Vacuum-assisted closure therapy with omental transposition for salvage of infected prosthetic femoral-distal bypass involving the femoral anastomosis

Vascular graft infections are associated with the potential for devastating sequelae, including hemorrhage, septicemia, amputation, and death. Graft excision and debridement of the infected bed with revascularization via an extra-anatomic site or orthotopic vein bypass has been the traditional treatment of choice. Because the morbidity of these operations is substantial, less radical graft preservation techniques are desirable, such as myoplasty, omental flap transposition, and vacuum-assisted closure therapy. We report a patient with infection involving a prosthetic graft that was treated with vacuum-assisted closure and transposition of an omental tongue to enable coverage of the exposed graft.     

Cryopreserved saphenous vein homografts for femoral-distal vascular reconstruction

Cryopreserved saphenous vein homografts may serve as an alternative for femoral distal bypass conduits when suitable endogenous vein is not available. In a preliminary study, 6 patients underwent femoral distal bypass for limb salvage with cryopreserved saphenous vein with patency in 2 patients at 18 and 20 months, respectively. One graft, occluded at 14 months, was salvaged with thrombolytic therapy and percutaneous angioplasty, and is patent 7 months post intervention. Occlusion occurred in 3 grafts at 1 day, 7 days and 4 months, respectively. Reasons for reduced patency of cryopreserved grafts are related to destruction of the cellular components and fibrosis as a result of the cryopreservation and poor distal run-off present in these patients. Due to lower patency as compared to autogenous vein grafts, cryopreserved veins should be reserved for limb salvage when no autogenous vein is available for revascularization.     

Randomization of autogenous vein and polytetrafluorethylene grafts in femoral-distal reconstruction

A randomized, prospective, controlled study comparing autogenous saphenous vein and polytetrafluoroethylene (PTFE) grafts in infrainguinal arterial reconstructions has been initiated in three different institutions. A total of 446 operative procedures were divided into six groups, depending on the site of distal bypass insertion into the popliteal or an infrapopliteal artery and on whether the patient received a randomized vein or PTFE graft or an obligatory PTFE graft. The randomized saphenous vein graft patency to infrapopliteal arteries was significantly better (P less than 0.005) at 2 1/2 years than the patency of randomized or obligatory PTFE grafts to the same level. No significant differences between randomized vein grafts and randomized or obligatory PTFE grafts in the femoropopliteal position could be demonstrated up to 2 1/2 years, either above or below the knee. The need for such a study and the limitations of this preliminary report are discussed. The requirement for longer observation of greater numbers of cases is stressed. A current plan for usage of the PTFE graft in the lower extremity is presented.     

Secondary aortoduodenal fistulas: Value of initial axillofemoral bypass

Between January 1970 and April 1989, 20 patients underwent operation for secondary aortoduodenal fistulas. When the preoperative diagnosis was certain and emergency control of bleeding not required, initial axillofemoral bypass was performed before ablation of the infected aortic prosthetic graft during the same operation. When diagnosis was uncertain or severity of bleeding required emergency laparotomy, the therapeutic plan varied over time. Until 1980, we performed either a direct repair (three cases) or the ablation of the aortic graft followed by secondary axillofemoral bypass (four cases). After 1980, the order of procedures was 1) control of bleeding whenever necessary, 2) axillofemoral bypass, and 3) ablation of the aortic graft. Postoperative mortality was two of 13 in patients undergoing initial axillofemoral bypass, compared with six of seven patients undergoing direct surgery or initial ablation of the aortic graft. Of the 12 patients surviving the postoperative period, three died of aortic stump hemorrhage, four, 12, and 14 months after operation. Two patients had a new aortic graft inserted. Repeat replacement of the abdominal aorta graft was performed in one case and ascending thoracic aortobifemoral bypass in the other because of secondary thrombosis of the axillofemoral bypass. We conclude that initial axillofemoral bypass before dealing with the aortic graft improves the immediate prognosis in operations for secondary aortoduodenal fistulas. This procedure does not, however, preclude the possibility of aortic stump infection which can lead to recurrent aortoduodenal fistula. The risk of infection or secondary occlusion of axillofemoral bypass is minimal. Secondary prosthetic replacement is not systematically necessary.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, May 18–19, 1990, Nancy, France.     

Secondary abdominal compartment syndrome causing failure to wean from cardiopulmonary bypass

The abdominal compartment syndrome has been associated with trauma or primary abdominal procedures. The secondary abdominal compartment syndrome which is not associated with a primary abdominal process is seen in burns and other clinical situations where aggressive fluid resuscitation is needed. This case report describes a secondary abdominal compartment syndrome that occurred during an elective coronary revascularization which resulted in an inability to wean from cardiopulmonary bypass (CPB). After a decompressive laparotomy was done, the patient was successfully weaned from bypass.     

