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.     

Vascular homografts: clinical results

The authors review the results of clinical experiences regarding arterial and venous homografts. For the treatment of mycotic aneurysms and infected prostheses, in situ repair with vascular homografts represents a valuable alternative to conventional surgical treatments. In fact the large caliber arterial homografts allow safe in situ reconstruction, decrease early and midterm mortality and reinfection rates; the best results are achieved in case of infected grafts, whereas the prognosis of vasculo-enteric fistula remains very poor. The small caliber arterial homografts also have demonstrated satisfactory results in term of patency, although further experiences with longer follow-up are required. Vein homograft constitutes an alternative by-pass conduit for limb revascularisation in patients who lack adequate autogenous vein: although limb salvage rate is satisfactory, long term patency rate is poor when compared with autogenous veins. Improvement of preservation methodics, pharmacological control of rejection and tissue engineering represent the future perspectives in this field.     

Obturator bypass: a classic approach for the treatment of contemporary groin infection

As the number of cardiac and interventional radiologic procedures has risen, the frequency with which surgeons are called to treat groin complications has increased. Infectious groin problems that often involve foreign prosthetic material or remnants of percutaneous femoral closure devices are particularly challenging and require control of bleeding, removal of foreign material, wide debridement, and sometimes arterial resection. Management of the consequential limb ischemia in such cases is controversial. The purpose of this study is to review the utility of extra-anatomic common femoral bypass through the obturator foramen (obturator bypass) as a method of treating limb ischemia after arterial groin infection. From July 1992 through June 2001 a total of 12 patients (six male) presented with severe vascular infections of the groin and underwent obturator bypass. Infections occurred as a consequence of an isolated vascular graft infection (nine) or after a percutaneous interventional femoral access procedure (three). Patients presented with systemic sepsis and a draining sinus (six), infected pseudoaneurysm (two), or hemorrhage (four). Treatment included debridement of the groin wound, sartorius muscle flap coverage of the femoral vessels, antibiotics and synthetic (eight polytetrafluoroethylene and four Dacron) obturator bypass via a lower abdominal extraperitoneal incision from an aortobifemoral bypass graft limb to the superficial femoral artery (six), native iliac to femoral artery (three), iliac to popliteal artery (two), and aortobifemoral bypass limb to the popliteal artery (one). Graft patency and limb salvage were assessed by Kaplan-Meier life table analysis. There were two (17%) deaths (multisystem organ failure at postoperative days 9 and 6) and four major complications (25%) requiring reoperation in the first 30 days. Ten patients (83%) survived, healed their groin wounds, and are infection free. With a mean follow-up of 37 months graft patency and limb salvage at 60 months were 80 and 60 per cent, respectively. There were no late graft infections. We conclude that the obturator bypass is an effective and durable means of revascularization in the presence of the septic groin. This procedure belongs in the armamentarium of all surgeons managing these complications.     

Short-term and midterm results of an all-autogenous tissue policy for infrainguinal reconstruction

Saphenous vein is the optimal conduit for infrainguinal vascular reconstruction. In instances in which this vein is unavailable or of "poor quality," reliance has been placed on a variety of prosthetic materials for bypass grafting. However, long-term patency with these prosthetic grafts has been disappointing. In January 1985 we instituted a policy of using exclusively autogenous tissue for infrainguinal arterial reconstruction. During the ensuing 3-year period, 203 patients underwent 266 arterial operations below the inguinal ligament, with a prosthetic graft used in only 11 instances (4%). No patient was denied surgery for limb salvage because of a lack of available autogenous vein. Thirty-three percent of procedures were performed for failure of prior revascularization and 73% for limb salvage. The 3-year cumulative primary patency rate for all autogenous procedures was 72%. Procedures were divided into those that used greater saphenous vein (patency 77%) vs autogenous alternatives such as bypass with arm vein or lesser saphenous vein, vein patch angioplasty, and endarterectomy (patency 64%). The operative mortality rate was 1.4% and the 3-year limb salvage rate was 89%. Autogenous infrainguinal reconstruction can be performed in almost every instance with acceptable results, suggesting that the need for prosthetic bypass grafts in the lower extremity is less than has been previously reported.     

