Long-term results of infrainguinal revascularization with polytetrafluoroethylene: a ten-year experience.

Two hundred fifty-eight patients underwent 322 infrainguinal revascularizations with use of polytetrafluoroethylene (PTFE) between 1978 and 1988. The indication was limb salvage in 190 (59%) reconstructions. Two hundred nineteen (68%) were above-knee, and 75 (23%) were below-knee femoropopliteal bypasses. Twenty-eight (8.6%) were femoral-infrapopliteal bypasses, all done for limb salvage. Follow-up ranged from 24 to 144 months (mean, 66 months). The perioperative mortality rate (1 to 30 days) was 3.4% (9 patients), with no significant difference according to indication (2.9% vs 3.7%). Actuarial primary patency at 8 years for the entire series of femoropopliteal bypasses was 53% (above knee 53%; below knee 39%; p less than 0.05), and improved with additional procedures for a secondary patency of 72%. Femoropopliteal bypasses done for severe claudication had an 8-year actuarial primary patency of 63%, compared with 38% for limb salvage (p less than 0.02). Actuarial limb salvage in the latter group at 8 years was 66%. Femoral-infrapopliteal reconstructions with PTFE had a significantly lower primary patency at 3 years (22%, with a 37% limb salvage). Sixty-four percent of the failures for all reconstructions (N = 111) occurred within 12 months, with remarkable stabilization of patency curves beyond that interval. This experience represents the largest reported series of PTFE reconstruction with longest follow-up to date and may serve as a basis for comparison of other conduits. These results suggest an important role for PTFE in femoropopliteal revascularization and a limited role of this prosthetic conduit in femoral-infrapopliteal arterial reconstructions.     

A decade experience with infrainguinal revascularization in a dialysis-dependent patient population

OBJECTIVE: Although previous series have reported outcomes of lower extremity (LE) revascularization in patients with end-stage renal disease, the issue of LE bypass for limb salvage in this group has not been resolved. We herein present the largest series to date of a 10-year single-institution experience with LE bypass in patients with dialysis dependence. METHODS: With prospectively entered data from a university teaching hospital's vascular registry, we reviewed the records of all patients with dialysis dependence who underwent LE arterial bypass between January 1, 1990, and May 31, 1999. RESULTS: A total of 146 consecutive patients (177 limbs) underwent infrainguinal revascularization, of whom nearly all (92%) had diabetes and tissue loss (91%). The in-hospital mortality rate was 3% (five patients). The rates for perioperative congestive heart failure, myocardial infarction, arrhythmia, and wound infection were 2%, 3%, 5%, and 10%, respectively. The actuarial graft primary and secondary patency rates at 1 and 3 years were 84% and 85%, and 64% and 68%, respectively. The limb salvage rates were 80% and 80% at 1 and 3 years. The 1-year and 3-year cumulative survival rates were 60% and 18%, respectively. At 5 years, survival was poor with only 5% of the entire cohort of 146 patients still alive. Multivariate logistic regression analysis at 6 months identified age (odds ratio, 0.96, 0.91) and number of years on dialysis (odds ratio, 0.79, 0.74) as significant (P <.05) negative predictors of both limb salvage and survival, respectively. CONCLUSION: Infrainguinal arterial reconstruction can be performed on patients with dialysis dependence with acceptable rates of limb salvage given the high incidence rate of perioperative complications and poor longevity of this patient group. Advanced age and number of years on dialysis seem to correlate with poorer outcome.     

Myocardial revascularization. Early and late results after reoperation.

In a series of 4,522 consecutive patients who underwent aorta-coronary bypass (ACB) with the saphenous vein at the Texas Heart Institute, 32 had a second revascularization procedure. All patients were reoperated upon because of recurrence of incapacitating angina. Reappearance of angina was related to obstruction of the grafts alone in 6 patients, to the disease of other arteries alone in 16, and to both sources in the remaining 10 patients. In 9 patients progression of the native coronary disease was found, in 16 significant coronary obstructions had been left unbypassed at the time of initial operation, and in the remaining 7 patients inadequate indication and/or performance of revascularization was considered responsible for the failure. Of the 31 survivors, 61 per cent experienced complete relief of angina or were improved, whereas 39 per cent were unimproved. Reoperation was more successful in relieving angina when performed in patients with new lesions or with previously unbypassed lisions than when done in patients with graft occlusion. Incidence of myocardial infarction after the first and second procedure was similar (3 per cent). Reoperation was performed with a mortality rate of 3 per cent, comparable to that of the original procedure, but relief of angina was not achieved so consistently.     

