Comparison of off-pump and on-pump coronary artery bypass grafting in midterm results.

OBJECTIVE: Off-pump coronary artery bypass grafting (OPCAB) has become a procedure of choice for surgical treatment of coronary artery disease. Although early advantages of OPCAB were confirmed in comparison with conventional on-pump coronary artery bypass grafting (CABG), late cardiac complications are still controversial. We examined midterm results of OPCAB compared with standard CABG. METHODS: Between July 1997 and April 2002, 736 consecutive patients who underwent isolated CABG were retrospectively reviewed. The OPCAB group (Group I) comprised 357 patients (49%), and the on-pump CABG group (Group II) 379 patients (51%). Their preoperative, intraoperative, and follow-up data were analyzed. RESULTS: The mean number of distal anastomoses and the early graft patency were not greatly different between the two groups. The actuarial survival rate at 3 years was not significantly different between Group I (98.3%) and Group II (98.2%) (p = 0.71). The frequency of cardiac events was 4.2%/patient-year in Group I and 2.6%/patient-year in Group II (p = 0.12). The actuarial event free rates were not different between the two groups (p = 0.61). The cardiac event free rates at 3 years were significantly (p = 0.011) higher in patients with complete revascularization (96.7%) than without complete revascularization in Group I (69.2%) and in Group II (92.7% versus 85.9%, p = 0.026). CONCLUSIONS: Midterm clinical outcome in OPCAB is as good as conventional on-pump CABG. Incomplete revascularization caused cardiac events more frequently than complete revascularization both in OPCAB and on-pump CABG in the intermediate follow-up.     

Comparison of off-pump and on-pump coronary artery bypass grafting in midterm results

Objective: Off-pump coronary artery bypass grafting (OPCAB) has become a procedure of choice for surgical treatment of coronary artery disease. Although early advantages of OPCAB were confirmed in comparison with conventional on-pump coronary artery bypass grafting (CABG), late cardiac complications are still controversial. We examined midterm results of OPCAB compared with standard CABG. Methods: Between July 1997 and April 2002, 736 consecutive patients who underwent isolated CABG were retrospectively reviewed. The OPCAB group (Group I) comprised 357 patients (49%), and the on-pump CABG group (Group II) 379 patients (51%). Their preoperative, intraoperative, and follow-up data were analyzed. Results: The mean number of distal anastomoses and the early graft patency were not greatly different between the two groups. The actuarial survival rate at 3 years was not significantly different between Group I (98.3%) and Group II (98.2%) (p=0.71). The frequency of cardiac events was 4.2%/patient-year in Group I and 2.6%/patient-year in Group II (p=0.12). The actuarial event free rates were not different between the two groups (p=0.61). The cardiac event free rates at 3 years were significantly (p=0.011) higher in patients with complete revascularization (96.7%) than without complete revascularization in Group I (69.2%) and in Group II (92.7% versus 85.9%, p=0.026). Conclusions: Midterm clinical outcome in OPCAB is as good as conventional on-pump CABG. Incomplete revascularization caused cardiac events more frequently than complete revascularization both in OPCAB and on-pump CABG in the intermediate follow-up.     

Fate of claudicants after femoropopliteal vein bypass: prospective, long-term follow-up of 100 patients

Femoropopliteal bypass grafting for claudication is a controversial procedure. One hundred consecutive patients so treated were analysed for vein-graft patency, subsequent operation and survival. Initial success, treatment of incipient graft failure and attrition from death were the three critical factors influencing long-term benefit. Cumulative graft patency, after revision when necessary, was 89%, 86% and 78% at 2, 5 and 10 years respectively. In assessing the real benefit of surgery in this group, it is important to consider the effect of late deaths, as the life expectancy of these patients is so often shortened by related disease; the "cumulative palliation" (patient alive and graft patent) was 82%, 67% and 28% at the same time intervals. The concept of cumulative palliation sets a high standard in assessing results of vascular surgery, adding important information to the usual graft patency rates that ignore the effect of death. These results suggest a place for femoropopliteal vein bypass grafting in selected claudicants.     

