Infrainguinal revascularisation in the era of vein-graft surveillance--do clinical factors influence long-term outcome?
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)
Disruption of skin perfusion following longitudinal groin incision for infrainguinal bypass surgery.
OBJECTIVE: The objective of our study was to investigate whether such an incision results in a reduction in blood flow, and therefore haemoglobin oxygen saturation, across the wound. DESIGN: Microvascular oxygenation was measured with lightguide spectrophotometry in 21 patients undergoing femoropopliteal or femorodistal bypass procedures. A series of measurements were made in the groin, medial and lateral to the surface marking of the femoral artery. The mean oxygen saturation on each side was calculated, and the contra-lateral groin was used as a control. The measurements were repeated at 2 and 7 days postop. RESULTS: Oxygen saturation in the skin of the operated groins was increased significantly from baseline at 2 days postop (f = 25.80, p < 0.001) and had begun to return to normal by day 7. The rise was more marked on the lateral side of the wound than on the medial (f = 12.32, p < 0.001). There was no such difference in the control groins. All wounds healed at 10 days. CONCLUSIONS: These results show a significant difference in skin oxygenation between the lateral and medial sides of the groin following longitudinal incision. This may contribute to the relatively high incidence of postoperative infection in these wounds. (+info)
The iliopubic tract: an important anatomical landmark in surgery.
A band of fascial thickening, termed the iliopubic tract, lies on the posterior aspect of the inguinal region and has been described in the surgical literature as playing an important role during herniorraphy. This study was undertaken to examine the gross and microscopic anatomy of the iliopubic tract in 12 cadavers. The results confirmed that the iliopubic tract can be readily identified as a thickening of the transversalis fascia running deep and parallel to the inguinal ligament. It attaches to the superomedial part of the pubic bone medially, but laterally its fibres fan out within the fascia transversalis and fascia iliaca without bony attachment to the iliac spines. In contrast to the inguinal ligament, the histological analysis of the iliopubic tract shows a high elastin to collagen ratio. The functional significance of this structure merits further study, but there is no doubt that it is important in many approaches to inguinal herniorraphy. For this reason it is considered that the iliopubic tract deserves greater emphasis in the anatomy teaching of the inguinal region. (+info)
Women have increased risk of perioperative myocardial infarction and higher long-term mortality rates after lower extremity arterial bypass grafting.
PURPOSE: The purpose of this study was to determine the effect of gender on the immediate and long-term postoperative morbidity, mortality, and patency rates for infrainguinal autogenous vein bypass grafts. METHODS: Data were abstracted for consecutive patients who were followed in a prospective surveillance protocol after undergoing infrainguinal autogenous vein bypass grafting during the years 1988 to 1994. There were 165 grafts constructed in 148 patients (101 in 87 men, and 64 in 61 women). Gender differences were analyzed with Student t test or chi2 test for risk factors, indications for reconstruction, and complications. The patency rates and the long-term survival rates were compared by means of life-table analysis. Eagle criteria and long-term survival rates were compared with multivariate analysis. RESULTS: The mean follow-up period was 36 months (39 months for men, and 32 months for women), with a range of 6 to 123 months for the total follow-up period. The two groups did not differ in age at the time of operation (66.6 +/- 1.2 years for men, and 66.7 +/- 1.5 years for women) or in history of diabetes (48% for men, and 56% for women). The risks were similar for hypertension (48% for men vs 45% women), preoperative myocardial infarction (23% for men vs 26% for women), and previous coronary artery bypass grafting (9% for men vs 8% for women). The thallium stress scintigraphy results showed a diagnosis of proportionately more preoperative defects in men (reversible, 34% vs 18%, P <.05; overall, 75% vs 43%, P <.05). The 30-day limb loss rates (0.9% for men, and 0% for women) and mortality rates (2.2% for men, and 5% for women) were similar. Women had statistically more perioperative myocardial infarctions than did men (6 of 61, 9.8% vs 2 of 101, 2%; P <.05), as was documented with electrocardiography and cardiac isoenzymes. Two of these women died within a 30-day postoperative period. The 3-year primary patency rate was 85% for the men and 88% for the women, and the primary assisted patency rate was 97% for the men and 97% for the women. The secondary patency rate was 98% for the men and 97% for the women. The limb salvage rate was slightly higher for the men than for the women (93% vs 87%), although this was not statistically significant. The 5-year survival rate for women was statistically less than for men, with life-table analysis (58% for men vs 42% for women; P <.05). CONCLUSION: After distal bypass grafting, men and women have similar rates of patency and limb salvage, but women have a higher incidence rate of perioperative myocardial infarction and a decreased 5-year survival rate. These data suggest that women have unrecognized cardiac disease that affects them adversely in the perioperative period and the long term when compared with men who undergo the same operation. (+info)
Quality of life after infrainguinal bypass grafting surgery. Dutch Bypass Oral Anticoagulants or Aspirin (BOA) Study Group.
