carotid artery duplex scanning as part of a preoperative assessment for nonemergency cardiac procedures. Of these patients, 376 had isolated CABG, and 11 had combined carotid endarterectomy (CEA) and CABG. Patient demographics, risk factors, and preoperative neurologic symptoms were recorded and analyzed. Severe carotid artery disease was defined as a 80% or greater stenosis of either internal carotid artery by carotid artery duplex scanning. Patients were evaluated for neurologic events (cerebrovascular accident, transient ischemic attack, amaurosis fugax, or reversible ischemic neurologic deficits) during the in-hospital postoperative period. Results: The prevalence of SCD was 8.5% (33 patients). The 33 patients with SCD were significantly older (65.6 +/- 6.5 years vs 62.5 +/- 10.4 years,p = 0.02), had previous CEA (27.3% vs 2.0%, p = 0.00001), had preoperative neurologic symptoms (21.2% vs 5.9%, p = 0.002), and had peripheral vascular disease (PVD) (63.6% vs 16.9%, p = 0.00001). The sensitivity of PVD for SCD is 63.6% (n = 21/33) (specificity 83.1%, positive predictive value 25.9%, negative predictive value 96.1%). In patients undergoing CABG alone, those who had postoperative NE were older (69.6 +/- 6.7 years vs 62.5 +/- 10.3 years, p = 0.036) and more likely to have PVD (50% vs 19.7%, p = 0.034), SCD (40% vs 4.9%, p = 0.001) and previous CEA (40% vs 2.7%, p = 0.0002). The incidence of postoperative NE in patients with SCD was 18.2% vs 1.7% in patients without SCD (p = 0.001). The sensitivity of SCD for NE was 40% (n = 4/10) (specificity 95.1%, positive predictive value 18.2%, negative predictive value 98.3%). Conclusions: PVD may be helpful to identify patients at high risk for severe carotid artery stenosis. Postoperative NE in patients with CABG are associated with increasing age, carotid artery stenosis greater than 80%, previous CEA, and PVD. $$:

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