Technical consideration in the management of chronic mesenteric ischemia

Our aging population may result in a rise in the prevalence of chronic mesenteric ischemia. This report reviews our contemporary experience with a tailored surgical approach to chronic mesenteric ischemia. The medical records of 17 patients operated on for chronic mesenteric ischemia were retrospectively reviewed. Symptom-free survival and long-term patency documented by duplex scanning when available were also analyzed. Sixteen patients ranging in age from 32 to 80 years were included in the study. Seventy-five per cent of the patients were female. The most common preoperative complaints were postprandial abdominal pain and weight loss. Revascularization was tailored to the arterial anatomy and included bypass to the superior mesenteric artery (SMA) alone (eight), bypass to the celiac artery and SMA (six), SMA reimplantation onto the aorta (one), SMA/inferior mesenteric artery reimplantation (one), and transaortic endarterectomy of the celiac artery/SMA (one). Bypass conduits included Dacron (eight), saphenous vein (four), and polytetrafluoroethylene (two). Bypass grafts originated from the supraceliac aorta in 12 patients; the remaining bypass originated from the left limb of an aortofemoral graft. There was one perioperative death (mortality 5.6%). Follow-up duplex scans at a mean of 34 months (range 1-114) showed no graft thromboses. We conclude that a variety of surgical techniques can provide durable relief of mesenteric ischemia. A tailored approach to revascularization optimizes patency and provides long-term symptom-free survival.     

Distal thoracic aorta as inflow for the treatment of chronic mesenteric ischemia

PURPOSE: Mesenteric revascularization for chronic mesenteric ischemia (CMI) traditionally involves antegrade or retrograde bypass graft originating from the supraceliac or infrarenal aorta. The distal thoracic aorta (DTA) may provide a better inflow source than the abdominal aorta. The purpose of this study was to evaluate the results with the DTA used as inflow for the surgical treatment of CMI. METHODS: All patients undergoing mesenteric revascularization for CMI with grafts originating from the DTA were identified from 1990 to 1999. A ninth interspace thoracoretroperitoneal incision was used for exposure, and distal aortic flow was maintained by use of a partial occlusion clamp. RESULTS: Eighteen consecutive patients with CMI underwent mesenteric bypass grafting with the DTA used as inflow. All patients were admitted with chronic abdominal pain or weight loss, with two (12%) requiring urgent revascularization because of acute exacerbation of chronic symptoms. Fourteen (78%) patients had both celiac and superior mesenteric artery bypass grafts placed, and three (17%) patients had superior mesenteric artery grafts alone. There was one (6%) perioperative death and three (17%) major complications. There was no kidney failure, mesenteric infarction, or spinal cord ischemia. The life-table survival rate was 89%, 89%, and 76% at 1, 3, and 5 years, respectively. All 18 patients remained symptom free and required no additional procedures to assist patency. There was no evidence of graft stenosis or occlusion (100% patency) for those grafts evaluated objectively during the mean follow-up of 34.8 months (range, 1-97 months). CONCLUSIONS: Antegrade mesenteric revascularization with the DTA used as inflow is associated with low morbidity and mortality rates. Furthermore, it provides excellent midterm patency and survival results and should be considered as a primary approach for reconstruction of patients with CMI.     

The Surgical Treatment of Chronic Intestinal Ischemia: Results of a recent series

Due to the rarity of the condition, large and prospective series defining the optimal method of digestive arteries revascularization, for the treatment of chronic intestinal ischemia, are lacking. The aim of this consecutive sample clinical study was to test the hypotesis that flexible application of different revascularization methods, according to individual cases, will yield the best results in the management of chronic intestinal ischemia.

Eleven patients, of a mean age of 56 years, underwent revascularization of 11 digestive arteries for symptomatic chronic mesenteric occlusive disease. Eleven superior mesenteric arteries and one celiac axis were revascularized. The revascularization techniques included retrograde bypass grafting in 7 cases, antegrade bypass grafting in 2, percutaneous arterial angioplasty in 1, and arterial reimplantation in one case. The donor axis for either reimplantation or bypass grafting was the infrarenal aorta in 4 cases, an infrarenal Dacron graft in 4, and the celiac aorta in one case. Grafting materials included 5 polytetrafluoroethylene (PTFE) and 3 Dacron grafts. Concomitant procedures included 3 aorto-ilio-femoral grafts and one renal artery revascularization. Mean follow-up duration was 31 months.

