Multiple sequential femoral tibial grafting for severe ischemia.

For the past decade a common procedure used to salvage severely ischemic limbs has been autogenous vein bypass grafting to the distal popliteal artery or, if the popliteal trifurcation is occluded, to one of the tibial-peroneal branches. Reported limb salvage rate and long-term graft function varies considerably but in most series is low. To increase graft flow and to decrease resistance in femoral-poplitical-tibial grafts and thereby to perfuse the ischemic foot more effectively, we have employed multiple sequential anastomoses of a single vein graft to distal branches--a technique similar to that used occasionally in aortocoronary bypass grafting. The autogenous vein graft alone, or in combination with bovine heterograft, has been used in six patients with gangrenous toes or far advanced ischemia and in one patient with severe claudication. Multiple anastomoses below the knee were carried out in each patient. Anastomosis has been to a blind popliteal segment, then to a tibial or peroneal in four patients, to both tibials in another two patients, and to both tibials and the peroneal in one patient. Flow rates measured on the operating table clearly demonstrated a significant increase in flow through the graft with each additional anastomosis. There has been a greater response to surgery with return of pulses, warmth of the foot, and rapid healing as compared with previous patients having single femoral-tibial anastomoses. One failure occurred acutely from a technical problem early in the series; one failed at 3 months in a patient with pancreatic cancer and another patient died 2 weeks after operation of a myocardial infarct.

Carotid artery aneurysm of granulomatous origin.

A native of the Western Caroline Islands presented with a granulomatous aneurysm of the right common carotid artery measuring 7 to 8 cm, which was resected and replaced with a reversed segment of saphenous vein. Adequacy of the collateral circulation to the brain was established by occlusion of the common carotid artery with local anesthesia. This was followed by definitive operation with general endotracheal anesthesia and induced hypertension. Although tuberculosis was the most likely etiologic agent, sarcoid could not be ruled out. Granulomatous aneurysms of the common carotid are extremely rare, and if this case was sarcoid in origin, it is the first such case reported. Only one other similar aneurysm could be found in the literature. Of the various methods of reconstruction of the common carotid artery reported, autogenous reversed saphenous vein is recommended strongly.

A study of the diastolic flow velocity profile of the clinically uncomplicated mitral porcine bioprosthesis using an echo-Doppler technique.

Pulsed Doppler echocardiography was performed in 17 subjects who had clinically uncomplicated porcine bioprosthesis in the mitral position. A positive initial diastolic flow wave was present in all patients; end-diastolic A waves were seen in the sinus rhythm of every patient. The peak of the diastolic wave was delayed when compared with the normals in our laboratory. This wave had clearly demarcated ascending, mid- and descending segments. When contrasted with normal subjects, the slope of the diastolic wave was mildly reduced in all patients. Fine to coarse indentations on the descending and mid-segments were seen in 15/17 (88%) of the patients. We conclude that the diastolic flow profile of the clinically uncomplicated mitral bioprosthesis resembles mild mitral stenosis. Reduced orifice size and/or the physical properties of the bioprosthesis are the likely mechanisms for these alterations.

Left main coronary artery embolism: a case report.

A 27-year-old man had recurrent myocardial infarction found to be due to coronary embolism to the left main coronary artery with downstream embolization. The presumed etiology of thromboembolism was idiopathic cardiomyopathy. A unique method of treatment with Fogarty catheter retrieval was used.