Spence M. Taylor

The characteristics and anatomic distribution of lesions that cause reversed vein graft failure: A five-year prospective study ☆ ☆☆

PURPOSE The cause of vein graft failure in the intermediate postoperative period (3 to 18 months) has not been well defined. To delineate the incidence, characteristics, and anatomic distribution of lesions that cause graft failure in this critical interval, 227 consecutive infrainguinal reversed vein grafts (IRVGs) constructed at a single institution from July 1986 to December 1991 were prospectively entered into a duplex scan surveillance protocol. METHODS Duplex surveillance with arteriographic confirmation identified 29 patent, hemodynamically failing IRVGs during a mean follow-up of 22 months (range 1 to 64 months). An additional 18 grafts thrombosed before detection of any underlying abnormality; thrombolytic therapy and repeat operation uncovered the cause of occlusion in 12 of these grafts. The cause of graft failure (failing as well as failed) was therefore clear in 41 (87.2%) of 47 instances. RESULTS The causes of failure were intrinsic graft stenosis (n = 28; 59.6%), inflow failure (n = 6; 12.8%), outflow failure (n = 4; 8.5%), muscle entrapment (n = 2; 4.3%), and hypercoagulable state (n = 2; 4.3%). The most common intrinsic graft lesion was focal intimal hyperplasia (18 lesions in 16 grafts) in the juxtaanastomotic position, occurring solely in the vein graft itself. It occurred with equal frequency immediately distal to the proximal anastomosis or proximal to the distal anastomosis. Only rarely (n = 5) did this involve the juxtaanastomotic artery. Focal midgraft valvular stenoses (n = 6) and diffuse myointimal hyperplasia (n = 4) were also detected. The peak incidence of graft failure was 4 to 12 months after operation (70% within 12 months, 80% within 18 months). CONCLUSIONS We conclude that duplex surveillance of IRVGs is warranted by the 21% incidence of potentially remediable graft failure. A significant portion of these failures occur during the intermediate postoperative period (3 to 18 months), usually as a result of focal intrinsic vein graft lesions. With reversed vein conduits, these lesions arise predominantly in the vein graft itself, in the juxtaanastomotic position.

Prosthetic thigh arteriovenous access: outcome with SVS/AAVS reporting standards

PURPOSE Differences in the reporting methods of results for arteriovenous (AV) access can dramatically affect apparent outcome. To enable meaningful comparisons in the literature, the Society for Vascular Surgery and the American Association for Vascular Surgery (SVS/AAVS) recently published reporting standards for dialysis access. The purpose of the present study was to determine infection rates, patency rates, and possible predictive factors for prosthetic thigh AV access outcomes with the reporting standards of the SVS/AAVS. METHODS A retrospective analysis was performed of all patients who underwent placement of thigh AV access by the Surgical Teaching Service at Greenville Memorial Hospital between 1989 and 2001. Outcomes were determined based on SVS/AAVS Standards for Reports Dealing with AV Accesses. The rate of revision per year of access patency was also determined; this end point more accurately reflects the true cost and morbidity associated with AV access than do patency or infection rates alone. RESULTS One hundred twenty-five polytetrafluoroethylene thigh AV accesses were placed in 100 patients. Nine accesses were excluded from the study, six because there was no patient follow-up and 3 as a result of deaths unrelated to the access procedure and which occurred less than 30 days after access placement. There were six (4%) late access-related deaths. There were 18 (15%) early access failures, related to infection in 14 cases (12%), thrombosis in three cases (2%), and steal in one case (1%). Early failure was more common in patients with diabetes mellitus (P =.036). The primary and secondary functional patency rates were 19% and 54%, respectively, at 2 years. Infection occurred in 48 (41%) accesses. The patency and infection rates were not influenced by patient age, gender, body mass index, or diabetes mellitus. The median number of interventions per year of access patency was 1.68, and this outcome was positively correlated with body mass index (P <.001). CONCLUSIONS Prosthetic AV access in the thigh is associated with higher morbidity compared with that reported for the upper extremity, and should be considered only if no upper extremity AV access option is available. Early access failure and the requirement for an increased number of interventions to reestablish and maintain access patency are more common in patients with diabetes mellitus and obesity. The number of interventions per year of access patency is a valuable end point when assessing the outcome of AV access procedures.

