Upper extremity arterial bypass distal to the wrist.

Seventeen arterial bypass procedures distal to the wrist have been performed in 13 men and two women at the Oregon Health Sciences University during the past 9 years. Ten patients had traumatic true or false aneurysms of the ulnar artery with digital embolization. Five patients with end-stage renal disease had severe hand and finger ischemia manifested by rest pain or digital ulceration resulting from widespread forearm and hand arterial occlusions. Patients with aneurysms of the ulnar artery underwent excision and reversed autogenous vein grafting (n = 11) from the distal ulnar artery in the forearm to the superficial palmar arch. All the patients with end-stage renal disease had severe occlusive disease of the forearm and hand arteries and underwent a variety of procedures including radial-radial bypass (n = 2), ulnar-ulnar bypass (n = 2), radial-radial bypass with takedown of a Brescia-Cimino fistula (n = 1), and brachial-radial bypass (n = 1). High-quality upper extremity and magnification hand arteriography was essential for operative planning and was available on all patients. Distal saphenous vein from the ankle or foot was the graft source in 16 procedures and basilic vein the source in one procedure. All operations were performed with headlight illumination, optical loupes, fine sutures, and microvascular instruments. There were no operative deaths or major complications. The mean follow-up period was 14 months. Of the 17 grafts, 16 remained patent by clinical and vascular lab criteria. The single occlusion occurred in an ulnar aneurysm bypass and was accompanied only by mild intolerance to cold.(ABSTRACT TRUNCATED AT 250 WORDS)     

Result of bypass grafting for upper limb ischemia

Bypass grafting in the treatment of upper extremity ischemia is required far less frequently than it is in the lower extremity. The present study was undertaken to evaluate functional results and long-term patency of such grafts. Between 1978 and 1984, 33 bypass grafts were performed to relieve hand and forearm ischemia in 27 patients. The indication for bypass was neglected trauma (violent or iatrogenic) in 12 cases, primary arteriopathy in nine patients, and vascular complications of thoracic outlet compression in six patients. A reversed saphenous vein graft was used in 22 cases, and polytetrafluoroethylene was used in the remaining 11 procedures. Proximal anastomoses were from the aortic arch (one), subclavian artery (five), axillary artery (11), carotid artery (seven), and brachial artery (nine). Distal reconstructions were to the subclavian (three), axillary (three), brachial (16), radial (four), ulnar (two), and interosseous (five) arteries. Complete pre- and postoperative Doppler pressure measurements were available in 19 cases and demonstrated a significant increase in forearm systemic pressure index, from 0.51 before bypass to 0.86 postoperatively (p less than 0.001). Finger systolic pressure measurement in 10 patients also showed a significant improvement after operation. Follow-up of 31 grafts from 6 to 72 months (mean, 35.5 months) revealed an overall patency rate of 73% at 2 years and 67% at 3 years. Similar to lower extremity revascularization, more proximal grafts fared better; the 2-year patency rate was 83% for grafts at or above the brachial artery but only 53% for bypass distal to the brachial bifurcation. Major amputation was not required in any case, even after graft occlusion.     

Autogenous arterial bypass grafts: durable patency and limb salvage in patients with inframalleolar occlusive disease and end-stage renal disease

OBJECTIVE: The purposes of this study were to determine whether autogenous arterial grafts to distal pedal arteries improve the patency of grafts and limb salvage in patients with end-stage renal disease and nonhealing ischemic wounds and to better define the indications for autogenous arterial grafts. DESIGN: A review of consecutive patients with end-stage renal disease undergoing autogenous arterial grafts from 1994 through 1999 was carried out. The setting was a university hospital. All 11 patients with end-stage renal disease and nonhealing, ischemic wounds (stage IV SVS-ISCVS classification) undergoing autogenous arterial grafting from 1994 to 1999 were evaluated. Noninvasive studies confirmed inadequate perfusion pressures in all patients. Pre-bypass arteriography identified no major arteries patent at the level of the malleolus, with reconstitution of only a distal or branch pedal or plantar vessel less than 1 mm in diameter. Five patients with patent tibial vessels to just above the ankle underwent bypass surgery with autogenous arterial grafts alone. Six patients also had proximal occlusive disease that required grafts longer than the autogenous arterial grafts; in each of these six patients, an autogenous vein graft proximal to the autogenous arterial graft was placed through use of a composite technique. Inflow was from the common femoral artery in one patient, the popliteal artery in five patients, and a tibial artery in five patients. Outflow was to the medial plantar artery in five patients, the distal dorsalis pedis artery in three patients, the lateral plantar artery in two patients, and the superficial arch in one patient. The conduit was the subscapular artery in four patients, the deep inferior epigastric artery in four patients, the superficial inferior epigastric artery in two patients, and the radial artery in one patient. The main outcome measures were assisted primary graft patency and functional limb salvage rate. RESULTS: Follow-up ranged from 6 to 63 months (mean, 20 months); graft patency was determined by means of duplex scanning. All 11 patients are alive, and nine grafts are patent, including three after revision for graft stenosis. Assisted primary patency was 82% at 3 years. All nine patients with patent grafts remained ambulatory and had healed wounds or limited forefoot amputations. CONCLUSION: Autogenous arterial grafts were effective in treating limb-threatening ischemia in patients with end-stage renal disease and inframalleolar arterial insufficiency. Graft patency and limb salvage rates were higher than those reported for autogenous vein graft in these patients. Autogenous arterial grafting may therefore prove to be an effective alternative to autogenous vein grafting in selected patients.     

