Survival and limb salvage in patients with infected arterial prostheses

A series of 590 cases with a 2.5% rate of infection of arterial prostheses is presented. When one of the anastomoses was in the inguinal area, the incidence of prosthetic infection was higher. Two infections not involving the anastomotic site healed with conservative management. The three patients with aortoduodenal fistulas died. The long-term survival was 62%, and the amputation rate was 31%. During the last two years, a more aggressive surgical approach of total removal of the infected prosthesis and its replacement with an extraanatomic bypass has been instituted. With this approach, only one death and one amputation has occurred in six patients.     

Coronary revascularization with arterial graft alone]

In the period from December 1989 until July 1991, coronary revascularization were performed on 56 patients using arterial grafts and no venous grafts. The ages of the patients ranged from 43 to 85 years (average; 66.8 years), and there were 33 males and 23 females. Twenty-four patients had angina pectoris, 23 had old myocardial infarction and 9 had acute infarction. There were 3 patients with single-vessel coronary disease, 19 with double-vessel, 31 with triple-vessel and 9 with left main coronary disease. The bypass grafts used were 58 left internal thoracic artery (LITA) grafts, 29 right internal thoracic artery (RITA) grafts, and 56 right gastroepiploic artery (RGEA) grafts. Thus, 143 grafts were used and an average of 2.6 bypasses were created per patient. There were two operative deaths. One of these patients had acute myocardial infarct. Investigation of postoperative graft patency was performed in the 122 grafts that could be examined angiographically after surgery. Only 7 were obstructed, yielding a patency rate of 94.3%. By using both the ITA and RGEA, in situ anastomoses with all the coronary arteries could be performed. Also in emergency surgery arterial grafting was possible. This operative form is considered to be a useful technique and may be expected to produce favorable long-term results.     

Total arterial myocardial revascularization using new composite graft techniques for internal mammary and/or radial arteries conduits

BACKGROUND: Total arterial myocardial revascularization (TAMR) is feasible because of the excellent long-term patency of the arterial conduits. We present five new surgical configurations for TAMR. METHODS: Between December 1998 and July 1999, 34 patients with triple vessel disease underwent TAMR. All patients were in CCS III or IV. Sketelonized internal mammary arteries (IMAs) were used. The surgical techniques for TAMR consisted of Y or T composite grafts constructed between the in situ RIMA and free LIMA graft or radial artery (RA) conduit in three different configurations. Other techniques uses included a T graft constructed between the RA conduit and free LIMA graft in two configurations. Twenty-six (76%) patients underwent contrast-enhanced TTE color Doppler before and after adenosine provocative test, and seven (20%) patients had postoperative coronary angiography. RESULTS: Overall, 144 anastomoses (average number per patient, 4.2) were completed. One (2.9%) patient undergoing an inverted T graft technique died on postoperative day 2. Another patient (2.9%) undergoing the right Y graft technique using IMAs and RA suffered perioperative AMI due to RA conduit vasospasm. Contrast-enhanced TTE color Doppler before and after the adenosine provocative test and at 1 week postoperation revealed a coronary flow reserve (CFR) of 2.1 +/- 0.2 in the LIMA stem, and in the RIMA stem, a CFR of 2.3 +/- 0.3 (P < 0.007). In one patient undergoing the right Y graft technique using IMAs, we found only anomalous flow dynamic parameters of RIMA, suggesting a partial graft closure. The angiographic examination revealed a free LIMA graft closure. At 6 +/- 2.4 months after operation 33 patients were alive and free of angina. The IMAs stem evaluation by TTE color Doppler at follow-up revealed a 2.45 +/- 0.1 mm LIMA diameter and 2.6 +/- 0.2 mm RIMA diameter, which was more than early postoperative data of P < 0.001 and P < 0.007, respectively. CONCLUSION: These data indicate that TAMR in young patients perhaps offers a better postoperative outcome and perhaps should be part of the surgical armamentarium. These techniques apply the "nontouch" principle and should be taken into consideration in patients with a heavily calcified aorta. Contrast-enhanced TTE color Doppler is a safe, accurate, and noninvasive test, which allows assessment of IMA patency and CFR evaluation. The flow reserve of the IMAs seems to be adequate for multiple coronary anastomoses.     

Free arterial graft with domino patch for coronary revascularization

To improve the outcomes of coronary revascularization with free arterial grafts, we have devised a composite method that uses free arterial grafts with an arterial wall patch. After an arterial graft is anastomosed to the left external iliac artery (EIA), the EIA wall is excised (like a collar) and anastomosed to the aorta. The defect on the EIA is repaired with a vascular graft patch. Our domino patch method is simple, and it causes minimal wall thickness mismatch and allows the use of various arterial grafts anastomosed to any coronary artery. The procedures and early results are reported.     

