Ten year experience with infrainguinal revascularization for limb salvage.

BACKGROUND: Revascularization is the only alternative to amputation for patients with severe, symptomatic infrainguinal ischemia. It is the purpose of this study to determine the success of revascularization as defined by limb salvage in a personal 10-year operative experience. METHODS: Primary infrainguinal bypass procedures were performed on 312 threatened limbs of 271 consecutive patients in the period between January 1, 1983, and December 31, 1992. Repeat revascularization was performed for failing/failed grafts as long as the extremity was viable and an outflow vessel could be found by either preoperative or intraoperative angiography. RESULTS: Ten patients died within 30 days of the primary procedure (4%) and the 5-year patient survival was 57%. Major amputations (AK or BK) were performed on 50 extremities over the 10-year period; cumulative 72-month limb salvage was 72%. Fifty-eight of the 312 extremities (19%) required 81 reoperations for failing/failed grafts, including a second procedure in 58, a third procedure in 14, and a fourth procedure in 9. Graft occlusions in which revision was either not attempted or was ultimately unsuccessful occurred in 72 extremities and led to 44 amputations. Cumulative primary and secondary graft patency for autologous conduit was clearly superior to nonautologous conduit (57% and 67% vs 20% and 21% respectively at 60 months). CONCLUSIONS: We believe that this approach to infrainguinal revascularization is warranted as the mortality is low and the likelihood of success is high. A long term commitment to careful postoperative surveillance is mandatory as reintervention is frequently required to maintain graft patency and limb salvage.

Intensive surveillance of femoropopliteal-tibial autogenous vein bypasses improves long-term graft patency and limb salvage.

OBJECTIVE: The authors determined the impact of an intensive surveillance program of autogenous vein bypasses on patency and limb salvage. SUMMARY BACKGROUND DATA: Surveillance protocols of vein bypasses can identify graft-threatening lesions to permit elective revisions before thrombosis. The authors compared follow-up based on clinically indicated procedures with intensive surveillance. METHODS: From 1985 to 1994, 615 autogenous vein bypasses (454 in situ, 161 reversed/composite) to popliteal (n = 169) and tibial (n = 446) arteries were performed for critical limb ischemia (n = 507), claudication (n = 88), and popliteal aneurysm (n = 20). Intensive surveillance of autogenous vein bypasses consisted of ankle brachial index and duplex scan with graft velocities measured at 1 month, 3 months, 6 months, and every 6 months subsequently. After surgery 317 bypasses had intensive surveillance, 222 bypasses were clinically indicated for follow-up, and 76 bypasses were excluded because follow-up or patency was less than 31 days. RESULTS: Primary patency at 5 years was similar for bypasses treated by intensive surveillance (56%) and those treated with clinically indicated procedures (67%). Secondary patency and limb salvage at 5 years was significantly improved (p < 0.02) for bypasses followed by intensive surveillance (80% and 94%) compared with clinically indicated procedures (67% and 73%). Revision of patent bypasses was higher (p < 0.000001) for bypasses treated by intensive surveillance (61 of 70, 87%) compared with those treated with clinically indicated procedures (9 of 34, 26%). Secondary patency at 2 years was significantly higher (p < 0.02) for revision of patent bypasses (79%) compared with thrombosed bypasses (55%). CONCLUSIONS: Long-term autogenous vein bypass patency and limb salvage is significantly improved by intensive surveillance, permitting identification and correction of graft threatening lesions before thrombosis.

Pedal or peroneal bypass: which is better when both are patent?

PURPOSE: We compared autogenous vein pedal and peroneal bypasses, focusing on extremities that could have a bypass to either artery. METHODS: From 1985 to 1993 we performed a total of 175 pedal and 77 peroneal autogenous vein bypasses for rest pain (n = 75, 30%) and tissue loss (n = 177, 70%). One hundred ninety-six (78%) in situ saphenous vein and 56 (22%) reversed or composite vein bypasses were performed. One hundred fifty-two of these 252 bypasses were performed in extremities with both the pedal and peroneal arteries patent by arteriography. The vascular surgeon chose to perform 99 pedal and 53 peroneal vein bypasses in these 152 extremities. RESULTS: The angiogram score of the outflow arteries were similar for pedal and peroneal bypasses with the Society for Vascular Surgery and the International Society for Cardiovascular Surgery and modified scoring systems. At 2 years the primary and secondary patency rates for pedal bypasses (70% and 77%) were not significantly different compared with those for peroneal bypasses (60% and 72%). Limb salvage rates at 2 years were similar for pedal and peroneal bypasses for all patients (74% and 73%), patients with both pedal and peroneal arteries patent (83% and 72%), diabetics (76% and 66%), and patients with tissue necrosis (77% and 71%). CONCLUSIONS: Pedal and peroneal artery bypasses with equivalent angiogram scores have similar long-term graft patency and limb salvage. The choice between pedal or peroneal artery bypass should be based on the quality of vein and the surgeon's preference.