Operative risk in coronary revascularization of patients with ventricular dysfunction

The initial sixteen month experience in patients undergoing simple revascularization of coronary arteries shows that 81 per cent of these patients were either Class III or Class IV on the basis of the New York Heart Association scale preoperatively; 57 per cent had some degree of ventricular dysfunction on left ventricular cineangiography, 50 per cent had elevated left ventricular graft dysfunction at rest, and 57 per cent had elevation post angiography. The hospital mortality was 1.6 per cent in the first 252 patients, and 2 per cent of the patients had a definite perioperative myocardial infarction and a further 6 per cent had a possible myocardial infarction. The total number of patients operated on between January 1971 and March 1974 now exceeds 1,000 with a total over-all hospital mortality of ten patients or 1 per cent. We believe that mortality and morbidity are essentially unchanged and that the flow study instances of myocardial infarction, pericarditis, and arrhythmia are representative of our over-all experience. Whenever significant valvular disease or ventricular aneurysm is associated with occlusive coronary artery disease, we believe that revascularization is necessary to achieve lower mortality and that ventricular dysfunction per se in patients undergoing revascularization is only a relative contraindication to revascularization.     

Simultaneous aortic reconstruction and renal revascularization: risk factors and late results in eighty-nine patients

From 1973 through 1984, graft replacement of infrarenal aortic aneurysms (N = 56) or occlusive disease (N = 33) was performed in conjunction with simultaneous renal revascularization in 89 patients. Isolated renal artery stenosis was corrected by unilateral reconstruction in 56 patients (63%), but the remaining 33 (37%) had diffuse involvement that required either bilateral renal artery grafts or unilateral revascularization of solitary kidneys. The incidence of hypertension (greater than 180/90 mm Hg) refractory to preoperative medical therapy (88%), severe coronary disease documented by angiography (40%), and postoperative azotemia (33%) or oliguric renal failure (15%) was significantly higher among patients with bilateral renal artery disease (p less than 0.05). In addition, this group had twice the early mortality rate (15%) of patients having unilateral renal artery lesions (7.1%). During a mean follow-up interval of 37 months, medical control of hypertension was enhanced in 46 of the 80 operative survivors (58%), and renal function improved or remained stable in 63 survivors (79%). Five-year actuarial survival presently is 65% for the entire series, with a cumulative mortality rate of 38% among patients who underwent aneurysm resection (mean age 64 years) in comparison to 15% (p = 0.03) for those patients with aortoiliac occlusive disease (mean age 60 years).     

Operative technique in myocardial revascularization.

This article necessarily deals exclusively with vein and artery bypass grafts. The venous autograft remains the most versatile operation and data thus far compiled verify its reliability. We advocate normotensive, normothermic perfusion and recommend the interrupted suture technique for most anastomoses. Our guidelines for IMA grafting indicate its applicability for most anterolateral wall vessels, except for unstable emergency patients and those with a large left ventricular mass. We emphasize that the technical details are far more important than the steps involved in coronary artery operations. The operative techniques described and discussed herein are deceptively simple, and direct coronary artery surgery often appears uncomplicated to the inexperienced observerer. However, one should not attempt myocardial revascularization without the benefit of high quality cinecoronary arteriograms. An organized and experienced operative team is mandatory and, above all, the procedure itself must not be an endurance contest between surgeon and patient. Expeditious revascularization produces less morbidity and better overall results.     

Early and late results in patients with carotid disease undergoing myocardial revascularization

A ten-year review of 1,360 patients undergoing coronary artery bypass grafting (CABG) by the same surgeon was undertaken. Sixty-two patients with symptoms of coronary artery insufficiency underwent carotid endarterectomy prior to or at the time of CABG (Group I). Ninety-seven patients had asymptomatic carotid bruits but did not undergo carotid endarterectomy (Group II). Sixty of these patients were studied by ultrasonic duplex scanning or ocular pneumoplethysmography or both, and hemodynamically significant stenosis was detected in 50 (Group IIa). Group III included 80 patients without carotid artery disease matched with Group II for sex, age, and clinical status. Group IV consisted of 200 patients without carotid artery disease randomly selected from our series. Follow-up ranged from 3 to 120 months (median, 41 months). In patients with proven carotid artery disease (Groups I and IIa), operative mortality was greater than in the patients randomly selected (Group IV) (p less than 0.05) but similar to that in the matched Group III. Late neurological deficits were greater in patients with carotid disease not undergoing carotid endarterectomy (p less than 0.01). Patients with carotid artery disease had lower survival than Group IV patients (p less than 0.01) but similar survival to that in the matched Group III. This study suggests that (1) asymptomatic patients with carotid artery disease who undergo CABG are not at increased risk of perioperative stroke; (2) these same patients are at increased risk of late neurological deficit; and (3) carotid artery disease is an indirect sign of severe associated disease and therefore is associated with increased operative mortality and decreased life expectancy.     