Arterial graft extension with radial artery: a method of total arterial revascularization.

A method of total arterial revascularization is presented. This technique is based on the extension of a semi-skeletonized right internal thoracic artery graft with an entire radial artery in an end to end fashion. A complete arterial revascularization is achieved with a bilateral in situ internal thoracic artery strategy preserving the left internal thoracic artery to the left anterior descending artery bypass as an isolated graft. In our experience, this pattern of revascularization has been especially important in patients with atheromatous disease of the ascending aorta, a difficult situation in which a 'no-touch technique' is mandatory.     

Seeding endothelium onto canine arterial prostheses. The effects of graft design.

To identify prosthetic characteristics that support the proliferation of an endothelial lining, 14 different graft designs were studied in dogs. The grafts were prepared by the use of a technique of endothelial seeding that we described previously. They were studied two and four weeks after their implantation. Weft-knit Dacron grafts (water porosity from 1,400 to 1,650 mL/min/sq cm) were the most successful. A velour index (velour stitch frequency times velour loop height) was computed. When the internal velour index (IVI) was greater than 60,000 loop-mu/sq cm, the percentage of clot-free surface was 17.2 +/- 14.5%, compared with 62.0 +/- 26.9% when the IVI less than 60,000 loop-mu/sq cm. Endothelium could be detected on 61.5% of the grafts when the IVI less than 60,00 loop-mu/sq cm, compared with 0% when the IVI greater than 60,000 loop-mu/sq cm. The cells that formed the outer capsule were better organized and more adherent to the graft when an external velour was present, but external velour did not affect the inner lining. We conclude that weft-knit Dacron grafts with water porosities from 1,400 to 1,650 mL/min/sq cm and with limited internal velour (IVI less than 60,000 loop-mu/sq cm) are suitable substrates for single-staged endothelial-cell seeding.     

Management of wounds of exposed or infected knee prostheses.

Skin damage after total knee arthroplasty may jeopardise the functional benefit of the prosthesis. In such cases standard treatment is aimed at avoiding arthrodesis, sometimes replacing the implant and, in exceptional cases, amputation. In most cases early and adequate coverage of the soft tissue defect may make it possible to salvage the prosthesis. Ten patients with skin damage after total knee arthroplasty were treated by debridement of the wound, which was then covered with a pedicled gastrocnemius muscle flap. This was supported by local irrigation and systemic antibiotics. Seven patients were reviewed after a mean follow-up of 28 months (range 14-59). Six patients kept their prostheses and one had a relapse caused by infection at 22 months, which required removal of the prosthesis and secondary arthrodesis. The gastrocnemius muscle flap provides good quality coverage, permits early mobilisation and fast rehabilitation, and reduces the rate of arthrodesis after failure of total knee arthroplasty.     

人造血管旁路术后移植物感染的外科治疗

为评价人造血管旁路术后移植物感染外科治疗的临床疗效,作者对１９８５年～１９９５年上海中山医院收诊的２５０例人造血管旁路术后发生移植物感染的８例进行分析。临床表现为移植物外露伴创口溢脓、大出血、移植物和／或远端肢体动脉搏动消失、远端肢体坏疽。移植物感染率３．２％。外科治疗包括：（１）移植物去除、清创引流术;（２）移植物去除、清创引流加截肢术;（３）移植物去除、清创引流加近远端动脉人造血管重建术;（４）单纯清创引流术。结果显示,８例中６例痊愈,２例因吻合口破裂出血死亡。作者认为移植物感染的危险因素有：（１）糖尿病;（２）继发血肿;（３）同一部位多次手术。外科积极处理较保守治疗愈后更好。     

Treatment of anovaginal or rectovaginal fistulas with modified Martius graft

OBJECTIVE: The treatment of ano- or rectovaginal fistula is still difficult. The use of the Martius flap is well described as an adjunctive technique in their repair. We report our experience of a modified Martius flap in the management of ano- or rectovaginal fistula. METHOD: This is a retrospective study of 14 women presenting with an anovaginal (n = 9) or rectovaginal fistula (n = 5). All were treated by a modified Martius graft. The aetiology included Crohn's disease (n = 7), ulcerative colitis (n = 4), radio-induced (n = 1), obstetric (n = 1) and villous tumour (n = 1). RESULTS: All 14 fistulas healed within the 3 months after surgery. Subsequently, two patients with Crohn's disease required an abdominoperineal resection owing to progressive anal lesions. Two other patients experienced faecal incontinence which improved with functional rehabilitation treatment. CONCLUSION: A modified Martius flap is a valuable option in the treatment of ano- or rectovaginal fistula. In the case of Crohn's disease, however, the prognosis depends primarily on subsequent clinical evolution of the condition.     