Axillofemoral bypass. Expectations and results

We studied 33 patients who received axillofemorofemoral or axillofemoral polytef (polytetrafluoroethylene [PTFE]) grafts. The follow-up period ranged from six to 60 months. Most patients were operated on for limb salvage. The 30-day operative mortality was 7% for elective or urgent procedures and 67% for emergency procedures. Twelve amputations were performed, but nine were necessitated by preexisting tissue loss and three were performed below rather than above the knee following proximal revascularization. Cumulative graft patency was 91% at three years and 75% at five years. Patient survival was only 54% at three years and 41% at five years. Graft patency exceeded patient survival at every interval. In a select group of high-risk patients requiring proximal revascularization for limb salvage, axillofemorofemoral bypass offers an acceptable alternative to an in situ aortofemoral graft.     

Patency and limb salvage rates after distal revascularization to unclampable calcified outflow arteries

PURPOSE: Severe circumferential calcification of the outflow artery during lower-extremity distal revascularization is considered a poor prognostic factor for bypass graft patency. The aim of this study was to assess the influence of circumferential infrapopliteal arterial calcification on bypass graft patency and limb salvage rates, comparing patency and limb salvage rates in unclampable calcified distal outflow arteries with those observed in uncalcified distal outflow arteries. METHODS: From July 1990 to July 1997, of 441 distal bypass graft procedures performed by the same surgeon, 69 (16%, group I) involved unclampable calcified outflow vessels, whereas 83 (19%, group II) outflow vessels were uncalcified; the other 289 (65%) had varying intermediate degrees of calcification and were not included in this analysis. All procedures were performed for limb-threatening ischemia and involved standard vein patch angioplasty of the distal anastomotic site, irrespective of the conduit used. Primary and secondary patency, limb salvage, and survival rates were assessed by using Kaplan-Meier analysis. RESULTS: Groups were similar with regard to age, sex, and atherosclerotic risk factors except for a higher incidence of diabetes mellitus (88% vs 65%, P =.001) and renal failure (17% vs 5%, P =.01), including dialysis dependency (P =.01) in group I. Gangrene as an indication for surgery was statistically more frequent in group I (49% vs 29%, P =.01). The distal anastomotic locations and types of conduit involved were similar in the two groups. The femoral inflow level was used more often in group II (63% vs 38%, P =.003), the popliteal in group I (32% vs 17%, P =.03). Follow-up ranged from 30 days to 144 months, with a mean of 69 months. None of the patients were lost during the follow-up period. None of the patients died during the perioperative (30-day) period. Primary patency rates at 1, 3, and 5 years were 84%, 65%, and 52% for group I and 89%, 76%, and 69% for group II (P =.07.). Secondary patency rates at 1, 3, and 5 years were 96%, 82%, and 78% for group I and 96%, 85%, and 82% for group II (P =.58). Limb salvage rates at 1, 3, and 5 years were 93%, 83%, and 81% for group I and 97%, 90%, and 86% for group II (P =.39). CONCLUSIONS: Distal revascularization to unclampable, severely calcified outflow arteries can achieve much the same results to those obtained in uncalcified outflow arteries. A circumferentially calcified distal recipient artery should not be considered a major obstacle to an attempt at limb salvage bypass graft surgery.     

Femoropopliteal in situ saphenous vein bypass: Technical aspects and factors determining patency

The results and the factors influencing long-term patency rates in two technical variations of femoropopliteal «in situ» saphenous vein bypass procedures were evaluated retrospectively. Technique I (n=33) consisted of a limited approach to the saphenous vein, destruction of the valves with a Cartier stripper and no tributary ligation. Technique II (n=55) included complete exposure of the saphenous vein valvular destruction using Hall’s stripper and ligation of all tributaries. Early thrombosis was observed in 21% and 3.6% of cases in techniques I and II, respectively. The frequency of local complications was identical in both techniques (18%). Overall actuarial primary patency at 4 years was 70%. Secondary patency (including patency following reoperations for graft failure) was 88 % overall, 78.5% in technique I and 95% in technique II (p<0.05). The site of the distal anastomosis significantly influenced the four year cumulative patency rate (upper popliteal ?100%, lower popliteal ?93.6%, tibioperoneal vessels ?70.5%, p<0,05), whereas the number of patent leg vessels, the clinical stage of disease and the site of the proximal anastomosis (common femoral or superficial fernoral artery) did not. Results obtained with the in situ saphenous vein bypass using technique II were better than with technique I. Close follow-up and preventive reoperations clearly enhanced patency rates. The site of distal anastomosis significantly affected long-term results.     

