Postoperative changes in bypass vein grafts and collateral arteries after femoropopliteal arterial reconstructive surgery.

Postoperative changes in the bypass veins and collateral arteries after femoropopliteal arterial reconstructive surgery were evaluated on the basis of control arteriographic studies. Arteriographies were made in 87 cases after venous bypass reconstruction. There were three aneurysms during the follow-up. Ten of the 69 patent bypass veins showed multiple stenotic lesions one to six months after surgery. It was assumed that these changes were caused by intimal hyperplasia. There was a statistically significant decrease in the size of the profunda femoris artery when the reconstruction was functioning at the time of control arteriography. However, no significant decrease was found in the group in which the reconstruction failed before one year postoperatively. Similar observations were made regarding the size and number of the midzone and re-entry collateral vessels.     

Aorto-ilicofemoral arterial reconstructive surgery. With special reference to profunda revascularization.

A series of 177 patients undergoing 190 reconstructions for aorto-ilicofemoral arterial occlusive disease are reported. Operative procedures were carried out on a total of 294 limbs. On 87 of these, profunda revascularization was performed. The indication for surgery was advanced ischemia in 50% of the profunda revascularization patients and in 20.5% of the patients with superficial femoral arteries open or reconstructed. Dacron bypass graft was used in 99 reconstructions and ilicofemoral or femorofemoral vein graft in 8 cases. Endarterectomy was carried out in 83 cases. The overall operative mortality rate was 5.3%, renal failure being the most common cause of death. The 5-year survival rate was 73.5%. The rate of primary thrombosis was 2.6%. The 5-year cumulative patency rate of all aorto-ilicofemoral reconstructions was 91.3%. In the profunda revascularization group the corresponding percentage was 82.1%. There was no difference in the patency rate between reconstructions using Dacron graft or endarterectomy. The symptomatic results were good also in the profunda revascularization group, 93% of patients having relieved symptoms as an initial result of surgery. There were seven major amputations in 6 patients during the follow-up time and 5 patients needed further femoropopliteal reconstruction. It can be said that in most cases profunda revascularization is sufficient for satisfactory clinical results.     

Ten years after arterial bypass surgery for claudication: venous bypass is the primary procedure for TASC C and D lesions

Background  

The appropriate role for surgery and endovascular therapy for severe intermittent claudication (IC) remains controversial. We present our results after infrainguinal autogenous bypass for severe IC more than 10 years ago giving a reasoned argument to perform vein bypass as the primary procedure for severe IC.     

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.     

Femoropopliteal venous bypass in distal duplication of the great saphenous vein with bridge veins. Case report

A 74-year-old patient with peripheral arterial obstructive disease II B presented a full-length obstruction of the superficial femoral artery and additionally a segmental 10 cm long obstruction of the deep femoral artery. The arteries of the calf were patent. In this situation a bypass with an autologous vein was taken in advice. At surgery in December 1988 the great saphenous vein from the contralateral leg was prepared. It was found to be duplicated and contained numerous bridging veins. The duplication was maintained to compensate for the difference of calibre. The proximal anastomosis was done with the double-lumen graft including in between a split bridging vein. This arrangement provided favourable anatomic and functional outlets to the two saphenous branches. At follow-up in January 1990 the patient was fully reintegrated and had an unlimited walking distance. Doppler sonography showed normal closing pressure in the peripheral arteries. The intravenous digitalized subtraction angiography demonstrated regular perfusion of both branches of the duplicate bypass.     

Eschaemia during arterial reconstructive surgery. Biochemical changes as reflected in popliteal vein samples.

Blood gases, electrolytes, metabolites and enzymes were studied in the venous effluate from the leg and in the systemic blood of 8 patients suffering from obliterating arteriosclerosis, during and after reconstructive arterial surgery. The common femoral artery was clamped for 50 to 180 min. Marked hypoxia and acidosis, together with a rise in lactate, phosphate and creatinine concentrations were found in the popliteal vein samples. Changes in the electrolyte concentrations were also observed. The rises in K+ and Mg++ were most pronounced. None of the changes wre correlated to the occlusion time and only small inter-individual variations were recorded. Only minor systemic change occurred after restoration of blood flow. The maximum postoperative CPK-activity, however, was closely correlated to the occlusion time, but judging by the level of this activity the actual muscular damage caused by the ischaemia was moderate, even after prolonged arterial clamping.     

