Faculty Bibliography

Controversy continues as to whether percutaneous transluminal angioplasty (PTA) or surgical revision is the ideal modality for the treatment of failing grafts. This prompted a histopathologic analysis of failing human vein graft segments subjected to ex vivo balloon dilatation to define variables responsible for the discrepant results. Fifteen vein graft lesions from 14 patients with failing infrainguinal bypasses were recovered after surgical excision. Each graft lesion was focal and uniform in length (2.1 +/- 0.3 cm). Rings sectioned from adjacent regions of each vein graft lesion before and after balloon inflation were processed for histologic study, photomicrography, and image analysis. Angioplasty balloon size was selected on the basis of preoperative arteriograms. Graft lesions were divided into three groups based on lesion thickness and the degree of fibrosis and cellularity seen on sections stained with Masson's trichrome. The luminal area before angioplasty was not significantly different for the three groups (p > 0.2). Vein grafts with thick intimas (group 1) had significantly less luminal dilatation after angioplasty as compared with less thick intimal lesions (groups 2 and 3; p < 0.001). Those lesions with varying degrees of cellularity (groups 2 and 3) showed no significant differences in luminal diameter after angioplasty. However, the cellular lesions in group 2 consistently formed multiple intimal flaps that could produce PTA failures even with good luminal restoration. The varying histology of vein graft lesions and associated differences in intimal thickness and cellularity may be responsible for the inconsistent results following PTA. Estimates of wall thickness before angioplasty, particularly in the intimal area, may be helpful in evaluating which lesions might benefit most from PTA

Purpose: The conventional management of prosthetic graft infection (PGI), including graft excision and extraanatomic revascularization, continues to be associated with substantial morbidity. Rotational muscle flap (RMF) closure of the infected wound, with preservation of the graft, is an alternative, albeit controversial, approach. Methods: Over the last 7 years, 22 RMF procedures have been performed to close 19 wounds in 18 patients, ranging in age from 39 to 79 (mean 63.7) years, with PGI. Twenty-one grafts constructed of Dacron (13) or polytetrafluoroethylene (8) were covered in the groin (16), neck (2), or chest (1). The clinical presentations included abscess or purulent drainage in 14 grafts, hemorrhage in three, and infected false aneurysm in two wounds; positive bacterial culture results were obtained in each case. Results: There was one (5.6%) operative death. Healing was achieved in the 18 wounds of the 17 operative survivors. No patients have been lost to follow-up. Three (17.6%) of these 17 patients had recurrent infection, including one patient who underwent a secondary RMF procedure with graft salvage, one who underwent excision of an occluded graft, and one who underwent excision and extraanatomic bypass and died. Four other patients died 1 to 6 (mean 3) months after RMF closure with healed wounds. Eleven (92%) of the 12 survivors have healed wounds and intact grafts with follow-up ranging from 8 to 83 (mean 39) months. For the entire series 15 (88%) of these 17 patients had healed wounds and intact grafts, with a mean follow-up of 30 months. Conclusions: These results suggest that RMF procedures are well tolerated and can achieve acceptable long-term graft salvage in selected patients with PGI. $$:

In a prospective, randomized trial 6 mm polytetrafluoroethylene (PTFE) and 6 mm human umbilical vein (HUV) were compared in above-knee femoropopliteal bypass grafting. In claudicants a prosthetic graft was used intentionally, in limb-salvage cases only when autologous vein was insufficient. Ninety-six extremities were randomized (49 PTFE and 47 HUV). Operative indication was disabling claudication in 77 and limb salvage in 19 extremities. The two groups were comparable as to preoperative risk factors and operative and postoperative treatment. Median follow-up was 76 months (range 47 to 91 months), during which 23 patients died of nonrelated causes with functioning grafts. Thirty-eight grafts failed (33 because of occlusion and five for other reasons). At 6 years the primary patency rate was 38.7% in the PTFE group and 71.4% in the HUV group (p < 0.001). Corresponding rates for secondary patency at 6 years were 51.4% and 76.4% (p < 0.005). $$:

The treatment of unilateral iliac occlusion remains controversial. We report our experience with femorofemoral bypass (FF) and iliofemoral bypass (IF). One hundred sixty-two FFs and 82 IFs were performed during a 25-year period. Demographic characteristics of the two groups were similar. Operative indications included claudication in 32.1% of FFs and 19.5% of IFs, rest pain in 26.5% of FFs and 36.6% of IFs, ulcer in 8.0% of FFs and 3.7% of IFs, gangrene 13.6% of FFs and 23.2% of IFs, and acute thrombosis in 13.0% of FFs and 3.7% of IFs. Five-year primary and secondary patency rates for all FFs were 56.9% and 65.4% respectively. Those for all IFs were 74.9% and 79.2%. The primary patency rate of FF performed for chronic arterial occlusive disease was 73.3% at 3 years and 60.4% at 5 years and for IF it was 73.4% at 3 years. In the absence of prior arterial surgery in the groin, the primary patency rates of bypasses for chronic arterial occlusive disease were 78.3% for FF and 86.8% for IF at 4 years. Distal endarterectomy and acute ischemia adversely affected patency. The operative mortality rate was 6.2% for FF and 3.7% for IF. Eleven wound complications occurred in the FF group. Seven patients underwent graft removal without limb loss. One minor wound problem occurred in the IF group. Iliofemoral bypass avoids operation on an asymptomatic limb; FF avoids entry in the abdomen or retroperitoneum and can be performed under local anesthesia. In patients in whom either IF or FF is applicable, the choice between these two procedures should be individualized with these factors in mind. $$:

