Infected femoral artery pseudoaneurysm in drug addicts: the beneficial use of the internal iliac artery for arterial reconstruction

BACKGROUND: Infected femoral artery pseudoaneurysm (IFAP) is a severe complication in parenteral drug abusers, with difficult and controversial management. Ligation alone without revascularization is frequently associated with later intermittent claudication and limb amputation. Furthermore, arterial reconstruction with a synthetic or venous conduit is limited because of a contaminated field and, often, unavailability of autologous venous grafts. In this study, we present our experience with the internal iliac artery (IIA) as a graft for arterial reconstruction after IFAP excision in these patients. METHODS: Data of 14 consecutive patients who presented with IFAP secondary to parenteral drug abuse from 2001 to 2005 were analyzed. Twelve patients (85.7%) were male. The median age was 27 years (range, 19-42 years). In 13 cases, the IFAP involved the common femoral artery, and in 1 case it involved the profunda femoris artery (PFA). In nine patients, we used the IIA for arterial reconstruction (five as a patch and four as an interposition graft), whereas in two patients the arterial deficit was repaired with a great saphenous vein patch. In two cases, an extra-anatomic bypass with a synthetic polytetrafluoroethylene graft was performed. In one patient, the pseudoaneurysm involved the PFA and was treated with excision and ligation of the PFA. RESULTS: All nine patients who underwent revascularization with the use of IIA were free of claudication symptoms. None of them experienced any perioperative complications, had signs of reinfection, or required limb amputation during the follow-up period (median, 19 months; range, 4-52 months). Regarding the remaining five patients, one died 25 days after surgery because of multiorgan failure, and one underwent reoperation because of proximal anastomotic rupture of a synthetic graft. The latter patient finally underwent a transmetatarsal amputation. CONCLUSIONS: The use of IIA for arterial reconstruction after IFAP excision in drug abusers is safe and effective. These preliminary results indicate that the implementation of this technique offers many advantages compared with traditional treatment options.     

Common femoral artery ligation and local debridement: a safe treatment for infected femoral artery pseudoaneurysms

PURPOSE: The management of infected femoral artery pseudoaneurysms (IFAPs) is difficult and controversial. Use of synthetic or autologous conduit during arterial revascularization in these cases is complicated by the presence of sepsis and unavailability of autologous venous conduit. We present the results of common femoral artery (CFA) ligation and local drainage with debridement for the treatment of IFAP. METHODS: A retrospective chart review of six consecutive patients from 1995 to 1999 who presented with IFAP from intravenous drug abuse was performed. Inpatient records, anesthesia records, and outpatient clinic charts were reviewed. All patients were men with right-sided lesions. All six patients abused heroin, and five (83%) abused heroin and cocaine. All six patients had a duplex ultrasound scan, and five (83%) patients had a digital subtraction angiogram to confirm the clinical diagnosis. Proximal vascular control was achieved retroperitoneally through an oblique suprainguinal incision. After vascular isolation and test clamping of the distal external iliac artery (EIA), the pedal pulses were examined with continuous wave Doppler scan. If a Doppler signal was present, this was followed with CFA ligation and local drainage and debridement of the IFAP. RESULTS: Pain at injection site and fever with chills were present in five (83%) and three (50%) patients, respectively. A pulsatile groin mass and thigh or leg edema were present in five (83%) patients. Three patients (50%) had a palpable pedal pulse, and all six had a Doppler signal over a pedal artery at presentation. The mean white cell count was 15.6 thousand per cubic millimeter (range, 9.2-19.3). All patients had a Doppler signal over a pedal artery after distal EIA/CFA test occlusion and ligation. None of the patients required an amputation, and all six patients regained their preoperative ambulatory status. The mean follow-up period was 25 months. Two patients had mild claudication (5-6 blocks) at 18 months and 2 years after surgery. All six patients received drug rehabilitation, but they admitted to drug abuse after surgery and rehabilitation. CONCLUSION: CFA ligation and local debridement are safe treatment modalities for IFAP, if there is an intraoperative Doppler signal over a pedal artery during test occlusion of the distal EIA/CFA. CFA ligation avoids the use and therefore the risk of synthetic conduit infection, because there is a high incidence of postoperative drug injection despite aggressive drug rehabilitation.     

