Vascular graft infection: an analysis of sixty-two graft infections in 2411 consecutively implanted synthetic vascular grafts.

Among 2411 consecutive arterial reconstructions performed with synthetic prosthetic material in Denmark during a 4-year period, 62 patients (2.6%) developed graft infection. Graft infection occurred only when the groin had been incised. The incidence of infection and the spread of infection along the graft did not relate to the graft material used (Dacron velour, Dacron woven, polytetrafluoroethylene, and umbilical vein). Retrospective analysis disclosed predisposing or precipitating factors in 50 of the 62 cases; the most important seemed to be unsatisfactory surgical technique. Fifty-three percent of the graft infections occurred within 30 days. Gram-positive cocci were the most common pathogen. The 62 patients had been in the hospital for a mean of 90 days and had undergone an average of 1.4 operations for graft infections. Of the patients, 25.8% died and 30.6% underwent amputations. Vascular graft infection is still one of the major problems in vascular surgery; greater care should be taken to improve antiseptics, improve surgical technique, and establish a rational prophylactic antibiotic regimen. A prophylactic antibiotic regimen of a combination of cephalosporin and ampicillin is recommended.

Surgery for abdominal aortic aneurysms. A survey of 656 patients.

Between 1979 and 1988, 656 patients were operated upon for abdominal aortic aneurysm. Elective operation was performed in 287 patients (44%) and acute operation in 369 patients. A ruptured aneurysm was found in 218 patients (33%). Patients with arteriosclerotic heart disease, hypertension, impaired renal function or chronic pulmonary disease showed an increased perioperative mortality. Development of postoperative cardiac and renal complications could not be related to previous cardiac or renal diseases. The major postoperative complications were renal failure in 81 patients (12%), pulmonary insufficiency in 77 patients (11%) and cardiac complications in 96 patients (13%). Failure of one or more organs occurred in 153 patients (23%) and the mortality rate for patients with multiorgan failure was 68%. Complications leading to reoperation occurred in 93 patients (14%). The perioperative mortality was 18.8%. The mortality for elective cases was 4.8%, for symptomatic cases 17.2% and 37% for ruptured aneurysms. The five-year survival rate was 48% for ruptured aneurysms, 70% for symptomatic cases and 75% for elective cases. After six months the life expectancy in these three groups of patients were identical and comparable to the expected survival for a sex and age matched control population.

[Femoro-crural in situ bypass]. / Der femoro-crurale in-situ-Bypass.

During a period of 21 months from April 1986, 108 in situ femoro-crural bypass procedures were performed. The indication for surgery was in all cases a limb threatening ischemia. Always the technique described by Leather et al. was used. All the patients had obstructive disease of the crural arteries, thus the distal anastomosis was performed in a single crural or pedal artery for 102, and for 40 at the level of the ankle or foot. 97 per cent of the patients were discharged from the hospital with a salved limb, the one year patency was 76 per cent and one year limb survival 90 per cent. In our hands the in situ technique has shown much better results than the reversed vein technique.

[Infrainguinal bypass surgery of occlusive arteriosclerosis of the lower extremities using polytetrafluoroethylene (PTFE) vascular prostheses]. / Infraingvinale bypass-operationer for okklusiv underekstremitetsarteriosklerose med anvendelse af polytetrafluoroaetylen (PTFE)-karproteser.

During the past 15 years, PTFE vascular prostheses have been employed as an alternative graft material in patients with peripheral arteriosclerosis of the lower extremity and no suitable autogenous saphenous vein for employment as a bypass route. PTFE is a porous polymer of teflon which becomes incorporated into the tissue by invasion of fibroblasts into the material after implantation. The result of the operation as indicated by the patency of the prosthesis depends on the length of the bypassed occluded arterial segment, the quality of the artery where the distal anastomosis is made, the preoperative fall in pressure in the extremity, coagulopathy and the development of intimal hyperplasia. The results after short bypass operations are insignificantly different from the results after the use of autologous saphenous vein. The use of PTFE in infrainguinal bypass operations is an acceptable alternative to autogenous saphenous vein.

[Aseptic prosthesis infection caused by Dacron allergy or foreign body reaction? Treatment of 2 cases by replacement with PTFE prostheses]. / Aseptisk proteseinfektion forårsaget af Dacron-allergi eller fremmedlegemereaktion? Behandling af to tilfaelde med skift til PTFE-proteser.