PURPOSE: The purpose of this study was to compare quality of life in patients with and without various ischemic complications after infrainguinal bypass grafting surgery for occlusive vascular disease. METHODS: A sample of patients (n = 746) randomized in the Dutch BOA study (n = 2645), a multicenter trial that compared the effectiveness of oral anticoagulant therapy with aspirin in the prevention of infrainguinal bypass graft occlusions, was entered in this study. On the basis of clinical outcomes of the trial, the patients were grouped as follows: patients with patent grafts (n = 409); patients with nontreated graft occlusions, subdivided into an asymptomatic group (n = 32) and a symptomatic group (n = 65); patients with subsequent revascularizations (n = 194); patients with amputations (n = 36); and patients with failed secondary revascularizations followed by secondary amputation (n = 38). In case an outcome event occurred, the patients were regrouped accordingly. Every half year, the patients completed a Short Form-36 and a EuroQol questionnaire. A multilevel model was used for repeated measure analysis. RESULTS: The mean follow-up time was 21 months. The quality of life in patients with nontreated asymptomatic occlusions was roughly similar to the quality of life in patients with patent grafts. Patients with symptomatic nontreated occlusions had the lowest outcome with regard to pain as compared with the other groups. Furthermore, physical and social functioning was lower for these patients than for patients with patent grafts. Revascularizations, successful or not, negatively affected pain, social functioning, and physical and emotional role. After successful revascularization, some improvement was observed in pain, physical and social functioning, and general and mental health as compared with the group with nontreated symptomatic occlusions. Amputation deteriorated physical functioning strikingly, especially after failed secondary revascularization. These patients also had the lowest scores of all the groups in the dimensions of social functioning, physical and emotional role, and mental health. EuroQol score showed deterioration of quality of life after all events, except for asymptomatic occlusions. The same patterns emerged if we stratified our analysis according to the indication for the initial operation: claudication or limb salvage. Quality of life was constant over time in all the groups in the observed period. CONCLUSION: Quality of life in patients with asymptomatic occluded grafts is similar to quality of life in patients with patent grafts. Revascularization of symptomatic occluded grafts improves quality of life to a certain extent. Amputation, in particular after failed secondary revascularization, seemed to be the lowest possible outcome. The results of the Short Form-36 and EuroQol measurements were in line with the clinical expectations. The association of disease severity with scores on the instruments supports the construct validity of these outcome measures for an objective assessment of quality of life in controlled studies. (+info)
Sentinel node biopsy in early vulvar cancer.
Lymph node pathologic status is the most important prognostic factor in vulvar cancer; however, complete inguinofemoral node dissection is associated with significant morbidity. Lymphoscintigraphy associated with gamma-probe guided surgery reliably detects sentinel nodes in melanoma and breast cancer patients. This study evaluates the feasibility of the surgical identification of sentinel groin nodes using lymphoscintigraphy and a gamma-detecting probe in patients with early vulvar cancer. Technetium-99m-labelled colloid human albumin was administered perilesionally in 37 patients with invasive epidermoid vulvar cancer (T1-T2) and lymphoscintigraphy performed the day before surgery. An intraoperative gamma-detecting probe was used to identify sentinel nodes during surgery. A complete inguinofemoral node dissection was then performed. Sentinel nodes were submitted separately to pathologic evaluation. A total of 55 groins were dissected in 37 patients. Localization of the SN was successful in all cases. Eight cases had positive nodes: in all the sentinel node was positive; the sentinel node was the only positive node in five cases. Twenty-nine patients showed negative sentinel nodes: all of them were negative for lymph node metastases. Lymphoscintigraphy and sentinel-node biopsy under gamma-detecting probe guidance proved to be an easy and reliable method for the detection of sentinel node in early vulvar cancer. This technique may represent a true advance in the direction of less aggressive treatments in patients with vulvar cancer. (+info)
Up-regulation of beta-chemokines and down-modulation of CCR5 co-receptors inhibit simian immunodeficiency virus transmission in non-human primates.