Emerging role of endovascular grafts in complex aortoiliac occlusive disease

BACKGROUND: Aortobifemoral bypass is the standard therapy for complex aortoiliac occlusive disease. The purpose of this study was to examine the use of endovascular grafts as an alternative to aortobifemoral bypass in patients with advanced aortoiliac occlusive disease at high risk. METHODS: Endovascular grafts were placed in 23 limbs in 22 patients with TransAtlantic Inter-Society Consensus document (TASC) type C and D lesions. All procedures were performed in the operating room, and images were obtained with portable digital fluoroscopy. Surgical exposure of the ipsilateral common femoral artery was performed to enable safe closure of 9F to 12F sheath sites and to facilitate ipsilateral interventions in the distal external iliac artery. Concomitant infrainguinal outflow procedures were performed in 6 patients. RESULTS: Twenty of 22 patients were men; mean patient age was 63.2 +/- 3.2 years. Indications for intervention were rest pain in 12 of 23 limbs and tissue loss in 9 of 22 limbs. Risk factors included hostile abdomen or pelvis in 8 patients, coronary artery disease in 11 patients, end-stage renal disease in 3 patients, and severe chronic obstructive pulmonary disease in 3 patients. Each patient received a mean of 1.6 grafts. Initial technical success was 95.2%, with one technical failure. There was no 30-day mortality. All patients experienced at least one grade improvement per Society for Vascular Surgery reporting standards. Primary patency at 24 months was 84.2% +/- 8.0%, with a limb salvage rate of 95.3% +/- 5.0%. Mean (+/- SD) ankle brachial index improved from 0.49 +/- 0.22 to 0.87 +/- 0.26 (P <.001). CONCLUSION: Endovascular grafting to treat advanced aortoiliac occlusive disease can be accomplished with good clinical outcome and acceptable short-term patency. This endovascular technique can be a viable alternative to conventional surgical revascularization in patients with advanced aortoiliac occlusive disease at high risk.     

Realistic expectations for pedal bypass grafts in patients with end-stage renal disease

Purpose: Limb-threatening ischemia in patients with end-stage renal disease (ESRD) represents a challenging clinical problem. Multiple series have shown the inferior limb salvage rate for femoropopliteal or femorotibial bypass grafts in this group. This outcome study is restricted to those patients with ESRD who require pedal bypass grafts for attempted limb salvage. Methods: Between December 1, 1990, and December 31, 1997, 34 patients with ESRD underwent pedal bypass grafting on 41 limbs. This review explores the patient and bypass graft outcomes and their relationships to typical risk factors. Results: The average age in the study was 64 years (range, 39 to 85 years). Twenty patients (59%) were men, 31 (91%) had diabetes, 32 (94%) were hypertensive, and 28 (82%) had coronary artery disease, but only 10 patients (29%) were smokers. All the patients were undergoing dialysis except 2 patients with functioning renal transplants. All bypass grafting procedures were performed for limb salvage. The follow-up periods ranged from 1 to 84 months (average, 13.5 months). With life-table analysis, the cumulative assisted primary patency rate was 62% at 1 year and 62% at 2 years. The limb salvage rate was 56% and 50% at 1 and 2 years, respectively. All the patients who were seen with heel gangrene had early limb loss or died. Seven of the 16 amputations (44%) were performed despite patent bypass grafts. Ten of the 16 amputations (63%) occurred within 3 months of the surgery. The survival rate was 64% at 1 year and 52% at 2 years. After the bypass graft procedure, the mean ankle brachial index and the toe pressure rose from 0.48 to 1.05 and 18 to 86, respectively. Conclusion: Modest success can be expected with pedal bypass grafts in patients with ESRD, with most failures occurring in the first 3 months. Limb salvage rates lag behind graft patency rates because of progressive necrosis despite a hemodynamically functioning bypass graft. Heel gangrene is a strong predictor for a negative outcome. Lastly, overall patient survival rates are poor but comparable with the rates of other patients with ESRD. (J Vasc Surg 1998;28:976-83.)     

