Population-based study of ruptured abdominal aortic aneurysm.

BACKGROUND: The incidence of abdominal aortic aneurysms (AAAs) and their rupture has been reported to be decreasing. The aim was to evaluate trends in ruptured AAA (rAAA) incidence in the hospital district of Helsinki and Uusimaa (HUS) in southern Finland. This was a population-based retrospective review of all patients with rAAA in this well defined geographical area during 2003-2013. METHODS: Data for all patients treated for rAAA at Helsinki University Hospital, the only vascular surgery centre in an area of 1·5 million inhabitants, were collected from local vascular registry. All deaths attributed to rAAA were obtained from the cause of death registry of Statistics Finland. RESULTS: The mean(s.d.) age of the 712 patients with rAAA was 76·5(9·6) years; 76·7 per cent of them were men. Only 330 patients (46·3 per cent of those with rAAA) arrived alive at Helsinki University Hospital. The turn-down rate for surgical treatment was 10·3 per cent. Of the 296 patients operated on, 199 (67·2 per cent) were alive at 30 days. Only 27·9 per cent of all patients were alive 30 days after rupture of the AAA. The incidence of rAAA was 4·3 per 100 000 inhabitants and the mortality rate was 3·2 per 100 000 inhabitants. A decreasing trend was seen in incidence and mortality during the 11-year study interval. CONCLUSION: The incidence of rAAA is decreasing in the HUS district. Mortality from rAAA remains very high, because half of the patients die before reaching the hospital.

Rupture of Abdominal Aortic Aneurysms in Patients Under Screening Age and Elective Repair Threshold.

OBJECTIVES: The objective of this study was to identify the proportion of abdominal aortic aneurysm ruptures that occur before the screening age or threshold diameter for operative repair is reached. METHODS: The study was a retrospective analysis of RAAA patients including all RAAA patients admitted to Helsinki (HUH) and Tampere University Hospitals (TaUH) during 2002-2013. The data for age, gender, and comorbidities were collected from vascular registry and patient records. Computed tomography images taken at the time of admission were used for the measurement of maximum anteroposterior (AP) aneurysm diameter at the time of rupture. Age and diameter data were compared with risk factors. RESULTS: A total of 585 patients diagnosed with RAAA were admitted to the two hospitals during the 12 year period. The mean age at the time of rupture was 73.6 years (SD 9.5, range 42-96 years). 18.3% of patients were under 65: 21.4% of men and 3.0% of women. Men were on average 8 years younger than women. The odds ratio (OR) for rupture before 65 years of age for smokers was 2.1 compared with non-smokers, and 28.4% of smokers were under 65 at the time of rupture. Of all RAAA patients, 327 had a computed tomography scan confirming rupture. The mean AP diameter of the aneurysm was 75.6 mm (SD 15.8, range 32-155 mm). The mean size was significantly lower in women than in men (70.5 vs. 76.8, p = .005). CONCLUSIONS: The data from this study show that a fifth of men would not make it to the screening age of 65 before AAA rupture, the proportion being even larger in active smokers. The data from this study also supports the previous finding that aneurysm size at the time of rupture is significantly smaller in women.

Editor's Choice - Treatment of Aortic Prosthesis Infections by Graft Removal and In Situ Replacement with Autologous Femoral Veins and Fascial Strengthening.

