Optimal methods of aortoiliac reconstruction.

Alternate methods of aortic reconstruction for aortoiliac occlusive disease were reviewed in one author's (R.C.D.) personal series of 582 patients (1,105 limbs) during the 15 year period from 1963 to 1977. To illustrate certain trends, separate analysis was done for periods 1963 to 1969 (interval I) and 1970 to 1977 (interval II). During the earlier period, endarterectomy was performed in 72% of patients, with unilateral operations carried out in 15% of patients. Operative mortality was 5.1% and early failure occurred in 4% of patients. In contrast, in interval II graft procedures were done in 89% of patients, with mortality of only 2% and early failure in less than 1% of patients. Unilateral procedures were utilized infrequently (4%). Our analysis suggests that aortoiliac endarterectomy is still the procedure of choice for a small group (approximately 10%) with localized disease. For more extensive disease, aortofemoral grafts appear to be the procedure of choice. Patency of such grafts in the most recent interval was 91% at 5 years. Superior long-term function of aortofemoral grafts appears to be associated with use of a knitted Dacron prosthesis, end-to-end proximal anastomosis, and distal anastomosis which ensures patency of the profunda femoris outflow. The incidence of infection (0.3%) and false aneurysm formation (1.4%) was extremely low. In view of the low mortality rate and superior long-term success of direct reconstructions, extraterritorial grafts are felt to be rarely indicated.

Renal perfusion during complex aortic reconstruction: use of a radial-renal artery shunt.

Use a simple, expedient external shunt between the radial and renal arteries is described in two patients undergoing operation for abdominal aortic aneurysms involving the renal arteries. Such a shunt aided in preservation of postoperative renal function by allowing direct perfusion of the kidney during interruption of renal blood flow. Production of urine by the perfused kidney during clamping documented continued function during the period of renal artery occlusion. Other methods of renal protection during complex aortic reconstructions are discussed. Continuous perfusion of the kidney by means of such a shunt may be especially useful when a prolonged ischemic interval is anticipated, particularly if this involves a solitary kidney or a kidney with already diminished function preoperatively. Use of a larger cannula inserted into the brachial or axillary artery appears to be equally safe and simple and improves flow rates.

Femoropopliteal composite bypass grafts: current status.

Controversy continues regarding the best arterial substitute for femoropopliteal reconstruction if an adequate length of autogenous saphenous vein is not available. To evaluate the role of composite grafts as an alternate vascular conduit, we have analyzed our experience with 39 femoropopliteal composite grafts as compared with a similar group of 79 below-knee prosthetic reconstructions. The 5-year cumulative patency rates for composite and prosthetic reconstructions to the distal popliteal artery were not statistically different (38 +/- 9% and 31 +/- 8%, respectively). The amount of vein relative to prosthesis did not appear to influence late patency. Both alternate reconstructive methods were significantly inferior to the 73 +/- 3% 5-year patency rate of autogenous vein bypass grafts. Based on this experience, we have abandoned the use of composite grafts for primary femoropopliteal reconstruction, since currently available prosthetic grafts appear to have similar long-term function.

Comparative analysis of vein and prosthetic bypass grafts to the isolated popliteal artery.

The effectiveness of prosthetic femoropopliteal bypass grafts to salvage limbs and maintain long-term patency in lower extremities with a limited outflow tract is controversial. To evaluate the results of prosthetic grafts and compare them with the results of vein bypass grafts in limbs with a limited outflow tract, we reviewed a 15-year experience with 65 grafts to an isolated popliteal artery segment. Fifty-one grafts were performed with autogenous saphenous vein, and 14 grafts utilized a prosthetic conduit. The indication for surgery was rest pain in 22 patients and actual tissue necrosis in 43 patients. The operative mortality rate was 3.4%. The average preoperative absolute ankle blood pressure was 48 mm Hg. Following a successful bypass, an average increase of 45 mm Hg was noted. The mean intraoperative blood flow was 70 ml/min. The superior performance of autogenous vein grafts was quite marked, with a 5-year cumulative patency of 65.4 +/- 8.5% as compared with only 17.1 +/- 10.1% for prosthetic grafts. The limb salvage rate for the entire group was 69% at 5 years. These data show the efficacy of isolated segment femoropopliteal artery grafts in achieving long-term limb salvage and stress the superiority of vein grafts over prosthetic grafts in this location.

The value of electrocardiogram monitoring during treadmill testing for peripheral vascular disease.

In evaluating the arterial hemodynamics of the lower extremities in patients with peripheral vascular disease, the treadmill exercise test offers useful information concerning the peripheral circulation. The addition of electrocardiographic (EKG) monitoring during the treadmill examination provides a method of estimating the effectiveness of coronary circulation. In three groups of patients studied, the results demonstrated that EKG monitoring during the treadmill exercise test will reveal previously unsuspected arrhythmias and ischemia. Thus the safety of the patient is enhanced. In patients followed through the operative period, there was a high correlation between exercise-induced EKG changes and perioperative cardiac problems. The value of EKG monitoring during treadmill testing is clear and offers predictive information to the surgeon contemplating a revascularization procedure.

