[Extended total aortic arch replacement involving the proximal descending aorta through a median sternotomy].

From January 1986 to September 1995, total aortic arch replacement (TAR) for aortic dissection was performed using selective cerebral perfusion in 151 patients. In 18 patients, the surgical procedures of extended aortic arch replacement (EAR) involving the proximal descending aorta through a median sternotomy were applied. To evaluate the outcome of EAR, the early and late results were compared with those of non-extended aortic arch replacements (NAR) through a median sternotomy (n = 66). The early mortality rates for EAR and NAR were 5.6% and 16.7%, respectively (NS); the lower rate for EAR may be due to the fact that EAR were performed more recently than NAR. The differences between EAR and NAR with respect to the amount of blood transfused intraoperatively and the respiratory index at 12 hours after surgery were not statistically significant. In addition, the extracorporeal bypass time in EAR was no longer than that in NAR. Thus, as compared with the NAR procedure, the EAR procedure did not have a negative effect on early outcome. Regarding late results, the actuarial survival rates after EAR and NAR, respectively were 87% and 72% at 1 year, 87% and 69% at 3 years (NS). The early thrombo-occlusion rates of the remaining false lumens after TAR in broad aortic dissections were 56% after EAR and 33% after NAR (p = 0.21). These results suggest that EAR may be a more useful procedure in some patients requiring TAR.

Long-term results of patch repair for saccular aneurysms of the transverse aortic arch.

OBJECTIVE: Long-term results of patch repair in patients with a saccular aneurysm of the aortic arch were investigated. PATIENTS: From December 1984, 43 patients with a saccular aneurysm of the arch underwent patch repair. Indications for patch repair were determined as orifice diameter of aneurysm being less than 1/3 of the total circumference of the aorta. METHOD: Midsternotomy was used in 38 patients, and left thoracotomy in five. Selective cerebral perfusion was used in 28 patients, deep hypothermic circulatory arrest with retrograde cerebral perfusion in eight during the last 3 years, and partial cardiopulmonary bypass in seven. RESULTS: There were five (11.6%) early deaths, and causes were respiratory failure in two patients, low cardiac output in two, and gastrointestinal bleeding in one. Stroke was found in three patients (6.9%). During follow-up, seven patients died, two due to rupture of a residual or pseudoaneurysm, one due to reoperation of pseudoaneurysm, one due to stroke, two due to respiratory failure, and one due to unknown cause. Postoperative survival, including early death, was 69.3% at 5 years and 43.3% at 9 years. Aortic reoperation was done in three patients with a pseudoaneurysm formation and two survived. Freedom from reoperation was 91.7% at 5 years and 38.2% at 9 years. Event free ratio was 79.3 +/- 9.8% at 5 years and 37.6 +/- 18.6% at 9 years. CONCLUSION: Because of a high incidence of pseudoaneurysm or residual aneurysms after patch repair for a saccular aneurysm of the aortic arch, strict criteria for the patch repair should be applied or graft replacement of the aorta is recommended.

Graft-related complications after abdominal aortic aneurysm repair: reassurance from a 36-year population-based experience.

PURPOSE: Graft-related complications must be factored into the long-term morbidity and mortality rates of abdominal aortic aneurysm (AAA) repair. However, the true incidence may be underestimated because some patients do not return to the original surgical center when a problem arises. METHODS: To minimize referral bias and loss to follow-up, we studied all patients who underwent AAA repair between 1957 and 1990 in a geographically defined community where all AAA operations were performed and followed by a single surgical practice. All patients who remained alive were asked to have their aortic grafts imaged. RESULTS: Among 307 patients who underwent AAA repair, 29 patients (9.4%) had a graft-related complication. At a mean follow-up of 5.8 years (range, < 30 days to 36 years), the most common complication was anastomotic pseudoaneurysm (3.0%), followed by graft thrombosis (2.0%), graft-enteric erosion/fistula (1.6%), graft infection (1.3%), anastomotic hemorrhage (1.3%), colon ischemia (0.7%), and atheroembolism (0.3%). Complications were recognized within 30 days after surgery in eight patients (2.6%) and at late follow-up in 21 patients (6.8%). These complications were observed at a median follow-up of 6.1 years for anastomotic pseudoaneurysm, 4.3 years for graft-enteric erosion, and 0.15 years for graft infection. Kaplan-Meier 5- and 10-year survival free estimates were 98% and 96% for anastomotic pseudoaneurysm, 98% and 95% for combined graft-enteric erosion/infection, and 98% and 97% for graft thrombosis. CONCLUSIONS: This 36-year population-based study confirms that the vast majority of patients who undergo standard surgical repair of an abdominal aortic aneurysm remain free of any significant graft-related complication during their remaining lifetime.

