Bypass of superior vena cava. Fifteen years' experience with spiral vein graft for obstruction of superior vena cava caused by benign disease

Nine patients had operations for obstruction of the superior vena cava with superior vena caval syndrome caused by benign disease. Three patients had fibrosing mediastinitis, four had fibrosing mediastinitis with caseous necrosis, one had thrombosis of the superior vena cava around a pacemaker electrode, and one had spontaneous thrombosis of the superior vena cava. Patients ranged in age from 25 to 68 years. All bypass operations were performed with a composite spiral vein graft constructed from the patient's own saphenous vein, split longitudinally and wrapped around a stent in spiral fashion. The edges of the vein were sutured together to form a large conduit ranging in diameter from 9.5 to 15.0 mm. Six grafts were from the left innominate vein and three grafts were from the internal jugular vein. The grafts were placed into the right atrial appendage in all except one case, in which the graft was to the distal superior vena cava. Follow-up extends from 1 to 15 years. One patient required reoperation at 4 days for thrombosis at the innominate vein-graft anastomosis. Resection of the anastomosis and reconstruction of the graft rendered the patient symptom free. Two grafts closed during the first year after operation. One patient had advancing fibrosing mediastinitis, and a second bypass graft from the external jugular veins remain patent. Another patient had recurrence of spontaneous venous thrombosis. Thus seven of nine grafts remain patent for up to nearly 15 years and all but one patient is free of superior vena caval syndrome. These data show that bypass of the obstructed superior vena cava with a spiral vein graft relieves superior vena caval syndrome and demonstrate long-term patency of the graft.     

Localized idiopathic fibrosing mediastinitis as a cause of superior vena cava syndrome: a case report

An unusual case of superior vena cava syndrome, caused by localized fibrosing mediastinitis is presented. A 41-year-old woman had swelling of the face and upper extremities, associated with headache and fatigue. Radiologic investigations, which included venography, computed tomography and magnetic resonance imaging of the chest, documented the presence of superior vena caval (SVC) obstruction secondary to what appeared to be an intraluminal tumour. The patient underwent SVC resection and reconstruction with a spiral saphenous vein graft under cardiopulmonary bypass and deep hypothermic circulatory arrest. On histopathological examination localized idiopathic fibrosing mediastinitis causing SVC obstruction was diagnosed.     

Reconstruction of the vena cava and of its primary tributaries: a preliminary report

Encouraged by results from our research laboratory and from recent clinical reports, we performed reconstructions of the vena cava and/or its major tributaries on 16 patients (11 males and five females). Ages ranged from 8 to 81 years (median, 38 years). Eight patients had superior vena cava syndrome (benign, six; malignant, two). Two other patients had membranous occlusion of the inferior vena cava; four had iliocaval venous thrombosis; one had excision of the iliac veins for pelvic neurilemmoma; and one had inferior vena cava injury during orthotopic liver transplantation. The superior vena cava was reconstructed with spiral saphenous vein grafts in five patients and with expanded polytetrafluoroethylene in three. One spiral saphenous vein graft and one expanded polytetrafluoroethylene graft required revision; seven of the eight grafts were patent at follow-up, but one bifurcated spiral saphenous vein graft occluded at 3 months. The inferior vena cava and its tributaries were reconstructed with expanded polytetrafluoroethylene in five patients, spiral saphenous vein graft in two, and Dacron in one. At follow-up four of the expanded polytetrafluoroethylene grafts were patent. In contrast, one of the spiral saphenous vein grafts was occluded, and results of imaging studies of the other were inconclusive. Three of the five expanded polytetrafluoroethylene grafts had a concomitant temporary arteriovenous fistula at the groin; two had documented patency at follow-up. At the present time, spiral saphenous vein graft is our first choice for superior vena cava replacement. However, expanded polytetrafluoroethylene grafts are good alternatives and in the abdomen appear to perform better than spiral saphenous vein graft. These clinical results encourage us to perform further caval grafting in selected patients.     

