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)

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. $$:

Between Jan. 1, 1980, and Dec. 31, 1989, 2187 infrainguinal revascularization procedures were performed. In 130 of these cases with patent bypasses, hemodynamic deterioration was suspected, and urgent arteriography was performed. Twenty additional patients with aortofemoral, femorofemoral, or axillofemoral bypasses demonstrated hemodynamic deterioration. In 93% of failing grafts the condition was suspected because of recurrent symptoms or changes in the pulse examination. Two hundred eighty-five high-grade stenotic or occlusive lesions were identified in inflow arteries, outflow arteries, within the graft, or at proximal or distal anastomoses associated with these 150 grafts. One hundred sixty-one (57%) of these lesions were in patients with failing vein grafts; 115 (40%) were in patients with failing polytetrafluoroethylene (PTFE) grafts; and 9 (3%) were associated with failing composite vein/PTFE grafts. Stenotic lesions less than 5 cm in length were initially treated with percutaneous transluminal balloon angioplasty (PTA). Occlusive lesions, stenoses greater than 5 cm in length, and PTA failures were treated surgically. The overall 6-year cumulative secondary patency rate for failing grafts was 65%, and the limb salvage rate was 75%. The extended patency rate after the first intervention in the failing state was 56% at 5 years. The 5-year secondary patency rate for grafts initially treated with PTA (58%) was not significantly different (p = 0.25) from that for grafts treated initially with surgery (71%). Percutaneous transluminal angioplasty was effective for inflow stenoses of the iliac, femoral, and popliteal arteries and for some outflow lesions.(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective evaluation of 213 consecutive infrainguinal bypass procedures was performed to determine the effect of anesthesia technique on the postoperative complication rate. Limb salvage was the indication for surgery in 92% of cases. No significant differences were observed in age, sex, indication for surgery, presence of cardiovascular and pulmonary risk factors, American Society of Anesthesiologists classification, or Goldman scores between patients receiving epidural anesthesia and those receiving general endotracheal anesthesia. Epidural anesthesia was used for 96 procedures and general endotracheal anesthesia was used in 117 cases. Cardiac complications for the epidural anesthesia and general endotracheal anesthesia groups, respectively, included a mortality rate of 5% versus 3%, nonfatal infarctions in 6% versus 7%, and reversible cardiac events in 14% versus 16%. A high-risk subgroup of 69 patients (American Surgical Association classes IV and V or Goldman score greater than 10 points) also had no significant difference in outcome between epidural anesthesia and general endotracheal anesthesia. Major noncardiac complications occurred in an additional 8% of each group. Regional and general anesthesia therefore produce equivalent cardiovascular risk for infrainguinal arterial reconstruction. These results suggest that indicated operations should not be postponed or avoided for patients either requiring or requesting general anesthesia. Furthermore, other investigations of cardiac risk in vascular surgery do not require a uniform anesthetic technique for valid interpretation of results

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

Infection of an aortic prosthetic graft represents one of the most difficult diagnostic and therapeutic challenges to the vascular surgeon. The presentation of this complication, the degree of ischemia of the lower extremities, and the overall medical status of the patient determine the urgency and optimal treatment to maximize limb salvage and survival. Although partial or total graft preservation can be a treatment option if the infection is localized to the distal limb of an aortofemoral graft and all anastomoses are intact, treatment of an infected aortic prosthetic graft often requires total graft excision, preferably preceded by revascularization of the lower extremities through lateral uninfected routes. Careful selection of the many time-honored and newly developed diagnostic and treatment modalities is necessary to lower morbidity and mortality rates in patients with this complication

