Effect of Cord Blood Magnesium Level at Birth on Non-neurologic Neonatal Outcomes.

OBJECTIVE: We examined the effects of magnesium sulfate on non-neurologic neonatal outcomes with respect to cord blood magnesium level. STUDY DESIGN: We conducted a secondary analysis of the Maternal-Fetal Medicine Units Beneficial Effects of Antenatal Magnesium (MFMU BEAM) trial comparing the upper and lower quintiles of cord blood magnesium level. Outcomes included cerebral palsy (CP), necrotizing enterocolitis (NEC), retinopathy of prematurity (ROP), bronchopulmonary dysplasia (BPD), and assessments of mental and motor disability. Logistic regression was used to estimate adjusted odds ratios (aORs) of each outcome, controlling for gestational age (GA), birth weight, and treatment group (TG). RESULTS: A total of 1,254 women of the 2,444 included in the BEAM trial had cord blood magnesium levels recorded. GA and birth weight were lower and TG was more common in the upper quintile cohort (p < 0.001). Neonates in the upper quintile were more likely to have severe NEC (OR, 2.41, 95% confidence interval [CI]: 1.11-5.24), ROP (OR, 1.65, 95% CI: 1.05-2.59), and BPD (OR, 1.70, 95% CI: 1.04-2.73). Adjustment for covariates demonstrated no difference in the NEC, ROP, and BPD rates, although there was a decrease in rates of mental disability index < 70 which was not seen in the unadjusted analysis (aOR, 0.49, 95% CI: 0.25-0.99). CONCLUSION: Higher cord blood magnesium levels do not appear to have adverse non-neurologic effects on the neonate and may demonstrate improvement in neurologic outcomes.

Group B Streptococcus (GBS) Colonization and Disease among Pregnant Women: A Historical Cohort Study.

Background: Maternal GBS colonization is associated with early-onset neonatal sepsis and extensive efforts are directed to preventing this complication. Less is known about maternal risks of GBS colonization. We seek to provide a modern estimate of the incidence and impact of maternal GBS colonization and invasive GBS disease. Methods: A single center historical cohort study of all births between 2003 and 2015 was performed. Data was collected via electronic health record abstraction using an institutional specific tool. Descriptive statistics were performed regarding GBS status. Inferential statistics were performed comparing risk of adverse pregnancy outcomes in cohorts with and without GBS colonization as well as cohorts with GBS colonization and invasive GBS disease. Results: A total of 60,029 deliveries were included for analysis. Overall, 21.6% of the population was GBS colonized and 0.1% had invasive GBS disease. GBS colonization was associated with younger maternal age, Black race, non-Hispanic ethnicity, chronic hypertension, preexisting diabetes, and tobacco use (p<0.01). In the adjusted analyses, there was an increased risk of gestational diabetes (aRR 1.21, 95% CI 1.11-1.32) in colonized pregnancies and a decreased incidence of short cervix (aRR 0.64, 95% CI 0.52-0.79), chorioamnionitis (aRR 0.76, 95% CI 0.66-0.87), wound infection (aRR 0.75, 95% CI 0.64-0.88), and operative delivery (aRR 0.85, 95% CI 0.83-0.88). Conclusions: This modern-day large cohort of all births over a 12-year period demonstrates a GBS colonization rate of 21.6%. This data reflects a need to assess maternal and perinatal outcomes in addition to neonatal GBS sepsis rates to inform decisions regarding the utility of maternal vaccination.

Chagas Disease Screening in Maternal Donors of Publicly Banked Umbilical Cord Blood, United States.

To assess patterns of Chagas disease, we reviewed results of screening umbilical cord blood from a US public cord blood bank during 2007-2014. Nineteen maternal donors tested positive for Trypanosoma cruzi parasites (0.04%). Because perinatal transmission of Chagas disease is associated with substantial illness, targeted prenatal programs should screen for this disease.

Cystic fibrosis involving the cervix, mimicking a well-differentiated adenocarcinoma: a case report.