Value of continued efforts at limb salvage despite multiple graft failures.

Treatment of patients with limb-threatening ischemia after multiple failed bypasses remains difficult and controversial. Further revascularization procedures despite failure of the original procedure may be viewed as futile. The purpose of this report is to determine the efficacy of third or fourth revascularization procedures after the original and second procedures fail. Over a 10-year period from January 1, 1983, to December 31, 1992, 312 infrainguinal bypasses were performed on 271 consecutive patients for foot salvage. The overall limb salvage rate was 84%, and the operative mortality rate was 3.7% (10 patients). Sixteen patients (5.8%) had repeat infrainguinal bypasses performed after failure of two or more prior bypass procedures in the same leg. Twenty-three reconstructions were performed in these 16 patients. There were no operative deaths. One half of these patients had major amputations performed within the first year following their tertiary or fourth reconstructive procedure. Sixty-two percent of patients have survived longer than 3 years after their third or fourth procedure. One half of these patients have maintained graft patency and an excellent quality of life. Only 22% of the patients requiring amputation ambulated with a prosthesis, whereas all revascularized patients ambulated. Although this subset of patients is known to have an increased risk of repeated graft failure and limb loss, we believe continued efforts at limb salvage despite multiple previous graft failures is justified.

Cerebral hyperperfusion syndrome: an etiology of seizures following carotid endarterectomy.

Cerebral hyperperfusion syndrome after carotid endarterectomy is an uncommon but distressing complication. Findings in nearly all these patients include the presence of ipsilateral high-grade carotid artery stenosis, postoperative ipsilateral headache followed by seizures, and transient neurologic deficits. It appears to be caused by the loss of autoregulation within the brain, usually occurring between 5 and 7 days postoperatively.

Utility of femorofemoral bypass. Comparison of results with indications for operation.

Sixty-eight patients underwent femorofemoral bypass (FFB) at the University of Louisville Affiliated Hospitals over a 9-year period from 1980 to 1989. There were patients with acute ischemia requiring emergency operation, those with chronic ischemia following failed aortic reconstruction, good-risk patients with chronic ischemia who had FFB as the procedure of choice, and poor-risk patients who were unsuitable for other procedures. Patients operated on for acute ischemia had a significant number of infectious complications, with five of eight graft failures in this group due to infection. Primary patency rates were similar in all groups, with a 5-year primary patency of 42 per cent. Overall operative mortality was 4.4 per cent. Satisfactory limb salvage rates (75%) suggest that FFB is an acceptable option for providing inflow in patients with acute ischemia or for patients with a failed previous vascular prosthesis. FFB provides adequate inflow in poor-risk patients not suitable for aortic reconstruction, but patency rates do not warrant its use as a procedure of choice in good-risk patients.

Utility of inframalleolar arterial bypass grafting.

Sixty-five patients received 68 inframalleolar arterial grafts for severe rest pain, foot ulceration, or gangrene. Patients were elderly with an average age of 68 years (median 72); most had several operative risk factors. Reversed saphenous vein grafts were used early, but most conduits were in situ vein grafts. The recipient vessel was the dorsalis pedis artery in 39 patients, the posterior tibial in 27, and tarsal branches in two. Preoperative angiography was routinely performed with biplanar and digital arterial techniques, but in nearly a third a suitable bypass vessel was not identified preoperatively. When vessels were identified there was usually only a single patent artery suitable for bypass grafting below the knee. There were five postoperative deaths (7.6%). Eight grafts (11%) required early revision for thrombosis or retained valve, and six were salvaged and remained patent. Poor vein quality appeared responsible for the two early failures. Six late graft occlusions occurred from 4 to 39 months (mean 14 months). Three of these patients had no recurrence of their ulceration, but two required amputation, and one has continued rest pain. One additional amputation was required in a patient with a patent graft. Eleven late deaths (16%) occurred (nine with patent grafts) primarily of cardiac causes.

Management of aortic prosthetic infections.

