Above-knee polytetrafluoroethylene femoropopliteal bypass graft: Is it a reasonable alternative to the below-knee reversed autogenous vein graft?

To determine whether an above-knee polytetrafluoroethylene (AK-PTFE) femoropopliteal bypass graft might be an acceptable alternative to a below-knee reversed autogenous saphenous vein (BK-ASV) bypass graft, we compared 51 AK-PTFE grafts to 39 concurrently performed BK-ASV grafts. All patients were staged by preoperative noninvasive vascular laboratory criteria into limiting claudication or limb salvage groups and by intraoperative arteriography according to degree of runoff. There was no significant difference in the primary graft patency at 36 months between the AK-PTFE group (63%) and the BK-ASV group (72%). Secondary graft patency among the AK-PTFE group was improved by minor distal graft revision to 88% at 36 months. The preoperative noninvasive hemodynamic evaluation status was an influential factor; the graft patency rate among the patients with limiting claudication was superior to that among the limb salvage group, but the degree of runoff as shown by intraoperative angiography did not appear to have an effect on cumulative patency. Resting Doppler ankle/brachial artery pressure ratios did not predict subsequent occlusion of AK-PTFE grafts. Atherosclerosis is a progressive and systemic disease that frequently involves both the coronary and tibial vessels. AK-PTFE spares autogenous saphenous vein so that it can be reserved for use in coronary artery bypass or in subsequent treatment of more distal tibial vessel disease.

The costs of surgery for limb-threatening ischemia.

The clinical courses of 106 patients with limb-threatening ischemia were traced for as long as 5 years to determine the cost of their care. Seventy-eight patients initially treated with vascular reconstruction accrued an average of $40,769 +/- $3726 in costs over a mean follow-up period of 805 +/- 57 days, during which they had an average of 2.4 +/- 0.2 hospitalizations or 67 +/- 6 inpatient days. Twenty-eight high-risk patients treated with primary amputation accrued $40,563 +/- $4729 in costs over a mean follow-up period of 663 +/- 97 days, during which they had an average of 2.2 +/- 0.3 hospitalizations or 85 +/- 10 inpatient days. Successful revascularization resulted in lower costs ($28,374) than did primary amputation ($40,563) or failed reconstruction ($56,809). Patients with ischemic tissue loss accrued costs more rapidly than did patients with rest pain only. The high cost of providing care for these patients and the advent of diagnosis related group reimbursement mandate that proposed treatment protocols be evaluated not only for their effectiveness but also for their cost-effectiveness.

The economic impact of acute variceal bleeding: cost-effectiveness implications for medical and surgical therapy.

The hospital costs and its respective components for 32 patients with acute variceal bleeding were determined. The average total cost for treating the 32 patients was $35,000. The cost for those patients who underwent elective surgery ($53,000) was approximately twofold that of the elective medical group. Nutritional and metabolic rehabilitation that prolonged hospitalization, reutilization of the intensive care unit, and perioperative blood requirements were the significant factors that increased the cost of treating the surgically treated patients. Derivation of the cost/benefit ratio, however, showed that the decreased rehospitalization rate of the surgically treated group and the apparent better "quality of life" almost offset the increased initial hospital costs for this group.

Emergency and urgent operations for ulcerative colitis. The procedure of choice.

Eighty consecutive emergency and urgent colectomies for ulcerative colitis were performed. One-stage total proctocolectomy was performed in 37 patients, with a 9.1% mortality; ileostomy with subtotal colectomy was performed in 43, with a 7.0% mortality. The overall mortality was 7.5%. Postoperative morbidity after total proctocolectomy (mean postoperative hospitalization, 27.6 days; nonseptic complication rate, 29.4%; septic complication rate, 29.4%) was not substantially different from that after subtotal colectomy (postoperative hospitalization, 33.3 days; nonseptic complications, 45.0%; septic complications, 35.0%). Survivors of subtotal colectomy required abdominal-perineal resection of the colorectal remnant in 75.7% of patients, and no patient had successful subsequent ileorectal anastomosis. It is suggested that one-stage total proctocolectomy be adopted as the surgical procedure of choice in emergency or urgent operations for ulcerative colitis.

Subclavian artery insufficiency. Treatment with axilloaxillary bypass.

Twenty patients underwent axilloaxillary bypass at Tufts-New England Medical Center, Boston, between 1973 and 1983, all for tight stenosis or occlusion of the subclavian artery. Review of records was possible for 19 cases. Symptoms included intermittent claudication and numbness of the upper extremity, as well as dizziness, vertigo, and ataxia due to episodes of vertebrobasilar insufficiency. Dacron, reversed saphenous vein, and polytetrafluoroethylene grafts were inserted, with all but one occupying a subcutaneous tunnel across the sternum. There were no operative deaths, and morbidity was minimal. The median follow-up was 83 months. The early patency rate was 94%, with a cumulative patency rate of 89% at ten years of follow-up, as determined by the life-table method. Our experience supports axilloaxillary bypass as a safe and effective treatment for symptomatic subclavian artery insufficiency.