Open surgical and endovascular treatment of superior vena cava syndrome caused by nonmalignant disease

OBJECTIVES: The purpose of this study was to evaluate the role of endovascular and open surgical reconstructions in patients with superior vena cava (SVC) syndrome caused by nonmalignant disease. METHODS: Clinical data from 32 consecutive patients who underwent endovascular or open surgical reconstruction of central veins because of symptomatic benign SVC syndrome between November 1983 and June 2001 were retrospectively reviewed. RESULTS: The study included 17 male and 15 female patients (mean age, 38 years; range, 5-69 years). Presenting symptoms were head fullness (n = 26), dyspnea or orthopnea (n = 23), headache (n = 17), or dizziness (n = 11); physical signs were head swelling (n = 31), chest wall collateral vessels (n = 29), facial cyanosis (n = 18), or arm swelling (n = 17). Etiologic factors included mediastinal fibrosis (n = 19), indwelling catheter (n = 8), idiopathic thrombosis (n = 4), or post-surgery (n = 1). Two patients were heterozygous for factor V Leiden; 1 patient had antithrombin III deficiency. Twenty-nine patients underwent surgical reconstruction with 31 bypass grafts: spiral saphenous vein (n = 20), superficial femoral vein (n = 4), human allograft (n = 1), or expanded polytetrafluoroethylene (ePTFE, n = 6). Eleven patients underwent percutaneous transluminal angioplasty or stenting; 3 primary and 8 secondary endovascular procedures were performed to treat graft stenosis (n = 7) or occlusion (n = 1). There were no early deaths. Five early graft failures in 3 ePTFE grafts and 2 bifurcated vein grafts (thrombosis, n = 4; stenosis, n = 1) were successfully treated with open surgical revision. Over a mean follow-up of 5.6 years (range, 0.4-16.6 years) in surgical patients, 17 additional secondary interventions were performed in 8 patients, 14 endovascular and 3 surgical. Primary, assisted primary, and secondary patency rates of surgical bypass grafts were 63%, 79%, and 85%, respectively, at 1 year, and 53%, 68%, and 80%, respectively, at 5 years. Graft patency was significantly higher in vein grafts compared with ePTFE grafts (P =.02). Mean follow-up after percutaneous transluminal angioplasty or stenting was 3.1 years (range, 1 day-11.7 years). Twelve secondary endovascular interventions were performed in 6 patients (primary group, 3 of 3; secondary group, 3 of 9 grafts in 8 patients) to maintain patency in 11 of 12 reconstructions. Mean follow-up in the entire patient cohort was 5.3 years (range, 0.4-16.6 years). In 79% of patients symptoms had resolved or were significantly improved at last follow-up. CONCLUSIONS: Surgical treatment of benign SVC syndrome is effective over the long term, with secondary endovascular interventions to maintain graft patency. Straight spiral saphenous vein graft remains the conduit of choice for surgical reconstruction, with results superior to those with bifurcated vein and ePTFE. Endovascular treatment is effective over the short term, with frequent need for repeat interventions. It does not adversely affect future open surgical reconstruction and may prove to be a reasonable primary intervention in selected patients. Patients who are not suitable for or who fail endovascular intervention merit open surgical reconstruction.     