Infections of aortic vascular prostheses remain a dreaded complication. Although removal of the graft has generally been recommended in the literature, the role of lesser procedures, the need for alternate revascularization, and a precise plan of attack are ill defined. We have treated 18 patients with infection of aortic prostheses. Specific risk factors potentially promoting infection included reoperation, septic complications, or gastrointestinal entry at the time of graft placement. Clinical signs of infection included chronic draining sinus in eight patients, localized groin abscess in three patients, groin swelling in four patients, gastrointestinal bleeding in two patients, and pseudoaneurysm in one patient. Treatment by local therapy, including catheter irrigation of sinus tracts, debridement, and local antibiotics, resulted in failure in eight of nine patients. If the sinogram of a groin sinus showed no communication with the body of the graft, resection of a graft limb was successful in 66 percent of the patients. If the sinus communicated with the body of the graft, total resection was mandatory. When total excision was necessary, all patients required revascularization by means of an extraanatomic bypass. The mortality rate was 33 percent and was primarily due to bleeding fistulas. An aggressive approach to this serious problem with early graft excision is encouraged.

The influence of sepsis and ischemia on the natural history of the diabetic foot.

One hundred seventeen diabetic patients with lesions involving 174 extremities were reviewed to evaluate the natural history of the problem and specifically those factors that influence its course both acutely and chronically. The extremities of diabetic patients with foot lesions can be categorized based on severity of infection and presence of ischemia. Half of these patients developed lesions in the contralateral extremity either concurrently (synchronous) (7%) or later (metachronous) (43%). Major amputation was required in 59 of the 174 extremities evaluated (34%). In patients with metachronous lesions, unilateral amputations were required in 28 per cent of patients and bilateral amputations in 26 per cent. Limb salvage by revascularization required 1.4 operations per extremity, carried 2 per cent operative mortality and was successful in 66 per cent. Although 24 per cent of these patients died within 5 years of the initial presentation of their foot lesions, these data suggest that limb salvage attempts are reasonably successful and relatively safe. The combination of extremity sepsis and ischemia in the diabetic adversely effects the survival of both the extremity and the patient.

Factors influencing the risk of early and late serious infection in adults after splenectomy for trauma.

We reviewed the clinical course of 245 adults who underwent splenectomy for trauma to assess the risk of both early and late serious infection. Twenty-one patients (9%) had an early serious infection (sepsis) during hospitalization for splenectomy. The mortality rate was 62% in patients with early sepsis, and encapsulated bacteria were isolated from the blood of 43% of patients with sepsis. Only one of 58 patients with isolated splenic injury had sepsis (2%), and the risk of early sepsis increased when three or more concomitant injuries were present (p less than 0.05). Stepwise multiple regression analysis revealed that patients with injuries to the pancreas, colon, or central nervous system or with extremity fractures had an increased risk of sepsis (p less than 0.05). The risk of sepsis was not influenced by age, the type of injury, delay in operation, use of drains, or other individual injuries. Sufficient information was available to assess the risk of late serious infection for 140 surviving patients (63%). Follow-up ranged from 2 to 277 months. Three late infections occurred at 2, 8, and 15 years after splenectomy; two were due to Streptococcus pneumoniae. None of these patients died. There were no identifiable factors influencing the risk of late infection. These results suggest that the risk of early serious infection in adults after splenectomy for trauma is low when isolated splenic injury is present but that this risk is increased by both the degree of injury and the presence of certain associated injuries. Encapsulated bacteria are frequent pathogens in both early and late infections. The mortality rate related to an early septic episode is high, but the risk of late serious infection is low and is not related to identifiable factors that decrease host defenses.

Peritoneovenous shunts: predictive factors of early treatment failure.

Death or uncorrectable shunt malfunction occurred within 4 months in a majority (23) of 39 consecutive alcoholics who had peritoneovenous shunts. Clinical, biochemical, and operative variables in these patients were reviewed to detect factors that might predict early failure. Hepatorenal disease, expressed as the sum of total bilirubin and creatinine greater than 4 mg/dl, characterized 15 of 18 early deaths and was a reliable preoperative criterion of clinical outcome (p less than 0.001). Except for prothrombin elevation, abnormal coagulation indices did not predict early failure. Encephalopathy was more prevalent in patients who died (p less than 0.05). Among operative variables, failure to drain ascites was associated with more hospital deaths (p less than 0.05) and documentation of venous catheter placement in a central location reduced likelihood of early shunt malfunction (p less than 0.001). Preference for the LeVeen or Denver shunt did not affect the rate of early shunt malfunction. The overriding predictive factor was hepatorenal disease, both obvious and occult, by which judicious patient selection may avoid early death in surgical palliation for intractable alcoholic ascites.

Mortality and rebleeding after hypertensive variceal disconnections.