There was no operative mortality. Cumulative survival rate was 88,9% at 36 months (SE 12,1%). Primary patency rate was 90% at 36 months (SE 11,6%). The symptom free rate was 90% at 36 months (SE 11.6%). Direct reimplantation, antegrade and retrograde bypass grafting, all allow good mid-term results: the choice of the optimal method depends on the anatomic and general patient’s status. Associated infrarenal and renal arterial lesions can be safely treated in the same time of digestive revascularization. Angioplasty alone yields poor results and should be limited to patients at poor risk for surgery.     

The surgical treatment of chronic intestinal ischemia: results of a recent series

Due to the rarity of the condition, large and prospective series defining the optimal method of digestive arteries revascularization, for the treatment of chronic intestinal ischemia, are lacking. The aim of this consecutive sample clinical study was to test the hypothesis that flexible application of different revascularization methods, according to individual cases, will yield the best results in the management of chronic intestinal ischemia. Eleven patients, of a mean age of 56 years, underwent revascularization of 11 digestive arteries for symptomatic chronic mesenteric occlusive disease. Eleven superior mesenteric arteries and one celiac axis were revascularized. The revascularization techniques included retrograde bypass grafting in 7 cases, antegrade bypass grafting in 2, percutaneous arterial angioplasty in 1, and arterial reimplantation in one case. The donor axis for either reimplantation or bypass grafting was the infrarenal aorta in 4 cases, an infrarenal Dacron graft in 4, and the celiac aorta in one case. Grafting materials included 5 polytetrafluoroethylene (PTFE) and 3 Dacron grafts. Concomitant procedures included 3 aorto-ilio-femoral grafts and one renal artery revascularization. Mean follow-up duration was 31 months. There was no operative mortality. Cumulative survival rate was 88.9% at 36 months (SE 12.1%). Primary patency rate was 90% at 36 months (SE 11.6%). The symptom free rate was 90% at 36 months (SE 11.6%). Direct reimplantation, antegrade and retrograde bypass grafting, all allow good mid-term results: the choice of the optimal method depends on the anatomic and general patient's status. Associated infrarenal and renal arterial lesions can be safely treated in the same time of digestive revascularization. Angioplasty alone yields poor results and should be limited to patients at poor risk for surgery.     

Use of the ascending aorta as bypass inflow for treatment of chronic intestinal ischemia

PURPOSE: Surgical revascularization of intestinal arteries is an effective long-term treatment for chronic intestinal ischemia (CII) regardless of the technique used. Conventional antegrade or retrograde bypass techniques are the most common modalities for extensive lesions that cannot be treated by endarterectomy or transposition. In this report, we describe our experience with an antegrade bypass technique from the ascending aorta in patients with no other available inflow. METHODS: From April 1990 to May 2004, we performed antegrade bypass from the ascending aorta to the celiac artery, superior mesenteric artery (SMA), or both in five patients. These cases accounted for 2.4% of the 211 patients who underwent surgery on intestinal arteries during the study period. Results: Four patients presented with symptomatic CII, and one patient had no intestinal ischemic symptoms. The underlying disease was Takayasu disease in two cases, Erdheim-Chester disease in one case, chronic aortic dissection in one case, and atherosclerosis in one case. Two patients had already undergone an unsuccessful revascularization attempt with another technique. Bypass was performed alone in three cases in association with revascularization of the ascending aorta, aortic arch, and proximal descending thoracic aorta in one case and in association with revascularization of the ascending aorta and proximal aortic arch and renal autotransplantation in one case. Recovery was uneventful in all cases. One venous graft occluded because of technical defects and required reoperation for prosthetic graft replacement on the 10th postoperative day. Symptoms of CII resolved in all cases. Four months after the procedure, one patient underwent dilatation of an asymptomatic stenosis of the SMA distal to the bypass. During the 50th month after the procedure, a new re-stenosis of the SMA appeared. Left untreated, this stenosis led to asymptomatic occlusion of the mesenteric segment of a sequential aortoceliomesenteric bypass 13 months later. This aortoceliac bypass and the other four bypasses were patent after 4, 31, 46, 52, and 120 months of follow-up. CONCLUSION: Antegrade intestinal artery bypass from the ascending aorta is an effective alternative for patients who have no other available inflow for conventional antegrade or retrograde bypass and for patients in whom major technical difficulties are likely after multiple exposures of the thoracoabdominal aorta. Although indications are uncommon, antegrade intestinal artery bypass can provide durable revascularization of the intestine.     