Early results of endovascular aortic aneurysm surgery with aortouniiliac graft, contralateral iliac occlusion, and femorofemoral bypass.

PURPOSE: The aim of this study was to evaluate the feasibility of endovascular aortic aneurysm repair with use of an aortouniiliac graft secured with self-expanding (Gianturco) stents. METHODS: Thirty patients with a median age of 72 years (age range, 52 to 86 years) and aneurysm diameter of 6.0 cm (range, 4.0 to 9.0 cm) were treated with an aortouniiliac endovascular graft. Of these 30 procedures, 28 were carried out electively and two as emergencies for leaking aneurysm. Of the 30 patients, 21 (70%) were considered to be at high risk for open surgery. A modified Gianturco stent, Dacron graft, and Wallstent were used for these procedures. RESULTS: Endovascular repair was successfully carried out in 25 of 30 (83.3%) patients. All these patients were mobile and had resumed a normal diet within 48 hours of the procedure. The overall 30-day mortality rate was two in 30 (6.6%), but it was one in 28 (3.5%) for the elective cases; all deaths occurred in the group at high risk for surgery. Other complications encountered within 30 days of procedure included myocardial infarction in one patient, pneumonia in two patients, homonymous quadrantanopia in one patient, and colonic ischemia in one patient, giving an overall morbidity rate of four in 30 (13.3%). At a median follow-up of 4 months (range, 1 to 13 months), 27 of 30 (90%) patients remain alive and well. CONCLUSION: Endovascular aortouniiliac repair of abdominal aortic aneurysm with Gianturco stent is feasible in both elective and emergency situations. It appears to be minimally traumatic, and the majority of patients deemed to be at high risk for open surgery can safely undergo endovascular repair. However, data on more patients with longer follow-up is required to determine its role in the management of abdominal aortic aneurysm.

Survival and aortic events after graft replacement for thoracoabdominal aortic aneurysm.

Graft replacement remains the procedure of choice for patients with thoracoabdominal aortic aneurysm. Since there is little information regarding the long-term survival following these major vascular operations which may carry a risk of various late complications, a retrospective analysis of 10 years follow-up was undertaken. The results of 172 consecutive operations for thoracoabdominal aortic aneurysm were analysed retrospectively. Hospital mortality rate was 10.5%. Temporary postoperative haemodialysis was necessary in 10.4% of cases and paraplegia occurred in 8.2%. The mean (s.e.) overall cumulative 2-, 5- and 10-year observed survival rate was 76(3.4), 53(4.5) and 19(7)%, respectively while expected survival of a background population at 2, 5 and 10 years was 94%, 85% and 71%, respectively. Reoperation for an early (< 7 days) or late (> 7 days) aortic event was necessary in 31 patients. If performed electively, the hospital mortality rate for late aortic reoperation was only 7% but an emergency reoperation, hospital mortality rate was 100%.

Advances in the surgical repair of ruptured abdominal aortic aneurysms.

Over the past two decades, the mortality rate for elective repair of infrarenal abdominal aortic aneurysms has improved to an acceptable level (< 5%). However, surgical results of ruptured abdominal aortic aneurysms have remained fairly constant with about 50% in hospital mortality rates. Growing experience with the use of the left retroperitoneal exposure for elective aortic surgery allowed the authors to extend the use of this technique to the repair of ruptured abdominal aortic aneurysm. The extended left retroperitoneal approach using a posterolateral exposure through the 10th intercostal space allowed the surgeon expeditiously and reliably to obtain supraceliac aortic control by dividing the left crus of the diaphragm in all patients. In total, 104 aortic replacements were performed for ruptured abdominal aortic aneurysm during the past 7 years. Of these patients, 87 were men and 17 women; mean(range) age was 72(52-95) years. Hemodynamic instability (as defined by a systolic blood pressure of < 90 mmHg) was present before surgery in 41% (43/104) of patients. The operative mortality rate was 27.9% (29/104). Preoperative hemodynamic instability, time of operative delay and aortic cross-clamp time did not correlate with operative mortality. The median duration of intensive care unit stay was 4 (range 1-60) days and hospital stay 11 (range 6-175) days. The results of this series identified that a change in the operative technique for the repair of ruptured abdominal aortic aneurysm beneficially affected patient survival. The authors suggest that expeditious supraceliac control without thoracotomy is an excellent alternative and offers an advantage in the surgical management of ruptured abdominal aortic aneurysm.

