A two-staged technique for basilic vein transposition.

The dilemma of creating a fistula in patients without a use-able cephalic vein can be addressed by basilic vein transposition, yet results of the classic single-stage procedure are inconsistent and surgeon utilization of this procedure is variable. This article describes a two-staged technique for basilic vein transposition. The two-staged technique is likely to facilitate higher fistula rates in patients unable to have a direct fistula, and warrants consideration by surgeons striving to achieve higher fistula rates.

The necessity of mandatory exploration of penetrating zone II neck injuries.

To reevaluate the validity of our policy of mandatory surgical exploration of penetrating zone II neck injuries, the charts of 110 patients who underwent surgical exploration for such injuries were reviewed. Fifty-three percent of the patients had normal findings at exploration, whereas 33% had injuries involving vascular structures of the neck and 14% had nonvascular injuries. Injuries were not suspected on clinical grounds preoperatively in 23% of the patients in whom surgical exploration revealed injury. The injuries most likely to escape preoperative diagnosis were isolated venous injuries and isolated pharyngoesophageal injuries. Arteriography yielded false-negative results in two arterial injuries. No deaths and only a 5% incidence of minor complications occurred in the group with no injuries detected at exploration. We conclude that surgical exploration of penetrating zone II neck injuries is safe and appropriate.

Effect of prostaglandin E1 on blood flow in normal and ischemic canine hindlimbs.

Prostaglandin E1 (PGE1) is a potent vasodilator that will increase peripheral blood flow. After infusion of PGE1, little is known about the distribution of flow between skin and muscle or the effect of PGE1 on an ischemic leg. We infused intra-arterially PGE1 (5 ng/kg/min) into normal and ischemic canine hindlimbs. Radioactive microspheres were used to measure nutrient flow to skin and muscle and flow shunted through arteriovenous connections. Intra-arterial PGE1 caused significant increases in skin blood flow in both normal and ischemic hindlimbs. Shunted flow did not increase. Muscle flow increased in normal canine hindlimbs, but this increase was prevented by femoral artery ligation. We conclude that PGE1 increases absolute nutrient flow rather than opening arteriovenous shunts in the canine hindlimb. Skin flow is most sensitive to prostaglandin infusion. Muscle flow is increased in normal but not ischemic limbs. PGE1 may be useful in situations where vasospasm is a prominent feature. The role of PGE1 in atherosclerotic ischemic disease remains unclear.

Results of venous reconstruction after civilian vascular trauma.

The treatment of venous injuries remains controversial. In an attempt to evaluate the results of current management of venous injuries, we retrospectively reviewed our experience between 1979 and 1984. During this period 142 patients had sustained injuries to 158 veins in the neck (31 patients), abdomen (45 patients), upper extremity (20 patients), and lower extremity (62 patients). Overall, 90 venous injuries (61%) were repaired, including 83% of caval and iliac vein injuries and 90% of injuries to the common femoral, superficial femoral, and popliteal veins. There was no morbidity after repair of 73 major veins. Morbidity occurred in four of 11 patients after ligation of major veins (edema in two patients and above-knee amputation in two others). Both ligation (N = 51) and repair (N = 17) of lesser veins (jugular, brachial, profunda femoral, tibial, and minor abdominal veins) resulted in no morbidity. Overall mortality was 6% with all deaths occurring in patients with abdominal venous trauma. These data indicate that repair of venous injuries can be performed without morbidity and that minor veins can be ligated without adverse sequelae. However, in view of the morbidity associated with ligation of major veins, efforts to restore flow to these injured vessels appear appropriate unless contraindicated by life-threatening injury.

Results of arterial reconstruction of the foot.

Sixty-five patients with critical ischemia required bypass to foot vessels. These procedures were performed by five different techniques: (1) femoral-foot bypass with in situ saphenous vein; (2) femoral-foot bypass with reversed autogenous saphenous vein; (3) femoral-foot bypass with polytetrafluoroethylene (PTFE); (4) popliteal-foot bypass with reversed autogenous saphenous vein; and (5) popliteal-foot bypass with PTFE. The two-year patency rate of femoral-foot bypass with in situ vein (96%) was significantly higher than femoral-foot bypass with reversed vein (42%), while both procedures demonstrated significantly higher patency than femoral-foot bypass with PTFE (0%). Popliteal-foot bypass with reversed vein (92%) was superior to both popliteal-foot bypass with PTFE (27%) and femoral-foot bypass with PTFE (0%). Femoral-foot bypass with in situ vein and popliteal-foot bypass with reversed vein have appreciably increased vein utilization, graft patency, and limb salvage.

Jejunal interposition for recurrent gastroesophageal reflux in children.

There is limited experience with surgical treatment for recurrent gastroesophageal reflux after an antireflux procedure. In four pediatric patients with recurrent reflux after surgical therapy, interposition of an isoperistaltic segment of jejunum produced excellent short-term results. Further follow-up is needed as experience broadens. At the present time, this procedure merits consideration in patients with recurrent gastroesophageal reflux.

Ankle bypass: should we go the distance?

