Ralph A. Deterling

Long-term results with the above-knee popliteal expanded polytetrafluoroethylene graft.

Since approximately 30% to 40% of autogenous vein bypass grafts to the femoropopliteal level may occlude within 5 years of implantation, additional vein will be required for subsequent revisions. We undertook a study to determine whether the preferential use of an above-knee expanded polytetrafluoroethylene bypass graft to save vein is an appropriate option. We reviewed our experience with 114 above-knee expanded polytetrafluoroethylene bypass reconstructions. Life-table analysis of primary and secondary graft patency was carried out by the method of Peto and statistically analyzed for the influence of clinical indication, runoff as determined by both preoperative and intraoperative completion arteriography, smoking, and diabetes. The 5-year primary patency rate of 57% for patients with claudication was comparable to contemporary randomized or retrospective series with below-knee autogenous vein for that indication, and it was superior to the patency rate for limb salvage. The status of the runoff vessels was an important determinant of outcome. The 59 limbs with good arteriographic runoff (2 to 3 vessels) had a markedly higher 5-year patency rate (70%) than the poor arteriographic runoff (0 to 1 vessels) group (30%). Continued cigarette smoking and diabetes mellitus also appeared to affect adversely primary graft patency in our hands. Our data support the use of preferential above-knee expanded polytetrafluoroethylene grafts in patients with good angiographic runoff. This approach does not appear to prejudice the limb against secondary revisionary procedures or the use of a new autogenous graft, if required.

Correlation of operative findings with angiographic and noninvasive hemodynamic factors associated with failure of polytetrafluoroethylene grafts

The causes of autogenous saphenous vein (ASV) graft failure have been well described and are predominantly due to stenosis of the ASV graft during the first year after implantation. Distal atherosclerotic disease is a late cause of ASV graft failure. Furthermore, with failure of the ASV graft the clinical and hemodynamic status of the limb usually reverts to the preoperative state. To better define the causes and hemodynamic consequences of polytetrafluoroethylene (PTFE) graft failure, we reviewed the pathologic findings at surgery and compared these with arteriograms made prior to and after occlusion and sequential noninvasive hemodynamic studies in 36 patients with failed PTFE grafts (greater than 30 days after operation). Distal atherosclerotic disease was the most frequent cause of PTFE failure (23 of 36 limbs, or 64%), and it appeared as early as the first 6 months after implantation. Doppler pressures after PTFE failure deteriorated significantly (p less than 0.05) at the thigh, calf, and ankle levels. A blinded comparison of preoperative with postoperative arteriograms revealed significant progression of disease. Because of significant involvement of the popliteal artery in our series, treatment of intimal hyperplasia with patch angioplasty (seven cases, or 19%) was short lived and sequential extension was required. Distal atherosclerotic disease therefore appeared to be the most common cause of PTFE graft failure and occurred much earlier after implantation than with ASV graft failure. Deterioration of the hemodynamic state of the limb correlated with this high degree of distal atherosclerotic disease.

Improved localization and survival in patients with intraabdominal abscesses

Abstract A review of 100 consecutive patients with intraabdominal abscesses treated since the advent of the CAT scanner has been presented. Each patient was analyzed with regard to etiology, bacteriology, sensitivity of preoperative diagnostic studies, method of drainage, mortality, and morbidity. Abscesses developed in 71 percent of these patients as a result of spontaneous intraabdominal disease, and in 29 percent as a complication of operation or procedures. Sixty percent of cultures grew anaerobic organisms. The sensitivity of CAT scanning (92 percent) was significantly better than that of ultrasonography (77 percent) or gallium scanning (75 percent). When ultrasound was used in conjunction with CAT scanning there was no improvement in sensitivity. Patients who had CAT scans were more likely to have extraserous drainage (p

Systemic idiopathic fibrosis: Report of a case of the concomitant occurrence of retractile mesenteritis and retroperitoneal fibrosis

Abstract A case of the concomitant occurrence of retractile mesenteritis and retroperitoneal fibrosis is reported. The pathology and pathogenesis of the two conditions appear to be identical. It is therefore suggested that the two disease processes, along with mediastinal fibrosis, sclerosing cholangitis, Riedels thyroiditis, and pseudotumor of the orbit are manifestations of the same systemic disease of fibrofatty connective tissue occurring in different locations. The etiology of systemic idiopathic fibrosis is obscure. The most cogent theory is that it represents a hypersensitivity reaction, possibly autoimmune in nature, to an as yet unknown antigen.

