Vascular

Case records of 166 patients with 180 major arterial limb injuries inflicted between 1959 and 1991 were reviewed. A total of 167 (95.4%) repaired arteries initially remained patent. Nine patients developed ischaemic contracture of their limbs, which required amputation. Late follow-up of 6 months — 30 years (mean 5 years) was obtained for 75 patients; 73 of these repairs remained patent. Early diagnosis, prompt treatment, complete débridement, appropriate coverage of the repaired vessels, fasciotomy when indicated and simultaneous treatment of concomitant injuries are crucial factors in successful limb salvage and in maintaining patency of the repaired vessels.

Fifty-five vascular graft infections were personally managed by the author over an 8-year period. For 22 patients with aortic graft infection, Staphylococcus epidermidis was the most common pathogen (18 of 22 patients), presenting as limb thrombosis in nine and pseudoaneurysm in five. All patients underwent staged extra-anatomic reconstruction and graft resection 4–5 days later. For 33 patients with peripheral infection, S. aureus was the most common pathogen (29 of 33 patients), presenting as clinical graft sepsis usually within months of initial operation. Local therapy was successful in seven of nine patients, whereas graft resection with autologous reconstruction achieved limb salvage in all 11 patients involved. Overall, the mortality rate was 9.1% for 22 aortic and zero for 33 peripheral infections; amputation rates were 14 and 12%, respectively.

The significance of positive bacterial cultures from intraluminal thrombus in patients undergoing repair of abdominal aortic aneurysm remains controversial. Over the last 4 years, thrombus was cultured during aneurysm repair in 116 patients. All patients received cephalosporin antibiotic before and for 48 h after operation. Although none of the aneurysms appeared to be clinically infected, six patients (5.2%) had positive cultures. Four groups were identified based on the bacteria cultured: group I, coagulase-negative staphylococci, light growth (three patients); group II, coagulase-negative staphylococci, light growth and ‘Streptococcus viridans’ (one patient); group III, Bacillus sp., heavy growth (Gram-negative stain) (one patient); group IV, Clostridium perfringens, occasional growth (one patient). One of the six patients died during resection; the other five are alive without graft infection at 5–24 (mean 12) months after operation. The absence of graft infection suggests that positive cultures were not clinically significant or were adequately covered by the antibiotic prophylaxis. The incidence of positive cultures was lower than previously reported. Routine culture of aneurysm thrombus in the absence of clinical infection is probably not cost-effective.

A new, compliant, highly porous, non-woven, polyurethane vascular prosthesis has been developed in an effort to improve on the performance of currently available prosthetic grafts for infrainguinal reconstruction. From April 1990 to August 1991, 57 femoropopliteal bypass grafts were implanted in 47 patients by surgeons at five university centres. In all instances, the saphenous vein was unavailable, unusable or reserved for use elsewhere. An empirical perioperative risk score for acute occlusion (0–20) was developed, based on such factors as severity of clinical ischaemia, quality of inflow and outflow, site of distal anastomosis and associated drug therapy. Primary cumulative patency was calculated according to standard life-table analysis. Poor inflow and a distal anastomosis below the knee were significant factors affecting graft patency (P= 0.001 and P= 0.001 respectively). Six-month cumulative patency for the 25 grafts with good inflow and above or mid-knee anastomoses (79%) was superior to the cumulative patency for all 57 grafts (59%). There was a significant improvement in patency rates between ‘low’ (22 grafts) and ‘medium risk’ (27 grafts) patients and ‘high risk’ (eight grafts) ones (risk scores 0–10 and 11–20 respectively) at a level of P= 0.001. There were two operative deaths (4%). Of the 19 postoperative occlusions, six occurred within 30 days and 18 within 6 months. These data indicate that the patency rates achieved with this new graft compare favourably with other available prosthetic grafts. In addition, the graft demonstrates superior handling characteristics and eliminates bleeding through suture holes. There is also the possibility that rapid tissue ingrowth, neointima formation and compliance will reduce intimal hyperplasia and increase long-term patency.