We describe clinicopathologic and immunohistochemical features of an unusual case of cystic fibrosis manifesting in the cervix as a mass lesion, mimicking cervical adenocarcinoma. A 24-year-old nulligravida with cystic fibrosis developed heavy postcoital vaginal bleeding 4 months after starting oral contraceptives and was found to have a cervical mass. She underwent a loop electrosurgical excision of the mass, and microscopic examination revealed a florid endocervical proliferation, extending to the margins. This lesion was initially interpreted as an invasive, well-differentiated endocervical adenocarcinoma. However, on subsequent review, the lesion was found to have a low rate of proliferation, no evidence of an infiltrative growth pattern, and abundant acute inflammation. Given these findings and the absence of any residual endocervical lesion on a subsequent cold knife conization, we determined that this was a benign, likely reactive, lesion. This case, together with previous studies, suggests that women with cystic fibrosis can develop proliferative endocervical lesions and that oral contraceptives may contribute to their development.

Efficiency of the kidney disease outcomes quality initiative guidelines for preemptive vascular access in an academic setting.

BACKGROUND: The National Kidney Foundation-Kidney Diseases Outcomes Quality Initiative (KDOQI) for vascular access guidelines state that patients with late-stage chronic kidney disease (CKD) should undergo native arteriovenous fistula (AVF) creation at least 6 months before anticipated start of hemodialysis (HD) treatments to obviate the need for other vascular access types, such as grafts or central catheters. OBJECTIVE: The objective of this study was to determine the incidence of HD, the functional patency, and associated morbidity of AVFs in patients with late-stage CKD placed according to KDOQI. METHODS: Consecutive patients with late-stage CKD who underwent AVF creation using KDOQI guidelines for anatomy between January 2003 and December 2007 at two tertiary academic centers were retrospectively evaluated. Baseline demographics, AVF type, and clinical comorbidities were recorded. Patients were stratified into one of four groups (groups A-D) over the follow-up course based on two end points: patency of their AVF and whether or not they began HD. The ideal primary outcome was AVF maturation and use for HD (group A; cumulative functional patency). Other outcomes included AVF patency but no HD (group B), HD with AVF failure (group C), or no HD and AVF abandonment (ie, death, refused hemodialysis, kidney transplant, or fistula failure; group D). Secondary outcomes were time to first cannulation, complications, and secondary interventions. RESULTS: AVFs were created (46% forearm and 54% upper arm) in 150 patients with CKD (85% men, median age 63 years old). At a median follow-up of 10 months, 74 patients (49%) were receiving HD and of these, 48 patients (65%) were using their AVF (group A), whereas 26 patients (35%) were not due to fistula failure (group C). Thirty-four patients (23%) never initiated HD treatments, but had a viable AVF (group B), and 42 patients (28%) never initiated HD and abandoned their AVF (group D). Overall, AVF abandonment was 51%. Mean maturation time of all AVFs successfully cannulated was 285 days (range, 30-1265 days). Complications encountered were maturation failure for cannulation (15%), focal stenosis requiring intervention (13%), inadequate flows on HD (9%), steal syndrome (9%), and thrombosis (8%). Cumulative functional patency for all AVFs was 19% and 27% at 6 and 12 months, respectively, with a mean number of two interventions per AVF (range, 1-10). Mortality during the study was 23%. CONCLUSION: Despite successful creation and maturation of a preemptive AVF in nearly two-thirds of patients who started HD during the follow-up and given the following observations: the high overall mortality of the population, the morbidity and costs in secondary procedures of AVF creation, and the high incidence of abandonment, it is unclear if this strategy would demonstrate a benefit in a randomized trial when compared to other access strategies.

Magnesium sulfate for neuroprotection in the setting of chorioamnionitis.

PURPOSE: We examined the effects of magnesium on premature neonatal outcomes complicated by chorioamnionitis. MATERIALS AND METHODS: We conducted a secondary analysis of data from the BEAM Trial, an RCT to determine if antenatal magnesium decreases the incidence of CP in preterm birth. We compared the effect of magnesium sulfate by the presence or absence of chorioamnionitis. Outcomes examined include CP, IVH, NEC, BPD, and assessments of mental and motor disability. Logistic regression was used to estimate adjusted odds ratios of each outcome. RESULTS: About 1944 women were included in this analysis of which 228 were diagnosed with chorioamnionitis. Demographic characteristics were similar between women randomized to receive magnesium or placebo. Magnesium therapy demonstrated no significant reduction in CP in the presence of chorioamnionitis (OR 0.76, CI: 0.19-2.76) but does demonstrate benefit in the absence of chorioamnionitis (OR 0.52, CI: 0.31-0.86). CONCLUSIONS: Antenatal magnesium did not show a clear neuroprotective effect in the setting of chorioamnionitis.