Results of 1000 consecutive elective abdominal aortic aneurysm repairs.

In order to identify major risks for death and complications from elective repair of abdominal aortic aneurysm, the authors analyzed their experience with the last 1000 such repairs over a 15-year period. Of the patients, 772 were men and 228 were women; average age was 70 (range 37-92) years. Some 20% of the patients had severe chronic obstructive pulmonary disease and 33% had baseline creatinine level > 115 mumol/l. Fifteen patients were dialysis-dependent and 24% (242/1000) had significant cardiac disease. Operation used a retroperitoneal approach in 834 patients and a transperitoneal approach in 166. The perioperative mortality rate was 2.4%, but this did not change either chronologically or with technique: some 50% of the deaths were due to cardiac causes. Renal and pulmonary impairment did not affect mortality or complication; 64% of non-fatal complications were distributed in the renal (17%), pulmonary (19%) and cardiac groups (28%). The authors' experience showed that patients with cardiac disease remain at significant risk for post-abdominal aortic aneurysm repair complications in spite of selective preoperative cardiac evaluation. Renal and pulmonary risk factors did not cause additional mortality or morbidity. They suggest that elective abdominal aortic aneurysm repair can be performed with low mortality and morbidity, even in increasing numbers of high-risk patients.

Polytetrafluoroethylene grafts for carotid repair.

Polytetrafluoroethylene grafts are well established for bypassing occlusive disease in the lower limb but there are few reports which deal with the long-term results of such grafts in the neck. The present study was undertaken to evaluate the immediate and long-term results of polytetrafluoroethylene grafts for carotid repair. Between 1982 and 1991, 591 carotid operations (mostly endarterectomies) were performed by the authors. In 32 cases a polytetrafluoroethylene graft was used to replace (n = 12) or to bypass (n = 20) a stenotic lesion of the internal carotid artery. Postoperative angiography was obtained in all patients and the follow-up extended from 1 month to 9 years (mean 30 months) with clinical and duplex scan surveillance. There were no deaths within the first postoperative month. There was one acute postoperative stroke (3%) caused by plaque dislodgement and one symptomless occlusion demonstrated by routine angiography. During follow-up, seven patients died from other causes. No patient developed new neurological symptoms but routine duplex assessment showed one symptomless graft occlusion. The cumulative survival rate was 96% at 1 year and 91% at 4 years. The cumulative primary patency rate was 93% at 1 month, 89% at 1 year and 89% at 4 years. In specific situations polytetrafluoroethylene grafting is an adequate alternative to carotid endarterectomy but is not recommended by the authors as a routine procedure because of its occlusion rate (> 6.2%).

[The surgical treatment for acute aortic dissection and changing concept of surgical procedures].

The first prominent report on the surgical treatment for acute aortic dissection was published by DeBakey in 1975. Since then, many various techniques have been applied for the surgery on dissection at ascending aorta and aortic arch. The basic understanding for the surgical treatment are focused to the climination of intimal tear as well as resection and closure of dissecting lumen and restore the blood flow only to the true lumen. The associated complications such as acute dissection AR should also be repaired simultaneously. At the present, the graft replacement of ascending aorta has become first choice of procedure. No matter where the intimal tear is located, the simultaneous replacement of assending aorta and aortic arch has been proposed recently as the most radical approach toward Type A dissection, although this extended approach has to be carefully evaluated in the future.

[Result of surgery for aneurysms of distal aortic arch and proximal descending aorta].