Results of infrainguinal revascularization in patients with end-stage renal disease

OBJECTIVES: The aim of this retrospective study was to evaluate the efficacy of bypass in patients with endstage renal disease (ESRD) and to determine predictive factors and precise bypass indications. METHOD: Forty one patients with ESRD underwent 50 bypass, 6 limbs were stage II and 44 stage III or IV according to Leriche and Fontaine classification. Revascularisations procedures were 47 infrainguinal bypass and 3 miscellaneous. Median follow up was 17,0+/-15,7 months. RESULTS: Perioperative mortality rate was 12% (n = 6). Morbidity was as follow : 1 perioperative major imputation and 8 secondary ones. There were 26 secondary death (12 from cardiac events), cumulative survival rate declined to 42,9+/-7,7% and limb salvage rate to 77,2+/-7,5% at 2 years. Primary and secondary potency rates were 53,5+/-10,4% and 70,6+/-10%. Quality of life was good in 28% of revascularised patients. Among risk factors, myocardial events showed a statistical significance in predicting survival, good runoff and bypass occlusion showed a statistical significance in predicting limb salvage. CONCLUSION: Revascularisation can be performed in ESRD patients. However to improve the results full evaluation of myocardial risks, skin lesions and infection of the feet, available autologous vein and nutritional status may be needed in those patients.     

Duplex-guided infrainguinal balloon angioplasty and stenting. A 4-year experience

AIM: The traditional technique of infrainguinal arterial balloon angioplasties involves the use of fluoroscopy and contrast material. We performed these procedures under duplex guidance to eliminate radiation exposure and avoid nephrotoxic effect of contrast. METHODS: Over the last four years, 274 patients (59% males) with a mean age of 74+/-9 years (range 42-97 years) had a total of 360 attempted balloon angioplasties of the superficial femoral (SFA) and/or popliteal arteries under duplex guidance. Cannulation of common femoral artery, manipulation of the guidewire across the stenoses and/or occlusions of the SFA and/or popliteal artery, and balloon dilation were achieved with duplex guidance alone. Infrapopliteal angioplasties of 80 arteries were attempted in 54 cases (15% of all cases). RESULTS: Overall technical success for femoral-popliteal segment was 95% (342/360 cases) and 96% (77/80 cases) for infrapopliteal segment. CONCLUSION: Duplex guided balloon angioplasty and stent placement appears to be a safe and effective technique for treatment of femoral-popliteal and infrapopliteal arterial occlusive disease.     

Operative mortality, mortality and late results in bronchial carcinoma]

457 patients with a bronchial carcinoma of the years 1947--1962 are compared with 126 patients of the years 1969--1970 and set up in comparison to the whole clinical material of the years 1960--1975. In the period between 1969 and 1970 radical resections were performed in 20% more patients than in the first period (1947--1962). Older patients were in the last period (1970--1974) more frequent. 8% of all patients in which lobectomy was performed and 5.5% of the patients in which pneumonectomy was performed were older than 70 years of age. Overall mortality has remained unchanged for exploratory thoracotomy (19%), palliative resection (17.5%) and "radical" resection (14%). For simple pneumonectomy the overall mortality went down from 19.2% (1960--1964) to 9.6% (1970-1974) and for simple lobectomy from 14.4% to 3.8%. The five-year survival rate after radical resections was 8% (first period 0%) and after simple resections 26% (26.2%). Patients with stage I epidermoid carcinoma had a five-year survival rate of 46%. Those with stage II (spread to ipsilateral hilar nodes) a five-year survival rate of 14.3% Patients with palliative resections and exploratory thoracotomy died within 16 months.     

The late functional results of upper limb revascularization and replantation

The functional results in 25 of 30 patients after successful upper limb revascularization or replantation were evaluated by subjective-patient surveying and objective measurements. Young patients with complete, sharply amputated extremities at the wrist level or those with incomplete injuries and uninjured peripheral nerves had the best functional results. Multiple-level, diffuse crush, or avulsion injuries, even if the injuries were incomplete, and patients with high-level nerve injury had less return of function.     

Subclavian revascularization. A quarter century experience.