A prospective study was undertaken to define the comparative value of physical examination versus duplex scanning in the detection of femoral false aneurysm and arteriovenous fistula after percutaneous femoral artery puncture. Fifty-three patients were referred to the vascular surgery service after femoral artery catheterization for evaluation of a groin hematoma or a new femoral bruit. All patients were evaluated initially by a vascular surgeon and then by duplex scan. The results of these evaluations were compared with the findings at operation. Physical examination was 100% sensitive and 100% specific in the diagnosis of arteriovenous fistula, whereas duplex scan achieved a sensitivity of only 58% and a specificity of 100%. Physical examination was 92% sensitive and 93% specific in the detection of femoral false aneurysm compared with a sensitivity of 83% and a specificity of 100% for duplex scanning. Physical examination is the best method for detecting and following patients with arteriovenous fistula. False aneurysms can be detected reliably by physical examination, although evaluation with a duplex scan is necessary to identify the precise size and anatomy of these lesions.

Varicose veins are not generally used as arterial bypass grafts despite their physiological endothelial flow surface. The large, irregular diameter and the thin wall renders these veins inadequate. Experimental studies have shown that a considerable reduction in the diameter of veins can be achieved by external wrapping without the generation of obstructing folds of the vein wall. A Dacron mesh tube surrounding varicose veins was used as a bypass graft in 13 infrainguinal arterial reconstructions. Ligated larger side branches and connections of the mesh segments caused irregularities of the otherwise smooth flow surfaces. Ten grafts were patent after a mean follow-up of 17 months. Two grafts have remained patent despite severe outflow obstruction in one and proximal occlusion in the other; both underwent successful interventions. The antithrombogenic properties of these grafts were partly due to a marked increase of the vasa vasorum. Externally constricted varicose veins may be used as arterial bypass conduits with good intermediate-term patency.

The most frequently used conduit for infrainguinal or coronary artery bypass is the saphenous vein, and this report describes the ultrasonic evaluation of anatomic variations in over 1400 limbs. The thigh portion of the greater saphenous vein consisted of a single venous conduit in 67% of the limbs, a complete double system in 8%, a branching double system in 18% and a closed loop double system in 7%. In 92% of the cases, the vein was in medial position, with the remaining 8% positioned laterally. In the calf, a single vein was observed in 65% of the limbs with the remainder demonstrating a double venous system. The vein was positioned anteriorly in 85% of the limbs. The remaining 15% were positioned posteriorly, with 7% of these being a single dominant vein. Proper knowledge of saphenous vein anatomy is vital to the surgeon preparing to use this vein as a bypass conduit and can aid in its preoperative assessment.

Thrombectomy and thrombolysis are often advocated in the treatment of phlegmasia cerulea dolens, but frequently result in incomplete clot removal, recurrence of thrombosis, local and systemic hemorrhagic complications and chronic venous stasis; this state is associated with a rate of major amputation and death of up to 50%. Non-operative therapy includes elevation, hydration and heparinization and excludes all methods aimed at surgical removal or chemical lysis of the thrombus. In 1982 It was decided to use non-operative therapy as the first line of treatment for phlegmasia cerulea dolens. In the last 9 years seven extremities in six patients with this condition have been treated. One patient had advanced gangrene on presentation and one underwent emergency thrombectomy. Five extremities (in five patients) were treated with non-operative therapy. Ischemia was rapidly corrected in all five patients. Edema resolved completely after 3–4 days in four patients. There were no complications attributable to the therapy. Two of six (33%) patients died from terminal disease. Non-operative therapy appears to be effective in preventing limb loss and avoiding the risks of thrombectomy and thrombolysis in critically ill patients.

The histological features of lipodermatosclerosis and eosinophilic fasciitis and its variants were compared in a prospective study of outpatients attending the vascular clinic and inpatients in the Department of Medicine of a regional university hospital. Main outcome measures examined were swelling and induration of the subcutaneous layers with a stocking distribution in the calves. The inflammatory and fibrosing alterations involving the panniculus adiposus, superficial fascia and perimysium were essentially indistinguishable histologically in patients with lipodermatosclerosis or eosinophilic fasciitis and its variants. The intensity of the subcutaneous induration was related to the underlying nosological entity and the duration of the process. Infectious cellulitis was found to aggravate the clinical symptoms of lipodermatosclerosis. Since the stereotypical inflammatory and fibrosing processes in lipodermatosclerosis and eosinophilic fasciitis and its variants are similar irrespective of the initiating factors, it is suggested that there is a common final pathway in the pathogenesis of both disorders.