We examined the surgical result for non-dissecting aneurysm of distal aortic arch and proximal descending aorta, for which aneurysm, proximal aortic clamp cannot be set at descending aorta because of the proximal progression of aneurysm. In 25 cases out of all 46 cases for 18 years, before 1990, aortic arch was clamped for proximal aortic control with the aid of temporary bypass, femoral artery-vein bypass or left heart bypass (clamp group). In 10 cases proximal aortic clamp was set between innominate and left common carotid artery and in 15 cases between left common carotid artery and left subclavian artery. In the former, temporary or permanent bypass was made to left common carotid artery. After 1990, in 21 cases, aortic arch was not clamped with the aid of separate cerebral perfusion (no clamp group). In the comparison of surgical result between two groups, no clamp group showed less postoperative complication rate in brain damage (28% vs 14%) and bleeding (16% vs 5%) and showed better operative mortality (20% vs 14%) and better hospital mortality (32% vs 19%). Now, in the surgery for non-dissecting aneurysm of diatal aortic arch and proximal descending aorta, it is preferable not to clamp aortic arc, employing separate cerebral perfusion.

The thrombosed prosthetic graft is a risk for infection of an adjacent graft.

BACKGROUND: A bland thrombosed graft may be more susceptible to the future risk of infection than a patent graft. Once infected, that graft can threaten other patent grafts. Therefore, the purpose of the following study was to assess the role a thrombosed graft might play in infection of contiguous patent bypasses. METHODS: From 1990, a retrospective review was performed using the operative and medical records of cases in which a prosthetic graft infection was identified arising in association with an adjacent thrombosed graft. RESULTS: A total of 22 cases of prosthetic arterial bypass infection were treated at our institution from January 1990 through September 1995. Of these, 7 (32%) were identified by the operative report as arising in a thrombosed prosthetic graft and spreading to an attached or adjacent patent prosthetic graft. All patients had multiple bypasses prior to infection, mean 5.4 +/- .75 (range 3 to 8). All thrombosed infected grafts were infrainguinal polytetrafluoroethylene (PTFE) for limb salvage: 6 femoralpopliteal and 1 femorotibial. Mean interval time between placement of the primarily infected graft and removal was 14.6 +/- 6.7 months (range 1 to 53). The secondarily infected patent bypasses were inflow procedures to the same limb in 6 cases: 1 aortofemoral, 2 ileofemoral, 2 axillofemoral, and 1 femoral femoral graft. The thrombosed infrainguinal bypass was directly attached to the secondarily infected bypass in 5 cases and near but not attached in 1 case. One secondarily infected prosthetic graft was a femoraldistal bypass placed adjacent to the thrombosed graft. Four patients had above-knee amputations with a clinically bland graft divided at the time of amputation. In these 4 patients and 2 additional cases, wet gangrene or infection was present in the distal extremity prior to the development of prosthetic graft infection. At the point that infection became clinically apparent, the thrombosed graft was removed in all cases and the secondarily infected graft was removed in 4 of 7 cases. Overall mortality was 57%. CONCLUSIONS: A thrombosed prosthetic graft near a patent prosthetic bypass may become secondarily infected and threaten the patent graft. We recommend total removal of any thrombosed prosthetic graft in proximity to a patent prosthetic bypass when the risk of infection is high or at the time of subsequent amputation for gangrene.

Management and outcome of infrapopliteal arterial graft infections with distal graft involvement.

PURPOSE: The purpose of this study was to determine the outcome of patients with infrapopliteal artery graft infections (InfraPopGIs) who presented with graft infection distal to the popliteal artery. PATIENTS AND METHODS: Between July 1, 1979 and June 30, 1994, 27 patients presented with infrapopliteal artery graft infections (18 polytetrafluoroethylene [PTFE], 9 autologous vein). The infection involved the anastomosis in 22 cases (8 anterior tibial, 8 posterior tibial, 4 peroneal, 2 dorsalis pedis arteries) and was localized to the body of the graft in 5 cases (4 calf, 1 ankle). All bypasses were originally performed for limb salvage. Twelve patients with patent grafts and intact anastomoses were managed by complete graft preservation. Fifteen patients presented with occluded grafts (10), anastomotic hemorrhage (4), or systemic sepsis (1) and were treated by total or subtotal graft excision. RESULTS: The hospital mortality rate was 19% (5 of 27) and the amputation rate in survivors was 27% (6 of 22). These results were compared with a mortality rate of 13% (15 of 114; P > 0.05) and a limb loss rate of 10% (10 of 99)(P = 0.05) in 114 patients during this period who presented with infection proximal to the tibial arteries. Of 6 survivors with graft infections who required amputations, 5 lacked a suitable outflow artery for a secondary bypass and 1 developed progressive gangrene despite a patent secondary bypass. Among the other 16 survivors, 7 (44%) limbs remained viable without requiring a secondary bypass, 6 (37%) limbs were salvaged with successful preservation of patent grafts, and 3 (19%) required secondary bypasses to prevent limb loss. CONCLUSIONS: Patients presenting with infrapopliteal artery graft infections have higher amputation rates than patients with more proximal infected peripheral grafts. Selective graft preservation and selective revascularization when outflow arteries are available are essential adjuncts to minimize high rates of limb loss associated in patients with graft infections.

