Barry Sussman

A decade of experience with the glutaraldehyde-tanned human umbilical cord vein graft for revascularization of the lower limb

Between October 1975 and November 1985, 907 lower limb bypasses were constructed in 715 patients (799 limbs) with glutaraldehyde-stabilized umbilical veins (UV-G) used as the predominant, or sole, graft material. Each reconstruction was classified in one of eight categories depending on the site of the distal anastomosis: above- and below-knee popliteal, anterior and posterior tibial, peroneal, trifurcation, sequential, and crural (tibial or peroneal) bypasses with adjunctive distal arteriovenous fistulas. Primary and secondary cumulative graft patency rates were determined for each category as well as cumulative actual palliation that combines end points of graft failure, amputation, and death. Half-life patencies for popliteal, tibial, and peroneal bypasses were 6.5, 2.3, and 1.7 years, respectively. Perioperative graft thrombosis occurred in 11% of popliteal reconstructions compared with 22% for the crural group. Nonocclusive graft failure caused by infection, aneurysm, or progressive foot gangrene occurred in 87 grafts (8%). The overall infection rate was 4.3%. Anastomotic aneurysms (1.4%) and strictures (2.1%) occurred infrequently as isolated phenomena. The incidence of graft dilatation and aneurysms assumed significant proportion after 5 years (36% aneurysms and 21% dilation); the diagnosis was particularly facilitated by B-mode imaging. Nevertheless, the overall clinical impact of graft degradation remained minimal (6% after 5 years). Twenty-two of 26 graft aneurysms were excised with successful graft replacement achieved in 10. During this 10-year period, our attitudes did change with regard to the indication for UV-Gs in relation to the maturation of infrapopliteal reconstructive surgery, appreciation of the superior results attainable with in situ saphenous vein, recognition of morphologic changes in long-term UV-G implants, and the growing documentation of poor results with polytetrafluorethylene in the crural position. We believe that UV-G is an acceptable alternative to the absent or deficient autologous vein, particularly in patients with limited life expectancy and where expediency may be a critical factor.

The Stapled Gastrointestinal Tract Anastomosis: Incidence of Postoperative Complications Compared with the Sutured Anastomosis

Performance of gastrointestinal anastomosis by means of surgical stapling devices has achieved popularity in the last decade even though no detailed study has been reported comparing complications following the stapled anastomosis with those following hand sutured procedures performed by the same surgeons. We have reviewed 812 operative procedures on the gastrointestinal tract performed in one hospital over a four year period. Stapled anastomoses were performed in 472 with 13 (2.8%) complications related to the anastomosis; in 296 sutured anastomoses there were nine (3.0%) related complications. Comparison did not disclose any significant difference in the number of complications in these two groups. In 44 instances wherein the anastomosis contained both staples and sutures, there were no related complications. Further analysis of the patients in each group disclosed that stapling procedures were utilized in a much higher percentage of those operations which were performed under emergency conditions or in the presence of intra-abdominal sepsis, intestinal obstruction, and carcinomatosis. If the technical details of surgical stapling are mastered, this technique appears to be as safe as suturing in the performance of anastomoses in the gastrointestinal tract.

Laparoscopic management of acute small-bowel obstruction.

AbstractBackground: A retrospective review is given of the authors’ experience with a consecutive series of acute small-bowel obstruction unresponsive to medical management. Methods: There were 33 exploratory laparoscopies. The etiology was accurately diagnosed in 100% of the cases. Twenty-five (76%) were secondary to postoperative adhesions, of which 18 (72%) were successfully treated by laparoscopic lysis of adhesions. Minilaparotomy was needed to treat iatrogenic perforation (two), gangrenous bowel (one), and Meckel’s diverticulectomy (one). Formal laparotomy was utilized for small-bowel resection (two), malignant adhesions (two), and intolerance of pneumoperitoneum (one). Four cases of incarcerated hernias were treated by conventional herniorrhaphy. Results: Overall, 67% of our cases were spared formal laparotomy. Conclusion: We conclude that laparoscopy is an excellent diagnostic modality in acute small-bowel obstruction, the majority of which can be simultaneously managed laparoscopically. Laparotomy should be reserved for malignant adhesions, surgical misadventure, or when the pathology dictates.

Biodegradation and aneurysm formation in umbilical vein grafts. Observations and a realistic strategy.

