Assessment of Microvessel Permeability in Murine Atherosclerotic Vein Grafts Using Two-Photon Intravital Microscopy.

Plaque angiogenesis and plaque hemorrhage are major players in the destabilization and rupture of atherosclerotic lesions. As these are dynamic processes, imaging of plaque angiogenesis, especially the integrity or leakiness of angiogenic vessels, can be an extremely useful tool in the studies on atherosclerosis pathophysiology. Visualizing plaque microvessels in 3D would enable us to study the architecture and permeability of adventitial and intimal plaque microvessels in advanced atherosclerotic lesions. We hypothesized that a comparison of the vascular permeability between healthy continuous and fenestrated as well as diseased leaky microvessels, would allow us to evaluate plaque microvessel leakiness. We developed and validated a two photon intravital microscopy (2P-IVM) method to assess the leakiness of plaque microvessels in murine atherosclerosis-prone ApoE3*Leiden vein grafts based on the quantification of fluorescent-dextrans extravasation in real-time. We describe a novel 2P-IVM set up to study vessels in the neck region of living mice. We show that microvessels in vein graft lesions are in their pathological state more permeable in comparison with healthy continuous and fenestrated microvessels. This 2P-IVM method is a promising approach to assess plaque angiogenesis and leakiness. Moreover, this method is an important advancement to validate therapeutic angiogenic interventions in preclinical atherosclerosis models.

Development of a Decision Tree to Streamline Infrainguinal Vein Graft Surveillance.

BACKGROUND: Duplex ultrasound (DU) remains the gold standard for identification and grading of infrainguinal vein graft stenosis. However, DU-based graft surveillance remains controversial. The aim of this study was to develop a decision tree to identify high-risk grafts which would benefit from DU-based surveillance. METHODS: Consecutive patients undergoing infrainguinal vein graft bypass were enrolled in a DU surveillance program. An early postoperative DU was performed at a median of 6 weeks (range 4-9). Based on the findings of this scan and 4 established risk factors for graft failure (diabetes, smoking, infragenicular distal anastomosis, revision bypass surgery), a classification and regression tree (CART) was created to stratify grafts into grafts which are at high and low risk of developing severe stenosis or occlusion. The accuracy of the CART model was evaluated using area under receiver operator characteristic curve (ROC). RESULTS: Of 796 vein graft bypasses performed (760 patients), 64 grafts were occluded by the first surveillance visit and 732 vein grafts were entered into surveillance program. The CART model stratified 299 grafts (40.8%) as low-risk and 433 (59.2%) as high-risk grafts. One hundred twenty-six (17.2%) developed critical vein graft stenosis. Overall, 30-month primary patency, primary-assisted and secondary patency rates were 76.2%, 83.6%, and 85.3%, respectively. The area under ROC curve for the CART model was 0.88 (95% confidence interval 0.81-0.94). Primary graft patency rates were higher in low-risk versus high-risk grafts (log rank 186, P < 0.0001). Amputation rates were significantly higher in the high-risk grafts compared with low-risk ones (log rank 118, P < 0.0001). CONCLUSION: A clinical decision rule based on readily available clinical data and the findings of significant flow abnormalities on an early postoperative DU scan successfully identifies grafts at high risk of failure and will contribute to safely improving the efficacy of infrainguinal vein graft surveillance services.

Endoscopic vein harvesting in lower extremity arterial bypass: a systematic review.