OBJECTIVE: Twenty-five years of experience with subclavian revascularizations were reviewed to determine the long-term patency rates of different extrathoracic approaches. SUMMARY BACKGROUND DATA: Although it is generally agreed that proximal subclavian stenosis should be treated by an extrathoracic route whenever possible, the optimum procedure is debated. Alternatives include subclavian carotid bypass, subclavian-to-subclavian or axillo-axillary bypasses, and the authors' preferred technique of subclavian carotid transposition (SCT). METHODS: Records were researched for the past 25 years in a single specialty surgical clinic for extrathoracic subclavian revascularizations. One hundred ninety such procedures were identified, and hospital charts and office medical records were reviewed for procedure, preoperative symptoms, blood pressure differentials, and postoperative complications. Patency was determined by physical examination, differential blood pressures, Doppler spectral analysis, duplex examinations, and arteriography. RESULTS: Bypass procedures were used infrequently, and although the results are reported, they are excluded from any analysis. Subclavian carotid transposition was used in 178 procedures. All anastomoses were found to be patient at follow-up, except for one, which failed at 26 months. Mean follow-up was 46 months, with five patients lost to follow-up. Overall mortality rate was 2.2%, with the mortality falling to 1.1% if only subclavian carotid transposition patients are included. CONCLUSIONS: Subclavian carotid transposition should be the treatment of choice for routine subclavian carotid occlusive disease because of its exceptional long-term patency and low morbidity.     

Institutional results and meta-analysis of outcome after infrainguinal surgical revascularization in patients greater than 80 years old

Our aim was to evaluate the outcome after infrainguinal bypass revascularization in patients greater than 80 years old with lower limb ischemia treated at our institution and to perform a meta-analysis of literature data to better estimate current postoperative results. Eighty-four infrainguinal bypass procedures were performed in 76 patients of at least 80 years of age. Major outcome end points included survival, limb salvage, and amputation-free survival. Systematic review and meta-analysis of literature data on immediate and late outcome in patients older than 80 years who underwent infrainguinal surgical revascularization have been performed. At 30 days, seven patients (8.3%) died and seven major amputations (8.3%) occurred. Kaplan-Meier estimates of survival at 1, 3, and 5 -years were 73.8, 59.8, and 43.1 per cent; leg salvage 78.9, 71.4, and 67.8 per cent; and amputation-free survival 58.3, 42.7, and 28.2 per cent, respectively. The mean survival was 4.6 ± 0.4 years. Only Finnvasc score greater than 2 was predictive of poor late amputation-free survival (at 5 years: 4.5 vs 42.3%; relative risk, 2.19; 95% confidence interval, 1.27 to 3.76). Eleven studies were additionally available for analysis. Pooled estimates of survival at 30 days, 1 year, and 5 years were 94.8, 86.0, and 47.6 per cent, respectively, and of leg salvage were 95.5, 84.7, and 84.1 per cent, respectively. Infrainguinal bypass in patients older than 80 years carries a significant operative risk and is associated with suboptimal long-term amputation-free survival, which is particularly poor among patients with a Finnvasc score greater than 2.     

Surgical treatment of renovascular hypertension and respective late results. A twenty years experience.

This paper presents the long term results following operative reconstruction for renovascular hypertension in 115 patients operated upon over a period of 20 years. There were 71 (61.7%) males and 44 (38.3%) females with a median age of 46 years (range 16-67). Renal revascularization was unilateral in 96 (83.4%) cases and bilateral in 19 (16.6%). Dacron knitted bypass grafts, were used in 51 and PTFE in 33 instances. Saphenous vein grafts were used in 11 patients. In 15 cases treatment was by local endarterectomy with concomitant angioplasty (12 unilateral and 3 bilateral). Simultaneous aortorenal reconstruction was undertaken in 38 (33%) patients. There were no deaths in the group with isolated renal artery reconstruction. In the group of aortorenal reconstructions, two deaths were encountered (5.7%). Postoperatively, blood pressure was either normal or improved in 83 (72%) patients at a mean follow-up period of 48.3 months (range 1-195 months). The best results were obtained in younger individuals with segmental renal artery lesions. Linear progression analysis, showed age to be a major determinant in the postoperative response to hypertension. There was a greater degree of long term success in patients with fibromuscular dysplasia, as compared to individuals with atherosclerosis. Crude survival probabilities, were 78% and 61% at 5 and 10 years respectively. Late deaths encountered in the present series, were mostly attributable to myocardial infarction (7.8%). In this series, the best results were obtained in individuals younger than 50 years of age, with segmental renal artery lesions.     