PEG-hirudin/iloprost coating of small diameter ePTFE grafts effectively prevents pseudointima and intimal hyperplasia development.

OBJECTIVES: Small diameter PTFE grafts are prone to thrombosis and intimal hyperplasia development. Heparin graft coating has beneficial effects but also potential drawbacks. The purpose of this study was to evaluate the experimental efficacy of PEG-hirudin/iloprost coated small caliber PTFE grafts. METHODS: Thirty-six femoro-popliteal ePTFE grafts (expanded polytetrafluoroethylene, diameter 4 mm) were inserted into 18 pigs. Grafts were randomised individually for each leg and grouped for 3 groups. Group I consisted of native ePTFE grafts, group II were grafts coated with a polylactide polymer (PLA) without drugs and group III grafts were coated with PLA containing a polyethylene glycol (PEG)-hirudin/iloprost combination. The follow-up period was 6 weeks. Patency rates were calculated and development of pseudointima inside the grafts was noted. Thickness of intimal hyperplasia at the distal anastomoses was measured using light microscopy. RESULTS: Patency rates for group I were 6/9 (67%), for group II 9/10 (90%) and 12/12 (100%) for group III. In groups I and II there was a significant reduction of blood flow proximal to the graft at graft harvest, to 29+/-12 and 28+/-20 ml/min respectively (both p<0.01 versus preoperative value), whilst in group III blood flow, 99+/-21 ml/min, remained at the preoperative level. Subtotal stenosis due to development of pseudointima was noted in each of the native and PLA coated grafts but not in group III grafts. Intimal hyperplasia at the distal anastomosis was lowest in group III. CONCLUSIONS: The PEG-hirudin/iloprost coating of ePTFE prostheses effectively reduced pseudointima and intimal hyperplasia development and led to superior graft patency.     

Do the long-term results of carotid surgery influence the status of the contralateral carotid artery?]

AIM: The main cause of long-term death and disability of patients undergoing carotid artery surgery is coronary artery disease. To identify the prognostic value of the status of the contralateral artery, we studied the course of 224 patients operated consecutively on one or both carotid arteries in the same institution between 1985 and 1995. PATIENTS AND METHODS: The 224 patients were divided into three groups: group I (n = 56) having an occluded contralateral carotid artery; group II (n = 56) in which both carotids were operated on; and, group III (n = 112) having a normal contralateral carotid artery. The clinical status of all patients was ascertained by one of us for all patients except one. This study concerned also the course of 40 patients (group R) belonging to the three groups, who had during the follow-up period a coronary and/or a peripheral vascular intervention with a preoperative coronarography. RESULTS: The median follow-up was 62.8, 78 and 65 months for groups I, II and III, respectively. Actuarial survival rates were 67%, 73%, 72.5% at 5 years, and 39%, 51.5% and 42% at 10 years, for group I, II and III respectively. Actuarial stroke-free rates were 96%, 100%, 91% at 5 years, and 96%, 100% and 78.5% at 10 years for group I, II and III respectively. Actuarial cardiac death rates were 26%, 23%, 19% at 5 years, and 49%, 42% and 37% at 10 years for group I, II and III, respectively. None of the differences between the three groups regarding these three different end-points was significant. The group R fatal or non-fatal cardiac event-free rates at 5 and 10 years were 88% and 53% respectively. When compared with the rates of other patients (without revascularization): 68% and 25.5% at 5 and 10 years, the results were almost significant (P = 0.07). Average age for group R patients was significantly lower (65 vs. 69 years, P < 0.05). Using Cox's model, age alone emerged as a factor influencing survival (P = 0.07) but not revascularization (P = 0.13). CONCLUSION: The status of the contralateral artery does not influence the long-term prognosis of patients undergoing carotid artery surgery. A periodic cardiological and vascular follow-up of these patients tends to improve their survival.     