INTRODUCTION: Aortic prosthetic graft infection (AGI) is a major challenge in vascular surgery. Eradicating the infection requires prosthetic material removal, debridement, and lower limb revascularization. For the past 15 years, we have used femoral veins for aorto-iliac reconstruction and tensor fascia lata to strengthen the upper anastomosis. OBJECTIVE: The purpose of this single institution retrospective study is to present results regarding in situ replacement of infected aortic grafts with autologous femoral veins (FVs). METHODS: From October 2000 to March 2013, patients treated for AGI with graft removal and autologous FV reconstruction at Helsinki University Hospital were included. Primary outcome measures were 30 day mortality, long-term treatment related mortality, and re-infection rate. Secondary outcome measures were long-term all cause mortality and event free survival (graft rupture, re-intervention, major amputation). RESULTS: During a 13 year period 55 patients (42 male, 13 female) were operated on using a venous neo-aorto-iliac system for AGI. The mean follow up was 32 months (1-157 months). The 30 day mortality rate was 9% (5) and overall treatment related mortality 18% (10). All cause mortality during follow up was 22 (40%) and overall Kaplan-Meier survival was 90.7% at 30 days, 81.5% at 1 year, and 59.3% at 5 years. Graft rupture occurred in three (5%) cases, two of which were caused by graft re-infection (4%). Four patients required major amputation, one of them on arrival and three (5%) during the post-operative period. Nine (16%) patients needed interventions for the vein graft, and two graft limbs occluded during follow up. CONCLUSION: In situ reconstruction for aortic graft infection with autologous FV presents acceptable rates of morbidity and mortality, and remains the treatment of choice for AGI at Helsinki University Hospital.

Strategies for free flap transfer and revascularisation with long-term outcome in the treatment of large diabetic foot lesions.

OBJECTIVE/BACKGROUND: To analyse the impact of ischaemia and revascularisation strategies on the long-term outcome of patients undergoing free flap transfer (FFT) for large diabetic foot lesions penetrating to the tendon, bone, or joint. METHODS: Foot lesions of 63 patients with diabetes (median age 56 years; 70% male) were covered with a FTT in 1991-2003. Three groups were formed and followed until 2009: patients with a native in line artery to the ulcer area (n = 19; group A), patients with correctable ischaemia requiring vascular bypass (n = 32; group B), and patients with uncorrectable ischaemia lacking a recipient vessel in the ulcer area (n = 12; group C). RESULTS: The respective 1, 5, and 10 year amputation free survival rates were 90%, 79%, and 63% in group A; 66%, 25%, and 18% in group B; and 50%, 42%, and 17%, in group C. The respective 1, 5, and 10 year leg salvage rates were 94%, 94%, and 87% in group A; 71%, 65%, and 65% in group B; and 50%, 50%, and 50% in group C. In 1 year, 43%, 45%, and 18% of the patients in groups A, B, and C, respectively, achieved stable epithelisation for at least 6 months. The overall amputation rate was associated with smoking (relative risk [RR] 3.09, 95% confidence interval [CI] 1.8-5.3), heel ulceration (RR 2.25, 95% CI 1.1-4.7), nephropathy (RR 2.24, 95% CI 1.04-4.82), and an ulcer diameter of >10 cm (RR 2.08, 95% CI 1.03-4.48). CONCLUSION: Despite diabetic comorbidities, complicated foot defects may be covered by means of an FFT with excellent long-term amputation free survival, provided that a patent native artery feeds the ulcer area. Ischaemic limbs may also be salvaged with combined FFT and vascular reconstruction in non-smokers and in the absence of very extensive heel ulcers. Occasionally, amputation is avoidable with FFT, even without the possibility of direct revascularisation.

The natural course of abdominal aortic aneurysms that meet the treatment criteria but not the operative requirements.

INTRODUCTION: Abdominal aortic aneurysms (AAAs) of 55 mm diameter or growth >5 mm in 6 months are commonly accepted treatment criteria. The aim of this study was to establish the outcome of aneurysms that met the treatment criteria but not the operative requirements. MATERIAL AND METHODS: Patients (n = 154) who were declined from operative care of AAA in Helsinki University Central Hospital (HUCH) during 2000-2010 were retrospectively analysed. Reasons for exclusion were identified. The follow-up period extended until the end of April 2012. The rupture rate and mortality were determined. The patients were analysed according to the aneurysm diameter: 55-60, 61-70 and >70 mm. RESULTS: The reasons for exclusion from operative treatment were cardiorespiratory co-morbidities in 33%, cancer in 8%, overall condition in 33% and patient's choice in 21% of the patients. Regardless of the size of the aneurysm, the cause of death was aneurysm rupture in 43%, which was confirmed either in hospital or in autopsy for 76% of the patients. Of the ruptured aneurysms, 12 were operated of which five survived. CONCLUSIONS: A ruptured aneurysm is the most common cause of death among patients unfit for surgery; this should be considered in the preoperative evaluation process, especially since 5 of the 12 patients survived the ruptured AAA (RAAA) operation.