Spontaneous rupture of autogenous saphenous vein graft in bypass surgery for peripheral arterial disease possibly associated with collagen disease

We encountered two cases of spontaneous rupture of a saphenous vein bypass graft for lower-leg peripheral arterial disease possibly associated with collagen disease. Rupture occurred 5?and 14 days postoperatively. Neither case had any signs of infection, graft degeneration, or evident injury, but both were associated with collagen disease diagnosed at another hospital. We believe that an association with collagen disease might have contributed to vein wall fragility in the present cases.     

Durability of autogenous vein and polytetrafluoroethylene bypass grafts to the carotid arteries

BACKGROUND: Bypass for extra-cranial arterial disease is infrequently carried out. We reviewed our experience to determine the outcome of carotid artery grafting using either an autogenous vein or polytetrafluoroethylene (PTFE). METHODS: Details of patients were recorded prospectively as part of a vascular surgical registry. Patients identified from the registry as having carotid artery bypass procedures were classified according to the type of conduit used. Comparison was made between patients with autogenous vein and PTFE grafts. RESULTS: Between 1978 and 2002, 24 patients (13 men and 11 women) mean age 60.0 +/- 13.4 years (range, 20-81 years) underwent 28 bypass procedures (three were bilateral and one was a reoperation). Symptomatic carotid disease was the clinical indication in 20 of 28 procedures (71.4%). Pathological indications included advanced atherosclerosis of the carotid arteries (15), past radiotherapy (4), failed stenting (3), resection of carotid body tumour (2), trauma (1), reoperation on a failed graft (1), carotid aneurysm (1) and iatrogenic carotid occlusion (1). An autogenous vein was used in 16, PTFE in 11 and autogenous artery in 1 of the patients. Using the Kaplan-Meier method, the overall patient cumulative 5-year survival was 84% and cumulative 5-year stroke-free survival was 93%. The combined perioperative stroke and mortality rate was 7.1%. Two patients had transient ischaemic attacks (7.1%), one had cranial nerve palsies (3.6%) and one required reoperation for bleeding (3.6%). Five-year cumulative graft primary patency using the Kaplan-Meier method was 74% for PTFE grafts and 92% for autogenous vein grafts (P = 0.37). CONCLUSION: Carotid artery bypass is a safe and a useful treatment option for complex extra-cranial arterial disease. Either PTFE or autogenous veins may be used as conduits.     

Wound complications of autogenous subcutaneous infrainguinal arterial bypass surgery: predisposing factors and management

To identify factors predisposing to wound infection and necrosis complicating in situ or other subcutaneous autogenous lower extremity vein bypass procedures, we retrospectively analyzed all such cases performed in our hospital between July 1983 and July 1988. Among 163 subcutaneous autogenous bypass grafts, wound complications developed in 28 (17%). According to progressive depth of involvement as defined in the text, 10 patients had grade I complications, six had grade II, and 12 had grade III complications with threatened or actual graft exposure. Factors significantly associated with wound morbidity were female gender, chronic steroid therapy, in situ bypass grafting, use of continuous incision (all p less than or equal to 0.05, chi square); diabetes mellitus, ipsilateral limb ulcer, limb salvage indication (all p less than 0.01); and bypass grafting to the dorsalis pedis artery (p less than 0.02). A logistic regression analysis identified four factors (in situ bypass grafting, steroid therapy, ipsilateral ulcer, and dorsalis pedis bypass grafting) that predicted a cumulatively increasing risk of wound complications, and in whose absence wound complications were rare. Grade I and II complications responded to standard regimens of wound care and intravenous antibiotics without loss of any graft or limb. In spite of aggressive efforts to provide secondary soft tissue coverage, grade III complications led directly to four major amputations and one death. Measures to prevent these morbid sequelae must include preoperative control of infection in the ischemic foot and meticulous attention to operative technique.     