OBJECTIVE: Endoscopic vein harvesting (EVH) for arterial bypass surgery may be associated with lower wound complication rates than open vein harvesting (OVH), but other long-term outcomes remain controversial, and there are concerns that graft patency may be poorer after EVH compared with OVH. We conducted a systematic review of all available evidence for EVH in lower extremity arterial bypass (LEAB). METHODS: A literature search of Medline, Embase, Ovid and Cochrane databases between 1996 and 2013 was performed using the terms "endoscopic vein harvesting", "minimally invasive vein harvest", "peripheral bypass surgery", and "lower extremity bypass surgery", and detailed in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Primary outcomes were graft patency and overall wound complication rates. Secondary outcomes were wound infection, length of hospital stay, and cost-effectiveness. Summary estimates were calculated by random effects meta-analysis if sufficient data were available. RESULTS: We identified 18 cohort studies and case series, with considerable clinical heterogeneity, including 2,343 patients. Meta-analysis of six studies revealed a significantly reduced rate of primary patency after EVH (hazard ratio 1.29, 95% confidence interval [CI] 1.03-1.63), with no significant difference between EVH and OVH with respect to wound infection in 12 studies (odds ratio 0.81, 95% CI 0.61-1.08). There was a lack of strong evidence to support the secondary outcomes of EVH. CONCLUSION: EVH reduces primary patency rates after LEAB, but does not demonstrate an advantage with respect to postoperative wound complications. However, the available data are heterogeneous, and uncertainty is introduced by both evolution in technology and increasing technical experience. EVH should be used with caution and in the context of formal research.

Association between endoscopic vs open vein-graft harvesting and mortality, wound complications, and cardiovascular events in patients undergoing CABG surgery.

CONTEXT: The safety and durability of endoscopic vein graft harvest in coronary artery bypass graft (CABG) surgery has recently been called into question. OBJECTIVE: To compare the long-term outcomes of endoscopic vs open vein-graft harvesting for Medicare patients undergoing CABG surgery in the United States. DESIGN, SETTING, AND PATIENTS: An observational study of 235,394 Medicare patients undergoing isolated CABG surgery between 2003 and 2008 at 934 surgical centers participating in the Society of Thoracic Surgeons (STS) national database. The STS records were linked to Medicare files to allow longitudinal assessment (median 3-year follow-up) through December 31, 2008. MAIN OUTCOME MEASURES: All-cause mortality. Secondary outcome measures included wound complications and the composite of death, myocardial infarction, and revascularization. RESULTS: Based on Medicare Part B coding, 52% of patients received endoscopic vein-graft harvesting during CABG surgery. After propensity score adjustment for clinical characteristics, there were no significant differences between long-term mortality rates (13.2% [12,429 events] vs 13.4% [13,096 events]) and the composite of death, myocardial infarction, and revascularization (19.5% [18,419 events] vs 19.7% [19,232 events]). Time-to-event analysis for those patients receiving endoscopic vs open vein-graft harvesting revealed adjusted hazard ratios [HRs] of 1.00 (95% CI, 0.97-1.04) for mortality and 1.00 (95% CI, 0.98-1.05) for the composite outcome. Endoscopic vein-graft harvesting was associated with lower harvest site wound complications relative to open vein-graft harvesting (3.0% [3654/122,899 events] vs 3.6% [4047/112,495 events]; adjusted HR, 0.83; 95% CI, 0.77-0.89; P < .001). CONCLUSION: Among patients undergoing CABG surgery, the use of endoscopic vein-graft harvesting compared with open vein-graft harvesting was not associated with increased mortality.

Is it safe to perform endoscopic vein harvest?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: in [patients undergoing coronary revascularisation] is [endoscopic vein harvest] superior to [open harvest] in improving [clinical outcome and cost effectiveness]? Altogether >166 papers were found using the reported search, of which eight represented the best evidence to answer the clinical question. All papers agree that endoscopic vein harvesting (EVH) reduces the level of postoperative pain (pain score for EVH=0.52+/-0.95; open technique=1.02+/-1.51; P=0.03) and wound complications (range from 3 to 7.4% for EVH and 13 to 19.4% for conventional technique). These clinical benefits were associated with a high level of patient satisfaction. On average, four papers found that the length of hospital stay was reduced in the EVH group [weighted mean difference (WMD) -1.04 to -0.85; confidence interval (CI) -1.92 to -0.16; P=0.02]. The overall occlusion rates of venous grafts after six months were 21.7% for EVH and 17.6% for open technique. There were no differences in the six months occlusion and disease rates between EVH and conventional vein harvest (CVH), as determined by means of univariate analysis (P=0.584). However, some papers (PREVENT-IV sub-analysis and Yun et al.) called into question EVH by reporting high vein occlusion rates. At six months, this was 21.7% for EVH and 17.6% for open technique rising to 46.7% vs. 38.0% (P<0.001) at 12-18 months. At three years, endoscopic harvesting was also associated with higher rates of death, myocardial infarction, or repeat revascularisation (20.2% vs. 17.4%; P=0.04), death or myocardial infarction (9.3% vs. 7.6%; P=0.01), and death (7.4% vs. 5.8%; P=0.005). We conclude that EVH reduces the level of postoperative pain and wound complication, with a high-level of patient satisfaction but a sub-analysis of a large RCT has recently called into question the medium- to long-term patency of grafts endoscopically harvested.