The role of vascular registries in improving the management of abdominal aortic aneurysm.

Treatment of abdominal aortic aneurysm (AAA) is one of the vascular surgical index procedures and an important part of the total workload. Whichever way treated, it typically has high mortality and morbidity. Furthermore, endovascular repair is still a relatively new treatment method and under evolution. Therefore continuous quality control with subsequent outcome analysis, benchmarking, intervention and reassessment are mandatory to achieve high level aneurysm care. Vascular registries are tools for this audit. The aim of this review is to focus on the problems and solutions related to attempts to improve the management of abdominal aortic aneurysm with emphasis on the experience gathered in Finland. This includes great variations in dynamics over time in Southern Finland. To control the influence of patient selection and case-mix, total hospital mortality is emphasized as the most appropriate outcome measure of the level of treatment of ruptured abdominal aortic aneurysm (RAAA). Total aneurysm mortality (including total hospital mortality of RAAA and other AAA surgery) is introduced as an outcome measure of vascular service.

Internal arteriovenous fistula within a radial forearm flap--a novel technique to increase femorodistal bypass graft flow to the diabetic foot and flap covering ischaemic tissue loss.

BACKGROUND: The fascio-cutaneous radial forearm flap is especially suitable to rebuild the contour of the foot, but because of low natural low flow this flap lacks the beneficial effect of large muscle flaps on bypass graft flow. The aim of this study was to introduce a novel technique of flap coverage combined to vascular bypass: an internal av-fistula was created within a radial forearm flap. METHODS: Nine critically ischaemic limbs were treated with a modified radial forearm flap in the Department of Plastic and Vascular Surgery, Helsinki University Central Hospital 1998-2003. All the patients were candidates for a major amputation unless this combined operation was attempted. A two-team approach was used: the vascular surgeon performed the distal bypass and the radial forearm flap was raised by the plastic surgeon. In eight cases a femorodistal bypass was performed and in the ninth the vein graft supplied the flap directly. The internal fistula within the flap was created between the distal end of the radial artery and either the cephalic vein or the concomitant vein of the radial artery. Flow was measured during surgery. RESULTS: Vein graft flow increased significantly after the radial forearm flap anastomosis (76 vs 44 ml/min, p=0.016). The flow of both the bypass graft and the flap artery were higher with the av-fistula patent (p=0.016 and p=0.004). Graft patency was 89% at 2 years. Infection was a major cause of amputation, 1- and 2-year limb salvages being 67 and 53%. CONCLUSION: In a group of diabetic patients increased flow in a vascular bypass graft was achieved by an internal av-fistula within a radial forearm flap. This method is useful in selected cases with poor run off and large ischaemic lesions.

Prediction of survival after 48-h of intensive care following open surgical repair of ruptured abdominal aortic aneurysm.

OBJECTIVE: To identify predictive factors for 30-day mortality after 48 h of maximal treatment in intensive care unit (ICU) after repair for ruptured abdominal aortic aneurysm (RAAA). DESIGN: Retrospective study in the ICU of the university central hospital. MATERIALS AND METHODS: Between 1999 and 2003, a total of 197 patients were admitted to emergency unit due to RAAA, and 185 of them underwent open surgical repair. A total of 138 patients survived at least 48-h and were included in a study to identify factors predictive of 30-day mortality by logistic regression analysis. RESULTS: Thirty-day mortality of all RAAA patients was 46% (87/197) whereas the 30-day mortality for those alive at 48 h was 22% (31/138). Forward stepwise multivariate logistic regression analysis revealed that only organ dysfunction by SOFA score (sequential organ failure assessment) at 48-h, preoperative Glasgow Aneurysm Score, and supra-renal clamping in operation were independent predictors of death. CONCLUSIONS: Degree of organ dysfunction by SOFA score was the best predictor of 30-day mortality in RAAA patients alive at 48-h after open surgical repair.