Limb salvage in end-stage renal disease (ESRD). Comparison of modern results in patients with and without ESRD

We reviewed our experience with femoral-popliteal-tibial reversed vein bypasses performed for limb salvage in 226 patients without and 19 patients with end-stage renal disease (ESRD). While 18-month primary patency rates were comparable (85% and 89%), limb salvage was significantly lower (76% vs 95%) in patients with ESRD. Five amputations in the ESRD group were required for nonhealing, large foot ulcers in diabetic patients despite patent arterial bypass while only five of 13 amputations in patients without ESRD were required in the presence of patent grafts. The need for major amputation despite patent bypass in diabetic patients with ESRD who have extensive foot gangrene or ischemic ulceration occurs sufficiently often that we recommend primary amputation be considered in these patients without regard to possible vascular reconstruction.     

Angioplasty of the distal anastomosis und runoff arteries of occluded infrainguinal bypasses

BACKGROUND: We investigated the clinical results of transluminal angioplasty performed through infrainguinal bypass grafts for stenotic or occlusive lesions at the distal anastomosis and/or in the runoff arteries in high risk patients and the influence of different parameters on limb salvage, primary and secondary patency rate. PATIENTS AND METHODS: Between January 2001 and March 2005 we performed 49 transluminal angioplasties on stenotic or occlusive lesions at the distal anastomosis and/or in the runoff arteries in 49 (16 female, 23 male, mean age 71.1 years) patients with occluded infrainguinal bypass. 20 angioplasties occurred in the runoff arteries, 5 at the distal anastomosis and 24 at both locations at a median of 11.3 months (range 2-85 months) after infrainguinal bypass grafting). 20 procedures were on popliteal artery above the knee, 21 below the knee and 8 on crural arteries. RESULTS: Kaplan-Meier analysis showed a cumulative limb salvage of 87.6 and 76.4 % after 6 months and two years, respectively. Patients with gangrenous lesions had a 5 times higher risk of amputation (Cox-regression model). Primary and secondary patency rates were at 6 months 85.1 and 91.1 % respectively and were at one year 73.3 and 78.8 % respectively. Patients with end stage renal disease were in 4 times hazard to primary occlusion and patients with gangrenous lesions 5 times to secondary occlusion (Cox-regression model). CONCLUSION: Even if the long-term results of angioplasty on stenotic or occluded lesions at the distal anastomosis and/or in the runoff arteries are inferior to the results of surgical revisions reported in literature, angioplasty in high risk patients with absence af a vein may be the first line alternative intervention for limb salvage.     

Early experience with popliteal to infrapopliteal bypass for limb salvage

In an attempt to improve graft patency and limb salvage in patients with isolated tibial vessel and/or popliteal-tibial vessel occlusive disease, bypass grafts from the popliteal or distal superficial femoral artery to infrapopliteal arteries were used in patients requiring bypass for limb salvage. During a 2 1/2-year period, 23 patients with patent axial vessels and hemodynamically normal inflow to the level of the knee underwent such bypasses. Cumulative graft patency and limb salvage rates at 31 months were 84% and 70%, respectively. Five of the six patients who required below-knee amputation did so because of progressive gangrene in the presence of a patent bypass. Short bypasses between the popliteal and infrapopliteal arteries can significantly contribute to limb salvage in patients with tibial vessel occlusive disease and may be particularly useful in patients with saphenous veins too short for longer bypasses.     

