Patency of autogenous saphenous vein versus polytetrafluoroethylene grafts in femoropopliteal bypass for advanced ischemia of the extremity

Eighty-six femoropopliteal bypass operations were performed for ischemic ulceration, gangrene or rest pain in 77 patients whose mean preoperative ABI was 0.35. In this homogeneous patient sample, we compared prospectively a trial of saphenous vein versus PTFE grafts. During the follow-up period amputations were required in 30 per cent of the patients with a vein graft and in 31 per cent of patients with a PTFE graft. However, the presence of gangrene significantly decreased the interval to first occlusion (p less than 0.001). Over-all, autogenous saphenous vein grafts had longer patency than PTFE grafts in both the femoropopliteal and distal bypass positions. This advantage prevailed when 45 of the patients were randomized, although not at statistically significant levels. In patients without gangrene who underwent limb salvage, bypassing the diseased femoropopliteal segment with either of the graft materials increased graft patency and limb salvage compared with patients who had ischemic tissue necrosis.     

The transition to "in situ" vein bypass grafts

In situ saphenous vein bypass grafts were used to revascularize 109 lower extremities in 99 patients during 1984. Of those, 102 were single length grafts carried out in 53 males and 39 females with an average age of 69 and 75 years old, respectively. The expected associated risk factors were observed: smoking in 69 per cent, hypertension in 57 per cent, heart disease in 52 per cent and diabetes in 31 per cent of the patients. Grafts were performed for limb salvage in 71 patients, claudication in 30 and aneurysm in one. Single length grafts originated from the common (47), superficial (27), deep femoral (18) or popliteal (four) arteries or proximal Dacron (polyester) grafts (six); 93 per cent of the grafts were to an infrageniculate target site, while 44 per cent extended to an infrapopliteal artery and 7 per cent to the ankle. Operating time including completion angiography, which was done in every instance, was comparable to that with reversed vein grafts. The patency rate at one year was 96 per cent or 87 per cent when claudication or limb salvage was the indication for operation, and 92 per cent or 86 per cent when the distal anastomosis was to a popliteal or infrapopliteal artery. Limb salvage rates were 97 per cent at one month and 91 per cent at one year. All five amputations occurred in patients receiving infrapopliteal grafts for gangrene. The survival rate was 97 per cent at one month and 85 per cent at one year.     

Results of vein graft reconstruction of the lower extremity in diabetic and nondiabetic patients

The results of 171 vein grafts of the lower extremity were evaluated. These were placed between January 1981 and December 1987 in 150 patients, 75 diabetic and 75 nondiabetic, to determine the influence of diabetes on the outcome of the procedure. One and four year patency rates were determined by a life table analysis. No statistical differences in primary patency were found between the patients with diabetes and those without diabetes for all indications of operations (one year, diabetic patients 95 +/- 3 per cent, nondiabetic patients 85 +/- 3 per cent; four years, diabetic patients 89 +/- 11 per cent and nondiabetic patients 80 +/- 12 per cent; p = n.s.). For those operated upon for salvage of the limb because of rest pain, ulceration or gangrene, patency in diabetic patients at one year approached a statistically significant advantage (diabetic patients 94 +/- 4 per cent versus nondiabetic patients 79 +/- 8 per cent; p = 0.056). We believe that arterial reconstruction of the lower extremity can be performed upon patients with diabetes with the same high degree of success for revascularization and salvage of the limb as can be accomplished in nondiabetic patients. This is true even though those with diabetes present with necrosis of the tissue and more often require bypass to distal tibial arteries.     

