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.     

The human umbilical vein graft in below-knee femoropopliteal and femorotibial surgery: an eight year experience

The authors present a series of 175 femoropopliteal (below-knee) and 65 femorotibial reconstructions with the human umbilical vein (HUV) graft performed over an eight year period. With a mean follow-up of 36.7 months (range one month to 84 months) the early patency rate of 89% decreased to 54% after five years. Longterm patency was found to be primarily related to the location of the distal anastomosis and the quality of the outflow, showing a statistically significant decrease after repeat revascularization. Early thrombosis, even in the absence of a technical failure and late aneurysmal degeneration remain the major problems associated with the use of the HUV graft. It is therefore recommended that these reconstructions be preserved for patients with advanced ischemia or a limited life-expectancy.     

Vein graft surveillance improves patency in femoro-popliteal bypass

Sixty-three patients undergoing femoro-popliteal bypass using autologous vein were prospectively screened for the development of graft related strictures by clinical assessment, intravenous digital subtraction angiography (IVDSA) and Duplex scanning. Eighteen strictures were identified in 14 grafts. Clinical examination detected only 11% of lesions, IVDSA detected 83% of lesions and Duplex scanning detected all 18 lesions. Seventeen lesions had occurred by 6 months from the time of operation which suggests that screening should begin early. Treatment by percutaneous transluminal angioplasty (PTA) was offered for eight strictures and dilatation was complete in all cases. No stricture recurred in the follow-up period. Cumulative patency in this series of screened and selectively treated vein grafts was compared with a previous series of 216 femoro-popliteal vein grafts and an improvement in 1 year potency of 15% was achieved (log rank test, chi 2 = 5.12, P = 0.02).     

A comparative evaluation of polytetrafluoroethylene, umbilical vein, and saphenous vein bypass grafts for femoral-popliteal above-knee revascularization: a prospective randomized Department of Veterans Affairs cooperative study

PURPOSE: Currently, the choice of a vascular prosthesis for a femoral-popliteal above-knee arterial bypass graft is left to the surgeon's preference, because the available information on comparative evaluations is inconclusive. The Department of Veterans Affairs (VA) Cooperative Study 141 was established to identify whether improved patency exists with different bypass graft materials for patients with femoral-popliteal above-knee bypass grafts. METHODS: Between June 1983 and June 1988, 752 patients at 20 VA medical centers were randomized to receive either an externally supported polytetrafluoroethylene (PTFE; N = 265), human umbilical vein (HUV; N = 261), or saphenous vein (SV; N = 226) for an above-knee femoral-popliteal bypass graft. The indication for the bypass grafting operation was limb salvage in 67.5% of the patients. Patients were observed every 3 months for the first year and every 6 months thereafter. All patients were instructed to take aspirin (650 mg) daily for the duration of the study.Doppler-derived ankle-brachial indices (ABIs) were determined preoperatively and serially postoperatively. A bypass graft was considered to be patent when the Doppler-derived postoperative ABI remained significantly improved (more than 0.15 units higher than their preoperative value) and additional objective information, such as angiograms or operations, did not contradict these observations. Patency failure also included bypass grafts that were removed because of an infection or aneurysmal degeneration. Patency rates were compared by using the Kaplan-Meier life table analysis. RESULTS: The cumulative assisted primary patency rates were statistically similar among the different conduit types at 2 years (SV, 81%; HUV, 70%; PTFE, 69%). After 5 years, above-knee SV bypass grafts had a significantly (P 相似文献   

