Preoperative saphenous and cephalic vein mapping as an adjunct to reconstructive arterial surgery.

B-mode ultrasound was prospectively evaluated for its ability to preoperatively assess the adequacy of venous conduit for arterial reconstruction. Fifty-one patients who had lower extremity revascularization had real-time imaging of the saphenous and cephalic veins. Veins were judged adequate based on size, compressibility, and absence of sclerosis or intraluminal echoes. All mapped veins were explored and assessed by the standard criteria for suitability. Vein size was determined from completion angiograms, and wound complications recorded and compared with patients who had similar procedures in the 12 months before the use of vein mapping. Preoperative mapping was found to be accurate in 50 to 51 patients (98%). Vein size as determined by B-mode ultrasound correlated well with angiograms, R = 0.8539 overall with R greater than 0.9 in the last 7 months of the study. Wound complications occurred in 2% of the patients who had preoperative mapping and in 17% of the historic controls. Preoperative vein mapping using B-mode ultrasound is an accurate method of determining vein suitability for use in arterial reconstruction. It improves operative planning and can contribute to a reduction in wound complications. Veins determined to be unusable by preoperative scanning need not be explored.     

Great saphenous vein protection in arterial reconstructive surgery

An original method of great saphenous vein bypass protection during reconstructive arterial surgery is described. The use of a reinforced prosthetic support (Ringed PTFE), surrounding the vein, avoids possible compression by anatomical structures and strangulation by scar tissue after reoperation. This technique can also prevent eventual dilatation of the vein graft. Since 1981, this technique has been successfully applied to 30 selected patients. On the basis of clinical experience, the authors conclude that this method is safe and effective, and may increase the long-term patency rate of saphenous vein grafts.     

Use of bone graft substitutes in lower extremity reconstructive surgery

Autologous iliac crest graft has been a standard source of supplementary bone for treating bony defects, fractures and arthrodeses. Bone graft substitutes have recently become widely available. This paper reports on the use of bone graft substitute in 28 patients that otherwise would have required an iliac crest graft. Twenty-four of the 28 operations were successful in the primary procedure with four patients requiring a second procedure that was then successful.     

Vein grafts in reconstructive microsurgery of the lower extremity.

This paper describes surgical techniques and results of lower extremity microsurgical reconstruction using vein grafts. During a 5 year period, free tissue transfers were used to reconstruct 118 lower extremity defects in 109 patients. In 28 of these cases (24%), saphenous vein grafts were used when reconstruction would otherwise have been difficult or impossible. A preliminary arteriovenous fistula was established between the proximal arterial source and the final venous drainage in the majority (26) of cases. Venous drainage was left intact at the point of entry into the deep venous system in 23 cases. Three complications included anastomotic clotting in 2 patients and postoperative blow-out of the vein graft in another; all were treated without flap loss. Flap survival was 86% in vein grafted patients and 94% in those cases in which vein grafts were not used. Flap loss was related in each case to the nature of the pre-existing condition, rather than to vein grafting per se.     

Outcomes following ipsilateral great saphenous vein bypass for lower extremity arterial injuries

ObjectiveUse of autologous great saphenous vein (GSV) grafts for repair of extremity arterial injuries is well established. Contralateral great saphenous vein (cGSV) is traditionally used in the setting of lower extremity vascular injury given the risk of occult ipsilateral superficial and deep venous injury. We evaluated outcomes of ipsilateral GSV (iGSV) bypass in patients with lower extremity vascular trauma.MethodsPatient records at an ACS verified Level I urban trauma center between 2001 and 2019 were retrospectively reviewed. Patients who sustained lower extremity arterial injuries managed with autologous GSV bypass were included. Propensity-matched analysis compared the iGSV and cGSV groups. Primary graft patency was assessed via Kaplan-Meier analysis at 1-year and 3-years following the index operation.ResultsA total of 76 patients underwent autologous GSV bypass for lower extremity vascular injuries. 61 cases (80%) were secondary to penetrating trauma, and 15 patients (20%) underwent repair with iGSV bypass. Arteries injured in the iGSV group included popliteal (33.3%), common femoral (6.7%), superficial femoral (33.3%), and tibial (26.7%), while those in the cGSV group included common femoral (3.3%), superficial femoral (54.1%), and popliteal (42.6%). Reasons for using iGSV included trauma to the contralateral leg (26.7%), relative accessibility (33.3%), and other/unknown (40%). On unadjusted analysis, iGSV patients had a higher rate of 1-year amputation than cGSV patients (20% vs. 4.9%), but this was not statistically significant (P = 0.09). Propensity matched analysis also found no significant difference in 1-year major amputation (8.3% vs. 4.8%, P = 0.99). Regarding ambulatory status, iGSV patients had similar rates of independent ambulation (33.3% vs. 38.1%), need for assistive devices (58.3% vs. 57.1%), and use of a wheelchair (8.3% vs. 4.8%) compared cGSV patients at subsequent follow-up (P = 0.90). Kaplan-Meier analysis of bypass grafts revealed comparable primary patency rates for iGSV versus cGSV bypasses at 1-year (84% vs. 91%) and 3-years post-intervention (83% vs. 90%, P = 0.364).ConclusionIpsilateral GSV may be used as a durable conduit for bypass in cases of lower extremity arterial trauma where use of contralateral GSV is not feasible, with comparable long-term primary graft patency rates and ambulatory status.     