The influence of diabetes mellitus upon peripheral vascular disease

The treatment of 332 consecutive patients referred to a peripheral vascular unit with rest pain, ulceration or gangrene of the lower limb has been studied. Ninety-seven (20 per cent) of the patients had diabetes mellitus. Although diabetes was related to adverse limb salvage and patient survival rates, this could be accounted for by the influence of initial presenting clinical features and treatment upon survival time. The influence of these factors upon survival time was still strong even when the data were stratified for diabetric status. Thus, an extensive amputation carries the worse prognosis, with a less extensive amputation intermediate between an extensive amputation and any other form of therapy. Patients with both rest pain and ulceration or gangrene have a poor prognosis when assessed by either limb salvage or mortality. The majority of the patients with less extensive amputations are diabetic. This is related to the high incidence of localized ulceration among those in the diabetic group. In diabetics, a less extensive amputation, if clinically indicated, is worthwhile because of the low incidence of a subsequent extensive amputation after a less extensive amputation and the better survival rate for those patients with less extensive amputations as compared with those with extensive amputations.     

Intra-arterial streptokinase in the treatment of acute arterial thrombosis

Streptokinase and catheter thrombectomy were retrospectively compared in 25 patients who presented with acute ischemia to investigate whether the use of intra-arterial streptokinase offers an advantage in the treatment of acute arterial or graft thrombosis. Streptokinase was used in all patients presenting with acute thrombosis unless the ischemic limb would not tolerate the time required for clot lysis. Complete thrombolysis was achieved in 47 per cent of the occlusions treated with streptokinase and initial limb salvage rate in 37 per cent of the patients. Subsequent surgical procedures were required in seven of eight patients with successful thrombolysis. Catheter thrombectomy reestablished vessel or graft patency in 86 per cent of the procedures and achieved initial limb salvage in 67 per cent of the patients. Long term (greater than six months) patency was achieved in 25 per cent of the patients treated with streptokinase and 44 per cent of the patients with catheter thrombectomy. Streptokinase did not prevent the need for further surgical intervention, improve early patency of these vessels or promote limb salvage when compared with that of catheter thrombectomy.     

Extra-anatomic bypass with expanded polytetrafluoroethylene

Expanded polytetrafluoroethylene has been used successfully for femoropopliteal bypass, aortopulmonary bypass and as a venous substitute. Thirteen patients with impending limb loss had extra-anatomic bypasses with expanded polytetrafluoroethylene. Five patients with unilateral iliac disease had femorofemoral bypass for impending limb loss, and five debilitated patients underwent axillofemoral and bifemoral bypass for limb salvage. Nine of ten patients had salvage of the extremities. Three patients had extended profundoplasty, two combined with polytetrafluoroethylene femoropopliteal bypass to isolated popliteal artery segments. Two of these patients had limb salvage. The patency rate is 92 per cent, and the limb salvage rate is 85 per cent in this difficult group of patients. The follow-up period extends to 28 months, and 12 patients are beyond one year. In six patients, polytetrafluoroethylene carotid subclavian bypass was performed for the subclavian steal syndrome; all patients had relief of the symptoms. One patient underwent axillary-axillary bypass with excellent results. Expanded microporous polytetrafluoroethylene with its high patency, shortened operating time, biocompatibility and excellent tissue incorporation is an excellent arterial substitute. The pliability and no requirement for preclotting make polytetrafluoroethylene ideally suited for patch angioplasty and suturing in areas difficult to expose.     

Profundaplasty as the only reconstructive procedure in patients with severe ischemia of the lower extremity

Twenty-one profundaplasties were performed as the only reconstructive procedure. All of the patients had severe ischemia of the lower extremity with serious symptoms, such as rest pain or gangrene, or both. There was no postoperative mortality. Two patients had a crural amputation, and one patient, a femoral amputation performed during the first three months postoperatively. All of the other patients improved, and there was a significant rise in distal blood pressures after one week, further increasing after three months. At follow-up study, 15 of the patients had considerably less symptoms than preoperatively or were free of symptoms. There was a limb salvage rate of 83 per cent after 60 months. The operation is recommended whenever possible in patients with severe ischemia of the lower extremity when the possibilities of other reconstructive procedures are considered to be poor.     

Synchronous aortofemoral or iliofemoral bypass with revascularization of the lower extremity.