Forty-five patients had operative disconnections of portoazygos venous collaterals for variceal hemorrhage. Nineteen alcoholic patients had urgent partial azygos disconnection (PAD) to control bleeding; this involved intragastric variceal and coronary and distal gastric-vein ligation. A complete azygos disconnection (CAD), which also included splenectomy, was done urgently in 14 patients and electively in 12 patients; 15 were alcoholics. All patients were assessed for operative risk by a modified Child's classification. Hospital mortality after urgent PAD or CAD in alcoholics was 67%, largely due to intraperitoneal sepsis or hepatorenal failure with recurrent hemorrhage. Operative modified Child's classification of survivors was better (lower) than in nonsurvivors. Eleven nonalcoholic patients had CAD; two died of intraperitoneal sepsis. Nine survivors did not rebleed nor have encephalopathy develop during an average follow-up of 41 months. Complete azygos disconnection was a good alternative, particularly in the elective setting, for patients with nonalcoholic portal hypertension.

Breast cancer in 120 women under 35 years old. A 10-year community-wide survey.

We reviewed the records of 120 women, age 35 years or younger, with the diagnosis of breast cancer at ten hospitals in the Milwaukee metropolitan population of 1 million between 1970 and 1980. We analyzed epidemiologic factors, methods of diagnosis, treatment, and mortality. While 57 per cent of the patients sought medical attention within 6 weeks of the first symptom, 34 per cent waited longer, and physicians postponed biopsy more than 2 months in another 7 per cent. Most often, the first symptom was a painless lump (61%) and the histology was ductal carcinoma (73%). Only 61 per cent of the patients had preoperative mammography, and 52 per cent of the radiographs were interpreted as benign or negative. Estrogen receptors were obtained in only 38 per cent. At the time of presentation, only 3 per cent had evidence of distant metastases. Mastectomy with or without nodal dissection and/or pectoral muscle excision was performed on 97 per cent of the patients. Twelve per cent of the patients had or developed bilateral breast cancer. Chemotherapy, irradiation, and hormone manipulation were used alone or in combination (with or without mastectomy) in 76 per cent. Although complete 10-year survival data are not yet known, 25 per cent of the 120 patients are dead of the disease and 10% are lost to follow-up and presumed dead. These data indicate that in women age 35 years or younger with breast cancer, patient and physician delay in diagnosis has been common. Estrogen receptors and mammography have been underutilized in this patient population. However, in this community, young patients fared no worse than older women.

Pregnancy and breast cancer.

To examine the relationship of pregnancy to survival in patients with breast cancer, we reviewed the records of 120 women under 36 years of age over a ten-year period and found 15 who were pregnant or lactating when breast cancer was diagnosed or who became pregnant after treatment. All 15 had mastectomy for therapy. Four of the ten patients who were pregnant or lactating had positive lymph nodes, as did three of the five who became pregnant later. Mean survival is 40 months in the six living patients who were pregnant or lactating, and 35 months in the four living patients who became pregnant later. Four of the seven patients with positive nodes (57%) are alive at a mean of 55 months after diagnosis. There was no significant relationship between chemotherapy, irradiation, immunotherapy, or ovarian ablation and subsequent survival. Pregnancy did not appear to influence the outcome. Survival in patients with positive nodes slightly exceeded expectation.

A comparison of prosthetic materials used to repair abdominal wall defects.

A large abdominal wall hernia, not amenable to primary closure, may require insertion of a prosthesis. The ideal prosthesis maintains strength, is incorporated by surrounding tissues, and does not stimulate adhesions. These qualities vary among available synthetic prostheses. We tested tensile strength, bursting strength, and adhesion formation in response to six materials used in repair of abdominal wall hernias. Adult Sprague-Dawley rats (196) were randomly divided into a control group and six experimental groups. A 4 by 4 cm full-thickness resection of abdominal wall was closed with patches of polypropylene mesh (Marlex), polyglactin 910 mesh (Vicryl), expanded polytetrafluoroethylene (Gore-tex), Dacron-reinforced silicone rubber (Silastic), preserved human dura (PHD), or polypropylene mesh overlying gelatin film (Marlex and Gelfilm, respectively). In controls the 4 cm longitudinal full-thickness incisions were closed primarily. Seven rats randomly selected from each group were sacrificed after 1, 2, 4, and 8 weeks; bursting and tensile strength (tensiometer) and adhesion formation were assessed. There were no differences in bursting strength among the experimental groups at each testing period. Although bursting strength increased linearly with time it was significantly weaker than in controls at 1 and 8 weeks (P less than 0.05). Tensiometric data were inconclusive due to wide variability within the experimental groups. Adhesion formation was moderate to maximal at all evaluation periods for Marlex and Gore-tex. Early adhesion formation was minimal to moderate for both PHD and Vicryl, but later increased with PHD and decreased with Vicryl as this prosthesis was absorbed. No adhesions formed with Marlex and Gelfilm until the gelatin dissolved (1 week), after which the adhesion response was similar to that with Marlex alone. No adhesions formed after Silastic implantation, but graft extrusion and evisceration were common (75%). Controls had no adhesions at all evaluation periods. Wound strength was similar for all prosthetic materials. Absorbable prosthetic Vicryl provided the best long-term protection against adhesions.