Femoral Pseudoaneurysm in Drug Addicts—Excision without Revascularization is a Viable Option

PURPOSE: To present a series of patients presenting with femoral pseudoaneurysm. RESULTS: Seventeen patients who presented with a femoral pseudoaneurysm during a 1 year period were included in this study. Parenteral drug abuse was the most common aetiological factor. The femoral artery was most commonly involved at its bifurcation. Sixteen patients (94%) had excision of the pseudoaneurysm with ligation of vessel and debridement without any revascularization and one patient (6%) had reverse saphenous grafting after excision and ligation of vessels. Four amputations (23%) were performed. Three (17%) were major limb amputations, which included one above knee and two below knee amputations. Four patients (23%) developed intermittent claudication. CONCLUSION: Excision of the pseudoaneurysm with ligation of vessels and wide debridement without immediate revascularization in infected pseudoaneurysms is a safe and effective treatment.     

Routine revascularization with resection of infection femoral pseudoaneurysms from substance abuse

Infected femoral artery pseudoaneurysms in narcotic addicts present challenging management options. Our policy of routine revascularization is based on the concern that a high rate of amputations must follow ligation and resection alone or with selective delayed revascularization. Fifteen of 16 patients with infected pseudoaneurysms of femoral arteries, treated with resection and bypass grafts, were observed from 1 to 44 months. Obturator bypass grafts were used in 10 patients, iliac-femoral grafts in three, axillopopliteal in one, and right external iliac crossover to left popliteal in one patient. One limb, unsalvageable at presentation, was amputated primarily, along with resection of pseudoaneurysm and femoral artery ligation, without bypass grafting. One iliac-femoral graft became infected and then thrombosed 4 months after operation. Unsuitable distal arteries and impending necrosis led to above-knee amputation. One late failure among 15 revascularization attempts (7%) is significantly lower than the 11% to 33% amputation rates reported in the literature with resection of pseudoaneurysm alone and delayed selective revascularization. The other 14 patients had functioning limbs without claudication or rest pain. Our experience indicates that revascularization at the time of resection of infected pseudoaneurysm offers better prospects for limb salvage.     

Infected femoral pseudoaneurysm in intravenous drug abusers.

The result of surgical treatment of 21 infected femoral pseudoaneurysms in 19 intravenous drug addicts was evaluated. Eight pseudoaneurysms involved only the common or superficial femoral artery and 13 involved the femoral bifurcation. Excision and ligation was performed as the sole procedure in 19 instances, and revascularization by bypass through the obturator route was carried out in two. The mean follow-up was 12.3 months. One patient required an above-knee amputation. The resultant ischaemia was greater after triple vessel ligation (mean ankle:brachial pressure index (ABPI) 0.41) than single vessel ligation (mean ABPI 0.58). Postoperative bleeding occurred in one patient. Intermittent claudication was present in 14 patients after excision and ligation. Claudication was universal and more severe after triple than after single vessel ligation. There was no subsequent limb loss. Excision and ligation is safe and is the treatment of choice for infected femoral pseudoaneurysm in drug addicts.     

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.     

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.     

假性股动脉瘤的外科治疗

目的总结假性股动脉瘤的外科治疗方法。方法回顾性分析我科2002年5月~2006年6月收治的23例假性股动脉瘤患者,其中注射毒品引起14例,外伤性6例,医源性3例。1例拒绝手术,22例假性动脉瘤被切除,其中8例行股动脉修补,10例行人工血管搭桥,3例行股动脉结扎,1例下肢缺血坏死,股动脉缺损无法修补或搭桥,行高位截肢术。结果拒绝手术的1例出院1周后死亡,其余均痊愈出院。3例失访,19例获随访,平均1.7(1~3)年,3例股动脉结扎者患肢皮温正常,1例人工血管旁路手术者术后3年复查DSA示人工血管闭塞但侧支循环良好,不影响患肢功能,其余患者效果良好。结论假性股动脉瘤一经发现须早期手术治疗,破裂、感染会严重影响治疗效果甚至危及生命。假性动脉瘤切除、自体血管重建或人工血管搭桥是首选治疗方法。对病程较长、瘤体较大、压迫症状明显者可行高位股动脉结扎。     

Femoral pseudoaneurysm from drugs of abuse: ligation or reconstruction?

