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This study assesses the patency of superficial femoral vein used as a crossover femoral artery bypass conduit in patients presenting either with localized groin sepsis, generalized sepsis or in patients with occluded or heavily diseased superficial femoral artery outflow. Twenty patients were followed prospectively with femoral crossover grafts constructed of superficial femoral vein. Twelve patients presented with sepsis and 8 with chronic ischemia from iliac artery occlusion and severely diseased superficial femoral artery outflow. Graft patency was assessed with regular duplex ultrasound examination. There was one perioperative death. Six patients died during the follow-up period. Mean follow-up time was 24.3 months. No graft occluded or required revision. There was no limb loss, graft infection, or graft hemorrhage. Superficial femoral vein offers an effective femoral crossover bypass graft in patients with either localized/generalized sepsis or disadvantaged outflow tracts.

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PURPOSE: To present the use of sartorius myoplasty (SM) and superficial femoral vein (SFV) in a graft-sparing approach to vascular graft infection. METHODS: Twenty-five patients were treated for Szilagyi grade III groin infections during the last 10 years. Fifteen presented early (E), mean 2 months; 10 late (L), mean 6.5 years. Bacteria E/L: Staphylococcus epidermidis 1/7, S aureus 6/0, other gram positive 1/0, gram negative 4/1, mixed 6/0 (one pseudomonas). There were 13 aortofemoral (AF), 5 crossover, and 7 femoral distal reconstructions. SM was used to cover exposed grafts after radical debridement. When the graft was free-floating or bleeding, this segment was removed and replaced with SFV. The remaining infection was controlled with antibiotics. RESULTS: One of 10 patients treated by SM alone required SFV replacement for bleeding. Four of 9 AFs treated by partial SFV replacement +/- SM had persistent infection treated by complete graft removal in 3. Six grafts were removed electively in lower risk situations. There was no perioperative mortality, and no early or late limb loss. CONCLUSIONS: This experience supports an attempt at aggressive local treatment in frail patients.

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BACKGROUND: Inadequate autogenous vein is often the limiting factor in femoral-distal reconstruction. Sequential grafts, distal arteriovenous fistulae (AVF), and autogenous cuffs have been recommended in this setting. This paper describes a new method of composite reconstruction, enhanced with a popliteal AVF. PATIENTS AND METHODS: Data was collected prospectively on 13 patients (14 limbs) who presented with severe ischemia (rest pain or ulcer 6, gangrene 8). The average age was 75 years. Eleven of the reconstructions were to tibial outflow tracts. The novelty of the technique is in the construction of a controlled AVF between the upper end of an autogenous vein graft and the popliteal vein. An uncomplicated autogenous anastomosis is created distally. The synthetic graft is placed between the common femoral artery and the vein graft distal to the AVF. The flow is balanced between the fistula and the outflow tract by narrowing the fistula while monitoring the pressure in the graft system. RESULTS: Patency was assessed by color duplex scan. Two grafts occluded (at 5 and 7 months) and 1 was revised at 12 months. Mean peak systolic velocity in the synthetic portion was 130 cm/s. Limb edema has not been a problem. There were 2 perioperative cardiac deaths. Mean follow up is 15 months (range 6 to 36). CONCLUSION: The addition of a controlled AVF below the synthetic portion of a composite graft appears promising when vein is in limited supply.

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PURPOSE: The purpose of this study was to present the use of superficial femoral vein (SFV) as an arterial bypass graft when ipsilateral saphenous vein is inadequate. METHODS: Data collected prospectively were reviewed on 24 patients (25 limbs) who had an arterial bypass with SFV performed by the authors between January 1, 1988, and December 31, 1991. Many anatomic sites are represented. The indication for operation was gangrene in six patients, severe rest pain or ulceration in 11, mild to moderate rest pain in six, and graft infection in two. There had been 42 previous reconstructions in these 25 limbs. RESULTS: There has been surprisingly little long-term disability from removal of the SFV. Immediately after surgery four limbs developed acute venous congestion that resolved quickly. Twenty percent of the patients with patent grafts have continued to wear a pressure gradient stocking for swelling 1 year after surgery, one patient requires additional pressure to control induration. All grafts were patent at 30 days. During a mean follow-up of 2 years, three grafts have required revision, and three have occluded. Stenosis did not develop at valve sites or in the body of the SFV portion of any of these grafts. There were two deaths from heart-related causes in the first 30 days after operation. Life-table analysis for the whole group shows a primary patency rate of 66% (SE 10.3%) and an assisted patency rate of 80% (SE 8.7%) at 2 years. CONCLUSIONS: SFV harvest is well tolerated, even in the absence of ipsilateral saphenous vein. The magnitude of the operation is greater than saphenous vein harvest but yields a thick-walled vein of excellent diameter with many applications as an autogenous conduit, particularly where a large-diameter graft is indicated.

