高龄患者体外与非体外循环冠状动脉旁路移植术后早期呼吸功能的比较

目的探讨体外循环冠状动脉旁路移植术(on-pump coronary artery bypass grafting,on-pump CABG)与非体外循环冠状动脉旁路移植术(off-pump coronary artery bypass grafting,off-pump CABG)对高龄(≥70岁)患者术后早期呼吸功能的影响。方法将2000年12月至2006年2月在我科接受on-pump CABG和off-pump CABG的高龄冠心病患者分为两组(on-pump组和off-pump组),每组30例,分别进行围术期动脉血气分析和肺功能的测量。结果两组患者术前肺功能和动脉血气指标差异无统计学意义;术后第1d和第3d红细胞压积(Hematocrit,Hct)值、术后1~3d动脉血氧分压值、术后第4~6d的用力肺活量(forced vital capacity,FVC)、第1秒用力呼气量(first second forced expiratory volume,FEV1.0)、一秒率(FEV1.0/FVC%)等on-pump组均低于off-pump组(P<0.05),术后平均带气管内插管时间和住院时间on-pump组长于off-pump组(P<0.05)。结论高龄冠心病患者施行off-pump CABG较on-pump CABG术后早期呼吸功能恢复良好。     

非体外循环冠状动脉旁路移植术的病理生理与麻醉处理

冠状动脉旁路移植术(coronary artery bypass grafting,CABG)是常见的心脏手术.非体外循环冠状动脉旁路移植术(off-pump coronary artery bypass,OPCABG)最早于1964年在圣彼得堡完成,但很快随着体外循环(cardiopulmonary bypass,CPB)技术及心脏停跳液的发展而被弃之不用.     

体外循环与非体外循环冠状动脉旁路移植术后肾损害的危险因素分析

目的 探讨非体外循环冠状动脉旁路移植术(off-pump CABG)或体外循环冠状动脉旁路移植术(on-pump CABG)患者术后肾损害的危险因素,旨在为术后提供较好的肾保护措施.方法 对自1990年1月至2006年8月收治的849例单纯行冠状动脉旁路移植术(CABG)患者的临床资料进行回顾性分析.采用单因素和logistic多因素分析术后急性肾损害(AKI)的风险因素.结果 off-pump CABG患者中发生AKI 61例(11.8%,61/518),on-pump CABG患者中发生AKI 63例(19.0%,63/331).行off-pump CABG患者的血清肌酐(Scr)峰值时间为术后12h,on-pump CABG患者为术后24h;off-pump CABG术后有AKI患者Scr快速恢复期为24～48h, on-pump CABG术后有AKI患者为48～72h.logistic回归多因素分析结果显示:大体重指数(OR=1.190,1.179)、急诊手术(OR=2.737,3.678)、合并糖尿病(OR=1.705,2.042)、外周血管疾病(OR=2.002,2.559)、射血分数≤30%(OR=2.267,4.606)和心功能Ⅲ～Ⅳ级(OR=1.861,1.957)为off-pump CABG和on-pump CABG患者术后发生AKI的独立风险因素;脉压差≥60mmHg、冠状动脉3支病变为off-pump CABG患者术后发生AKI的独立风险因素;而术中和术后使用主动脉内球囊反搏(IABP)对行on-pump CABG患者术后肾功能具有保护作用(OR=0.146),可减少AKI发生的可能.结论 对AKI预防和治疗的关键期为麻醉至off-pump CABG术后48h和on-pump CABG术后72h.AKI是病情发展的重要阶段,肾功能检测阳性结果提示可能有肾损害存在,并通过有效的措施和治疗方法阻止肾功能进一步恶化,使肾功能逆转.     

非体外循环和体外循环冠状动脉旁路移植术在二次冠状动脉旁路移植术中的应用

目的研究对比在二次冠状动脉旁路移植术(re-CABG)患者中分别采用非体外循环和体外循环下冠状动脉旁路移植术(off-pump CABG和on-pump CABG)的临床早期结果,探讨通过合理手术方式的选择,提高re-CABG的手术疗效。方法自2000年4月到2006年6月,21例首次CABG后因心绞痛复发患者在阜外心血管病医院接受了re-CABG手术,其中10例行off-pump CABG(off-pump组),11例行on-pump CABG(on-pump组)。两组患者术前性别、年龄、体重、心肺功能、心绞痛程度、左心室舒张期末内径、射血分数、合并高血压、糖尿病等方面差异无统计学意义(P>0.05)。结果 On-pump组中患者术后死亡1例,冠状动脉远端吻合口数多于off-pump组(P<0.05);off-pump组无手术死亡,在手术时间、术后呼吸机辅助时间、胸腔引流液量、输血量和手术后住院时间等方面,均明显少于on-pump组(P<0.05)。结论 Off-pump CABG和on-pump CABG技术在re-CABG中都可以取得满意疗效,off-pump CABG下施行re-CABG安全可靠。     