A plan for management of infected arterial pseudoaneurysm has evolved from our experience with 23 such aneurysms treated between 1981 and 1989 and followed for up to 66 months. Eighteen femoral artery aneurysms are the primary focus of this report. Because we were concerned about the high probability of amputation expected from acute interruption of the femoral artery, we were reluctant to limit initial management to ligation and debridement alone. However, significant complications developed in 12 patients who underwent revascularization, requiring 3 amputations and 13 secondary arterial operations in addition to debridements and skin grafts. In contrast, no amputations were required in six patients who underwent primary arterial ligation and debridement. We recommend primary ligation that controls the septic focus, removes the danger of hemorrhage, and is not accompanied by the threat of secondary arterial infection. After ligation, limb viability is assessed during surgery by presence of an audible Doppler signal at the ankle. Revascularization is considered only when absence of a Doppler signal indicates acute limb ischemia.     

Arterial reconstruction with deep leg veins for the treatment of mycotic aneurysms

PURPOSE: Mycotic pseudoaneurysms (MPA) remain challenging clinical problems. Primary surgical management includes control of hemorrhage and debridement of the infected arterial wall. Because critical ischemia may develop after arterial resection, revascularization has been a secondary goal of treatment. Standard anatomic graft placement or prosthetic bypass grafting has been compromised by a high rate of recurrent infection. Extra-anatomic reconstruction is preferred, with the basic goals being threefold: (1) the use of autogenous graft material to reduce the risk of reinfection; (2) the avoidance of significant size mismatches; and (3) graft placement that is anatomically inaccessible, because drug abuse causes many of these lesions. This study reviews a recent series of MPAs applying these treatment goals. METHODS: In a 2-year period, the superficial femoral and proximal popliteal veins were used in the repair of eight MPAs of the common femoral (5), common iliac (1), and brachial (1) arteries, and the infrarenal aorta (1). Most patients (5 of 7) were known intravenous drug users, who had a painful pulsatile mass in an injection area. Two patients had systemic sepsis, one patient with an infected common iliac pseudoaneurysm and one patient with an MPA of the infrarenal aorta. The diagnosis of MPA was made by means of duplex/computed tomography scanning and confirmed by means of arteriography in all cases. RESULTS: Obturator bypass grafting was performed by using a reversed deep leg vein in the five femoral MPAs. An ilioiliac, cross-pelvic bypass grafting procedure with a deep vein was used to repair an MPA of the common iliac artery. A deep vein was also used as a "pantaloon" aortobiiliac graft and for a brachial artery repair. Staphylococcus aureus was revealed by means of cultures in nearly all cases. Distal arterial perfusion was normal after reconstruction. Patients had no significant postoperative leg swelling. No new venous thrombosis below the level of deep vein harvest was revealed by means of duplex scanning. There were no septic complications. CONCLUSION: The superficial femoral/popliteal veins may be particularly useful for limb revascularization in patients with MPAs. This autogenous conduit provides an excellent size-match and a suitable length for reconstruction, because peripheral, axial arteries are generally affected. No clinically significant limb morbidity was related to deep vein removal. Late follow-up is challenging in such cases, but will be required to accurately determine the durability of this strategy.     

Experience with femoro-popliteal vein as a conduit for vascular reconstruction in infected fields.

OBJECTIVE: to review the outcome of femoro-popliteal vein grafts for arterial reconstruction in the presence of sepsis. PATIENTS AND METHODS: twenty-six patients underwent 27 arterial reconstructions with femoro-popliteal vein in the presence of infection. Five had mycotic aneurysms (3 aortic, 1 iliac and 1 femoral), 21 had prosthetic graft infections (9 aortic, 8 femoro-femoral, 2 axillo-femoral, 1 ilio-femoral and 1 femoral dacron patch) and one underwent superior mesenteric artery reconstruction following ischaemic small bowel perforation.Arterial reconstruction followed debridement of infected tissue, removing any infected graft, povidone iodine washout and appropriate antibiotic cover. Where possible, new grafts were placed in a clean field or wrapped in omentum. Four femoral anastomoses were covered by rectus femoris flaps. RESULTS: there was one early postoperative death (4%) and no limb loss. All others remained free from infection with patent grafts at 1 month to 5 years (median 22 months). Three major wound infections healed without exposing the graft. One infarcted rectus femoris flap required removal. Donor limb swelling was transient. Five required percutaneous angioplasty and one underwent open profundaplasty within 3 months. CONCLUSION: femoro-popliteal vein reconstruction with debridement and appropriate antibiotic therapy is recommended for the treatment of arterial or graft infections.     