Complex venous and arterial reconstruction with deep vein after pelvic exenterative surgery: a case report

Effective local regional control for solid tumor malignancies is dependent upon prerequisite surgical excision with negative margins. Invasion of contiguous adjacent structures, particularly in anatomical spaces of limited size, may preclude the surgical goal of histologically negative margins. From a historical perspective, the invasion of vascular structures in the pelvis has proved to be a significant limitation in achieving local regional disease control with surgical resection. In recent years, advances in the field of vascular surgery have caused us to reassess the historical criteria of resectability when blood vessels are focally invaded by malignancy. En bloc resection of adjacent vessels has been reported primarily with head and neck extirpations and increasingly with hepatobiliary and pancreatic lesions. In many cases, where the local vasculature is invaded or impinged by the tumor, venous structures are often ligated while arteries are bypassed with an appropriate conduit. In pelvic exenterative surgery, significant morbidity from chronic limb edema and deep venous thrombosis may result from the ligation of larger veins. This is especially the case when multiple major venous structures such as the common and the external iliac vein, as well as the hypogastric vein, are all simultaneously interrupted. To the best of our knowledge, there is no prior report examining venous reconstruction using the femoral vein for pelvic exenterative surgery requiring major iliac artery and venous resection. Herein we describe a case of a complex vascular reconstruction after pelvic exenterative surgery in a patient with recurrent rectal cancer invading multiple adjacent contiguous structures, including the iliac vessels.     

Aorto-coronary vein bypass and valvular surgery.

During the period 1972--1975, 26 patients underwent valvular surgery combined with aorto-coronary saphenous vein bypass at Ullev?l Hospital, Oslo. Aortic valve replacement was performed in 13 patients, mitral valve replacement in 8 and double valve replacement in 3 patients. The Bj?rk-Shiley tilting disc valve was used in all cases. A Carpentier ring was inserted in one case and an open mitral commissurotomy was performed in another. Twenty-nine saphenous vein grafts were inserted. Three early deaths (all patients in functional class IV (NYHA)) were due to myocardial failure. There were 2 late deaths (both patients in functional class III before operation) of which one was due to myocardial infarction and the other to ventricular fibrillation. The overall mortality was 19%. At follow-up with a mean observation time of 11 months, 19 of the 21 survivors were improved at least one functional class. Only 2 patients had mild angina pectoris. No valvular dysfunction was found. Twenty-one of 22 re-examined grafts were patent (95% graft patency). Valvular surgery combined with aorto-coronary vein bypass in this material shows low mortality and good clinical and haemodynamic results in patients in functional class II and III. Patients should be operated upon before they reach functional class IV, as the mortality in that group is very high.     

Arterial reconstruction at diverse sites using nonreversed autogenous vein. An application of venous valvulotomy.

Improved instrumentation for venous valve extirpation has allowed rapid development of the in situ technique for femoral-tibial arterial reconstruction. Extension of this valvulotomy technique permits the expeditious construction of branched, nonreversed saphenous vein grafts for multiple vessel revascularization, and allows use of veins otherwise unsuitable in length for certain arterial bypass procedures. The nonreversed vein graft also appears to offer advantages over the reversed graft with regard to the size of the proximal and distal anastomoses when used as an aortorenal or iliorenal graft as well as in other anatomic locations. Over the past 30 months these techniques were used to implant 10 vein grafts at diverse sites in nine patients with initial success in all instances and one late graft failure.     

Influence of coumarin treatment on patency and limb salvage after peripheral arterial reconstructive surgery.

The effect of coumarin on patency, limb salvage, and survival after primary femoro-popliteal and femoro-distal reconstructions was studied in 116 randomized patients (61 in the study group and 55 in the control group). All patients were treated postoperatively with heparin. Patients allocated to the study group received dicumarol (a coumarin derivative) orally postoperatively. The overall patency after 1 year was 75 +/- 6%, compared with 74 +/- 6%, after 2 years 65 +/- 9 compared with 57 +/- 8%, and after 3 years 46 +/- 11% compared with 42 +/- 9% (mean +/- SE) in the study and control groups, respectively. There were no statistically significant differences in limb salvage or survival rates between the two groups. In contrast, coumarin treatment was associated with serious bleeding complications in 4% to 5% of the study patients. As expected, limb salvage was lower in patients with critical ischemia (p less than 0.03), and this was also true for survival (p less than 0.04), which was also influenced by the level of the reconstruction; survival was lower in patients with femoro-distal reconstructions (p less than 0.001). Our results demonstrate that coumarin treatment does not improve outcome in routine femoro-popliteal and femoro-distal reconstructive surgery.     