Infrarenal aortic occlusion: A reassessment of surgical indications☆

Citing a high incidence of proximal propagation of aortic thrombosis, several authors have advocated aortic reconstruction for all patients with infrarenal aortic occlusion irrespective of their preoperative symptoms and potential operative risks. To test this thesis, the records and follow-up data of 38 patients seen at our institution between 1965 and 1982 with infrarenal aortic occlusion were analyzed. Twenty-four of the 38 patients were treated surgically (Group I); 16 (42 percent) had an aortobifemoral graft and 8 (21 percent) had an axillofemoral bypass graft. When the 14 patients who did not have surgery (Group II) and the 8 patients who had an axillofemoral graft were combined, 22 patients (58 percent) did not have aortic reconstruction (Group III), thus the aortic thrombus was left in situ. There was no significant difference in cumulative survival between the three groups at 4 year follow-up. Of 13 patients in Group III who were followed for more than 6 months (mean 48 months), none died from proximal propagation of aortic thrombosis. The decision for surgical intervention in patients with distal aortic occlusion should be arrived at, as in other patients with aortoiliac occlusive disease, by weighing preoperative symptoms and operative risks and not primarily by the level of risk of proximal propagation of thrombosis.

Management of combined segment disease

Eighty-five of 148 inflow procedures were performed for combined segment disease. Our study shows that aortofemoral bypass is clinically and functionally superior to axillofemoral bypass in limbs with combined segment disease and hemodynamic criteria for limb salvage. The results of these two procedures are comparable for claudicant limbs. A derivative of segmental plethysmography, the predictive index, can select preoperatively those limbs that will fail to respond to aortofemoral bypass alone. Finally, either in limbs selected for aortofemoral bypass with both ischemic tissue lesions and a predictive index greater than 0.2 or in limbs selected for axillofemoral bypass with ischemic tissue lesions alone, a synchronous procedure can be performed with relatively low morbidity and excellent early functional results.

Obstructive jaundice in the elderly patient

Abstract Obstructive jaundice is among the most frequent indications for abdominal operation upon the elderly. The cases of fifty-six patients seventy years of age or older who came to operation because of jaundice are reviewed. Slightly less than one-third of these patients harbored malignancies. In none of these was a curable lesion found. Palliation was achieved only by direct decompression of the common duct. Internal decompression was most successful, but choledochostomy was adequate in two of six patients. In the patients with benign disease a curative procedure was preferable, but cholecystostomy was often a valuable preliminary step, and occasionally it was all that was needed. Cholecystostomy performed to relieve jaundice must adequately decompress the common duct, and must be abandoned in favor of direct drainage of the common duct when it does not accomplish this. There was a high incidence of unrelated medical disorders requiring careful preoperative evaluation and treatment. The duration of jaundice prior to operation had no influence on mortality or morbidity. Hence there is no justification for rushing the elderly patient to surgery merely because of the development of obstructive jaundice. The elderly patients with benign disease had a mortality of 26 per cent, and a high incidence of nonfatal complications. Many of these unfortunate results could have been avoided had elective surgery been undertaken soon after the onset of the first symptoms of biliary tract disease.

HEMODYNAMIC ASPECTS OF UNCONTROLLED CROSS CIRCULATION IN DOGS.

Summary Studies were conducted to test the hemodynamic effects of a common channel in uncontrolled cross circulation. These results were compared with the effects of arterial and arteriovenous cross circulation without a common channel. Under the conditions of these experiments, there was significantly less hypotension in animals subjected to arterial cross circulation with or without common channel than in animals subjected to arteriovenous cross circulation. On the basis of these experiments as well as previous observations on crossed aortic grafts, it is concluded that arterial cross circulation with a common channel is the optimum means of achieving uncontrolled cross circulation.