70岁以下多支冠状动脉病变患者体外与非体外循环冠状动脉旁路移植术的比较

目的比较非体外循环冠状动脉旁路移植术(off-pump CABG)与体外循环冠状动脉旁路移植术(on-pump CABG)治疗70岁以下多支冠状动脉病变患者的疗效,为其手术术式选择提供依据。方法 2007年6月至2009年6月,共收治了196例70岁以下多支血管病变患者,其中男152例,女44例;年龄46～69岁,平均年龄55.00岁。根据采用的手术术式不同,将196例患者分为两组,off-pump CABG组:94例,on-pump CABG组:102例。比较两组患者移植血管的种类和支数、术中输血量、术后呼吸机辅助时间、住院时间、围术期并发症发生率及病死率等。结果 off-pumpCABG组中有2例患者术中因循环不稳定改为on-pump CABG,最终有1例死于多器官功能衰竭。on-pumpCABG组术后死于严重低心排血量和心脏骤停各1例。两组移植血管材料、围术期并发症发生率和病死率差异无统计学意义(P0.05);而术中off-pump CABG组远端吻合口数量(3.22±0.65个vs.4.52±1.11个,t=9.807,P=0.000)、输血量(312.57±305.26mlvs.744.86±279.37ml,t=10.317,P=0.000)、术后呼吸机辅助时间(10.71±5.32hvs.17.12±4.67h,t=8.683,P=0.000)、住院时间(17.75±3.04dvs.21.24±6.46d,t=4.782,P=0.000)少于或短于on-pump CABG组。off-pump CABG组随访93例,on-pump CABG组随访100例,随访时间2～26个月。所有随访患者均生存,无心绞痛发作。结论 on-pump CABG和off-pump CABG治疗70岁以下多支冠状动脉病变患者的早期临床疗效差异无统计学意义,但on-pump CABG组血管化比较完全。off-pump CABG目前仍不能取代on-pump CABG,而远期预后仍有待长期随访观察。     

低手术风险患者体外循环与非体外循环冠状动脉旁路移植术早期结果分析

目的 总结低手术风险冠心病患者施行体外循环冠状动脉旁路移植术(on-pump CABG)与非体外循环冠状动脉旁路移植术(off-pump CABG)的早期临床效果.方法 对48例低手术风险冠心病患者(EuroSCORE≤2)分别施行on-pump CABG(on-pump组)与off-pump CABG(off-pump组),对比分析两组患者的手术情况、术后呼吸机辅助时间、胸腔引流量、血液制品的使用、主要并发症、特殊用药、住院时间及住院费用等临床指标;并监测血流动力学、心肌酶谱指标.结果 两组患者的手术时间、移植血管根数、胸腔引流量、术后主要并发症和住院时间等方面比较差异无统计学意义(P＞0.05),呼吸机辅助时间、血液制品的应用和住院总费用on-pump组高于off-pump组(P＜0.05).两组的血流动力学指标、心肌酶谱分析结果差异无统计学意义(P＞0.05).结论 off-pump CABG与on-pump CABG均为有效的冠状动脉再血管化的方法,对低手术风险冠心病患者应选择off-pump CABG手术方式.     

磷酸肌酸钠复合氨甲环酸对非体外循环冠状动脉旁路移植术患者心肌和血液保护作用的研究

目的 研究在非体外循环下行冠状动脉旁路移植术(off-pump coronary artery bypass grafting,OPCABG)中应用磷酸肌酸钠及氨甲环酸对缺血心肌的保护及血液保护作用.方法 将拟行OPCABG术的冠心病患者280例按完全随机法分为4组,每组70例,实验组、磷酸肌酸钠组、氨甲环酸组和对照组...     