The descending branch of lateral femoral circumflex artery in arterial CABG: early and midterm results

BACKGROUND: Different arterial conduits have been used for coronary artery bypass grafting (CABG), avoiding remote cardiac events associated with graft failure and improving the quality and expectancy of life in patients with coronary artery disease. The goal of this study was to evaluate the early and midterm results of total arterial CABG with the descending branch of the lateral femoral circumflex artery (DLFCA). METHODS: Between February 1997 and December 2001, 147 patients underwent arterial CABG using the DLFCA at our department. The patients were followed to determine perioperative cardiac events. Angiographic follow-up controls were performed at the end of surgery in 81 patients (55.1%), within 1 year in 82 patients (55.7%), and within 3 years in 48 patients (32.6%). The actuarial survival and event-free rates, the occurrence of late cardiac events and death, the cumulative rate of the DLFCA graft patency, and the incidence of spasm were investigated. RESULTS: The DLFCA was used in all patients (113 men and 34 women, with a mean age of 56 +/- 12.6 years). The proximal anastomoses of the DLFCA was performed with the left internal mammary artery (LIMA) in 95% and with the right internal mammary artery (RIMA) in 5% of patients. The distal anastomoses of the DLFCA was performed with the left anterior descending (LAD) coronary artery in 3.5%, with the diagonal artery in 17%, with the intermedius ramus in 7.5%, with the posterior interventricular artery in 2%, and with the branch of circumflex artery in 70% of patients. The in-hospital mortality and morbidity rates were 0% and 7.4%, respectively. Complications related to DLFCA harvesting was transient dysesthesia of the thigh, observed in 6 patients (4%). No postoperative myocardial infarction attributable to DLFCA bypass was observed. During the late follow-up period of 22.09 +/- 16.8 months, cardiac events were observed in 14 patients (9.5%), including recurrence of angina in 6, arrhythmia requiring hospitalization in 4, congestive heart failure in 2, percutaneous transluminal angioplasty in 1, and sudden death in 1 patient. Actuarial 1- and 3-year survival rates after surgery were 100% and 99.3%, respectively. Actuarial 1- and 3-year event-free rates were 97.3% and 90.5%, respectively. Actuarial 1- and 3-year patency rates were 97.5% and 93.7%, respectively. CONCLUSIONS: No adverse effects were exhibited after CABG using the DLFCA graft in this early and midterm follow-up period. The excellent patency rate of DLFCA and the low incidence of spasm stimulate us to continue and extend the use of the DLFCA in CABG.     

Influence of pancreas and kidney transplant function on recipient survival

The aim of this study was to evaluate long-term survival after simultaneous pancreas and kidney (SPK) transplantation in relation to function of both grafts. Among 67 recipients who received SPK transplants between 1988 and 2004, 35 had follow-up longer than 18 months, and were divided into: group I (n = 20), recipients with good function of both grafts; group II (n = 7), patients who had lost transplanted pancreas but had still good kidney graft function; group III (n = 8), patients who had lost both grafts. Comparison of survival rates and analysis of the reason of mortality among groups was performed. The cumulative survival rate was significantly higher in group I than in group III (after 3, 5, 10 years: 100%, 100%, 80% vs 75%, 50%, 37%, respectively). Cumulative survival rate for group II after 3, 5, 10 years was 100%, 100%, 33%, respectively. There were no significant differences in survival rates between groups I and II and between groups II and III. In group I deaths for cardiovascular event and for leukemia were noted. In group II deaths due to cardiovascular event and sepsis were observed. In group III all patients died due to cardiovascular events and the mean time from loss of pancreas and kidney graft function to death was: 75 +/- 51 months (range from 19 to 142), and 49 +/- 26 months (range 19 to 99), respectively. Good pancreas and kidney graft functions prevent death due to cardiovascular event.     

Efficacy of Hemobahn in the treatment of superficial femoral artery lesions in patients with acute or critical ischemia: a comparative study with claudicants.