In a series of 756 glutaraldehyde-stabilized umbilical vein grafts implanted over a 7 1/2-year period, aneurysms were identified in seven cases. The earliest aneurysm was seen at 31 months after implantation and the remainder between 43 and 79 months after surgery. Corrective surgery was performed in five cases and succeeded in four. Although definite mechanisms have not been identified, mechanical fatigue, reversal of aldehyde crosslinks, and immunologic factors may be operative. The pathologic changes include: (1) actual dilation of both graft and mesh with or without intraluminal thrombus and, (2) maintenance of graft diameter with erosion of the umbilical vein and polyester mesh rupture leading to perigraft hematoma and false aneurysm formation. Microscopic examination and infrared spectral analysis confirmed the presence of host-contributed lipid in some specimens. Although this is a low incidence of aneurysm formation, umbilical vein grafts should be selected primarily for patients with limited life expectancy or for whom alternative materials with comparable or superior patency rates are not available or acceptable. Periodic angiography, particularly after 3 or 4 years, is recommended as a routine part of follow-up examinations. Improved graft materials and control of host environmental factors are potential means to reduce the noted degradation.

Adventitial cystic disease of the popliteal artery: Failure of percutaneous transluminal angioplasty as a therapeutic modality

Adventitial cystic disease of the popliteal artery is an important cause of peripheral vascular insufficiency in the young and middle-aged man. The pathologic feature is a mucinous cyst located within the adventitia of the artery that expands and secondarily compromises the vessel lumen. Although physiologically quite different, this process is easily mistaken for arteriosclerosis. The clinical history of sudden claudication in a young nonsmoking man, combined with characteristic angiographic features, are important clues to the correct underlying pathology. Treatment generally consists of cyst evacuation or local bypass. This article was prompted by the failure of percutaneous transluminal angioplasty to achieve durable success in controlling this unique type of arterial disease. Subsequent surgical intervention proved satisfactory, lending support to this modality as the treatment of choice.

Adjunctive arteriovenous fistula with tibial and peroneal reconstruction for limb salvage

Arteriovenous fistulas were constructed as an adjunct to femoral peroneal and tibial bypasses in 13 patients threatened by imminent limb amputation. Previous attempts at conventional vascular reconstructive procedures had failed in nine patients. Deficient or absent pedal arches were noted in all patients, as were poor quality or small crural arteries. Graft patency was achieved in 11 cases and limb salvage in 10. There was no mortality. A steal phenomenon occurred in one patient and was successfully treated by secondary popliteal vein ligation. These preliminary results clearly indicate that an adjunctive arteriovenous fistula can maintain patency in a femoral tibial or peroneal bypass graft while preserving flow into the markedly diseased distal circulation.

Transmetatarsal amputation: The role of adjunctive revascularization

Over a 12-year period, 160 transmetatarsal amputations were performed in patients with peripheral vascular occlusive disease. The following groups were defined: group 1 - nonreconstructable disease (n = 40); group 2 - transmetatarsal amputation in conjunction with distal revascularization (n = 99); group 3 - reconstructable disease but transmetatarsal amputation performed without simultaneous revascularization (n = 21). There were nine early deaths in the entire series, for an operative mortality rate of 5.6%. The lowest rate of transmetatarsal amputation healing (24%) occurred in group 1. An 86% healing rate was achieved in group 3, but in seven cases (33%) some type of revascularization was required within 3 months of the amputation. In group 2 the healing rate was 62% but reached 83% where the bypass remained patent for at least 3 months after the amputation. Long-term patency rates also affected healing. Healing was not influenced by the number of local procedures (single vs multiple). The presence of severe infection or extensive necrosis necessitated open transmetatarsal amputation in 89 cases; the remaining 71 amputations involved primary closure. Since many patients were treated at a time when diagnostic modalities as well as the operative indications and techniques differed somewhat from the current practice, much of the information regarding group I patients in particular should be considered as a negative historical control and any conclusion from our data should be adjusted accordingly. Healing after amputation at the transmetatarsal level can be expected in the majority of instances in which revascularization can be performed with predictable patency, even when the standard criteria for performing such amputations are liberalized.(ABSTRACT TRUNCATED AT 250 WORDS)

Glutaraldehyde-stabilized umbilical vein prosthesis for revascularization of the legs: Three year results by life table analysis