Results of infrainguinal bypass for limb salvage in patients with end-stage renal disease

Limb salvage in patients with end-stage renal disease (ESRD) is complicated by the diffuse, obstructive, calcific arteriopathy that makes anastomotic technique especially critical. Furthermore, decreased resistance to infection and impaired wound healing produced by host-factor deficiencies such as diabetes mellitus, hypoalbuminemia, uremia, and immunosuppression produce additional obstacles to successful limb salvage. This report summarizes our experience with distal arterial bypass procedures in these patients. A total of 32 bypass procedures were performed for limb salvage in 24 patients (17 diabetic) during a period of 5 years. The operative mortality rate was 6%. During the same period, 635 infrainguinal bypass procedures were performed by the in situ technique in patients without ESRD. Primary bypass patency was comparable in both groups at 24 months (92% vs 90%). In the group with ESRD, overall limb salvage was 83% at 2 years. Life-table analysis of bypass patency and limb salvage was thought not to be appropriate in the population with ESRD beyond 2 years because of the increased mortality rate (38%; 9/24) during this interval. It is important that limb salvage was achieved in diabetic patients with ESRD in the presence of extensive foot gangrene or ischemic ulceration. Revascularization should be considered strongly for limb salvage in all patients in this difficult population.     

Analysis of Endovascular Graft Treatment for Aortoiliac Occlusive Disease: What Is Its Role Based on Midterm Results?

OBJECTIVE: To analyze the authors' midterm results (up to 4 years) using endovascular grafts to treat aortoiliac occlusive disease in patients with limb-threatening ischemia. SUMMARY BACKGROUND DATA: Endovascular grafts are being used to manage some aortoiliac lesions formerly treated by aortofemoral or extraanatomic bypass grafts. However, widespread acceptance of these new grafts depends on their late patency and clinical utility. METHODS: Between January 1993 and December 1997, 52 patients with aortoiliac occlusive disease were treated with endovascular grafts. The primary indication for treatment was gangrene or ulceration in 42 patients (81%) and rest pain in 10 patients (19%). Sixteen patients had symptomatic contralateral limbs that were also treated, and 27 (52%) patients required a synchronous infrainguinal bypass. Results up to 4 years were evaluated by life table analysis. RESULTS: Forty-six (88%) of the patients had complete follow-up of 3 to 57 months (median 22 months). Six patients were lost to follow-up at a mean of 20 months after surgery. The 4-year primary and secondary patency rates for the endovascular grafts were 66.1% and 72.3% respectively. Six patients required a major amputation, and the limb salvage rate was 88.7%. Four-year patient survival was 37%, with 23 patients dying during this follow-up period. CONCLUSIONS: Endovascular grafts can often be used when conventional procedures are contraindicated or technically impractical. These grafts are a valuable alternative to extraanatomic and aortofemoral bypasses in high-risk patients with aortoiliac occlusive disease and critical ischemia.     

Descending thoracic aorta to iliofemoral artery bypass grafting: A role for primary revascularization for aortoiliac occlusive disease?

Purpose: Bypass grafts that originate from the descending thoracic aorta to the iliac or femoral arteries are well described but are not commonly used as primary procedures, and the long-term results remain unknown. A 15-year experience with 50 descending thoracic aorta to iliofemoral artery bypass grafts for aortoiliac occlusive disease is the basis of this report. Methods: From January 1983 to December 1997, patients who underwent bypass grafting procedures from the descending thoracic aorta to the iliac or femoral arteries were identified. Surgical indications, morbidity and mortality rates, primary and secondary patency rates, limb salvage rates, and survival rates were determined. Results: Fifty descending thoracic aorta to iliofemoral artery bypass grafting procedures were performed—24 (48%) for severe claudication, 22 (44%) for rest pain, and 4 (8%) for ischemic ulceration. A primary procedure was performed in 31 patients (62%) for complete occlusion (21 patients) and severe atherosclerotic disease (10 patients) of the infrarenal aorta. The indications for 19 secondary revascularizations (38%) were prior aortic or extra-anatomic graft failure in 17 cases and aortic graft infection in 2 cases. The follow-up periods ranged from 1 to 150 months (mean, 39 months). The cumulative life-table 5-year primary patency, secondary patency, limb salvage, and survival rates were 79%, 84%, 93%, and 67%, respectively. An improved patency trend was observed for patients who underwent operation for severe claudication as compared with limb-threatening ischemia (92% and 69%; P = .07). However, there was no difference between primary and secondary operations in primary patency rates (81% and 79%; P = NS) or survival rates (72% and 62%; P = NS). Conclusion: Descending thoracic aorta to iliofemoral artery bypass grafting has excellent overall long-term results. These results support its more liberal use for primary revascularization, especially for patients with severe atherosclerotic disease or complete occlusion of the infrarenal aorta. (J Vasc Surg 1999;29:249-58.)     