The impact of adjuvant av-fistula on cuffed Femorocrural PTFE bypass grafting: flow and pressure response.

OBJECTIVE: The aim of the present study was to assess the effect of an adjuvant av-fistula on prosthetic bypass grafting and whether intraoperative flow measurements could predict patency and adverse events of cuffed femorocrural PTFE bypass with or without an av-fistula. METHODS: A total of 50 patients in need of vascular reconstruction for critical limb ischaemia (CLI) but with no suitable venous conduit were included. RESULTS: The flow values in patients with av-fistula were significantly higher (p=0.009) than in the group without the fistula but the higher flow values did not result in improved patency. The maximum flow velocity (Vmax) in the av-fistula group was significantly higher in the immediate postoperative period (p=0.04), but there was no difference in patency. When a flow value of 50 ml/min was used as a cut-off point, patients with a higher flow had significantly better immediate patency (p=0.025). CONCLUSION: The adjuvant av-fistula neither caused any adverse effects nor had any effect on patency.

Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia?--a prospective randomised multicentre trial.

INTRODUCTION: A lack of suitable veins can cause serious problems when attempting to revascularise critically ischaemic legs. Prosthetic grafts have much worse patency in the femocrural position, despite the use of distal anastomotic cuffs. The use of adjuvant AV-fistula at the distal anastomosis should increase the graft flow above the thrombotic threshold velocity and thus increase prosthetic graft patency. AIM: The aim of the study was to evaluate the benefit of an adjuvant AV-fistula on the patency of a femorocrural PTFE bypass with a distal vein cuff. MATERIALS AND METHODS: This prospective randomised multicentre trial was conducted in four centres. A total of 59 patients with critical leg ischaemia and no suitable veins for grafting were randomised to receive a femocrural PTFE bypass and distal vein cuff, with or without an adjuvant AV-fistula. Thirty-one patients were randomised to the AV-fistula group (AVFG) and 28 to the control group (CG). Six patients were lost to follow-up during the 2-year study time. RESULTS: There were six immediate occlusions in each treatment group, but half of these were saved by re-operation. The mean postoperative ankle-brachial index (ABI) was 0.85 in the AVFG and 0.94 in the CG. The primary and secondary patency rate at 2 years was 29 and 40% for the AVFG and 36 and 40% for the CG (NS). Leg salvage at 2 years was 65 and 68%, respectively (NS). CONCLUSION: Adjuvant AV-fistula does not improve the patency of a femorocrural PTFE bypass with a distal vein cuff.

Long-term survival and health-related quality of life of patients with ruptured abdominal aortic aneurysm.

INTRODUCTION: the outcome of ruptured abdominal aortic aneurysm (RAAA) patients is most frequently measured as operative or in-hospital mortality rate. However, survival alone is not an indicator of quality of the treatment. Assessment of quality of life (QoL) is used increasingly and is a relevant measure of outcome. OBJECTIVE: to assess long-term survival and QoL of patients undergoing repair of RAAA. DESIGN: follow-up study with cross-sectional QoL evaluation. MATERIALS AND METHODS: between 1996 and 2000, 199 of 220 patients with RAAA underwent surgery. Survivors were sent the generic the RAND 36-item Health Survey (RAND-36) self-administered questionnaire. RESULTS: total hospital mortality and operative mortality were 103 of 220 (47%) and 82 of 199 (41%). Of the 117 initial survivors, 21 were deceased at the time of the study. When compared to an age- and sex-adjusted general population, only physical functioning was significantly impaired (p=0.01) in the 82 of 93 (88%) RAAA survivors who responded. CONCLUSIONS: survivors after repair of RAAA had almost the same QoL as the norms of an age- and sex-adjusted general population, justifies an aggressive operative policy in RAAA.

