Faculty Bibliography

OBJECTIVE: The authors report on their 20-year experience with 120 patients with infected extracavitary prosthetic arterial grafts (95 polytetraflouroethylene, 25 Dacron). Throughout this experience, an effort was made, when appropriate, to salvage all or a portion of these infected grafts. METHODS: When patients had arterial bleeding (20 cases) or systemic sepsis (6 cases), immediate graft excision was performed. When the infected graft was occluded (43 cases), subtotal graft excision was performed, leaving an oversewn 2- to 3-mm graft remnant to maintain patency of the artery. Complete graft preservation was attempted in 51 cases in which the graft was patent, the patient was not septic, and the anastomoses were intact. Aggressive operative wound debridement was repeated, as necessary, to achieve wound healing. The preferred method of revascularization, when necessary, included secondary bypasses tunneled through uninfected (often lateral) routes. Follow-up averaged 3 years (range, 1 month-20 years). RESULTS: This strategy resulted in a hospital mortality of 12% (14/120) and a hospital amputation rate in survivors of 13% (14/106 threatened limbs). Of the surviving patients treated by complete graft preservation, the hospital amputation rate was only 4% (2/45) and long-term complete graft preservation was successful in 71% (32/45) of cases. Partial graft preservation also proved successful in 85% (35/41) of surviving patients who had occluded grafts. Successful complete graft preservation was as likely when gram-negative or gram-positive bacteria were cultured from the wound, with the exception of Pseudomonas (successful graft preservation in only 40% [4/10] of cases). CONCLUSION: Based on this 20-year experience, the authors conclude that selective partial or complete graft preservation represents a simpler and better method of managing infected extracavitary prosthetic grafts than routine total graft excision

PURPOSE: The absence of sufficient length of suitable autologous vein occasionally prohibits the treatment of severe distal lower extremity arterial occlusive disease with a standard distal bypass originating from the common femoral artery. During the past 11 years, we have therefore selectively performed short distal bypasses originating from the infrapopliteal arteries in patients with limb-threatening ischemia and occlusive lesions limited to the distal tibial and peroneal arteries. This report summarizes our experience with these tibial artery based distal bypasses. METHODS: Forty-two distal lower extremity arterial bypasses originating from infrapopliteal arteries in 41 patients were performed over an 11-year period. Autologous vein was used as the bypass conduit in all cases. Extensions from a more proximal bypass were excluded. RESULTS: The primary patency rate of these tibiotibial bypasses was 77% at 1 year and 62% after 5 years. The limb salvage rate after 5 years was 74%. The perioperative mortality rate was low (2%), but the 5-year patient survival rate (64%) was similar to that with more standard lower extremity arterial reconstructive procedures. CONCLUSIONS: Tibiotibial bypass is an effective limb salvage procedure in carefully selected patients with distal tibial artery occlusive disease and limited autologous vein. It offers a durable means of distal revascularization in circumstances in which a standard operation might not be desirable or possible

This study describes the varied histologic features and ultrastructure of human saphenous veins obtained from patients undergoing infrainguinal arterial reconstruction. Portions of 30 remnant veins were fixed at arterial pressure (100 mmHg). Vein specimens were obtained from 13 men and 17 women, with a mean age of 70.2 years. Ten veins (33%) were from diabetic patients. Samples of fixed veins were prepared for light and electron microscopy. The luminal surface contained valves and redundant intimal folds at the site of ligated side branches. Microvalves were present at the orifices of several 1-mm vein tributaries. The endothelial cells lining the intima were often discontinuous and were aligned in a variable pattern. The thicknesses of the vein walls varied from 20 to 360 microns, with increased connective tissue matrix in the intima and medial layers of thick-walled veins. Some 10% of the veins demonstrated spindle cells in the intima; these cells had a smooth muscle cell phenotype and varied with respect to the degree of cellular differentiation. Regions of vein wall calcification were occasionally seen and were always present in association with a thickened vein intima. Variations in the structure of the saphenous vein from patients undergoing bypass surgery are common. The relationship between altered saphenous vein morphology and subsequent vein graft stenosis needs to be defined

BACKGROUND: Endovascular stented grafts employ a new technique that blends intravascular stent and prosthetic graft technologies. These devices may be used to treat arterial aneurysms, occlusive disease, and vascular injuries. This report describes the application of stented grafts to the treatment of limb-threatening ischemia secondary to occlusive disease of the aorta, iliac, and femoral arteries. METHODS: Three patients with limb-threatening ischemia and severe comorbid medical illnesses were treated with transvascular stented grafts that were composed of 6-mm thin-walled polytetrafluoroethylene grafts and Palmaz balloon expandable stents. The grafts were inserted through a cutdown in an artery remote from the site of occlusion and introduced into the vascular system within 14-Fr introducer sheaths. RESULTS: Technical success was documented in all three patients with restoration of arterial continuity following stent graft deployment. Patency and limb salvage has been achieved to 1 year. One patient required further dilatation of the proximal stent at 6 weeks. Complications were limited to an iliofemoral deep vein thrombosis in one patient. CONCLUSIONS: Endovascular stented grafts can be inserted to treat limb-threatening ischemia. Although these initial results are encouraging, greater experience in more patients observed for longer periods of time is necessary before this technique can be advocated for widespread use

We reviewed 95 cases of vein graft and anastomotic lesions treated with percutaneous transluminal balloon angioplasty (PTA) and 30 cases treated surgically. The therapy was deemed a failure if the lesion recurred or if the graft closed. The 21-month patency rate of lesions treated surgically was 86%, which was significantly better than the 42% patency rate for all lesions treated with PTA (P < 0.01). An evaluation of the lesion and graft characteristics that could influence the patency of stenotic lesions treated with PTA included: lesion length, minimum graft diameter, lesion location, and lesion type. The 66% patency rate at 24 months for the 41 simple lesions (single, nonrecurrent, < 15 mm in length, and within grafts > or = 3 mm minimal diameter) was significantly better than the 17% patency rate for the 50 complex lesions (multiple, recurrent, > or = 15 mm in length, or within grafts < 3 mm in minimal diameter) (P < 0.01). In addition, the 21-month patency rate for the surgically treated group (86%) was not significantly better than that of the angioplasty-treated simple lesions (66%). When feasible, vein graft lesions are best treated with simple surgical interventions. PTA can be useful to maintain the patency of severely compromised grafts prior to surgical repair, to treat simple lesions difficult to reach surgically, and for patients with medical contraindications for an operation