Renal transplantation for end-stage polycystic kidney disease

From 1963 to 1984, 56 renal transplants were performed in 51 patients with end-stage renal failure due to autosomal dominant polycystic kidney disease (ADPKD). There were 49 cadaver and 7 living-related transplants. Overall patient and graft survival was 88 per cent and 66 per cent at one year, 59 per cent and 49 per cent at five years, respectively. There was no significant difference in patient or graft outcome with cadaver versus living-related donor kidneys. One-year graft success with and without pretransplant bilateral nephrectomy (BN) was 78 per cent versus 58 per cent, respectively (n.s.). Patient survival after return to dialysis after graft loss was not compromised by the earlier performance of BN. In patients who did not undergo pretransplant BN, there were no complications from the retained native kidneys after transplantation. In cadaver recipients, the two-year graft success rate with and without preliminary blood transfusions was 54 per cent versus 61 per cent, respectively (n.s.). Cadaver graft survival with and without adjunctive antilymphocyte globulin (ALG), excluding 3 recipients managed with cyclosporine, was 88 per cent versus 50 per cent at one year, and 70 per cent versus 32 per cent at five years, respectively (p less than 0.05). This beneficial effect of ALG was still evident when only transfused cadaver recipients were analyzed and was achieved with no resulting compromise in patient survival. Follow-up computerized tomography (CT) scanning of the transplant kidney in 10 recipients with a long-term (1-9 years) functioning allograft showed no evidence of recurrent ADKPKD.     

Endovascular repair of aortic allograft aneurysmal degeneration: a case report

Aortoenteric graft fistula remains a dreadful complication of aortic surgery. Good results have been reported using in situ graft replacement with arterial allografts. Late aneurysmal degeneration of the graft itself may necessitate further repair. We report the case of such an aneurysmal degeneration 7 years after implantation of the allograft. Endovascular repair was performed with a Vanguard device; complete exclusion was obtained immediately. At 6-month follow-up, the patient was alive and well. Duplex and computed tomography scans showed an excluded aneurysm with a slight reduction in size. Endovascular stent grafting may be a therapeutic option for treating patients with late allograft degeneration.     

Surgical management of hypothenar and thenar hammer syndromes: a retrospective study of 31 instances in 28 patients

This retrospective study assessed the results of treatment of 29 cases of hypothenar hammer syndrome and two cases of thenar hammer syndrome. Three hands were symptom free, 15 were improved, 11 were unchanged and two were worse at a mean follow-up of 43 (range 4-60) months. Follow-up colour-coded Duplex sonography of revascularizations (n=27) revealed 13 patent, five occluded and one partially thrombosed grafts, seven grafts with aneurysmal dilatations and one coiled graft. Colour-coded Duplex sonography results after venous interposition graft combined with endoscopic thoracic sympathectomy were no better than venous interposition graft alone. All three arterial interposition grafts and two end-to-end-reconstructions were patent. The Duplex outcomes of the revascularizations did not correspond well with the clinical outcomes. Endoscopic thoracic sympathectomy was associated with a high rate of inconvenient side effects.     

Infrapopliteal composite bypass with autologous vein and second generation glutaraldehyde stabilized human umbilical vein (HUV) for critical lower limb ischaemia.

OBJECTIVE: To audit a single center consecutive series of infrapopliteal composite bypasses with second generation glutaraldehyde stabilized human umbilical vein. DESIGN: Retrospective study. PATIENTS: From January 1996 to July 2006 89 femoro-distal bypasses were constructed in 85 patients with HUV and residual vein segments as composite grafts in the absence of sufficient length of autologous vein. METHODS: All patients with infrainguinal bypass operations were registered prospectively. Bypasses to infrapopliteal arteries performed with HUV-composite grafts were reviewed for graft patency, limb salvage, patient survival and possible biodegeneration of the HUV. RESULTS: Early graft thrombosis was noted in 21.3%, necessitating revision surgery. Primary, primary assisted and secondary patency rates were 35%, 40% and 42% respectively, with a limb salvage rate of 87% after 5 years. Graft infection occurred in 7 limbs. Aneurysmal HUV graft degeneration was not detected by duplex scanning. CONCLUSION: HUV-composite bypasses provide acceptable patency and favorable limb salvage rates. Patency was similar to previous series using PTFE-composite bypasses but was significantly inferior to vein bypass. Possible biodegradation of the HUV grafts seems to be of minor clinical relevance.     