A non-cognate mechanism of protection against human immunodeficiency virus-1 (HIV-1) infection involves up-regulation of beta-chemokines, which bind and may down-modulate the CCR5 co-receptors, thereby preventing transmission of M-tropic HIV-1. The objective of this investigation was to evaluate this mechanism in vivo in non-human primates. Rhesus macaques were immunized by a modified targeted lymph nodes (TLN) route with recombinant simian immunodeficiency virus (SIV) glycoprotein 120 (gp120) and p27 in alum, and adsorbed recombinant granulocyte-macrophage colony-stimulating factor (GM-CSF) with either interleukin (IL)-2 or IL-4. Immunization induced significant increases in the concentrations of CD8 cell-derived suppressor factor (CD8-SF), regulated on activation normal T cells expressed and secreted (RANTES), macrophage inflammatory protein (MIP)-1alpha and MIP-1beta, and down-modulation of the proportion of cells expressing CCR5 (r = 0.737, P<0.05). The macaques were then challenged with SIVmac 220 by the rectal mucosal route. The plasma SIVmac RNA showed a significant inverse correlation with the CD8-SF or the concentration of the three beta-chemokines (r = 0.831 and 0.824, P<0.01), but a positive correlation between the proportion of CCR5+ cells and SIVmac RNA (r = 0.613, P = 0.05). These results demonstrate for the first time in vivo that immunization up-regulates beta-chemokines, which may down-modulate CCR5 co-receptors, and both functions are significantly correlated with the viral load. Hence, the non-cognate beta-chemokine-CCR5 mechanism should be considered as complementary to specific immunity in vaccination against HIV. (+info)
High prevalence of iliofemoral venous thrombosis with severe groin infection among injecting drug users in North East Scotland: successful use of low molecular weight heparin with antibiotics.
Injecting drug use, mainly of heroin, currently represents a major public health issue in the North East of Scotland. The recent tendency of the committed injecting drug user to inject into the groin has created novel problems for the Infection Unit. Data are presented on 20 consecutive patients admitted between 1994 and 1999 with iliofemoral venous thromboses, often complicated by severe soft tissue infections and bacteraemia as a result of heroin injection into the femoral vein. Nine had coexistent groin abscesses, four had severe streptococcal soft tissue infection of the right thigh, groin and lower abdomen, and two had coincidental soft tissue infections of the upper limb. Nine were bacteraemic on admission. All of the patients were chronic injecting drug users with a median injection duration of 6.5 years. The 18 patients tested for hepatitis C virus were all seropositive. None of the 14 patients tested was positive for HIV. Seventeen patients were treated with subcutaneous low molecular weight heparin (tinzaparin), three having received intravenous unfractionated heparin initially. The tinzaparin was self administered and given for a median duration of seven weeks. One patient declined to have any treatment. Three months after presentation eight patients were asymptomatic, seven had a persistently swollen leg, and five were lost to follow up. None developed clinically apparent pulmonary embolism after institution of anticoagulant therapy. The management of iliofemoral venous thrombosis in injection drug users is problematic because of poor venous access, non-compliance with prescribed treatment, ongoing injecting behaviour, and coexistent sepsis. It is unlikely that a randomised trial of standard treatment with heparin and warfarin versus low molecular weight heparin alone would be practical in this patient group. These retrospective data indicate that the use of tinzaparin in injecting drug users is feasible and appears to result in satisfactory clinical responses. The possibility of concomitant infection in injecting drug users with venous thrombosis should always be addressed, as it appears to be a common phenomenon. Early drainage of abscesses and antimicrobial chemotherapy, often administered intramuscularly or orally because of lack of peripheral venous access, is central to the appropriate care of these patients. (+info)