Faculty Bibliography

Our prior anecdotal experience with unsuspected preexisting saphenous vein disease prompted us to study its incidence, its relation to graft failure, and to identify techniques for its detection. Thick-walled, postphlebitic sclerotic occluded, postphlebitic sclerotic recanalized, calcified, and varicose vein lesions were detected in 63 (12%) of 513 infrainguinal vein bypasses. In 13 (2% to 5%) cases, severe saphenous vein disease precluded use of the vein. In the remaining 50 cases, the entire vein or a portion thereof, with minimal or unsuspected disease, was used for bypass. Early graft failures occurred in 10 (20%) of the 50 cases. The cumulative primary patency rate at 30 months for bypasses performed with diseased veins was 32%. This was significantly less than the 73% cumulative primary patency rate for bypasses with veins without detectable disease (p less than or equal to 0.001). Retrospective evaluation of preoperative duplex ultrasonography (n = 21) originally used to evaluate saphenous vein length and diameter correctly identified thick-walled, occluded, calcified, and varicose veins in 62% of cases. Intraoperative methods of vein evaluation included inspection, palpation, irrigation, catheter or valvulotome insertion to identify obstruction, and intraoperative arteriography. Histologic examination of diseased veins demonstrated a spectrum of disease with thickening of the intima and media, vein wall calcification, and luminal recanalization. We conclude that (1) unsuspected preexisting saphenous vein disease occurs in approximately 12% of cases and results in both early and late graft failures; (2) detection, in some cases, is possible with duplex ultrasonography and intraoperative techniques; and (3) diseased veins that are recanalized, calcified, or thick-walled should not be used if an alternative vein is available

The value of the popliteal-to-distal artery bypass in limb salvage is well documented. However, the influence of progression of disease in the superficial femoral artery or proximal popliteal artery, and the role of percutaneous transluminal angioplasty of these vessels before bypass have not been adequately assessed. To evaluate these and other factors, we reviewed our experience with 153 nonsequential popliteal-to-distal artery bypasses performed over a 12-year period. Limb salvage was the indication for all procedures, and 87% of the patients were diabetic. The 5-year primary and secondary graft patency rates were 55% and 60%, respectively, and the limb salvage rate was 73%. Preoperative arteriograms were evaluated for stenosis in the superficial femoral artery or popliteal artery proximal to the graft. Fifty-six grafts with a proximal stenosis 20% or less were identified and had primary graft patency of 77% at 2 years, similar to the 70% patency for the 20 grafts placed distal to a 21% to 35% stenosis. The 18 grafts placed distal to a stenosis greater than 35% had 53% 2-year primary graft patency (p = 0.25). Percutaneous transluminal angioplasty of a superficial femoral artery or popliteal artery stenosis (24% to 85% luminal narrowing) in 19 limbs resulted in 68% 2-year graft patency, not significantly lower than grafts with 35% or less proximal stenosis (75%, p = 0.25). Other factors associated with significant decreases in graft patency included a vein graft diameter less than 3.0 mm, a dorsalis pedis outflow site, and poor quality outflow. Thus the popliteal-to-distal bypass is a durable procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

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. $$:

Arterial bypass with autogenous vein has achieved excellent results in the treatment of lower extremity arterial occlusive disease. Greater saphenous vein has proven to be the conduit of choice for lower extremity bypass for limb salvage surgery, with lesser saphenous vein and cephalic vein serving as alternative sources of autogenous vein. The recent literature has emphasized graft surveillance with duplex scanning to detect significant flow-altering lesions associated with the bypass graft so these lesions can be repaired prior to graft thrombosis. The best method of graft revision has not been clearly established, but it has been substantiated that graft repair will lead to extended graft patency in an otherwise doomed bypass. In addition, recent evidence has described the potential role of saphenous vein disease in the early and late vein bypass failure. $$:

Several factors influence pulmonary hemodynamics after lung transplantation: reimplantation response, lung rejection reaction and imperfect anastomosis technique. In this experiment, five cases presented marked elevation of mean pulmonary artery pressure at the time or right pulmonary artery occlusion test performed two weeks postoperatively. Left atrial cuff rejection reaction arose in one case in which edema and stenosis of the pulmonary vein outflow tract were evidenced. This finding demonstrated that the changes in pulmonary hemodynamics after transplant suggest the possibility of inducement by left atrial cuff rejection reaction

Nonoperative therapy includes conservative noninterventional modalities and the endovascular interventional modalities of percutaneous transluminal angioplasty and a variety of laser systems and atherectomy devices. The role and impact of all nonoperative treatments are considered in the perspectives of the natural history of lower-extremity arteriosclerosis and its present surgical (operative) treatment. Nonoperative treatments may replace and/or facilitate surgical treatment in operative candidates. Nonoperative methods may also justify treatment in patients who cannot or should not be subjected to surgery. Facts and opinions relating to these uses of nonoperative treatments are presented, and the qualifications and credentialing of individuals who should be treating patients with lower-extremity ischemia resulting from peripheral arteriosclerosis are discussed