体外循环与非体外循环下冠状动脉旁路移植术移植血管流量对比分析

目的比较非体外循环下冠状动脉旁路移植术(off-pump coronary artery bypass graft,OPCABG)与传统体外循环下冠状动脉旁路移植术(conventional on-pump coronary artery bypass graft,CCABG)移植血管通畅性。方法利用瞬时血流测定技术(transit-time flow meter,TTFM)对105例CCABG和140例OPCABG移植血管进行测量,并记录平均流量(mean flow,Qm)及搏动指数(pulsatility index,PI)。结果2组一般情况无显著性差异,2组旁路移植血管数目及血管材料无差异。流量测定结果,乳内动脉OPCABG组(n=101)Qm(37.2±26.6)ml/min,PI3.3±1.3;CCABG组(n=75)Qm(39.5±21.8)ml/min,PI3.3±1.2,两组差异无显著性(t=-0.612、0.000,P>0.05),大隐静脉流量两组也无显著性差异[OPCABG组(n=335)Qm(36.8±27.4)ml/min,PI3.1±1.5;CCABG组(n=281)Qm(40.9±...     

老年患者体外与非体外循环冠状动脉旁路移植术术后急性肾损伤的对比研究

目的对比研究老年患者(年龄≥70岁)体外循环冠状动脉旁路移植术(cardiopulmonary coronary artery bypass grafting,CCABG)和非体外循环冠状动脉旁路移植术(off-pump coronary artery bypass grafting,OPCAB)对术后急性肾损伤(acute kidney injury,AKI)发生的影响。方法回顾性分析我中心2009年1月1日至2017年12月31日接受单纯冠状动脉旁路移植术(coronary artery bypass grafting,CABG)的老年患者的临床资料。剔除术前接受肾脏替代治疗、肌酐值记录缺失、急诊手术及合并其他手术的病例。期间单纯行CABG患者共3 346例,其中老年患者(年龄≥70岁) 1 405例(42.0%),根据是否使用体外循环机将该组老年患者分为CCABG组(956例)和OPCAB组(449例)。比较两组术后AKI的发生率及严重程度。结果 CCABG组术后AKI共发生306例(32.0%),OPCAB组138例(30.7%),两组差异无统计意义(P=0.677)。依据急性肾损伤信息网(AKIN)分期进一步细分,CCABG组较OPCAB组分别如下:AKINⅠ期:211例(22.1%)/93例(20.7%);AKINⅡ期:51例(5.3%)/23例(5.1%);AKINⅢ期44例(4.6%)/22例(4.9%),两组差异无统计意义(P=0.579,1.000,0.788)。住院期间CCABG组新发肾功能衰竭需透析患者31例(3.2%),OPCAB组10例(2.2%),两组差异无统计意义(P=0.376)。结论老年CABG患者术后发生AKI常见,且以AKIⅠ期为主,术后新发肾功能衰竭需透析比例总体较低。OPCAB较CCABG,并不能显著降低老年CABG患者术后AKI的发生率及严重程度。     

影响非体外循环冠状动脉旁路移植术后心房纤颤术前因素的多因素分析

目的 探讨术前因素对非体外循环冠状动脉旁路移植术(off-pump coronary artery bypass grafting,OPCAB)后心房颤动(postoperative atrial fibrillation,POAF)发生率的影响.方法 回顾性分析我科2010年1月～2011年12月237例首次接受OPCAB的临床资料,对POAF的术前影响因素进行单因素和logistic回归分析.结果 POAF发生率16.9％(40/237).logistic回归分析显示年龄(OR=1.068,95％CI:1.019 ～1.118,P=0.006)、BMI(OR=1.138,95％ CI:1.010 ～1.281,P=0.034)、舒张压(OR=1.056,95％ CI:1.020 ～1.094,P=0.002)及左心房前后径(OR=1.089,95％ CI:1.002～1.184,P=0.046)是OPCAB后POAF的术前危险因素.结论 年龄、BMI、舒张压及左心房前后径是OPCAB后发生POAF的术前危险因素.     

