Robert P. Leather

Instrumental evolution of the valve incision method of in situ saphenous vein bypass

The previously stated advantages of the valve incision method of in situ saphenous vein arterial bypass have now been confirmed by others. However, this method has been limited by its time-consuming technical demands. Considerable experience with this bypass in conjunction with retrograde serial valve disruption with instruments of similar design principle (by Hall and Cartier) has been accumulated in Europe. However, the combination of the trauma of blunt valvular fracture and the sensitivity of endothelium to frictional shear has precluded use of these instruments in veins less than 4 mm in size, and the results have not been significantly better than those obtained with reversed vein bypass. An instrument (valve cutter) that achieves serial valve incision safely and consistently without mandatory exposure of each valve site has now been developed. Of the last 166 consecutive bypasses, the saphenous vein was suitable for use of this instrument in 116 instances (70%). The patency of these bypasses as determined by life-table analysis has shown no significant difference when compared with bypasses performed under similar conditions in which the cutter was not used. On the basis of this investigative and clinical experience, the majority of in situ saphenous vein arterial bypasses can be safely facilitated and simplified by use of this instrument.

The anatomy of the greater saphenous venous system

To define surgical anatomy, a prospective study of the greater saphenous venous system in 385 instances in 331 patients was carried out with the use of prebypass phlebography (either pre- or intraoperative). The phlebographic interpretations were confirmed during the operative procedures and from the completion angiogram. These details were recorded and analyzed by a specific computer program. These data consisted of a number of superficial branches, perforators, the identification of valve leaflets, sinuses, and the size and position of the main venous trunk both in the thigh and in the calf. The study showed that a single trunk was present in the thigh in 65% of patients and in the calf in 45%. The remainder were variants of double systems. In two thirds of patients who had complete double systems, the larger system was used for in situ bypass but the rest required the use of parts of both systems. Phlebography was accurate in the depiction of the anatomic variations (93%), double systems, cross connections, and perforator branches (87%). However, the number of competent valves could not be accurately determined (accuracy, 68%). The diameter of the vein was frequently underestimated (in 80% by 1.1 +/- 0.4 mm) and hence could not be used as an index of vein adequacy. After phlebography, four patients had transient rises in serum creatinine levels and one had an iatrogenic thrombosis of a distal segment. This study suggests that the precise anatomy of the greater saphenous venous system should be determined preoperatively by phlebography since this information is valuable for proper surgical planning before vein is used as a graft or for in situ bypass in the lower extremity.

Carotid endarterectomy by eversion technique: its safety and durability.

SUMMARY BACKGROUND DATAnThe outcome of standard longitudinal carotid endarterectomy (CEA) can be measured by preservation of neurologic function with a low incidence of restenosis. Closure of the internal carotid arteriotomy with or without a patch may predispose to restenosis. Alternatively, transection of the internal carotid artery at the bulb with eversion endarterectomy allows expeditious removal of the plaque and direct visualization of the endpoint. Because the proximal internal carotid artery is anastomosed to the common carotid artery, this obviates the need for patch closure. The authors report their results with this technique in more than 2200 procedures.nnnMETHODSnFrom May 1993 to March 1998, 1855 patients underwent 2249 CEAs using the eversion technique. During the same period, 410 patients had 474 CEAs by standard technique. Three hundred fifteen procedures in the eversion group and 65 procedures in the standard group were combined CEA and coronary artery bypass grafts. Most solo CEAs (97%) were performed in awake patients using regional anesthesia. Shunts were used on demand in 6% of CEAs.nnnRESULTSnThe operative mortality rate was 1.02% (16/1575) in the solo eversion group and 2.2% (9/410) in the standard group. There were 18 permanent neurologic deficits (0.8%) in the eversion group and 11 (2.3%) in the standard group. Transient neurologic deficits occurred in 20 patients (0.9%) in the eversion group and 13 patients (2.7%) in the standard group. Of the 1855 patients, 1786 (96%) presented for duplex ultrasound follow-up. There were seven (0.3%) stenoses greater than 60% in the eversion group versus five (1.1%) in the standard group.nnnCONCLUSIONSnEversion CEA can be performed safely with a low rate of stroke and death and a minimal restenosis rate in short- and long-term follow-up.

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.

Comparison of patency rate and structural changes of in Situ and reversed vein arterial bypass

Abstract We hypothesize that in situ vein may be a better arterial conduit than reversed vein. In order to evaluate this hypothesis, 47 in situ and 22 reversed vein bypasses from femoral to below knee arterial reconstructions were done for limb salvage and followed at 3-month intervals up to 30 months. Patients age, sex, and run-off were similar in both groups. The cumulative patency rates at 12 and 30 months were 95 and 92% for the in situ group in contrast to 63 and 63% for the reversed group. These differences were significant (P

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.

Eversion endarterectomy of the internal carotid artery: Technique and results in 449 procedures