剖解外腋—股,股—股动脉旁路移植术治疗主髂动脉闭塞症

目的 探讨剖解外腋－股、股－股动脉旁路移植术治疗主髂动脉闭塞症的疗效。方法 采用解剖外旁路移植术治疗主骼动脉闭塞症患者３２例。１８例腹主动脉或两侧髂动脉闭塞者采用腋－股动脉旁路术,其中２例为腋－两股动脉旁路术;１４例单侧髂动脉闭塞者采用股－对侧股动脉旁路术。采用腋－肌动脉旁路的患者,术中８例用真丝人造血管移植,１０例四氟乙烯（Ｇｏｒｅ－Ｔｅｘ）人造血管;股－股动脉旁路术中６例用真丝人造血管移植,１     

Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs

PURPOSE: The long-term patency for infrapopliteal bypass grafting with prosthetic material is less than optimal. Our experience demonstrates a 40% patency at 2 years for these grafts. Several adjuvant techniques have been developed to improve patency rates, two of which are a remote distal arteriovenous fistula and the creation of a distal vein cuff. This study summarizes our experience with these two techniques. METHODS: Between 1987 and 1998, 107 bypass graftings were performed to the below-knee popliteal or tibial vessels with the use of polytetrafluoroethylene. One group (48 bypass grafts) had polytetrafluoroethylene with adjuvant distal arteriovenous fistula (DAVF), and a second group (59 bypass grafts) was reconstructed with a distal vein cuff (DVC). The type of bypass grafting that was performed was based on surgeon experience and preference. Indications and demographics were similar in the two groups. All patients underwent the operation for limb-threatening ischemia, including gangrene (DAVF, 23%; DVC, 9%), ulceration (DAVF, 27%; DVC, 51%), and rest pain (DAVF, 50%; DVC, 40%). RESULTS: The primary patency rate was 48% and 38% at 3 years for DAVF and DVC, respectively. Secondary patency was 48% and 47% at 3 years, with limb salvage rates of 76% and 92% for DAVF and DVC, respectively (P <.05). Attempted thrombectomy without continuation of patency was undertaken in two patients with a failed DAVF. Attempts at restoration after thrombosis were made in eight patients with failed DVCs. Five patients underwent thrombectomy, of which four procedures were successful. Three patients had thrombolytic therapy, and two of these remained patent. CONCLUSION: Adjuvant techniques, including DAVF and DVC, produce acceptable long-term patency and limb salvage rates in bypass grafts performed to the below-knee popliteal and tibial vessels. This study suggests that DVCs may offer improved limb salvage rates and a greater opportunity for revision when bypass graft failure occurs.     

Treatment of aortoiliac disease by axillofemoral artery bypass.

Between July 1, 1971 and June 30, 1977, 45 axillofemoral artery bypass procedures were performed on 39 men and 5 women whose average age was 67.7 years. Twenty-four patients received 25 unilateral axillofemoral bypasses; the remaining 20 patients underwent axillobifemoral artery procedures. The indication for surgery in 42 patients was limb salvage; the other 2 had infected aortic prostheses. All patients in the former group had serious associated disorders which would have made a conventional intra-abdominal procedure hazardous. The early mortality was 2.3% and the late mortality 29.6%. Of these 45 grafts 20 became occluded; however, 8 of the occluded grafts were successfully revised and have remained patent. For the 25 unilateral grafts at risk the 5-year cumulative patency rate determined by life-table methods was 50.6% and for the 20 bilateral grafts it was 89.7%. Our experience indicates that axillobifemoral bypass has a significantly (P less than 0.02) higher patency rate than unilateral axillofemoral bypass and is an acceptable alternative to conventional intra-abdominal procedures in elderly and poor-risk patients with aortoiliac disease.     

