Y.P. Panayiotopoulos

Fatal Colonic Ischaemia after Stent Graft for Aortic Aneurysm

The development of new technology has led to renewed interest among both surgeons and radiologists in the treatment of infrarenal aortic aneurysms by endovascular techniques. Parodi and Palmaz pioneered the endovascular repair of aortic aneurysms using a straight stent graft. 1 Chuter et al. developed a means of deploying a bifurcated graft via the transfemoral route 2 and other series have been reported recently. 3 However, all new techniques have a learning curve. We report a case of fatal internal iliac artery embolism associated with insertion of a stent graft used to treat a symptomatic abdominal aortic aneurysm.

A scoring system to predict the outcome of long femorodistal arterial bypass grafts to single calf or pedal vessels

OBJECTIVES The aim of this study was to develop a scoring system to predict the outcome of long femorocrural and femoropedal bypass grafts performed for critical limb ischaemia. SETTING Teaching hospital. METHODS An analysis of 109 consecutive femorodistal bypass grafts performed for critical lower limb ischaemia between June 1991 to December 1994. Factors shown to affect the outcome were: inflow, number of patent calf vessels, graft material, straight flow to the foot and patent pedal vessels. These variables were weighted according to their relative significance (multivariate Cox regression) and a scoring system (ranging from 0 to 10) was developed. RESULTS Patients with a preoperative score of 0-4 (n = 35) showed a secondary patency of 36% at 1 month, 12% at 3 months and 0% at 10 months (Cum SE = 6.90/0.0). Secondary patency rates for the 46 patients with score 5-7 were 88.7% at 3 months, 56.3% at 12, and 45.1% at 2 and 3 years (Cum SE = 9.82), while the respective values for the 28 patients with score 8-10 were 92.7%, 88.5% and 81.7% (Cum SE = 8.08). The difference was highly significant (p = 0.000) in all tests of equality. In addition, the median total hospital cost was 12,600 Pounds for the group 0-4 compared with 8100 Pounds (group 5-7) and 4400 Pounds (group 8-10) (p = 0.0085). CONCLUSIONS This preoperative scoring system appears to correlate well with the outcome of distal revascularisation to single calf or pedal vessels. If applied to patient selection, it could significantly reduce the total hospital cost per leg saved. A prospective testing of its predictive ability is needed and is in progress.

The Concept of Knee Salvage: Why Does a Failed Femorocrural/pedal Arterial Bypass Not Affect the Amputation Level?

OBJECTIVES There is continued controversy over whether a failed distal bypass influences the level of amputation. This issue is important as the number of arterial bypass grafts undertaken for critical ischaemia is increasing, followed by an increasing number of failed grafts. SETTING Teaching hospital. STUDY DESIGN AND MATERIALS: A prospective analysis of 109 consecutive femorocrural/pedal bypass grafts performed between June 1991 and January 1995 on patients presenting with severe critical lower limb ischaemia (CLI) to a single vascular unit. A further 43 amputations for non-reconstructible distal disease were also analysed. CHIEF OUTCOME MEASURES Mortality, amputation, rehabilitation, survival and knee salvage rates. The Kaplan-Meier method was used for comparison of factors associated with knee preservation. RESULTS Primary amputees had a higher in-hospital mortality (18% vs. 10%) but similar 3 year survival rates (30%) compared with secondary amputees (36.6%). Patients with successful grafts showed a trend towards better survival (61.9% at 3 years) compared to amputees (38.6% at 42 months, p = 0.061). Below- to above-knee amputation ratio was similar in the two groups (0.85 in secondary vs. 0.95 in primary amputees). Factors significantly associated with knee salvage at 3 years were shown to be: the condition of the inflow (81.9% for good vs. 43.1% for impaired, p = 0.000) the state of the profunda femoris artery (good 93%, impaired 71%, occluded 37% p = 0.0001) and the graft material (vein 81.8% vs. PTFE 59.8%, p = 0.033). The presence of tissue loss (p = 0.0523) and secondary procedures (p = 0.0879) showed a trend to become significant. Multivariate and Cox regression analysis showed that the most important factors were the inflow (p = 0.001), the state of the profunda (p = 0.001), the graft material (p = 0.034) and previous revascularisation attempts (p = 0.019). CONCLUSIONS The factors which determine knee loss are a compromised inflow state, the presence of an inadequate profunda femoris, previous revascularisation attempts and the use of synthetic graft material. Most of these factors (with the exception of infection related to revascularisation) are present before reconstructive arterial surgery is performed and this study shows that failure of a distal graft does not affect the final amputation level.