Secondary surgical-site infection after coronary artery bypass grafting: A multi-institutional prospective cohort study

Objective

To analyze patient risk factors and processes of care associated with secondary surgical-site infection (SSI) after coronary artery bypass grafting (CABG).

Secondary prevention following coronary artery bypass grafting has improved but remains sub-optimal: the need for targeted follow-up

A focused review of secondary preventive medication following revascularisation provides an opportunity to ensure optimal use of these agents. A retrospective analysis of our in-house cardiothoracic surgical database was performed to identify patients undergoing non-emergency, elective surgical revascularisation discharged on four secondary preventive medications: aspirin; beta-blockers; ACE-inhibitors and statins. Of 2749 patients studied, 2302 underwent isolated coronary artery bypass grafting (CABG), mean age 65.5 years (S.D. 9.15). Overall, 2536 (92%) patients were prescribed aspirin. Beta-blockers were prescribed in 2171 (79%) patients overall, in 1096/1360 (81%) of patients with a history of myocardial infarction and in 465/619 (75%) of patients with left ventricular systolic dysfunction (LVSD). Overall, 1518 (55%) patients were prescribed an ACE-inhibitor and 179 (6.5%) an angiotensin receptor blocker (ARB); one of these agents was prescribed in 446/619 (72%) patients with LVSD and 915/1360 (67%) patients with a history of previous myocardial infarction. Overall, 2518 (92%) patients were prescribed a statin. Secondary preventive therapies are prescribed more commonly on discharge after CABG than in previous studies, but there is a continuing under-utilisation of ACE-inhibitors. To maximise the potential benefits of these agents, further study is required to understand why they are not prescribed.     

Beating coronary bypass with right-heart bypass

Two patients with bilateral obstructive carotid artery disease underwent beating heart coronary bypass including revascularization of the circumflex branch using right-heart bypass in a stable hemodynamic state. Without this mechanical support, lifting the left ventricle for the exposure of the posterior wall could impair the hemodynamic state of the patient. Right-heart bypass in addition to aortic no-touch technique can be a safer option for complete coronary revascularization in patients at high risk for neurological complications.     

Coronary artery bypass without cardiopulmonary bypass.

The purpose of this article is twofold: to describe our technique for performing coronary artery bypass grafting without cardiopulmonary bypass (off pump) and to demonstrate that this operation is safe, in terms of mortality and certain indices of morbidity. Very little has been published in regard to off-bypass operations. From 1985 through 1990, 220 patients underwent operation off bypass; 220 on-pump controls were retrospectively matched for number of grafts, left ventricular function, and date of operation. Groups were compared in terms of mortality and ten indicators of morbidity. The same analysis was performed for ten subgroups. We found no statistically significant difference between groups in mortality (off pump, 1.4% [3/220]; on pump, 2.4% [5/220]), which held across all subgroups. Patients undergoing operation off pump required blood far less often (not transfused: off pump, 72.7% [160/220]; on pump, 54.6% [116/220]; p = 0.005 by Fisher's exact test), and the low output state occurred statistically less frequently off pump (off pump, 5.5% [12/220]; on-pump, 12.7% [28/220]; p = 0.01 by Fisher's exact test). Further research should be directed to which subgroups can be operated on to advantage off pump and which, if any, groups of patients should be confined to on-bypass operations.     

Coronary artery bypass surgery without cardiopulmonary bypass

In the years 1994 and 1995, 1087 patients underwent coronary artery bypass grafting at our institution. Of these, 297 were operated on without cardiopulmonary bypass. 239 were male, and 58 were female. Their ages ranged from 28 to 81 years (54.43 ± 9.63). Of the total, 294 were operated on electively, two as a coronary reoperations, and one as an emergency after a failed percutaneous transluminal coronary angioplasty procedure. In all patients complete revascularization was the aim, and a cardiopulmonary bypass team was kept on standby. Median sternotomy was performed as the exposure in all patients, except a patient who underwent a coronary reoperation through a left thoracotomy incision. The average of the distal anastomoses was 1.51 ± 0.6, ranging from 1 to 3. The left internal thoracic artery was used in 292 operations, which was an individual graft in 284, a sequential graft in five, and a free graft in four. Major complications in the early postoperative period were noted in three patients as reoperation for excessive bleeding. One patient had reoperation for left internal thoracic artery spasm, and one patient had lower extremity ischemia caused by intraoartic balloon counterpulsation. Hospital mortality was 0.3% with one patient. It is our belief that in selected cases coronary artery bypass grafting without cardiopulmonary bypass is a safe procedure with the advantage of improvement in recovery during the postoperative period.     