Two patients with Dacron bifurcation prostheses developed recurrent aseptic purulent inflammation around the prostheses. After replacement of the Dacron prostheses with PTFE prostheses the symptoms disappeared, suggesting that an allergic reaction or a foreign body reaction was responsible for the inflammation.

[Prognosis for the critically ischemic lower extremity when surgical revascularization is not possible]. / Prognosen for den kritisk iskaemiske underekstremitet som ikke kan revaskulariseres karkirurgisk.

Of 427 patients with chronic critical ischemia of the lower extremity admitted for infrapopliteal bypass surgery, thirty-four (8%) were considered technically inoperable: in 26 cases due to total occlusion of the runoff vessels, and in eight due to a poor runoff and no suitable vein. The symptoms were rest pain in 24 cases and gangrenous ulceration in ten. During a follow-up of eight to twenty-eight months five (15%) patients improved significantly, and complained only of claudication. Three patients, suffering rest pain, were unchanged at nine months follow-up, and 25 (74%) patients had a major amputation performed during the follow-up period. The remaining patient died the day after admission. The mortality rate of these patients was significantly increased compared to that of the 393 patients who underwent infrapopliteal bypass surgery, who in turn had a higher mortality rate than that of an age- and sex-matched Danish population. The group of patients who preserved their limb could not be identified by either ankle- and toe-pressure measurements or clinical evaluation.

[In situ bypass and diabetes]. / In situ bypass og diabetes.

From 1986 through to 1990 a total of 483 in situ bypass procedures were performed in 444 patients. Preoperative risk-factors were equally distributed among diabetic (DM) and non-diabetic (NDM) patients, except for smoking habits (DM:48%, NDM:64%, p = 0.002) and cardiac disease (DM:45%, NDM:29%, p = 0.005). Critical limb-ischaemia was more often present in diabetic than non-diabetic patients (DM:57%, NDM:36%, p = 0.0002). Diabetic patients had a significantly lower distal anastomosis than non-diabetic patients (p = 0.00001). There were no differences among diabetic and non-diabetic patients regarding three years primary and secondary patency (58% and 64% respectively), and regarding major amputations. However, the rate of minor amputations was higher in insulin-dependent compared with non-insulin-dependent diabetics, who in turn had a higher rate than non-diabetics (p < 0.00001). A markedly decreased survival rate was found in diabetics (p < 0.00005). We found the in situ bypass technique very useful in the treatment of critical ischaemia of the lower limb in diabetic patients. The overall results in diabetic patients, whether insulin-dependent or not, were equal to those in non-diabetic patients.

[Vascular surgery in patients with impaired renal function]. / Karkirurgisk behandling hos patienter med påvirket nyrefunktion.

The purpose of the study was to evaluate the effect of surgery for renal artery stenosis in patients with impaired renal function. The design was a retrospective investigation with follow-up. The material consisted of 42 such patients operated at Rigshospitalet between 1980 and 1990. Renal function and blood pressure status was evaluated preoperatively and at follow-up. The perioperative mortality was 5% (n = 2) and morbidity 21% (n = 9). At discharge from hospital renal function was maintained in 38 patients (90%), including three patients who at the time of operation were without diuresis and had been in dialysis for up to 28 days. Twenty-three patients were still alive at postoperative follow-up at a median of 66 months. The cumulative five-year survival was 62%, which was significantly lower than that of a sex- and age-matched population. Eleven patients developed terminal renal insufficiency during the follow-up period. The cumulative preservation of renal function was 77% after five years. In conclusion, reconstruction of the renal arteries in patients with declining renal function and renal artery stenosis or occlusion can save renal function such that dialysis may be avoided in most cases.

[Surgical treatment of renovascular hypertension caused by renal artery stenosis. A retrospective study]. / Kirurgisk behandling af renovaskulaer hypertension forårsaget af nyrearteriestenose. En retrospektiv opgørelse.

During a 10 year period 58 patients with renovascular hypertension due to renal artery stenosis were treated surgically. A retrospective analysis of the results was carried out. No perioperative mortalities occurred. Ten percent of the patients developed hypertension again after an average of 27 months. At follow-up (median 65 months), 85% of the patients had normal blood pressure or either no, modest or considerably reduced anti-hypertensive medication. It is concluded that surgical treatment of renovascular hypertension is a safe and effective procedure.