Bypassing aortoiliac stenosing lesions to the profunda femoria alone, even with extensive end-arterectomy and angioplasty of the latter, will not provide predictable excellent results in the presence of gangrene and occlusion in the femoral popliteal system. With severe pregangrene and rest pain, residual ischemic complaints are also common, and if lesions are present, healing is incomplete or, at best, delayed. Alternatively, femoropopliteal or tibial bypass, in the presence of even moderately diminished inflow, is subject to either early or delayed closure, unless proximal repair is also performed in appropriately selected patients. Synchronous correction of tandem lesions involving the aortoiliac and femoropopliteal segments should, therefore, be considered for limb salvage only and particularly in the presence of focal gangrene, excision or debridement of which can be anticipated to heal after successful bypass. Major diminution in femoral inflow usually indicates the need for proximal repair only, even in the presence of distal lesions. Noninvasive studies and intraoperative flow determinations are not uniformly helpful in patient selection. Synchronous aortofemoral or iliofemoral and femoropopliteal or tibial reconstructions were performed upon 38 patients, 15 of whom had no prior vascular operation and 23 of whom had previously undergone either aortofemoral or femoropopliteal bypasses that had failed. Graft patency for all patients was 76 per cent, and although it was better for the patients in group 1 than for those in group 2, no statistical significance existed between the two groups. Improved patient selection and criteria for performing synchronous reconstructions might originally have been of benefit for the patients in group 2, avoiding more difficult secondary repairs. It must be emphasized, however, that synchronous reconstructions should not be done routinely in the presence of multilevel disease. Rather, specific indications do exist and should be considered on an individual basis.     

The follow-up of patients with cancer of the cervix treated by radical hysterectomy and radical pelvic lymphadenectomy

In Table V the 197 cancers are divided into the various stages and the salvage for each stage is shown. The total number of deaths from squamous-cell cancer and from adenocarcinoma is also shown.For squamous-cell cancer 177 operations were done; 33 (18.6 per cent) patients had positive nodes. The uncorrected 5 plus to 13 plus year salvage in these 33 patients was 12 (36.3 per cent). Deaths from all causes in the 177 patients numbered 49 (28.6 per cent). The uncorrected salvage was 128 (72.3 per cent).For adenocarcinomas 20 operations were done; 6 (30 per cent) patients had positive nodes. One patient (16.6 per cent) with positive nodes has lived 13 plus years. There were 8 (40 per cent) deaths from all causes in the 20 patients. The uncorrected salvage in the 20 patients operated upon was 12 (60 per cent).If the 33 (18.6 per cent) patients with positive nodes were excluded from the 177 cases of squamous-cell cancer, in the remaining 144 patients there were 28 (19.4 per cent) deaths in the period of 5 plus to 13 plus years. This would give an uncorrected salvage in all patients with negative nodes of 116 (80.6 per cent).If the 6 (30 per cent) patients with positive nodes were excluded from the 20 patients with adenocarcinoma there would be 2 deaths (14 per cent). This would give an uncorrected salvage in all patients with negative nodes of 12 (86 per cent).     

Review of arterial thoracic outlet syndrome with a report of five new instances

Arterial damage, causing ischemia of the limb, occurs in less than 5 per cent of all instances of thoracic outlet syndrome. Arterial complications are usually associated with cervical ribs or rudimentary first ribs, but 12 per cent have occurred in patients with no osseous abnormality. The physiopathologic factors begin with compression of the subclavian artery which, in most patients, produces stenosis, poststenotic dilatation, formation of aneurysms and mural thrombosis. In other patients, aneurysms do not form, but the compression still causes stenosis, intimal injury and mural thrombosis. With either scenario, distal embolization can occur and produce signs and symptoms of ischemia that can limb-threatening. In this study, more than 200 patients reported previously and five additional sides in four patients were reviewed. Treatment depends upon the condition of the patient at presentation. Those with osseous abnormalities and no aneurysm or symptoms are not treated, while those with poststenotic dilatation or small aneurysms undergo rib resection only. Aneurysms more than twice the arterial diameter, intimal injury or mural thrombus are indications to resect, replace or bypass the subclavian artery. Patients who have had distal embolization and severe ischemic symptoms require, in addition to the aforementioned, distal thromboembolectomy, dorsal sympathectomy or both. Good results from treatment have been reported in 84 per cent of the 137 patients reported since 1970; 3 per cent required amputation and 3 per cent had cerebral emboli. Because the severe arterial complications were primarily the result of delayed therapy, they can best be avoided by early recognition, diagnosis and treatment.     