Increased preoperative c-reactive protein level as a prognostic factor for postoperative amputation after femoropopliteal bypass surgery for CLI.

BACKGROUND AND AIMS: We evaluated the possible predictive role of C-reactive protein (CRP) on the immediate postoperative outcome after femoropopliteal bypass surgery for critical leg ischaemia (CLI). MATERIAL AND METHODS: 138 patients with CLI who underwent 143 femoropopliteal reconstructions. RESULTS: The immediate postoperative period secondary patency rate was 87%, leg salvage rate was 94%, and survival rate 97%. Nine patients (6.3%) had 30-day postoperative major amputation, three of them despite a patent bypass graft because of progression of foot infection. The preoperative serum concentration of CRP was the only predictor of postoperative major amputation (p = 0.004; for an increase of 10 mg/l: OR, 1.188; CI 95%, 1.059-1.332). The median preoperative serum concentration of CRP among patients who did not have major amputation was 13.0 mg/l (range, 1-185), whereas it was 47.5 mg/l (range, 5-168) among those who had amputation after bypass graft occlusion, and 115.0 mg/l (range, 34-222) among those who had amputation despite a patent bypass graft (p = 0.008). CONCLUSIONS: CRP may be a useful marker in risk stratification for postoperative amputation in patients undergoing femoropopliteal bypass surgery for CLI.

Redo bypass surgery to the infrapopliteal arteries for critical leg ischaemia.

OBJECTIVES: to evaluate the results of redo bypass surgery to the infrapopliteal artery and the value of adjuvant arteriovenous fistula (AVF) in this setting. DESIGN: retrospective study. MATERIALS: fifty-one redo reconstructions to the infrapopliteal arteries were done for critical leg ischaemia in 45 patients who have had primary infrainguinal reconstructions to the popliteal artery in 20 cases (39%), the crural arteries in 18 (35%), and the pedal arteries in 13 (25%). METHODS: a PTFE prosthesis was used in 21 cases (41%). A Miller cuff was used in 16 prosthetic grafts. Adjuvant AVF was added to three autogenous vein and 12 prosthetic grafts. RESULTS: at 2 years, the primary patency rate was 42%, the secondary patency was 43%, the limb salvage was 67%, the survival was 77%, and 53% of patients were alive with salvaged leg. The primary patency rate with a vein graft was 44% at 1 year, with prosthesis plus AVF 67%, but with prosthesis without AVF only 19%. Secondary patency rates were similar. Prosthetic graft with AVF and those without AVF achieved a 1-year leg salvage rate of 100% and 51%, respectively (p =0.01). Patients with adjuvant AVF had a worse 2-year survival rate that those without AVF (31% vs 89%) (p =0.007; RR: 8.87, CI 95%: 1.62-48.42). CONCLUSIONS: redo bypass surgery using autogenous vein graft may achieve satisfactory long-term results. The use of adjuvant AVF may improve patency of redo infrapopliteal prosthetic bypass grafts.

Popliteal-to-distal bypass grafts for critical leg ischaemia.

BACKGROUND: To assess the value of revascularization to crural and pedal arteries using the popliteal artery as inflow source. EXPERIMENTAL DESIGN: Retrospective study with a mean follow-up period of 15.2 months (range, 0-46). SETTING: Academic referral center. PATIENTS: 62 patients with critical leg ischaemia and popliteal artery suitable as inflow source for infrapopliteal arterial revascularisation. INTERVENTIONS: 66 popliteal-to-distal bypass procedures, of which 18 popliteal-crural bypass grafts and 48 popliteal-pedal bypass grafts. MAIN OUTCOME MEASURES: Bypass graft patency, leg salvage, survival and success defined as patients alive with leg. RESULTS: At 1-month, 1-year, and 2-year follow-up, the primary patency rates were 87%, 58%, and 55%, secondary patency rates were 95%, 70%, and 67%, leg salvage rates were 97%, 88%, and 88%, while 88%, 70%, and 66% of patients were alive with legs at the same intervals. At 2-year follow-up the survival rate was 72%. Above-knee popliteal-to-distal bypasses achieved better primary patency (p=0.02) and corrected primary patency rates (p=0.01) than below-knee popliteal-to-distal bypasses. Diabetes and uraemia affected the survival and patients alive with leg rates. CONCLUSIONS: Popliteal-to-distal bypass surgery is worthwhile for the management of severe, isolated infrapopliteal atherosclerotic disease. Diabetic and uraemic patients are at high risk for both leg and life loss after revascularisation. Grafts originating from the above-knee popliteal artery may achieve better patency rates than those originating from the below-knee popliteal artery.