This report reviewed the results of 47 distal arterial reconstructions to or below the level of the malleolus. The operations were performed by the techniques of popliteal-to-distal bypass (20 procedures) and in situ bypass (27 procedures). Seventy-five percent of patients had gangrene of ischemic ulceration, and all procedures were performed for limb salvage. Seventy-three percent of all patients were diabetic. The patency rates for popliteal-to-distal bypass with reversed saphenous vein were 92 percent at 24 months and 57 percent at 60 months, with a limb salvage rate of 70 percent at 60 months; the patency rates for popliteal-to-distal bypass with PTFE were 53 percent at 12 months and 0 at 36 months, with a limb salvage rate of 53 percent at 36 months; and the patency rate for in situ saphenous vein bypass was 96 percent at 24 months, with a limb salvage rate of 80 percent at 24 months. Early results are promising for ankle bypass using the techniques of popliteal-to-distal and in situ bypass.

Efficacy of femorofemoral bypass for intermittent claudication. Clinical and hemodynamic assessment.

Twenty patients treated by femorofemoral bypass were retrospectively reviewed to determine if femorofemoral bypass was efficacious in the treatment of disabling claudication. The data have clearly demonstrated that two criteria are necessary for the successful outcome of femorofemoral bypass. First, the donor artery should be hemodynamically normal in order to support the recipient limb. This can be determined by either a normal treadmill exercise test result or by a normal preoperative intraarterial papaverine test result. Second, the patient's functional improvement will be dependent on the status of the runoff vessels in the recipient limb; therefore, many patients with patent superficial femoral and popliteal arteries will have excellent results (50 percent in this series), whereas those with occluded superficial femoral or popliteal arteries or both will have less improvement (40 percent in this series). Therefore, femorofemoral bypass should be used in the treatment of intermittent disabling claudication in the properly selected patient.

Optimal limb salvage in penetrating civilian vascular trauma.

To evaluate current treatment of peripheral vascular trauma, we reviewed our recent experience with noniatrogenic penetrating vascular injuries of the extremities. Between 1979 and 1984, 139 patients sustained 204 vascular injuries inflicted by single gunshots (64%), stabbings (24%), and shotguns (12%). Eighty-four percent of patients underwent preoperative arteriography, which revealed occult arterial injury in 13 patients (9%). Compartmental hypertension necessitated fasciotomy in 19% of patients and was required more often after combined arterial and venous injuries (29%) than after isolated arterial injury (14%). Arterial continuity was restored by interposition grafting with reversed saphenous vein (62%), end-to-end anastomosis (19%), vein patch angioplasty (8%), or primary repair (4%). After arterial repair, completion angiography detected the need for revision in 8% of patients. Arterial ligation was performed in 7% of injuries and was only used in the treatment of tibial and distal profunda femoris injuries. Forty-five percent of patients sustained concomitant venous injury; 64% of all venous injuries and 90% of femoropopliteal venous injuries were repaired. No deaths occurred, and a single patient required amputation. We conclude that a protocol of preoperative arteriography, liberal. use of fasciotomy, frequent use of autologous interposition grafts, repair of major venous injuries, and routine use of completion arteriography can result in limb salvage rates that approach 100% after penetrating vascular trauma to the extremities.

Abdominal aortic aneurysm: the case for elective resection.

Abdominal aortic aneurysms are one of the more common problems faced by the vascular surgeon. A review of 898 aneurysms resected at the University of Rochester from 1955 to 1982 revealed a sequential decrease in mortality for elective surgery from 13% in 1955 to 1965, to 8.4% from 1966 to 1973, and 5.6% in the last 8 years. Mortality for resection of ruptured aneurysms remained high (70%). The incidence of ruptured aneurysms has not changed significantly in the last 16 years. For 1980 and 1981 we calculated the hospital costs of surgical treatment of abdominal aortic aneurysms. The mean total cost after elective resection was +10,114 compared with +18,223 after rupture. Increased costs after rupture reflected both a longer stay and more intensive and expensive medical care. Using discharge data from U.S. hospitals in 1979, we extrapolated our cost and mortality data to a national level. Assuming a mortality rate for elective resection of 5% and a mortality rate for resection after rupture of 50%, we estimated that in 1979 +50 million and over 2000 lives could have been saved if patients with abdominal aortic aneurysms had been identified and subjected to elective resection. The incidence of ruptured abdominal aortic aneurysms remains unacceptably high. Mortality from this disease can best be reduced by increased physician awareness and prompt surgical referral.(ABSTRACT TRUNCATED AT 250 WORDS)

Subclavian steal despite ipsilateral vertebral occlusion.

In the classic subclavian steal syndrome, vertebrobasilar insufficiency is caused by reverse flow in the vertebral artery ipsilateral to a subclavian stenosis or occlusion. We present two patients with vertebrobasilar insufficiency and ipsilateral vertebral and subclavian occlusive disease. The postulated mechanism of vertebrobasilar insufficiency is reverse flow in collateral neck vessels. In both patients, symptoms were relieved by carotid subclavian bypass. Thus, vertebral occlusion ipsilateral to a subclavian stenosis does not preclude subclavian steal syndrome.

Improved results in the treatment of civilian vascular injuries associated with fractures and dislocations.

Patients with vascular injuries associated with fractures or dislocations of the extremities were managed according to a standard protocol, which included the liberal use of preoperative arteriography, early fasciotomy when indicated, individualization of timing and type of orthopedic procedures, arterial reconstruction primarily with interposition reversed saphenous vein grafts, repair of major venous injuries, routine completion arteriography, and regular postoperative monitoring of Doppler-derived ankle/brachial indices. Adherence to these principles led to a limb salvage rate of 97% in 38 patients with such injuries.