The treatment of patients with penetrating extremity trauma in proximity to major arteries as well as the nonoperative treatment of clinically occult arterial injuries remain controversial. Duplex ultrasonography (DUS) has recently been advocated in this setting. We therefore studied experimentally induced arterial injuries in dogs to correlate the natural history, duplex findings, and histopathologic condition of different injuries and to help define criteria for operation. Fifty-two canine femoral and carotid arteries were randomized to have surgically created intimal flaps (n = 15), crush injuries (n = 15), or lacerations (n = 15) or to be controls (n = 7). An experienced sonographer, blinded to the presence or type of injury, evaluated the vessels every 10 days for 1 month. Histopathologic study was performed 1 month after injury when the arteries were retrieved. The sensitivity (96.5%), specificity (86.4%), and accuracy (95.1%) of DUS in evaluating arterial injuries at 1 month correlated well with histopathologic evaluation. All arteries subjected to crush injuries showed abnormal duplex findings. These findings correlated well with the histologic picture of severe injury (arterial wall thickness = 2.72 x +/- 0.23 x control; intramural hemorrhage, 93%; mural thrombus, 60%). DUS and histologic study revealed healing of intimal flaps in 27% of the arteries. Other intimal flaps deteriorated (stenoses, 47%; dilation, 13%; occlusion, 13%). Most lacerations (86%) revealed duplex evidence of healing within 10 days of injury. This was confirmed by histologic study at 1 month in 73% of lacerated arteries. This study confirms the accuracy of DUS in diagnosing various arterial injuries and shows that the natural history of these injuries varies with the mechanism of injury.(ABSTRACT TRUNCATED AT 250 WORDS)

Between 1975 and 1991, we treated 16 patients with infected lower extremity autologous vein grafts performed for limb salvage by complete graft preservation. Traditional treatment of these infections includes immediate graft excision and complex revascularization procedures to prevent limb loss. The infection involved an intact anastomosis in 12 patients or the body of a patent graft in 4 patients. None of the patients was systemically septic. All patients were treated with appropriate intravenous antibiotics. Six patients were treated by placement of autologous tissue on the exposed graft (4 rotational muscle flaps, 2 skin grafts), and 10 were treated with antibiotic-soaked dressing changes and repeated operative debridements to achieve delayed secondary wound healing. This treatment resulted in a 19% (3 of 16) mortality rate and an 8% (1 of 13) amputation rate in survivors. Of the six patients managed by autologous tissue placement onto the infected graft, five patients had wounds that healed without complications, and one died of a myocardial infarction. Of the 10 patients treated by delayed secondary wound healing, 2 developed anastomotic hemorrhage, which resulted in death in 1 patient and above-knee amputation in the other, 1 died of a myocardial infarction, 1 developed graft thrombosis, and 6 had wounds that healed. Placement of autologous tissue to cover an exposed, infected patent vein graft with intact anastomoses may prevent graft dessication, disruption, and thrombosis, which renders graft preservation an easier, safer method of treatment compared with routine graft excision

Correction of symptomatic vascular steal distal to an arteriovenous fistula requires either fistula ligation or banding. Ligation carries the obvious disadvantage of destruction of a functioning angioaccess, whereas banding procedures have been plagued by the complexity of many of the reported techniques and by the difficulty of balancing fistula flow with distal perfusion. In this study a simple plication technique is described that avoids the introduction of any additional foreign material and that quantifies distal perfusion by means of intraoperative pulse volume recordings. Five patients have been treated by this method, two with autologous vein fistulas and three with bridge fistulas using polytetrafluorethylene. All five have had resolution of their ischemic symptoms with an increase in intraoperative pulse volume recordings of 5 mm or more. Only three of the patients had restoration of the radial pulse, which was not a specific end point of the banding procedure. Furthermore, all fistulas remained patent for at least 6 months and continued to provide adequate flows for hemodialysis. Banding/plication is clearly preferable to fistula closure for the management of steal syndrome. The method described herein is simple and hemodynamically identifies the minimal constriction that will resolve symptoms and preserve fistula flow