Jeffrey L. Kaufman

Is long vein bypass from groin to ankle a durable procedure? An analysis of a ten-year experience

Long vein bypass from the femoral artery to the level of the ankle may be performed with good initial success despite extreme bypass length and limited outflow tracts. However, the long-term performance of these bypasses remains to be defined. During the last 10 years we have performed single greater saphenous vein in situ bypass to the ankle level in 270 patients. There were 187 male and 83 female patients, and 61% of the patients were diabetic. The operative mortality rate was 3.7%. Cumulative bypass patency was 79% at 3 years and 73% at 5 years. In a similar manner, limb salvage was 93% at 3 years and 89% at 5 years. The patency rate was similar for various inflow arteries (common femoral, 88 cases; proximal superficial femoral, 135 cases; and deep femoral, 41 cases) and outflow tracts (dorsal pedal, 72 cases; anterior tibial, 59 cases; posterior tibial, 72 cases, and peroneal, 67 cases). Short bypasses, composite bypasses, free-vein grafts, and bypasses proximal to 10 cm above the ankle were excluded from this analysis. These data show that a long bypass to the ankle level for limb salvage is a durable procedure. The basic concept of bypassing all occlusive disease to the distal open artery in patients undergoing limb salvage should be an acceptable dictum. Excellent long-term patency and limb salvage rates are achievable by following this principle.

Treatment of abdominal aortic aneurysm by exclusion and bypass: An analysis of outcome

Abdominal aortic aneurysm is conventionally treated by aneurysmorrhaphy with inlying graft. Alternatively, division of the aorta, with suture closure of the distal aorta and outflow vessels (exclusion of the aneurysm), and end-to-end proximal to distal bypass may be performed. However, the long-term fate of this operation has not been determined. Specifically, concern exists that the excluded blood filled aneurysm may not thrombose or may be the source of late sepsis. During an 8-year period we have treated 280 abdominal aortic aneurysms (urgent and elective) by exclusion of the abdominal aortic aneurysm sac and bypass via the posterolateral retroperitoneal approach. Mean age was 70 years (range, 44 to 88), with 217 men and 63 women. Preoperative CT scanning and aortography were performed to assess arterial anatomy. Seventy tube grafts and 260 bifurcation grafts were used. Thirty-day mortality rate was 4%. Estimated blood loss was 731 +/- 52 ml; mean transfusion requirements were 456 +/- 82 ml. The minor complication rate was 6%, and it is of great interest that there were no cases of ischemic colitis requiring colectomy. Aneurysm sacs thrombosed except in two anticoagulated patients who required further treatment. No late infections occurred. Five-year bypass patency rate was 98%. These data demonstrate that this method of treatment effectively minimized operative dissection and blood loss and therefore is a viable alternative for the management of abdominal aortic aneurysms.

Hemodynamic characteristics of failing infrainguinal in situ vein bypass

The successful follow-up of distal arterial reconstructions for the identification of the failing bypass in the postoperative period hinges on a knowledge of the natural history of flow characteristics in these reconstructions. Over a 4-year period resting and hyperemic bypass flow, fistula flow, conduit diameter, and distal peak systolic velocity of 350 in situ bypasses were measured serially. B-mode ultrasound imaging of the entire bypass was performed to identify specific stenoses. Measurements were performed 5 to 9 days after operation, every 2 months for the first year, and every 6 months thereafter. Distal bypass flow less than 25 ml/min, a ratio of hyperemic/resting distal bypass flow less than 2.5, and vein size less than or equal to 3.0 mm inner diameter all correlated with bypass stenosis (greater than 50%) or occlusion (p less than 0.01). Contrary to previous studies, a distal peak systolic velocity of less than 45 cm/sec did not correlate with bypass stenosis or occlusion. A low distal peak systolic velocity did correlate with bypass stenosis or occlusion in bypasses larger than or equal to 3.5 mm inner diameter (p less than 0.03). However, no combination of these factors was able to accurately predict preocclusive stenosis or occlusion. Distal bypass flow was highest initially but reached a plateau 6 to 12 months after operation. Fistula flow, although very high initially, showed marked decrement with time.

Adventitial cystic disease of the femoral vein: A case report and review of the literature ☆

Painless edema of the left leg developed in a 65-year-old man without a history of venous disease, and he was found to have a mass compressing the lumen of the left common femoral vein. The intramural cyst was drained through transvenous exposure and found to contain mucoid material. This is the seventh case of adventitial cystic disease of a vein in the world literature. Analogous to adventitial cystic disease of arteries, it is defined by venography, CT scanning, and duplex ultrasonography. Surgical drainage is the treatment of choice.