Factors affecting symptomatic vs asymptomatic vein graft stenoses in lower extremity bypass grafts.

OBJECTIVE: To determine differences in patients undergoing lower extremity vein graft revisions presenting with and without recurrence of preoperative symptoms. DESIGN: Retrospective case-control study of a prospectively maintained database. SETTING: University and veterans' administration hospitals PATIENTS: Two hundred nineteen lower extremity vein graft revisions were performed in 161 patients from January 1995 to January 2007. Patients were categorized as asymptomatic or symptomatic (recurrence of initial symptoms) at the time of revision. MAIN OUTCOME MEASURES: Univariate analysis was performed to assess differences in patient demographics, details of initial operation, site of recurrent lesion, and follow-up surveillance data between symptomatic and asymptomatic patients. Independent predictors of symptomatic recurrence were identified with multivariate logistic regression. Primary assisted patency was compared between revisions performed for symptomatic and asymptomatic lesions. RESULTS: Vein graft stenoses were asymptomatic in 125 cases (57%) and symptomatic in 94 cases (43%). Symptomatic recurrences were associated with a significantly greater drop in ankle brachial index than asymptomatic lesions (mean [SD], 0.21 [0.03] vs 0.11 [0.02]; P = .003). Distal graft or outflow lesions were significantly associated with symptom recurrence (P = .048). Multivariate analysis identified ankle brachial index decrease (odds ratio, 6.803; 95% confidence interval, 1.418-32.258; P = .02) and the use of alternate graft conduit (odds ratio, 2.633, 95% confidence interval, 1.243-5.578; P = .01) as independent predictors of recurrent symptoms. Overall 5-year patency was the same regardless of preoperative symptoms (82% symptomatic and 88% asymptomatic; P = .30). CONCLUSIONS: Symptomatic recurrences are associated with larger decreases in ankle brachial index, distal lesions, and alternate conduit grafts. Duplex surveillance is necessary to identify asymptomatic vein graft stenoses. Because graft patency is independent of preoperative symptoms, surveillance consisting of clinical follow-up with ankle brachial index evaluation warrants further consideration.

Repeat axillofemoral grafting as treatment for axillofemoral graft occlusion.

BACKGROUND: Patency of failed axillofemoral (ax-fem) grafts following thrombectomy is so poor, aortofemoral grafts are recommended as treatment for ax-fem graft thrombosis. In patients who are not candidates for aortic grafting, repeat ax-fem grafting is an alternative to thrombectomy. This report compares our experience treating ax-fem graft thrombosis with replacement or revision vs thrombectomy. METHODS: Patients treated with ax-fem grafts from October 1985 to April 2001 were identified, and those who underwent reoperation for thrombosis were reviewed. Limb salvage and patency of revision procedures (thrombectomy vs repeat ax-fem grafting) were determined using Kaplan-Meier curves. RESULTS: Three hundred thirty-five patients underwent ax-fem grafting, and 39 (11.6%) of the 335 required reoperation for graft failure. Twenty-five of these 39 patients had 51 operations for graft thrombosis: 42 graft replacements and/or anastomotic revision(s), and 9 thrombectomies. At 18 months, mean +/- SD patency following thrombectomy was 11% +/- 10%, while that for graft replacement or anastomotic revision was 54% +/- 8% (P<.001). Limb salvage at 18 months following revision for thrombosis was 88% +/- 5%. CONCLUSIONS: The large majority of ax-fem grafts do not require reoperation. For failure due to thrombosis, repeat ax-fem grafting provides excellent limb salvage. Axillofemoral graft replacement and/or anastomotic revision has superior patency to thrombectomy.

Carotid surgery following previous carotid endarterectomy is safe and effective.