Replacement of the ascending aorta with composite valve grafts: long term results.

BACKGROUND AND AIMS OF THE STUDY: Long term survival after replacement of the aortic root is improving. The most common cause of late death is progression of disease in the remaining aorta (dissection or atherosclerosis). The purpose of this study was to review our clinical experience with composite graft replacement of the aortic root with special reference to long term results. MATERIALS AND METHODS: One hundred twenty-six patients (mean age: 53 years) with different pathologies of the ascending aorta underwent aortic root replacement with a composite-graft prosthesis over a 12-year period. Twenty-three patients had previously undergone cardiovascular surgery. The surgical technique included resection of the ascending aorta with the aortic valve and end-to-side anastomosis between full-thickness buttons of the aortic wall with the coronary ostia and the graft. One or more associated cardiovascular procedures were performed in 24 cases. Long term follow up to July 1995 is complete. Uni- and multivariate analysis were performed to identify risk-factors for early and late mortality and reoperation. RESULTS: Twenty-three patients died during the first 30 days (18%). Sixteen of them had aortic dissection. The most common cause of early death was heart failure. Twenty-three patients died during the follow up time with heart failure, again, being the most common cause of death. Thirteen late reoperations on the composite-graft or the remaining aorta were performed in 12 patients, six of whom had Marfan's syndrome. The 30-day mortality at reoperation was 30%. CONCLUSIONS: This surgical option offers good long term results with a five-year actuarial survival of 67% or 75% when the 30-day mortality is excluded. Careful follow up of patients with Marfan's syndrome and/or aortic dissection is mandatory to increase the long term survival.

Endovascular stent-graft repair of thoracic aortic aneurysms.

Conventional repair of aneurysms of the descending thoracic aorta entails thoracotomy and graft interposition. For elderly patients and those with previous operations, obesity, respiratory insufficiency, or other comorbidities, such a procedure entails significant mortality and morbidity. Transluminal stent-graft placement offers an alternative approach with potentially less morbidity and quicker recovery; however, the effectiveness and durability of stent-grafts remain uncertain. METHODS: Since July 1992, thoracic aortic stent-grafts have been placed in 44 patients with a variety of pathologic conditions. Each graft was individually constructed from self- expanding, stainless-steel Z stents covered with a woven Dacron polyester fabric graft. Craft dimensions were determined from spiral computed tomographic scans. All implants were performed in the operating theater under fluoroscopic and transesophageal echocardiographic guidance. Follow-up was by computed tomography and contrast angiography in all cases. PATIENT DATA: There were 36 men and 8 women. Mean age was 66 years (range 35 to 88 years). Mean aneurysmal diameter was 6.3 cm (range 4.0 to 9.4 cm). Etiologies included 23 degenerative aneurysms, four posttraumatic aneurysms, four pseudoaneurysms, and one chronic aortic dissection. RESULTS: There were three early deaths (<30 days) and two late deaths. One early death resulted from graft failure. There were two instances of paraparesis or paraplegia, with one associated early death. A single stent was deployed in 27 patients, two stents were required in 14 patients, and three stents were required in three patients. In 23 patients, vascular access was attained through the femoral artery; abdominal aortic access, either native or graft, was necessary in the remaining 21 patients. Twelve grafts were placed in conjunction with open abdominal aortic surgical procedures. Mean follow-up (98% complete) was 12.6 months (range 1 to 34 months). One late death occurred from aneurysmal expansion and rupture in a patient with a persistent midgraft leak. The second late death may have resulted from aneurysmal rupture. Immediate thrombosis was achieved in 36 patients, and late thrombosis was achieved in three others. Failure to achieve complete aneurysmal thrombosis occurred in five patients, however, and one individual (previously noted) died of aneurysmal expansion and rupture; the remaining four are being carefully monitored. Only one patient has required conversion of the stent to an open procedure; a contained rupture of the false lumen of a chronic dissection eventually necessitated total descending thoracic aortic exclusion. CONCLUSIONS: These early results support the hypothesis that endovascular stent-graft placement may be a safe and durable treatment for selected patients with aneurysmal disease of the descending thoracic aorta. Large introducer size (26F outer diameter) and relatively limited angulation capability, as well as imprecise deployment techniques, currently limit its applicability. Distal embolization and stent migration have not been observed. Failure to achieve complete aneurysmal thrombosis may allow continued aneurysmal expansion and rupture. Further follow-up is clearly necessary to evaluate the true long-term effectiveness of this procedure.

