Moshe Haimov

Iliofemoral versus femorofemoral bypass: The case for an individualized approach ☆ ☆☆

The treatment of unilateral iliac occlusion remains controversial. We report our experience with femorofemoral bypass (FF) and iliofemoral bypass (IF). One hundred sixty-two FFs and 82 IFs were performed during a 25-year period. Demographic characteristics of the two groups were similar. Operative indications included claudication in 32.1% of FFs and 19.5% of IFs, rest pain in 26.5% of FFs and 36.6% of IFs, ulcer in 8.0% of FFs and 3.7% of IFs, gangrene 13.6% of FFs and 23.2% of IFs, and acute thrombosis in 13.0% of FFs and 3.7% of IFs. Five-year primary and secondary patency rates for all FFs were 56.9% and 65.4% respectively. Those for all IFs were 74.9% and 79.2%. The primary patency rate of FF performed for chronic arterial occlusive disease was 73.3% at 3 years and 60.4% at 5 years and for IF it was 73.4% at 3 years. In the absence of prior arterial surgery in the groin, the primary patency rates of bypasses for chronic arterial occlusive disease were 78.3% for FF and 86.8% for IF at 4 years. Distal endarterectomy and acute ischemia adversely affected patency. The operative mortality rate was 6.2% for FF and 3.7% for IF. Eleven wound complications occurred in the FF group. Seven patients underwent graft removal without limb loss. One minor wound problem occurred in the IF group. Iliofemoral bypass avoids operation on an asymptomatic limb; FF avoids entry in the abdomen or retroperitoneum and can be performed under local anesthesia. In patients in whom either IF or FF is applicable, the choice between these two procedures should be individualized with these factors in mind.

Hemodynamic Evaluation of Angioaccess Procedures for Hemodialysis

variety of angioaccess procedures including arteriovenous fistulas (AVF) and grafts. The mean blood flow rate was 270.3 ± 125.6 ml/min in a standard radiocephalic AVF. Flow rates below 140 ml/min resulted in early AVF failure. Forearm radiocephalic grafts had a mean flow rate of 283.3 ± 76.4 ml/min. Side brachial artery-end axillary vein fistulas with interposition of 8 mm grafts (bovine heterografts and Gore-Tex grafts) had flow rates with a mean value of 1323.6 ± 456.9 ml/min. With smaller diameter grafts (5-6.5 mm), the mean flow rate was 666.0 ± 155.6 ml/min. The retrograde arterial flow toward the fistulas was also measured. In 73.3% of functional standard radiocephalic AVFs, retrograde distal arterial flow amounted to a mean value of 53.2 ± 23.9 ml/min. The mean retrograde flow was 254.0 ± 177.9 ml/min in 90.9% of the 8 mm brachioaxillary graft fistulas, and 90.0 ± 56.6 ml/min in 66.7% of the forearm radiocephalic graft fistulas. A symptomatic arterial &dquo;steal&dquo; syndrome developed in one of 16 (6.3%) functioning standard AVFs, three of 11 (27.7%) of the 8-mm brachioaxillary graft fistulas, and one of six (16.7%) of the 5-6.5-mm brachioaxillary graft fistulas. Cardiac output was determined in 3 patients with high initial graft flows (above 1500 ml/min). The cardiac indexes in these 3 patients were 6.0 L, 4.5 L, and 8.5 L. Introduction

The dorsalis pedis bypass—Moderate success in difficult situations

Recent reports have documented excellent results for inframalleolar reconstructions. We reviewed our outcomes for dorsalis pedis bypass and report a more modest rate of success. We analyzed reasons for failure. Sixty-nine patients underwent 73 dorsalis pedis bypass procedures between 1984 and 1991. Seventy-eight percent of the patients were diabetics. Inflow was from the external iliac in 1, femoral in 35, popliteal in 34, and tibial in 3. The operative indication was gangrene in 57%, ulcer in 22%, and rest pain in 21%. Forty-six percent of limbs had foot infection, with six requiring minor amputation before the bypass and 24 requiring minor amputation after bypass. There was one perioperative death. Twenty-nine grafts failed over the course of the series. The primary patency rate at 2 years was 59.2%. The limb salvage rate was 73.5%. Of the 10 perioperative failures, four were due to continued foot infection, four to marginal vein quality, and two to skin necrosis of the bypass incisions. Graft failure occurred at 3 to 30 months in 10 of 14 patients who had deficient anterior arches, with segmental occlusion of the dorsalis pedis or its branches. Six of the 14 patients with extensive infections of the forefoot or extensive heel ulcers required amputation with patent bypasses. In dorsalis pedis bypass, failure to achieve limb salvage was more likely in patients with marginal vein quality, deficient anterior pedal arches, and extensive foot infection. In patients where the chance of failure appears to be unacceptably high, primary amputation should be considered.