[4 years of experiences with Karbase. A tool for quality development in vascular surgery]. / Fire års erfaringer med Karbase. Et redskab til kvalitetsudvikling i karkirurgi.

Karbase, a Danish register for vascular surgery is presented with data from four years experience. The register consists of 65 variables centered on risk factors, the perioperative course as well as follow-up information. During the four-year period 1989-1992 a total of 4902 admissions were registered in 3810 patients. Surgery was performed during 4005 admissions. Output data from Karbase is presented with results on survival and postoperative complications, related to preoperative risk factors. The incidence of surgical wound infections was 3.9%, with a significant reduction during the years (p = 0.004). Karbase is now used by all vascular surgical units in Denmark. We conclude that the establishment of a continuous registration has been beneficial to the department. We have achieved valid data on treatment, outcome and complications in relation to individual risk factors. In the future the use of Karbase will be extended with the aim of further quality development, locally as well as nation wide.

[Vena saphena magna in situ bypass to the ankel and foot. A prospective assessment of results of 101 procedures in 94 patients with threatening amputation]. / Vena saphena magna in situ-bypass til ankel og fod. En prospektiv opg|relse af resultaterne af 101 procedurer hos 94 amputationstruede patienter]

The results of 101 in situ by-pass operations to the ankle and foot are given. Seventy-five percent of the patients had other arteriosclerotic manifestations and 55% were diabetics. Ninety-nine percent of the operations were limb salvage surgery. The accumulative secondary patency rate was 87% after one month and 65% after three years. The results did not differ from by-pass surgery to the crural arteries. The wound complication rate was 16% with an infection rate of 7% and the major amputation rate was 8% after one month and 10% after three years. The survival of this selected group of patients was lower than a group of sex- and age-matched controls. The long term results of this type of advanced by-pass surgery in limb threatening ischaemia are very satisfactory and should be a must in every vascular surgeon's armamentarium.

[Excimer laser-assisted balloon angioplasty of the femoro-popliteal segment]. / Excimer-laser-assisteret ballonangioplastik af det femoropopliteale segment.

In the Department of Vascular Surgery RK, The University Hospital in Copenhagen, the authors have treated 16 patients with ischaemia in the lower limb by means of laser-assisted balloon angioplasty. A pulsed ultraviolet excimer-laser was employed. It proved possible to break down the occluding arterial lesion in 12 patients (75%). In one patient, this was not followed-up by balloon angioplasty and, in another patient, the reconstruction closed on the first day after operation. The primary success of the procedure, defined as breaking down of the occlusion with the laser-catheter followed by balloon angioplasty and an increase in the ankle/brachial index of greater than 15%, was found to be 10/16 or 62%. The remaining four patients, in whom it did not prove possible to break down the arterial lesion with laser, were treated by means of conventional vascular surgical reconstruction. On follow-up examination after an average of nine months, nine out of the ten patients (90%) still had a patent reconstruction after laser-assisted balloon angioplasty. This new endovascular laser-procedure appears to be suitable for selected patients, but must be assessed more meticulously before it is possible to determine its future placing in the vascular surgical therapeutic armamentarium.

[Mortality and survival after surgery for abdominal aortic aneurysm. A 10-year follow-up]. / Letalitet og overlevelse efter operation for abdominalt aorta-aneurisme. En ti års opgørelse.

From 1979-1988, 656 patients were operated for abdominal aortic aneurysm. The perioperative mortality was 18%. The mortalities for elective, symptomatic and ruptured aneurysms were 5%, 17% and 38% respectively. The overall five year survival rate was 58%. In 87% of the patients one or more risk factor was found. Survival was unaffected in patients with a single risk factor, whereas patients with two or more risk factors had lower five year survival. Postoperative organ failure increased the perioperative mortality and the five year survival in patients with multiorgan failure was 20%. In view of the fact that 56% of the patients are operated on as emergencies, this study stresses the importance of early diagnosis and elective treatment.

[Registration of postoperative wound complications at a department of vascular surgery]. / Registrering af postoperative sårkomplikationer på en karkirurgisk afdeling.