OBTURATOR FORAMEN BYPASS IN THE MANAGEMENT OF INFECTED PROSTHETIC VASCULAR GRAFTS

The obturator foramen bypass graft remains an excellent option for revascularking the lower extremity when dealing with an infected prosthetic vascular graft in the groin. In this series, six obturator foramen bypass grafts were performed in five patients for infectious groin complications following vascular surgery. Conservative measures such as local antibiotic irrigation and abscess drainage designed to preserve the graft in situ had failed to eradicate the infection in all instances and was complicated by suture-line haemorrhage in three instances. An aggressive approach should be adopted, aimed at excision of the infected graft. The obturator foramen bypass graft remains a durable graft for limb salvage. Five out of six obturator foramen bypass grafts were patent after 11–26 months follow up.     

Infrascrotal, Perineal, Femorofemoral Bypass for Arterial Graft Infection at the Groin

HYPOTHESIS: Infrascrotal, perineal, femorofemoral bypass is an acceptable procedure for treating infection of a prosthetic arterial graft limited to a unilateral groin. DESIGN: A consecutive sample clinical study with a mean follow-up of 29 months. SETTING: The surgical department of an academic tertiary care center and an affiliated secondary care center. PATIENTS: Nineteen patients with a mean age of 68 years with prosthetic graft infection at the outflow anastomosis on a femoral artery at the Scarpa triangle underwent an infrascrotal, perineal, femorofemoral bypass, with excision of the graft material limited at the groin. The recipient artery was the profunda femoris artery in 12 cases, the superficial femoral in 5, and the distal common femoral artery in 2. MAIN OUTCOME MEASURES: Cumulative survival, recurrence of sepsis, primary graft patency, and limb salvage rates expressed by standard life-table analysis. RESULTS: Postoperative mortality rate was 5%. Cumulative (SE) survival rate was 65% (11.6%) at 3 years. Cumulative (SE) rate of freedom from recurrent sepsis was 88% (8.6%) at 3 years. Cumulative (SE) primary patency and limb salvage rates were 86% (9.4%) and 91% (7.9%), respectively, at 3 years. CONCLUSION: Femorofemoral bypass with an infrascrotal perineal approach is a valuable procedure for the treatment of femoral arterial graft infection limited at a unilateral groin.     

The use of expanded microporous polytetrafluoroethylene for limb salvage: a preliminary report.

Initial laboratory and clinical evaluations of a new prosthetic material, expanded microporous polytetrafluoroethylene (PTFE), for small vessel replacement is promising and encourages further clinical trial. Frequently the autogenous saphenous vein is not available for bypass procedures, and alternative arterial substitutes have not proved reliable for replacement of small vessels. In this study, 15 patients with impending loss of limb and no available saphenous vein underwent revascularization of the lower extremity with expanded microporous PTFE grafts. Thirteen of 15 patients now demonstrate viable extremities with a resulting over-all early patency and limb salvage rate of 87 percent for this series. Follow-up ranges from one to 8 months. Seven patients had diabetes mellitus and eight had atherosclerotic heart disease. Nine grafts crossed the knee joint. In all patients arterial runoff was poor. Six patients had previous femoropopliteal bypasses, five with autogenous veins and one with Dacron velour. Two patients had multiple previous operations that failed, first with autogenous vein and later with fabric grafts. The current limb salvage and patency rate of 87 percent in high-risk patients suggests that expanded PTFE may be the prosthesis of choice when an autogenous vein is not available and possibly an equally good substitute when the venous autograft is available.     