The results of in situ prosthetic replacement for infected aortic grafts.

BACKGROUND: Treatment of aortic graft infection with graft excision and axillofemoral bypass may carry an increased risk of limb loss, aortic stump blowout, and pelvic ischemia. A review of patients with aortic graft infection treated with in situ prosthetic graft replacement was undertaken to determine if mortality, limb loss, and reinfection rates were improved with this technique. METHODS: The clinical data of 25 patients, 19 males and 6 females, with a mean age of 68 years (range 35 to 83), with aortic graft infection, treated between January 1, 1989, and December 31, 1998, by in situ prosthetic graft replacement were reviewed. Follow-up was complete in the 23 surviving patients and averaged 36 months (range 4 to 103). RESULTS: Twenty aortofemoral, 3 aortoiliac, and 2 straight aortic graft infections were treated with excision and in situ replacement with standard polyester grafts in 16 patients (64%), or with rifampin-soaked collagen or gelatin-impregnated polyester grafts in 9 patients (36%). Fifteen patients (60%) had aortic graft enteric fistulas, 8 patients (32%) had abscesses or draining sinuses, and 2 patients (8%) had bacterial biofilm infections. Thirty-day mortality was 8% (2 of 25). There were no early graft occlusions or amputations. There was one late graft occlusion. There were no late amputations. The reinfection rate was 22% (5 grafts). All reinfections occurred in patients operated upon for occlusive disease. Only one reinfection occurred in the rifampin-soaked graft group (11% versus 29%, P = NS). Reinfection tended to be lower in patients with aortoenteric fistulas and without abscess. Autogenous tissue coverage provided statistically significant protection against reinfection. There were no late deaths related to in situ graft infection. CONCLUSIONS: Patients treated with in situ graft replacement had an 8% mortality and 100% limb salvage rate. Reinfection rates were similar to those of extra-anatomic bypass, but a trend of lower reinfection rates with rifampin-impregnated grafts was apparent. Patients with aortoenteric fistula and without abscess appear to be well treated by the technique of in situ prosthetic grafting and autogenous tissue coverage.     

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.     

A modified method for management of prosthetic graft infections involving an anastomosis to the common femoral artery

In the last 10 years we have treated 28 patients with 33 groin infections involving a common femoral artery anastomosis of prosthetic arterial grafts (2 aortic Dacron grafts, 31 peripheral polytetrafluoroethylene grafts). Management included complete graft preservation for patent infected grafts (11 cases), subtotal excision of occluded infected grafts leaving an oversewn 2 to 3 mm graft remnant attached to a patent artery critical for limb survival (16 cases), and total graft excision with arterial oversewing or ligation for anastomotic bleeding (6 cases). Essential treatment adjuncts included (1) radical operative wound debridement, and (2) secondary revascularization by means of bypasses tunneled via lateral uninfected routes, and unusual approaches to uninvolved patent outflow arteries (i.e., the distal superficial or deep femoral or popliteal arteries) after isolation of the infected wound. Follow-up averaged 3 years (1 to 10 years). This plan of treatment resulted in an 11% (3/28) hospital mortality and an amputation rate of 13% (4/30 threatened limbs). Of the 25 survivors with 30 infected groin grafts, 87% (26) of the wounds healed uneventfully by secondary intention within 1 to 8 weeks (mean, 4 weeks) and have remained healed. One infected groin wound did not heal and required delayed total graft excision. Three patients had late anastomotic disruption with hemorrhage at 8 months, 2 years, and 4 years after initial treatment. This selected use of complete or partial graft preservation and other essential treatment adjuncts are proposed as a safer, easier method for managing infected prosthetic arterial grafts in the groin.     