Inferior outcomes of autogenous infrainguinal bypass in Hispanics: an analysis of ethnicity, graft function, and limb salvage.

INTRODUCTION: Recent evidence suggests disparities exist among racial groups with peripheral arterial disease (PAD). Hispanics (HI) are the fastest growing demographic in the United States, but little outcome data is available for this population. Therefore, we undertook this study to compare the results of autogenous infrainguinal bypass grafting in HI to Caucasians (CA) and African Americans (AA). METHODS: This was a comparative cohort study of prospectively collected registry data of infrainguinal bypass performed at a tertiary center. Patient demographics and comorbidities, operative indications, bypass graft characteristics, and postoperative courses were analyzed. Cumulative patency rates, limb salvage, mortality, and factors associated with these outcomes were determined using Kaplan-Meier analysis and Cox proportional hazards models. RESULTS: From January 1, 1985, through December 31, 2007, 1646 consecutive patients (1408 CA, 57 HI, and 181 AA) underwent 1646 autogenous infrainguinal reconstructions. HI and AA were younger and more often diabetic than CA but HI had less chronic renal insufficiency (CRI) and dialysis-dependence than AA. AA, but not HI, more commonly underwent bypass for critical limb ischemia (CLI) in comparison to CA (AA 90% vs CA 80%, P < .0001; HI 86%). HI and AA bypass grafts had inflow and outflow distal to that in CA. Perioperative mortality (2.3%) and morbidity were similar between groups. Five-year primary patency (+/- standard error [SE]) was significantly lower in HI compared to CA and similar to that in AA (HI 54% +/- 7% vs CA 69% +/- 1%, P = .02; AA 58% +/- 4%). Cox proportional hazard modeling showed high-risk conduit, age <65, CLI, female gender, and AA race were risk factors for failure of primary patency. Secondary patency of HI grafts, unlike AA, was not different than that in CA. Five-year limb salvage (+/- SE) was significantly lower in HI compared to CA and similar to that in AA (HI 80% +/- 6% vs CA 91% +/- 1%, P = .004; AA 83% +/- 3%). Hispanic ethnicity, CLI, high-risk conduit, age <65, CRI, female gender, and diabetes were significant predictors of limb loss. CONCLUSION: Autogenous infrainguinal bypass surgery in HI is associated with primary patency and limb salvage inferior to that of CA and similar to that of AA, despite HI rates of CLI equivalent to CA and HI comorbidities less severe than AA. HI ethnicity was an independent predictor of limb loss. Our data provides evidence of outcome disparities in HI treated aggressively for their PAD. Further investigation with regard to biologic and social factors is required to delineate the reasons for these inferior outcomes in HI patients.

Patency of infra-inguinal vein grafts--effect of intraoperative Doppler assessment and a graft surveillance program.