The use of ultrasound during reconstructive arterial surgery of the lower extremities

Real-time, B-mode ultrasonography is a dependable method of vascular imaging for use during arterial reconstruction. It has been demonstrated in both animal and human studies to detect accurately intimal flaps, arteriotomy stricture, and intraluminal thrombi. Sonographic images are 3-dimensional and dynamic. Scans can be repeated as often as necessary and in different views to characterize lesions fully. Operative sonography has a sensitivity of 100%, specificity of 94%, and accuracy of 94% compared to 68%, 85%, and 83%, respectively, for operative arteriography. There are limitations to sonography. It can only evaluate vessels in the operative field and is useless for assessment of the arterial run-off. The high sensitivity of sonography will lead to the discovery of defects that likely pose no threat to the success of the reconstruction. The surgeon will have to decide what lesions are significant and what lesions warrant reexploration. The role of operative ultrasonography in arterial surgery is to complement arteriography. This can be accomplished by assessing areas not readily visualized by arteriography and by providing additional information to assist the surgeon in obtaining a technically successful reconstruction.

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Resumen La ultrasonografía modo B de tiempo real es un método confiable de imagenología vascular en el curso de reconstrucciones arteriales. Se ha demostrado tanto en estudios en animales como en humanos que es capaz de detectar con certeza la presencia de pliegues (flaps) de la íntima, estrecheces por arteriotomía, y trombos intraluminales. Las imágenes sonográficas son tridimensionales y dinámicas, y las escanografías pueden ser repetidas tan frecuentemente como sea necesario, y en proyecciones diferentes, para la total definición de las lesiones. La sonografía operatoria posee una sensibilidad de 100%, una especificidad de 94%, y una certeza de 94%, en comparación con 68%, 85%, y 83%, respectivamente, de la arteriografía operatoria. Existen limitaciones de la sonografía. Sólo puede valorar vasos dentro del campo operatorio y no tiene utilidad en la valoración del árbol arterial de desagüe. La elevada sensibilidad de la sonografía da lugar al descubrimiento de defectos que probablemente no signifiquen amenaza en cuanto al éxito de la reconstrucción. El cirujano debe decidir sobre cuales lesiones son de significación y cuales merecen reexploración. El papel de la ultrasonografía en la cirugía arterial es el de complementar la arteriografía. Esto se logra mediante la valoración de áreas no fácilmente visualizadas por la arteriografía y la provisión de información adicional que ayuda al cirujano a lograr una reconstrucción técnicamente exitosa.

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Résumé L'échographie B temps réel est une méthode d'imagerie vasculaire sûre à employer lors de la reconstruction artérielle. Il a été démontré chez l'animal et chez l'homme qu'elle permet avec précision de déceler les lambeaux d'intima, les rétrécissements de l'axe vasculaire et les thromboses intra-artérielles. Les images obtenues sont en 3 dimensions et dynamiques. L'exploration peut être répétée aussi souvent qu'il est nécessaire en différentes positions pour bien définir les lésions. La sensibilité de l'exploration est de 100%, sa spécificité de 94%, et sa précision de 94% comparées respectivement aux chiffres de 68%, 85%, et 83% de l'artériographie opératoire. Il y a cependant des limites à l'échographie. Elle permet seulement d'évaluer l'état des vaisseaux dans le champ opératoire et elle ne permet pas d'apprécier le flux artériel. La grande sensibilité de la sonographie aboutit à la découverte de petites altérations qui ne sont pas la source de complications. C'est au chirurgien de reconnaitre les lésions qui par leur importance méritent attention et de ce fait une nouvelle exploration. Le rôle de l'échographie est en fait complémentaire de celui de l'artériographie. La méthode permet d'apprécier les zones qui ne sont pas explorables par l'artériographie et d'apporter au chirurgien des éléments complémentaires d'information qui lui permettent d'obtenir une reconstruction artérielle vouée au succès.