Operation for late complications of aortic grafts

In a period of seven years, 120 revision operations were performed for complications occurring in 1,284 aortic bifurcation grafts. The reasons cited for operation were: graft limb occlusion or stenosis in 82 patients, false aneurysm in 28 and symptomatic disease distal to the graft in ten. Preferred operations were replacement of the graft and distal anastomosis for occlusion or complete reconstruction of the anastomosis with fresh graft material for a false aneurysm. The operative mortality rate was 1.6 per cent and three patients (2.5 per cent) underwent amputation after multiple procedures. This group of 120 patients with complications was compared with a random sample of 300 patients with aortic bifurcation grafts with no complications. In the group with complications, there were significantly fewer patients who underwent sympathectomy or profundaplasty and significantly more with an iliac rather than a femoral artery graft insertion. Those patients who had graft complications develop also had a significantly higher hematocrit level at the first procedure.     

Predictors of success in bypass grafts to the isolated popliteal segment

Of 130 infrainguinal bypasses, 25 grafts to an isolated popliteal segment (IPS) were examined for clinical, anatomic and hemodynamic predictors of success. Fourteen autogenous veins (AV) and 11 polytetrafluoroethylene (PTFE) grafts were performed, all for limb salvage. A discontinuous tibial vessel was present in 72 per cent but only 24 per cent were graftable. A mean of 1.7 named collaterals were seen in IPS. Mean preoperative ankle pressure (APR) was 26.29 and ankle to brachial index (ABI) was 0.17. Segmental pressure gradient indices were also measured. Mean follow-up time was 13.6 months (a range of two to 43 months). One hundred per cent immediate graft patency and patient survival rates were obtained. Postoperative APR improved to 86.3 millimeters of mercury and ABI to 0.63 (p less than 0.05). Crude late patency rate was 72 per cent and limb salvage rate was 76 per cent. Cumulative life table patency rate was 58.8 per cent and limb salvage was 68 per cent at 36 months. Patency rate for AV (84.1 per cent) was better than PTFE (41.7 per cent). In 39 concurrent tibial grafts, cumulative patency rate at 36 months was 68 per cent for simple bypass grafts. Success could not be predicted by the length of the IPS, number of collaterals, profunda disease, number of discontinuous or graftable tibial vessels, APR or ABI and profunda popliteal collateral index. The tibial gradient index reflecting poor runoff was significantly greater in failed grafts (p less than 0.05). Bypass grafts to the IPS are a safe and reliable alternative to tibial bypass grafts. The AV performed better than PTFE grafts. The tibial gradient index appears to be a promising indicator for predicting graft success.     

Prognostic indicators in femoropopliteal and distal bypass grafts

Over a period of six years, 265 femoropopliteal and infrapopliteal bypasses were performed in 243 patients with infrainguinal arterial occlusive disease. The cumulative patency rate for all grafts was 70.9 per cent at one year, 59.3 per cent at three years and 48.5 per cent at five years. Femoropopliteal bypasses showed a significantly better patency rate than femoral infrapopliteal grafts and autogenous vein grafts had a significantly higher patency rate than human umbilical vein grafts. No demonstrable difference in patency rates was shown in patients with and without diabetes. Synchronous proximal and distal revascularization for limb salvage in properly selected patients with multisegmental disease achieved a cumulative patency rate of 100 per cent at two years with no operative deaths. Therefore, this procedure is recommended, but individualization of treatment rather than routine synchronous repair is urged.     