The use of axilloaxillary artery bypass grafting as a successful approach for patients with symptomatic atherosclerosis of the brachiocephalic arteries has been described but remains limited as a result of concern over its subcutaneous, trans-sternal position and long-term patency. The aim of this study was to help define the indications, complications and patency of axilloaxillary artery bypass grafting for the treatment of subclavian and innominate artery occlusive disease. A retrospective review was performed of ten patients who underwent this operation over a 15-year period at the authors' institution and of 253 cases reported in the literature. The most common complication was transient brachial plexopathy, occurring in 3.5% of patients, and graft infection or skin erosion was noted in 1.6%. Incidence of perioperative myocardial infarction, stroke and death was <2%, in contrast to other approaches which may involve thoracotomy, sternotomy, or carotid dissection and clamping. Recent series, including the authors', report a long-term primary patency rate (> 5 years) of around 90%. Because of its ease of performance, low morbidity and mortality, and excellent long-term patency, the authors propose that the axilloaxillary artery bypass is the procedure of choice in appropriately selected patients with symptomatic occlusive disease of the innominate and subclavian arteries.

The contribution of the hypogastric and superior mesenteric arteries to inferior mesenteric artery collateral (back) pressure (r-IMA) was measured in eight patients who were free from arterial disease and were operated on for small sigmoid carcinoma. Peak and mean r-IMAs were measured after clamping both common iliac arteries and the middle colic artery together with the marginal artery of Drummond. Measurements were repeated after the injection of 50 mg papaverine into the inferior mesenteric artery. For comparison the r-IMA was normalized against the radial artery pressure to create the r-IMA:radial artery pressure ratio. At peak systolic pressure the r-IMA:radial artery pressure was approximately 0.6. This fell with crossclamping of the middle colic artery and marginal artery of Drummond; a slightly greater fall was observed when the common iliac arteries were clamped. The findings were similar when mean pressures were compared. The changes in pressure ratio observed after collateral clamping were slightly amplified by injection of papaverine. These data suggest that the hypogastric arteries make at least as great or a slightly greater contribution to r-IMA than do the middle colic artery plus marginal artery of Drummond. The data also indicate the presence of other substantial collaterals. These findings stress the importance of the hypogastric collateral supplying the sigmoid colon when the inferior mesenteric artery is acutely occluded as it is during aneurysm resection.

A total of 85 occluded superficial femoral arteries were treated using the rotational transluminal angioplasty catheter system (ROTACS). The mean length of the occlusions was 7cm; 76% were uncalcified or only slightly calcified whereas 24% were calcified or highly calcified. The mean preoperative ankle:brachial index was 0.51. Primary success was achieved in 62 of 85 cases (73%). The mean length of reperfused occlusions was 6.2 cm: 26% of these lesions were calcified. The mean ankle:brachial index was 0.91. There were 23 primary failures (27%): reperfusion was impossible in 11 cases (Including one complicated by perforation) and there were eight dissections, three cases where residual stenosis exceeded 50%, and one other unspecified failure. The mean length of these occlusions was 10.5 cm; 17% were calcified. Two patients developed a distal embolus and one died 10 days after reperfusion. The probability of primary patency of a reperfused artery was 44% at 1 year. Forty-two of the 62 patients who achieved primary success remained symptom free; the mean length of the original occlusion was 4.5 cm. Fifteen patients developed a new area of stenosis whereas five others exhibited new occlusion after a mean interval of 6 months. The mean length of these reperfused arteries was 9 cm. The probability of secondary patency at 1 year was 58%. Arterial calcification did not appear to influence the feasibility of reperfusion using the catheter. The main factor determining successful reperfusion was the length of the occlusal defect (P <0.05). Reperfusion using the ROTACS did not improve the feasibility of reperfusion by conventional transluminal angioplasty. Although venous bypass remains the method of choice for treatment of an occluded superficial femoral artery, reperfusion using the ROTACS is a valid alternative for short, calcified occlusions in elderly patients with no remaining venous capital.