[Surgical treatment of acute aortic dissections--a clinical study using a ringed intraluminal graft].

From 1984 to 1994, surgery was performed using a ringed intraluminal graft (RIG) in 75 patients with acute aortic dissection (DeBakey's type I in 37 cases, type II in 10 cases and type III in 28 cases). The operative death rate was 24% for type I, 30% for type II and 21% for type III. The average time from onset to surgery was short (47 +/- 67 hours for type I, 34 +/- 36 hours for type II and 47 +/- 77 hours for type III). The outcome of these cases indicated that this technique was effective for saving the lives of patients in the acute early stage of aortic dissection. No characteristic complications developed after this surgery. The postoperative course of patients was followed by using CT scans, MRI, angiography. No patients developed aneurysmal formation in the ligated area or dislocation of the RIG. There were no deaths directly attributable to the RIG. Patients who were autopsied in the late postoperative period showed no aneurysm of the ligated area or necrosis of the aortic wall. In conclusion, RIG surgery effectively saved the life of patients with acute aortic dissection and the RIG could be used as prosthetic graft for long-term periods.

[Immediate and long-term results of replacement of the ascending aorta in aneurysm or dissection]. / Résultats immédiats et éloignés du remplacement de l'aorte ascendante pour anévrysme ou dissection.

Between April 1974 and November 1992, 181 patients were operated for aneurysm (106) or dissection (75) of the ascending aorta. Eighty patients had replacement with a valvular conduit with reimplantation of the coronary arteries (Bentall procedure), 48 had aortic valve replacement with replacement of the supra-coronary ascending aorta and 53 underwent isolated replacement of the ascending aorta. Twenty-nine patients (16%) died in the postoperative period, mainly of myocardial or neurological complications. Univariate statistical analysis completed by logistic regression analysis revealed the following predictive factors of early death: NYHA Stage IV, angina, reoperation for haemorrhage or tamponade (all < 0.05). All surviving patients were followed up (total follow-up: 788 years; mean: 62 months; range: 1 to 181 months). There were 20 secondary deaths, 40% of which were related to complications of aortic valve replacement. The 5 and 9 year survivals were 76 and 70% respectively, perioperative mortality included, and 89% of patients were in NYHA functional Stage I. Analysis of survival data did not reveal any predictive factor of secondary death. Eight patients were reoperated at long-term. The operative mortality of replacement of the ascending aorta remains high, especially in cases of dissection. The long-term results seem excellent with a low reoperation rate. Late mortality seems mainly due to complications of aortic valve replacement.

Early and late survival after surgical treatment of culture-positive active endocarditis.

OBJECTIVE: To describe a 30-year experience with surgically treated culture-positive active endocarditis. DESIGN: We retrospectively reviewed the microbiologic, clinical, and operative findings and the survival data in 151 patients with culture-positive active endocarditis encountered between 1961 and 1991. RESULTS: The mean age of the 110 male and 41 female patients was 49.8 years. Native valve endocarditis was present in 86 patients, and prosthetic valve endocarditis (PVE) was diagnosed in 65. The aortic valve was involved in 62% of patients, the mitral valve in 25%, and both valves in 10%. The operative mortality was 26%. The most important univariate determinants of mortality were an abscess at operation (P = 0.01) and renal failure (P = 0.03). A trend toward a higher mortality with PVE and staphylococcal infection was noted. For hospital survivors, the 5- and 10-year survival was 71% and 60%, respectively. Univariate determinants of an adverse long-term survival were annular abscess (P = 0.01), renal impairment (P = 0.01), heart failure (P = 0.02), and aortic valve involvement (P = 0.05). On multivariate analysis, the most important adverse determinants of long-term survival were heart failure (P = 0.02), renal impairment (P = 0.02), and PVE (P = 0.03). Thirty patients required a subsequent reoperation; of these, seven required a second and two a third operation. The most common reason for reoperation was periprosthetic regurgitation without infection (N = 19). Four operations were performed for recurrent endocarditis. At 5 and 10 years, the risk of reoperation was 23% and 36%, respectively. CONCLUSION: Although surgical treatment of culture-positive active endocarditis is still associated with substantial mortality, the long-term outcome of hospital survivors is excellent. Subsequent reoperations for periprosthetic leak are common, but recurrent infection is uncommon.

