Max R. Gaspar

Prevention of high flow problems of arteriovenous grafts. Development of a new tapered graft.

Blood flow of 2 to 3 liters/min was measured in polytetrafluoroethylene (PTFE) arteriovenous dialysis grafts. The flow studies were done at the time of graft banding for high output cardiac failure or peripheral steal. Routine tapering of the arterial end of these grafts to a diameter of less than 5 mm has virtually eliminated this problem. Prototype tapered PTFE grafts supplied by the graft manufacturers have been very acceptable during 12 months of use.

Routine aortography before abdominal aortic aneurysmectomy. A prospective study.

Routine preoperative arteriography was studied prospectively in 104 patients with abdominal aortic aneurysms. The patients were from the private practice of 11 vascular surgeons. Information regarding patient clinical status was gathered and compared with aortographic and intraoperative findings. Special attention was focused on the question of operation modification as dictated by aortographic findings. The surgeons were further asked whether the information gained from surgical exploration was equal to that obtained from arteriography. It is concluded that because of low yield of benefit, economic considerations, time delay, and minor but distinct risks of the procedure, arteriography should be used selectively rather than routinely in such patients.

Prolene sutures are not a significant factor in anastomotic false aneurysms.

Anastomotic false aneurysms have been a significant complication in vascular surgery, and the sutures used have been a major cause. Monofilament sutures have been indicated as contributing to the formation of false aneurysm. However, most of the monofilament sutures operative in the formation of false aneurysms have been made of polyethylene. Polypropylene, although significantly different from polyethylene, has been associated and possibly confused with it. Very few anastomotic aneurysms have resulted from breakage of polypropylene sutures. In this series of 2,400 vascular anastomoses in which polypropylene sutures were used, there were 10 false aneurysms; however, only one resulted from suture failure. In that patient, two Dacron grafts were anastomosed with 5-0 polypropylene suture. Polypropylene is a satisfactory and safe suture material for vascular anastomoses. It does not fragment or break easily when properly handled, and therefore is not a principal cause of false aneurysms.

Comparison of Payne and Scott operations for morbid obesity.

One hundred five patients were operated upon for morbid obesity using accepted criteria for operation. Forty-five patients with the Payne operation (35 cm of jejunum anastomosed end-to-side to 10 cm of ileum) were compared with 45 patients having the Scott operation (30 cm of jejunum anastomosed end-to-end to 15 cm of ileum with the proximal cut end of ileum vented into the transverse colon). The weight loss in the first two years was similar, although the Scott procedure patients lost slightly more weight. Comparison of the two groups by a new grading system also showed little difference in the two procedures. The Scott procedure takes longer and subjects the patient to an additional anastomosis. Study of a smaller group of patients having the Scott operation with varying lengths of jejunum and ileum indicates that there should not be less than 30 cm of jejunum nor more than 15 cm of ileum left in continuity. The length of jejunum is particularly important in the production of weight loss, and accurate intraoperative measurement of intestinal length is crucial. In the postoperative period the length of functional jejunum and ileum can be determined by upper gastrointestinal barium roentgenograms.

Devastating distal arterial trauma and continuous intraarterial infusion of tolazoline

Trauma due to motor vehicles accident and urban violence have made distal arterial reconstruction an increasingly important part of the surgeons work. During the 20 month period from October 1980 to May 1982, 13 patients with below the knee and 2 patients with forearm trauma had nonviable extremities despite fastidious vascular and orthopedic reconstruction. A continuous intraarterial infusion of tolazoline into the femoral or brachial arteries restored vascular perfusion and viability in 13 of 15 patients (87 percent), with eventual limb salvage in 67 percent. Seven of 15 patients (47 percent) had transient systemic hypertension. There was no mortality. There exists in patients with these catastrophic injuries a local low-flow state due to a combination of distal arterial spasm and venous outflow obstruction. Tolazoline, a peripheral alpha-adrenergic blocking agent, increases blood flow, albeit nonnutritionally, and thus theoretically prevents thrombosis due to stasis in the repaired distal vessel. When limb loss seems inevitable, a trial of intraarterial tolazoline is justified.

Acute arterial injuries of the upper extremity

Abstract Prompt recognition and immediate surgical repair is recommended in the management of acute arterial injuries to the upper extremity. This therapeutic concept is most urgent in injuries involving the larger proximal vessels where hemorrhage frequently threatens survival. Well established incisions and current vascular surgical technics preclude equivocation in the management of injuries in this location. Damage to peripheral arteries of the arm and forearm should also be repaired immediately in order to restore optimal circulation unless such emergency repair jeopardizes survival of the patient. Ligation can be performed in injuries in this location with minimal risk of amputation. Arteriography is helpful in establishing the diagnosis of arterial injury in equivocal cases and will reduce the number of negative explorations. Careful attention must be paid to the total problem of trauma in patients with acute arterial injury of the upper extremity since associated damage to nerves and tendons is the determining factor in restoration of function and rehabilitation of the patient.

Selective Use of Arteriography in the Assessment of Aortic Aneurysm Repair

Routine preoperative arteriography is advocated by many vascular surgeons before abdominal aortic aneurysm repair. We have used a selective approach based on the facts that arteriography is expensive, time-consuming, potentially hazardous, and often unwarranted. Based on preoperative indications, arteriography was used selectively in 41 of 100 consecutive patients prior to abdominal aortic aneurysmectomy. Many patients had more than one indication. A total of 82 specific indications were recognized. The most frequent indications were diminished lower extremity pulses (24), claudication (20), severe coronary artery disease (11), cerebrovascular disease (7), prior arterial reconstruction (8), hypertension in patients 60 years of age or less (5), evidence of other aneurysms (4), major renal anomaly (1), blue toe syndrome (1), and thoracic aneurysm (1). The 41 arteriograms produced 125 specific arteriographic abnormalities with an average of three per study. The most arteriographic abnormalities were in those patients with claudication and the least for those with hypertension. The arteriogram revealed information that would not have been obvious at operation, nor would it have led to operative procedure modification in only 10 patients. In the 59 patients not having arteriography, three had intraoperative findings which demanded a modification of the operative procedure. Thus, in only 13 patients was arteriography definitely useful. Presumably it was not indicated in the other 87. By comparing the cases in which the operation was modified with the presence of a specific indication, we have developed a predictability index as a guide for performing arteriography. Multiple indications increased the likelihood of operation modification only if four or more indications were present.

Aortoiliac thromboendarterectomy: Technic and results

Summary One-hundred and five patients who underwent aortoiliac thromboendarterectomy are presented. The operative mortality was 4.7 per cent. Four patients died in the early postoperative period. Of ninety-six patients available for analysis ninety-two (95.8 per cent) have had a satisfactory result (87.6 per cent of the total series). Operative deaths, surgical failures necessitating reoperation, and unsatisfactory results are analyzed, and the technic of the operation is described.

A technic for carotid thromboendarterectomy

An exacting technic for carotid thromboendarterectomy is described. Certain anatomic features and pitfalls are discussed along with specific instrumentation. Intraoperative use, insertion, and removal of the inlying carotid shunt are described.

THE INFLUENCE OF TRAUMA ON EXPERIMENTAL AORTIC ATHEROMATOSIS.

Summary The influence of blunt aortic trauma on the development of experimental atheromatosis has been observed in rabbits fed normal as well as high cholesterol diets. Trauma alone did not produce a significant degree of atheromatous change within the 65 day period of these experiments. Trauma did not accelerate the formation of atheromatous lesions at the site of injury. The earlier appearance of generalized abdominal aortic atheromatous lesions in the traumatized animals fed a high cholesterol diet is unexplained.