Update and validation of the Society for Vascular Surgery wound,ischemia, and foot infection threatened limb classification system

The diagnosis of critical limb ischemia, first defined in 1982, was intended to delineate a patient cohort with a threatened limb and at risk for amputation due to severe peripheral arterial disease. The influence of diabetes and its associated neuropathy on the pathogenesis-threatened limb was an excluded comorbidity, despite its known contribution to amputation risk. The Fontaine and Rutherford classifications of limb ischemia severity have also been used to predict amputation risk and the likelihood of tissue healing. The dramatic increase in the prevalence of diabetes mellitus and the expanding techniques of arterial revascularization has prompted modification of peripheral arterial disease classification schemes to improve outcomes analysis for patients with threatened limbs. The diabetic patient with foot ulceration and infection is at risk for limb loss, with abnormal arterial perfusion as only one determinant of outcome. The wound extent and severity of infection also impact the likelihood of limb loss. To better predict amputation risk, the Society for Vascular Surgery Lower Extremity Guidelines Committee developed a classification of the threatened lower extremity that reflects these important clinical considerations. Risk stratification is based on three major factors that impact amputation risk and clinical management: wound, ischemia, and foot infection. This classification scheme is relevant to the patient with critical limb ischemia because many are also diabetic. Implementation of the wound, ischemia, and foot infection classification system in critical limb ischemia patients is recommended and should assist the clinician in more meaningful analysis of outcomes for various forms of wound and arterial revascularizations procedures required in this challenging, patient population.     

Selective non-operative management of pseudoaneurysms and arteriovenous fistulae complicating femoral artery catheterization.

Femoral arterial pseudoaneurysms or arteriovenous fistulae may sometimes complicate percutaneous femoral artery catheterization procedures. Most surgeons recommend prompt operative repair because of the unfavorable natural history of pseudoaneurysms or arteriovenous fistulae secondary to violent or accidental arterial trauma. However, the natural history of catheterization-induced pseudoaneurysms and arteriovenous fistulae has not been well documented. Accordingly, we prospectively studied the natural history of 22 pseudoaneurysms, 8 arteriovenous fistulae, and 3 combined lesions, identified by duplex scan in 32 patients following trans-femoral cardiac, peripheral vascular, or vascular access arterial catheterization procedures. Angiographic procedures were performed with the use of 5-8F introducer sheaths. A femoral artery complication was significantly more likely to result from coronary balloon angioplasty (9/304; 3.0%) than from diagnostic cardiac catheterization (21/2476; 0.8%) (p less than 0.003; chi square). Fourteen patients (13 pseudoaneurysms, 1 combined pseudoaneurysm/fistulae) underwent surgical repair. Pain and/or enlarging hematoma resulted in repair within two days of the diagnosis in 8 patients. The need for chronic anticoagulation prompted elective repair in 2 patients. A pseudoaneurysm was repaired in one patient five days following catheterization when it became painful. In three stable patients, asymptomatic pseudoaneurysms were repaired electively during another surgical procedure. There were no operative deaths. One patients (7%) developed a wound infection postoperatively. Eighteen patients (19 arterial lesions: 9 pseudoaneurysms, 8 arteriovenous fistulae, 2 combined pseudoaneurysms/arteriovenous fistulae) with improving symptoms and stable physical signs were followed by serial clinical evaluation and duplex scans. Seventeen of 19 (89%) of these lesions resolved spontaneously within 5-90 days (mean 30.7 days).(ABSTRACT TRUNCATED AT 250 WORDS)     

Venous reconstructions using the superficial femoral–popliteal vein

Purpose: To demonstrate the feasibility of venous reconstructions with the superficial femoral–popliteal vein (SFPV).Methods: Seven patients who underwent a variety of major venous reconstructions using SFPV were reviewed in a retrospective, observational study.Results: Three central venous reconstructions (thoracic and abdominal) and four peripheral major venous reconstructions were performed with SFPV autografts. In all patients, the SFPV grafts provided an excellent size match and were of adequate length without the need for enlargement by paneling or spiraling techniques. Postoperative anticoagulation medication was not used. There were no early graft failures, and patency was documented by duplex ultrasound, venogram, or both in all patients at a mean of 20 months follow-up. Venous thromboembolism has not occurred, and lower extremity venous morbidity has been minimal.Conclusions: The SFPV graft demonstrates versatility and durability in selected patients who require large-caliber conduits for venous reconstruction. Because of its size and availability, the SFPV is an excellent conduit for major venous reconstruction. (J Vasc Surg 1997;26:829-37.)     