Amputation level and distal bypass salvage of the limb

The feasibility of revascularization of the lower extremity for salvage of the limb with grafts to the tibial and peroneal arteries has been well established. The results of prior reports have suggested that a failed distal bypass may convert a lower extremity amputation to a higher level than afforded by primary amputation. We reviewed all distal, tibial or peroneal artery bypasses performed at our institution during the period of March 1980 through October 1986. Fifty-three patients with 59 threatened lower extremities underwent distal bypass for salvage of the limb. No patient was excluded from review. Thirty-eight patients in the study group had diabetes, and 41 had a prior smoking history. In the postoperative period, six patients were lost to follow-up study, nine patients died, with follow-up data complete in 47 of the study group. The maximum length of follow-up study was 78 months, and the average length was 24 months. Data were examined by life table analysis with respect to cumulative salvage of the limb and graft patency. During the period of review, 12 major amputations were required (nine below-knee and three above-knee) for a cumulative salvage rate of 59 per cent. Of the distal grafts which failed (n = 27), three of 27 of the limbs required above-knee amputation. We conclude that a failed tibial or peroneal artery bypass does not preclude the possibility of salvage of the limb and does not predispose to a subsequent amputation.     

Level of amputation after failure of limb salvage procedures

It has been claimed that the level of amputation is rendered higher by unsuccessful limb salvage bypass procedures. To evaluate this premise, we analyzed 242 major amputations performed for atherosclerotic vascular disease. One hundred and sixty-one amputations were performed as primary operations--50 per cent being below knee and 50 per cent, above knee amputations. Eighty-one amputations followed failure of an arterial revascularization. Twenty-three amputations, 13 below knee and ten above knee, followed late closure of such bypass procedures. Early failure of the bypass in 58 patients resulted in 46 below knee and 12 above knee amputations. After failure of 45 bypasses to arteries distal to the popliteal, 14 of the patients required above knee amputation. Following 28 unsuccessful femoropopliteal bypasses, only two patients needed above knee amputation. Thus, the risk of jeopardizing the knee joint should not be considered a major contraindication to limb salvage procedures, especially if a femoropopliteal bypass is contemplated.     

Polytetrafluoroethylene vein composite grafts across the knee

Fifteen Gore-tex vein composite femoral-popliteal artery bypass procedures were performed during the four year period of December 1975 to December 1979. Nine were performed for salvage of the limb and six, for incapacitating claudication. Preoperatively, all patients had an arteriographic evaluation of the outflow tract. CPR by the life-table method was 63 per cent at six years. Early failures were three occlusions within two months in patients with poor outflow. One late occlusion occurred at 16 months, and the limb was salvaged with a femoral tibial bypass graft. Another late occlusion was treated by thrombectomy at 24 months with continued patency. Late revision was carried out in one patient at seven months. This consisted of repair of a stenosis of the distal popliteal artery with salvage of the graft. Only two of ten grafts available for evaluation beyond one year have become occluded. All patients operated upon for claudication or with good runoff have patent grafts. On the contrary, none of the grafts to an isolated popliteal segment remained patent. When there is not sufficient autogenous saphenous vein available for femoral-popliteal bypass, the ready availability of a synthetic graft makes it an attractive choice. Nevertheless, our 63 per cent CPR at six years strongly suggests that the composite graft is a durable option.     

Salvage mastectomy for local and regional recurrence after breast-conserving operation and radiation therapy.