Multivessel sequential bypass grafting without cardiopulmonary bypass

Background Multivessel sequential coronary artery bypass grafting without cardiopulmonary bypass has become a reality. Initially the revascularization of posterior coronary arteries (obtuse marginal branches of the circumflex artery) was difficult due to access and difficulty in stabilization of the heart as well as compromising the haemodynamic status of the heart. With stabilization of the heart with Octopus II (Medtronic, Inc. Minnesota, USA) we have demonstrated that sequential grafts as well as composite arterial grafts can easily and safely be used in complete arterial revascularization of the myocardium. Methods From January 1, 1996 till December 31, 1999, 832 consecutive patients underwent coronary artery bypass surgery without cardiopulmonary bypass. From July 1998, seventy-nine patients operated had atleast 1 conduit used as a sequential graft and 12 patients had composite ‘Y’ grafts. Before July 1999, 67 patients (61 sequential and 6 ‘Y’ conduits) underwent surgery without mechanical stabilization (Group A) and after July 1999 in 24 patients (18 sequential and 6 ‘Y’ conduits) mechanical stabilization (Octopus II) was used. Results Total number of sequential anastomosis including composite grafts was not significantly different in both groups. But due to Octopus II stabilization, number of anastomosis in composite ‘Y’ graft group significantly increased from 2.96 ±0.2 to 4.02 ±0.3. Also intramyocardial coronary artery revascularization which was only 10.4% in Group A increased to 20.8% in Group B. In Group A only 8.9% composite grafts were performed while in Group B it was 25% which was statistically significant. Conclusions Cardiac stabilization with Octopus II has improved ability for revascularization of remote coronary arteries arising from circumflex. Although overall anastomoses have not increased, the number of patients receiving composite grafts using all arterial conduits have increased significantly. Patency rates of all sequential conduits as well as composite grafts have remained equally good in both groups.     

Repeat leg bypass after multiple prior bypass failures

Purpose: The optimal treatment of patients with severe lower extremity ischemia after multiple failed prior bypasses is unclear. It is presently unknown whether failure of attempted revascularization in these patients is so likely that such operation should not be elected. We have maintained an aggressive surgical policy of repeated revascularization regardless of prior failures. A review of our clinical experience with this difficult patient group was performed to determine the results of this policy.Methods: From 1980 to 1992, 85 revascularization procedures were performed in 81 patients with lower extremity ischemia after failure of two or more prior infrainguinal bypasses in the same leg. All patients were prospectively entered and monitored in our vascular registry. Seventy-two operations were the third procedure, six operations were the fourth procedure, and seven operations were the fifth procedure on the same extremity. Twenty-six of the 85 procedures (30%) were revisions of failing grafts discovered by routine surveillance methods, whereas 59 were replacements of thrombosed grafts. Autogenous reconstruction was used in 67 procedures (79%), and prosthetic reconstruction was used in 18 procedures (21%). The distal anastomosis was to the popliteal artery in 19 patients and infrapopliteal artery in 66.Results: Mean time to failure of the first leg bypass was 24 months and 4.9 months for the second bypass. Detailed hematologic screening revealed identifiable hypercoagulable disorders in nine (15%) of 59 patients screened after 1987. All nine had anticardiolipin antibodies. The operative mortality rate was 4%. Mean follow-up after the most recent operation was 17 months. The primary patency rate at 4 years was 79.8%. The limb salvage rate was 69.6% at 4 years.Conclusions: These results indicate that limb revascularization after two or more failed leg bypasses results in low operative mortality rates and surprisingly good primary patency and limb salvage rates at 4 years. The patient survival rate through 4 years is unexpectedly high. In our opinion these results justify an aggressive policy of limb revascularization after multiple failed prior bypasses. (J VASC SURG 1994;19:268-77.)     

Cardiopulmonary bypass

The purpose of cardiopulmonary bypass is to maintain perfusion and oxygenation of the vital organs in the absence of heart and lung function, usually to facilitate surgery on the heart, but occasionally in other situations. Although the intricacies of the modern extracorporeal circuit and the conduct of cardiopulmonary bypass are the domain of the clinical perfusion scientist (‘perfusionist’), safe surgery mandates a good understanding of some fundamentals by the anaesthetist and the surgeon. This review is aimed at the anaesthetist. First, we will systematically examine the main components of the extracorporeal circuit, travelling in the direction that blood travels, from the venous cannula to the arterial cannula. Then we will describe the process of preparing for bypass, ‘going on’, conducting a bypass run, and weaning and separation from bypass. It is crucial to have clear communication between the surgeon, perfusionist and anaesthetist. This can be difficult for the novice because a quite specific language has evolved in cardiac operating theatres to signal key events in the cardiopulmonary bypass sequence. As we go through this article, we will highlight commonly used terminology and expressions used.     

Cardiopulmonary bypass

Extracorporeal cardiopulmonary bypass (CPB) facilitates surgery on the surface and within the chambers of the heart. It provides the function of the heart and lungs, giving the blood momentum and carrying out gas exchange, respectively. CPB allows the heart and lungs to be isolated from the systemic circulation.