Thrombogenicity and related biological properties of heparin bonded collagen coated polyester and human umbilical vein prosthetic vascular grafts

BACKGROUND: Multiple factors contribute to the process of prosthetic graft failure. Some of them are specifically related to the biological behavior of the used materials. To pursue the ideal substitute for the autologous vein graft, many materials have been taken into consideration. Of these, polyester (Dacron) and human umbilical vein (HUV, Dardik) bypass grafts have gained much attention in vascular surgical practice over the years. This study compares the results of both in vivo and in vitro investigations on graft thrombogenicity and neo-intimal formation in collagen-coated heparin bonded Dacron and in HUV bypass grafts. It is an adjunct to our clinical comparison of graft materials in infrainguinal arterial reconstruction. METHODS: In 12 adult Beagle dogs, a patch was sewn onto the abdominal aorta (Dacron, n = 6; HUV, n = 6). At defined interval times, thrombocyte aggregation was measured with nuclear imaging of 99mTechnetium labeled platelets. Post-mortem histological analysis of the interface between the native vessel wall and the patch was performed in all animals. RESULTS: At 4 h (2.67, SD = 0.77) and after 2 weeks (2.21, SD = 0.28) after implantation, significantly higher thrombogenicity was measured in the HUV grafts compared to Dacron grafts (1.98, SD = 0.10 and 1.98, SD = 0.11, P = 0.02 and 0.025, respectively). At 4 weeks, no significant difference could be found (HUV, 2.26; SD = 0.29; Dacron, 2.11; SD = 0.16; P = 0.23). Measurement of 'neo-intimal' thickness after explantation of the patch at 28 days after the initial procedure showed a significant difference: in HUV grafts the mean thickness of the inner lining was 0.76 mm (SD = 0.50), compared to 0.16 mm (SD = 0.10) in the Dacron grafts (P = 0.013). CONCLUSION: HUV grafts showed a higher thrombogenicity at 4 h and 2 weeks after insertion of the graft compared to Dacron grafts. At 4 weeks this difference is not present. After 28 days the inner ('neo-intimal') lining is significantly more pronounced in HUV grafts than in Dacron grafts.     

Femorodistal vein bypass graft stenoses

Eighty femorodistal in situ vein bypass grafts have been evaluated at 3-monthly intervals clinically, with ankle:brachial pressure indices (ABI), by intravenous digital subtraction angiography (IV DSA) and by Duplex scanning. Five grafts (6 per cent) failed in the perioperative period. Nineteen (25 per cent) of the remaining 75 grafts subsequently developed stenoses on IV DSA during the first 12 months. All angiographic stenoses were detected by Duplex scanning using velocity ratio criteria before the development of symptoms or a measurable decline in ABI, i.e. while non-haemodynamically significant. This technique involves scanning the entire length of the graft but allows even minor stenoses to be detected and progression of stenoses can be determined. At a mean follow-up of 12 months (3-18 months), four (7 per cent) of the fifty-six grafts without stenoses occluded. Eight (42 per cent) of the nineteen stenosed grafts either occluded or developed symptoms. None of the occluded grafts in this series could be salvaged. Non-haemodynamically significant vein stenoses can be detected non-invasively, occur frequently and are associated with graft failure.     

Human umbilical vein versus heparin-bonded polyester for femoro-popliteal bypass: 5-year results of a prospective randomized multicentre trial.

PURPOSE: To compare long-term patency of Heparin-Bonded Dacron (HBD) and Human Umbilical Vein (HUV) vascular prostheses in above-knee femoro-popliteal bypass surgery. DESIGN: A prospective randomized multi-centre clinical trial. PATIENTS AND METHODS: Femoro-popliteal bypasses were performed in 129 patients between 1996 and 2001. After randomization 70 patients received an HUV and 59 an HBD prosthesis. Patients were followed up every three months during the first postoperative year and yearly thereafter. The median follow-up was 60 months (range 3-96 months). Graft occlusions were detected by duplex scanning, angiography or surgical exploration. RESULTS: The cumulative primary patency rates were 79%, 66% and 58% at 1, 3 and 5 years postoperatively. Primary patency rates for HUV were 74%, 64% and 58% at 1, 3 and 5 years and 84%, 68% and 58% for HBD, respectively (log-rank test, p=0.745). Overall secondary patency rates were 82%, 72% and 61% at 1, 3 and 5 years postoperatively. The overall cumulative limb salvage at 5 years follow-up was 89% (CI 80%-91%) and was not dependent on graft type. Smoking (p=0.019), number of patent crural arteries (p=0.030) and previous cerebro-vascular events (p=0.030) were significant predictors of graft occlusion. CONCLUSION: There was no difference in long-term graft performance between HUV and HBD for above knee infrainguinal bypass.     