Intraoperative duplex monitoring of infrainguinal vein bypass procedures

PURPOSE: The purpose of this study was to evaluate intraoperative duplex scanning of infrainguinal vein bypass grafts to detect technical and hemodynamic problems, monitor their repair, and correlate findings with the incidence of thrombosis and stenosis repair rates within 90 days of operation. METHODS: Color duplex scanning was used at operation to assess vein/anastomotic patency and velocity spectra waveforms of 626 infrainguinal vein bypass grafts (in situ saphenous, 228 grafts; nonreversed translocated saphenous, 170 grafts; reversed saphenous, 147 grafts; alternative [arm, lesser saphenous], 81 grafts) to the popliteal (n = 267 grafts), infrageniculate (n = 323 grafts), or pedal artery (n = 36 grafts). The entire bypass graft was scanned after intragraft injection of papaverine hydrochloride (30-60 mg) to augment graft flow. Vein/anastomotic/artery segments with velocity spectra that indicate highly disturbed flow (peak systolic velocity, >180 cm/sec; spectral broadening; velocity ratio at site, >3) were revised. Grafts with a low peak systolic velocity less than 30 to 40 cm/s and high outflow resistance (absent diastolic flow) underwent procedures (distal arteriovenous fistula, sequential bypass grafting) to augment flow; if this was not possible, the grafts were treated with an antithrombotic regimen, including heparin, dextran, and antiplatelet therapy. RESULTS: Duplex scanning prompted revision of 104 lesions in 96 (15%) bypass grafts, including 82 vein/anastomotic stenoses, 17 vein segments with platelet thrombus, and 5 low-flow grafts. Revision rate was highest (P <.01) for alternative vein bypass grafts (27%) compared with the other grafting methods (reversed vein bypass grafts, 10%; nonreversed translocated, 13%; in situ, 16%). A normal intraoperative scan on initial imaging (n = 464 scans) or after revision (n = 67 scans) was associated with a 30-day thrombosis rate of 0.2% and a revision rate of 0.8% for duplex-detected stenosis (peak systolic velocity, >300 cm/s; velocity ratio, >3.5). By comparison, 20 of 95 bypass grafts (21%) with a residual (n = 29 grafts) or unrepaired duplex stenosis (n = 53 grafts) or low flow (n = 13 grafts) had a corrective procedure for graft thrombosis (n = eight grafts) or stenosis (n = 12 grafts; P <.001). Overall, 8% of patients with bypass grafts underwent a corrective procedure within 90 days of operation. Secondary graft patency was 99.4% at 30 days and 98.8% at 90 days (eight graft failures). CONCLUSION: The observed 15% intraoperative revision rate coupled with a low 90-day failure/revision rate (2.5%) for bypasses with normal papaverine-augmented duplex scans supports the routine use of this diagnostic modality to enhance the precision and early results of infrainguinal vein bypass procedures.     

Benign superior vena cava syndrome: stenting is now the first line of treatment

BACKGROUND: Endovascular repair (EVR) is emerging as first-line treatment for patients with superior vena cava (SVC) syndrome of benign etiology, but data on its durability remain scarce. The aims of this study were to assess the efficacy and durability of EVR and compare results of EVR with open surgical reconstruction (OSR). METHODS: Data from 70 consecutive patients undergoing treatment for benign SVC syndrome between November 1983 and November 2006 were retrospectively reviewed. RESULTS: There were 30 males and 40 females (mean age, 41 years; range, 5-75 years). Etiology included indwelling catheters or pacemaker wires in 35 patients, mediastinal fibrosis in 31, idiopathic thrombosis in 2, hypercoagulable disorder in 1, and postsurgical thrombosis in 1. In 42 patients, OSR was done through a median sternotomy: repair was with spiral saphenous vein in 22, expanded polytetrafluoroethylene (ePTFE) in 13, femoral vein grafts in 6, and human allograft in 1. Fifteen OSRs followed failed EVR interventions. EVR was attempted in 32 patients and was successful in 28 (88%): 19 had stenting, 14 had percutaneous transluminal balloon angioplasty (PTA), 2 had thrombolytic therapy with PTA, and 3 had stenting. All four technical failures subsequently underwent OSR. There were no early deaths in either group. Periprocedural morbidity was 19% after OSR and 4% in the EVR group. Six early surgical graft failures were successfully treated with surgical revision; one restenosis after EVR was restented. During a mean follow-up of 4.1 years (range, 0.1-17.5 years) after OSR, 11 patients underwent 18 secondary interventions. Mean follow-up after EVR was 2.2 years (range, 0.2-6.4 years), and nine patients underwent 21 secondary EVR interventions. Primary, assisted primary, and secondary patency rates of surgical bypass grafts were, respectively, 45%, 68%, and 75% at 3 and 5 years. Primary, assisted primary and secondary patency rates after EVR were 44%, 96%, and 96% at 3 years. Assisted primary patency was significantly higher in vein grafts than in ePTFE grafts (P = .05). Assisted primary and secondary patency was significantly higher in patients undergoing stenting compared with PTA (P = .02). At last follow-up, 93% of patients in both OSR and EVR groups had significant relief from symptoms. CONCLUSIONS: OSR of benign SVC syndrome is effective, with durable long-term relief from symptoms. EVR is less invasive but equally effective in the mid-term, albeit at the cost of multiple secondary interventions, and is an appropriate primary treatment for benign SVC syndrome. OSR remains an excellent choice for patients who are not suitable for EVR or in whom the EVR fails.     