Omental pedicle graft in the management of infected ascending aortic prostheses

Two patients had mediastinal infections with chronic draining sinus tracts that involved a vascular prosthesis in the ascending aorta. In 1 patient, a false mycotic aneurysm developed and in the other, a beginning rupture of the proximal suture line. In both patients, the infection was cured by replacing the infected aortic prosthesis combined with wrapping the new prosthesis with a pedicled omental graft. An omental graft was used to protect the vascular prosthesis and minimize the risk of recurrent infection.     

Coronary arterial revascularization in dialysis patients

It is recently reported that among chronic renal dialysis patients myocardial infarction accounts 7.4% of all the cause of death in Japan. In order to improve the mortality of dialysis patients the treatment of ischemic heart disease (IHD) is a major problem. We review previous reports and discuss about the treatment of IHD in dialysis patients. The collected data from the previous reports written about CABG in dialysis patients shows that the mortality of CABG is 7.8% (30/387), the probability of perioperative myocardial infarction (PMI) 8.6% (21/243), brain infarction 1.6% (4/243) and major infection 5.8% (14/243). 3-year and 5-year mortality rate after CABG is reported to be 69-80% and 48-56%, respectively. The result of CABG is excellent and shows that this procedure improves the mortality of dialysis patients with IHD. The procedural mortality of PTCA is 5.6% (8/143), the probability of PMI is 7% (10/143). Many reports shows the high probability of the recurrence of chest pain (60-86%). This procedure when performed in dialysis patients is incomplete because of the calcification of the coronary artery. Even among the dialysis patients it is preferable to perform CABG positively.     

Direct union of coronary arteries after excision of short segments—An approach without arterial sutures,prostheses, or adhesives

Ten dogs underwent excision of a short segment of the diagonal branch of the left anterior descending coronary artery, the distal left circumflex coronary artery or one of its branches. Hemostasis was secured by suturing the overlying epicardium except in two animals in which the addition of a pericardial patch was necessary to control bleeding. Arterial sutures, prostheses, or adhesives were not used. Two animals died in the first 36 hr after surgery, one of massive pulmonary atelectasis, the other of bleeding. Arteriograms in the eight surviving animals showed healing of the divided coronary arteries with excellent distal filling in seven of them. Vascular union was noted as early as the fifth postoperative day and as late as the end of the 3-month follow-up period.The possibility of applying this simple surgical technique to certain instances of coronary arterial occlusive disease is discussed.     

Enteral and parenteral nutrition in patients with enteric fistulas and short bowel syndrome

Significant advances in the use of enteral and parenteral nutrition in patients with either enteric fistulas or short bowel syndrome include increased usage of enteral nutrition because of its trophic effects on the gut and increased usage of both enteral and parenteral nutrition in the home setting. Current investigations are directed toward identifying gut-specific fuels and dietary and pharmacologic enhancement of nutrient utilization.     

Coronary arterial revascularization in an adult with congenitally corrected transposition of great arteries and dextrocardia

OBJECTIVES: Congenitally corrected transposition of great arteries with dextrocardia is an extremely rare lesion in adulthood. This group of patients does not live long enough for atherosclerotic coronary artery disease processes, because of existing comorbid anomalies. METHODS: We report a 47-year-old man with isolated congenitally corrected transposition of great arteries, dextrocardia, and athersclerotic coronary artery disease. The patient underwent coronary artery revascularization with cardiopulmonary bypass. The free left internal mammary artery (LIMA) was grafted to the tiny left anterior descending artery (LAD), and the reversed saphenous vein Y graft was anastomosed to the posterior descending and posterolateral branches of the morphologic right coronary artery. RESULTS: The patient recovered uneventfully. He is alive and well 24 months after the surgery. CONCLUSIONS: To our knowledge, the present case is the first congenitally corrected transposition of great arteries with dextrocardia treated with grafted coronary artery bypass. Early and full revascularization is very important for the systemic right ventricle exposed to a systemic workload. The vessel pathologies and technical details of this unusual case are discussed in this paper.     