During the period 1 March 1987 to 31 December 1988, current registration of all vascular surgical operations in the Department of Vascular Surgery RK, Rigshospitalet, was undertaken employing a PC-based programme (DANOP-DATA). A total of 1,898 primary vascular surgical operations were performed on 1,335 patients. During the entire period, 48 (2.5%) patients with wound infection were registered. In half of these, the infection was superficial and in the remainder the infection was deep. Comparison between 1987 and 1988 revealed a non-significant tendency towards a lower incidence of infection in 1988. Significantly more wound infections were found after non-sterile operations (p = 0.005). Significantly more deep infections were found on employing synthetic vascular prostheses (p less than 0.00001) and with inguinal incisions (less than 0.05). No significant connection could be found with age, duration of preoperative hospitalization, duration of operation and the degree of planning of the operation. The authors find that computer-based monitoring of the surgical activity is a good which renders current assessment and analysis of the pattern of complications possible. The authors did not find that DANOP-DATA was sufficient for registration in a special department for vascular surgery and a programmel (KARBASE) has been developed which is more suitable for this purpose.

[Surgery of ruptured abdominal aortic aneurysm. Are the results compatible with the effort?]. / Operation for rumperet abdominalt aorta-aneurisme. Stoar resultaterne mål med indsatsen?

During 1979-1988 218 patients were operated on for ruptured abdominal aortic aneurysm. On admission 110 patients (50%) were in shock. Patients with a systolic blood pressure less than 100 mmHg, anuria on admission, peroperative bleeding of more than five litres and aged more than 70 years had an increased mortality. The intraoperative mortality was 15% and the postoperative mortality 21%. The perioperative mortality decreased from 45% in 1979 to 32% in 1988. The most frequent complications were renal failure and respiratory insufficiency, both were associated with a mortality of more than 50%. The five year survival was 48%. This study has revealed that patients with ruptured abdominal aortic aneurysm have an acceptable prognosis. The investigation emphasizes the importance of early diagnosis and elective operation to avoid rupture.

[Percutaneous transluminal angioplasty of iliac occlusions]. / Perkutan transluminal angioplastik af iliacaokklusioner.

Percutaneous transluminal angioplasty (PTA) has become an established treatment modality for iliac artery stenosis. PTA of iliac artery occlusions, however, remains a topic of controversy due to difficulties with mechanical recanalization, a lower patency rate and a higher complication rate than obtained after PTA of iliac artery stenosis. During a three year period, we performed 31 PTA's of iliac artery occlusions. The primary recanalization rate was 71% (22 occlusions). Stents were applied in 16 patients. The cumulated patency rates were 95% and 85% after one and six months respectively. There was one late reocclusion after two years. We found a tendency towards inferior patency in the longer occlusions (> or = 5cm). The complication rate was 10% due to three episodes of distal embolisation, all of which were successfully treated immediately with additional PTA and stenting. These results are in accordance with the results of international studies, and suggest that PTA is a useful alternative to surgical treatment of iliac artery occlusions, albeit long occlusions involving both the common and the external iliac artery should be excluded.

[Early and late results after surgery of abdominal aortic aneurysm]. / Tidlige og sene resultater efter operation for abdominalt aorta-aneurisme.

From 1983-1987, 388 patients were operated upon for abdominal aortic aneurysm. Elective operation was performed on 171 patients (44%) with a mortality of 2.9%. Emergency operation was done in 277 patients of whom 132 (34%) had ruptured aneurysms. The mortality for ruptured aneurysms was 36% and 21% for patients operated on as emergencies without signs of rupture of the aneurysm. The five year survival rate was 75% after elective operation, 60% after emergency operation and 40% after operation for ruptured aneurysm. The high mortality after emergency operation for abdominal aortic aneurysm confirms the importance of early diagnosis and elective operation before rupture occurs.

[Femoro-crural reconstruction in Denmark 1983-1987]. / Femoro-krurale rekonstruktioner i Danmark 1983-1987.

From 1983 to 1987, 293 femoro-crural bypasses were performed in eight centers for vascular surgery in Denmark. The activity increased in the period from 15 to 135 bypasses per year. The increase took place particularly 1986, when the in situ saphenous vein bypass was introduced in Denmark. A total of 203 bypasses were performed at the University Hospital of Copenhagen, Rigshospitalet: 108 in situ bypasses, 51 bypasses with arterial protheses and 44 bypasses using reversed vein. The cumulated graft patency after one year was 76% for the in situ bypasses, 26% for the bypasses with arterial protheses and 32% for reversed vein. The cumulated limb survivals after one year were 90%, 66% and 63%, respectively.