Infrainguinal bypass surgery: factors determining late graft patency

The results of 373 infrainguinal bypass grafts, in a single centre, between 1980 and 1988 are reviewed. One hundred and thirty in situ vein (ISV), 47 reversed saphenous vein (RSV), 118 polytetrafluoroethylene (PTFE) and 78 human umbilical vein (HUV) grafts were used. The indications for surgery were disabling claudication in 25 per cent of patients and limb salvage in 75 per cent. In 36 per cent of operations the distal anastomosis was above the knee and in 64 per cent it was below the knee. Overall 5-year patency rates and limb salvage rates respectively were, for ISV (41 and 69 per cent), RSV (62 and 90 per cent), PTFE (31 and 67 per cent) and HUV (29 and 59 per cent). There was no significant difference in patency among these grafts at the above-knee level, but significant differences between vein and prosthetic grafts were evident below the knee (P less than 0.001). Using a proportional hazards model the three factors that consistently correlated with late graft patency were graft type (P less than 0.001), site of distal anastomosis (P less than 0.001) and distal run-off (P less than 0.001). Overall, the results suggest that prosthetic grafts are a suitable alternative to autogenous vein when the distal anastomosis is above the knee, but vein should always be used, if available, below the knee joint.     

Comparison of duplex ultrasonography and venography in the diagnosis of deep venous thrombosis

Sixty-five patients with suspected deep venous thrombosis (DVT) in 68 limbs were entered consecutively into a study to compare venography with duplex ultrasonography scanning. Both tests were performed on 64 limbs, venography being contraindicated in four. Overall, duplex scanning correctly identified 86 per cent of DVTs diagnosed on venography and correctly excluded 80 per cent with negative venograms. Nearly all errors arose in the diagnosis of calf DVT. In the femoral vein duplex scanning had a specificity of 100 per cent and a sensitivity of 95 per cent. In addition, duplex scanning provided data on the limb not undergoing venography. Of 55 limbs that underwent bilateral duplex scanning, five had thrombus in the femoropopliteal segment and a negative contralateral venogram. In addition, three Baker's cysts were diagnosed. Duplex scanning can be used in patients in whom venography is contraindicated and may also provide information about the contralateral limb. We regard femoropopliteal duplex scanning as sufficiently accurate that treatment can be initiated on the basis of the scan. Duplex scanning should replace venography as the standard method of diagnosing femoropopliteal DVT; radiographic studies should now be required only when the scan result is in doubt.     

Klinische Ergebnisse mit der denaturierten humanen Umbilikalvene (HUV) und der ovinen Kollagenprothese (Omniflow®) als kleinkalibriger prothetischer Gefäßersatz

Prosthetic bypass grafts are frequently used in lower limb bypass surgery and dialysis access surgery in the absence of suitable autologous veins. As alternatives to the available synthetic PTFE or Dacron prostheses, biological vascular prostheses, such as denaturated human umbilical veins (HUV) and ovine collagen prostheses (Omniflow®) have been used during the past two decades. Although biological prostheses exhibit a tendency for early graft thrombosis and aneurysmal degeneration they have proved to be durable vascular conduits. Historical and contemporary results with these biological materials regarding graft patency, limb salvage and biodegeneration are presented.     

