Infrainguinal revascularisation in the era of vein-graft surveillance--do clinical factors influence long-term outcome?
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OBJECTIVES: To investigate the variables affecting the long-term outcome of infrainguinal vein bypass grafts that have undergone postoperative surveillance. DESIGN: A retrospective analysis. PATIENTS AND METHODS: Details of 299 consecutive infrainguinal vein grafts performed in 275 patients from a single university hospital were collected and analysed. All grafts underwent postoperative duplex surveillance. Factors affecting patency, limb salvage and survival rates were examined. These factors were gender, diabetes, hypertension, aspirin, warfarin, ischaemic heart disease, run-off, graft type, early thrombectomy, level of anastomoses and indication for surgery. RESULTS: The 6-year primary, primary assisted and secondary patency rates were 23, 47, and 57%, respectively. Six-year limb salvage and patient survival were 68 and 45%, respectively. Primary patency was adversely influenced by the use of composite vein grafts. Early thrombectomy was the only factor that significantly influenced secondary patency. Limb salvage was worse in diabetic limbs, limbs with poor run-off and in grafts that required early thrombectomy. Postoperative survival was better in males, claudicants and in patients who took aspirin. CONCLUSIONS: Although co-morbid factors did not influence graft patency rates, diabetes did adversely effect limb salvage. This study, like others before it, confirms that aspirin significantly reduces long-term mortality in patients undergoing infrainguinal revascularisation. (+info)
Isolated femoropopliteal bypass graft for limb salvage after failed tibial reconstruction: a viable alternative to amputation.
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PURPOSE: Femoropopliteal bypass grafting procedures performed to isolated popliteal arteries after failure of a previous tibial reconstruction were studied. The results were compared with those of a study of primary isolated femoropopliteal bypass grafts (IFPBs). METHODS: IFPBs were only constructed if the uninvolved or patent popliteal segment measured at least 7 cm in length and had at least one major collateral supplying the calf. When IFPB was performed for ischemic lesions, these lesions were usually limited to the digits or small portions of the foot. Forty-seven polytetrafluoroethylene grafts and three autogenous reversed saphenous vein grafts were used. RESULTS: Ankle brachial pressure index (ABI) increased after bypass grafting by a mean of 0.46. Three-year primary life table patency and limb-salvage rates for primary IFPBs were 73% and 86%, respectively. All eight IFPBs performed after failed tibial bypass grafts remained patent for 2 to 44 months, with patients having viable, healed feet. CONCLUSION: In the presence of a suitable popliteal artery and limited tissue necrosis, IFPB can have acceptable patency and limb-salvage rates, even when a polytetrafluoroethylene graft is used. Secondary IFPB can be used to achieve limb salvage after failed tibial bypass grafting. (+info)
Superficial femoral eversion endarterectomy combined with a vein segment as a composite artery-vein bypass graft for infrainguinal arterial reconstruction.
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OBJECTIVE: The purpose of this study was to determine the results of composite artery-vein bypass grafting for infrainguinal arterial reconstruction. METHODS: This study was designed as a retrospective case series in two tertiary referral centers. Forty-eight of 51 patients underwent the procedure of interest for the treatment of ischemic skin lesions (n = 42), rest pain (n = 3), disabling claudication (n = 1), and infected prosthesis (n = 2). The intervention used was infrainguinal composite artery-vein bypass grafting to popliteal (n = 18) and infrapopliteal (n = 30) arteries, with an occluded segment of the superficial femoral artery prepared with eversion endarterectomy and an autogenous vein conduit harvested from greater saphenous veins (n = 43), arm veins (n = 3), and lesser saphenous veins (n = 2). The main outcome measures, primary graft patency rates, foot salvage rates, and patient survival rates, were described by means of the life-table method for a mean follow-up time of 15.5 months. RESULTS: The cumulative loss during the follow-up period was 6% and 24% at 6 and 12 months, respectively. The primary graft patency rates, the foot salvage rates, and the patient survival rates for patients with popliteal grafts were 60.0% +/- 9.07%, 75.7% +/- 9.18%, and 93.5% +/- 6.03%, respectively, at 1 month; 53.7% +/- 11.85%, 68.9% +/- 12.47%, and 85. 0% +/- 9.92% at 1 year; and 46.7% +/- 18.19%, 68.9% +/- 20.54%, and 53.1% +/- 17.15% at 5 years. For infrapopliteal grafts, the corresponding estimates were 72.4% +/- 7.06%, 72.9% +/- 6.99%, and 92.7% +/- 4.79% at 1 month; 55.6% +/- 10.70%, 55.4% +/- 10.07%, and 77.9% +/- 9.02% at 1 year; and 33.6% +/- 22.36%, 55.4% +/- 30.20%, and 20.8% +/- 9.89% at 5 years. CONCLUSION: The composite artery-vein bypass graft is a useful autogenous alternative for infrainguinal arterial reconstruction when a vein of the required quality is not available or when the procedure needs to be confined to the affected limb. (+info)
The value of late computed tomographic scanning in identification of vascular abnormalities after abdominal aortic aneurysm repair.