Long-Term Results of Aorta-Superior Mesenteric Artery Bypass Using a New Route

Purpose Several methods of revascularization after mesenteric ischemia have been proposed. Using a new route, we performed retrograde loop bypass grafting to the superior mesenteric artery (SMA) with a ringed expanded polytetrafluoroethylene (ePTFE) graft.Methods We anastomosed the graft to the infrarenal aorta, which ran behind the left renal hilum, turned ventral, and was anastomosed to the SMA in an antegrade fashion hemodynamically. Five patients underwent this procedure, which resulted in remarkable symptomatic relief.Results There were no postoperative deaths or serious complications, although some patients suffered paralytic ileus. All of the grafts remained patent during long-term follow-up, ranging from 17 to 72 months (mean: 37.8 months). Postoperative angiograms showed good configuration of the graft, which did not compress the renal vessels.Conclusion Infrarenal aorta-SMA bypass relieved mesenteric ischemia and achieved good long-term graft patency. Thus, we consider it to be an effective and durable vascular procedure to reduce postoperative mortality and morbidity.     

Surgical revascularization for chronic intestinal ischemia

AIM: The aim of this study was to assess outcome after surgical revascularization for chronic intestinal ischemia (CII). METHODS: From 1980 until 2003, 34 patients underwent revascularization for CII. Records were reviewed for operative technique, perioperative mortality and long-term outcomes. CII was diagnosed on the basis of clinical, arteriographic and angio-magnetic resonance imaging (MRI) criteria. Revascularization patency was monitored by arteriography, color duplex ultrasound scanning (CDS), computed tomography (CT)-scanning or angio-MRI. RESULTS: The celiac artery (CA) was severely diseased in 26 cases and the superior mesenteric artery (SMA) in 30 cases. Four patients presented single-vessel, 15 patients two-vessel, and 15 three-vessel involvement. Revascularization was performed by either simple (N=15) or double (N=19) bypass grafting. In 2 patients bypass grafting was combined with reimplantation. One patient underwent reimplantation alone. Median follow-up was 45 months. The 30-day mortality rate was 3%; there were 22 late death (64%). Primary revascularization patency was 94% at 1 month and 79.4% at 4 years. Clinical success rates were 85% and 70% respectively at 1 month and at 4 years. CONCLUSION: To choose the most suitable intervention, the Authors distinguished isolated CII treatable by single SMA revascularization from the digestive arteritis affecting the supramesocolic level of the abdomen, which requires double CA and SMA revascularization.     

Surgical treatment of chronic mesenteric arterial insufficiency

The treatment of 41 patients with chronic mesenteric insufficiency is reviewed: 20 men and 21 women with a mean age of 59 years were treated and observed for an average of 42 months. Thirty-one patients had symptoms of intestinal angina whereas 10 patients underwent prophylactic revascularization during other aortic operations. All but one patient had revascularization of the superior mesenteric artery, alone or in combination with another revascularization. Various surgical techniques were used, including retrograde bypass in 24 patients, antegrade bypass in 11 patients, and endarterectomy in the remaining six patients. Seven patients had acute abdominal symptoms and required emergency operation while in the hospital awaiting elective revascularization. There were two deaths in the perioperative period (4.9%), both caused by bowel necrosis. Six patients are known to have had late revascularization failure, resulting in recurrent symptoms in three patients and two subsequent deaths. All patients who remained asymptomatic after late graft failure had undergone multiple vessel revascularization; no patient revascularized prophylactically had symptoms of intestinal angina during the follow-up period. Early mesenteric revascularization is a safe and effective method of relieving the symptoms of chronic visceral ischemia and may prevent the development of fatal bowel necrosis.     