PURPOSE: To assess the results of covered stents in the treatment of superficial femoral artery (SFA) occlusive disease. METHOD: From July 2000 till June 2003, 32 patients (34 limbs) were scheduled for procedures including Hemobahn deployment in the SFA. Indication for treatment was claudication (group I, N=15 patients and 16 limbs, 31.2% occlusions) or critical and acute ischemia (group II, N=17 patients and 18 limbs, 61.1% occlusions). TASC D SFA lesions were excluded. No limb artery was patent pre-operatively in 19% and 89% of limbs in groups I and II, respectively (p=0.00001). RESULTS: Outflow procedures were performed simultaneously in one limb in group I and 12 in group II (p=0.0003). The technical, hemodynamic and clinical success rates were 100, 100 and 94.1%, respectively. Mean follow-up was 18.1 months. Primary patency rates at 12 months were 81.3+/-10.6% in group I and 88.6+/-9.0% in group II (p=0.547). At 12 months, the secondary patency and limb salvage rates were, respectively, 87.5+/-8.9 and 100% in group I and 87.5+/-8.93 and 94.45+/-6.71% in group II. CONCLUSION: Treatment of SFA occlusive lesions (excluding TASC D lesions) with the Hemobahn covered stent yielded good results for both claudicants with good outflow and patients with critical or acute ischemia with bad outflow, if concomitant outflow-improving procedures were performed.     

Lower limb revascularization with a new bioactive prosthetic graft: early and late results

The aim of the study was to evaluate the immediate and long-term results of femoropopliteal bypasses performed with a new bioactive heparin-treated expanded polytetrafluoroethylene (ePTFE) graft in a single-center experience. From March 2002 to April 2006, 51 patients underwent lower limb revascularization with a new bioactive ePTFE prosthetic graft with covalent end-point attachment of heparin to the graft surface. Data concerning preoperative assessment, intraoperative strategy, drug administration, and follow-up surveillance program were prospectively collected in a dedicated database; early results were analyzed in terms of graft patency, amputation rate, and deaths. Follow-up consisted of clinical and duplex scan examination at 1, 6, and 12 months and yearly thereafter. Midterm results in terms of primary and secondary patency, limb salvage, and survival were analyzed. Patients were predominantly male (35 patients, 71%), with a mean age of 71 years (SD = 9.05). Indications for surgical revascularization were critical limb ischemia in 36 patients and severe intermittent claudication in 15 patients. Interventions were performed for occlusion of a native vessel in 35 cases, whereas 12 patients had late thrombosis of a femoropopliteal bypass; the remaining four patients were operated on for an occluded popliteal artery aneurysm. Intervention consisted of below-knee bypass in 34 patients, while the other 17 had an above-knee revascularization. No perioperative deaths occurred. Cumulative 30-day graft patency was 88%, with an amputation rate of 4% (two cases). Results were similar in above- and below-knee revascularizatons. Mean duration of follow-up was 18 months (SD = 7). Cumulative estimated 24-month survival and primary patency rates were 97% and 80.2%, respectively; the corresponding limb salvage rate was 85.7%. Long-term results did not significantly differ in above- and below-knee revascularizatons. In our experience, the use of a modified ePTFE graft with covalent end-point linkage of heparin molecules on the graft surface provides good early and midterm results, with low rates of graft thrombosis and amputation.     

Comparison between supra- and infrainguinal inflow sites for infrapopliteal PTFE bypasses with complementary arteriovenous fistula and vein interposition.

PURPOSE: the purpose of this retrospective study was to evaluate whether an inflow source proximal to the inguinal ligament had an adverse effect on infrapopliteal bypasses with complementary arteriovenous fistula/vein interposition (AVF/VI) when compared to similar bypasses originating from the common femoral artery (CFA). PATIENTS AND METHODS: over the last seven years, 112 infrapopliteal PTFE bypasses with AVF/VI were performed in 103 patients. There were 58 men and 45 women with ages ranging from 47 years to 88 years (mean 71 years). Indication for surgery was critical ischaemia in all. Seventy-seven (69%) of these were secondary operations and 35 cases (31%) were primary. A 6-mm ringed PTFE graft was used in all cases. A complementary distal AVF/VI was added in all cases. In 56 cases, the bypass originated from the common femoral artery (group I) and, in the remaining 56, it originated from the external or common iliac artery (group II). RESULTS: the overall perioperative mortality rate was 3%. The cumulative primary patency rates at 1, 2 and 3 years were 66%, 63% and 53% for group I and 72%, 66% and 59% for group II, respectively (NS). CONCLUSIONS: these data show that infrapopliteal PTFE bypasses with AVF/VI have similar patency rates when originating from arteries proximal to the inguinal ligament or from the CFA.     