Arterial intervention and reduction in amputation for chronic critical leg ischaemia.

BACKGROUND: Untreated chronic critical leg ischaemia (CLI) usually leads to an amputation or death of a patient. Surgical and endovascular interventions may improve arterial flow. Long infrainguinal reconstruction may be the most useful method for preventing amputations. The value of different reconstruction methods was assessed by their impact on amputation incidence. METHODS: A nationwide 2-year analysis of the incidence of major amputations and reconstructions for CLI was done in Finland (population 5.1 million). Incidences were compared in hospital regions with more than 150 000 inhabitants. RESULTS: The overall amputation incidence was 216 per million inhabitants per year. The corresponding incidence of arterial reconstructions was 203 per million inhabitants per year. There were large variations in the incidence of amputations and reconstructions; 20-fold differences in infrapopliteal surgical reconstructions and 30-fold differences in endovascular procedures were found. There was a correlation between a high incidence of infrapopliteal surgical reconstructions and a low incidence of amputations. This correlation was found for below-knee amputations only. CONCLUSION: These results suggest that long surgical reconstructions improving perfusion directly to the ischaemic tissue can improve leg salvage.

Limits of infrapopliteal bypass surgery for critical leg ischemia: when not to reconstruct.

The aim of this study was to identify the risk factors affecting the immediate 30-day postoperative outcome of infrapopliteal bypass grafts. A series of 511 revascularization procedures to the infrapopliteal arteries have been performed in 439 patients with critical leg ischemia. There were 306 crural bypasses and 205 pedal bypasses. The 30-day postoperative primary and secondary patency rates were 77.5% and 83.4%, respectively; the leg salvage rate was 89.8%; the survival rate was 94.7%; and 85.1% of patients were alive with a salvaged leg. A history of myocardial infarction, angina pectoris, or stroke had a great impact on the postoperative cardiac and cerebrovascular fatal and nonfatal complications. C-reactive protein arose as an important predictor of the length of hospital stay (p = 0.03), postoperative cardiac complications (p = 0.02), leg salvage (p = 0.009), amputation with patent graft (p = 0.009), and patients who survived with a salvaged leg (p = 0.006). Poor results were achieved in patients on long-term dialysis. Surgical experience had an influence on leg salvage (p = 0.02) and on patients alive with salvaged leg rates (p = 0.009). Infrapopliteal bypass surgery is a demanding procedure requiring high surgical skill and experience. Revascularization may be contraindicated when severe coronary disease, previous stroke, renal failure requiring long-term dialysis, diabetes, or high serum concentration of C-reactive protein coexist with critical leg ischemia, as these patients are at high risk for early postoperative leg or life loss.

Successful percutaneous endovascular treatment of a ruptured popliteal artery aneurysm.

A rupture of the popliteal artery is a rare but dangerous complication of aneurysmal disease. It accounts for 4% of all popliteal artery aneurysms encountered and threatens the loss of the extremity and, infrequently, is also life-threatening.(1) when this clinical entity is confronted, a prompt operative intervention is indispensable for increasing the chances of limb salvage. We report the first, to our knowledge, successful endovascular treatment of a ruptured popliteal artery aneurysm with a new polytetrafluoroethylene stent-graft in a patient who was unfit for a conventional surgical approach because of his severe pulmonary disease.