Outcomes in the Management of Vascular Prosthetic Graft Infections Confined to the Groin: A Reappraisal

The management of vascular prosthetic graft infections confined to the groin continues to be controversial. To critically evaluate this problem, we reviewed the records of our vascular registry from December 1992 through February 1995 and found 17 incidences of groin sepsis involving a vascular prosthesis in 10 patients. These included a proximal prosthetic femoropopliteal bypass (n=6), an aortobifemoral graft limb (n=5), an ileofemoral bypass (n=3), a prosthetic femoral patch (n = 2), and an aortofemoral/femorofemoral bypass (n=1). The mean age of these patients was 65 years. Six patients were diabetic, four were on systemic steroids, and two were diabetic and on steroids. All infections were Szilagyi grade III including three in which the patients presented with local hemorrhage. Treatment consisted of irrigation, radical debridement with or without in situ graft replacement, and local rotational muscle flap coverage in nine cases, graft excision with extra-anatomic (obturator ileofemoral bypass) graft replacement in six cases, and excision alone in two cases. Of the 17 infections treated operatively and followed from 1 week to 18 months (median 5 months), eight (47%) showed no evidence of recurrence, six (35%) recurred, two (12%) caused early death, and one resulted in a thrombosed graft requiring extra-anatomic reconstruction. Of the nine infected grafts treated locally with muscle flaps, six showed recurrent infection from 3 weeks to 15 months and one thrombosed for a total local treatment failure rate of 78%. Only two grafts are free of infection at 4 and 5 months, respectively. Of the six incidences of infection treated with obturator bypass, four (66%) are free of infection and two resulted in patient death; both infections treated with excision alone were eradicated but resulted in a major lower extremity amputation. These data question the growing acceptance of debridement and local muscle flap coverage for the treatment of all prosthetic vascular graft infections confined to the groin, especially in patients who are diabetic or on systemic steroids.

Surgical implications of early failed endovascular intervention of the superficial femoral artery

BACKGROUND It is generally accepted that failed infrainguinal bypass with prosthetic material significantly compromises arterial run off, which may limit future revascularization. It is well known that the negative consequences of early vein graft thrombosis are limited, but the effect of failed peripheral angioplasty on the distal vasculature is poorly studied. The purpose of this study was to determine whether early failure after superficial femoral artery intervention influences subsequent revascularization options. METHODS Between July 1, 1998, and June 30, 2006, 276 patients underwent endovascular intervention of the superficial femoral artery. A prospective analysis of angiograms done before the intervention and after early failure (<or=200 days) was performed in a blinded fashion by three attending vascular surgeons to determine the optimal distal bypass site if an operation were to be performed. Inter-rater reliability of the angiogram scores was assessed using the Fleiss generalized kappa for multiple raters. Potential distal anastomotic sites were classified as above knee popliteal, below knee popliteal, tibial, or no adequate site. A consensus classification was determined for each patient (2 of 3 raters). RESULTS Of the 276 patients who underwent endovascular intervention of the superficial femoral artery, early failure was noted in 24 limbs in 23 patients. Angiographic records were available for 21 limbs in 20 patients (60% men; mean age, 65.3 +/- 11.3 years), of which 60% had critical limb ischemia, 40% had claudication, and 65% had diabetes. The distal bypass site was altered in six limbs (28.6%); four from popliteal to tibial and two from above knee to below knee popliteal. Inter-rater reliability was 0.54 (moderate/good). The procedures performed on these early failures were percutaneous transluminal angioplasty +/- stent (n = 14), infrainguinal bypass (n = 5), and no treatment (n = 1). Only 0.4% (1 of 276) of patients required major limb amputation due to early failure of a superficial femoral artery intervention. CONCLUSIONS Early failure after isolated endovascular intervention of the superficial femoral artery is infrequent and alters the distal target in 30% of early-failure patients if open bypass is planned. Salvage with repeat angioplasty, if necessary, can be accomplished in most patients, and the need for limb amputation is exceedingly rare. The early failure results in this study support a more liberal application of endovascular intervention to the superficial femoral artery in patients with lower extremity ischemia, especially claudication. The repercussions of late endovascular failure as well as the effects of disease progression need further study.

Can the Perclose suture-mediated closure system be used safely in patients undergoing diagnostic and therapeutic angiography to treat chronic lower extremity ischemia?

PURPOSE Mechanical closure devices for arterial hemostasis after angiography, such as the Perclose suture-mediated closure system, are designed to decrease time to ambulation and improve patient comfort. Although these devices are safe and efficacious, to date there has been little reported about use of the Perclose device in a cohort consisting exclusively of patients with lower extremity peripheral vascular disease. The purpose of this study was to determine the safety and efficacy of routine use of the Perclose system in patients with documented peripheral vascular disease undergoing angiography to treat chronic lower extremity ischemia. METHODS The Perclose device was placed for arterial closure after femoral artery access in 500 consecutive patients with documented peripheral vascular disease (ankle-brachial index, <0.8) who underwent diagnostic angiography or percutaneous intervention because of chronic lower extremity ischemia. These 500 patients composed 91% of all patients who underwent angiography because of chronic lower extremity ischemia between January 1, 2001, and April 1, 2002. All complications associated with the Perclose device were identified and reviewed. RESULTS Of the 500 arteries, 54% were accessed for diagnostic angiography and 46% for intervention. Perclose device placement was successful in 475 attempts (95%). Overall major complication rate was 1.4% (7 of 500 arteries). Complications included one death from retroperitoneal hemorrhage; three episodes of limb ischemia, two requiring operation and one requiring lytic therapy; two pseudoaneurysms; and one hematoma, which prolonged hospitalization. The hematoma was the only complication in the 25 patients with failed Perclose device placement. There were no infections requiring admission or operation. CONCLUSION The Perclose suture-mediated closure device is efficacious and can be used safely in selected patients with documented peripheral vascular disease. Complications associated with this device tend to be more severe than those historically reported for manual compression. Substantial experience with use of this device is required to achieve excellent results in patients with difficult anatomy.