Inverted T graft: novel technique using composite radial and internal thoracic arteries

BACKGROUND: Multiple arterial revascularization is feasible because of the excellent long-term patency of the arterial grafts compared with venous grafts. We present a new operative technique for multiple arterial revascularization using composite radial and internal thoracic arterial grafts. METHODS: Between January and September 1997, 12 patients had coronary artery bypass grafting with inverted T graft. The indications for inverted T graft were aortic calcification in 4 patients, repeat coronary artery bypass grafting in 1 patient, and total arterial revascularization in 7 young patients. The inverted T graft was constructed by interconnecting the coronary arteries and radial artery with end-to-side and side-to-side anastomoses, and by anastomosing the internal thoracic artery to the side of radial artery. RESULTS: Overall, 38 distal anastomoses (average number per patient, 3.2) were made with an inverted T graft. There were no deaths or perioperative myocardial infarctions. Postoperative angiography disclosed that all of the anastomoses were patent. CONCLUSION: This technique allows multiple arterial revascularizations without technical difficulty. It is useful in patients with aortic calcification, repeat coronary artery bypass grafting patients, and young patients who are candidates for total arterial revascularization.     

Open surgery for atherosclerotic chronic mesenteric ischemia

BACKGROUND: This study was undertaken to document the results of our current practice of open mesenteric revascularization to enable comparison with the recent trend of percutaneous endovascular therapy for the treatment of chronic mesenteric ischemia. METHODS: Patients were identified via operation code data as well ongoing audit data from 1992 until 2006. Only patients with a history of chronic mesenteric ischemia secondary to atherosclerosis for 3 months or longer were included in the study. Follow-up data have been collected prospectively and include clinical examination and history, as well as graft surveillance consisting of mesenteric duplex ultrasonography, computed tomography, and/or angiography every 6 months for 3 years and then yearly thereafter. RESULTS: Thirty-nine consecutive patients underwent 41 open revascularization procedures for chronic mesenteric ischemia, comprising 67 bypass grafts. The mean patient age was 65 years (range, 45-85 years), and 44% (n = 17) were male. Symptoms were present on average for 11 months (range, 4-48 months) before treatment. The average weight loss was 11.4 kg, and three patients (7.6%) also had evidence of ischemic enteritis. There was one perioperative death, thus giving a perioperative mortality rate of 2.5%. Perioperative morbidity occurred in five patients (12.2%). Primary graft patency was 92% at 5 years. Seven patients died during follow-up, which ranged from 4 to 161 months (mean, 39 months)-one (2.5%) from mesenteric ischemia. Two (5%) other patients have had recurrent mesenteric ischemic symptoms. CONCLUSIONS: Open surgical mesenteric revascularization by bypass grafting for atherosclerotic-induced chronic mesenteric ischemia can be performed with low mortality and morbidity and provides excellent long-term primary patency rates and symptom-free outcomes. Pending more data on the acute and long-term results of endovascular techniques, open mesenteric revascularization remains the gold standard for most patients with chronic mesenteric ischemia.     