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PURPOSE: The purpose of this study was to determine the prevalence of late arterial abnormalities after aortic aneurysm repair and thus to suggest a routine for postoperative radiologic follow-up examination and to establish reference criteria for endovascular repair. METHODS: Computed tomographic (CT) scan follow-up examination was obtained at 8 to 9 years after abdominal aortic aneurysm (AAA) repair on a cohort of patients enrolled in the Canadian Aneurysm Study. The original registry consisted of 680 patients who underwent repair of nonruptured AAA. When the request for CT scan follow-up examination was sent in 1994, 251 patients were alive and potentially available for CT scan follow-up examination and 94 patients agreed to undergo abdominal and thoracic CT scanning procedures. Each scan was interpreted independently by two vascular radiologists. RESULTS: For analysis, the aorta was divided into five defined segments and an aneurysm was defined as a more than 50% enlargement from the expected normal value as defined in the reporting standards for aneurysms. With this strict definition, 64.9% of patients had aneurysmal dilatation and the abnormality was considered as a possible indication for surgical repair in 13.8%. Of the 39 patients who underwent initial repair with a tube graft, 12 (30.8%) were found to have an iliac aneurysm and six of these aneurysms (15.4%) were of possible surgical significance. Graft dilatation was observed from the time of operation (median graft size of 18 mm) to a median size of 22 mm as measured by means of CT scanning at follow-up examination. Fluid or thrombus was seen around the graft in 28% of the cases, and bowel was believed to be intimately associated with the graft in 7%. CONCLUSION: Late follow-up CT scans after AAA repair often show vascular abnormalities. Most of these abnormalities are not clinically significant, but, in 13.8% of patients, the thoracic or abdominal aortic segment was aneurysmal and, in 15.4% of patients who underwent tube graft placement, one of the iliac arteries was significantly abnormal to warrant consideration for surgical repair. On the basis of these findings, a routine CT follow-up examination after 5 years is recommended. This study provides a population-based study for comparison with the results of endovascular repair. (+info)
Right atrial bypass grafting for central venous obstruction associated with dialysis access: another treatment option.
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PURPOSE: Central venous obstruction is a common problem in patients with chronic renal failure who undergo maintenance hemodialysis. We studied the use of right atrial bypass grafting in nine cases of central venous obstruction associated with upper extremity venous hypertension. To better understand the options for managing this condition, we discuss the roles of surgery and percutaneous transluminal angioplasty with stent placement. METHODS: All patients had previously undergone placement of bilateral temporary subclavian vein dialysis catheters. Severe arm swelling, graft thrombosis, or graft malfunction developed because of central venous stenosis or obstruction in the absence of alternative access sites. A large-diameter (10 to 16 mm) externally reinforced polytetrafluoroethylene (GoreTex) graft was used to bypass the obstructed vein and was anastomosed to the right atrial appendage. This technique was used to bypass six lesions in the subclavian vein, two lesions at the innominate vein/superior vena caval junction, and one lesion in the distal axillary vein. RESULTS: All patients except one had significant resolution of symptoms without operative mortality. Bypass grafts remained patent, allowing the arteriovenous grafts to provide functional access for 1.5 to 52 months (mean, 15.4 months) after surgery. CONCLUSION: Because no mortality directly resulted from the procedure and the morbidity rate was acceptable, this bypass grafting technique was adequate in maintaining the dialysis access needed by these patients. Because of the magnitude of the procedure, we recommend it only for the occasional patient in whom all other access sites are exhausted and in whom percutaneous dilation and/or stenting has failed. (+info)
Infrarenal endoluminal bifurcated stent graft infected with Listeria monocytogenes.
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Prosthetic graft infection as a result of Listeria monocytogenes is an extremely rare event that recently occurred in a 77-year-old man who underwent endoluminal stent grafting for infrarenal abdominal aortic aneurysm. The infected aortic endoluminal prosthesis was removed by means of en bloc resection of the aneurysm and contained endograft with in situ aortoiliac reconstruction. At the 10-month follow-up examination, the patient was well and had no signs of infection. (+info)
Endovascular stent graft repair of aortopulmonary fistula.
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Two patients who had aortopulmonary fistula of postoperative origin with hemoptysis underwent successful repair by means of an endovascular stent graft procedure. One patient had undergone repeated thoracotomies two times, and the other one time to repair anastomotic aneurysms of the descending aorta after surgery for Takayasu's arteritis. A self-expanding stainless steel stent covered with a Dacron graft was inserted into the lesion through the external iliac or femoral artery. The patients recovered well, with no signs of infection or recurrent hemoptysis 8 months after the procedure. Endovascular stent grafting may be a therapeutic option for treating patients with aortopulmonary fistula. (+info)
Frame dislocation of body middle rings in endovascular stent tube grafts.
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OBJECTIVES: To understand the cause, and propose a mechanism for frame dislocation in endovascular grafts. MATERIALS AND METHODS: Five tube grafts were explanted due to secondary distal leakage 15-21 months after operation. One bifurcated graft was removed during emergency operation after aortic rupture caused by secondary leakage. A second bifurcated graft was harvested from a patient with thrombotic occlusion of one limb, who died after transurethral prostatic resection. The inside of the grafts were examined endoscopically. The stent was inspected after removal of the fabric, broken ligatures were counted and examined by scanning electron microscopy. The fabric strength was tested by probe puncture. RESULTS: We found 17-44% of the stent ligatures of the body middle rings to be loose. The knots were intact. Degradation of the polyester textile was not observed. CONCLUSIONS: Continuous movements in the grafted aorta and blood pressure impose permanent stress to the stent frame and the polyester fabric resulting in morphological changes in the body middle ring of grafts. The clinical implications of the suture breakages are unknown although they may be related to distal secondary leakage in tube grafts. (+info)