Can the retroperitoneal approach be used for ruptured abdominal aortic aneurysms

The retroperitoneal approach for elective treatment of abdominal aortic aneurysms is an accepted alternative to midline transperitoneal approaches and may provide less physiologic insult and a smoother postoperative course. In recent years we have preferentially used the extended retroperitoneal approach for ruptured abdominal aortic aneurysms to derive similar physiologic benefits for these patients. Over a 6-year period (1983 to 1989) 76 cases of ruptured abdominal aortic aneurysms were treated by emergency aortic replacement. After exclusion of 13 patients whose aneurysmal ruptures were unusual, such as aortoenteric fistula, aortocaval fistula, chronic contained rupture, or visceral involvement, 63 patients were retrospectively studied. Thirty-eight patients were treated via a standard transperitoneal celiotomy and 25 via a left retroperitoneal incision. No significant differences were found between the two groups in regard to cardiac or pulmonary function or duration of preoperative hypotension. Operative mortality was lower in the retroperitoneal group (three of 25, 12%) as compared to the transperitoneal group (13 of 38, 34.2%). Furthermore, the retroperitoneal group required less ventilatory support and tolerated enteral feedings quickly. Length of stay in the hospital was also significantly reduced in the retroperitoneal group. These data indicate that many ruptured abdominal aortic aneurysms can be successfully treated through the left retroperitoneal approach. In this nonrandomized clinical series increased survival rates and shorter periods of postoperative recovery were noted in the patients operated with the retroperitoneal approach.

An animal model for instructing and the study of in situ arterial bypass

A canine model that used the cephalic vein to bypass from the brachial to the ulnar artery was designed for use in instructing and evaluating surgical technique needed for constructing an in situ arterial bypass. This model was used for instructing vascular residents in the in situ vein bypass technique. The use of this model enabled the resident to become more adept with the instruments for valve incision and construction of small vessel anastomosis. The improvement in the residents operative technique was reflected by a decrease in the number of technical complications (missed valves, missed arteriovenous fistulas, poorly constructed anastomoses) and improved patency rate.

Acute Arterial Insufficiency of the Male Genitalia

Three patients developed severe ischemia of the penis or scrotum from acute arterial occlusion. In one case, nonhealing ulceration of the glans developed after atheroembolism to the dorsal penile artery. One patient had penile ischemia after ligation of pelvic and femoral collateral circulation during repair of an aorto-bilateral-iliac artery aneurysm. A third patient had ischemia of the penis and scrotum from thromboembolism to the iliac arteries during repair of an aortoenteric fistula. Only seven patients have been described with acute arterial occlusion and severe ischemia of the male genitalia. A rare phenomenon because of rich collateral circulation, acute ischemia of the genitalia nevertheless must be recognized as a sign of severe vascular disease and a consequence of major arterial ligation or occlusion in the pelvis and groins.

The Role of Extraanatomic Exclusion Bypass in the Treatment of Disseminated Atheroembolism Syndrome

We treated six patients with disseminated atheroembolism complicated by severe and unremitting pain from bilateral foot lesions. All patients had multiple and severe medical risk factors. One patient had a recent myocardial infarction, six patients had renal failure, and three were undergoing hemodialysis. Definitive aortic reconstruction was therefore precluded. After failing a course of medical therapy, each patient was treated with axillobifemoral bypass with exclusion-ligation of the external iliac arteries. Healing of foot wounds occurred in 11 of 12 limbs at risk, with one below-knee amputation required for progressive forefoot necrosis. In 12 patients with severe cardiopulmonary disease and limited life expectancy, exclusion-ligation bypass is an effective and safe palliative procedure for severe disseminated atheroembolism.

Local Anesthesia for Surgery on the Foot: Efficacy in the Ischemic or Diabetic Extremity

The efficacy, risks, and benefits of the use of local anesthesia for surgery on the foot were assessed in 75 patients who underwent 127 procedures with lower calf, ankle, metatarsal-ray, and digital blocks. There were 23 procedures on digits alone, 97 forefoot operations (transmetatarsal amputations, wound debridements, closures, osteotomies, joint resections), six ankle or hind-foot amputations, and one open ankle disarticulation. There were no complications directly related to the use of local anesthesia; specifically, no extension of preexisting infection or ischemia due to injection in the foot. There were three deaths (30-day mortality 4%). The procedures were uniformly well tolerated, even in patients with ongoing myocardial ischemia or severe metabolic disorders. Local anesthesia is a safe and effective method to perform local debridement or amputation of the foot in an ischemic or diabetic extremity.

Flow/velocity characteristics of arterial bypass stenoses

In the carotid system with relatively constant blood flow, peak systolic velocity within a stenosis (PSVST) can characterize the degree of hemodynamic stenosis. We have studied flow/velocity characteristics in an in vitro model of stenosis within conduits of varying diameters in an attempt to quantify the degree of stenosis from flow/velocity profiles in peripheral vein bypasses. A Harvard pulsatile flow pump (70 BPM) pumped human blood (HCT, 35-45%) through thin-walled polytetrafluoroethylene (3-6 mm in i.d.) into a variable peripheral resistance maintaining a constant mean blood pressure of 80 mm Hg over a flow range of 0-500 ml/min. A Diasonics DRF400 duplex scanner with a 10-MHz imager and 4.5-MHz Doppler probe was used to image and Doppler the conduits and measure flow through them. Validation of Doppler flow measurements (DF) was performed comparing them with flow measured (MF) by timed collection. PSVST within and pressure drop across a 50% stenosis was measured for each of the conduits sizes over a range of 0-500 ml/min MF. The results show a good correlation between DF and MF (r = 0.99, P less than 0.001) for the whole range of internal diameters. In each 50% stenosed conduit, PSVST correlated well with MF (r = 0.95, P less than 0.001). Curves were constructed of MF vs PSVST for each 50% stenosed conduit. We conclude that measurement of volumetric flow, conduit diameter, and peak systolic velocity within a vein bypass can objectively predict bypass stenoses of 50% or greater.