Vascular laboratory criteria for the management of peripheral vascular disease of the lower extremities.

From experience gained in over 4,500 vascular laboratory procedures, segmental Pulse Volume Recorder (PVR) tracings, systolic pressure measurements, and other noninvasive laboratory techniques have been found extremely useful in the management of patients with arteriosclerotic peripheral vascular disease. Both PVR recordings and limb pressures were found to be important and are used in complementary fashion. Although arteriography is essential in defining structural lesions and in establishing graftability, noninvasive vascular studies provide an inexpensive, accurate, reproducible method for assessing functional significance of arterial disease. These studies contribute to the diagnosis, definition of severity, and establishment of an objective baseline prior to medical or surgical therapy. Because they may be used in a repetitive manner, they are extremely useful in establishing success of a given therapy and in the long-term follow-up of patients. Based upon our experience, laboratory criteria have been developed which allow accurate identification of ischemic rest pain, aid in predicting healing of foot lesions or below-knee amputations, and quantitate the functional disability of claudication.

Intestinal ischemia complicating abdominal aortic surgery.

A 9-year experience with 2137 patients undergoing infrarenal abdominal aortic reconstruction was reviewed to determine both the incidence of intestinal ischemia and the clinical, anatomic, and technical factors associated with this complication of aortic surgery. A total of 24 (1.1%) patients had overt intestinal ischemia, documented by reoperation or endoscopic findings. Of these, colon ischemia occurred in 19 (0.9%) and small bowel ischemia developed in 5 (0.2%) patients. The incidence after elective operation for aneurysmal or occlusive disease did not differ, but patients with ruptured aneurysms and those undergoing reoperative procedures for total graft replacement were at higher risk. Preoperative angiography was most helpful in ascertaining risk. Ligation of a patent inferior mesenteric artery was the most common (74%) feature in patients with colon ischemia. With preexisting inferior mesenteric artery occlusion, impairment of collateral circulation was attributable to superior mesenteric artery disease, dissection or retractor injury, prior colon resection, or exclusion of hypogastric perfusion. Bloody diarrhea was the most frequent postoperative symptom and colonoscopy the most reliable means of diagnosis. One half of patients with colon ischemia required resection after late recognition of perforation. All cases of small bowel ischemia were related to superior mesenteric artery disease or injury or use of suprarenal clamping. The overall mortality rate was 25% but rose to 50% if bowel resection was required. Intestinal ischemia remains an infrequent but serious complication of aortic surgery. Despite a multifactorial cause, identification of patients at increased risk can lead to operative strategies to reduce its occurrence.

Leiomyosarcoma of the inferior vena cava. Diagnosis and surgical management.

Leiomyosarcoma of vascular origin are rare tumors arising most frequently from the inferior vena cava (IVC). We report on three patients one of whom underwent definitive resection. These tumors most commonly involve the upper segment of the IVC, and appear with manifestations of the Budd-Chiari syndrome. Lesions at this level are not amenable to surgical therapy. Tumors of the middle and lower segments of the IVC usually cause right-sided pain. Diagnosis is difficult, but is best approached preoperatively by angiography and vena cavography. Optimal therapy of lesions at these levels is surgical resection. Resection of the IVC below the hepatic veins is possible with renal function preserved by collateral drainage of the left renal vein.

Intermittent aortic-graft obstruction secondary to anastomotic aneurysms.

Diagnosis of anastomotic aneurysms is usually suggested by simple palpation of a pulsatile mass on physical examination. Diagnosis may be more difficult, and clinical appearance more unusual, for those aneurysms occurring in an intra-abdominal location. This article reports an unusual manifestation of bilateral iliac-artery false aneurysms, ie, intermittent obstruction of aortic-graft blood flow. Femoral pulses were absent and significant peripheral ischemia present with the patient's legs extended. Femoral pulses returned to normal with the patient's legs flexed. Perianastomotic fibrosis, the mass effect of the false aneurysms, and possible kinking of the partially disrupted suture line with tensing of the psoas muscle on extension of the legs are possible causes of the intermittent obstruction to blood flow. The varied clinical manifestations and general principles of operative repair of anastomotic aneurysms are described.

Tender pulsatile abdominal mass. Abdominal aortic aneurysm or not?