OBJECTIVE: To assess the value of intraoperative graft flow and resistance measurements and a graft surveillance program to predict at-risk infra-inguinal bypass grafts. METHODS: Four hundred sixty-eight infra-inguinal bypass procedures performed between 1995-2006 underwent intraoperative measurement of graft flow and resistance using a Scimed OpDop. These data were correlated with graft outcome at six weeks. Two hundred fifty-four (73%) grafts were entered into a graft surveillance program and the effect of this on primary-assisted graft patency was assessed. RESULTS: Overall primary and primary-assisted graft patency was 81% and 83% at six weeks and 42% and 64% at three years. Grafts failing by six weeks had significantly lower flow (130.5 mL/min vs. 150.5 mL/min, P = .009) and higher resistance (0.67 peripheral resistance units (PRU) vs. 0.57 PRU, P = .004) than those remaining patent. However, OpDop measured flow and resistance was a poor predictor of graft failure in individual cases (area under ROC curve, 0.57). While there was no statistical difference in primary 18-month patency rates between grafts undergoing surveillance and those undergoing clinical follow up (55% vs. 76%, P = .133), primary-assisted 18-month patency rates were significantly higher in the surveillance group (83% vs. 77%, P = .042). CONCLUSION: Intraoperative measurements of graft flow and resistance do not predict graft outcome at six weeks. However, surveillance does identify at-risk grafts and improves mid-term primary-assisted patency.

Female gender and oral anticoagulants are associated with wound complications in lower extremity vein bypass: an analysis of 1404 operations for critical limb ischemia.

BACKGROUND: Infrainguinal bypass (IB) surgery is an effective means of improving arterial circulation to the lower extremity for patients with critical limb ischemia (CLI). However, wound complications (WC) of the surgical incision following IB can impart significant morbidity. METHODS: A retrospective analysis of WC from the 1404 patients enrolled in a multicenter clinical trial of vein bypass grafting for CLI was performed. Univariate and multivariable regression models were used to determine WC predictors and associated outcomes, including graft patency, limb salvage, quality of life (QoL), resource utilization (RU), and mortality. RESULTS: A total of 543 (39%) patients developed a reported WC within 30 days of surgery, with infections (284, 52%) and hematoma/hemorrhage (121, 22%) being the most common type. Postoperative anticoagulation (odds ratio [OR], 1.554; 95% confidence interval [CI] 1.202 to 2.009; P = .0008) and female gender (OR, 1.376; 95% CI, 1.076 to 1.757; P = .0108) were independent factors associated with WC. Primary, primary-assisted, and secondary graft patency rates were not influenced by the presence of WC; though, patients with WC were at increased risk for limb loss (hazard ratio [HR], 1.511; 95% CI 1.096 to 2.079; P = .0116) and higher mortality (HR, 1.449; 95% CI 1.098 to 1.912; P = .0089). WC was not significantly associated with lower QoL at 3 months (4.67 vs 4.79, P = .1947) and 12 months (5.02 vs 5.13, P = .2806). However, the subset of patients with serious WC (SWC) demonstrated significantly lower QoL at 3 months compared with patients without WC, (4.43 vs 4.79, respectively, P = .0166), though this difference was not seen at 12 months (4.94 vs 5.13, P = .2411). Patients with WC had higher RU than patients who did not have WC. Mean index length of hospital stay (LOS) was 2.3 days longer, mean cumulative 1-year LOS was 8.1 days longer, and mean number of hospitalizations was 0.5 occurrences greater for patients with WC compared with patients without WC (all P < .0001). CONCLUSIONS: WC is a frequent complication of IB for CLI, associated with increased risk for major amputation, mortality, and greater RU. Further detailed investigation into the link between female gender and oral anticoagulation use with WC may help identify causes of WC and perhaps prevent or lessen their occurrence.

Impact of outcomes research on the management of vascular surgery patients.