Prosthetic patch remnants to treat infected arterial grafts

PURPOSE: Our previous experience with the traditional management of infected prosthetic arterial grafts, which included graft excision and vein patch repair of the involved artery, was complicated by a high incidence of vein patch rupture. This study assessed the treatment of infected prosthetic grafts with subtotal graft excision and oversewing of small graft remnants. METHODS: During the last 20 years, we treated 53 wounds involving 45 infected prosthetic grafts in 42 patients by means of subtotal graft excision and oversewing of a residual 2- to 3-mm graft remnant (patch) at an intact arterial anastomosis. This technique was selectively used to maintain patency of small-diameter arteries (41 common femoral, five deep femoral, three axillary, two iliac, and two popliteal), which were critical for limb salvage or amputation healing. This strategy avoided difficult dissection of the underlying artery in scarred wounds and obviated the placement of a new patch in an infected field. Graft remnants were polytetrafluoroethylene in 51 cases and Dacron in two cases. Of the 45 grafts, 31 were occluded and 14 were patent. All infected tissue was widely debrided, wet-to-dry dressing changes were performed three times daily, and appropriate intravenous antibiotics were administered for at least 1 week. Secondary bypass grafting procedures were performed as needed to achieve limb salvage. The follow-up period in surviving patients averaged 32 months (range, 1 to 218 months). RESULTS: No complications were directly attributable to prosthetic patch remnants in 92% of cases (49 of 53 cases). Six of 42 patients (14%) died during hospitalization (three of cardiac complications and three of sepsis with multiple organ failure). Two infected pseudoaneurysms developed 8 and 34 months after surgery, and two wounds failed to heal. Sixteen secondary bypass grafting procedures were necessary to achieve limb salvage. Patch oversewing led to limb salvage without the need for secondary revascularization in 26 other cases and to the successful healing of 10 amputated limbs when secondary revascularization was not possible. CONCLUSION: Prosthetic patch remnants are a useful adjunct that simplify management of infected prosthetic grafts, are associated with a low incidence of wound complications, and help maintain patency of essential collaterals to achieve limb salvage or heal an amputation.     

Surgical treatment of methicillin-resistant Staphylococcus aureus infection following infrainguinal arterial reconstruction.

A 64-year-old man was referred to our hospital with Methicillin-resistant Staphylococcus aureus (MRSA) infection following infrainguinal arterial reconstruction. As repeated MRSA sepsis occurred, we decided to remove the infected graft with distal revascularization via circuitous graft tunneling to avoid serious infections and allow limb salvage. An iliofemoro bypass was performed via an extra-anatomical bypass, from just below the iliac crest into the musculus quadriceps femoris using an 8 mm-ringed polyester gelatin polypropylene tube graft, with complete debridement of a groin infection. Postoperative 3-dimentional CT angiography revealed that the prostheses was patent and the patient had an uneventful postoperative course. We concluded that this extra-anatomical bypass was a safe procedure and an excellent option for patients with an infected vascular prosthetic graft in the groin after previous revascularization, like in our case with no available autogeneous vein grafts.     

Endovascular treatment of aneurysms after implantation of an aortic-femoral homograft bypass

CASE REPORT: We report on two rare endovascular procedures concerning aneurysmatic complications of arterial homografts. In both cases infected aortobifemoral grafts were explanted und replaced by cryopreserved aortofemoral homografts on the left side. The revascularisations on the right side were performed with the deep femoral vein in one case, and by desobliteration of the iliac artery in the other case. After 4 and 10 months, respectively, we found aneurysmatic enlargements of the aortic anastomoses. In both cases we excluded a false aortic aneurysm by uniiliac stentgrafts in combination with a femoro-femoral cross-over bypass for the contralateral leg. Both operations were carried out successfully. However, one patient developed an infection of the stent graft. We explanted the stent graft und performed an aortobifemoral bypass procedure with arterial cryopreserved homograft once again. CONCLUSIONS: Both aneurysmatic complications after aortofemoral homograft implantation could be treated successfully by an endovascular approach. Possible late complications caused by the implantation of homografts or by endovascular procedures can be only detected in due time by a follow-up at short intervals.     

Experience with cryopreserved arterial allografts in the treatment of prosthetic graft infections

The authors present a retrospective study on 30 patients with prosthetic graft infection. Included are 25 patients with aortic graft infection, three with infection of a femorodistal bypass and two with infected axillofemoral grafts. There were 23 isolated primary prosthetic graft infections and seven aorto-enteric fistulas. Treatment consisted of graft excision and replacement with cryopreserved arterial homografts, harvested from brain-death multi-organ donors. The in situ technique was used in 27 cases. Eight patients died postoperatively and two deaths were from allograft related complications. The operative mortality rate was 11% for isolated aortic graft sepsis and the early limb salvage rate was 100%. Persistent or recurrent infection was noted in two cases. The mean follow-up of the series was 24.5 months and occlusive complications occurred in five patients (23%), which resulted in two major amputations. Serial CT scans showed abnormalities in six of the 22 survivors, all of them related to the aortic segment of the allograft. It is concluded that in situ reconstruction with cryopreserved arterial allografts represents an acceptable alternative, especially in the treatment of isolated aortic graft sepsis. Continued follow-up towards late deterioration and/or occlusive complications remains mandatory.     