Positive blood culture as an aid in the diagnosis of secondary aortoenteric fistula.

The successful management of aortoenteric fistula (AEF) requires early diagnosis. To evaluate the accuracy of our diagnostic approach, the hospital course of seven patients with AEF was reviewed. In six patients, the initial bleeding episodes were of the low volume type characterized by hematemesis and melena or by melena alone. All patients were febrile. In six patients, blood cultures obtained preoperatively were positive for enteric organisms identical to those found in cultures obtained intraoperatively from the AEF site. Roentgenographic examination of the upper gastrointestinal (GI) tract performed in three patients was diagnostic for AEF in only one. Endoscopy in seven patients revealed a bleeding suture line in one. Angiography was not diagnostic in the six patients in whom it was performed. When patients are seen with the triad of GI bleeding, a history of aortic surgery, and fever, aerobic and anaerobic blood cultures should be obtained. If blood cultures are positive for enteric organisms, the diagnosis of AEF should be strongly suspected, and early surgical intervention is indicated.

Transcatheter thromboembolectomy of acute renal artery occlusion.

Direct surgery of the renal artery has been performed for the relief of acute thrombotic or embolic occlusion of the renal artery to restore adequate renal perfusion and prevent irreversible renal failure. Occasionally, severe medical disease may increase surgical risk to a prohibitive level. An angiographic technique has been devised to provide an alternative approach and has been successfully used on five occluded renal arteries in four patients, with measurable benefit.

Intraoperative prereconstruction arteriography.

Intraoperative arteriography was performed in 57 patients undergoing arterial reconstructive surgery of the lower extremity prior to selection of the site for the distal anastomosis. In 42 patients (74%), this procedure proved to be of significant benefit. Prereconstructive intraoperative arteriography influenced surgery for seven patients in the following ways: (1) two patients had visualization of vessels not demonstrated on the preoperative arteriogram; and (2) five patients had demonstration of occlusive disease that favored selection of a more distal site of anastomosis. In the remaining 35 patients, the tibial vessels and arch were visualized more clearly, so that the degree and extent of disease were better appreciated. This may have important prognostic significance. On postreconstructive arteriography, an additional five patients were shown to have an anastomotic defect that was corrected in the operating room. Intraoperative arteriography is a rapid, safe, and simple procedure that should be considered as an adjunct in reconstructive surgery of the lower extremity.

Management of variceal hemorrhage: results of a standardized protocol using vasopressin and transhepatic embolization.

We reviewed the courses of 40 patients with variceal bleeding treated with a standardized protocol, including intravenous (IV) vasopressin (Pitressin) and transhepatic embolization. Twelve of the 32 patients with acute episodes of massive variceal bleeding responded to the administration of IV vasopressin alone. Of the 20 patients who did not respond to vasopressin therapy, emergency transhepatic portography with embolization produced cessation of bleeding in ten (50%). The remaining ten patients who failed to respond to either IV vasopressin therapy or transhepatic embolization died, regardless of whether they were treated with aggressive medical therapy or emergency portosystemic shunt. Transhepatic embolization in both the emergent and elective situation demonstrated a thrombotic complication rate of 20%, which limited or precluded eventual therapy with elective portosystemic shunt. Because of this relatively high incidence of occult portal thromboses after transhepatic embolization, transhepatic portography should be obtained routinely prior to elective portosystemic shunts in those patients who have a history of transhepatic embolization.

Below-knee amputation: is the effort to preserve the knee joint justified?

The records of 50 patients (31 men and 19 women, ranging in age from 49 to 89 years) undergoing definitive below-knee amputation for ischemia from May 1971 to May 1979 were reviewed. Forty-three (86%) had ulceration or necrosis involving the foot or toes. Seven had rest pain without tissue loss. Overall healing rate was 86%. Seven patients (14%) failed to heal and required reamputation above the knee; the functional status of the remaining 43 patients was graded preoperatively and at the time of late follow-up (mean, 3.4 years). Twenty-five of 35 (71%) unilateral below-knee amputees could walk with a prosthesis; ten could not. Seventeen patients (34%) either required an additional, higher amputation or did not use the knee joint to increase mobility. The patient with marginal circulation and marked preoperative functional limitations may have the above-knee level as the chosen site for amputation.

Prophylactic interruption of the inferior vena cava: immediate and long-term hemodynamic effects.