Natural history of infrainguinal vein graft stenosis relative to bypass grafting technique

Purpose: To determine whether the incidence of vein graft stenosis is related to bypass grafting technique and thus modification of postoperative surveillance protocols may be required.Methods: From 1991 to 1996, 338 infrainguinal vein bypasses constructed using in situ (n = 131), reversed (n = 120), nonreversed translocated (n = 48), or spliced/upper extremity vein (n = 39) grafting techniques were evaluated by intraoperative duplex scanning to optimize bypass construction and serially thereafter to detect developing vein graft stenoses. Bypass procedures were performed in 322 patients for critical limb ischemia (83%), claudication (13%), or popliteal aneurysm (4%). Using life-table analysis, graft patency and revision/failure rates were compared relative to grafting technique, need for operative revision, and intraoperative duplex scan results.Results: Three-year primary and secondary graft patency rates were higher (p < 0.001) for in situ bypass grafts (85%/97%) compared with reversed (57%/83%), nonreversed translocated (62%/78%), or alternative (51%/76%) vein bypass grafts. During a mean follow-up interval of 19 months, the incidence of graft revision was higher for reversed saphenous (23%) and alternative (28%) vein bypass grafts compared with in situ (10%) or nonreversed (16%) saphenous vein bypass grafts. Despite a normal intraoperative graft duplex scan, the revision/failure rate of reversed vein grafts was 2.5 times greater than in situ/nonreversed translocated vein conduits (primary patency rate at 3 years, 60% vs 87%, p = 0.009). Bypass grafts modified at operation on the basis of duplex scanning were two times more likely to require postoperative revision than grafts with normal intraoperative scans.Conclusions: The incidence of postoperative graft stenosis and need for revision varies with bypass grafting technique. Reversed vein bypasses and grafts modified at operation may be more prone than in situ vein bypass grafts to develop stenosis and thus require intensive surveillance. Infrainguinal vein graft failure and the need for revision may be reduced by the adoption of bypass grafting techniques that include valve lysis and intraoperative duplex scan assessment. (J Vasc Surg 1997;25:211-25.)     

Surgical reconstruction of iliofemoral veins and the inferior vena cava for nonmalignant occlusive disease

PURPOSE: Venous reconstructions are rarely performed, and factors affecting long-term results of bypass grafts implanted in the venous system are not well defined. In this report we updated our experience. METHODS: The clinical data of all patients who underwent venous reconstruction for iliofemoral or inferior vena caval (IVC) occlusion due to nonmalignant disease between January 1985 and June 1999 were retrospectively reviewed. Patients were classified, and outcomes were compared according to the guidelines of the Joint Vascular Societies. RESULTS: Forty-two patients, 23 males and 19 females (mean age, 40 years; range, 16-81), underwent 44 venous reconstructions. Thirty-six patients had limb swelling or venous claudication, 38 had pain, and 14 had healed or active ulcers. The cause of obstruction was congenital in two and acquired in 40 (deep vein thrombosis, 25; trauma, 5; retroperitoneal fibrosis, 4; IVC occlusion devices, 4; others, 2). Eighteen patients underwent saphenous vein crossover grafts (Palma procedure), 17 had expanded polytetrafluoroethylene (ePTFE) grafts implanted (femorocaval, 8; iliocaval, 5; crossfemoral, 3; cavoatrial, 1), 6 patients had spiral vein grafts (5 iliac/femoral and 1 cavoatrial), and 1 underwent femoral vein patch angioplasty. Clinical follow-up averaged 3.5 years (median, 2.5), and graft follow-up with imaging studies averaged 2.6 years (median, 1.6). Seven patients were lost to follow-up. The secondary 3-year patency rate for all reconstructions was 62%. Palma procedures had a 4-year patency rate of 83%. The secondary patency rate of iliocaval and femorocaval ePTFE bypass grafts at 2 years was 54%. The secondary patency was lower in patients with an arteriovenous fistula (P =.023). All ePTFE grafts had a 45% patency rate at 2 years, not significantly different from saphenous vein grafts (83%, P =.16). Clinical scores improved with graft patency (median, 0.0 vs 1.5; P =.044). CONCLUSIONS: Venous reconstructions for iliofemoral or IVC obstruction offer 3-year patency rates of 62%. The Palma procedure with autologous saphenous vein had the best long-term patency, whereas long-term success with ePTFE was moderate. The use of an arteriovenous fistula to improve graft patency remains controversial.     