Cardiopulmonary bypass recommendations in adults: the northern New England experience

Using a regional cardiopulmonary bypass (CPB) registry, we compared the practice of CPB at eight northern New England institutions to recently published recommendations. We examined CPB practice among 3597 adult patients undergoing isolated coronary artery bypass grafting surgery from January 2004 to June 2005. Registry variables were used to compare regional CPB practice to recommendations on topics of neurologic protection (pH management, avoidance of hyperthermia, minimizing return of pericardial suction blood, aortic assessment, arterial line filtration), maintenance of euglycemia, reduction of hemodilution, and attenuation of the inflammatory response. We report overall regional practice (regional minimum, maximum). All centers used alpha-stat pH management and arterial line filters. Avoidance of hyperthermia (temperature < 37degrees C) was achieved during 23.4% of procedures (regional minimum, 1.5%; maximum, 83.2%). Minimizing return of pericardial suction blood was achieved in 23.7% of cases (0.7%, 93.6%). Aortic assessment was performed during 45.7% of procedures (1.3%, 98.9%). Maintenance of euglycemia (< 200 mg/dL) was accomplished in 82.7% (57.1%, 97.9%) of cases. Hemodilution (hematocrit < 23% on CPB) was lower for men 32.4% (20.6%, 52.3%) than women 77.9% (64.7% 88.9%). Men were less likely to receive red blood cell transfusions in the operating room (11.0%; 1.8%, 20.9%) than women (54.6%; 30.1%, 70.6%). In an effort to attenuate the inflammatory response, surface coated circuits were used in 83.3% of procedures (8.8%, 100%). During this time, gaps existed between regional CPB practice and recently published recommendations. We continue to prospectively measure CPB practice relating to these recommendations to monitor and improve the care provided to our patients.     

Long-term evaluation of EC-IC bypass patency

Summary The EC-IC Bypass Study Group could not detect any benefit from surgery compared to medical management in the prevention of stroke in 1985 [15]. During the past years surgical revascularization was re-evaluated and considered as an appropriate treatment for a small subgroup of patients with recurrent focal cerebral ischaemia and impaired haemodynamics. This retrospective study examines the long-term benefit and patency rate of bypass.We present a follow-up of 5.6 years of 47 patients, all of whom underwent byupass surgery after 1985. Forty patients suffered recurring transient ischaemic attacks due to uni- or bilateral internal carotid artery occlusion. Examination included neurologic status, TCD with CO₂ or Diamox challenge, angiography, CT and SPECT scans.Neurological improvement was seen in 23% of patients with better results after early surgery, a worsening in 22% suffering further ischaemic events on a postoperative average of 2.8 years. Patency rate for vein graft material was 50%, for the STA-MCA procedure 91%. Occlusion of the vein graft occurred on an average after 1.4 years, other anastomosis after 2.7 years.We conclude that only few patients derived long-term benefit from EC-IC bypasses. Functioning of the bypass worsens over time, suggesting a role for surgery predominantly in the first year of ischaemic events due to insufficient collateral supply. Actual indications for bypass surgery may be patients with failure of maximal medical therapy and progressive ischaemia and haemodynamic compromise.     

Early results of off-pump coronary artery bypass

Objective: The purpose of this study is to compare the operative results of off-pump coronary artery bypass (OPCAB) and on-pump (conventional) coronary artery bypass (CCAB), to clarify qualitative problems and whether OPCAB is less invasive or not. Methods: OPCAB was consecutively performed in 63 patients and CCAB in 63 patients between July 1998 and December 2003. Results: The mean number of bypass grafts was 2.43 ±0.82 in the OPCAB group and 2.70±0.71 in the CCAB group (p=0.096). In-hospital mortality was 0% in the OPCAB group and 3.2% in the CCAB group. The incidence of perioperative myocardial infarction was 0% in the OPCAB group and 3.2% in the CCAB group. The incidence of postoperative major complications was significantly lower in the OPCAB group than in the CCAB group (OPCAB group=4 complications, CCAB group=13 complications). Cerebrovascular accidents occurred in 1.6% of patients in both groups. The incidence of sternal infection or mediastinitis was 0% in the OPCAB group and 3.2% in the CCAB group. The early patency rate of graft was 94.0% in the OPCAB group and 92.8% in the CCAB group, and was not significantly different (p=0.822). Conclusion: Operative mortality and major complications after surgery in OPCAB were lower than that in CCAB. The early patency rate in OPCAB was as good as that in CCAB. It is considered that OPCAB is less invasive and the quality of bypass in OPCAB is as good as that in CCAB.     