Surgery of popliteal artery aneurysms: a 12-year experience

BACKGROUND: Management of asymptomatic popliteal aneurysm is controversial, and the prognosis for acutely thrombosed aneurysm is notoriously poor. We evaluated the management and outcome for popliteal aneurysm. PATIENTS AND METHODS: A retrospective review of all patients with popliteal aneurysm between 1988 and 2000 was carried out. Fifty-two limbs were operated on in 41 patients. Data collected included findings at presentation, operative details, graft patency, limb salvage, complications, and 30-day mortality. RESULTS: Initial findings included acute ischemia (n = 14), no symptoms (n = 29), acute rupture (n = 2), chronic ischemia (n = 5), and symptoms of nerve or vein compressive (n = 2). All patients with symptomatic aneurysms and 22 patients with asymptomatic aneurysms (21 larger than 2 cm in diameter, 1 with thrombus at duplex ultrasound scanning) underwent surgery as first-line treatment. Of the 7 patients with asymptomatic aneurysm managed with surveillance with duplex ultrasound scanning, acute ischemia developed in three, 1 aneurysm ruptured, compressive symptoms developed in 1, and 2 remained asymptomatic but required surgery because of aneurysm enlargement (>2 cm). Of the 17 patients with acute ischemia, 13 had neurologic signs and underwent immediate thromboembolectomy (trifurcation alone in 8, ankle-level arteriotomy in 4) and bypass grafting (n = 12) or inlay grafting (n = 1), and the other 4 underwent intra-arterial thrombolysis initially. Of these 4 procedures, 2 were successful and had elective surgery; the other 2 required urgent surgery because of secondary distal embolism and failure of recanalization. Thirteen of the 17 grafts were to the crural vessels. Bypass grafting (medial approach) was used in 16 of the 17 patients with acute ischemia, all 5 patients with chronic ischemia, and the 8 patients with no symptoms. An inlay technique (posterior approach) was used in 16 patients with no symptoms, the 3 patients with symptoms of nerve or vein compression, and 1 patient with acute ischemia. The distal anastomoses were to the below-knee popliteal artery in 35 patients and the crural arteries in 15 patients, using autologous vein. Two of the patients with rupture underwent ligation alone, the other undergoing bypass grafting in addition. The overall 5-year primary patency rate was 69%, secondary patency rate was 87%, and limb salvage rate was 87%. Limb salvage was achieved in 14 of the 17 patients with acute ischemia. Patients with asymptomatic aneurysms had better secondary graft patency (100%) compared with symptomatic aneurysms (74%; P <.01). Acute ischemia, technique used, and crural artery grafts were not predictors of graft failure with either univariate or multivariate analysis. Symptomatic aneurysms were associated with more postoperative complications and greater 30-day mortality (4 of 28 vs 0 of 24). CONCLUSION: Thromboembolectomy followed by crural bypass grafting is an effective treatment for popliteal aneurysm with severe acute limb ischemia. Outcome is better with surgical management of asymptomatic popliteal aneurysm compared with symptomatic aneurysm.     

The consequences of a failed femoropopliteal bypass grafting: comparison of saphenous vein and PTFE grafts

OBJECTIVES: Although there are numerous reports comparing saphenous vein (SV) and polytetrafluoroethylene (PTFE) with respect to the patency rates for femoropopliteal bypass grafts, the clinical consequences of failed grafts are not as well described. This study compares the outcomes of failed SV and PTFE grafts with a specific emphasis on the degree of acute limb ischemia caused by graft occlusion. METHODS: Over a 6-year period, 718 infrainguinal revascularization procedures were performed, of which 189 were femoropopliteal bypass grafts (SV, 108; PTFE, 81). Society for Vascular Surgery/International Society for Cardiovascular Surgery (SVS/ISCVS) standardized runoff scores were calculated from preoperative arteriograms. Clinical categories of acute limb ischemia resulting from graft occlusion were graded according to SVS/ISCVS standards (I, viable; II, threatened; III, irreversible). Primary graft patency and limb salvage rates at 48 months were calculated according to the Kaplan-Meier method. RESULTS: Patients were well matched for age, sex, and comorbidities. Chronic critical ischemia was the operative indication in most cases (SV, 82%; PTFE, 80%; P =.85). Runoff scores and preoperative ankle-brachial index measurements were similar for the two groups (SV, 6.0 +/- 2.5 [SD] and 0.51 +/- 0.29; PTFE, 5.3 +/- 2.8 and 0.45 +/- 0.20; P =.06 and P =.12). The distal anastomosis was made below the knee in 60% of SV grafts and 16% of PTFE grafts (P <.001). Grade II ischemia was more likely to occur after occlusion of PTFE grafts (78%) than after occlusion of SV grafts (21%; P =.001). Emergency revascularization after graft occlusion was required for 28% of PTFE failures but only 3% of SV graft failures (P <.001). Primary graft patency at 48 months was 58% for SV grafts and 32% for PTFE grafts (P =.008). Limb salvage was achieved in 81% of SV grafts but only 56% of PTFE grafts (P =.019). CONCLUSIONS: Patients undergoing femoropopliteal bypass grafting with PTFE are at greater risk of ischemic complications from graft occlusion and more frequently require emergency limb revascularization as a result of graft occlusion than patients receiving SV grafts. Graft patency and limb salvage are superior with SV in comparison with PTFE in patients undergoing femoropopliteal bypass grafting.     