Distal revascularization–interval ligation for limb salvage and maintenance of dialysis access in ischemic steal syndrome

Purpose: Traditional options for treating ischemic steal syndrome related to a functioning dialysis access graft or fistula include banding or ligation. Unfortunately, these techniques usually result in inconsistent limb salvage, loss of a functional access, or both. We report our experience with an alternative method of limb revascularization that eliminates steal while maintaining continuous dialysis access.Methods: Patients who had critical limb ischemia and functioning arteriovenous fistulae (AVF) underwent color-flow duplex scanning, digital photoplethysmography, and arteriography. Arterial ligation distal to the AVF origin eliminated the steal physiologic mechanism while arterial bypass grafting from above to below the AVF revascularized the extremity (distal revascularization–interval ligation [DRIL] procedure).Results: From March 1994 through December 1996, 21 patients with functioning extremity AVFs presented with critical ischemia and steal syndrome. Eleven patients had chronic ischemia with rest pain, paresthesias, or ulcerations related to nine native fistulae (six brachiocephalic, two basilic vein transpositions, one radiocephalic) and two prosthetic bridge grafts (one upper arm, one lower extremity). Acute ischemia developed in 10 patients related to three native fistulae (two brachiocephalic, one radiocephalic) and seven prosthetic bridge grafts (three forearm, three lower extremity, one upper arm). All 21 patients were treated with the DRIL technique. Three of these patients required treatment for ischemia at the time of AVF construction. Nineteen of 21 bypass procedures were performed with autogenous vein, including nine brachial-brachial, three brachial-radial, two radial-radial, two brachial-ulnar, one popliteal-popliteal, one femoral-popliteal, and one femoral-peroneal. Polytetrafluoroethylene grafts were used for one external iliac-popliteal bypass graft and one axillary-brachial bypass graft. Limb salvage and maintenance of a functional fistula were achieved in 100% and 94%, respectively, at 18 months by life-table analysis.Conclusion: The DRIL technique reliably restores antegrade flow to the ischemic limb, eliminates the potential pathway for the steal physiologic mechanism, and maintains continuous dialysis access in these difficult patients.     

Cryopreserved saphenous vein homografts for femoral-distal vascular reconstruction

Cryopreserved saphenous vein homografts may serve as an alternative for femoral distal bypass conduits when suitable endogenous vein is not available. In a preliminary study, 6 patients underwent femoral distal bypass for limb salvage with cryopreserved saphenous vein with patency in 2 patients at 18 and 20 months, respectively. One graft, occluded at 14 months, was salvaged with thrombolytic therapy and percutaneous angioplasty, and is patent 7 months post intervention. Occlusion occurred in 3 grafts at 1 day, 7 days and 4 months, respectively. Reasons for reduced patency of cryopreserved grafts are related to destruction of the cellular components and fibrosis as a result of the cryopreservation and poor distal run-off present in these patients. Due to lower patency as compared to autogenous vein grafts, cryopreserved veins should be reserved for limb salvage when no autogenous vein is available for revascularization.     

Early results with use of gracilis muscle flap coverage of infected groin wounds after vascular surgery

INTRODUCTION: Management of a nonhealing femoral wound after vascular surgery can pose a challenging problem, particularly when there is prosthetic material involved. We prefer to use pedicled gracilis muscle flaps (PGMFs) to cover problematic groin wounds when more conventional management is not possible. METHODS: We describe the technique for using PGMFs to provide groin coverage, report a summary of our short-term and long-term results, and describe why we prefer this reconstructive technique. RESULTS: Twenty PGMFs were placed in 18 patients to treat nonhealing and infected groin wounds. Exposed prosthetic vascular reconstructions were covered with the PGMF in 14 wounds, and in situ autogenous vascular reconstructions were covered in four. Seven wound infections were polymicrobial, 10 had a single gram-positive organism, and one had a single gram-negative organism. Pseudomonas cultured out in four wounds, and Candida in one wound. Two patients had a virulent combination of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococcus. Complete healing was initially achieved in all wounds, and no patient died within 30 days of surgery. Two PGMFs failed, at 2 weeks and 2 months, respectively, one from tension on the flap pedicle and one from acute inflow occlusion. Underlying prosthetic reconstruction was salvaged in 12 of 14 wounds; the remaining wounds with autogenous reconstructions or exposed femoral vessels all closed successfully. At a mean follow-up of 40 +/- 10 months there were no recurrent groin infections. Seven patients died, at 2.5, 3, 8, 12, 14, 22, and 28 months, respectively. CONCLUSION: PGMF transposition is an effective option to cover infected or exposed femoral vessels or salvage prosthetic graft material in the groin. In appropriately selected patients, when complete graft removal and extra-anatomic bypass is not an acceptable option, gracilis muscle flap coverage is a viable alternative. The technique is relatively simple, and morbidity from PGMF harvest is minimal.     