     

Albumin kinetics and oedema following reconstructive arterial surgery of the lower limb

Of 26 patients who had either femoro-popliteal or aorto-iliac bypass surgery pitting oedema occurred in the reconstructed limb during the post-operative period in 13. Eleven of 13 patients (84.6%) who had a femoro-popliteal bypass developed oedema compared to 2 of 13 (15.4%) who had aorto-iliac operations (P less than 0.001 chi squared). There was a significant reduction in the serum concentration of total protein and the albumin fraction after operation in both groups of patients (P less than 0.01). The concentration of protein and albumin remained lower than the pre-operative values until the end of the study period but the mean values did not at any stage fall below the lower limit of the normal range. Albumin labelled with I125 was used to investigate changes in the albumin content of the reconstructed limbs. Following femoro-popliteal bypass there was a three fold increase in I125 albumin compared to the non-operated limbs and this persisted to the end of the study period (P less than 0.001). After aorto-iliac surgery there was only a small transient accumulation of I125 albumin in the legs compared to the pre-operative value (P less than 0.02). In both groups of patients large accumulations of albumin were associated with the presence of pitting oedema. It was concluded that altered albumin kinetics play an important part in the development of post-reconstruction oedema. The possible mechanisms involved are discussed together with the practical implications of the results.     

Efficacy and durability of autogenous saphenous vein conduits for lower extremity arterial reconstructions in preadolescent children.

OBJECTIVE: Limb length discrepancies (LLDs) in growing children may accompany extremity arterial occlusions. Revascularization with vein grafts has been questioned because of degenerative graft changes observed at other sites. This study was undertaken to define vein graft durability and efficacy in lower extremity revascularizations in preadolescent children.Study Design: Fourteen children (10 boys, 4 girls) with a mean age of 7.3 years (range, 2-11 years) who underwent 16 lower extremity revascularizations with greater saphenous vein grafts were subjected to follow-up with graft ultrasonography, ankle/brachial indices (ABIs) with and without exercise, and limb length determinations. A mean of 5.7 years elapsed between the onset of ischemia and operation. Arterial occlusions resulted from cardiac catheterizations (11), arteritis (1), dialysis cannulation (1), and penetrating trauma (1). Indications for operation included LLD (6), claudication (4), both LLD and claudication (3), markedly diminished ABIs with a potential for LLD (2), and a traumatic transection with hemorrhage (1). The reconstructions with 15 reversed and one in situ vein grafts included iliofemoral (11), femorofemoral (1), aortofemoral (1), femoropopliteal (1), popliteal-popliteal (1), and popliteal-posterior tibial (1) arterial bypass grafts. RESULTS: Among patent grafts available for follow-up, 36% (5 of 14) remained unchanged, 50% (7 of 14) developed nonaneurysmal dilatation, and 14% (2 of 14) exhibited nonprogressive aneurysmal expansion. One graft became occluded, and one graft was lost to follow-up. Collectively, the grafts manifest an 11.2% expansion at an average of 10.7 years postoperatively. ABIs increased from 0.75 preoperatively to 0.97, at an average of 11.0 years postoperatively. LLDs were reduced from 1.66 to 1.24 cm, at an average of 11.4 years postoperatively. CONCLUSION: Vein graft reconstructions of lower extremity arteries in preadolescent children are durable. They provide an efficacious means of restoring normal blood flow, and in 70% of children their preexisting LLDs were reduced.     

下肢静脉造影在下肢静脉曲张患者中的应用及阻塞性下肢静脉曲张发生的预测因素

目的 探讨下肢静脉造影检查在下肢静脉曲张中应用的临床意义,并分析阻塞性下肢静脉曲张可能相关的预测因素.方法 选取2019年1月至2021年12月因下肢静脉曲张于海军军医大学第二附属医院诊治的74例患者(111条患肢)为研究对象,对所有患肢行下肢静脉造影检查,采用病例报告表形式记录患者相关信息,根据有无深静脉阻塞表现分为...     