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This report describes exploration of the proximal anterior tibial artery by extension of the standard below-knee approach to the popliteal artery. The anterior tibial artery is "poplitealized," giving excellent access to perform an anastomosis. The proximal medial approach depends on precise arteriography and is particularly suited to the in situ saphenous vein bypass and redo surgery. Advantages over previously described exposures include a shorter graft, ease of graft alignment, protection of the peroneal nerve, and the absence of a lateral counterincision. This exposure has been used on 12 of 14 anterior tibial grafts during the past 2 years.

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PURPOSE: This report describes surgical access to occluded vein grafts for thrombolysis by direct cutdown where indirect angiographic techniques have failed. METHOD: A sheath is introduced directly into the proximal vein graft. Distal thrombus is lysed following standard protocol. The residual thrombus at the origin of the graft is removed surgically, and the area is closed with a patch angioplasty. RESULTS: Distal thrombus was completely lysed in two vein grafts without bleeding complications. CONCLUSION: The thrombus "cork" that forms at the upper end of an occluded vein graft may deflect the angiographer's guide wire, but the distal thrombus usually remains soft and amenable to lysis. Angiographic access should not be a limiting factor in thrombolysis of an occluded vein graft.

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The long-term success of sartorius myoplasty in 14 of 16 patients who presented with an exposed vascular graft in an infected groin is described. The presenting complications were wound dehiscence (ten patients), hemorrhage (two), skin erosion (two), late bilateral fistulas (one) and false aneurysm (one). Ten grafts were prosthetic and six autogenous. Positive cultures were obtained from 15 wounds; four grew Staphylococcus epidermidis, the remainder mixed or Gram-negative bacteria. Each groin was radically debrided, including the surface of the arterial graft, and, if possible, closed immediately with a sartorius myoplasty applied directly to the graft. Twist, fan and loop myoplasties were equally effective. Grossly infected wounds were debrided initially and obviously infected grafts were replaced in situ before myoplasty. Sartorius myoplasty is recommended as an elegant solution for the infected groin in which there is an exposed arterial graft.

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The authors report their initial experience in 52 patients with three different techniques of peripheral artery atherectomy--the Tracwright (Kensey), used in 19 patients, the Simpson AtheroCath, used in 19 patients and the transluminal extraction catheter, used in 14 patients. The indications for atherectomy were claudication in 42 (80%) and limb-threatening ischemia in 10 (19%). There were no deaths. Complications included three arterial perforations, one thrombosis and one groin hematoma requiring operative evacuation. There were no distal embolizations. Atherectomy was initially unsuccessful in 15 (29%) patients. For the successfully completed procedures, the 1-year primary patency rates were as follows: Tracwright (Kensey) catheter 56%, Simpson catheter (63%) and transluminal extraction catheter (0%). Use of subsequent nonoperative procedures on recurrent stenoses produced secondary patency rates of 77% for the Tracwright (Kensey) technique, 80% for the Simpson catheter technique and 78% for the transluminal extraction catheter technique. The authors conclude that their early results justify further evaluation of these three techniques. Use of the transluminal extraction catheter is associated with higher rates of occlusion and restenosis.

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The aim of this study was to correlate the stated size of Dacron grafts (Microvel) with their actual internal diameter and to compare this with measurements by ultrasound in the early postoperative period. Grafts of stated diameters of 7, 8, 9, and 10 mm were studied. Grafts were measured by graded probes and by measuring the width of the longitudinally opened graft and calculating the diameter. Each graft accepted a probe 1 mm larger than its stated size very easily and 2 mm greater when stretched. By open measurement, the grafts were 1.3 to 1.8 mm greater than their stated diameter without stretching. Twenty grafts were studied by duplex ultrasound for diameter and peak systolic velocity within 3 months of implantation. The grafts were 12% larger than their stated graft size. Some of the larger grafts showed low velocity and wall thrombus. We conclude that Microvel grafts are larger than their stated diameter. The same size discrepancy was seen in in vitro measurements of Vascutek (Dacron) grafts but not in polytetrafluoroethylene (Gortex) grafts. Since flow velocity is related to the diameter of the graft, this information should be useful when choosing the diameter of a prosthetic vascular graft.

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Brachial vein has been overlooked as a conduit for arterial bypass. It can be harvested with very little morbidity. A deep incision placed on the medial aspect of the upper arm allows exposure of the brachial and basilic veins, giving access to vein of adequate length and diameter for many applications. The medical deep veins of the upper arm are usually our first alternative to ipsilateral saphenous vein for autogenous reconstruction. Because of inconsistent anatomy and nomenclature in this area, we refer to these veins as the "deep brachial vein complex".