With the perceived high risk of repeat carotid surgery, carotid angioplasty and stenting have been advocated recently as the preferred treatment of recurrent carotid disease following carotid endarterectomy. An experience with the operative treatment of recurrent carotid disease to document the risks and benefits of this procedure is presented. A review of a prospectively acquired vascular registry over a 10-year period (Jan. 1990-Jan. 2000) was undertaken to identify patients undergoing repeat carotid surgery following previous carotid endarterectomy. All patients were treated with repeat carotid endarterectomy, carotid interposition graft, or subclavian-carotid bypass. The perioperative stroke and death rate, operative complications, life-table freedom from stroke, and rates of recurrent stenosis were documented. During the study period 56 patients underwent repeat carotid surgery, comprising 6% of all carotid operations during this period. The indication for operation was symptomatic disease recurrence in 41 cases (73%) and asymptomatic recurrent stenosis >/=80% in 15 cases (27%). The average interval from the prior carotid endarterectomy to the repeat operation was 78 months (range 3 weeks-297 months). The operations performed included repeat carotid endarterectomy with patch angioplasty in 31 cases (55%), interposition grafts in 19 cases (34%), and subclavian-carotid bypass in 6 cases (11%). There were three perioperative strokes with one resulting in death for a perioperative stroke and death rate of 5.4%. One minor transient cranial nerve (CN IX) injury occurred. Mean follow-up was 29 months (range, 1-116 months). Life-table freedom from stroke was 95% at 1 year and 90% at 5 years. Recurrent stenosis (>/=80%) developed in three patients (5.4%) during follow-up, including one internal carotid artery occlusion. Two patients (3.6%) underwent repeat surgery. Repeat surgery for recurrent cerebrovascular disease following carotid endarterectomy is safe and provides durable freedom from stroke. Most patients are candidates for repeat endarterectomy with patching, but interposition grafting is often required. These results strongly support the continued role of repeat carotid surgery in the treatment of recurrent carotid disease.

The role of Mycoplasma and Ureaplasma in adverse pregnancy outcomes.

Genital mycoplasmas are frequently found in the vaginal flora across socioeconomic and ethnic groups and have been demonstrated to be involved in adverse perinatal outcomes. Both Mycoplasma and Ureaplasma spp cause inflammation potentially leading to spontaneous preterm birth and PPROM as well as postdelivery infectious complications and neonatal infections. Herein we have provided an overview of the existing literature and supportive evidence for genital mycoplasma's role in perinatal complications. Future research will need to focus on clearly delineating the species, allowing for discrimination of their effects.

Quinary debulking for epithelial ovarian cancer.

We report a case of optimal quinary debulking for recurrent papillary serous carcinoma of the ovary involving the liver parenchyma through the full thickness of the diaphragm into the lung parenchyma. Multiple debulking procedures for ovarian cancer are controversial, especially when there is extensive upper abdominal or thoracic disease. Selection criteria for such extensive surgery include: good functional status, long disease-free interval, and absence of other systemic disease. Our patient tolerated her procedure well without evidence of residual disease over 6 months postoperatively.

Coexisting atypical polypoid adenomyoma and endometrioid endometrial carcinoma in a young woman with Cowden Syndrome: Case report and implications for screening and prevention.

► Cowden Syndrome is a rare hereditary cancer syndrome, which confers an increased risk of breast, thyroid, endometrial and colon cancer. ► Atypical polypoid adenomyoma does not generally represent a premalignant lesion, but must be carefully screened for foci of malignancy. ► Cancer screening must be intensified for patients who meet the diagnostic criteria for Cowden Syndrome.

Charlottesville Health Access: a locality-based model of health care navigation for the homeless.

The authors describe Charlottesville Health Access (CHA), an initiative to get people who are homeless into the health care system. A community homeless shelter worked with faculty and students from the Univ. of Virginia Schools of Medicine and Nursing to create and run the program.

The sartorius muscle flap: an important adjunct for complicated femoral wounds involving vascular grafts.