Autogenous composite vein bypass graft for infrainguinal arterial reconstruction

PURPOSE: Lower extremity arterial reconstruction in the absence of adequate greater saphenous vein remains a challenging problem in contemporary vascular practice. The purpose of this review is to evaluate the long-term results of autogenous composite vein grafts used for infrainguinal arterial bypass grafting. METHODS: We retrospectively evaluated a prospective vascular registry and reviewed inpatient and office records. RESULTS: From June 1983 to September 1999, 165 autogenous composite vein infrainguinal bypass grafts were performed in 154 patients (87 men, 67 women; mean age, 69 years). The mean follow-up was 25 months (range, 3-147). Patients had the usual risk factors, including a 30% incidence of prior coronary bypass grafting. Forty-eight percent of bypass grafts were performed after failed previous reconstructions, and 90% were performed for limb salvage. The conduits were comprised of 2 segments (75%), 3 segments (23%), and 4 segments (2%). The distal anastomosis was at the popliteal level in 17% and the tibial/pedal level in 83%. The 30-day operative mortality rate was 1.8%. Perioperative graft failure (< 30 days) occurred in 18 bypass grafts (11%), resulting in early amputation (< 30 days) in 1.2%. The overall 5-year cumulative patency rates were 44% +/- 5% for primary patency, 63% +/- 5% for primary-assisted patency (PAP), and 65% +/- 5% for secondary patency (SP). A high revision rate for stenosis or thrombosis was required during follow-up to maintain patency of the grafts (27%). Limb salvage was 81% +/- 5% at 5 years. Primary reconstructions with composite vein fared significantly better than secondary reconstructions (SP 76% vs 54% at 5 years, P <.01). Arm vein composites showed superior patency compared with greater saphenous vein composites (SP 79% vs 61% at 5 years, P <.05). CONCLUSIONS: Infrainguinal reconstruction with autogenous composite vein results in durable graft patency and limb salvage rates in patients with few alternatives for revascularization. Intensive graft surveillance with aggressive graft revision is necessary to achieve these results.     

Reconstruction of the superior vena cava: Benefits of postoperative surveillance and secondary endovascular interventions

Purpose: Superior vena cava (SVC) reconstructions are rarely performed; therefore the need for surveillance and the results of secondary interventions are unknown. Methods: During a 14-year period 19 patients (11 male, 8 female; mean age 41.9 years, range 8 to 69 years) underwent SVC reconstruction for symptomatic nonmalignant disease. Causes included mediastinal fibrosis (n = 12), indwelling foreign bodies (n = 4), idiopathic thrombosis (n = 2), and antithrombin III deficiency (n = 1). Spiral saphenous vein graft (n = 14), polytetrafluoroethylene (n = 4), or human allograft (n = 1) was implanted. Results: No early death or pulmonary embolism occurred. Four early graft stenoses or thromboses (spiral saphenous vein graft, n = 2, polytetrafluoroethylene, n = 2) required thrombectomy, with success in three. During a mean follow-up of 49.5 months (range, 4.7 to 137 months), 95 imaging studies were performed (average, five per patient; range, one to 10 studies). Venography detected mild or moderate graft stenosis in seven patients; two progressed to severe stenosis. Two additional grafts developed early into severe stenosis. Four of 19 grafts occluded during follow-up (two polytetrafluoroethylene, two spiral saphenous vein graft). Computed tomography failed to identify stenosis in two grafts, magnetic resonance imaging failed to confirm one stenosis and one graft occlusion, and duplex scanning was inconclusive on graft patency in 10 patients. Angioplasty was performed in all four patients with severe stenosis, with simultaneous placement of Wallstents in two. One of the Wallstents occluded at 9 months. Repeat percutaneous transluminal angioplasty was necessary in two patients, with placement of Palmaz stents in one. Only one graft occlusion and one severe graft stenosis occurred beyond 1 year. The primary, primary-assisted, and secondary patency rates were 61%, 78%, and 83% at 1 year and 53%, 70%, and 74% at 5 years, respectively. Conclusions: Long-term secondary patency rates justify SVC grafting for benign disease. Postoperative surveillance with contrast venography is indicated in the first year to detect graft problems. Endovascular techniques may salvage and improve the patency of SVC grafts. (J Vasc Surg 1998;27:287-301.)     