Perforated marginal ulcer after gastric bypass for obesity: a systematic review

Marginal ulcers are a recognized complication of gastric bypass procedures for obesity. Perforated marginal ulcer (PMU) is a life-threatening complication of marginal ulcers. We performed a systematic review to understand the presentation, management, and outcomes of PMUs. PubMed, Google Scholar, and Embase databases were searched to identify all studies on PMUs after gastric bypass procedures. A total of 610 patients were identified from 26 articles. The mean age was 39.8±2.59 years, and females represented most of the cohort (67%). The mean body mass index was 43.2±5.67 kg/m². Most of the patients had undergone a Roux-en-Y gastric bypass (98%). The time gap between the primary bariatric surgery and the diagnosis of PMU was 27.5±8.56 months. The most common presenting symptom was abdominal pain (99.5%) and a computed tomography scan was the diagnostic modality used in 72% of the patients. Only 15% of patients were on prophylactic proton pump inhibitors or H2 blockers at the time of perforation, and 41% of patients were smoking at the time. Twenty-three percent of patients were on nonsteroidal anti-inflammatory drugs. Laparoscopic omental patch repair of the perforation (59%) was the most used technique; 18% of patients underwent open surgery, and 20% were managed non-surgically. Thirty-day mortality was 0.97%; it was 1.21% (n=5) and 0% (n=0) in those who were managed surgically and nonsurgically, respectively. Ulcers recurred in 5% of patients. In conclusion, PMU is a surgical emergency after gastric bypass that can result in significant morbidity and even mortality. This is the first systematic review in scientific literature characterizing this condition.     

Infrageniculate thin-walled PTFE bypass: Preliminary study of 53 cases

Between May 1, 1983 and May 1, 1985, 53 patients whose mean age was 75 years, and who presented with rest pain or ischemic changes had infrageniculate insertion of femoropopliteal or femorotibial thin-walled polytetrafluoroethylene (PTFE-TW) bypasses. Occlusive atherosclerotic disease was present in all patients. Postoperative follow-up ranged from 6 to 30 months. One patient died in the immediate post-operative period whereas 15 others died later during follow-up. There was one case of prosthetic sepsis. No anastomotic aneurysms occurred. Actuarial analysis of overall patency rates in significant population samples showed that 88% and 68% of bypasses were functional at one month and two years, respectively. The overall rate of early amputation was 17%. Overall limb salvage was 67% at 30 months. In patients over 75, 85% of bypasses were patent at one year whereas life expectancy for one year in this same group of patients was 49%. Although this is a preliminary study, results obtained with this new material suggest that an average gain of 20% in patency rates can be expected compared to those recorded with standard PTFE prostheses. The PTFE-TW vascular prosthesis may be the material of first choice for the geriatric patient in order to promote early hospital discharge and return to the home environment. Even though long-term patency rates of venous grafts are better, we believe that the use of PTFE-TW prostheses in elderly patients with limited life expectancy may be preferred.     

Combined aortobifemoral and femoropopliteal bypass in the management of patients with extensive atherosclerosis

Certain patients have atherosclerosis in both aortoillac and femoropopliteal segments of the arterial tree and thus do not have a good result from reconstruction of the aortoiliac segment. No method has been developed to identify these patients and we do not know whether, by combining a femoropopliteal bypass with an aortobifemoral bypass, the results can be improved. We present a series of 153 patients with severe multilevel occlusive disease treated by simultaneous reconstruction and followed for up to 6.5 years. The cumulative patency of the femoropopliteal bypasses was 80% at four years. Functional and symptomatic improvement was excellent, and operative mortality was low when one considers the age and poor general condition of the patients.     

Unilateral iliac artery occlusive disease: A randomized multicenter trial examining direct revascularization versus crossover bypass

This randomized trial compared the patency of direct unilateral aorto- or iliofemoral prosthetic bypass with that of crossover femorofemoral or iliofemoral bypass in unilateral atheromatous occlusive disease of the iliac artery. Between May 1986 and March 1991, 143 patients were enrolled in this study (74 crossover and 69 direct revascularizations). Cardiovascular risk factors, preoperative symptoms, and atheromatous lesions were similar in both groups. Patients were followed by Duplex scanning with systolic pressure index measurements. Routine digital subtraction arteriograms were obtained postoperatively and separately, when hemodynamic anomalies developed. Mean follow-up was 22 months. One patient with direct revascularization died postoperatively. Primary patency of direct revascularizations was 89.8% at 48 months compared with 52% for crossover bypass. This difference was statistically significant. Secondary patency of direct and crossover revascularization at 48 months was 92.9% and 93.6%, respectively (not significant). Even though crossover bypasses seem attractive because of their technical simplicity and low morbidity, our results suggest that direct revascularizations are preferable in the young patient with no major operative risks, while crossover bypasses remain indicated in patients at risk.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, June 20–21 1991, Marseille, France.     