A reevaluation of intraarterial thrombolytic therapy for acute lower extremity ischemia

PURPOSE This study was performed to clarify the role of intraarterial thrombolytic therapy (IATT) in the management of acute lower extremity ischemia. METHODS A retrospective review of 77 patients undergoing 84 courses of high-dose regional urokinase IATT from July 1981 to June 1991 was performed. The group included patients with acute thrombosis of lower extremity bypass grafts (n = 48) or native arteries (n = 36), presenting with ischemic but viable limbs, minimal or no motor dysfunction, and an absence of muscle rigor or compartment syndrome. The data were then examined individually by site of thrombosis to evaluate patient selection for IATT. RESULTS Complete lysis, complications (either distal thromboembolism or bleeding), and early limb loss occurred in 59.5%, 11%, and 6% of infusions, respectively. IATT precluded the need for operative intervention in 49% of acutely ischemic limbs. When surgery was required, successful IATT precisely localized responsible lesions and reduced the magnitude of operation. A subset of 13 patients were identified in whom either no intrinsic abnormality or poor runoff were evident after lysis and were treated with anticoagulation alone. CONCLUSIONS These data show IATT to be especially suitable for thrombosis of native iliac or femoropopliteal arteries and infrainguinal vein grafts. IATT serves primarily as an adjunct in management of acute lower extremity ischemia. After successful IATT, subsequent therapy can be tailored to the anatomic cause of thrombosis.

The utility and durability of vein bypass grafts originating from the popliteal artery for limb salvage

BACKGROUND Short vein grafts originating from sites distal to the common femoral artery have been reported to be useful in selected patients with tibial artery disease. From 1987 to 1993, we performed 504 consecutive infrainguinal vein bypass grafts, of which 56 (11%) originated from the popliteal artery, 25 above and 31 below the knee. PATIENTS AND METHODS The patients were 16 women and 37 men, with a mean age of 62.4 years. Eighty-seven percent were diabetic, 57% had clinically obvious coronary artery disease, and 28% had end-stage renal disease (ESRD). The indication for surgery was ulceration or gangrene in 93% of cases. We preferentially used reversed greater saphenous vein harvested from the thigh to optimize conduit quality and avoid lower leg wound complications. The outflow artery sites were: dorsal pedal (17), posterior tibial (14), peroneal (10), anterior tibial (8), lateral or medial plantar (5), and sequential tibial (2). All patients were followed postoperatively with serial duplex surveillance. The mean follow-up was 12.5 months (range 1 to 66). RESULTS In-hospital mortality was 5.4%. Mortality at 24 months was 19% overall and 38% in patients with ESRD. Limb salvage was 77% at 3 years, 92% in patients with normal renal function versus 59% in those with ESRD (P < 0.003). Primary graft patency by life-table analysis was 94% at 1 month and 84% at 3 years. Five patients with patent grafts required amputation, 4 early and 1 late. Eight months after surgery, 1 patient (1.8%) developed superficial femoral artery stenosis which was diagnosed by duplex surveillance and successfully treated by percutaneous transluminal balloon angioplasty. CONCLUSIONS Vein bypass grafts originating from the popliteal artery are effective and durable. Proximal disease progression rarely poses a significant threat to long-term graft patency. Patients with ESRD, blind tibial outflow tracts, and extensive forefoot lesions appear to be at increased risk of limb loss even with continued graft patency.