Superficial femoral vein: A useful autogenous harvest site

Purpose: The purpose of this study was to present the use of superficial femoral vein (SFV) as an arterial bypass graft when ipsilateral saphenous vein is inadequate.Methods: Data collected prospectively were reviewed on 24 patients (25 limbs) who had an arterial bypass with SFV performed by the authors between January 1, 1988, and December 31, 1991. Many anatomic sites are represented. The indication for operation was gangrene in six patients, severe rest pain or ulceration in 11, mild to moderate rest pain in six, and graft infection in two. There had been 42 previous reconstructions in these 25 limbs.Results: There has been surprisingly little long-term disability from removal of the SFV. Immediately after surgery four limbs developed acute venous congestion that resolved quickly. Twenty percent of the patients with patent grafts have continued to wear a pressure gradient stocking for swelling 1 year after surgery, one patient requires additional pressure to control induration. All grafts were patent at 30 days. During a mean follow-up of 2 years, three grafts have required revision, and three have occluded. Stenosis did not develop at valve sites or in the body of the SFV portion of any of these grafts. There were two deaths from heart-related causes in the first 30 days after operation. Life-table analysis for the whole group shows a primary patency rate of 66% (SE 10.3%) and an assisted patency rate of 80% (SE 8.7%) at 2 years.Conclusions: SFV harvest is well tolerated, even in the absence of ipsilateral saphenous vein. The magnitude of the operation is greater than saphenous vein harvest but yields a thick-walled vein of excellent diameter with many applications as an autogenous conduit, particularly where a large-diameter graft is indicated. (J VASC SURG 1994;20:947-52.)     

Surgical treatment of superior vena cava syndrome (SVC)

SVC syndrome is occurred by the occlusion or stenosis of the superior vena cava secondary to malignant mediastinal tumor. Up to this report, surgical intervention has been thought to be difficult. Recently, extent of the tumor has been diagnosed exactly by CT scan, NMR, and angiography. Several cases undergoing complete resection of the tumor with the technique of vascular surgery have been reported. During the past 10 years, we have experienced 21 cases of SVC syndrome. 16 patients had operations and 5 patients had radiation or chemotherapy. The methods of operations were as follows: complete resection of the tumor 1, complete resection of the tumor and reconstruction of SVC 2, subtotal resection of the tumor and reconstruction of SVC 2, bypass of SVC only 5, extra-anatomical bypass 3. PTFE grafts were placed between right subclavian vein and SVC or left subclavian vein and right atrium. Extra-anatomical bypass were placed between jugular vein and femoral vein. PTFE bypass graft provides effective treatment for SVC obstruction with immediate and long term relief of SVC syndrome.     

Superior vena cava syndrome: relief with a modified saphenojugular bypass graft

Superior vena cava (SVC) syndrome is a disabling and potentially life-threatening complication. SVC revascularization can be achieved by means of endovascular or direct surgical reconstructions. In the patient on whom we report, these two options were not possible, and a peripheral venous bypass grafting procedure was done with a technical innovation. Right upper-extremity swelling developed in a 55-year-old woman after radiation therapy for lung carcinoma. A left subclavian vein Port-A-Cath induced extensive thrombosis of the left innominate, axillosubclavian, and jugular veins. She was referred to our institution with very symptomatic SVC syndrome after two failed endovascular interventions. The occlusion of both innominate veins and chronic thrombus extending into the left axillosubclavian and internal jugular veins was confirmed by means of a venogram. A third endovascular attempt failed. The presternal skin had severe radiation-induced damage precluding direct SVC reconstruction. A bypass grafting procedure from the right internal jugular to the femoral vein was performed with spliced bilateral greater saphenous veins tunneled inside an externally supported expanded polytetrafluoroethylene graft. Postoperatively, the patient had no symptoms, and graft patency was confirmed by means of duplex ultrasound scanning. A saphenojugular bypass grafting procedure can offer prompt and durable relief of SVC syndrome when endovascular or direct surgical reconstructions are not possible. This rarely used peripheral venous bypass grafting procedure was modified by tunneling the vein graft inside an externally supported polytetrafluoroethylene graft to prevent kinking or compression.     