Penetrating injuries of the axillary artery.

This is a retrospective study of 32 patients with penetrating injury of the axillary artery. There was an overall mortality of 6% entirely accounted for by associated injuries. Pre-operative angiography was used in 12 of these patients either to confirm the presence of an injury or to define its location. Twelve patients underwent lateral arteriorrhaphy or an end-to-end anastomosis and 19 patients had an interposition graft. No immediate problems were experienced with polytetrafluoroethylene grafts compared with autogenous vein grafts. There were 14 patients with a concomitant venous injury; 13 were repaired and only transient arm oedema was experienced. Eleven patients had a brachial plexus injury and, of these, nine underwent a secondary nerve repair with a poor outcome. Axillary artery injury has a good prognosis with a morbidity related mainly to associated nerve injury and a mortality accounted for by injuries to other body systems.

A comparative evaluation of externally supported polytetrafluoroethylene axillobifemoral and axillounifemoral bypass grafts.

PURPOSE: We analyzed a current 78-month experience with externally supported (ringed) polytetrafluoroethylene (PTFE) axillobifemoral (AxBF) and axillounifemoral (AxUF) bypass grafts to address the controversy about whether the addition of a femorofemoral limb to an axillofemoral bypass graft improves the patency results. METHODS: Between January 1988 and June 1994, 36 AxBF and 22 AxUF externally supported PTFE ringed bypass grafts were performed at our institution. The age of the patients in the AxBF group was 67 +/- 11 years and 69 +/- 11 years in the AxUF group. The male/female ratio was 22:13 (AxBF) and 8:9 (AxUF). In 71% of cases (29/36 AxBF, 12/22 AxUF), the operations were performed for aortoiliac atherosclerotic occlusive disease in patients with significant medical risk factors or a "hostile" abdomen. The remaining 29% were patients requiring revascularization during treatment of an infected aortic graft. Bypass patency was assessed in the follow-up period by clinical evaluation, color-flow duplex imaging, or segmental limb pressure measurements. RESULTS: There was no significant difference in the 30-day operative mortality rate for all AxBF bypasses (11%) and all AxUF bypasses (6%) (p = 0.89 by chi-squared testing). The primary and secondary patency rates for the whole group of bypasses were 80% and 89% at 3 years, respectively (SE < 0.1). Between the AxBF and AxUF groups, there were no significant differences in either primary patency (80% for each group) or secondary patency (91% in AxBFs vs 85% in AxUFs) (SE < 0.1) at 2 years (Wilcoxon rank sum test). CONCLUSIONS: These data show no differences in the patency of externally supported PTFE AxBF and AxUF bypass grafts up to 2 years after implantation.

Composite graft (Medtronic-Hall) replacement of the ascending aorta and aortic valve in aortic aneurysms: what is adequate follow-up?

Between 1987 and 1994, 39 patients underwent 41 replacements (2 reoperations) of the aortic valve and ascending aorta by composite grafts with mechanical valves. One patient had annuloaortic ectasia, one had a sinus of valsalva aneurysm, 13 patients had a Debakey type I acute dissection, 10 had a Debakey type II acute dissection including two Marfan patients, and 14 had atherosclerotic aneurysms. 6 patients (15%) died within a postoperative period of 30 days. The mean follow-up time was 40 months (1-82 months). Twenty-six patients were restudied by clinical examinations and computed tomography of the chest (CT). Two patients required emergency reoperation due to disruption of the proximal aortic anastomosis and right coronary anastomosis. Both patients had been diagnosed to have Marfan disease. Anastomotic dehiscence of composite grafts has a potentially high risk of lethal complications. In follow-up examination computed tomography was performed as a simple and accurate method to detect complications such as pseudoaneurysms, but up to now did not give the indications for reoperation. We suggest that complications may occur not only in the early postoperative period so that regular CT-scan control studies (every 6 to 12 months) should be performed in all patients who undergo composite graft replacement.