Multicenter Randomized Prospective Trial Comparing a Pre-cuffed Polytetrafluoroethylene Graft to a Vein Cuffed Polytetrafluoroethylene Graft for Infragenicular Arterial Bypass

Poor patency of synthetic grafts for infragenicular revascularization has led to use of distal vein patches or cuffs. The aim of this study was to compare the distally widened Distaflo^TM PTFE graft, which mimics a vein cuff, with a PTFE graft with distal vein modification. In this prospective, randomized, multicenter trial we compared use of a precuffed PTFE graft wit that of PTFE grafts with distal vein modification for infragenicular revascularization in patients with critical limb ischemia without saphenous vein. Study end points were primary and secondary patency and limb salvage rates at 2 years. From January 28,1999 to November 1, 2000, 104 patients were enrolled in 10 North American centers. Thirteen were excluded for protocol violation. Ninety-one bypasses were performed in 89 patients with a mean age of 73 years (range 47-90). By randomization, 47 bypasses were done with the precuffed graft and 44 with PTFE graft with vein cuff. Both groups were comparable for comorbidities and operative variables, except for a higher incidence of acute ischemia in the precuffed group (19% vs. 4.5%, p = 0.03). Bypass was a redo procedure in 53% and was performed at the infrapopliteal vessels in 79%. Operative mortality was 2.2% (2/91). Mean follow-up was 14 months (range 1-30). At 1 and 2 years, primary patency was 52% and 49% for the precuffed group and 62% and 44% for the vein cuffed group, respectively (p = 0.53). At 1 year and 2 years, the limb salvage rate was 72% and 65% for the precuffed group and 75% and 62% in the vein cuffed group (p = 0.88). Although numbers are small and follow-up short, this midterm analysis shows similar results for the Distaflo precuffed grafts and PTFE grafts with vein cuff. A precuffed graft is a reasonable alternative conduit for infragenicular reconstruction in the absence of saphenous vein and provides favorable limb salvage.Presented at the Twenty-eighth Annual Meeting of the Peripheral Vascular Surgery Society, Chicago, IL, June 7, 2003.See Appendix 1 for list of Distaflo^TM trial investigators and participating centers.     

Minimally invasive direct coronary artery bypass grafting: intermediate-term results

BACKGROUND: Intermediate- and long-term clinical outcome and graft patency in minimally invasive direct coronary artery bypass grafting (MIDCABG) procedures remain a concern. METHODS: Over a 13-month period, 66 MIDCABG procedures were performed utilizing robotic-assisted internal mammary artery (IMA) harvesting and direct CABG through a 5-cm thoracotomy without cardiopulmonary bypass. Clinical follow-up was obtained on all patients. Graft patency was assessed in 61 of 66 consecutive patients 6 months (range 2 to 15 months) postoperatively. Group I consisted of 45 patients who underwent IMA angiography and group II consisted of 16 patients who underwent both a nuclear stress test and transthoracic Doppler examination. All group II patients had abnormal preoperative nuclear stress tests for comparison. RESULTS: To date, all 66 patients are alive. Graft patency rates in the two groups were 97.8% (45 of 46 grafts in 45 patients) in group I and 100% (15 of 15 grafts), with one indeterminate study, in group II. The overall patency rate for the entire study group was 98.3% (60 of 61 grafts). Sixty-two of 66 (93.9%) patients were able to return to their normal level of activity within 3 weeks. CONCLUSIONS: This study demonstrates that the MIDCABG with thoracoscopic IMA harvesting can achieve effective intermediate-term revascularization and an acceptable clinical outcome.     