Twenty-nine patients had symptomatic pulsatile abdominal masses. Initially six patients underwent emergency surgical exploration without prior arteriography. An abdominal aortic aneurysm was found in only one patient. In the next 23 patients, in whom arteriography was performed, no aneurysm was detected and emergency surgery could be avoided. In patients with symptomatic pulsatile abdominal masses, in the absence of hypovolemic shock the initial diagnostic study should be abdominal angiography. It is an accurate and safe procedure, and supplies the necessary preoperative information should abdominal aortic surgery become necessary. If, however, no aneurysm is found, valuable information is still obtained with regard to the underlying disease process.

Comparison of above-knee and below-knee anastomosis in femoropopliteal bypass grafts.

Experience with 555 femoropopliteal reconstructions was reviewed to evaluate the optimal location of the distal anastomosis. Autogenous vein was employed in 347 (63%) grafts and various prosthetics in 208 (37%). Vein grafts demonstrated marked superiority in late patency (73% at five years) vs prosthetic grafts (35% at five years). Below-knee (BK) anastomosis resulted in slightly better long-term patency in the vein graft group. In contrast, above-knee (AK) anastomosis was clearly preferable when prosthetic grafts were employed, particularly in patients with poor runoff or limb-threatening ischemia. The incidence of major amputation was greater following failure of BK grafts, reflecting the fact that a greater proportion of such grafts were done for limb salvage. However, failure of BK grafts did not appear to alter the level of amputation as compared with failed AK grafts.

The advantage of early operation for abdominal aortic aneurysm.

Factors affecting mortality in 493 consecutive patients undergoing operation for abdominal aortic aneurysms (AAAs) over a five-year period were analyzed. Cases were divided into three categories, based on clinical appearance: asymptomatic, symptomatic but unruptured, and ruptured. Patient age, relevant associated diseases, aneurysm size, conduct of the operation, mortality, and causes of death were reviewed and compared. Characteristics related to mortality were patient age and aneurysm size. In patients under 70 years of age, operated on electively, mortality was under 1% (two deaths in 242 patients). There were no deaths in 67 patients with aneurysms measuring 5 cm or less. Mortality increased as the aneurysms became larger and the patient older. We believe that elective operation for small asymptomatic aneurysms in younger patients will result in further reduction of morbidity and mortality associated with repair of AAAs.

Neurologic sequelae with internal carotid artery occlusion.

A retrospective review of the clinical course surrounding internal carotid artery occlusion (ICO) was undertaken in 97 patients with 106 instances of ICO. No neurologic symptoms could be attributed to more than half of the ICOs. Of the 52 symptomatic occlusions, 19 (37%) were associated with transient ischemic attacks and 33 (63%) with fixed strokes. Only 10% of all patients had permanent disabling neurologic sequelae. There was no correlation between development of neurologic symptoms and the side of the ICO, the presence or severity of contralateral carotid artery disease, or other risk factors. Women, however, were twice as likely as men to develop a fixed stroke with ICO. Seventy-six of these patients underwent reconstructive carotid surgery. Although there was a high rate of abnormal intraoperative findings with electroencephalographic monitoring (32 of 62 cases), with the use of intraoperative shunts there was no increase in the postoperative stroke complication rate (1.8%). These data suggest that the concern that ICO leads to serious fixed neurologic deficits may be overestimated, and that its presence does not adversely affect carefully performed contralateral carotid endarterectomy.

Femoropopliteal and tibioperoneal artery reconstruction using human umbilical vein.

We used 99 human umbilical vein (HUV) grafts for femoropopliteal or tibioperoneal artery reconstruction in 94 patients. Results were calculated according to the life-table method for several categories possibly influencing graft patency. For above-knee v below-knee distal anastomosis, there was no difference in patency or limb-salvage rates at 30 months. Comparison of good and poor runoff situations disclosed similar 30-month graft patency rates, but significantly better limb-salvage rates among patients with good runoff. Primary revascularization fared significantly better than secondary procedures in terms of patency and limb salvage. We found no significant differences between HUV and polytef (polytetrafluoroethylene) for above-knee anastomoses or good runoff situations. However, patency and limb salvage were better for HUV use in below-knee anastomosis and poor runoff situations. The HUV may offer advantages in long-term patency and limb salvage in selected patients.

Femoropopliteal graft failures. Clinical consequences and success of secondary reconstructions.

We examined 188 failed femoropopliteal grafts during a 16-year period to evaluate the clinical consequences of graft failure and success of secondary revascularization procedures. In limbs with grafts placed for claudication, conditions of 9% with failed grafts remained improved despite graft occlusion, 67% returned to preoperative status, and 24% showed worsened ischemia. One third of claudicants with failed grafts underwent secondary procedures. Ultimately, only 7% of failed grafts in claudicants resulted in amputation, and overall risk of limb loss in patients undergoing operation for claudication alone was low (2%). After failure of grafts performed for limb-salvage indications, 21% of limbs were still improved, and 79% reverted to limb-threatened status, more than half of the limbs undergoing subsequent reoperation. Overall, secondary attempts at reconstruction appeared justified. Although the five-year patency rate of such grafts was only 31%, limb salvage was achieved in 52%, with relatively low morbidity and mortality.