Paraileostomy hernia: a clinical and radiological study

Forty-six patients who underwent colectomy with end ileostomy for ulcerative colitis (n = 33) or Crohn's disease (n = 13) have been reviewed for paraileostomy hernia (PIH) formation 1-16 years after surgery. PIH developed in 13 of these patients (28 per cent) and was not related to the original disease or excessive weight gain. Twenty-eight patients underwent limited computed tomography (CT) scanning of the stomal region. Eight of these had a clinically detectable PIH, which was demonstrated on CT. A further two patients had PIH demonstrated on CT which was not detected by clinical examination. The rate of PIH was similar where the stoma emerged lateral to the rectus abdominis muscle (six out of 16 patients, 37 per cent) to where the stoma emerged through the rectus (four out of 12 patients, 33 per cent). Recurrence following operative repair of PIH was common. PIH occurs more frequently than previously supposed. CT can detect PIH and may be useful in evaluating a patient with stoma-related symptoms for occult PIH formation.     

Patterns of patency of 596 vein grafts up to seven years after aorta-coronary bypass.

The long-term behavior of vein grafts and their effect on the native circulation were studied by examining 596 vein grafts in 343 patients at a mean follow-up of 15.4 months, range zero to 84 months. Serial studies were performed on 27 patients with 38 grafts. The over-all graft patency rate was 84 per cent, and the rate after more than 5 years was 89 per cent. The patency rate in asymptomatic patients was 91 per cent compared with 81 per cent in the remainder. The patency of grafts attached distal to total occlusions was 82 per cent (78/82). The angle of origin of the grafts from the aorta did not appear to influence patency or the severity of intimal proliferative changes. In 76 patients with 126 grafts, pre- and postoperative cineangiograms were compared, and changes in the graft and underlying coronary artery classified as Groups 1 to to 6: Group 1, patent graft, bidirectional flow in the grafted vessel, proximal lesion unchanged; Group 2, patent graft, bidirectional flow, proximal lesion progressed to occlusion locally; Group 3; patent graft, distal flow only, occlusion of lesion and segment between graft and lesion; Group 4, graft occluded, native artery unaltered; Group 5, graft occluded, native artery now occluded at lesion and region of anastomosis; Group 6, new distal lesion. Results were as follows; Group 1, 58 per cent; Group 2, 21.2 per cent; Group 3, 5 per cent, Group 4, 12.5 per cent; Group 5, 2.5 per cent; and Group 6, 0.8 per cent. Native coronary arteries undergoing closure (Group 2) had lesions 95 per cent or greater in 93 per cent of patients. The rate of closure of ungrafted lesions was 2 per cent. We believe these results encourage the continued used of vein bypass grafts.     

Limitations of human umbilical vein grafts

Sixty modified human umbilical vein (HUV) grafts were used for arterial reconstruction in 48 patients between December 1979 and December 1981. Forty-four patients had limb-threatening ischemia (rest pain or tissue loss) and four had disabling claudication. Thirty-four patients had HUV grafting after a primary arterial reconstruction had failed. Fourteen had HUV used for their initial arterial bypass. The distal anastomosis was to the popliteal artery in 27 grafts (5 above and 22 below the knee) and the distal calf arteries in 33 (anterior tibial 10, posterior tibial 9, peroneal 14). The cumulative patency rate, calculated by the modified life-table method, was 34% at 1 year and 18% at 2 years. Fifteen patients required major amputation after graft failure; 13 of these healed below the knee. Preoperative and postoperative ankle/brachial systolic pressure indices and intraoperative blood flow did not correlate with graft failure. These results reflect the limitations of HUV as a graft material in patients with severe ischemia of the lower extremities. The prognostic factors that determined the outcome of arterial reconstruction with HUV in these patients remain to be defined.     