Influence of Patient Characteristics and Treatment Options on Outcome of Patients with Prosthetic Aortic Graft Infection

This study was undertaken to determine the influence of patient characteristics and treatment options on survival and limb loss after treatment of prosthetic aortic graft infection. Fifty-three patients treated for prosthetic aortic graft infection were reviewed. Twenty-three presented with groin infection, 12 with sepsis, 10 with aortoenteric fistula, 4 with limb ischemia, and 4 with pseudoaneurysm. Treatment included staged extraanatomic bypass (EAB) plus graft excision in 23 patients, simultaneous EAB and graft excision in 18, in situ graft replacement in 5, and local therapy only in 7. Axillofemoral bypass was done for revascularization in 53 limbs and axillopopliteal bypass in 16 limbs. The results of this study showed that morbidity and mortality of prosthetic aortic graft infection is influenced by the presentation and type of treatment of the infected graft. Staged axillofemoral bypass (when possible) plus graft excision appears to be associated with acceptable outcome (survival with limb salvage in 74%).     

Polytetrafluoroethylene grafts in the rapid reconstruction of acute contaminated peripheral vascular injuries

Conventional wisdom dictates that autogenous tissue interposition be used in contaminated wounds when direct vascular repair is not feasible. Although there are few reports of successful use of PTFE grafts in grossly contaminated wounds, doubt still exists regarding the use of any prosthetic material in such wounds for reconstruction of vascular injury. Twenty-five vascular reconstructions were performed in 20 patients during a 3.5 year period. These patients had life-threatening multiple trauma and severe local tissue damage along with their arterial and venous injuries in open contaminated wounds after blunt (16 patients) and penetrating (4 patients) trauma. In all patients, 6 mm PTFE was used for interposition bypass for arterial injuries, and in five of these patients, 8 mm PTFE was used for concomitant venous interposition bypass. One patient died and there was one arterial and one venous graft thrombosis in the same patient 3 months after a shotgun blast injury to the groin, but there was no limb loss. All other grafts remained patent without wound infection, sepsis, or anastomatic disruption. Under the circumstances of these peripheral vascular injuries, PTFE was an acceptable choice for primary reconstruction in our patients. Its ready availability in many calibers, sparing of autogenous vein for future use, and its expedience in vascular reconstruction comprise the advantages of using PTFE in multiply traumatized patients without producing the feared evidence of infected prosthetic grafts.     

Vascular prosthetic Graft Infection: Epidemiology,Bacteriology, Pathogenesis and Treatment

Vascular prosthetic graft infection remains a major surgical challenge. Prevention of risk factors and antibiotic therapy can reduce but not eradicate it. Management of infected vascular grafts depends on several factors, including the location of the infected prosthesis, the extent of infection, and the underlying micro-organism. Classic treatment consists of extra-anatomic bypass grafting. The disappointing results due to the high mortality and amputation rate have kindled interest in alternative approaches, such as in situ reconstruction with antibiotic-bonded prostheses, autogenous veins or arterial allografts.

Purpose: We focused on the treatment of aortic graft infection by means of both fresh and cryopreserved arterial allograft. Here, the experience of the Italian Collaborative Vascular Homograft Group is reported. Methods: Between March 1994 and December 2000 seventy-nine patients with aortic graft infection were treated. The results of 68 patients are analysed. Eleven patients were treated with fresh, and 51 with cryopreserved homograft. Emergency surgical procedures were performed in 12 patients (11%). Aortoenteric fistula was diagnosed in 22 patients. The mean interval between the first procedure and the insertion of a homograft for patients with infected aortic graft was 3 years (range 1–15). The mean duration of follow-up was 30 months (range 1–68). Clinical and duplex scanning evaluation were routinely performed. Computer tomography (CT), magnetic resonance (MR), or arteriography were performed on the basis of duplex scanning results.