INTRODUCTION: Femoral wound complications can threaten vascular grafts. Muscle flaps can be used to facilitate soft-tissue coverage and graft salvage. We report a series of sartorius flaps performed by vascular surgeons in the treatment of complicated femoral wounds. METHODS: Rotational sartorius flaps were performed to attempt salvage of underlying vascular grafts. We reviewed a prospective database to determine the outcomes of sartorius flaps on facilitating wound healing and graft salvage and patency. RESULTS: From 2005 to 2008, 21 sartorius flaps were performed in infected or threatened femoral wounds. Original operations included femoral endarterectomy with patch repair in 8, aortofemoral graft in 6, axillofemoral graft in 4, and femoral-distal bypass in 3 patients. Complete wound healing occurred in 18 patients (86%). Primary wound closure was achieved in 7 patients. Secondary wound closure was achieved in 11 patients with mean healing time of 2.3 months. All vascular reconstructions remained patent at the 9.5-month follow-up. CONCLUSIONS: Sartorius muscle flaps are effective at facilitating complicated femoral wound healing while maintaining graft salvage and patency.

Angiographic evaluation of carotid artery grafting with prefabricated small-diameter, small-intestinal submucosa grafts in sheep.

The purpose of this study was to report the longitudinal angiographic evaluation of prefabricated lyophilized small-intestinal submucosa (SIS) grafts placed in ovine carotid arteries and to demonstrate a variety of complications that developed. A total of 24 grafts, 10 cm long and 6 mm in diameter, were placed surgically as interposition grafts. Graft patency at 1 week was evaluated by Doppler ultrasound, and angiography was used for follow-up at 1 month and at 3 to 4 months. A 90% patency rate was found at 1 week, 65% at 1 month, and 30% at 3 to 4 months. On the patent grafts, angiography demonstrated a variety of changes, such as anastomotic stenoses, graft diffuse dilations and dissections, and aneurysm formation. These findings have not been previously demonstrated angiographically by other investigators reporting results with small-diameter vessel grafts made from fresh small-intestinal submucosa (SIS). The complications found were partially related to the graft construction from four SIS layers. Detailed longitudinal angiographic study should become an essential part of any future evaluation of small-vessel SIS grafting.

Ruthenium(II) tris(bipyridine)-centered poly(ethylenimine) for gene delivery.

Ruthenium(II) tris(bipyridine)-centered poly(ethylenimine) (Ru PEI) was synthesized via acid hydrolysis of Ru tris(bipyridine)-centered poly(2-ethyl-2-oxazoline) (Ru PEOX), and the luminescence, DNA entrapment, and transfection efficiencies were evaluated. Emission maxima for Ru PEI samples are red-shifted compared to Ru PEOX precursors, and the luminescence lifetimes are shorter in both methanol and aqueous solutions. Slower oxygen quenching of Ru PEOX and Ru PEI luminescence versus [Ru(bpy)3]Cl2 (bpy = bipyridine) is attributed to polymer shielding effects. Ru PEI luminescence is similar in the presence and absence of DNA. Ru PEI (7900 Da) and linear PEI (L-PEI; 22,000 Da) fully entrapped DNA (5.4 kb; pcDNA) at an N/P ratio of 2. LNCaP prostate cancer cells were transfected with a plasmid encoding for green fluorescent protein using Ru PEI and L-PEI vectors for comparison. For N/P = 48, the transfection efficiency for Ru PEI was approximately 50% relative to that of L-PEI.

Risk factors for autogenous infrainguinal bypass occlusion in patients with prosthetic inflow grafts.