Two hundred patients were evaluated retrospectively to determine the clinical effects of prophylactic inferior vena cava (IVC) interruption in association with aortic reconstruction. No pulmonary embolism occurred in the group with IVC interruption, but embolisms did occur in seven of 68 patients who had aortic reconstruction performed without IVC interruption. In two patients, the pulmonary embolism was fatal. Postoperative incidence of deep vein thrombosis was fatal. Postoperative incidence of deep vein thrombosis was 9% in both groups. Clinical and hemodynamic effects of prophylactic IVC interruption were studied in 20 additional patients. Venous hemodynamics (maximum venous outflow, inferior vena cava pressure, and ambulatory venous pressure) showed no change following interruption in 19/20. Sixteen patients from the original group of patients with prophylactic interruption were studied hemodyamically. No pulmonary embolism was clinically evident. One new case of deep vein thrombosis was seen. Again, venous hemodynamics showed no change as a result of IVC interruption. Prophylactic IVC interruption is a safe means of decreasing the incidence of pulmonary embolism without increasing venous-related morbidity.

Fate of the retained rectum after subtotal colectomy for inflammatory disease of the colon.

Of forty-nine consecutive patients who underwent subtotal colectomy for inflammatory disease of the colon, 73.5 per cent required subsequent combined abdominoperineal resection of the retained rectum and only two patients had successful ileoproctostomy. For the patient whose rectum is substantially diseased along with the rest of the colon, one-stage total proctocolectomy is the preferred operation.

Improvements in the diagnosis and management of aortoenteric fistula.

To assess the impact of an aggressive approach (early operation, graft removal, and extraanatomic bypass) adopted by us 5 years ago in patients with aortic synthetic grafts and gastrointestinal bleeding, we reviewed our 15 year experience with aortoenteric fistula in 13 patients. The courses of six patients from the recent series (1979 through 1984) were contrasted with those of seven patients from our earlier series (1968 through 1978). Twelve of 13 patients presented with gastrointestinal bleeding (usually low volume), and no patient presented in shock. Six of seven patients in Series I (earlier series) had positive blood cultures, whereas only two of six in Series II (recent series) had this finding. Of the 13 patients, 10 underwent preoperative endoscopy. It was only with consistent visualization of third and fourth portions of the duodenum that a diagnosis of aortoenteric fistula was established (three of four patients 75 percent). Although the upper gastrointestinal series was abnormal more frequently (five of seven patients, 71 percent) than arteriograms (three of nine patients, 33 percent), the latter was more specific for a predisposing lesion. At surgery, nine (70 percent) patients had an anastomotic fistula and four (30 percent), a false aneurysm. Although only one of seven patients in Series I survived (14 percent), four of six patients in Series II were alive at last follow-up in September 1984 (67 percent). Early diagnosis followed by prompt operation with removal of the synthetic graft and extraanatomic bypass is associated with an improved survival for patients with aortoenteric fistula, but the degree of preoperative sepsis as indicated by positive blood cultures appears to be an important prognostic sign.

Infrarenal aortic occlusion: a reassessment of surgical indications.

Citing a high incidence of proximal propagation of aortic thrombosis, several authors have advocated aortic reconstruction for all patients with infrarenal aortic occlusion irrespective of their preoperative symptoms and potential operative risks. To test this thesis, the records and follow-up data of 38 patients seen at our institution between 1965 and 1982 with infrarenal aortic occlusion were analyzed. Twenty-four of the 38 patients were treated surgically (Group I); 16 (42 percent) had an aortobifemoral graft and 8 (21 percent) had an axillofemoral bypass graft. When the 14 patients who did not have surgery (Group II) and the 8 patients who had an axillofemoral graft were combined, 22 patients (58 percent) did not have aortic reconstruction (Group III), thus the aortic thrombus was left in situ. There was no significant difference in cumulative survival between the three groups at 4 year follow-up. Of 13 patients in Group III who were followed for more than 6 months (mean 48 months), none died from proximal propagation of aortic thrombosis. The decision for surgical intervention in patients with distal aortic occlusion should be arrived at, as in other patients with aortoiliac occlusive disease, by weighing preoperative symptoms and operative risks and not primarily by the level of risk of proximal propagation of thrombosis.

Management of combined segment disease.

Eighty-five of 148 inflow procedures were performed for combined segment disease. Our study shows that aortofemoral bypass is clinically and functionally superior to axillofemoral bypass in limbs with combined segment disease and hemodynamic criteria for limb salvage. The results of these two procedures are comparable for claudicant limbs. A derivative of segmental plethysmography, the predictive index, can select preoperatively those limbs that will fail to respond to aortofemoral bypass alone. Finally, either in limbs selected for aortofemoral bypass with both ischemic tissue lesions and a predictive index greater than 0.2 or in limbs selected for axillofemoral bypass with ischemic tissue lesions alone, a synchronous procedure can be performed with relatively low morbidity and excellent early functional results.