Results: The analysis was performed on 68 cases for which there were sufficient reliable data. Eleven deaths occurred during the early postoperative period (30days), a mortality rate of 16%. There were also seventeen late deaths, a mortality rate of 25%. Eleven patients had graft occlusion; six cases were successfully treated with thrombectomy. In three cases leg amputation was necessary. The results of fresh and cryopreserved homografts were compared. No significant differences of early postoperative mortality, late mortality, homograft-related mortality, graft failure were observed. The presence of aortoenteric fistula is a negative predicting factor of perioperative early mortality, which causes a rapid decline in the survival curve. Thirty-six months after the surgery the actuarial survival of the patients was 51% and the actuarial patency of the allograft was 41%.

Conclusion: No significant difference in terms of clinical outcome was observed when using fresh, rather than cryopre-served homografts. The only factor that significantly influenced the survival rate appeared to be the aorto-enteric fistula.     

Ankle bypass: should we go the distance?

This report reviewed the results of 47 distal arterial reconstructions to or below the level of the malleolus. The operations were performed by the techniques of popliteal-to-distal bypass (20 procedures) and in situ bypass (27 procedures). Seventy-five percent of patients had gangrene of ischemic ulceration, and all procedures were performed for limb salvage. Seventy-three percent of all patients were diabetic. The patency rates for popliteal-to-distal bypass with reversed saphenous vein were 92 percent at 24 months and 57 percent at 60 months, with a limb salvage rate of 70 percent at 60 months; the patency rates for popliteal-to-distal bypass with PTFE were 53 percent at 12 months and 0 at 36 months, with a limb salvage rate of 53 percent at 36 months; and the patency rate for in situ saphenous vein bypass was 96 percent at 24 months, with a limb salvage rate of 80 percent at 24 months. Early results are promising for ankle bypass using the techniques of popliteal-to-distal and in situ bypass.     

Infrainguinal bypass grafting in patients with end-stage renal disease and critical limb ischaemia: is it worthwhile?

Patients with end-stage renal disease (ESRD) constitute an increasing proportion of patients undergoing infrainguinal bypass surgery for critical limb ischaemia (CLI). The aim of this retrospective study was to determine graft patency, healing of pedal lesions, limb salvage and survival following infrainguinal arterial reconstruction in this high-risk subset of patients. 34 patients with ESRD undergoing 37 bypass procedures for CLI (rest pain 2; tissue loss 35) were identified from the vascular registry. These included 13 femoropopliteal and 24 femorotibial bypasses with autogenous (67.6%) or prosthetic (32.4%) materials. The median age in this series was 62 years and 79% were diabetics. Using life-table analysis, the cumulative primary patency rate was 88% at 1 month and 81% at 2 years. The resulting limb salvage rate amounted to 94 and 86% at 1 month and 2 years, respectively. Healing of the pedal lesions was accomplished in only 50% of patients at 6 months. Toe lesions could be treated more successfully than forefoot and deep heel defects (p = 0.04). With a perioperative mortality of 3/37 cumulative survival rate declined to 21% at 2 years. Late mortality correlated significantly with a history of previous myocardial infarction or congestive heart failure (p = 0.001). Infrainguinal revascularisation can be performed in dialysis-dependent patients with acceptable patency and limb salvage rates. However, bypass grafting should be mainly reserved to patients without severe cardiac disease and to those without extensive tissue loss.     

Cryopreserved arterial homografts. A treatment alternative for infected vascular reconstructions]

Deep wound infection or prosthetic vascular graft infection is one of the most challenging complications in vascular surgery with a substantial early and late morbidity and mortality. Surgical treatment usually consists of complete removal of infected vessels or prosthetic vascular grafts followed by extraanatomic bypass procedures. However, this method is associated with significant mortality and amputation rates. Herein, we report two patients with deep wound and prosthetic vascular graft infection who underwent successful in situ reconstruction with cryopreserved arterial homografts. Although the long-term results are missing, this approach may offer a possible treatment alternative for this potentially life-threatening complication.