OBJECTIVE: In patients with prosthetic inflow (PI) grafts the proximal anastomosis of autogenous infrainguinal bypass (AIB) can be placed on the PI or on a distal native vessel in the groin. This study was performed to determine the effect of placement of an AIB proximal anastomotic site in a patient with ipsilateral PI. METHODS: Patients undergoing AIB and PI between January 1990 and July 2002 were included in the study. They were classified into two groups on the basis of location of the proximal anastomosis. In group 1 the AIB proximal anastomosis was placed on the PI in the groin, whereas in group 2 the AIB proximal anastomosis was placed on a distal native groin artery. Patency, limb salvage, and patient survival in the two groups were calculated with the Kaplan-Meier method. The Cox proportional hazards model was used to determine independent risk factors affecting AIB patency. RESULTS: Two hundred twenty-nine patients underwent AIB and PI. In group 1, 23 AIBs became thrombosed concurrent with 26 PI occlusions, and in group 2, 7 AIBs became thrombosed concurrent with 36 PI occlusions (P <.001). Five-year assisted primary patency, limb salvage, and patient survival in groups 1 and 2 were 50% and 75% (P <.001, log-rank test), 78% and 90% (P =.005, log-rank test), and 56% and 69% (P = NS, log-rank test), respectively. Factors independently associated with AIB occlusion are hypertension (hazard ratio [HR], 3.41; 95% confidence interval [CI], 1.65-7.05; P =.001), postoperative warfarin sodium therapy (HR, 1.86; 95% CI, 1.07-3.23; P =.03), continued smoking (HR, 1.72; 95% CI, 0.93-3.18; P =.08), AIB arising from PI (HR, 2.38; 95% CI, 1.35-4.18; P =.003), and PI occlusion (HR, 3.70; 95% CI, 2.15-6.36; P <.001). CONCLUSION: A proximal AIB anastomosis located directly on the PI is an independent risk factor for decreased AIB patency of equal or greater importance than current smoking, hypertension, or PI occlusion. The proximal anastomosis of an AIB in a patient with an ipsilateral PI should be placed on a distal native artery.

Choice of autogenous conduit for lower extremity vein graft revisions.

BACKGROUND: Surgical revision to repair stenosis is necessary in about 20% of lower extremity vein grafts (LEVGs). Alternate conduit, especially arm vein, is often necessary to achieve a policy of all-autogenous revisions. Although basilic vein harvest necessitates deep exposure in proximity to major nerves, it typically uses a large vein unaffected by prior intravenous lines and as such appears ideally suited for revisions in which a segmental interposition conduit is needed for revision within the graft or for extension to a more proximal inflow or distal outflow site. In this report, we describe our experience with the use of the basilic vein for LEVG revisions compared with other sources of autogenous conduit. METHODS: All patients who underwent LEVG were placed in a duplex scan surveillance program. LEVGs that developed a focal area of increased velocity or uniformly low velocities throughout the graft with appropriate lesions confirmed with angiography were candidates for revision. All patients who underwent graft revision with basilic vein segments from January 1, 1990, to September 1, 2001, were identified, and their courses were reviewed for subsequent adverse events (further revision or occlusion) and complications of harvest. These revisions were compared with revisions in which cephalic and saphenous vein were used. RESULTS: One hundred thirty basilic veins were used to revise 122 LEVGs. The mean follow-up period after revision was 28 +/- 27 months. Ninety-three grafts (71%) remained patent with no further revision, and 37 grafts (29%) either needed additional revisions (22 grafts) or were occluded (15 grafts). Only four of these adverse events (11%) were directly attributed to the basilic vein segment. Ten of 43 grafts revised with cephalic vein (23%) were either revised or occluded, of which three were related to the cephalic vein segment (P = not significant, compared with basilic vein). Twenty-four of 81 grafts revised with saphenous vein (30%) were either revised or occluded, of which 11 were attributed to the saphenous vein segment (P <.01, compared with basilic vein). Two patients (1.5%) had complications from basilic vein harvest (one hematoma, one arterial injury). No neurologic injuries resulted from basilic vein harvest. CONCLUSION: The basilic vein is a reliable and durable conduit when used to segmentally revise LEVGs. Stenoses rarely occur within interposed basilic vein segments, and excellent freedom from subsequent revision or occlusion is possible. We conclude the basilic vein can be safely harvested with minimal complications and is ideally suited for use as a short segment interposition graft for LEVG revision.

Comparison of procedural outcomes after lower extremity reversed vein grafting and secondary surgical revision.

