Thrombectomy for late graft limb occlusion: our experience in 182 consecutive cases.

Late occlusion of an aortofemoral bypass graft is usually caused by fibrointimal hyperplasia or progressive atherosclerosis. Several surgical approaches have been advocated in order to minimize the operative risk, to correct the impaired inflow and to provide a satisfactory outflow. In the last 16 years, in the Institute of Vascular Surgery and Angiology of the University of Milan, we have operated upon 182 consecutive thrombosed grafts. Inflow was restored by performing a graft limb thrombectomy using a Fogarty balloon catheter and simultaneously employing an endarterectomy ring stripper to dislodge tenaciously adherent fibrinous material and thrombotic plug. As the superficial femoral artery was generally occluded, usually a good outflow was achieved by profundaplasty in 101 cases (55.5%) or direct bypass (interposition graft), to a more distal segment of the profunda femoris artery in 55 cases (30.2%). Concomitant popliteal or tibial revascularization was done in the remaining 26 cases (14.3%) when pre-operative or intra-operative findings suggested an inadequate collateral network through the profunda femoris artery. Early re-occlusion, which occurred in 14 cases (7.6%), generally due to insufficient outflow, was corrected by additional intervention in 7 cases (3.8%), while 7 legs were amputated for extensive atherosclerotic disease. Six patients died giving a mortality rate of 3.3%. This low rate in a high risk population is probably related to our policy of operating under loco-regional anaesthesia. Long term results, with a patency rate of 62.0% at 3 years and 60.2% at 5 years (life table method), prove that this operation is a durable procedure for correction of graft limb thrombosis.

Femoral noninfected anastomotic aneurysms. A report of 56 cases.

Fifty-six femoral non infected anastomotic false aneurysms (FAAs) were observed in 49 patients admitted to the Institute of Vascular Surgery, University of Milan, from 1975 to 1988; in 6 patients they were bilateral. These aneurysms developed after primary revascularization procedures at a mean interval of 66 months (range 12 to 156 months); one recurred after reparative surgery. Forty-four FAAs (78.6%) were asymptomatic, whereas 3 (5.3%) were complicated by acute expansion and 9 (16.1%) by thrombosis. Host vessel degeneration was the cause of aneurysm formation in most cases. A history of hypertension was present in 30% of the patients. All anastomotic aneurysms were operated upon except for one small aneurysm that was asymptomatic. In 5 patients aneurysm resection was carried out on both sides. The surgical technique was endoaneurysmectomy in all the cases with insertion of an interposition graft in 48 cases, a fabric patch in 2 cases and prosthesis re-anastomosis in 5 cases. One case of peripheral embolization occurring in the early postoperative period was successfully treated and there was no operative mortality. In our opinion elective repair of these aneurysms should be recommended whenever possible because of their propensity to develop serious complications and the operative morbidity is low.