In situ saphenous vein for lower extremity revascularization.

BACKGROUND. During a 6-year period, 349 in situ saphenous vein bypass grafts were performed for limb salvage by three surgeons. METHODS. Outflow anastomoses were constructed to the infrageniculate popliteal (25%), posterior tibial (20%), peroneal (20%), anterior tibial (19%), and dorsal pedal arteries (7%). Mean patient age was 70 1/2 years. RESULTS. The 30-day mortality rate was 3.2%, and 19% died during the ensuing 68-month interval. At 1, 24, and 60 months primary graft patency was 89%, 77%, and 74%, secondary graft patency was 91%, 80%, and 78%, and cumulative limb survival was 94%, 88%, and 84%, respectively. Cumulative patency rates at 60 months depending on outflow site were as follows: popliteal (85%), anterior tibial (80%), posterior tibial (70%), dorsal pedal (68%), and peroneal (60%). Patency at the peroneal position was significantly inferior to that of other infrapopliteal sites combined (p less than 0.05). Cumulative limb survival at 60 months, according to outflow site, was as follows: popliteal (95%), anterior tibial (85%), posterior tibial (78%), dorsal pedal (73%), and peroneal (67%). There was no significant difference in limb salvage among infrapopliteal outflow sites. However, patency rates and limb salvage were significantly better for the popliteal outflow site than the infrapopliteal outflow sites (p less than 0.01). CONCLUSIONS. (1) A 5-year graft patency rate of 78% and a limb salvage rate of 84% are achievable, (2) peroneal bypass is associated with a lower rate for graft patency but not limb salvage, and (3) popliteal bypass has the best graft patency and limb salvage rates.     

MSCT静脉造影在下肢静脉成像中的应用

目的探讨MSCT静脉成像（MSCTV）在下肢静脉成像中的应用价值。方法对临床高度怀疑下肢疾病的54例患者进行MSCTV、超声检查、DSA检查。以DSA检查为金标准,对比分析MSCTV和超声检查的诊断效能。结果 DSA检出39例患者有下肢静脉疾病,MSCTV检出38例患者有下肢静脉疾病,超声检出26例患者有下肢静脉疾病。以DSA检查为金标准,超声检查对下肢静脉疾病的诊断的敏感度66.67%（26/39）,特异度100%（15/15）,阳性预测值100%（26/26）,阴性预测值53.57%（15/28）;MSCTV对下肢静脉疾病的诊断敏感度97.44%（38/39）,特异度100%（15/15）,阳性预测值100%（38/38）,阴性预测值93.75%（15/16）。与DSA检查符合率：超声检查为75.93%（41/54）,MSCTV为98.15%（53/54）。结论 MSCTV是一种无创性成像方法,与DSA的成像结果符合率高,对诊断下肢静脉疾病有重要临床意义。     

Cryopreserved saphenous vein allogenic homografts: an alternative conduit in lower extremity arterial reconstruction in infected fields.

Autologous saphenous veins are considered the best arterial substitute for lower extremity revascularization in infected fields. The search continues for a vascular conduit in instances when an autologous biologic grafting is not feasible. Herein we report our experience with eight patients in whom cryopreserved saphenous vein allogenic homografts were used in 10 lower extremity arterial reconstructions for limb salvage with coexisting infection. Six patients with eight prosthetic grafts including four femoropopliteal, two femorotibial, a femorofemoral, and a femoroperoneal graft required complete or partial graft excision as a result of overt infection. The two remaining patients included one with an infected femoral pseudoaneurysm and another with extensive chemical burns. All cryopreserved saphenous vein allogenic homografts were of identical match to the ABO/Rh blood groupings of the recipient patients. No immunosuppressive drugs were administered after operation. Mean follow-up was 9.5 months (range, 6.0 to 14.0 months). One patient died 5 weeks after operation with a patent graft. Two grafts occluded during follow-up; in one graft, patency was restored with thrombectomy alone. The remaining seven arterial reconstructions continue to be patent with no evidence of aneurysmal dilation with complete eradication of the primary infection. These preliminary findings suggest that cryopreserved saphenous vein allogenic homografts can serve as interim conduits for lower extremity arterial reconstruction to preserve limb viability when autogenous conduits are unsatisfactory or unavailable. Further definitive reconstruction may thereafter be necessary once sepsis is eradicated and sufficient wound healing is achieved.