A comparison of the use of cephalothin and oxacillin in vascular surgery.

A randomized trial comparing two prophylactic antibiotics in vascular surgery was reviewed retrospectively. Two hundred thirty-two patients were given cephalothin sodium, and 168 patients were given oxacillin sodium. The overall incidence of wound infection was 1.5%; there was only one prosthetic graft infection in 346 patients in whom prosthetic material was used. There was no significant difference in wound infection between the groups. When postoperative infection in other areas was considered, however, it appeared that cephalothin was a more suitable antibiotic for treatment of these infections despite its use prophylactically. Although this trial was uncontrolled, the low overall incidence of wound and graft infection would appear to support the use of prophylactic antibiotics in vascular surgery.

Oculopneumoplethysmography: its relationship to intraoperative cerebrovascular hemodynamics.

The oculopneumoplethysmography (OPPG) test has been proposed as an effective method to identify significant carotid artery stenoses. To evaluate the clinical relevance of OPPG testing performed without carotid compression, the results of the preoperative OPPG studies, intraoperative pressure gradient measurements, and intraoperative "stump" pressure determinations were correlated retrospectively with the severity of the carotid lesions. Patients with positive OPPG test results had a mean pressure gradient of 44 mm Hg, whereas those patients with negative results had a mean gradient of 20 mm Hg. Of the patients with true-positive OPPG test results, 94% (29/31) had lesions causing at least 70% diameter reduction. However, overall accuracy of OPPG testing in this series was only 63% (33/52), as 81% (17/21) of the patients with false-negative OPPG test results also had tight lesions. Without carotid compression, OPPG testing was not useful in predicting intraoperative stump pressure. The OPPG test reflects a balance between the severity of the carotid stenosis and the adequacy of compensatory collateral flow. A positive OPPG test result is reliable in identifying those patients at greatest risk from their carotid arterial lesion. Although a negative OPPG test result does not exclude a tight stenosis, it does provide information with regard to its hemodynamic significance.

Variable manifestations of vascular injury during lumbar disk surgery.

Major vascular injury is an unusual but well-recognized complication of lumbar disk surgery. Clinical manifestation of such injuries may be extremely variable. Isolated arterial laceration is most common, with early manifestation due to retroperitoneal hemorrhage. There are often few external signs of blood loss, however, and the diagnosis may not be recognized initially. Formation of an arteriovenous fistula or false aneurysm produces even fewer early signs, and diagnosis is often delayed for weeks or years. Six cases are described that illustrate the full spectrum of acute and chronic manifestations of such injuries. Two cases of acute hemorrhage due to arterial trauma were seen; one case was recognized intraoperatively and one in the recovery room. In four cases arteriovenous fistulae developed and were diagnosed from eight hours to eight years postoperatively. Two cases also had associated false aneurysms, one the probable source of pulmonary emboli and one the principal manifestation of the vascular injury.

Isolated popliteal segment v tibial bypass. Comparison of hemodynamic and clinical results.

Clinical and hemodynamic results of isolated popliteal segment, tibial, and sequential bypass grafts were compared in a retrospective review. Results were good with vein grafts to either an isolated segment or infrapopliteal vessel, with five-year patency rates of 71% and 72%, respectively. Prosthetic grafts performed poorly in both groups, and sequential grafts appeared advantageous in such circumstances. Average ankle pressure increased 49 mm Hg following successful isolated segment grafts. Although less than with patent tibial or sequential grafts, improvement was sufficient to relieve rest pain in all instances and heal ischemic lesions or local amputations in all but four patients. If an adequate vein is available and a good tibial vessel exists, distal grafting may be elected, particularly if advanced ischemic lesions demand restoration of pulsatile flow to the foot. If such conditions are not present, isolated segment grafting will give highly satisfactory results.

Aortofemoral graft for multilevel occlusive disease. Predictors of success and need for distal bypass.

Results of aortofemoral reconstruction of 181 consecutive patients with multilevel occlusive disease were reviewed and correlated with possible predictors of outcome. Overall, 74% of patients attained satisfactory relief of ischemic symptoms with proximal operation alone. Forty-six patients (26%) had an unsatisfactory result, 31 (17%) of whom underwent distal bypass grafts. Of 42 variables studied, 12 achieved statistical significance as predictors of outcome, and multivariate analysis identified five factors an independent indicators. Factors documenting hemodynamically significant inflow disease were associated most strongly with a good result. Several noninvasive laboratory variables were found helpful, particularly in assessing the hemodynamic compensation of distal disease. While no single variable reliably indicated the definite need for distal grafting, careful consideration of important factors together with the clinical situation will aid the surgeon in selection of the small group of patients best treated by synchronous aortofemoral and femoropopliteal grafts.