Preferential use of nonreversed vein grafts in above-knee femoropopliteal bypasses for critical ischemia: midterm outcome

We evaluated nonreversed vein grafts in above-knee bypasses for chronic critical limb ischemia in a retrospective study with intention-to-treat analysis in patients who underwent above-knee bypass grafting. During a 4-year period, 51 patients (men, 32; women, 19; mean age = 66 years) with 53 critically ischemic lower extremities underwent above-knee femoropopliteal bypass grafting. The follow-up evaluation consisted of clinical examination, assessment of the ankle-brachial systolic blood pressure index, and, whenever necessary, duplex scanning. Three (5.7%) deaths occurred within 30 days, two from myocardial infarction and one from an undetermined cause. The 2-year cumulative success rate was 82.5 +/- 9.6% for primary patency, 84.6 +/- 8.9% for secondary patency, 90.1 +/- 7.3% for tertiary patency, 86.9 +/- 7.6% for limb salvage, 77.7 +/- 8.4% for survival, 68.0 +/- 11.1% for composite patency, and 68.4 +/- 9.3% for amputation-free survival; the corresponding estimates for vein grafts alone were 86.6 +/- 9.2%, 88.9 +/- 8.6%, 89.0 +/- 8.5%, 88.1 +/- 8.1%, 81.1 +/- 9.1, 76.8 +/- 11.1%, and 72.6 +/- 10.2%. Three prosthetic grafts failed and were replaced with an arm vein graft. Nonreversed vein bypass grafts in above-knee revascularization of critically ischemic limbs are justified.     

Role of supraceliac aortic bypass in visceral artery reconstruction.

Twelve patients underwent transabdominal, supraceliac aortomesenteric bypass for celiac and superior mesenteric artery occlusive disease. Nine patients had bypass for intestinal ischemia (five acute, four chronic), and one patient each had bypass for arcuate ligament syndrome, thoracoabdominal aneurysm, and an infected aortic stump "blowout." Three aortoceliac, 9 aortohepatic, and 10 aortosuperior mesenteric artery bypasses were performed. Prosthetic grafts were used for the bypasses in 11 of the 12 patients. One death occurred in a patient with preexisting hepatic necrosis and renal failure secondary to acute mesenteric ischemia. During a mean follow-up of 26 months, one graft thrombosis occurred and required revision for recurrent symptoms. Supraceliac aortomesenteric bypass appears to be a safe and effective procedure for visceral revascularization.     

Result of bypass grafting for upper limb ischemia

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

Long-term outcome after treatment of aortic graft infection with staged extra-anatomic bypass grafting and aortic graft removal

OBJECTIVE: The purpose of this study was to determine long-term outcome in patients with infected prosthetic aortic grafts who were treated with extra-anatomic bypass grafting and aortic graft removal. METHODS: Between January 1989 and July 1999, 36 patients were treated for aortic graft infection with extra-anatomic bypass grafting and aortic graft removal. Extra-anatomic bypass graft types were axillofemoral femoral (5), axillofemoral (26; bilateral in 20), axillopopliteal (3; bilateral in 1) and axillofemoral/axillopopliteal (2). The mean follow-up was 32.3 +/- 4. 8 months. RESULTS: Four patients (11%) died in the postoperative period, and two patients died during follow-up as a direct consequence of extra-anatomic bypass grafting and aortic graft removal (one died 7 months after extra-anatomic bypass graft failure, one died 36 months after aortic stump disruption). One additional patient died 72 months after failure of a subsequent aortic reconstruction, so that the overall treatment-related mortality was 19%, whereas overall survival by means of life table analysis was 56% at 5 years. No amputations were required in the postoperative period, but four patients (11%) required amputation during follow-up. Twelve patients (35%) had extra-anatomic bypass graft failure during follow-up, and six patients underwent secondary aortic reconstruction (thoracobifemoral [2], iliofemoral [2], femorofemoral [2]). However, with the exclusion of patients undergoing axillopopliteal grafts (primary patency 0% at 7 months), only seven patients (25%) had extra-anatomic bypass graft failure, and only two patients required amputation (one after extra-anatomic bypass graft removal for infection, one after failure of a secondary aortic reconstruction). Furthermore, primary and secondary patency rates by means of life table analysis were 75% and 100% at 41 months for axillofemoral femoral grafts and 64% and 100% at 60 months for axillofemoral grafts. Only one patient required extra-anatomic bypass graft removal for recurrent infection, and only one late aortic stump disruption occurred. CONCLUSIONS: Staged extra-anatomic bypass grafting (with axillofemoral bypass graft) and aortic graft removal for treatment of aortic graft infection are associated with acceptable early and long-term outcomes and should remain a primary approach in selected patients with this grave problem.     