Distal thoracic aorta as inflow for the treatment of chronic mesenteric ischemia

PURPOSE: Mesenteric revascularization for chronic mesenteric ischemia (CMI) traditionally involves antegrade or retrograde bypass graft originating from the supraceliac or infrarenal aorta. The distal thoracic aorta (DTA) may provide a better inflow source than the abdominal aorta. The purpose of this study was to evaluate the results with the DTA used as inflow for the surgical treatment of CMI. METHODS: All patients undergoing mesenteric revascularization for CMI with grafts originating from the DTA were identified from 1990 to 1999. A ninth interspace thoracoretroperitoneal incision was used for exposure, and distal aortic flow was maintained by use of a partial occlusion clamp. RESULTS: Eighteen consecutive patients with CMI underwent mesenteric bypass grafting with the DTA used as inflow. All patients were admitted with chronic abdominal pain or weight loss, with two (12%) requiring urgent revascularization because of acute exacerbation of chronic symptoms. Fourteen (78%) patients had both celiac and superior mesenteric artery bypass grafts placed, and three (17%) patients had superior mesenteric artery grafts alone. There was one (6%) perioperative death and three (17%) major complications. There was no kidney failure, mesenteric infarction, or spinal cord ischemia. The life-table survival rate was 89%, 89%, and 76% at 1, 3, and 5 years, respectively. All 18 patients remained symptom free and required no additional procedures to assist patency. There was no evidence of graft stenosis or occlusion (100% patency) for those grafts evaluated objectively during the mean follow-up of 34.8 months (range, 1-97 months). CONCLUSIONS: Antegrade mesenteric revascularization with the DTA used as inflow is associated with low morbidity and mortality rates. Furthermore, it provides excellent midterm patency and survival results and should be considered as a primary approach for reconstruction of patients with CMI.     

Femoral vein transposition versus femoral loop grafts for hemodialysis: a prospective evaluation

In this first clinical trial femoral vein transposition (FVT) was prospectively compared with its "graft" counterpart. Patients requiring vascular access due to occluded central veins were divided into two groups: group I (n = 17) underwent femoral loop grafts and group II (n = 15), FVT. Complications were recorded prospectively and patency rates were compared by the Kaplan Meier method with statistical comparisons by Mann Whitney U and chi-square tests as appropriate. Between 1999 and 2003 30 patients underwent 32 operations. Mean follow-up was 8.9 months in group I and 6.8 months in group II (P >.05). Three group I patients developed a steal, requiring closure of the fistula in one. Five group II patients developed a steal, requiring closure of the fistula in one. The incidence of steal was similar in both groups (P >.05). The infection rates were similar: 35.3% and 26.7% in group I versus group II (P >.05), respectively. Among the six infections in group I, four patients required excision of the graft due to infection, whereas only one arteriovenous fistula (AVF) was closed in group II for infection. The 1-year primary patency rate in group I was 37.5% versus 86.7% in group II (P <.05). In conclusion, Femoral AVF grafts have been condemned because of the unacceptable high rate of septic complications. FVT obviates the need for a graft and has fewer infectious problems and better patency rates.     

Bypass to the distal right coronary artery using in situ gastroepiploic artery

OBJECTIVE: We investigated the clinical outcomes after coronary artery bypass grafting (CABG) using the in situ gastroepiploic artery (GEA) exclusively bypassing to the distal right coronary artery (RCA). METHODS: Between, 1991 and 2002, 1020 consecutive patients (788 male and 232 female with a mean age of 63.6 +/- 9.7) underwent CABG to the distal coronary artery using in situ GEA in the Shin-Tokyo Hospital Group. Their perioperative and follow-up data were retrospectively analyzed. RESULTS: The in-hospital morbidity rate was 15.1% and the mortality rate was 0.6%. Postoperative myocardial infarction associated with GEA graft failure occurred in two cases. Among the survivors, follow-up was completed in all patients with a mean period of 4.7 +/- 2.4 years. Actuarial 3- and 5-year angina or intervention-free rates were 93.6% and 89.9%, respectively. Actuarial 3- and 5-year survival rates were 95.8% and 91.6%, respectively. Postoperative angiography was performed on 482 patients within 1 year, 115 patients with 3 years, and in 87 patients more than 4 year after surgery. The GEA patency rates at 1, 3, and 5-year were 95.7%, 90.2%, and 85.7%, respectively. These patency rates were compared with other graft materials (the saphenous vein n = 291, radial artery n = 186, and right internal thoracic artery n = 23) used for bypass to the distal RCA, and we found no significant differences (p = 0.29). CONCLUSION: The perioperative and clinical remote results of GEA grafting were satisfactory. The angiographic patency rates of GEA to the distal RCA was not inferior to the saphenous vein graft in this study.     

