Fifteen-year experience in axillofemoral bypass with externally supported knitted Dacron prosthesis in a Japanese hospital.

BACKGROUND: Recently, several reports in the United States have demonstrated remarkable improvement in the patency of axillofemoral (AXF) bypass with an externally supported prosthesis. The purpose of this study was to review the prognoses regarding graft patency, limb salvage, and survival of patients who underwent AXF bypass grafting with an externally supported, knitted Dacron prosthesis (EXS) in a Japanese hospital and to analyze what factors affected the graft patency. METHODS: The clinical records of 81 patients with arteriosclerosis obliterans (ASO) who underwent 47 axillounifemoral bypasses and 34 axillobifemoral bypasses with EXS were retrospectively checked and, by uni- and multivariate analysis, perioperative factors were evaluated. RESULTS: The cumulative primary and secondary patency rates of AXF bypass grafts were 81% and 88%, 73% and 80%, and 70% and 77% at 3, 5, and 7 years, respectively, with no change thereafter. Limb salvage rate was 100%. The operative mortality was 3.7% and the survival rate was 63%, 41%, and 35% at 3, 5, and 7 years, respectively. The risk factors adversely affecting the patency were age (younger than 75 years), poor distal runoff, and preoperative leukocyte count (more than 8,000/microL) by univariate analysis, none of which were significant by stepwise multivariate analysis. CONCLUSIONS: AXF bypass using EXS was an acceptable procedure in ASO patients at high risk for conventional anatomic bypass or with limited life expectancy, and there was no significant risk factor that independently affected the patency.

Reoperation for graft failure of femoropopliteal bypass with externally supported knitted Dacron prosthesis.

BACKGROUND: Aggressive reoperation for failing or failed femoropopliteal (FP) bypass has been affirmative despite graft material. There has been no report regarding results of reoperation for FP bypass with externally supported knitted Dacron prosthesis (EXS). The aim of this study is to justify aggressive reoperation of FP bypass with EXS and to examine risk factors affecting the result of reoperation. METHODS: A retrospective review was performed on 204 patients undergoing 212 FP bypasses (with EXS between January 1982 and December 1997 and 34 FP EXSes of 32 patients underwent reoperation for graft failure until March 1998. The cumulative graft patency (GP) and limb salvage (LS) rate after first reoperation for 34 FP bypass EXS were calculated and the importance of each perioperative factor on GP or LS was estimated by uni- and multivariate analysis. RESULTS: Reoperated 34 FP EXSes included 12 failing and 22 failed grafts and 14 limbs with failed grafts underwent reoperation for limb salvage. The GP of 34 grafts and LS of 14 limbs rate were 58 and 67% at 2 years, respectively. Univariate analysis identified graft thrombosis (2 years GP; failing graft: failed graft=78: 48%) and continuance of smoking (2 years LS; smoker: non-smoker=43: 100%) as a significant risk factor of GP and IS, respectively, neither of which was significant by multivariate analysis. CONCLUSIONS: Early diagnosis and treatment, before graft thrombosis, can lead to superior durability of GP and discontinuance of smoking is important for LS.

Surgical repair of primary aorto-jejunal fistula associated with non-specific inflammatory abdominal aortic aneurysm.

A 28-year-old man with aorto-jejunal fistula associated with primary saccular abdominal aortic aneurysm (AAA) was effectively treated by resection and replacement with polytetraflouroethylene graft. The aetiology was suspected to be a non-specific aortitis, a rare cause of aorto-enteric fistula.

Preliminary evaluation of a technique for inhibiting intimal hyperplasia: implantation of a resorbable luminal collagen membrane.

Pharmacologic control of intimal hyperplasia has been attempted through oral and intravenous administration of smooth muscle cell inhibitors. We report a more direct method of altering arterial healing using a novel bioresorbable membrane that can be applied to the lumen of an artery or anastomosis following endarterectomy or vascular reconstruction. Following a standard balloon injury, the infrarenal aortas of 3 kg female New Zealand white rabbits were opened and a thin membrane composed of collagen/chondroitin 6-sulfate copolymer was sutured to the posterior wall of each artery. Animals were killed at intervals of up to 3 months. All arteries remained patent. By 24 hours the membrane had become infiltrated with fibrin and red blood cells. An inflammatory response ensued and by 8 days the membrane was filled with mononuclear cells. At 3 months only a small remnant of the membrane remained. Intimal hyperplasia developed throughout the injured aorta. However, the hyperplastic response beneath the membrane was no greater than that observed in the adjacent injured aorta. A bioresorbable membrane can be sutured into the lumen of a small-diameter vessel without inducing thrombosis and without locally increasing intimal hyperplasia. A prosthesis of this type might be used to deliver inhibitors of smooth muscle cell proliferation and migration to the injured arterial wall.

Flow waveform analysis and long-term results of autogenous saphenous vein and polytetrafluoroethylene grafts in 140 arterial reconstructions of the lower limbs.

In previous work we have found that the outcome of grafts in the lower limbs correlated with the flow waveform pattern of the artery. We have retrospectively reviewed 140 femoro-popliteal bypass operations involving the use of 75 saphenous vein grafts and 65 polytetrafluoroethylene (PTFE) grafts. For grafts with type 0 or I flow waveform pattern the patency at 4 years (56%) was superior to grafts with the type II, III or IV flow waveform (35%) patterns (P less than 0.05). For saphenous vein grafts with type 0 or I flow, the patency rate was 78% at 3 years and 69% at 5 and 8 years. In contrast with type II, III or IV flow the patency rate was 52% at 3 years, 48% at 5 years and 34% at 8 years, with a statistical significance at 4 years (P less than 0.05). PTFE grafts with type 0 or I flow showed a tendency toward an increased patency which was not significant in comparison with the grafts with type II, III or IV flow (P = 0.12). Saphenous vein grafts with type II flow patterns had an increased occlusive rate in the first year whereas PTFE grafts had the same tendency within 2 years. In both types of graft, early occlusions within a month of operation were encountered in grafts with a type III or IV flow waveform pattern. These results indicate that the fate of the reconstructed arteries of the lower limb could be predicted by flow waveform analysis, and a careful and serial postoperative evaluation of the graft should be made, particularly those with type II, III or IV flow waveform patterns.

Recurrent multiple aneurysms in an axillofemoral graft with coagulopathy.

An 84-year-old man presented with multiple non-anastomotic aneurysms in a Dacron axillary femoral graft and coagulopathy. Histological examination and the clinical course suggested that a graft versus host reaction might be the main cause of the aneurysms.