Der kniegelenküberschreitende femoropopliteale Bypass mit der glutaral- dehydfixierten denaturierten menschlichen Nabelschnurvene (Dardik-Biograft) – Erfahrungen mit der modifizierten Prothese

Greater saphenous vein is the preferred graft material for below knee bypass. In the case of absent autologous vein, modified human umbilical vein (HUV) is used less frequently than synthetic grafts. To assess long-term graft patency and degenerative changes, the second generation of modified human umbilical vein graft was chosen for below knee femoropopliteal bypass when autologous vein was not available. Fifty-five below knee femoropopliteal bypasses were performed in 54 patients. In most cases the operation was performed for critical leg ischemia, disabling claudication, or severe acute ischemia. In 25% of patients, previous ipsilateral bypass had been performed. In no case was ipsilateral greater saphenous vein suitable. Early graft thrombosis occurred in 30.9% of patients. In 65%, revision with thrombectomy was successful. Primary (secondary) patency rate was 55.2% (75 .5%) with a limb salvage rate of 88.3% after 48 months. After a maximal follow-up of 57.4 months, duplex scanning could not demonstrate significant aneurysmal graft degeneration. Good graft patency and duplex scan results justify continued use of the second generation of modified human umbilical vein in peripheral bypass surgery when autogenous vein is not suitable.     

Internal mammary artery graft at reoperation: risks, benefits, and methods of preservation

To determine the effect of a prior internal mammary artery (IMA) graft on coronary artery bypass reoperation (CABR), we reviewed our experience with 410 consecutive patients: 313 received only saphenous vein grafts at initial coronary artery bypass grafting (CABG), and 97 received at least one IMA graft at CABG. Cardiac catheterization data before CABG were available in 110 patients (56 received only saphenous vein grafts, 54 received at least one IMA graft), allowing comparison of left ventricular function at CABG and CABR. Injury of the IMA graft occurred in 5 patients (1 death), but presence of an IMA graft was not an independent predictor of morbidity or mortality. Overall, the incidences of complications and deaths were higher in patients with saphenous vein grafts than in patients with IMA grafts, though not significantly so. Internal mammary artery grafts better preserved cardiac function: patients with IMA grafts had worse left ventricular function before CABG but better left ventricular function before CABR than patients with saphenous vein grafts. Left ventricular function deterioration from before CABG to before CABR was significantly less in patients with IMA grafts. We conclude that the risk of CABR is not increased by a previously constructed IMA graft and that left ventricular function is better preserved at CABR when an IMA graft was constructed at the initial operation.     

A prospective randomized trial comparing vein with polytetrafluoroethylene in above-knee femoropopliteal bypass grafting

OBJECTIVE: Despite many clinical studies, there is still uncertainty as to whether venous material is superior to polytetrafluoroethylene for femoropopliteal reconstruction proximal to the knee joint. Supported by early satisfactory results with thin-walled, stretched polytetrafluoroethylene for suprageniculate bypass grafts, a prospectively randomized clinical trial was designed to evaluate the effectiveness of reversed saphenous vein in comparison with that of polytetrafluoroethylene in above-knee arterial reconstruction. METHODS: In a 3-year period, 151 above-knee femoropopliteal bypass graft operations were performed in 136 patients (77 male, 59 female). The indication for operation was severe claudication in 120 cases, rest pain in 20 cases, and ulceration in 11 cases. For the bypass graft, a reversed saphenous vein was used in each of 75 cases, and a polytetrafluoroethylene prosthesis was used in each of 76 cases. Preoperative risk factors were diabetes (24%), a history of myocardial infarction (23%), and current status with respect to smoking (74%). There was no hospital mortality; 5% of patients had minor postoperative complications. RESULTS: After 2 years, the primary patency was 83% for saphenous vein and 67% for polytetrafluoroethylene (P =.065); the secondary patency was 83% for saphenous vein and 77% for polytetrafluoroethylene (P =.298). During a follow-up period of 2 years, we found no statistically significant difference in primary and secondary patency between saphenous vein and polytetrafluoroethylene. We found no predictive factor for occlusion of either bypass graft. CONCLUSION: The use of polytetrafluoroethylene above the knee is a reasonable alternative in femoropopliteal bypass grafting that is associated with acceptable short-term patency rates.     

