Mark Kahn

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.

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.

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)

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.

Current status of duplex Doppler ultrasound in the examination of the abdominal vasculature

Duplex Doppler ultrasound has come to play a central role in the diagnosis of a broad spectrum of vascular diseases such as carotid artery occlusive disease and deep vein thrombosis. The role of duplex Doppler in the evaluation of intra-abdominal vascular disease remains unclear. This article summarizes the current status of duplex scanning in the investigation of the mesenteric arteries, the renal arteries, and the portal venous system. The examination is technically demanding, operator-dependent, time-consuming, and frequently unsatisfactory due to bowel gas, obesity, complex anatomy, or postoperative alterations in the normal anatomic patterns. Its advantages reside primarily in the absence of toxicity and in the generation of physiologic as well as anatomic information. In centers with the proper instrumentation and a skilled technician, duplex examination can be useful in the diagnosis and management of abdominal vascular disease and avoids the inherent dangers of contrast angiography.

Clostridial mycotic aneurysm of the thoracoabdominal aorta : A case report

Clostridial infection of the aorta is a rare and life-threatening condition. The management of a mycotic aneurysm involving the thoracoabdominal aorta due to Clostridium septicum infection is presented. Successful surgical management of the aortic infection involved arterial resection, wide debridement of the surrounding tissues, and in situ graft replacement. Sixteen additional cases of clostridial infection of the aortoiliac segment reported in the literature are also summarized. In ten of these 17 cases, an associated colonic adenocarcinoma was documented.

Primary and adjunctive intra-arterial digital subtraction arteriography of the lower extremities

Standard contrast arteriography (SCA) and intra-arterial digital subtraction arteriography (DSA) were performed during a 26-month period in 459 cases. The DSA group consisted of 22 aortoiliac studies, 66 crural-pedal arch studies, and 227 combinations. In addition, postoperative DSA was performed in 42 patients to evaluate graft patency, morphology, and inflow and runoff circulations. There were no significant differences in the quality of the preoperative aortoiliac studies performed by either SCA or DSA although, in select cases, one or the other of these techniques resulted in a superior study. Distal crural-pedal arch visualization was enhanced with DSA compared with SCA (85% vs. 65%) but when both were compared with their corresponding intraoperative completion arteriograms, the interpretive error rates resulted in comparable accuracies, false positive and negative rates, and predictive values. The likelihood of achieving graft patency in patients who have unsatisfactory preoperative visualization of the distal circulation by DSA is reasonable (11 of 27 patients) but inferior to the number obtained when there is adequate DSA visualization (40 of 53 patients). We conclude that DSA is a valuable adjunct to preoperative SCA but should not be used as the sole criterion for the assessment of operability for limb salvage. Intraoperative prereconstruction arteriography or direct surgical exploration of the crural arteries in patients with inadequate preoperative visualization will result in graft patency in a significant percentage of cases. Intra-arterial DSA for postoperative evaluation of lower limb bypass adds another dimension to analysis of graft structure and status of the host circulatory beds and also provides a method for accurate interpretation of postoperative data.

Recurrent intracaval renal cell carcinoma: The role of intravascular ultrasonography

The presence of extension into the vena cava does not preclude curative resection for extensive renal cell carcinomas. However, preoperative assessment of (1) the proximal extent of the tumor and (2) the degree of adherence within the vena cava is necessary to plan operative strategies. The following report describes the successful use of intravascular ultrasonography in the preoperative evaluation of a patient with recurrent renal cell carcinoma with vena caval extension.

Omental protection of autogenous arterial reconstruction following femoral prosthetic graft infection

Vascular graft infections in the femoral region that require synchronous revascularization are generally reconstructed with prosthetic grafts via extra-anatomic routes. If in situ revascularization is required, then autologous tissue provides optimal results. A particular challenge in this circumstance is achieving soft tissue coverage of the reconstruction where wide and radical débridement has removed the tissues ordinarily used for this purpose. If muscle flaps are not available or possible, the use of omentum is advocated. The omentum can be easily reached from behind the inguinal ligament and transposed on its bipedicled vascular base for coverage of vital structures in the femoral triangle, thereby obliterating dead space and providing a surface for both temporary and permanent skin coverage. The procedure is quite simple, can be performed rapidly, and should be considered for use in the dire situation that requires soft tissue coverage of exposed vessels in extraperitoneal locations.