Perioperative outcomes of infrainguinal bypass surgery in patients with and without prior revascularization

Objective

Although an increasing number of patients with peripheral arterial disease undergo multiple revascularization procedures, the effect of prior interventions on outcomes remains unclear. The purpose of this study was to evaluate perioperative outcomes of bypass surgery in patients with and those without prior ipsilateral treatment.

Lower limb revascularization with a new bioactive prosthetic graft: early and late results

The aim of the study was to evaluate the immediate and long-term results of femoropopliteal bypasses performed with a new bioactive heparin-treated expanded polytetrafluoroethylene (ePTFE) graft in a single-center experience. From March 2002 to April 2006, 51 patients underwent lower limb revascularization with a new bioactive ePTFE prosthetic graft with covalent end-point attachment of heparin to the graft surface. Data concerning preoperative assessment, intraoperative strategy, drug administration, and follow-up surveillance program were prospectively collected in a dedicated database; early results were analyzed in terms of graft patency, amputation rate, and deaths. Follow-up consisted of clinical and duplex scan examination at 1, 6, and 12 months and yearly thereafter. Midterm results in terms of primary and secondary patency, limb salvage, and survival were analyzed. Patients were predominantly male (35 patients, 71%), with a mean age of 71 years (SD = 9.05). Indications for surgical revascularization were critical limb ischemia in 36 patients and severe intermittent claudication in 15 patients. Interventions were performed for occlusion of a native vessel in 35 cases, whereas 12 patients had late thrombosis of a femoropopliteal bypass; the remaining four patients were operated on for an occluded popliteal artery aneurysm. Intervention consisted of below-knee bypass in 34 patients, while the other 17 had an above-knee revascularization. No perioperative deaths occurred. Cumulative 30-day graft patency was 88%, with an amputation rate of 4% (two cases). Results were similar in above- and below-knee revascularizatons. Mean duration of follow-up was 18 months (SD = 7). Cumulative estimated 24-month survival and primary patency rates were 97% and 80.2%, respectively; the corresponding limb salvage rate was 85.7%. Long-term results did not significantly differ in above- and below-knee revascularizatons. In our experience, the use of a modified ePTFE graft with covalent end-point linkage of heparin molecules on the graft surface provides good early and midterm results, with low rates of graft thrombosis and amputation.     

Combined myocardial and cerebral revascularization. A ten year experience

We report on the results of combined carotid endarterectomy and coronary artery bypass grafting in 82 patients. Vascular pathology was severe in these cases: 94% of patients had extensive multivessel coronary artery disease, 29% had unstable angina, 30% had severe left main stem stenosis and all patients had hemodynamically significant stenosis of at least one carotid artery, 13% had an additional occlusion of the contralateral internal or common carotid artery and 26% had severe bilateral carotid artery stenosis. The carotid lesion was asymptomatic in 64% of cases, 24% of the patients experienced previous transient cerebral ischemia and 12% of the patients had a history of completed stroke. Hospital mortality was 7.3%. Neurological deficit occurred in 7.3% but functional impairment was not permanent. Late results have been obtained for 76 survivors at a mean postoperative interval of 29 months. Five year life table survival rate was 86%. Follow-up showed that 3 patients (4%) have died and that 3 patients (4%) experienced a late neurologic event (one TIA; two strokes) but none of these events involved the cerebral cortex on the side of the carotid endarterectomy. The cumulative 5 year stroke free survival rate is 91%. We conclude that combined carotid endarterectomy and coronary artery bypass grafting can be done with an acceptable mortality rate in these critically ill patients and that the postoperative incidence of neurological events is low.     

Long-term results of infrainguinal arterial reconstruction with spliced veins are equal to results with non-spliced veins.

OBJECTIVES: to determine the long term patency of spliced and non-spliced infrainguinal vein grafts. METHODS: a prospective registry of all patients undergoing infrainguinal arterial reconstruction with autogenous vein material was retrospectively interrogated. RESULTS: between October 1988 and August 2000, 515 infrainguinal arterial reconstructions were performed on 472 patients. A total of 429 bypasses were performed with uninterrupted greater saphenous vein, 86 reconstructions using spliced vein segments. There was no significant difference in primary (63% vs 57%) and primary assisted patency (81% vs 81%) of limb salvage (88% vs 91%) at 5 years. Limb salvage was not different (88% and 91% respectively). CONCLUSION the splicing of vein grafts does not compromise patency of limb salvage.