Breast tumor incidence in rats after partial mammary resection.

The use of subcutaneous mastectomy in women at high risk for breast cancer is based on the assumption that surgical reduction of the tissue at risk results in a corresponding reduction in risk. To assess the validity of this assumption in an animal model, we subjected 120 female Sprague-Dawley rats to the mammary carcinogen 7,12-dimethylbenz(alpha)anthracene and a 20% fat diet. Two days later, one mammary ridge was excised in half of the animals (mastectomy group), and a midline incision was made without excision of tissue in the other half (control group). Seventy-nine rats survived dosing and operation and were observed for 77 weeks. After 15 weeks, 17 of 39 controls and seven of 40 animals with mastectomies had histologically confirmed neoplastic tumors of the breast. However, after 77 weeks, 32 of 39 controls and 35 of 40 animals in the mastectomy group had neoplastic tumors. The incidence of carcinogen-induced mammary neoplasms in rats progressed with time; whereas surgical reduction of breast tissue was followed by early reduction in neoplasias, the difference was not maintained.

Carcinoma of the gallbladder.

Results of a retrospective review of 20 consecutive patients with histologically proved carcinoma of the gallbladder encountered during a 15 year period confirm the historically established poor prognosis of the disease. One patient in whom the disease was discovered incidentally and early in its course is alive nine years after diagnosis. The other 19 patients died within eight months of diagnosis, regardless of the extent of the disease or method of treatment. By identifying patients who are at an increased risk, by virtue of such factors as cholelithiasis and advanced age, and scrutinizing all exposed or removed gallbladders for signs of abnormality, carcinoma of the gallbladder may be identified earlier. Then, since carcinoma of the gallbladder develops slowly and spreads along predictable pathways, radical cholecystectomy, including en bloc wedge resection of the gallbladder bed and adjacent nonvital tissue, performed upon patients with localized disease, probably offers the best chance for prolonged survival.

Recurrent gastric bezoars. A new approach to treatment and prevention.

A recurrent gastric phytobezoar was successfully dispersed using an endoscopically directed intermittent jet of dilute papain. Dissolution analysis of a retrieved bezoar fragment showed pancrelipase and Adolph's Meat Tenderizer to be effective specific solvents. The patient remained free of symptoms while on a prophylactic regimen of pancrelipase taken daily. However, when the patient discontinued his medication, the bezoar recurred. The dissolution process was successfully repeated. Selecting a reagent on the basis of demonstrated effectiveness should enhance the chance of successful dissolution of a phytobezoar, whereas prophylactic doses of the reagent may prevent its recurrence.

Pancreatic carcinoma.

This retrospective review of 33 consecutive patients with cancer of the pancreas was undertaken to investigate epidemiologic factors, presenting symptoms, diagnostic methods, site and extent of cancer, treatment approaches, and survival data. The most frequent presenting complaint, reported by 23 patients (70%), was abdominal pain. Diagnosis was established by radiography or radionuclide scanning in 11 patients (33%). Nine patients (27%) were inoperable. One patient (3%) received resection in attempt for cure, 15 (46%) had palliative bypass procedures, and eight (25%) had laparotomy only. Eighteen patients (55%) received chemotherapy, with or without operation, and two (6%) had irradiation. The mean survival was 5.1 months. One third of the patients were dead a month after diagnosis. All patients died within 16 months of diagnosis, regardless of treatment method or extent of disease.

Atypical clostridial bacteremia.

Forty-seven patients identified with clostridial bacteremia not characterized by histotoxicity were studied to define better the clinical presentation and results of treatment. Patients were categorized into three groups--one, elderly debilitated patients with multiple associated illnesses and no identifiable focus of infection; two, patients with alcoholism and systemic complications of alcohol abuse and no primary focus of infection, and three, patients with a mechanically treatable primary focus of infection. The over-all mortality was an unacceptable 57 per cent. Antibiotic therapy apparently did not affect the survival rate. Portal bacteremia and ineffective hepatic reticuloendothelial function may be significant factors in those patients without a primary focus of infection.