Vascular surgery has traditionally relied on prospective, randomized clinical trials, case-control series from single institutions of excellence, and case studies to guide clinical decision-making. However, the use of a number of new clinical research tools has allowed the vascular surgeon to more critically assess the indications for particular operations, the costs of various procedures from both a monetary and quality-of-life standpoint, and the "real world" outcomes that can be expected from practitioners across the United States, not just from centers of excellence. Decision analysis with modeling of cohorts with desired characteristics and vascular disease has allowed for the objective determination of procedural cost-effectiveness and evaluation of patient quality-of-life issues surrounding vascular procedures. The use of large national administrative databases has yielded important information concerning factors associated with improved outcomes after several vascular procedures across the entire United States, especially after relatively uncommon operations, such as thoracoabdominal aortic aneurysm repair. Administrative data have also enabled us to learn that access to various new endovascular procedures is somewhat limited, especially for the uninsured or poor. Hospital and surgeon volume, as a surrogate marker for quality, has been directly correlated with lower morbidity and mortality as well as differences in perioperative complications after multiple vascular procedures. A certificate of added qualification in General Vascular Surgery has also been shown to improve outcomes in patients undergoing vascular procedures. Finally, pioneered by the Veteran's Affairs administration and championed by the American College of Surgeons, prospectively collected data (National Surgery Quality Improvement Program) from the Veteran's Affairs and private sector hospitals is providing high-quality, risk-adjusted feedback about multiple vascular procedures to the hospital and the individual practitioner. Importantly, the body of literature generated using these new clinical research tools is being monitored by insurers and patients, as well as by the surgeons providing the care. This ultimately will have a direct impact on practice and referral patterns. It is therefore mandatory that vascular surgeons understand these new tools so that we can police our own practices before others, such as insurance companies and hospital administrators, do it for us.

A personal experience with the influence of diabetes and other factors on the outcome of infrainguinal bypass grafts for occlusive disease.

OBJECTIVE: To investigate the influence of diabetes mellitus and other factors on the outcome of all infrainguinal bypass grafts performed for occlusive disease by a single surgeon at a tertiary referral center. METHODS: The series includes 650 operations in 412 men and 238 women with median ages of 65 and 69 years, respectively. Critical ischemia was the indication for most procedures (n = 553, 85%), but 97 (15%) were done for claudication alone. Nearly half (n = 312, 48%) of the patients were diabetic, and 195 (30%) required insulin. All-autogenous vein was used for 389 grafts (60%). Synthetic or composite materials were employed for the remaining 261 grafts, 91 (35%) of which were entirely above the knee. Perioperative data were recorded contemporaneously and were supplemented by reviewing 558 of the 565 medical records and the Social Security Death Index. Survival, graft patency, and limb salvage were analyzed using logistic regression, Kaplan-Meier estimates and proportional hazards models. RESULTS: Diabetics were more likely to have critical preoperative limb ischemia (P < .001), elevated serum creatinine (P = .003) or a history of previous coronary intervention (P = .015), lower extremity revascularization (P < .001) or minor amputations (P = .002). The operative mortality rate was 4.8%, and there were 81 graft occlusions (12%) and 49 major amputations (7.5%) during the index hospital admission. Patency was immediately restored in 46 of the 81 occluded grafts, but their secondary patency rates were only 62 +/- 16% at 1 year and 26 +/- 18% at 5 years. Insulin-dependent diabetes was associated with a higher incidence of early amputation (odds ratio, 2.6; 95% confidence interval [CI], 1.4-4.8; P = .004). Overall survival was 52 +/- 4% at 5 years and 25 +/- 5% at 10 years, and there were 175 late graft occlusions (27%), a total of 198 related reoperations and 107 late amputations (16%). The risks for further occlusion and/or major amputation after three or more graft revisions were 65% and 71%, respectively. Insulin-dependent diabetes also was associated with higher late mortality (hazard ratio [HR], 1.5; 95% CI, 1.2-1.8; P = .001) and amputation rates (HR, 1.5; 95% CI, 1.0-2.1; P = .026), but other independent variables like age, elevated serum creatinine, critical preoperative ischemia, synthetic conduits, and previous ipsilateral bypass had at least as much influence as diabetes on survival, graft failure or limb loss. CONCLUSIONS: Diabetes was one of several factors influencing survival and limb preservation, but it did not adversely affect graft patency. The number of graft revisions was an important predictor of further occlusion or amputation.

Comparison of duplex ultrasound with digital subtraction angiography in the assessment of infra-inguinal autologous vein bypass grafts.