Secondary femoropopliteal bypasses with polytetrafluoroethylene (PTFE) grafts are widely regarded to be of questionable value. This has prompted some to abandon all attempts at secondary revascularization with PTFE and others to recommend that primary femoropopliteal bypasses be performed preferentially with PTFE grafts so that vein may be used for secondary procedures. Because we questioned both of these views, we reviewed all femoropopliteal bypasses done at our institution in the past 12 years and identified 73 secondary PTFE femoropopliteal procedures performed after a failed ipsilateral infrainguinal bypass (69 failed femoropopliteal; 4 failed femorodistal). Seventy (96%) secondary bypasses were performed for limb salvage and 3 (4%) for severe disabling claudication. Insertion of grafts to the popliteal artery was above the knee in 26 (36%) and below the knee in 47 (64%). Primary life-table graft patency at 4 years was only 38%. Forty-eight reinterventions in 34 limbs were required to restore or maintain graft patency in thrombosed or failing grafts. For thrombosed grafts, 20 interventions consisted of 9 simple thrombectomies and 11 thrombectomies with additional revision procedures (5 distal or proximal extensions, 6 patch angioplasties). Twenty-eight lesions threatening graft patency were treated by percutaneous transluminal angioplasty in 3, proximal or distal extensions in 20, and patch angioplasty in 5. As a result of these reinterventions, the overall secondary patency rate was 55% at 4 years, and the limb salvage rate was 74% at 4 years. Although aggressive follow-up and reintervention may be required, the use of secondary PTFE conduits in the femoropopliteal position is a viable option in patients undergoing limb salvage procedures who are at high risk.(ABSTRACT TRUNCATED AT 250 WORDS)

A 10-year-experience of 217 femoropopliteal bypasses to isolated popliteal artery segments in 207 patients is reported. Thirty-three femoropopliteal bypasses (15%) were performed with reversed saphenous vein and 184 (85%) with polytetrafluoroethylene grafts. Operative indications were gangrene in 121 (56%), nonhealing ulceration in 40 (18%), ischemic rest pain in 51 (24%), and claudication in 5 (2%) cases. The 5-year primary graft patency rate of these bypasses was 59% (reversed saphenous vein, 74%; polytetrafluoroethylene, 55%; p less than 0.05), the secondary 5-year graft patency rate was 61% (reversed saphenous vein, 79%; polytetrafluoroethylene, 56%; p less than 0.05), and the 5-year limb salvage rate was 78% (reversed saphenous vein, 78%; polytetrafluoroethylene, 78%). The 30-day operative mortality rate was 10%, and the 5-year patient survival rate was 38%. Eleven patients (5%) required lower extremity amputation because of progressive gangrene or extensive infection despite a patent bypass to an isolated popliteal artery segment. We conclude that femoropopliteal bypasses to isolated popliteal artery segments (1) have acceptable 5-year graft patency and limb salvage rates; (2) should be performed with reversed saphenous vein grafts when possible; (3) may be performed with polytetrafluoroethylene grafts if necessary, with a resulting limb salvage rate equal to that of reversed saphenous vein grafts; and (4) require sequential extension to an infrapopliteal artery in up to 20% of patients. In addition, the presence of an isolated popliteal artery segment is associated with a high operative mortality rate and limited life expectancy because of coronary artery disease

To determine whether unilateral aortofemoral (AUF) bypass is a safe and effective option for the treatment of unilateral limb-threatening ischemia in patients with aortic or bilateral iliac occlusive disease, we reviewed the results of 42 AUF bypasses performed using polytetrafluoroethylene grafts in patients operated on for limb salvage; 11 (26%) of the patients also underwent femoropopliteal or femorodistal (FP/D) bypasses. The indications for surgery were tissue necrosis or ulceration in 18 (43%) patients and rest pain in 17 (40%) patients. The 5-year primary graft patency and limb salvage rates for AUF bypass were 74% and 84%, respectively. The perioperative mortality rate was 5%. There were no significant differences in the primary graft patency or limb salvage rates in patients who underwent AUF bypass with or without FP/D bypass. Only 3 of 41 (7%) AUF bypass patients required subsequent femorofemoral bypass. We conclude that: (1) AUF bypass is a safe and effective surgical option in patients with unilateral limb-threatening ischemia and aortic or bilateral iliac occlusive disease; (2) the routine performance of an aortobifemoral or axillobifemoral bypass in patients with unilateral limb-threatening ischemia may be unnecessary; and (3) AUF bypass facilitates the combined inflow and infrainguinal operations that are frequently required for limb salvage in these patients