Methodologies,Devices, and New Surgical Concepts: Novel System for Percutaneous Cardiopulmonary Bypass

Percutaneous cardiopulmonary bypass (PCPB) has recently come to the forefront of medicine as a technique for resuscitating and supporting patients in various clinical situations. Current systems utilize small-diameter cannulas to aspirate blood under high suction into the cardiopulmonary bypass circuit. Aspiration-based systems have several disadvantages including risk of air embolism, blood hemolysis, and cavitation. Additionally, they are suboptimal for use during open-heart surgical procedures. A system with a venous cannula that employs gravity drainage has been evaluated. Once advanced into position over a guide- wire, the stylet is removed, causing the basket near the end of the cannula to expand. Blood flows into the cannula from side holes and the basket region, which prevents the vessel wall or atrium from collapsing around the catheter and impeding venous drainage. Hemodynamic, hematologic, and histologic examinations were performed on eight anesthetized mongrel dogs during 2 h of PCPB. All animals exhibited adequate tissue perfusion and right and left heart decompression. All animals were successfully weaned from PCPB and after 30 min exhibited normal myocardial function. No ischemic changes were observed in the heart, lung, kidney, or liver by light and electron microscopy. We conclude that full PCPB can be satisfactorily achieved by using a novel percutaneous venous cannula and gravity drainage     

Paracorporeal Artificial Heart in Postoperative Heart Failure

A pneumatically driven artificial heart with a tubular silicone rubber membrane and disc valves was used for functional heart replacement in the paracorporeal mode. A fluidic drive system allows adjustment of the heart rate, positive and negative pressures and systole/diastole ratio.
Since August, 1977, the artificial heart has been used in four patients with refractory postoperative heart failure not responding to volume loading, pH and electrolyte correction, catecholamines and intraaortic balloon pumping. Large cannulae were placed in the atria and great vessels. The ventricles were fixed on the chest paracorporeally. The assist system was used as a left heart bypass in one patient and as a biventricular bypass in three other patients. After 48–72 hours, the ventricular function recovered in three patients, permitting removal of the artificial heart. One patient died of cerebral complications six weeks later; the other two recovered completely and were released in good condition.
Profound postoperative heart failure can be completely reversed by the use of the paracorporeal artificial heart; the advantage of the system lies in the simplicity of its implantation and removal.     

Sequential bypass for multisegmental occlusive disease

We evaluated the effectiveness of a sequential bypass for multisegmental occlusive disease. Forty-seven multiple bypass grafts were performed on 43 patients ranging in age from 55 to 83 years (mean: 70 years). The indications for operation included incapacitating claudication in 20 limbs, resting pain in 15, and nonhealing ulcers in 12. An anatomical arterial bypass was performed on 36 limbs, consisting of an aorto-femoro-popliteal bypass in 21 limbs, a femoro-popliteal-posterior tibial bypass in 8, an ilio-femoro-popliteal bypass in 4, an ilio-femoro-posterior tibial bypass in 2, and a femoro-popliteal-plantar bypass in 1. Similarly, an extra-anatomical arterial bypass was performed on 11 limbs, consisting of an axillo-femoro-popliteal bypass in 6, a crossover femoro-femoro-popliteal bypass in 3, an axillo-femoro-posterior tibial bypass in 1, and a crossover femoro-femoro-anterior tibial bypass in 1. The follow-up period ranged from 3 to 77 months (mean: 23 months). Twelve graft failures occurred, and 2 of them required major amputations. The cumulative graft patency rate was 85% at one year and 65% at 3 years. Arterial Doppler examination revealed a mean preoperative ankle-brachial index of 0.29±0.25. The early and late mean postoperative ankle-brachial indices, however, increased to 0.97±0.19 and 0.84±0.25, respectively. Midterm results have indicated that such multiple sequential bypass grafts are effective.Presented at the 8th Congress Asian Surgical Association, Fukuoka, Japan, March 10–13, 1991