Left anterior descending coronary artery: long-term angiographic results of CABG with endarterectomy

AIM: The procedure of coronary bypass grafting (CABG) with coronary endarterectomy (CE) is controversial. However, in the setting of severely calcified coronary arteries CE may enable complete revascularization. Complete revascularization, especially of the left anterior descending artery (LAD), is important for long-term outcome. In this study we assessed long-term LAD graft patency and anterior wall function after CABG with CE of the LAD. METHODS: Between 1984 and 1992, 283 patients underwent CABG with CE of the LAD. In 50 patients (47 men), aged 59+/-7.6 (40-77), clinical reassessment and surveillance angiography were performed. In all patients complete revascularization had been achieved with 3.5+/-1 (1-5) grafts/patient with 1-3 CE/patient. The LAD was grafted either with a saphenous vein segment (N=38) or with left intern thoracic artery (N=12). A graft obstructed less than 50% in diameter was defined as patent. RESULTS: At follow-up 39 patients (78%) were in CCS class I/II and had improved significantly (P<0.000). Control angiography after 7.6+/-2.5 (3.5-11.7) years after CABG revealed a patent LAD graft in 30/50 patients (60%). Actuarial graft patency was 100%, 96%, and 56% after 2, 5, and 10 years and was lower in patients with diabetes (P=0.001). Deterioration of anterior wall motion was observed in 17 patients (34%) and was more frequent if anterior wall motion was preoperatively normal (P=0.002), irrespective of LAD graft patency. CONCLUSION: Clinical status and long-term graft patency of grafts on endarterectomized LAD is considerable. However, patients with preoperatively normal anterior wall function are at increased risk for myocardial damage in the long-term.     

Long-term surveillance by duplex scanning of nonrevised infragenicular graft stenosis

To define the prognosis of nonrevised graft stenosis, we studied 68 infragenicular bypass grafts in patients entered into our duplex surveillance program between 1986 and 1987. Patients were grouped according to the grade of stenosis as follows: grade I = <50% stenosis, grade II = 50% to 75% stenosis, and grade III = 75% to 99% stenosis. Time until maximum stenosis was stratified into three intervals (<3 months, between 3 and 12 months, and > 12 months). Cumulative patency rates from the time of maximum stenosis to failure were calculated using Kaplan-Meier analysis. Fifty-three grafts (78%) developed stenoses: 10 with grade I, 25 with grade II, and 18 with grade III stenosis. Eighty-nine percent of the 18 graft occlusions occurred within 2 years. Two grafts occluded after 2 years without any severe stenosis or preceding clinical signs. During follow-up 15 nonrevised stenosed grafts (four with grade I, five with grade II, and six with grade III stenosis) remained patent longer than 2 years with a mean follow-up of 72 months. Statistical analysis for graft failure determined that grade II to III stenoses led to graft occlusion significantly earlier than grade 0 to I stenoses (p = 0.017). If graft failures resulting from revision were separated from the analysis, the time interval from operation to maximum stenosis (within 1 year) remained marginally significant for predicting occlusion, whereas no correlation was found between the grade of maximum stenosis and occlusion. Thus the prognosis for graft stenosis depends on the grade of stenosis and on the time interval from operation to stenosis. Therefore duplex surveillance seems to be most important within the first 24 months only, but is of little use in predicting impending graft failure beyond 2 years in asymptomatic patients.Presented at the Fourth Annual Winter Meeting of the Peripheral Vascular Surgery Society, Breckenridge, Colo., January 21–23, 1994.