BACKGROUND: Postoperative surveillance of infra-inguinal vein grafts has arisen because of the high incidence of vein graft stenoses, which frequently progress to vein graft occlusion. The use of duplex ultrasound as the primary imaging method for graft surveillance is well established. This study aims to compare the accuracy of duplex ultrasound with the reference standard of digital subtraction angiography in the assessment of infra-inguinal vein grafts. METHODS: Sixty patients underwent routine postoperative duplex ultrasound as part of the local graft surveillance programme. Angiography was subsequently carried out on 18 grafts. Each lower limb arterial tree was divided into three segments (native arteries proximal to the graft, the graft itself and native arteries distal to the graft) resulting in a total of 42 comparisons. Degree of diameter stenosis on ultrasound was compared with angiography findings to determine concordance. Agreement was also expressed as a kappa value. RESULTS: Overall accuracy of duplex ultrasound was 88% (37/42). A kappa value of 0.80 indicates good agreement. In three of the five discordant cases, ultrasound correctly identified a stenosis, but overestimated the degree of stenosis compared with angiography. In each of the remaining two discordant cases, ultrasound identified a focal stenosis that was not apparent on angiography. In both cases, the area of duplex described abnormality responded to balloon angioplasty. CONCLUSION: Duplex ultrasound as part of the local vein graft surveillance programme is a reliable and accurate method in the detection of failing grafts and in some instances may be more sensitive.

[Cost comparison of different graft materials in femoropopliteal bypass: experience with G-DRG]. / Kostenanalyse verschiedener Bypassmaterialien in femoropoplitealer Position unter G-DRG-Bedingungen.

BACKGROUND: The German DRG classification refrains from medical accuracy of different surgical procedures by concentrating mainly on economic aspects. The process cost calculation of femoropopliteal bypass should as an example illuminate the charge of a surgical procedure under hospital conditions. METHODS: From 07/03 to 03/04 we analysed out of 71 peripheral arterial reconstructions 10 alloplastic grafts (PBP) and 10 autologous vein grafts (VBP) for femoropopliteal above-knee bypass through the process cost calculation. This required a classification of the procedure in different diagnostic and treatment sections (ward, intensive care, diagnosis, treatment (surgical procedure)). RESULTS: The average length of hospitalisation with VBP amounted to 12.2 +/- 3.6 (7-19) days, and with PBP to 14.0 +/- 8.0 (8-35) days. The duration of the surgical procedure was almost identical with 118 +/- 26 minutes (VBP) compared to 110 +/- 31 minutes (PBP), but in average 0.4 more assistants participated in VBP. One bleeding caused revision in VBP; one PBP led to extended length of hospitalisation because of wound complication. We diagnosed one asymptomatic bypass occlusion in VBP. The average total costs in VBP amounted to 4 368.10 euro (profit: 4 468.15 euro), in PBP to 5 069.50 euro (profit: 3 802.94 euro). CONCLUSION: The reconstruction of the superficial femoral artery with alloplastic or autologous vein graft is profitable in G-DRG. Although less medical staff in required in PBP the price of the prosthesis weakens the profit. The autologous vein graft shows furthermore a shorter length of hospitalisation. Further investigation into cost-effectiveness regarding long-term follow-up and patency rates could lead to consequences for the German health system.

[The Biocompound Shunt as a method of treatment of a. v. fistula aneurysm--a critical assessment]. / Der Biocompoundshunt als Therapiemöglichkeit bei Aneurysmata von Dialysefisteln--eine kritische Wertung.

We report our experiences with surgical repair of aneurysms of hemodialysis fistulas. After partial resection and suture of the aneurysm a perivascular metal mesh tubing (Biocompound Shunt) is applied to prevent the development of a new aneurysm. This method allows the use of the autologous vein for hemodialysis access for longer periods. In 6 patients treated in this way we found after a median period of 23 months a new dilatation of the vein of 10 up to 21 millimetres without stenosis, thrombosis or infection. All patients were satisfied with this type of surgery.

[Repair of defects at both ends of blood vessels in extremities with a great disparity in diameter by vein transplantation].