Radial artery patency: are aortocoronary conduits superior to composite grafting?

BACKGROUND: The radial artery (RA) can be used as either an aortocoronary (RA-Ao) or composite graft (T graft). Optimum use for the RA has yet to be established. We compared RA patency with these two techniques. METHODS: Between October 1993 and June 2001, 1505 patients underwent coronary artery bypass grafting using the RA as either a composite (n = 1022) or RA-Ao graft (n = 483). Angiograms performed on 203 (13.5%) patients with signs or symptoms of ischemia at an average of 26.1 +/- 18.5 months postoperatively were reviewed. RESULTS: Patients with RA-Ao grafts had a greater incidence of postoperative angiography versus patients with composite grafts (19% versus 11%; p < 0.01). Patients receiving T grafts had a greater number of anastomoses per patient (4.1 +/- 0.6 versus 3.0 +/- 1.0; p < 0.01) and a higher incidence of total arterial revascularization (100% versus 41%; p < 0.01). Regardless of grafting strategy, patency was significantly worse for targets of the right coronary artery (58% T graft; 67% RA-Ao; p < 0.01 for both) and for targets with less than or equal to 70% stenosis (59% T graft; 57% RA-Ao; p < 0.01 for both). The site of proximal anastomosis failed to effect RA patency (relative risk, 1.2; 95% confidence interval, 0.7 to 1.8; p = 0.50). CONCLUSIONS: The site of the proximal anastomosis does not appear to influence patency. Both RA-Ao and composite conduits are sensitive to target location and stenosis. Advantages of composite grafting include greater conduit length and minimizing aortic manipulation at the expense of increased complexity and the potential for hypoperfusion. These factors should be considered when choosing an RA grafting strategy.     

Splenic artery-to-superior mesenteric artery bypass for chronic mesenteric ischemia--a case report

Chronic mesenteric ischemia (CMI) is a serious vascular condition that if left untreated may progress to acute ischemia resulting in bowel necrosis and high surgical morbidity/mortality rates. Elective intervention has been shown to prevent this progression and relieve symptoms. Current open surgical intervention involves arterial bypass using a vein or synthetic graft conduit with the inflow originating from the aorta or iliac artery. In some circumstances, the splenic artery provides an additional treatment option for revascularization of the superior mesenteric artery. In certain cases, the splenic artery has several advantages over traditional surgical options. The splenic artery is an arterial conduit much like the internal mammary artery used in coronary artery bypass grafting. These grafts are known for their long-term patency and in selected clinical circumstances are preferred over venous grafts. Because the splenic artery has a natural inflow, only a single vascular anastomosis at the outflow vessel (the SMA) is necessary. This lessens the risk of anastomotic stenosis by decreasing the number of anastomoses created and it makes the procedure shorter in duration. The fact that the inflow is provided by the splenic artery makes cross-clamping of the aorta unnecessary, thereby lessening the risk of producing cardiac ischemia and declamping hypotension. A disadvantage is the risk of splenic ischemia with the possible need for splenectomy. The majority of individuals will have adequate collateral supply to the spleen via the short gastric arteries. The risk to the patient of splenectomy versus the benefits of a less complicated arterial reconstruction with avoidance of aortic cross-clamping must be weighed on a case-by-case basis. Preventing the progression to acute mesenteric ischemia with its increased mortality by timely restoration of adequate vascular supply is an important principle in treating patients with CMI. Controversy still exists over the best treatment option for these patients, whether it be antegrade versus retrograde bypass, single-vessel versus multivessel reconstruction, or open surgical repair versus endovascular intervention. In selected patients, the use of the splenic artery can be considered as an additional option for arterial reconstruction of the SMA.     