Forty-six patients initially treated for carcinoma of the breast by tumor excision and radiation therapy who had local and regional recurrence with no evidence of distant disease and who underwent salvage mastectomy at Memorial Sloan-Kettering Cancer Center between 1970 and 1990 were reviewed retrospectively. These patients represent a recent series of patients treated with breast-conserving surgery, radiation therapy and subsequent salvage mastectomy with a median follow-up period of five years (range of one to 20 years). The mean age at initial diagnosis was 52 years (range of 31 to 75 years). All patients had excision of the primary tumor; 27 underwent local excision with axillary dissection. The median radiation therapy dose to the breast was 48 Gy. The distribution of stage of disease at the time of breast conserving treatment was stage 0 in seven patients, stage I in 13 patients, stage II in 14 and stage III in one patient. Twenty-seven patients received conservation treatment at other institutions and were referred to our institution for salvage operation. Local and regional relapse occurred at a median of 28 months (range of five months to seven years) after initial treatment. Relapses occurred only in the breast in 35 patients, in the axilla in one patient and in both sites in ten patients. Salvage operation consisted of total mastectomy in 50 per cent, modified radical mastectomy in 33 per cent and radical mastectomy in 17 per cent. Follow-up evaluation after salvage mastectomy (median 28 months, range of one month to 18 years) yielded an actuarial proportion free of disease at five years of 55 per cent (+/- 11 per cent) and an over-all five year survival rate of 76 per cent (+/- 10 per cent). The median time to relapse was 97 months (+/- eight months) and the median survival time was 103 months (+/- seven months). The local recurrence rate after salvage mastectomy was 15 per cent. These data suggest that salvage mastectomy provides local control of recurrent carcinoma of the breast and relapse-free survival time may be improved by postsalvage systemic therapy.     

The histologically evaluated accuracy of lymphography in operative therapy of invasive cervix cancer stages Ib-IIb

118 of 129 pre-operative patients with invasive cervical carcinoma of stage Ib to IIb from 1974 to 1978 were examined lymphographically. Abdominal radical hysterectomy according to Wertheim with obligatory lymphonodectomy followed in all cases. Results of the histologic examination of lymphnodes have been compared with the findings from lymphography, whereby a coincidence could be proved in 84 per cent of all cases. The correlation for the lumbar and iliac lymphonodi was listed separately in 75 per cent of the cases. Lymphography gives significantly better results within the lumbar region with an accuracy rate of 92 per cent, a sensitivity of 100 per cent and a specificity of 98.5 per cent. It may be concluded that a lumbar lymphonodectomy is not necessary in the event of a negative lymphography.     

A technique for open diagnostic peritoneal lavage.

Fifty consecutive long saphenous vein graft operations for limb salvage performed between 1958 and 1965 were observed by periodic arteriography. Of 50 grafts, 11 failed within two years, and at the time of the final review, two patients had defaulted. Extended observations of the remaining 37 grafts up to 15 years showed three main complications. First, graft degeneration affected seven grafts with earliest evidence of elongation, tortuosity, irregular dilation or aneurysmal formation at four years. It did not affect any graft after eight years. One graft required replacement because of degeneration. Second, proximal dilation was seen in six grafts, but it did not compromise patency or function and had a maximal incidence at four to six years. Third, the site of the distal anastomosis was narrowed in eight patients, but the narrowing was severe in four. This complication occurred at six to eight years and affected 25 per cent of the surviving patients. The narrowing was caused by thrombus formation within the area of anastomosis and was amenable to further arterial reconstruction.     

Splenic conservation after multiple trauma in adults

The traditional management of splenic injuries is undergoing serious challenge. During the four year period from 1980 to 1983, 60 of 230 patients with injured spleens operated upon at the Maryland Institute for Emergency Medical Services' Shock Trauma Center have had splenic salvage. Motor vehicle accidents accounted for 57 of the 60 injuries (95 per cent). Fifty-eight patients (97 per cent) had major associated extra-abdominal injuries (average 1.9 injuries per patient) requiring additional operative procedures. Concurrent intra-abdominal injury was present in 37 patients (62 per cent). The mean operating time was 106 minutes; 98 minutes for those patients with isolated splenic injuries and 115 minutes for those with associated minor intra-abdominal injuries. The average amount of blood transfused during celiotomy was 3.5 units of packed red blood cells per patient. As familiarity and confidence with the techniques have accrued, the number of splenic preservation procedures has steadily increased from approximately 10 per cent to more than 50 per cent. Complications related to splenorrhaphy per se were few. The mortality was 10 per cent; all deaths were secondary to associated injuries. Criteria for and contraindications to splenic salvage in patients with multiple trauma are presented and discussed.