Axillopopliteal bypass for limb salvage.

Forty-one axillopopliteal bypass grafts have been placed in 30 patients for limb salvage in the past 12 years. The mean patient age was 65.6 years; 8 were women; 19 smoked; and six had diabetes. Sixteen grafts were straight axillopopliteal bypass grafts, and 25 were sequential axillopopliteal bypass grafts. Cumulative life-table primary patency rates at 1, 2, and 3 years were 70%, 56%, and 43%, respectively; secondary patency rates were 73%, 57%, and 50%, respectively. Corresponding limb salvage rates were 86%, 69%, and 69%, respectively. Ringed polytetrafluoroethylene (PTFE) graft patency at 3 years was 61% versus 40% for unsupported PTFE grafts (p = 0.35). Ringed PTFE axillofemoral grafts with sequential femoropopliteal saphenous vein grafts had a 3-year patency of 67%. Graft patency was restored in 25% of occluded grafts by thrombectomy and in 80% of occluded grafts by thrombectomy with graft revision (p = 0.21). Cumulative 3-year patient survival was 48%. The 30-day operative mortality rate was 20%; patients operated on for graft infection had a 30-day operative mortality rate of 36%. The data support the use of axillopopliteal bypass for limb salvage when standard revascularization techniques are contraindicated. Long-term patency is enhanced by use of externally supported PTFE and sequential femoropopliteal saphenous vein.     

Utility of inframalleolar arterial bypass grafting

Sixty-five patients received 68 inframalleolar arterial grafts for severe rest pain, foot ulceration, or gangrene. Patients were elderly with an average age of 68 years (median 72); most had several operative risk factors. Reversed saphenous vein grafts were used early, but most conduits were in situ vein grafts. The recipient vessel was the dorsalis pedis artery in 39 patients, the posterior tibial in 27, and tarsal branches in two. Preoperative angiography was routinely performed with biplanar and digital arterial techniques, but in nearly a third a suitable bypass vessel was not identified preoperatively. When vessels were identified there was usually only a single patent artery suitable for bypass grafting below the knee. There were five postoperative deaths (7.6%). Eight grafts (11%) required early revision for thrombosis or retained valve, and six were salvaged and remained patent. Poor vein quality appeared responsible for the two early failures. Six late graft occlusions occurred from 4 to 39 months (mean 14 months). Three of these patients had no recurrence of their ulceration, but two required amputation, and one has continued rest pain. One additional amputation was required in a patient with a patent graft. Eleven late deaths (16%) occurred (nine with patent grafts) primarily of cardiac causes.     

Therapeutic options for acute thrombosed in situ saphenous vein arterial bypass grafts

Abnormalities of the conduit, outflow tract, and graft hemodynamics are important elements in the mechanism of vein graft thrombosis, and their role must be defined when planning reoperation. In a consecutive series of 353 in situ saphenous vein bypass graftings performed for occlusive or aneurysmal disease, graft thrombosis occurred in 18 (5%) patients during the perioperative period and unexpectedly in 14 (4%) patients after discharge from the hospital. Assessment of graft hemodynamics (calculation of blood flow velocity) before thrombosis was helpful in predicting success after graft revision. Five grafts with known low flow (systolic flow velocity less than 40 cm/sec) that thrombosed in the perioperative period did not have patency restored by thrombectomy or graft replacement unless the outflow tract was also modified. If poor quality vein or technical error was the mechanism of thrombosis, translocation of the distal anastomosis to a proximal arterial segment (n = 4), and graft replacement with normal autologous vein (n = 5) or prosthetic graft (n = 1) were successful in relieving limb ischemia. After discharge from the hospital, unexpected graft thrombosis was successfully treated by a variety of secondary procedures (thrombolysis/thrombectomy, autologous or prosthetic replacement) if prior surveillance with duplex scanning demonstrated low flow as a result of graft stenosis (n = 7) or normal graft hemodynamics (n = 5). Prosthetic replacement of two failed bypass grafts with low flow caused by diseased outflow did not remain patent. Scrutiny of graft hemodynamics and limb arterial anatomy for alternative outflow sites can identify patients likely to benefit from reoperation after in situ bypass thrombosis.