OBJECTIVE: To repair defects at both ends of the blood vessels with a considerable disparity in the diameter of the both sides or with a large diameter in extremities by phleboplasty of branched and double autogenous veins. METHODS: Three kinds of phleboplasty: funnel-shaped, raincape-shaped and transposed Y-shaped were designed. Experiments in fresh blood vessels in vitro were completed successfully. These methods were used clinically to repair injured external iliac veins, femoral arteries and veins, and popliteal arteries and veins, to replant severed fingers and to transplant toenail flaps on thumbs by harvesting autogenous great saphenous veins, small saphenous veins and forearm veins in 36 cases, including 35 cases in emergency operation and 1 case in selective operation. The length of The phleboplasty of funnel-shaped could enlarge the grafted blood vessels ranged from 1.0 cm to 15.0 cm. RESULTS: The phleboplasty of funnel-shaped could enlarge the diameter by 1.0-1.25 times in anastomotic stomas. The phleboplasty of raincape-shaped could enlarge the diameter large enough to meet the demands for various blood vessels in extremities. The phleboplasty of transposed Y-shaped could provide large vein transplants. In 36 grafted veins, 35 were in patency. The blood supply in extremities was normal. CONCLUSION: The funnel-shaped and raincape-shaped phleboplasty of branched veins can enlarge the anastomotic stomas of grafted veins. The transposed Y-shaped phleboplasty of double femoral veins is an ideal way to repair injured primary blood vessels with a considerable disparity in the diameter of the both sides or with a large diameter in extremities.

Critical assessment of the outcome of infrainguinal vein bypass.

OBJECTIVE: To perform a more critical assessment of infrainguinal vein bypass. SUMMARY BACKGROUND DATA: Graft patency may give an unrealistic impression of the outcome of bypass surgery. METHODS: During a 6-year period, 236 patients undergoing primary vein grafts were entered into the study. An ideal outcome required the patient to have survived 12 months with a patent graft on duplex scanning, no perioperative complication, and no further related open or endovascular surgery or admission. RESULTS: At 12 months, the secondary graft patency rate was 82%; however, only 22% of patients had an ideal outcome. At 1 year, 44 (19%) patients died, 93 (39%) required further ipsilateral and 39 (17%) contralateral intervention, and a total of 108 (46%) were readmitted. An ideal outcome was more likely in patients receiving calcium channel blockers, principally because of improved primary patency, and less likely in those with cardiac failure requiring furosemide, principally because of worse survival in these patients. CONCLUSIONS: Few patients achieve an ideal result after infrainguinal vein bypass. Outcome may be improved by the use of calcium channel blockers. Careful consideration is required before performing revascularization in patients with cardiac failure.

Long-term assessment of cryopreserved vein bypass grafting success.

PURPOSE: When autogenous vein is unavailable, cryopreserved veins have been used in patients as a means of attempted limb salvage. We evaluated the long-term patency and limb salvage rates for patients undergoing bypass grafting with cryopreserved veins. METHODS: Medical records were reviewed for patients undergoing cryovein bypass grafting at two hospitals from 1992 to 1997. Follow-up data were obtained from subsequent admissions and office records. Primary outcomes were death, amputation, and primary patency. Skin integrity and additional bypass grafting procedures were assessed when data were available. Analysis was performed by means of life-table and chi(2) analyses with the Statistical Package for Social Sciences (SPSS). RESULTS: Seventy-six patients (mean age, 70 +/- 11 years) underwent 80 procedures. Indications for surgery were tissue loss (63%), rest pain (24%), acute ischemia (11%), and other (2%). Early complications included 3 deaths (4%), 14 acute thromboses (18%), and 7 major amputations (9%). The mean follow-up period was 17.8 +/- 20.89 months (range, 0-77 months). The primary patency rate was determined to be 36.8% at 1 year and 23.6% at 3 years by means of life-table analysis. The limb salvage rate was 65.5% at 1 year and 62.3% at 3 years. Skin integrity was found to be compromised in 17 (55%) of 31 patients who were available to follow-up. Nine patients (11.3%) underwent additional ipsilateral revascularization or revisions, with one of three of these patients eventually requiring a major amputation. CONCLUSION: Cryopreserved vein may be a reasonable alternative conduit for limb salvage when no autogenous tissue is available; it has an acceptable limb salvage rate (62.3%) at 3 years. Long-term patency remains relatively poor, with only 23.6% of originally placed grafts patent at 3 years. The use of cryopreserved veins should be strictly confined to limb salvage after a thorough search for autogenous tissue has been exhausted.