Angiographic scoring of vascular occlusive disease in the diabetic foot: relevance to bypass graft patency and limb salvage

OBJECTIVE: We graded the severity of occlusive disease in foot vessels of patients with diabetes and correlated the scoring obtained with graft patency and limb salvage. METHODS: In this retrospective review of 199 limbs studied by means of angiography in 117 patients with diabetes mellitus, 124 limbs underwent bypass grafting. Each dorsalis pedis (DP), lateral plantar (LP), and medial plantar (MP) artery was assigned a score according to the reporting standards of the Joint Vascular Societies Council (0, no stenosis > 20%; 1, 21%-49% stenosis; 2, 50%-99% stenosis; 2.5, < half the vessel length occluded; 3, > half the vessel length occluded.) A foot score (DP + MP + LP + 1) was calculated for each foot (1 to 10). The mean follow-up period was 14 months. RESULTS: For all 199 limbs and for the 124 limbs that underwent bypass grafting, the mean scores were similar for the DP, MP, and LP (1.8 +/- 1.0, 1.9 +/- 1.0, 1.9 +/- 1.0, respectively; P >.4). Only the MP and LP correlated with each other (r = 0.57; P <.0001). There were no scoring differences between limbs with symptoms and limbs that did not undergo bypass grafting. Bypass graft patency correlated with both the foot score and the MP score for tibial and inframalleolar grafts (P <.04). Patency correlated with the LP score only for inframalleolar bypass grafting procedures. The DP score alone did not differ between bypass grafts that remained patent and bypass grafts that failed. Bypass grafts in limbs with a foot score less than 7 and an MP score less than 2 had only a 2% failure rate. A foot score greater or equal to 7 was associated with a 30% failure rate for all bypass grafts (41% for inframalleolar grafts). Bypass grafts with low foot scores that failed did so much later than bypass grafts with high foot scores that failed (17 +/- 11 months vs 6 +/- 8 months; P <.02), possibly reflecting different etiologies for the failure. The limb salvage rate correlated with foot score (P <.05). The limbs that were saved had an average foot score of 6.4 +/- 2.0, versus 7.2 +/- 1.4 for limbs that required amputation. CONCLUSION: In patients with diabetes mellitus, the foot score is a useful tool for predicting the likelihood of graft patency and limb salvage for infrapopliteal revascularization. However, the relatively high bypass success rate (70%) in the presence of a high foot score (>or= 7) does not allow its use in identifying the subgroup of patients who are unlikely to benefit from bypass grafting surgery. It cannot be used as a means of selecting patients for primary amputation.     

Effect of radial artery harvest on collateral forearm blood flow and digital perfusion

BACKGROUND: Changes describing digital and forearm circulation after radial artery harvest have been reported infrequently. METHODS: This prospective study examined digital perfusion and forearm collateral circulation preoperatively and postoperatively in patients who underwent coronary artery bypass grafting with radial artery free grafts. Noninvasive evaluation was conducted with digital photoelectric plethysmography and color flow and pulsed Doppler studies. RESULTS: Thumb perfusion index decreased from 1.25 to 0.84 (30%, P <.001) in the unoperated extremities and from 1.23 to 0.80 (36%) in the operated extremities (P <.001). Doppler studies in extremities after radial artery harvest demonstrated an increase in ulnar artery diameter from 3.87 to 4.66 mm (15.7%, P <.001) and a rise in ulnar blood flow velocity from 38.96 to 48.46 cm/s (17.4%) preoperatively to 8 weeks postoperatively (P <.001). No hand ischemia was noted. CONCLUSIONS: Our study identified a mild reduction in digital perfusion and an increase in ulnar artery flow velocity and diameter with no clinical sequelae or compromise in hand function after radial artery harvest in properly selected patients.     

Combined percutaneous transluminal angioplasty and extraanatomic bypass for symptomatic unilateral iliac artery occlusion with contralateral iliac artery stenosis

We have reviewed our experience with percutaneous transluminal angioplasty of contralateral iliac stenosis and extraanatomic bypass of the occluded iliac artery. Twenty-two men and nine women with a mean age of 65 years (range 46 to 84) presented with symptomatic iliac occlusive disease. Twenty-four (77%) had disabling claudication, four (13%) rest pain, and three (10%) ischemic tissue loss. Six (19%) had undergone previous vascular reconstructive procedures. All had an occluded iliac artery on the symptomatic side and greater than 50% stenosis of the contralateral iliac artery. Percutaneous transluminal angioplasty of the iliac stenosis was done prior to extraanatomic bypass, using polytetrafluoroethylene. There were six late deaths after discharge. The only significant complication was a femoral artery thrombosis which was corrected when the bypass graft was performed. Cumulative primary graft patency was 89% at one year and 81% at three years. The crossover graft occluded in six patients, five within 48 months of surgery, and one after nine years. One of these occluded grafts was salvaged by thrombectomy, for a secondary patency rate of 85% at three years. Two patients required aortobifemoral bypass, one an iliobifemoral bypass and one an ilioprofunda bypass. One patient operated upon for rest pain came to below-knee amputation. Mean resting ankle/brachial systolic pressure index increased significantly on the side of the iliac occlusion from 0.35 ±0.21 to 0.70 ± 0.20 (p < 0.05, paired t test) after the combined procedure. There was no significant difference in the mean resting ankle/brachial systolic pressure index on the contralateral side (0.60 ± 0.22 to 0.65 ± 0.27, ns). Combined iliac percutaneous transluminal angioplasty and femorofemoral bypass is a safe alternative to aortobifemoral bypass for selected patients with aortoiliac arterial occlusive disease. Presented at the Royal Australasian College of Surgeons, General Scientific Meeting, May 1989, Melbourne, Australia.     