Lower extremity arterial revascularization in obese patients

BACKGROUND: Obesity and associated comorbidities are associated with a high rate of complications and technical difficulties after a number of surgical procedures. We studied the role of obesity in outcomes in lower extremity arterial revascularization. METHODS: We reviewed all lower extremity arterial revascularizations performed at our institution in 2000. Body mass index (BMI) greater than or equal to 30 kg/m(2) defined obesity. Perioperative outcomes, long-term survival, and graft patency were evaluated in obese and nonobese patients by using linear regression, the Fisher exact test, and Kaplan-Meier analysis. RESULTS: The study population consisted of 74 (26%) obese and 207 (74%) nonobese patients. Patient demographics of the obese and nonobese populations were similar. The mean BMI for obese patients was 35 +/- 5 kg/m(2) and in nonobese patients was 25 +/- 3 kg/m(2). The mean age of each group was 67 +/- 10 years (BMI > or =30 kg/m(2)) and 70 +/- 13 years (BMI <30 kg/m(2)). There were 45 (61%) obese men and 29 (39%) obese women. There were 128 (62%) nonobese men and 79 (38%) nonobese women. Diabetes was present in 76% of the obese and 70% of the nonobese patients. Perioperative myocardial infarction, 30-day mortality, and rate of reoperation within 30 days were not significantly different. Obese patients had higher increased postoperative wound infection rates (16% vs 7%; P = .04). Survival analysis showed 81% +/- 5% and 85% +/- 3% 1-year survival and 66% +/- 6% and 62% +/- 3% 3-year survival in obese and nonobese patients (P = .58), respectively. Kaplan-Meier estimates showed no effect of obesity on long-term graft patency, with 1-year graft patency rates of 82% +/- 6% and 81% +/- 4% in obese and nonobese patients, respectively (P = .79). CONCLUSIONS: Obese patients have similar limb salvage rates, perioperative cardiac morbidity, long-term survival rates, and long-term graft patency but have increased perioperative wound infections.     

Management of infected vascular prostheses.

Management of an infected vascular prosthesis must be aggressive. Aerobic and anaerobic cultures should be obtained immediately and broad spectrum antibiotics started at once and modified as culture and sensitivities direct. A period of intensive local wound care should be carried out for several days if possible, before removal of the infected prosthesis. Prolonged local therapy is usually ill-advised since healing is rarely permanent until the graft is removed and the patient is constantly in danger of suture line disruption. Hemorrhage requires immediate removal of the infected portion of the prosthesis. Revascularization should be considered at the time of graft excision only if limb viability is questionable; otherwise it is best to wait until the infection has cleared and the wound has healed. Immediate or late revascularization will usually require an extra-anatomic bypass through uninfected tissue. The best form of treatment is, of course, prevention, which includes meticulous surgical technique, elimination of sources of contamination prior to surgery, and the use of prophylactic, systemic and local antibiotics.     

Myocardial revascularization with combined arterial grafts utilizing the internal mammary and the gastroepiploic arteries

Coronary artery bypass grafting with a combined arterial graft using both the internal mammary artery and the right gastroepiploic artery was performed in 22 patients during a 21-month period. There were 17 men and 5 women ranging in age from 34 to 73 years (mean age, 53.4 years). Three patients were having a reoperation, and 2 patients had no segment of long saphenous vein available. Twelve patients were less than 55 years old. The mean number of distal anastomoses including vein grafts was 3.2 and the mean number of arterial grafts was 2.5 per patient. The mean aortic cross-clamp time was 63.8 minutes and the mean cardiopulmonary bypass time was 116.7 minutes. There was 1 early and 1 late death. The other 20 patients are alive without angina. Studied within 3 postoperative months, graft patency was 95% (19/20) in internal mammary artery and 93% (14/15) in gastroepiploic artery grafts. It is concluded that the combined arterial graft can be used safely and effectively, and its application facilitates complete revascularization with more arterial and fewer vein grafts.     

Total arterial revascularization with composite skeletonized gastroepiploic artery graft in off-pump coronary artery bypass grafting

BACKGROUND: Total arterial revascularization in coronary artery bypass grafting has recently become of great interest to many surgeons. At the same time, off-pump coronary bypass grafting has also become a popular procedure because of its low morbidity and mortality. Here we report our recent series of off-pump coronary bypass grafting performed with a grafting technique we developed by using the skeletonized gastroepiploic artery and the radial artery composite graft to achieve total arterial revascularization. METHODS: From September 2000 to April 2003, 98 patients underwent total arterial revascularization with the skeletonized gastroepiploic artery and radial artery composite graft on the beating heart. We used the gastroepiploic artery graft of choice in patients with a right coronary artery lesion. When multiple grafting was required in inferior, posterolateral, or lateral ventricular walls and the gastroepiploic artery graft was too short to cover these areas, we used the composite grafting technique. RESULTS: There were no in-hospital deaths and there was no severe morbidity among the study patients. Postoperative angiography showed graft occlusion at the anastomosis site between the gastroepiploic and radial arteries. The patency rate of the gastroepiploic arterial composite graft was 98.3% (118/120 distal anastomoses). CONCLUSIONS: A composite graft with the skeletonized gastroepiploic artery and the radial artery ensured sufficient caliber size and length for myocardial revascularization on inferior, posterolateral, and lateral ventricular walls. This composite graft can be used safely and effectively even in off-pump coronary bypass surgery with excellent early clinical and angiographic outcome in selected patients, although longer follow-up periods are necessary to draw definitive conclusions.