Fistula Elevation Procedure: Experience with 295 Consecutive Cases During a 7-Year Period

BACKGROUND Up to 50% of AV fistulas fail to mature, primarily because of problems with fistula cannulation. Fistula elevation procedure (FEP) is a simple superficialization procedure where the fistula is surgically exposed, mobilized, and elevated into a more superficial position for the purpose of facilitating AV fistula cannulation. The purpose of this study is to review use of FEP as an adjunct to fistula maturation. STUDY DESIGN Two hundred ninety-five FEPs were performed between February 1999 and December 2005. FEP was performed if the fistula was considered too deep to cannulate or if nurses were unable to cannulate the fistula. Kaplan-Meier life-table analysis was used to determine patency and for a subanalysis by location of FEP performed (172 brachial-cephalic, 70 brachial-basilic, 46 radial-cephalic, 7 superficial femoral vein). Survival curves were compared using log-rank test. RESULTS Functional primary patency rates for patients undergoing an adjunctive FEP were 73% at 6 months, 60% at 1 year, and 46% at 2 years. Secondary functional patency rates were 81% at 6 months, 71% at 1 year, and 59% at 2 years. There was no statistical significance in any outcomes based on anatomic site of elevation. CONCLUSIONS AV fistulas that might otherwise have been abandoned because of excessive depth or tortuosity can be successfully salvaged by an adjunctive FEP and achieve satisfactory longterm functional patency. FEP is a valuable adjunct to AV fistula creation, which will enhance fistula maturation rates.

The LEGS Score: A Proposed Grading System to Direct Treatment of Chronic Lower Extremity Ischemia

ObjectiveTo prospectively compare the Lower Extremity Grading System (LEGS)-derived “recommended treatment” to the actual treatment performed and to analyze LEGS intergrader scoring consistency by comparing blinded scoring results between physician graders. Summary Background DataDue to technical advances and the increased medical complexity of the aging population, the most appropriate treatment for chronic lower extremity ischemia—open surgery versus endovascular—is again in flux. In an attempt to standardize management, the LEGS score, based on the best available outcomes data, was devised by the physicians of an established vascular service. MethodsFrom March to June 2002, all chronically ischemic lower extremities that met standard indications for revascularization were prospectively enrolled and independently graded with the LEGS score by an “endovascular surgeon” and an “open surgeon” for comparative analysis. The results were then blindly evaluated to determine whether the LEGS-derived “recommended treatment” agreed with the actual treatment rendered and to assess for intergrader consistency. Agreement was assessed using kappa statistical analysis. ResultsOf the 137 presenting limbs (mean patient age 66.4 yo; 43% claudication, 57% limb-threatening ischemia), 107 were treated (65% endovascular, 30% open surgery, 5% amputation), 16 were pending treatment, and 14 were not treated because of patient refusal (n = 13) or death (n = 1). The LEGS score predicted the actual or offered clinical treatment in 90% of cases. The LEGS score comparison between physician graders resulted in identical “recommended treatment” in 116 of 128 cases for a 90.6% agreement. ConclusionsA reproducible scoring system to guide the treatment of patients with chronic lower extremity ischemia is possible. While systems like the LEGS score may have potential clinical application, their use as a treatment standardization tool for future prospective outcomes comparisons between open and endovascular surgery will be essential.

Proximal Anastomotic Failure Following Infrarenal Aortic Reconstruction: Late Development of True Aneurysms, Pseudoaneurysms, and Occlusive Disease

Distal anastomotic failure of aortic reconstructions attributable to femoral pseudoaneurysm or outflow stenosis has been well described, but little is known about proximal aortic anastomotic graft failure. A retrospective review was performed between January 1987 and March 1992 to characterize the presentation and management of proximal aortic anastomotic failure. Of 329 consecutive aortic reconstructive operations during this period, 11 (3.3%) were performed to correct complications arising at or adjacent to the proximal anastomosis of an aortic prosthesis. These included anastomotic pseudoaneurysm (n=6), true aneurysmal dilatation of the residual infrarenal or suprarenal aorta (n=4), and stenosis of the residual infrarenal aorta (n=1). The 11 patients had undergone prior infrarenal aortic reconstruction for either aneurysmal (n=5) or occlusive (n=6) disease an average of 120 months (range 36 to 175 months) before detection of proximal para-anastomotic graft failure. Eighty-two percent (n=9) of the proximal lesions were asymptomatic and were discovered incidentally during unrelated medical evaluations. Excluding the six pseudoaneurysms, four of the remaining five lesions developed in a relatively long segment of residual infrarenal aorta, including aneurysm above the graft (n=2), aneurysm below a proximal end-to-side anastomosis (n=1), and progressive proximal aortic atherosclerosis (n=1). Tube graft replacement of the proximal lesions was the most frequently performed operation (n=7); renal artery reimplantation or bypass was necessary in five cases (45%). Although there was no operative mortality, significant surgical morbidity occurred in three patients (27%). Proximal aortic graft complications tended to be asymptomatic and difficult to repair. Our data suggest that some lesions may be avoided by placing the original proximal aortic anastomosis end to end near the renal arteries. Appropriate noninvasive screening modalities may allow for more complete detection of these proximal anastomotic problems, especially in patients with remote aortic reconstructions.