BACKGROUNDnPreservation of neurological function with a low incidence of restenosis is a measure of the long-term durability of carotid endarterectomy. Routine and selective patch angioplasty of the internal carotid artery have both been used to reduce the incidence of restenosis. The European literature has had many reports of lower restenosis rates in patients undergoing eversion carotid endarterectomy. We evaluated our experience with the eversion carotid endarterectomy procedure over a 2-year period to identify any advantage of this technique.nnnMETHODSnBetween August 1993 and August 1995, 376 patients underwent 449 carotid endarterectomies (CEAs) using the eversion technique (described below). During the same period, 307 patients underwent 353 CEAs by standard endarterectomy. Demographics were similar in both groups. Fifty-two patients in the eversion group underwent combined open cardiac procedures and carotid endarterectomy. There were 47 such patients in the standard group. Duplex examination was performed after surgery at regular intervals to identify any recurrent stenosis.nnnRESULTSnOperative mortality was 4 of 376 (1.1%) and 6 of 307 (2%) in the eversion and standard groups, respectively. Shunts were used in 15 of 449 patients in the eversion group and 24 of 353 patients in the standard group. Cervical block anesthesia was used in 669 of 687 (97%) of patients undergoing CEA without coronary artery bypass grafting (CABG). There were four permanent neurologic deficits in the eversion group and seven in the standard group, for respective stroke rates of 0.9% and 2%, and there were three transient neurologic deficits in the eversion group and nine in the standard group. There was one (0.2%) restenosis in the eversion group; there were four (1.1%) in the standard group by follow-up duplex scan.nnnCONCLUSIONSnThese data demonstrate that eversion carotid endarterectomy can be performed with low stroke and mortality rates in the treatment of extracranial carotid occlusive disease. The incidence of restenosis was lower and approached significance in eversion endarterectomy when compared to standard carotid endarterectomy in the short-term follow-up in this series.

The lesser saphenous vein: an underappreciated source of autogenous vein

Use of the ipsilateral greater saphenous vein for arterial bypass procedures is frequently limited by previous stripping, bypass operations, or anatomic unsuitability. In such cases the contralateral greater saphenous vein or arm veins are often used. However, over the past 5 years we have used the lesser saphenous vein as a preferred alternative autogenous vein. Duplex scanning has been used in 311 cases for preoperative mapping and assessment with excellent correlation with actual anatomy found at operation. Harvest of the lesser saphenous vein has been facilitated by the use of a medial subfascial approach not requiring special positioning of the leg. A total of 91 lesser saphenous veins have been used for arterial bypass procedures; 66 of these were repeat cases. Vein use was 90.2%. In 40 of these cases the lesser saphenous vein was used as the entire conduit, including 10 in situ, 20 reversed vein (including 18 for coronary artery bypass), and 10 orthograde vein bypasses. In the remaining 33 cases the lesser saphenous vein was spliced to another vein to complete a bypass procedure. In the entire group, patency was 77% at 2 years. These data suggest that the lesser saphenous vein should be a principal alternative to ipsilateral greater saphenous vein for arterial bypass because of its ready availability, high use rate, ease of harvesting and preparation, and ideal handling characteristics.

Peroneal artery bypass: A reappraisal of its value in limb salvage

In general the surgical literature has expressed pessimism about the value of bypass to the peroneal artery for limb salvage. The combination of greater technical difficulty, low patency rates, and hemodynamic failures have led to the establishment of this prejudice. In a review of 284 arteriograms in limbs with infrapopliteal arterial occlusion, the peroneal artery was the least diseased in 40% and was the only available vessel in 37% of instances. One hundred fifty-two peroneal bypasses have been performed in a 7-year period, 116 by the in situ method, 23 with excised vein, and 13 by nonautogenous conduits. During the same period 125 anterior tibial and 114 posterior tibial bypasses were also done. The mean preoperative ankle/brachial indices were 0.27 for peroneal, 0.25 for anterior tibial, and 0.29 for posterior tibial bypasses. These were converted to mean postoperative indices of 0.84, 0.86, and 0.92, respectively. Corresponding transmetatarsal/brachial indices were 0.72, 0.75, and 0.90. Rest pain was relieved in all these patients, and in 94 patients with tissue loss, there were 11 major amputations, nine healed forefoot amputations, and 20 healed digital ray amputations. Hemodynamic failures were two in the peroneal, two in the anterior tibial, and three in the posterior tibial group with one perioperative amputation in each. The cumulative limb salvage rate at 3 years for the peroneal group was 81%. This experience has shown that the patency and limb salvage rates obtained are comparable to those for the anterior and posterior tibial arteries and that hemodynamic failure is an uncommon occurrence.(ABSTRACT TRUNCATED AT 250 WORDS)

Carotid endarterectomy can be safely performed with acceptable mortality and morbidity in patients requiring coronary artery bypass grafts

BACKGROUNDnPatients undergoing the placement of coronary artery bypass grafts (CABG) with hemodynamically significant carotid artery lesions pose a difficult problem for both cardiac and vascular surgeons. Despite numerous studies, there has been no consensus of opinion as to the proper management of these patients. In numerous series, the combined mortality and perioperative stroke rates in concomitant carotid endarterectomy and CABG procedures have ranged from 8% to 40%. This has made many surgeons consider staging these procedures.nnnMETHODSnRetrospective analysis of patients undergoing combined carotid endarterectomies and CABG from 1980 to 1993 were reviewed. Two hundred six procedures were performed in 189 patients. Seventeen patients had bilateral carotid endarterectomy performed with CABG. The average age of our patient population was 66 years, with 123 being male and 66 being female. Seventy-five percent of the patients were asymptomatic with the remainder having transient ischemic attacks, amaurosis fugax, or prior stroke.nnnRESULTSnOperative mortality was 2%, with three of four patients dying of cardiac failure and one of a stroke. A temporary neurologic deficit was seen in 2% of patients, and a permanent neurologic deficit was seen in 2 of 206, or 1%. Thirty shunts were used in this series, mostly in patients with contralateral carotid occlusion. All procedures were performed under general anesthesia with full invasive monitoring. One patient was re-explored for bleeding, and one patient had a temporary hypoglossal palsy. A total of 203 cases had the arteriotomies closed primarily, and 3 required patches.nnnCONCLUSIONnIn our experience, simultaneous carotid endarterectomy and CABG can be performed with an acceptable mortality and morbidity and does not appear to put the patient at an increased risk. Staging of these procedures may not be necessary in most cases.