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The aim of this prospective study was to evaluate the ability of duplex ultrasonography to identify infrainguinal grafts at high risk for failure. The criteria used identified low flow by low peak systolic velocity (less than 45 cm/s) and stenosis by high velocity (greater than 300 cm/s) or by velocity at the stenosis three times the velocity in the adjacent normal graft. A total of 114 patent grafts were scanned and compared with concurrent angiograms. Duplex scanning correctly identified 18 high-risk grafts by low-flow criteria and an additional 21 by stenosis criteria. There was one false-negative finding (sensitivity 98 percent). The velocity ratio of the stenosis to the adjacent graft was useful in estimating the degree of stenosis. Color flow duplex imaging reduced examination time through visual feedback by highlighting the graft and areas of high velocity. These results indicate that color flow duplex scanning, combining low- and high-peak systolic criteria, is a very sensitive screening test in the early detection of failing grafts.

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The authors analysed 267 consecutive primary aortofemoral grafts to identify the reasons for reoperation within the first 2 years postoperatively. Forty-one (8%) of the 521 limbs required a second operation. Precursors to reoperation were: occlusion of a superficial femoral artery (12%), gangrene (27%) and severe acute ischemia (35%). The rationale for reoperation was classified as technical 11, questionable selection (candidates for percutaneous transluminal angioplasty or inappropriate operation) 9, disease progress 11, residual symptoms 9, contralateral symptoms 1. The commonest technical problem was blind endarterectomy which preceded seven reoperations, five for thrombosis of the graft or a superficial femoral artery which was patent initially. Although 218 limbs had an occluded or severely stenosed superficial femoral artery, only 26 (12%) required reoperation within the first 2 years. The authors believe that the incidence of reoperation after aortofemoral bypass can be reduced by identifying the limbs at risk, by appropriate selection for percutaneous transluminal angioplasty, avoiding blind outflow endarterectomy and considering concomitant femoropopliteal bypass when gangrene is present.

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Horseshoe kidney is a rare abnormality that complicates aortic surgery. Three such cases are presented and the literature is reviewed. Although the diagnosis was not made preoperatively in any patient, all were managed safely. Two patients required preservation of abnormal renal arteries and one required division of the renal isthmus for exposure. Special attention is drawn to the need for lateral angiographic projections of this condition and to the intraoperative injection of indigo carmine dye to delineate the proper line of division of the renal isthmus.

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Eight patients were treated for complications arising from actual holes in prosthetic aortofemoral or aortoiliac grafts. All occurred more than 8 years after implantation. Presentations varied and included shock from a graft-to-enteric fistula, a rapidly expanding painful femoral aneurysm, an acutely ischemic limb, and rest pain. The whole graft is suspect and must be assessed by aortography, but graft deterioration can be localized, which simplifies management. In our patients, holes in the body of the graft or near the bifurcation were approached transabdominally. We replaced as much of the graft as was reasonable under the circumstances. Two of the four patients died. Five patients had graft holes in the inguinal region which we believe were related to tethering in that area. For this reason, we recommend cutting the inguinal ligament and prosthetic limbs no more than 8 mm in diameter. Partial retroperitoneal resection with external sleeve support has been a durable alternative to a complete redo operation in patients with degeneration isolated to the inguinal area.

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Tailoring treatment to the individual limb, by using flush ligation for the incompetent long saphenous vein and compression sclerotherapy for perforating veins and major control points, gives good control of venous disease. The long saphenous vein can be preserved in these circumstances. Compression sclerotherapy is easily repeated if necessary. Varicography and local ligation should be considered for large recurrences in the thigh where compression sclerotherapy is difficult. Compression sclerotherapy has replaced fasciotomy in my practice, and I strongly recommend this combined approach to surgeons interested in the treatment of venous disease.

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This report assesses patency, subsequent surgery, and the effect of late mortality in a series of 100 consecutive aortofemoral grafts performed for significant claudication on the basis of aortoiliac occlusive disease. Considering thrombosis or elective revision as failure, the primary patency rate at 5 and 10 years was 84 percent and 78 percent, respectively. However, most of these grafts were easily revised and remained patent for long periods, giving a secondary patency rate of 93 percent at 10 years. But survival is the critical factor in assessing what has really been accomplished for these patients. We believe that this is best expressed by cumulative actual palliation, that is, the patient alive, the graft patent, and the symptoms controlled without amputation. Cumulative actual palliation was approximately 75 percent at 5 years and 50 percent at 10 years. The palliation index (the proportion of living patients who were palliated) was more than 90 percent throughout the first 10 years. These data support the use of aortofemoral grafting in selected patients who suffer from intermittent claudication. Reporting the cumulative actual palliation, palliation index, and salvage index add precise and useful information to cumulative graft patency that disregards the effect of death.

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We are all collectors--collecting and organizing information being a very important part of medical practice. Viewing and collecting medical data are just the same as collecting stamps, and the personal computer has made it much easier for us. But we must get started, decide what to collect and how to display it. In vascular surgery, primary and secondary patency have been used to display results. In the author's opinion, the concept of actual palliation (a living patient with a patent graft) gives a much better reflection of what has actually been accomplished. In the "high-tech" future surgeons must know more about their collections than anyone else--or they will be directed by those who do. Let's accept the challenge now.

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