Endovascular repair of residual iliac artery aneurysms following surgery for ruptured abdominal aortic aneurysm.

Emergency repair of ruptured abdominal aortic aneurysm continues to have a high mortality. Such patients require expeditious operations to repair the ruptured segment rather than attempts to deal with all coexisting disease. The use of endovascular techniques obviates the need for open surgery to repair iliac aneurysms. We report two patients who, after successful repair of ruptured abdominal aortic aneurysms, had three iliac artery aneurysms treated successfully by embolisation in one case and percutaneous insertion of a self expandable stent graft in two cases. The issues that arise from such an approach are discussed with a review of the literature.

Recurrent coronary-subclavian steal syndrome treated by left subclavian artery stenting

The left internal mammary artery (LIMA) has better long-term patency rates than long saphenous vein grafts when used for coronary artery bypass surgery. 1 However, blood flow through it can be compromised by proximal disease in the left subclavian artery, resulting in recurrence of the symptoms of myocardial ischaemia. This has been termed the coronary-subclavian steal syndrome, and retrograde flow through the LIMA graft can be shown on coronary angiography. Various treatments have been used to correct this, including carotid-subclavian bypass, percutaneous transluminal angioplasty (PTA) and most recently, primary stenting. We describe a case initially treated with angioplasty, which recurred and eventually required percutaneous stenting with complete resolution of symptoms.

A PAPER FOR DEBATE : VEIN VERSUS PTFE FOR CRITICAL LIMB ISCHAEMIA : AN UNFAIR COMPARISON?

INTRODUCTION There is a widely held view that vein grafts for infrainguinal arterial reconstruction perform much better than prosthetic conduits, the best of which seems to be PTFE. Many randomised studies have been conducted which confirm this opinion, but is the difference as large as it is thought to be? One interesting feature of published trials is that the results for obligatory PTFE (when no vein is available) were much worse than the results for randomised PTFE grafts. The only way to explain this is that these groups of patients were not similar, and there are probably other factors which contribute to the difference in results when vein and PTFE grafts are compared. MATERIALS AND METHODS A consecutive series of 109 femoro-infrapopliteal grafts undertaken for critical limb ischaemia was analysed to see the difference between vein and PTFE with vein cuff grafts. RESULTS Vein grafts were superior to PTFE grafts when the whole cohort was included (p = 0.0038); however, there was no significant difference when the patients were stratified for inflow and runoff status. CONCLUSIONS The difference between vein and PTFE has probably been exaggerated in the past, due to differences in risk factors and in the extent of arterial disease between the two groups of patients. The advantage of vein becomes more significant with time.

Successful Intraarterial Thrombolysis of an Ischemic Limb Four Days After Laparoscopic Cholecystectomy

Abstract Intraarterial thrombolysis is usually contraindicated after abdominal surgery because of the risk of bleeding. However, it is a highly effective treatment for embolic acute limb ischemia, particularly for clearing the distal vessels. We report a case in which intraarterial thrombolysis was safely used 4 days after laparoscopic cholecystectomy in a patient with an acutely ischemic leg due to embolus.

Inadvertent rupture of a composite vein graft by angioplasty

The superiority of vein over polytetrafluoroethylene (PTFE) as a bypass conduit for grafts ending below the knee makes it the material of choice for this purpose. When insufficient long saphenous vein is available, lengths of arm vein may be used as a satisfactory alternative to make a composite graft. This may cause confusion in subsequent graft surveillance programs as the arm vein segment may show different characteristics from the remainder of the graft. We report a case where a stenosis developed in the arm vein segment of a bypass graft which subsequently ruptured during balloon angioplasty with formation of a false aneurysm. This was due to the balloon size being selected on the basis of the size of the long saphenous vein section of the graft instead of the arm vein segment. Full communication between surgeon and radiologist must include complete details of all materials used in bypass grafts in order to avoid potentially disastrous results from angioplasty.