Roger F. Smith

A thirty-year survey of the reconstructive surgical treatment of aortoiliac occlusive disease

With the view of assessing functional durability and the factors that influence or determine it, we reviewed the clinical course of 1748 reconstructive operations performed between Jan. 1, 1954, and Dec. 31, 1983 in the treatment of 1647 patients with aortoiliac occlusive disease (AIOD). Disabling intermittent claudication (in 65.6%), ischemic rest pain and/ or pregangrene (in 20.7%), and ischemic gangrene (in 13.7%) were the operative indications. Patency proven by angiography was the criterion of success. Follow-up was continuous and endless and 94% successful over a period of 30 years. Twenty-five percent of the patients were followed up for 11 to 30 years. The incidence of severe degree of occlusive involvement increased significantly from the first (9.3%) to the third (17.1%) decade of observation, whereas the perioperative mortality rate improved markedly from the first (7.4%) to the third (2.5%) decade. The aortobifemoral bypass (AF2B) procedure remained the most popular type of repair (with a perioperative patency rate of 91.4%) throughout, but both it and unilateral reconstructions lost some ground to remote (extra-anatomic) bypasses in the third decade. Atherosclerotic heart disease remained the most common cause of perioperative (50%) and late (60.2%) death. Among the early postoperative local complications graft thrombosis improved markedly from the first (8.3%) to the third (3.2%) decade. Graft infection remained rare (1.6% to 0.8%). The incidence of the most common late wound complication, anastomotic aneurysm at the common femoral level, remained relatively constant (5.7% per anastomosis), but it responded very well to surgical correction. The partial or complete secondary repair of all late complications (26.0%) improved the cumulative late patency rate in the AF2B procedures by 2% to 12% during 20 years of observation. The perioperative (97.3%), 5-year (76.6%), 10-year (76.6%), 15-year (72.5%), and 20-year (67.5%) cumulative patency rates of AF2B operations were highly satisfactory. The postoperative late survival rate of patients with AIOD declined rapidly (59% at 5, 33% at 10, 14% at 15 years). The cause of late death in 60.2% of the cases was atherosclerotic heart disease.

Infected femoral artery false aneurysms in drug addicts: evolution of selective vascular reconstruction.

Fifty-four infected femoral artery false aneurysms resulting from chronic drug addiction were managed surgically with an 11% amputation rate and no mortality. Angiography localized the arterial segment involved, which in turn influenced the type of operation performed. Twenty-six aneurysms of anatomically isolated femoral artery segments were ligated and excised without resultant amputation. However, of the 28 aneurysms involving the common femoral bifurcation, 18 required triple ligation and excision that led to six amputations. Six of the 28 aneurysms were reconstructed with autogenous saphenous vein grafts, three by prosthetic grafts, and one by primary anastomosis. No amputations followed vascular reconstruction. However, all synthetic grafts eventually developed septic complications that required graft removal. On the basis of this experience we recommend ligation and excision for single artery segment aneurysms and immediate autogenous reconstruction for selected common femoral bifurcation lesions. This approach has proved safe and has reduced our amputation and graft complication rates. Extensive uncontrollable wound sepsis may contraindicate revascularization. Under these circumstances we estimate a 33% risk of amputation when the common femoral bifurcation is excised.

Surgical treatment of carotid paragangliomas presenting unusual technical difficulties: The value of preoperative embolization

Although the application of reconstructive vascular surgical procedures to the treatment of carotid paragangliomas has made their resection the method of choice and has produced excellent cure rates, it has not obviated some of the technical problems presented by excessively vascular, adherent, or bulky lesions. Our experience with preoperative trans-catheter embolization for the reduction of the vascularity in six cases of this group of lesions is presented and the conclusion is made that preoperative embolization greatly reduced operative technical difficulties.

Secondary Arterial Repair: The Management of Late Failures in Reconstructive Arterial Surgery

The incidence and success of secondary operations after reconstructive arterial surgery were studied in a series of 4,247 cases of aneurysmal and occlusive arterial disease. Postoperative complications requiring secondary operations occurred, in order of frequency, as the result of defective healing (including infection), deterioration of the arterial implant, and degenerative arterial changes in the site of surgical intervention. A large variety of surgical techniques were used for correction, such as total replacement, segmental resection and replacement, remote bypass, thrombectomy, and partial excision and reanastomosis. Wth the exception of complications due to infection, the results of repair were good in 60% to 90% of the various categories; only 40% of the infected grafts could be managed without the loss of life or limb. The results appear to justify the trend noted in recent years to a more aggressive use of secondary, salvage operations.

Ureteral complications and aortoiliac reconstruction.

A 33-year experience with 58 ureteral complications in 50 of 3580 patients undergoing aortoiliac reconstruction was analyzed. Ureteral obstruction was treated before or in conjunction with aneurysm repair in six patients with aneurysmal disease. The remaining 44 patients had 46 ureteral complications after aortic reconstruction; complications included hydronephrosis (42), ureteral leak (3), and ureteral necrosis (1). A high incidence of associated graft complications was noted. Graft thrombosis developed in one of the six patients undergoing prior or simultaneous ureteral procedures, and graft infection developed in another. Thirty-six graft complications developed in 24 (55%) of the 44 patients with postoperative ureteral complications. The complications included 19 anastomotic aneurysms, eight graft limb thromboses, six graft infections, and three aortoenteric fistulas. Twenty-nine of the 44 patients with postoperative ureteral complications underwent ureteral or graft operations or both. These included five patients having ureteral operations alone, seven with a ureteral procedure and subsequent graft operation, eight requiring simultaneous ureteral and graft procedures, and nine undergoing a graft operation with ureteral observation. Six of these 29 patients (21%) died after operation, all from graft complications including aortoenteric fistulas (three), ruptured anastomotic aneurysms (two), and graft infection (one). Graft complications affected 55% of 44 patients with postoperative ureteral complications, compared to 12% of 3536 patients without ureteral complications (p less than 0.0001). Patients with postoperative ureteral complications were 4.4 times as likely to have graft complications compared to those without ureteral complications (p less than 0.0001). These data suggest that such urologic complications may be markers for recognition of or harbingers for graft complications.

Nephrogenic Hypertension (Goldblatt Kidney) Following Operative Trauma to the Renal Artery

The thrombosis of the right renal artery following operative injury set off a chain of events closely duplicating the arterial hypertension observed by Goldblatt after constriction or occlusion of the renal arteries in experimental animals. The resulting hypertension was severe, fulminating, prolonged, and resistant to treatment by hypotensive and ganglion-blocking agents; it was associated with pulmonary edema, myocardial infarction, and impairment of the renal function. Nephrectomy brought about a return of the blood pressure to normal levels. The concentration of renin in the removed kidney was 34 times greater than normal.