Axillofemoral bypass for aortoiliac occlusive disease

BACKGROUND: Although aortoiliac disease remains a common cause of lower extremity ischemia, the efficacy of axillofemoral bypass in this setting remains controversial. This report summarizes our institutional experience with axillofemoral bypass. METHODS: A retrospective review of consecutive axillofemoral bypass grafts was performed at a single institution between 1984 and 1997. Only patients presenting with chronic aortoiliac occlusive disease were included. Patient demographics, risk factors, indications for surgery and outcomes were recorded. Survival curves for primary patency were plotted using the Kaplan-Meier method according to the standards set by the Society of Vascular Surgery-International Society for Cardiovascular Surgery. Comparisons between groups were made using the log rank method. Statistical significance was assumed at P values <0.05. RESULTS: Sixty patients underwent axillofemoral bypass grafting of which 53 were bifemoral and 8 unifemoral. Forty-seven procedures were performed for limb salvage. Primary patency rates at 1, 3, and 5 years were 86%, 72%, and 63%, respectively. Thirty-day mortality rate was 4.9%. Sixty percent of graft occlusions occurred in the femorofemoral limb with continued patency of the axillofemoral limb. Risk factors, type of procedure and superficial femoral artery patency had no statistically significant effect on long-term patency. CONCLUSIONS: In the setting of diffuse, chronic aortoiliac occlusive disease, long-term patency rates of axillofemoral grafts approach those of aortobifemoral bypass and exceed those quoted for percutaneous transluminal angioplasty, with results that are highly reproducible. Axillofemoral bypass is an excellent option in those patients at prohibitive risk for direct aortic reconstruction or those with limited life expectancy.     

Combined aortofemoral and extended deep femoral artery reconstruction. Functional results and predictors of need for distal bypass

In patients with combined aortoiliac and femoropopliteal occlusive disease, severe involvement of the deep femoral artery (DFA) has often been considered an indication for simultaneous aortofemoral and femorodistal bypass grafting. In 73 patients (87 limbs) with multilevel disease, extended DFA reconstruction was performed with aortofemoral bypass. Five-year actuarial patency of the reconstructions and overall five-year actuarial limb salvage were 62.2% and 60.2%, respectively. Of 20 variables tested, four were significantly associated with the functional outcome of the procedures. Multivariate analysis identified two factors as predictive of outcome independently from other variables: preoperative ankle-brachial pressure index and angiographic status of the below-knee popliteal artery. However, in case of reoperation for occluded aortofemoral graft, these factors lost their validity. Extended DFA reconstruction is a valuable and durable procedure able to provide an adequate outflow and distal perfusion. Careful judgment in each clinical situation will aid in selecting a small group of patients in which simultaneous femorodistal bypass is required.     

Patency of radial arteries reconstructed after radial forearm flap harvest

Poor patency is cited as a reason to not perform radial artery reconstruction after the harvest of the radial forearm flap. The need for a long vein graft and the presence of a patent ulnar artery are offered as explanations for thrombosis of the reconstruction in this setting. Similar arguments have been made regarding radial artery reconstruction in the trauma setting. In this study, the patency rate for patients undergoing radial forearm flap harvest with immediate reconstruction with reversed interposition vein grafting was evaluated. The mean follow-up time was 24 months, and all seven patients had patent reconstructions. Ultrasound examination revealed slightly larger diameters of the vein grafts compared with native arteries. No areas of stenosis were detected. No complications resulted from harvest of the vein. From these data, we conclude that radial artery reconstruction can be performed with the expectation of patency.