Abstract Three hundred sixty-one vascular reconstructions for salvage of the leg were performed from 1975 to 1978 employing glutaraldehyde-stabilized umbilical veins. These included 183 bypasses to the popliteal segment, 108 to either of the tibial arteries and 70 to the peroneal artery. One hundred forty-one (77 per cent) of the popliteal reconstructions were below the knee. Operative mortality rates were 2.7,2.8, and 4.3 per cent for popliteal, tibial, and peroneal reconstructions, respectively. The cumulative patency rates at 36 months for each of the three types of reconstructions were 76.4 (popliteal), 63.4 (tibial), and 39.8 per cent (peroneal). The latter figure was statistically insignificant because of the small number of patients between 24 and 36 months. The cumulative patency rate for peroneal reconstructions at 2 years was 55.7 ± 6.2 per cent. Failures were usually due to inappropriate case selection or progressive disease, particularly in the distal circulation. Two grafts were removed because of wound infection and secondary graft infection. There were no instances of aneurysm formation or myointimal proliferation in the graft. These data support the continued use of the glutaraldehyde-stabilized umbilical vein as a suitable alternative to the autologous saphenous vein. The graft provides a reliable material for reconstruction of the leg that is nonantigenic, mechanically equivalent to normal vascular structures, and biocompatible as determined by physical and chemical modalities. The durability of these grafts is based on the thromboresistance of the flow surface and the cross-links established by aldehyde processing. In appropriately selected cases and with expert surgical technique, long-term graft function with limb salvage can be obtained.

Everted cervical vein for carotid patch angioplasty

Because of the theoretic benefits of autologous vein we undertook an investigation to evaluate cervical veins (facial, external jugular) as patch material after carotid endarterectomy. A device that stimulated both circumferential fixation by sutures and radial tension exerted on in vivo patches was constructed to measure burst strength of tissue. Mean bursting pressure for groin saphenous vein (n = 10) was 94.5 +/- 15.1 pounds per square inch (psi), 75.5 +/- 8.9 psi for ankle saphenous vein (n = 10), 83.3 +/- 14.5 psi for everted (double layer) cervical vein (n = 5) and 10 +/- 3.3 psi for single layer cervical vein (n = 5). No significant differences between saphenous vein at any level and everted (double layer) cervical vein, but all were significantly different from single layer cervical vein (p less than 0.05). From June 1987 through November 1989, 19 patients underwent 21 carotid endarterectomies complemented with adjunctive everted cervical vein patch angioplasty. Indications for surgery were asymptomatic stenosis (53%), transient ischemic attack (29%), and cerebrovascular accident with recovery (18%). All patients were studied after surgery with duplex scanning. Asymptomatic recurrent stenosis was observed in one patient. Transient hypoglossal nerve dysfunction occurred in one other patient. One postoperative death occurred as a result of massive aspiration. These results indicate that everted cervical vein is comparable to the saphenous vein in resistance to bursting and can yield similar results as patch material after carotid endarterectomy. Accordingly, saphenous vein can be spared and lower extremity incisions avoided.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical experience with everted cervical vein as patch material after carotid endarterectomy

PURPOSE The aim of this study was to evaluate the clinical efficacy of everted cervical veins used as patches after carotid endarterectomy. METHODS A prospective nonrandomized comparative analysis was performed on patients with either everted cervical veins or saphenous veins as patches after carotid endarterectomy. Two hundred ninety-six patients underwent 329 carotid endarterectomies during an 8 1/2-year period (1987 to 1995). Saphenous vein patches were used in 125 (38%) cases and everted cervical veins in 167 (51%). These two groups were compared clinically and by sonographic surveillance. The mean follow-up of patients in this study was 27 +/- 11 months. RESULTS No significant differences were noted regarding postoperative morbid events between the everted cervical and saphenous vein patch groups. Even at 5 years the percentage of patients without stroke for both groups exceeded 95%. Duplex surveillance studies also showed comparable percentages of recurrent moderate (50% to 69%) and severe (70% to 99%) stenosis, 5.6% and 6.9%, respectively, for everted cervical vein and 5.4% and 6.5%, respectively, for saphenous vein. Cumulative recurrent stenosis-free rates at 5 and 6 years exceeded 82% for each of the patch study groups. CONCLUSIONS Based on the results of this study everted cervical veins are useful adjuncts to carotid endarterectomy, when patch angioplasty is necessary or desirable. Their performance is comparable to that of saphenous veins. Cervical veins are usually available, even when the saphenous vein is absent or inadequate. In addition, good saphenous veins can be spared and lower extremity excisions avoided.