Pediatric splanchnic arterial occlusive disease: clinical relevance and operative treatment

OBJECTIVE: Splanchnic arterial occlusive disease is rare in childhood. The purpose of this study was to review the clinical relevance and operative treatment of these lesions in a unique experience from a single institution. METHODS: Seventeen children (11 boys and 6 girls) from 2 years to 17 years in age with critical narrowings of the celiac artery (CA) and superior mesenteric artery (SMA) underwent treatment at the University of Michigan from 1974 to 2000. Etiologic factors included embryologic fusion abnormalities of the fetal aortae during formation of the splanchnic arteries (n = 15), inflammatory aortoarteritis (n = 1), and radiation-induced arterial fibrosis (n = 1). Individual lesions included CA occlusions (n = 6) and stenoses (n = 7), SMA occlusions (n = 3) and stenoses (n = 11), and inferior mesenteric artery stenosis (n = 1). Fourteen children had abdominal aortic coarctations, and 15 had renal artery stenoses. Two patients had postprandial abdominal discomfort and food aversion, consistent with intestinal angina. Small stature affected five others, perhaps attributable to severe renovascular hypertension and failure to thrive. Ten children underwent intestinal revascularization, at the time of an aortoplasty or thoracoabdominal bypass for aortic coarctation (n = 7) or at the time of renal artery revascularization (n = 8). Primary splanchnic revascularization procedures included SMA-aortic implantation (n = 3), aorto-SMA and CA bypass with an internal iliac artery graft (n = 3) or a saphenous vein graft (n = 1), CA-aortic implantation at a stenotic SMA origin (n = 2), and CA and SMA intimectomy (n = 1). Secondary operations included SMA-aortic implantation (n = 2). RESULTS: All 10 children who underwent splanchnic revascularization have thrived, gained weight, and are free of abdominal pain, with follow-up periods averaging 9 years. No intestinal ischemic manifestations occurred in the seven children who did not undergo operation. CONCLUSION: Pediatric splanchnic arterial occlusive disease is a rare illness appropriately treated with operation in properly selected children.     

Early results of lower extremity infrageniculate revascularization with a new polytetrafluoroethylene graft

When an autologous vein is not available for lower extremity revascularization, prosthetic grafts are often required. However, prosthetic bypass grafts have limited patency for infrageniculate reconstruction. To potentially improve patency, a new geometric modification of the polytetrafluoroethylene (PTFE) graft, Distaflo (Impra, Tempe, AZ), has been developed for lower extremity bypass. We reviewed our early experience with the Distaflo graft in patients who required infrageniculate bypass for lower extremity ischemia when no suitable autologous saphenous vein was available. All patients were maintained on warfarin anticoagulation postoperatively. All grafts were followed at 6- to 12-week intervals with duplex ultrasound evaluation. Patient characteristics, operative procedures, and graft surveillance information were maintained on a computerized registry. Thirty-two patients with limb-threatening ischemia underwent 35 infrageniculate reconstructions with a Distaflo graft between February 26, 1999, and August 24, 2000. Thirty-two of 35 bypasses were performed on extremities that had previously undergone a surgical procedure. Forty-eight previous revascularization procedures were done on these 25 extremities. Thirty grafts were constructed to the tibial outflow sites, whereas the remaining five grafts were placed to the below-knee popliteal artery. One patient died on the second postoperative day secondary to unrelated causes, and only one graft (3%) failed during the same hospitalization. Fifteen of 35 grafts (43%) remained patent 1 to 30 months later. Four patent grafts (6%) were ligated between 2 and 14 months for infectious indications. When considering the 20 failed grafts, 9 patients underwent major amputation, 5 patients remain with chronically ischemic limbs, and 6 patients underwent additional bypass grafts. Twenty-three patients (72%) maintained limb salvage. The Distaflo PTFE graft achieves promising early patency for complex infrageniculate revascularization and may be used as an alternative conduit in patients with critical limb ischemia who do not have an adequate vein for lower extremity revascularization.