OBJECTIVE: Many lower extremity vein graft procedures require revision. Although morbidity associated with revision procedures is assumed minimal, this has not been previously quantified and may be underestimated. In this study, patient outcome after initial vein graft procedures and revisions are compared. METHODS: Records for all patients undergoing vein graft revision from January 1995 to August 2002 were reviewed for operation time, estimated blood loss, blood transfusion, hospital length of stay, perioperative complications, and functional status at discharge and at 2-month follow-up. Revisions were compared with the original operation and by revision type. RESULTS: One hundred sixty-five vein graft revisions were performed in 137 patients. In comparison with the initial bypass procedure, mean operation time (3.35 +/- 1.41 hours vs 2.58 +/- 1.04 hours; P <.001), estimated blood loss (272.4 +/- 249.9 mL vs 174.8 +/- 140.8 mL; P <.001), hospital length of stay (10.15 +/- 4.85 days vs 7.05 +/- 5.14; P <.001), and overall complication rate (35.8% vs 22.4%; P =.015) were significantly less for revision procedures. Revision of more than one site on the graft resulted in longer operation time (P =.003) and estimated blood loss (P <.001), but similar complication rates (P = NS), compared with revision at only one site. Revisions that involved only the graft resulted in decreased hospital length of stay compared with revisions involving extension to native inflow or outflow vessels (P <.02). Return to preoperative ambulatory status at discharge was 71% after initial operation, and was 92% after revision (P <.001). Return to independent living at discharge was 66% after the initial operation, and was 80% after revision (P <.01). CONCLUSIONS: Operative revisions were better tolerated than initial vein graft procedures, but are still major procedures. Hospital length of stay is longer for patients undergoing proximal or distal extension of the graft to native vessels and in patients who are not ambulatory and living independently at discharge. Patients undergoing vein graft revision should be counseled about potential morbidity.

Long-term outcome of revised lower-extremity bypass grafts.

PURPOSE: Reversed lower-extremity vein grafts (LEVGs) frequently require operative revisions to maintain patency. Identifying grafts that are at risk, however, requires an intensive duplex scanning-based surveillance program. Excellent 5-year graft patency and limb-salvage rates have previously been reported in patients undergoing graft revisions, but results beyond 5 years are essentially unknown, a factor that is of importance in an increasingly aging population. This study was performed to determine the results of surgical revisions of LEVGs after a follow-up as long as 10 years. METHODS: All patients undergoing placement of a LEVG were observed in a program of duplex scanning-based surveillance as long as the patient remained a candidate for graft revision. Grafts were considered for revision on the basis of the presence of focal areas of increased velocity, a prestenotic to intrastenotic velocity ratio more than 3.0, or uniformly low velocities throughout the graft. All lesions were confirmed with preoperative arteriography before revision. Assisted primary patency, limb-salvage, and survival rates were determined by means of Kaplan-Meier analysis in all patients who underwent LEVG revision from January 1990 to December 2000. RESULTS: A total of 1498 LEVG procedures were performed during the study period. A total of 330 surgical graft revisions were performed on 259 extremities in 245 patients. The median follow-up period was 38 months. The assisted primary patency rate of all grafts, the limb-salvage rate for patients undergoing surgery for limb-salvage indications, and the survival rate of all patients were 87.4%, 88.7%, and 72.4%, respectively, 5 years after the original bypass grafting procedure, 85.7%, 83.4%, and 67.8%, respectively, 7 years after the original bypass grafting procedure, and 80.4%, 75.4%, and 53.4%, respectively, 10 years after the original bypass grafting procedure. A total of 180 revisions (55%) were performed during the first year, 110 (33%) between the first year and the fifth year, and 40 revisions (12%) were performed on grafts older than 5 years. LEVGs revised within the first year after bypass grafting had lesions within the graft in 78%, in the native arterial inflow in 10%, and in the native arterial outflow in 12%. This differed significantly from the location of lesions in revisions performed between 1 and 5 years and after 5 years (graft, 63% and 62%; inflow, 20% and 19%; outflow, 17% and 19%; P >.05, Chi-square). CONCLUSION: Excellent assisted primary patency and limb-salvage rates can be achieved for as long as 10 years in LEVGs that require revision, with only a 7% drop in overall patency and limb-salvage rates between the fifth and 10th years. Although most revisions were required within the first year, 34% were performed between the first year and the fifth year, and 11% after 5 years. These data support the growing body of evidence that favors an aggressive regimen of duplex scanning surveillance of LEVGs for the life of the graft. Revised grafts have excellent patency through 10 years.