Does a completely accomplished duplex-based surveillance prevent vein-graft failure?

OBJECTIVES: to assess the benefits of duplex-based vein-graft surveillance over clinical surveillance with distal pressure measurements. DESIGN: prospective randomised comparative trial. MATERIAL AND METHODS: three hundred and forty-four patients with 362 consecutive infrainguinal vein bypasses were prospectively randomised to a follow-up regime with or without duplex scanning (ABI group and DD group) at 1, 3, 6, 9, and 12 months postoperatively. RESULTS: one hundred and eighty-three grafts were enrolled to the ABI group and 179 to the DD group. The primary assisted patency, secondary patency and limb salvage rates were 67%, 74%, 85% for the ABI group and 67%, 73%, 81% for the DD group. Ninety grafts in the ABI group and 57 in the DD group had surveillance that completely adhered to the protocol. The outcome was also similar for these groups at one year (77%, 87%, 94% and 77%, 83%, 93% respectively), although grafts were revised more frequently in the DD group. CONCLUSIONS: intensive surveillance with duplex scanning did not improve the results of any outcome criteria examined. To demonstrate any potential benefit of duplex scanning for vein-graft surveillance a multicentre study with a large number of patients to ensure sufficient power is needed.

Valvulotomy of non-reversed saphenous vein bypass grafts: a randomised, blinded, angioscopy-controlled study.

OBJECTIVES: to compare the result of vein valve disruption with two different valvulotomes during non-reversed saphenous vein bypass. DESIGN: a randomised, blinded clinical study. MATERIALS AND METHODS: twenty patients undergoing femorodistal non-reversed saphenous vein arterial bypass were randomised into two equal groups. Valve leaflet disruption was performed either with a standard size plastic valvulotome or with a metal valvulotome with an exchangeable cutting head. Valvulotomy was done after full exposure of the vein and completion of the proximal anastomosis. The result was evaluated by a surgeon blinded to the valvulotome used, using angioscopy. RESULTS: a total of 219 valve cusps were inspected with angioscopy. There were 83 completely lysed cusps (69%) by plastic and 76 (78%) by metallic valvulotomes (p=0.14). Of all the incompletely lysed cusps 12 (29%) occurred in the most proximal valve pocket treated with valvulotomy. CONCLUSIONS: no significant difference in performance between the investigated valvulotomes was found. Incomplete valvulotomy occurred mainly in the proximal part of the vein and was obviously caused by a size mismatch between the diameter of vein and the valvulotome. Construction of a valvulotome with a variable diameter cutting head is therefore recommended.

Predictive factors for adverse outcome of pedal bypasses.

OBJECTIVE: to identify the risk factors affecting the outcome of bypass grafts to the foot arteries. DESIGN: longitudinal observational study from a single institution. MATERIALS AND METHODS: one-hundred and sixty-five infrainguinal bypasses to the foot arteries were performed in 162 legs of 149 patients with critical leg ischaemia. RESULTS: at 1-month, 1-year, 2-year and 3-year follow-up, the primary patency rates were 74%, 43%, 38% and 34%, the secondary patency rates were 82%, 50%, 47% and 41%, the leg salvage rates were 88%, 66%, 66% and 60%, survival rates were 95%, 76%, 69% and 55%, whereas 82%, 53%, 49% and 36% of patients were alive with salvaged leg, respectively. Low preoperative plasma concentrations of C-reactive protein (CRP) and short grafts with more distal arterial inflow had a better outcome. Better primary and secondary patency rates were also achieved by experienced surgeons and by the use of in situ saphenous vein grafts. Pedal run-off scoring did not have any impact on the outcome of pedal bypasses. CONCLUSIONS: short pedal bypasses using in situ saphenous vein technique, done by an experienced surgeon, have the best outcome. Revascularisation to the foot arteries may carry a poor outcome in patients with elevated preoperative CRP concentration.