Faculty Bibliography

Purpose: Our purpose was to evaluate the efficacy and limitations of the Auth Rotablator, an atherectomy device recently approved by the U.S. food and Drug Administration for general use in treating peripheral arterial occlusive lesions. Methods: Between August 1987 and December 1990, 72 patients from three medical centers (University of California, Los Angeles, Montefore, and Stanford) underwent atherectomy with the Auth Rotablator in 79 limbs and 107 arteries: 2 iliac, 45 femoral, 29 popliteal, and 31 tibial. The average age among the 72 patients was 69 years (43 to 91 years), and 67% were men. Indications for atherectomy were claudication in 34 (43%), limb threat in 44 (56%), and asymptomatic in 1 (1%) case. Average ankle-brachial index was 0.47 (0 to 0.81). Average length of lesions was 9 cm (1 to 40 cm); 70 treated arterial segments were less than 10 cm and 37 were greater than 10 cm. All patients underwent arterial pulse examination, vascular laboratory Doppler measurement of ankle-brachial indexes, and arteriography before and after surgery and at follow-up intervals during a period of 15 to 41 months (mean 27 months). Results: Angiographic success (residual lumen < 25% stenosis) was achieved in 70 (89%) of 79 limbs and 82 (77%) of 107 arteries: iliac 1 (50%) of 2, femoral 38 (84%) of 45, popliteal 24 (83%) of 29, and tibial 19 (61%) of 31. In-hospital clinical and hemodynamic success was achieved in 61 (77%) of 79 limbs. The cumulative primary patency rate was 47% at 6 months, 31% at 12 months, and 18.6% at 24 months. Complications included hemoglobinuria in 10 cases (13%), emboli in eight cases (10%), dissection in five cases (6%), perforation in three cases (4%), hematoma in four cases (5%), and infection in one case (1%). There were nine early thromboses (11%) and two device-related amputations (2.5%). Conclusion: Peripheral atherectomy with the Auth Rotablator currently has limited application because of frequent early thromboembolic complications and poor late patency rates. Atherectomy is not generally recommended for treating peripheral arterial occlusive lesions until these problems with early thromboemboli, occlusions, and late restenoses are solved. $$:

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

Selective preservation of infected arterial grafts is an alternative to graft excision. The purpose of this study was to compare the outcome and cost of treating infected lower extremity arterial grafts with either muscle flaps (MFs) or delayed secondary intention (DSI) wound healing. Between 1985 and 1991 we treated 28 graft infections by graft preservation. All grafts (19 polytetrafluoroethylene, 8 autologous vein, and 1 Dacron) were patent with intact anastomoses and showed no signs of sepsis. Wounds in 18 patients were treated by repeated, aggressive operative debridement and allowed to heal by DSI. Wounds in 10 patients were treated with MFs (4 sartorius, 3 gracilis, 1 rectus abdominis, 1 semimembranous, and 1 gastrocnemius). Costs included anesthesiologists' and surgeons' fees, operating room charges, and daily semiprivate and ICU bed charges. Four (14%) patients died from cardiac complications (1 DSI and 1 MF), sepsis (1 MF), and anastomotic hemorrhage (1 DSI). Of the 24 survivors, 4 patients treated by DSI required graft excision for nonhealing wounds (2), graft thrombosis (1), and recurrent infection (1). However, 3 of these 4 patients were not candidates for MFs because the wounds were not considered acceptable for a flap. Twenty (83%) grafts in survivors were successfully preserved after long-term follow-up (mean 26 mo). No survivors required an amputation. Twenty patients who did not require graft removal were compared for treatment by MF (n = 8) or DSI (n = 12). Two MFs (both sartorius) in survivors necrosed and a new flap was required to successfully preserve the graft.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

Purpose: Vascular reconstruction alone can be insufficient for extremity salvage in some patients with severe soft-tissue wounds. We present our experience in 20 patients with vascular reconstruction for ischemic disease and free-tissue transfer for limb-threatening soft-tissue wounds. Methods: Nineteen patients underwent autogenous venous bypasses and one patient underwent an aortobifemoral bypass. Ten soft-tissue reconstructions were performed at the time of the vascular reconstruction and 10 were delayed. Free-tissue transferred included muscle, fasciocutaneous flaps, and omentum. Inflow to the flap was from the bypass graft (n = 12) or the distal tibial artery. Results: One free flap and graft failed immediately in the same patient. One successful flap and graft required a below-knee amputation for ongoing infection in the surrounding soft tissues. Eighteen of 20 patients have had free-flap and graft patency during the mean follow-up period of 17 months (range 6 to 33 months). These 18 patients ambulate independently. Conclusions: In patients with arterial insufficiency and severe soft-tissue wounds, combined vascular reconstruction and free-tissue transfer permits extended limb salvage with excellent functional results. $$:

Purpose: Cryopreserved saphenous vein allografts (CSVA) are available for use in arterial reconstructions; however, patency rates in the infrainguinal position are not well described. Methods: We reviewed our experience with 38 patients who underwent 43 infrainguinal bypasses with CSVA as the conduit. The group includes 21 women and 17 men with a mean age of 69 +/- 11 years. Mean follow-up is 8.2 +/- 5.5 months. Logistic regression was used to analyze five variables in an attempt to identify predictors of success or failure: distal anastomosis to the popliteal artery versus a crural artery, one-vessel versus two- or three-vessel runoff, postoperative anticoagulation versus none, primary reconstructions versus reoperations, and one segment versus two segments of CSVA required. Results:The cumulative patency rate at 12 months by life-table analysis is 66%. Logistic regression revealed that primary reconstructions were more likely to succeed than reoperations (p = 0.03) and operations completed with one segment of CSVA were more likely to succeed than those requiring more than one segment of vein (p = 0.03). Conclusions: We conclude that (1) the short-term patency of infrainguinal bypasses with CSVA suggests that they may be acceptable alternatives to prosthetic grafts in the below-knee position, and (2) primary reconstructions performed with one segment of CSVA are more likely to succeed. $$: