Long-term results of thrombectomy for late occlusions of aortofemoral bypass

Sixty-two first episodes of aortofemoral (eight patients) or aortobifemoral (42 patients) bypass thrombosis were operated upon in 50 patients between 1980 and 1985. There were 47 men and three women whose mean age was 58 years. Retrograde thrombectomy through the distal anastomosis was achieved in all cases by using either a balloon catheter or Vollmar rings. If thrombectomy was impossible, revascularization was ensured by an extraanatomic bypass or complete replacement of the graft. Angioplasty, repeat distal anastomosis or femoropopliteal bypass of the native runoff artery were done in 55 (89%) operations. The cause of thrombosis was elucidated in 45 cases. Suture line stenosis and atheromatous stenosis of the native runoff artery were the two most common causes. Three patients died and two required above-knee amputation in the immediate postoperative period. Contralateral embolism occurred in two patients undergoing retrograde thrombectomy. Mean follow-up was 47 months. Thrombectomy was possible in 51 of 62 prosthetic thromboses (Group I). Thirty-nine of these grafts have remained patent. Twelve instances of repeat thrombosis occurred, requiring either repeat thrombectomy or a new bypass. Primary patency in group I was 97.8%, 81.2%, and 71.3% at one, three, and five years, respectively. Thrombectomy was impossible in 11 graft thromboses (Group II). A new bypass was performed in all 11 cases. Primary patency in Group II was 100%, 75% and 50% at one, three, and five years, respectively. Retrograde thrombectomy combined with treatment of native runoff artery anomalies can restore long-term patency when thrombosis occurs late after aortofemoral bypass and is associated with low mortality and morbidity.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, May 18–19, 1990, Nancy, France.     

Femorofemoral crossover bypass for noninfective complications of aortoiliac surgery

Between 1973 and 1989, 39 femorofemoral crossover bypasses were performed to treat unilateral noninfective complications of aortoiliac surgery. The initial revascularization procedure, performed an average of 79.5 months previously, was an aortobifemoral bypass in 29 cases, an aorto- or iliofemoral bypass in six cases, an inlay graft for abdominal aortic aneurysm and aortoiliac endarterectomy in two cases each. The indications for femorofemoral crossover bypass included prosthetic occlusion in 35 cases, thrombosed false aneurysm in two, and further degradation after endarterectomy (iliac stenosis and occlusion in one case each). There was no operative mortality. One patient with acute ischemia upon admission and another with distal gangrene required below-knee and forefoot amputations, respectively. No amputations were required during the rest of the follow-up period. Three repeat aortobifemoral bypasses were performed because of occurrence of aortic or inflow vessel lesions. Primary and secondary actuarial five year patency rates for femorofemoral crossover bypasses were 59.7% and 78.4%, respectively. Femorofemoral crossover bypass can extend the benefits derived from direct aortoiliac surgery with low mortality and morbidity in the absence of associated aortic pathology (false aneurysm at the aortic implantation site or severe obstructive lesions). kg]Key wordsPresented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, May 18–19, 1990, Nancy, France.     

Surgical reconstruction of the internal carotid artery with contralateral occlusion without use of shunt

Between 1979 and 1989, 133 carotid artery reconstructions were performed in 130 patients with contralateral internal carotid artery occlusion. These 133 reconstructions represent 7.3% of 1815 revascularizations of the internal carotid artery for atheromatous lesions performed during the same period. There were 113 men (87%) and 17 women (13%) whose mean age was 64.8 years (range 38 to 83 years). Forty-two patients (32%) had coronary artery disease and 77 (59%) were hypertensive. Nineteen patients (14%) were asymptomatic; 16 (12%) had symptoms of isolated vertebrobasilar insufficiency; 19 (14%) had ipsilateral carotid symptoms (on the side of operation); 67 (51%) had contralateral symptoms (on the side of occlusion); and 12 (9%) had bilateral carotid symptoms. All procedures were performed under general anesthesia without the use of a shunt. Nine patients (6.8%) died in the postoperative period (eight of neurologic and one of respiratory causes). Twelve patients (9%) sustained a cerebral vascular accident (eight ipsilateral and four contralateral). Four of these cerebral vascular accidents were diagnosed upon awakening, the remaining eight occurred after an initial uneventful recovery. Combined neurologic mortality and morbidity was 9.8%. Patients with occlusive lesions of the contralateral carotid artery undergoing internal carotid artery reconstruction are at high risk for postoperative cerebral vascular accidents. It is in this group of patients that the various methods of monitoring and cerebral protection should be evaluated.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, May 18–19, 1990, Nancy, France.     

Vertebral artery reconstruction: Results in 106 patients

Between January 1982 and December 1989, we performed 109 revascularizations of the vertebral artery in 106 patients. Eighty-six patients (81%) had isolated vertebrobasilar insufficiency, 18 (17%) had associated carotid and vertebrobasilar pathology while two (2%) had isolated carotid symptoms. The procedures performed included 98 revascularizations of the proximal vertebral artery and 11 reconstructions of the distal vertebral artery. One distal revascularization was required after early failure of proximal revascularization. In 36 cases (34%), a concomitant ipsilateral carotid artery revascularization procedure was performed, and in one case, an ipsilateral subclavian artery aneurysm was excised. Two patients (1.9%) died post-operatively and five patients (4.7%) had nonfatal neurologic complications. Four of these seven complications occurred after combined vertebral and carotid surgery. One hundred early follow-up arteriograms were obtained (92% of reconstructions). There were four occlusions, two of which were associated with neurologic deficits. Three patients were lost to follow-up. Mean follow-up was 48 months (4–100 months). Seven patients died in the late follow-up period (after one month). Actuarial five year survival was 91%. Overall patency at five years was 96%. The study of late neurologic events showed that 63% of patients had complete recovery, 30% improvement, and 7%, failure or aggravation of symptoms.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, May 18–19, 1990, Nancy, France.     

Descending thoracic aorta as an inflow source for late occlusive failures following aortoiliac reconstruction

From November 1984 to March 1990, 10 descending thoracic aorta-to-femoral artery bypass procedures were performed after failure of one or several aortoiliofemoral reconstructions. All patients were men, mean age 60 years. Indications included noninfected false aneurysm of an infrarenal end-to-side aortoprosthetic anastomosis in one case; one occlusion of an axillofemoral bypass; degradation of an aortobifemoral prosthetic graft; two occlusions of aortofemoral bypass; and five occlusions of aortobiiliac or aortobifemoral bypasses. Eight bifurcated grafts, one aortoprosthetic tube graft, and one aortopopliteal tube graft were inserted. One patient died 23 days postoperatively of multiple organ failure. Three patients underwent a successful secondary lower limb reconstruction procedure (prosthetic limb thrombectomy, embolectomy, femoral bifurcation angioplasty in one case each). Mean survival time was 14 months (range 3–48 months). Two patients were lost to follow-up, and one died of myocardial infarction six months postoperatively with a patent bypass. Graft thrombosis occurred in two patients. One was treated by thrombectomy at five months, the other was treated by in-situ thrombolysis at 15 months. Both of these patients had patent grafts at 12 and 21 months, respectively. The four other patients had patent grafts at 48 months. Primary patency was 55.5% (5/9 survivors) and secondary patency was 100% (9/9). This is a relatively simple method for constructing an extraanatomic aortofemoral or aortobifemoral bypass in late failures of aortoiliofemoral reconstructive surgery without having to re-enter the abdomen.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, May 18–19, 1990, Nancy, France.     

Pre- and intraoperative transcranial doppler: Prediction and surveillance of tolerance to carotid clamping

We report 91 patients (mean age 70 years) operated upon, prospectively for a total of 100 carotid revascularizations (nine bilateral). Eighty-five of these patients had pre-, intra-, and postoperative transcranial Doppler investigations. Preoperatively, these 85 patients (92 procedures) were classified into two groups based on the results of their Doppler examinations: Group A (65 patients, 72 procedures), those who did not require an intraoperative indwelling shunt and Group B (20 patients, 20 procedures), those who did. The shunt was inserted only when the mean stump (back) pressure was less than 50 mmHg after cross-clamping. Group A all had satisfactory collaterality with a functional anterior and one or two posterior communicating arteries. Group B had no communicating arteries (anterior or posterior) identified by transcranial Doppler. In 17 of 20 patients in this group, the stump pressure was less than 50 mmHg and a shunt was placed. The overall prediction based on Doppler examination of whether or not patients would need a shunt during operation for the two groups A and B (i.e., 92 procedures) was correct in 95.6% (88/92) of cases. Moreover, six hemodynamically significant stenoses (four in the cavernous portion, two in the middle cerebral artery) were disclosed. Sensitivity and specificity of transcranial Doppler as correlated with arteriographic findings were 70 and 90%. Preoperative transcranial Doppler can measure the velocities of the principal cerebral arteries and the collateral capacity of the circle of Willis, and can forecast tolerance to carotid cross-clamping. Intraoperatively, the velocity of flow in the middle carotid artery was correlated with stump pressure, which allowed for surveillance of the shunt.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, May 18–19, 1990, Nancy, France.     

Atherosclerotic occlusive disease of the superior mesenteric artery: Late results of reconstructive surgery

Between 1975 and 1988, 103 patients underwent reconstruction of the superior mesenteric artery for atherosclerotic occlusive disease. Patients undergoing revascularization with associated mesenteric infarction were excluded. There were 89 men and 14 women whose mean age was 57.2 years. Six patients were operated on emergently for impending mesenteric infarction; six patients underwent revascularization after intestinal resection for ischemic lesions; 20 patients had typical abdominal angina; 39 patients had nonspecific abdominal symptoms, and 32 patients underwent revascularization of their superior mesenteric artery for asymptomatic lesions. Revascularization of the celiac axis and inferior mesenteric artery was associated in 36 and four cases, respectively. Four patients (4%) died postoperatively. Four early occlusions (4%) were observed. During the follow-up period (mean=69 months), 18 patients died; five patients had recurrent intestinal ischemic symptoms, four of whom died. All surviving patients underwent follow-up duplex scanning, examination, and arterial or venous digitalized angiograms in selected cases. Nine patients (9%) had anatomical abnormalities: two stenoses and seven occlusions. Failure of revascularization of the superior mesenteric artery was observed in patients with severe initial intestinal ischemia. Late complications were not statistically significantly related to the different techniques of revascularization used. Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, June 23–24, 1989, Strasbourg, France.     

Innominate artery involvement in type iv Ehlers-Danlos syndrome

We report two cases of innominate artery involvement in patients with Ehlers-Danlos syndrome. In the first patient, spontaneous dissection of the innominate artery was treated successfully. In the other, the patient died of spontaneous rupture of the innominate artery in the early postoperative course after operation for aneurysm of the celiac artery. Arterial complications occurring in Ehlers-Danlos syndrome are rare but pose difficult diagnostic and therapeutic problems for the vascular surgeon due to arterial wall fragility.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, May 18–19, 1990, Nancy, France.     

Simultaneous reconstruction of infrarenal abdominal aorta and renal arteries

From 1980 to 1990, 48 (4.7%) of 1,002 patients underwent elective aortic reconstruction and simultaneous renal artery reconstruction. Forty-five men and three women (mean age: 66.5 years) had 59 renal artery lesions (51 stenoses, six occlusions, one dysplasia, and one aneurysm) associated with 20 infrarenal aortic aneurysms and 28 aortoiliac occlusive lesions. One nephrectomy and 58 renal artery reconstructions were performed (35 prosthetic bypasses, 11 vein bypasses, six direct reimplantations, five transaortic endarterectomies, and one resection of an intrahilar aneurysm followed by autotransplantation). Operation was always indicated for the aortic lesions. Indication for renal artery repair was hypertension in 33 cases (17 associated with renal insufficiency) and one with isolated renal insufficiency. In the remaining 14 cases, surgery was deemed preventive. One patient died (2%). There were 12 nonfatal complications two of which were kidney failures requiring chronic extrarenal epuration. Routine follow-up arteriograms showed four postoperative renal artery occlusions. Mean follow-up was 35.8 months. Four patients were lost to follow-up; 10 died secondarily. Five year survival was 72.1±19.1%. Secondary patency of renal artery reconstruction was 89.5±9.4% at five years. Late results were favorable in 45% of patients with hypertension and in 39% of patients with renal insufficiency. Mortality in simultaneous aortic and renal artery reconstruction is not superior to that of isolated infrarenal aortic surgery.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, June 21–22, 1991, Marseille, France.     

Occlusive disease of the renal arteries and chronic renal failure: The limits of reconstructive surgery

In order to investigate the value of renal revascularization in patients with chronic renal failure and associated occlusive lesions of the renal arteries, the long-term results of 48 revascularizations in 43 patients operated upon between January 1980 and May 1988 were analyzed. There were 36 men and 7 women whose mean age was 61.8 years (range 36 to 79 years). The diagnosis of kidney failure was based on serum creatinine levels greater than 120 micromoles/L on two consecutive determinations. Patients were divided into four groups: Group I (23 patients) had a creatininemia between 120 and 200 µmoles/L, Group II (16 patients) between 200 and 350 µmoles/L, Group III (2 patients) between 350 and 800 µmoles/L and Group IV (2 patients) who had chronic renal failure requiring hemodialysis. Hypertension was found in 37 patients. Renal artery restoration was unilateral in 38 patients, 12 of whom had a solitary kidney. Restoration was bilateral in five patients. In 24 patients, renal artery surgery was associated with reconstruction of the infrarenal aorta. Three patients undergoing associated aortic procedures (7%) died after surgery. Thirty-nine patients were followed for a mean of 35.1 months; one patient was lost to follow-up. Improvement or stabilization of renal function was noted in 24 patients (62%). Deterioration was found in 15 patients (38%), six of whom presently required chronic hemodialysis. In Groups I and II, 69.5% of patients stabilized or improved their kidney function. Renal function worsened in all patients in Groups III and IV. We conclude that restorative renal surgery can improve renal function in patients whose preoperative serum creatinine levels are less than 350 µmoles/L. In this population of patients, associated aortic restoration should be performed only when absolutely necessary.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, Strasbourg, France, June 23–24, 1989.     

Simultaneous aortoiliac reconstruction and renal transplantation: is it safe?

A 54-year-old man with an aortoiliac aneurysm and renal failure due to renal artery thrombosis was placed on a transplantation waiting list. The aneurysm had a 3 cm diameter and, therefore, did not require aortoiliac reconstruction, while its evolution was followed by ultrasound color-doppler every six months. The aneurysm was stable and two years later, when a cadaver kidney became available, a preoperative ultrasound color-doppler showed initial wall dissection. Therefore, an abdominal aneurysmectomy using a standard Dacron bifurcation graft and renal transplantation were successfully carried out. The patient had no associated complications and 24 months after transplantation and aneurysmectomy currently has good renal function and distal pulses. Only 20 cases of simultaneous aortoiliac reconstruction and renal transplantation have been reported in the literature. The excellent results of our case and those reported in the literature prove that patients who have both severe aortoiliac disease and end-stage renal failure can safely undergo simultaneous aortic reconstruction and renal transplantation. However, the atherosclerosis in these patients is a generalized process, so that in the pretransplant protocol special attention should be paid to detecting coronary artery atherosclerosis. In fact, coronary artery disease may have a priority claim to therapy because of the high risk of myocardial infarction. Our own policy is to put the patient back on the waiting list for renal transplantation after treatment for coronary artery disease. Furthermore, considering that the management for aortoiliac disease and kidney failure is safe in both simultaneous and staged cases, we think that the real issue is whether or not these patients with coronary atherosclerosis can be candidates for renal transplantation. We believe that each transplant centre has to develop its own general policy for these critically ill patients on the basis of its own experience.     

Persistent proatlantal artery associated with carotid artery stenosis treatment by percutaneous transluminal balloon angioplasty

A 58-year-old man had an asymptomatic tight stenosis of the internal carotid artery associated with a persistent proatlantal artery. This as well as other compositional arterial anomalies of the basilar artery were discovered on arteriograms. The stenosis was successfully treated by percutaneous transluminal balloon angiopfasty. Therapeutic choices are discussed in this setting because of the risk of carotid clamping in the presence of persistent carotid-basilar anastomoses. kg]Key wordsPresented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, May 18–19, 1990, Nancy, France.     

Graft occlusion following aortofemoral Dacron bypass

We report on a series of 930 patients who received an aortobifemoral Dacron graft between 1963 and 1988. The operative mortality was 5.6% and the mean follow-up reached 5.45 years (range one month to 23.6 years). Late occlusion was noted in 125 patients and the primary patency rate decreased to 74% and 69%, respectively at 10 and 15 years. Long-term patency was primarily (p < 0.05) dependent on (1) the date of operation, (2) postoperative smoking habits, (3) distal occlusive disease, and (4) age of the patients at the time of surgery. Vascular reconstruction for late thrombosis was performed for 110 late occlusions in 103 patients. Included were 95 unilateral and 15 bilateral occlusions. The method of choice was graft limb thrombectomy (unilateral occlusion) or anatomical graft replacement (bilateral occlusion or unilateral occlusion when thrombectomy proved to be impossible). Associated outflow reconstructions consisted of profundaplasty in 73.3% of the cases. A mean yearly thrombosis rate of 9.4% (range 4–14%) resulted in a five year patency rate of 59%. Differences between graft thrombectomy and anatomical replacement were not statistically significant. Reconstruction for secondary occlusions was associated with a 25% thrombosis rate. Tertiary occlusion in six cases invariably led to major amputation. A total of 20 patients ultimately needed a major amputation, resulting in an eight year limb salvage rate of 79%.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, May 18–19, 1990 Nancy, France.     

Prevention of vascular graft infection by rifampin bonding to a gelatin-sealed dacron graft

This study examines the efficacy of rifampin bonding to a gelatin-sealed knitted Dacron graft to prevent perioperative bacteremic vascular graft infection. Antibiotic bonding was obtained by soaking grafts for 15 minutes in a 1 mg/ml saline solution of rifampin at 37°C. Nineteen dogs had thoracoabdominal aortic bypass: seven (group I) received a rifampin treated graft; six (group II) received an untreated gelatin-coated graft; and six (group III) received an uncoated Dacron graft. Two days later bacteremic challenge was produced by rapid intravenous injection of 5×10 ⁵ colony forming units of methicillin resistantStaphylococcus aureus.Grafts were harvested five days after this challenge and cut into 10 fragments, each submitted to bacterial counts. Results were expressed as CFU/cm ² of graft material. In group I, no graft was infected, whereas all grafts in groups II and III were infected (p<0.05). Median bacterial counts from the infected fragments (median±SD) were similar in groups II (2.5×10⁵ CFU/cm²) and III (4×10⁴ CFU/cm²). Blood cultures at time of sacrifice were negative in all dogs in group I and positive in five of six dogs in groups II and III. Cultures of liver, spleen, kidney, and lung specimens were always negative in group I and positive in 22 of 24 specimens in group II and 23 of 24 specimens in group III. Soaking a gelatin-sealed Dacron graft in rifampin solution evidently prevents early bacteremic graft infection and secondary foci of infection in this model.Presented at the Annual Meeting of the French Vascular Surgery Society, Nancy, France, May 18–19, 1990.     

Intraoperative flow waveform analysis aids in preventing early graft failure following reconstruction of arteries of the legs

To enable early detection and treatment of vascular defects leading to early graft failure, intraoperative flow waveform analyses were carried out during lower extremity arterial reconstructions in 226 patients undergoing 102 aortoiliac/femoral and 124 femorodistal bypass grafts. Flow waveform types III or IV indicated early graft failure. These were noted in seven grafts (6.9%) in the aortoiliac/femoral position and in eight grafts (6.5%) in the femorodistal position. The main cause of the abnormal flow waveform pattern was misinterpretation of preoperative arteriographic findings in aortoiliac/femoral reconstructions and technical errors in anastomoses in femorodistal reconstructions. Of 15 grafts with an abnormal flow waveform pattern, 13 were effectively repaired with patch angioplasty, graft extension, or replacement with thrombectomy. In two grafts, the repair failed and amputation had to be done. Thus, intraoperative flow waveform analysis is a simple, useful, and safe method to detect vascular defects leading to early graft failure. Unless assessment of preoperative arteriographic findings in aortoiliac/femoral reconstructions are accurate and anastomotic techniques in femorodistal reconstructions are refined, early graft failure may occur.     

Inflow atherosclerotic disease localized to the common femoral artery: Treatment and outcome

Severe occlusive disease of the common femoral artery without significant aortoiliac disease is not common in our experience. Since 1978 we have operated upon 29 limbs in 22 patients (mean age 60) with localized common femoral artery disease. Indications for operation were claudication in 31% and impending limb loss in 69%. Operations included common femoral artery endarterectomy with patch angioplasty (19 limbs), patch angioplasty alone (two limbs), and common femoral artery endarterectomy without a patch (three limbs). Operative mortality was zero; there were nine wound complications, one patient had a myocardial infarction with early thrombosis. Symptomatic relief was obtained in 20 of 22 patients. All minor amputations healed. The mean postoperative ankle/brachial index increased to 0.67 from 0.49. Mean follow-up is 37 months (one–118 months); there have been 10 late deaths. Cumulative two and five year patency rates are 82% and 74%, limb salvage is 80% and 80%, respectively. Major amputations were required in five patients at two, two, 12, 23, and 68 months. Further inflow procedures were required in four patients: three aortobifemoral bypasses and one axillofemoral bypass. Although this disease has an uncommon inflow level, it is amenable to safe, durable, local procedures. Presented at the Midwestern Vascular Surgical Society Meeting, Chicago, Illinois, September 30, 1989     

Late upper extremity embolic complications of occluded axillofemoral grafts

The use of axillary femoral grafting in the treatment of patients at high risk for aortoiliac reconstruction has become a widely accepted treatment modality. Ischemia and even loss of the donor upper extremity have been reported to occur early after graft occlusion. This report describes three patients who developed emboli to the upper extremity at nine, 15, and 34 months following occlusion of their axillary femoral graft. Based on our experience, we consider an occluded axillofemoral graft a permanent threat to the viability of the donor upper extremity. Anatomic changes suggestive of potential ischemia include: presence of a blind pouch in the graft stump, or Y elongation of the artery with proliferative changes in the intima.     

Aortic and Iliac Reconstruction after Kidney Transplantation: Experience with an Algorithm for Renal Protection

Advances in renal transplantation have allowed for improved survival and an increased age of recipients. This has resulted in more aortoiliac lesions requiring intervention. The optimal approach for renal protection during aortoiliac surgery remains unknown. A retrospective review of transplant patients admitted to Toronto General Hospital for aortoiliac reconstruction between 1990 and 2000 was performed. A total of 20 aortic reconstructions were carried out in 18 patients: 5 patients with ascending aortic repairs and 15 patients with aortoiliac reconstructions. Of the five ascending repairs, all had cardiopulmonary bypass and four were performed under hypothermic arrest. There was one allograft loss in the postoperative period and one mortality. Of the 15 aortoiliac reconstructions 12 had protection: 10 temporary axillofemoral artery bypasses and 2 renal cold perfusion. In the 10 patients with temporary bypass protection, there were no graft losses. There was no graft loss in the hypothermic perfusion group. Of the three patients without protection, there was one graft loss. The postoperative rise in serum creatinine was significantly higher (p <0.05) in the no-protection group than in those receiving temporary bypass protection. Our algorithm of (1) temporary axillofemoral bypass, (2) cold perfusion if temporary bypass cannot be performed, and (3) clamp and sew if the patient is too unstable allows for surgery with excellent graft survival.     

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.     

Liver Transplantation for Post reperfusion Syndrome due to Surgical Packing of a Lacerated Liver

Abstract  The liver is the most frequently injured intra-abdominal organ and is the main cause of death in patients with abdominal injuries (mortality 10–15%). Grades III and IV liver injuries may present a complex problem to the surgeon. Several techniques to prevent exsanguination have been described including perihepatic packing, hepatic artery ligation, liver suturing or resection, and hepatectomy with transplantation. We report a case of a trauma patient who underwent perihepatic packing to control bleeding. Following pack removal, the patient developed severe cardiorespiratory depression resulting from postreperfusion syndrome requiring emergency total hepatectomy and liver transplantation. Types I–III hepatic injuries can safely be treated conservatively. Complex injuries (types IV and V) result in significant mortality, often requiring operative intervention. Indications of transplantion are uncontrollable hemorrhage or irreversible liver dysfunction. Literature reports describe liver transplantation as a second line treatment of complications following initial treatment. Our patient underwent liver transplantation as a second line treatment. The decision to transplant was based on two pathologic findings, ischemic changes of the liver and sudden cardio-respiratory decompensation following restoration of the blood supply to the liver. Both complications are emergencies, leading to death if not recognized and treated instantly. A total hepatectomy with temporary portocaval shunt followed by liver transplantation immediately or at a later stage is a life saving treatment for such cases.