Duplex scan surveillance during the first year after infrainguinal autologous vein bypass grafting surgery: costs and clinical outcomes compared with other surveillance programs.

PURPOSE: In this study we assessed the costs and clinical outcomes of duplex scan surveillance during the first year after infrainguinal autologous vein bypass grafting surgery and compared duplex scan surveillance, ankle-brachial index surveillance, and clinical follow-up. METHODS: In a clinical study, 293 patients (mean age, 70.1 years; 58.7% men) with peripheral arterial disease were observed in a duplex scan surveillance program after infrainguinal autologous vein bypass grafting surgery. Costs were calculated from the health care perspective for surveillance and subsequent interventions from 30 days to 1 year postoperatively. All costs are presented in 1995 US dollars per patient. In a simulation model, we estimated the costs and amputations of duplex scan surveillance, ankle-brachial index surveillance, and clinical follow-up conditional on the indication for surgery. The main outcome measure was the incremental cost per major amputation per patient avoided during the first postoperative year. RESULTS: Duplex scan surveillance was the least expensive ($2823) and resulted in the fewest major amputations (17 per 1000 patients examined), compared with ankle-brachial index surveillance ($5411 and 77 amputations per 1000 patients) and clinical follow-up ($5072 and 77 amputations per 1000 patients). In patients treated for critical limb ischemia, duplex scan surveillance was the least expensive ($2974) and resulted in the fewest major amputations (19 per 1000 patients). Under all surveillance programs, 13 major amputations per 1000 patients treated for intermittent claudication were performed, and clinical follow-up had the lowest costs ($1577). In a sensitivity analysis that assumed that duplex scan surveillance could have avoided six major amputations per 1000 patients treated for intermittent claudication compared with the other programs, duplex scan surveillance had an incremental cost of $80,708 per major amputation per patient avoided compared with clinical follow-up. CONCLUSION: Duplex scan surveillance is highly effective for patients treated for critical limb ischemia, leading to a reduction of major amputations and consequently to a reduction in costs compared with other surveillance programs. In patients treated for intermittent claudication, the evidence supporting duplex scan surveillance is less firm, but if duplex scan can avoid six major amputations per 1000 patients examined, the incremental costs are justified.

[Assessment of the results of surgical treatment of multiple lesions of lower limb arteries]. / Otsenka rezul'tatov khirurgicheskogo lecheniia bol'nykh s mnozhestvennym porazheniem arterii nizhnikh konechnostei.

121 one-stage "two-floor" reconstructions were performed in multiple lesions of lower limbs arteries. Their results were compared with results of 197 reconstructions of aorto-iliac segment with revascularisation of the firifory of deep femoral artery (DFA). In immediate postoperative period better results were achieved after one-stage "two-floor" reconstructions. There were 70.9% of good results after revascularisation of DFA and 88.4%--after one-stage "two-floor" reconstructions. In long-term period (up to 5 years) after "two-floor" reconstructions the patency of the distal bypasses was lower than that of proximal bypasses since the second year of follow-up. Patency of the distal bypasses after one-stage "two-floor" reconstructions depends on a type of plastic material, location of distal anastomosis of the femoro-popliteal bypass and does not depend on location of the proximal anastomosis. Patency of combined bypasses was lower than one of autovenous bypasses and biografts since the second year of follow-up, patency of femoro-tibial bypasses was lower than that of femoro-popliteal bypasses since the third year of follow-up.