Vascular complications of the intra-aortic balloon pump.

The lower extremity complications of 100 consecutive patients who required the placement of an intra-aortic balloon pump (IABP) during a 3-year period were studied. Indications for the IABP included hypotension during cardiac catheterization (33%) or coronary angioplasty (13%), hemodynamic instability after open heart surgery (35%), unstable angina (5%), and cardiac arrest (14%). The incidence of IABP morbidity was 29%. Complications included ischemia (25%), bleeding (2%), lymph fistula (1%), and femoral neuropathy (1%). Twenty patients required 1 or more surgical interventions for lower extremity vascular complications. The majority of patients who underwent operation (70%) had significant pre-existing arterial occlusive disease. Local femoral artery reconstruction or repair was performed in 18 patients. Two patients had adjunctive bypasses. Continued IABP support was required in four patients after treatment of complications. One patient (1%) had an above-knee amputation. Limb ischemia was treated nonoperatively by removal of the IABP in five patients. Color-flow duplex scans were useful in distinguishing hematomas from pseudoaneurysms as well as for assessing femoral artery flow. We conclude that: (1) limb ischemia remains the primary complication of the IABP; (2) pre-insertion documentation of the severity of existing peripheral arterial disease by noninvasive studies may aid in the management of subsequent acute limb ischemia; (3) femoral artery thrombectomy or endarterectomy is usually sufficient for revascularization; and (4) noninvasive color flow studies are an important diagnostic tool in the nonoperative management of limb complications.     

Management of infected lower extremity autologous vein grafts by selective graft preservation.

Between 1975 and 1991, we treated 16 patients with infected lower extremity autologous vein grafts performed for limb salvage by complete graft preservation. Traditional treatment of these infections includes immediate graft excision and complex revascularization procedures to prevent limb loss. The infection involved an intact anastomosis in 12 patients or the body of a patent graft in 4 patients. None of the patients was systemically septic. All patients were treated with appropriate intravenous antibiotics. Six patients were treated by placement of autologous tissue on the exposed graft (4 rotational muscle flaps, 2 skin grafts), and 10 were treated with antibiotic-soaked dressing changes and repeated operative débridements to achieve delayed secondary wound healing. This treatment resulted in a 19% (3 of 16) mortality rate and an 8% (1 of 13) amputation rate in survivors. Of the six patients managed by autologous tissue placement onto the infected graft, five patients had wounds that healed without complications, and one died of a myocardial infarction. Of the 10 patients treated by delayed secondary wound healing, 2 developed anastomotic hemorrhage, which resulted in death in 1 patient and above-knee amputation in the other, 1 died of a myocardial infarction, 1 developed graft thrombosis, and 6 had wounds that healed. Placement of autologous tissue to cover an exposed, infected patent vein graft with intact anastomoses may prevent graft dessication, disruption, and thrombosis, which renders graft preservation an easier, safer method of treatment compared with routine graft excision.     

Analysis of wound healing time and wound-free period as outcomes after surgical and endovascular revascularization for critical lower limb ischemia

Background

Traditional end points, such as amputation-free survival, used to assess the clinical effectiveness of lower limb revascularization have shortcomings because they do not account independently for wound nonhealing and recurrence or patient survival. Wound healing process and maintenance of a wound-free state after revascularization were not well-studied. The aim of this study was to elucidate the long-term clinical course of ischemic wounds after revascularization. We focused on initial wound healing process as well as the maintenance of a wound-free state after achievement of wound healing. We introduced a wound-free period (WFP; the period during which limbs maintained an ulcer-free state) and Wound Recurrence and Amputation-free Survival (WRAFS) as parameters and tested their effectiveness in evaluating clinical outcomes of limbs treated using endovascular therapy (EVT) and surgical revascularization.