Faculty Bibliography

We have treated 30 patients requiring urgent or emergent vascular procedures in the first 6 weeks after a myocardial infarction (median 11 days) from 1977 through 1989. Forty operations were performed, including 28 lower extremity revascularizations, 10 major amputations and revisions, and two carotid endarterectomies. There were four postoperative deaths (three cardiac related) and two nonfatal reinfarctions. Cardiac complications did not correlate with age, interval from myocardial infarction to surgery within the initial 6 weeks, type of anesthesia, or complexity of operation. Twenty of 24 patients survived attempts at leg revascularization, with ultimate limb salvage in 16. Our cardiac complication rate of 17% (5/30 patients) was reasonably close to that predicted by the Goldman risk scale for classes II and III and significantly better than class IV and also better than that predicted by the Cooperman risk scale for vascular surgery, despite the more recent preoperative myocardial infarctions in our patients. We attribute our low morbidity and mortality to the extracavitary nature of the procedures and possibly to improvements in anesthetic and perioperative management. Patients requiring urgent revascularization for limb salvage should not be denied surgery on the basis of a recent myocardial infarction

Secondary interventions play an important role in achieving the ultimate goal of limb salvage after primary infrainguinal interventions fail. By employing the described strategies and principles for secondary arterial reconstructions below the inguinal ligament, good results in terms of patency of the reoperated primary reconstruction or the secondary reconstruction can be obtained with significantly augmented limb salvage at a low cost in operative morbidity and mortality. These results mandate that vascular surgeons maintain an aggressive attitude toward the use of these secondary operations when a primary procedure fails to achieve or maintain its intended goal and a patient is faced with imminent limb loss because of distal ischemia

Ventricular ejection fraction is widely regarded as a prognostic indicator of perioperative myocardial infarction. To evaluate this premise the prevalence of perioperative myocardial infarction or cardiac death was analyzed in relation to preoperative resting gated pool ejection fraction in 85 patients undergoing vascular surgery for infrainguinal bypass grafting. Patients were divided into three groups on the basis of ejection fraction. Group I consisted of 50 patients with ejection fractions of 56% to 92%. Nine (18%) perioperative myocardial infarctions occurred in group I, and there were no cardiac deaths. Group II consisted of 20 patients with ejection fractions of 37% to 55%. Three (15%) myocardial infarctions occurred in this group, and there were no cardiac deaths. Group III included 15 patients with ejection fractions of 20% to 35%. Three (20%) cardiac events occurred in group III including one nonfatal myocardial infarction and two (13%) cardiac deaths. Statistical analysis showed no significant difference in prevalence of cardiac events between any group. These results suggest that resting ejection fraction is a poor predictor of perioperative myocardial infarction in patients undergoing vascular surgery. Patients with normal ejection fractions, but underlying coronary artery disease, are still at significant risk for a perioperative cardiac event

This is a report by an ad hoc committee to the Joint Council of the Society for Vascular Surgery and the International Society for Cardiovascular Surgery (North American Chapter) concerning guidelines that hospitals may use or modify when judging individual applicants for hospital and operating room privileges in vascular surgery. The committee recognizes that the completion of training and obtaining a board certificate is testimony to the qualification but not necessarily the competence of an individual to practice vascular surgery. This report identifies three categories of applicant for privileges in vascular surgery; the surgeon who just completed training, the surgeon who completed training after 1984, and the surgeon who completed training before 1984. In addition, the committee recognizes the importance of periodic vascular surgery privileges renewal for established surgeons. Several pathways are defined for use by hospital privilege committees to evaluate the competence of an individual to be granted privileges in general vascular surgery. The ad hoc committee also has outlined a program for evaluation of established surgeons for renewing privileges in vascular surgery using a mechanism of case outcome audit. Finally, a review mechanism, potential corrective actions, and an appeals mechanism are also suggested. This report represents optimal criteria that may require modification by individual hospitals to meet local community needs and standards. It is the hope of the ad hoc committee that this report will help hospitals and practicing physicians improve the quality of care and treatment outcome in patients with vascular disease

In the last 12 years we have performed 55 axillopopliteal bypass graftings with 6 mm polytetrafluoroethylene grafts for limb salvage in 50 patients who were at high risk for limb loss. Indications for this procedure were (1) severe atherosclerotic disease of the common, superficial, and deep femoral arteries (33 cases); (2) failed aortofemoral bypass grafting with sufficient fibrosis or disease progression in the deep femoral artery (five cases); (3) insufficient hemodynamic and clinical improvement after axillofemoral bypass grafting (10 cases); and (4) sepsis in the groin from a previously infected graft (seven cases). The 30-day operative mortality rate was 8%, and the 5-year cumulative patient survival rate was 40%. Overall 1-, 3-, and 5-year cumulative primary graft patency rates were 58%, 45%, and 40%, respectively. Comparable limb salvage rates were 83%, 68%, and 58%. Repeat operations increased 5-year patency rates from 40% to 59% (p less than 0.05). Three-year patency rate for grafts placed in the presence of poor angiographic runoff in one vessel was 62% and for good angiographic runoff (two to three vessels) it was 57% (NS). Grafts to the above-knee popliteal artery had a patency rate of 67% at 3 years, whereas for grafts that crossed the knee joint it was 51% (NS). Three-year patency rate for 24 straight axillopopliteal grafts was 42%, and for 31 sequential axillofemoral-popliteal grafts it was 74% (p less than 0.05). These results show that axillopopliteal bypass grafting is justified when other standard operations are not possible in patients who are in imminent danger of limb loss, and that every possible effort should be made to use the common or deep femoral artery as part of a sequential axillofemoral-popliteal procedure