Long-term results of living related kidney transplantation: a retrospective study on 114 recipients followed over 10 years

The long-term patient and graft survivals, causes of death, complications and rehabilitation status in the second decade were analyzed in 114 patients who received living related kidney transplants and were followed up for 10 years or longer. Azathioprine and prednisolone were used for basal immunosuppressive therapy in all patients. The actual patient and graft survival rates at 10 years were 76.3 per cent and 50.9 per cent respectively, the main causes of death being serious infection (10 cases), malignant disease (5 cases), cerebral bleeding (4 cases), hepatic failure (3 cases), gastrointestinal bleeding (2 cases) and cardiovascular disorder (2 cases). Four patients died from complications after re-admission for hemodialysis. The cumulative patient and graft survival rates at 15 years in 58 patients whose graft survived for over 10 years were 87 per cent and 75 per cent, respectively. Of the 51 patients still surviving at the end of the study, the complete rehabilitation rate was 90.2 per cent, however, de novo malignant disease and hepatic disorder were significant complications which not only disturbed the patients' quality of life but also reduced their survival rate. Therefore, regular follow-up of patients and appropriate management procedures are necessary to enhance the long-term success of kidney transplantation.     

Improved graft patency and altered remodeling in infrainguinal vein graft reconstruction for aneurysmal versus occlusive disease

PURPOSE: This study attempted to determine whether autogenous vein used for infrainguinal reconstruction in patients with aneurysmal disease might demonstrate an altered adaptive response compared with those patients who underwent reconstructive surgery for occlusive disease, potentially altering graft patency. METHODS: From 1974 to 1997, 43 patients underwent vein grafting for 60 popliteal artery aneurysms (PAA). RESULTS: In an attempt to monitor early vein graft adaptation, serial graft surveillance by Duplex ultrasound scan was performed in a statistically valid subset of age-, sex-, and distal anastomotic site-matched patients with PAA and patients with occlusive disease (OD; n = 8 PAA; n = 8 OD). Compared with an age-matched and sex-matched cohort of patients (n = 60 grafts in each group) with occlusive disease and who had femoral below-knee bypass grafts (FBP) only, patients undergoing infrainguinal reconstruction for PAA had a higher 5-year primary graft patency (92% +/- 4% for PAA vs 66% +/- 7% for FBP; P <.01). Duplex surveillance demonstrated a progressive increase in arterialized vein graft diameter in the PAA group versus the OD group. In univariant analysis, aneurysmal disease was a significant predictor of final follow-up diameter (P =.002). In a linear regression model, controlling for diameter at first follow-up after bypass grafting, first follow-up diameter was also predictive of final follow-up diameter. CONCLUSION: These data suggested altered remodeling of vein grafts in patients with popliteal artery aneurysm, which may have a beneficial effect on patency.     

Experience with central high flow arteriovenous fistulas in patients requiring chronic parenteral chemotherapy or hemodialysis

Fifty central high flow arteriovenous fistulas were constructed using bovine arterial heterograft during the past four years to provide vascular access in forty-four patients requiring cyclic infusion chemotherapy or chronic hemodialysis. Overall long-term patency of thirty-six axillary-axillary and fourteen axillary-internal jugular fistulas was approximately 80 per cent, and of those fistulas that failed, 87 per cent were successfully revised. All failures occurred within the first year after construction and were confined to the group of patients receiving cyclic infusion chemotherapy. Most of the failures could be directly related to constant rather than intermittent use of the fistulas. Complications other than graft occlusion occurred in three patients and prompted surgical intervention—in one patient for brachial artery thrombosis, in one for unilateral facial edema after axillary-internal jugular fistula, and in one for aneurysmal degeneration of the midsegment of one axillary-axillary graft. There was no operative mortality, and there were no septic, hemorrhagic, or significant wound healing complications in this high risk group of patients. Hemodynamic evaluations of both acute and chronic fistulas showed an approximate 20 per cent increase in cardiac output, cardiac index, and right ventricular stroke work index which were subjectively and objectively well tolerated in those patients studied. Ease and comfort of cannulation of these fistulas for blood sampling, infusion chemotherapy, and hemodialysis were uniformly acceptable to both nurses and patients.Central high flow arteriovenous fistulas have proved a safe, durable, well tolerated means of providing vascular access in patients whose usual routes have been exhausted but who remain candidates for cyclic infusion chemotherapy or chronic hemodialysis.