Endoscopic versus open saphenous vein harvest for femoral to below the knee arterial bypass using saphenous vein graft

BACKGROUND: Although the use of endoscopic vein harvest (EVH) in coronary artery bypass grafting is accepted, few studies have documented the implementation of EVH in peripheral vascular disease surgery. We hypothesized that EVH improves outcomes compared with open vein harvest (OVH) in patients undergoing femoral to below the knee arterial bypass surgery. METHODS: The charts of 144 consecutive patients undergoing infrainguinal bypass surgery over the course of 27 months were reviewed. A femoral to below the knee arterial bypass with saphenous vein was done in 88 patients (29 had EVH, 59 had OVH). The preoperative characteristics evaluated were age, gender, renal function, history of diabetes, hypertension, tobacco use, and previous infrainguinal bypass surgery on the affected side. End points included wound complications, length of hospital stay, operative time, angiographic and operative interventions for graft occlusion, patency rates, limb salvage, acute renal failure, myocardial infarction, and death. RESULTS: Patient characteristics and demographics were similar in the EVH and OVH groups. No operative intervention for occlusion was required in the EVH group (0/29) compared with 13.4% in the OVH group (8/59) (P = .03). At the mean follow-up time of 21 months, primary patency rate was 92.8% in the EVH group and 80.6% in the OVH group (P = .12). No significant differences were found between the EVH and OVH groups in postoperative complications, length of hospital stay, operative time, patency rates, limb salvage, and death. CONCLUSION: Despite our initial concerns of damaging the venous conduit with a minimally invasive approach to saphenous vein harvest, EVH in our experience has resulted in a trend toward improved patency rates and decreased infectious wound complications while affording the benefit of improved cosmesis. An endoscopic approach results in smaller incisions, decreased interventions for occlusion, and improved outcomes compared with OVH. EVH is the procedure of choice for harvesting saphenous vein for femoral to below the knee arterial bypass surgery.     

Results of bypass to the popliteal and tibial arteries with alternative sources of autogenous vein

Purpose: The goal of an all-autogenous policy for infrainguinal arterial bypass requires that many bypasses be performed with alternative autogenous veins (AAV) because an adequate length of ipsilateral or contralateral greater saphenous vein (GSV) is not available. The durability and efficacy of infrainguinal vein bypasses constructed of venous conduits other than a single segment of greater saphenous vein (SSGSV) is, however, questioned.Methods: AAV and GSV bypasses were reviewed from 1980 through 1994. Patients who required bypass to the popliteal or a tibial artery were compared for vascular surgical history and vascular disease risk factors and life-table survival. AAV and SSGSV procedures were compared for indications for surgery, morbidity and mortality rates, limb salvage rates in patients who underwent surgery for limb-salvage indications, subsequent need for revision, and life-table assisted primary patency.Results: Nine hundred nineteen autogenous vein bypasses were performed to the popliteal or a tibial artery 187 (20%) with AAVs, including whole or partial arm vein conduits in 144 grafts (77%). One hundred fourteen AAVs (61%) required vein splicing. The mortality rate was 2% for SSGSV bypasses and 1% for AAV bypasses. The morbidity rate was higher for GSV surgery as a result of increased wound complications (11% vs 5%; p = 0.02). Sixty-seven percent of patients with AAV bypass extremities had undergone previous ipsilateral arterial surgery, compared with 20% of patient with SSGSV bypasses (p = 0.0005). AAV bypasses were more likely to be to a tibial artery (71% vs 45%; p < 0.0001). Twelve percent of SSGSV and 15% of AAV popliteal bypasses required revision (p = NS). The 5-year assisted primary patencies were 82%, 77%, and 63%, with limb salvage rates of 91%, 86%, and 74% for ipsilateral SSGSV, contralateral SSGSV, and AAV femoropopliteal bypasses, respectively. Twelve percent of SSGSV and 30% of AAV tibial bypasses required revision (p = 0.0001). The 5-year assisted primary patencies were 74%, 82%, and 72%, with limb salvage rates of 84%, 92%, and 78% for ipsilateral SSGSV, contralateral SSGSV, and AAV femorotibial bypasses, respectively.Conclusion: AAV bypasses can provide overall results comparable with SSGSV bypasses. (J VASC SURG 1996;23:272-80.)