PERSISTENT IMMUNOGLOBULINURIA IN IRREVERSIBLE RENAL ALLOGRAFT REJECTION IN HUMANS

SUMMARY To evaluate the extent of injury in short- and long-term renal allografts, the urinary excretion of IgG, IgA, and IgM was observed during acute rejection crisis. In reversible rejection, treatment resulted in prompt correction of immunoglobulinuria, whereas in irreversible crisis urinary immunoglobulin levels continuously increased in spite of the same antirejection treatment. A good prognosis in long-term allografts was shown by low levels of immunoglobulinuria; unstable graft function had higher levels. Immunoglobulinuria can be used as an additional test to evaluate the reversibility of acute rejection, and also has significance in the long-term situation.

Percutaneous transcatheter embolization of lesions of the extremities

Our experience with nine patients in whom percutaneous transcatheter embolization was utilized in the extremities is presented. These include three patients with peripheral hemangiomas who were successfully embolized as the primary therapy; two patients who were embolized prior to surgery to minimize blood loss and shorten anesthesia time; two patients with neoplasm of an extremity as a means of palliation; and two patients with traumatic vascular lesions. Indications and potential complications are discussed, and the various embolic agents available are reviewed to define the options available to the angiographer and surgeons in planning therapy.

Suture Breakage Following Carotid Endarterectomy Surgery

The author reports a case of suture breakage that occurred forty-eight hours after a right carotid endarterectomy was performed in a sixty-eight-year-old man. The problem was corrected at reoperation, but the patient died a week later with irreversible brain damage.

Pseudoaneurysm Formation in a Gore-Tex Graft Used for Hemodialysis

Gore-Tex has become the graft material of choice for angioaccess in hemodialysis patients. We present the first report of a pseudoaneurysm arising at the puncture site of a Gore-Tex prosthesis.

Prevention of acute experimental arterial thrombosis by defibrination.

Department of Surgery, the Mount Sinai School of Medicine of the City University of New York, New York. This research was supported by a grant from The Hartford Foundation, New York, New York. The arterial thrombosis subsequent to vessel wall injury is initiated by adherence of platelets to the subendothelial tissues.’ Further progression and extension of the thrombosis depends on several factors, among which the development of a fibrin net is most important. It has been shown by us2 , 3 and other investigators4~ 5 that pharmacological agents which prevent platelet aggregation are effective in the prevention of experimentally induced arterial thrombosis. Using the same experimental model we have studied the incidence and evolution of arterial thrombosis in a state of afibrinogenemia induced with &dquo;ancrod&dquo; * a

Major vascular surgery in patients with terminal renal failure.

* Assistant Professor, Department of Surgery, the Mount Sinai School of Medicine of the City University of New York, New York. ** Associate Professor, Department of Surgery, the Mount Sinai School of Medicine of the City University of New York, New York. *** Associate Professor of Clinical Medicine, the Mount Sinai School of Medicine of the City University of New York, New York. From the Departments of Surgery and Medicine, Mount Sinai Hospital Services, City Hospital Center at Elmhurst and the Mount Sinai School of Medicine of the City University of New York, New York. Patients suffering from terminal renal failure present a complicated challenge to the vascular surgeon. In addition to chronic anemia, debility and predisposition to infection, which accompany terminal renal failure, some patients have a definite bleeding tendency due to a quantitative and qualitative defect in blood platelets. 1, 2, 3 Heparinization for hemodialysis, which is required soon following surgery aids to the already considerable surgical risk. This report will deal with the experience in performing major vascular procedures in three patients suffering from end stage kidney disease.