Successful direct revascularization in a 54-year-old man with embolism of the basilar artery following St Jude Medical valve replacement for mitral regurgitation 6 years earlier is reported. He arrived at the hospital in a deep coma. Computed tomography showed no new lesions, but subsequent angiography revealed occlusion of the basilar tip, bilateral posterior cerebral arteries and right superior cerebellar artery. Direct thrombolytic therapy was performed using 420000 units urokinase through an infusion catheter placed in the basilar artery. The patient immediately regained consciousness, with only slight diplopia. Direct thrombolytic therapy is considered to be an effective treatment for thromboembolism following prosthetic valve replacement in certain selected cases.

A traumatic pseudoaneurysm of the right gastroepiploic artery in a 55-year-old woman was resected using laparoscopy. The durations of anaesthesia and operation were 260 and 220 min respectively. Blood loss was minimal. The perioperative period was uneventful; the patient needed no analgesic treatment and ate her first meal on the morning of the day after surgery. She was discharged 5 days later and has progressed well for 5 months since surgery without any abnormal findings.

Cardiac events continue to be the leading cause of perioperative mortality following peripheral vascular reconstruction. The role of preoperative cardiac screening and prophylactic myocardial revascularization in patients without clinical evidence of coronary artery disease is undefined. Fifteen patients with no clinical evidence of coronary artery disease who were found to have reversible defects on dipyridamole-thallium scans and severe correctable coronary artery disease underwent aortocoronary artery bypass grafting. There was one (6.7%) operative death. Three patients (20%) developed postoperative complications: two atrial fibrillation and one breakdown of the saphenous vein harvest site. Thirteen patients underwent subsequent peripheral vascular surgery: seven had abdominal aortic procedures, three infrainguinal reconstruction, two carotid endarterectomy and one carotid-subclavian artery bypass. There were no perioperative or late deaths, cardiac complications, electrocardiographic changes, or episodes of angina associated with the peripheral vascular procedures. Thus, dipyridamole-thallium imaging appears to help select a group of symptom-free, but high cardiac risk, vascular patients in whom preparatory myocardial revascularization and subsequent peripheral vascular surgery can be performed with acceptable mortality and morbidity. The life expectancy of these patients may be improved and, specifically, the risk of their subsequent vascular surgery may be reduced by this approach.

A total of 224 patients with angina pectoris and a left ventricular ejection fraction in the range of 10–30% (mean 24.2%) underwent coronary artery bypass grafting between April 1986 and August 1991. These patients received a mean (s.d.) of 2.9 (0.3) aortocoronary vein grafts. The overall operative mortality rate was 8.9%. The 1-, 2- and 3-year survival rates were 87.7%, 86.7% and 85.2%, respectively. Analysis of operative risk factors showed that patients with an end-diastolic left ventricular pressure >24 mmHg were significantly more at risk (mortality rate 20.0%, P<0.05) than those with an end-diastolic left ventricular pressure ≤24 mmHg (mortality rate 6.2%). Patients with a perioperative cardiac index <2.51 min⁻¹m⁻² had higher mortality (25.4%) than those with a cardiac index 2.51 min⁻¹m⁻² (mortality 1.9%, P<0.001). The operative mortality rate of patients with a cardiac index <2.51 min⁻¹m⁻² and an end-diastolic left ventricular pressure >24 mmHg was 40.5%. Patients with a left ventricular ejection fraction of 10–20% were not significantly more at risk (P>0.05) than those with a left ventricular ejection fraction of 21–30%.

It is new possible experimentally to measure myocardial blood flow of the beating heart using a helium-neon (He-Ne) laser Doppler flowmeter. A myocardial probe was redesigned to reduce its size and weight, and a method devised of fixing the probe to the beating cardiac surface to allow its clinical application. This modified laser flowmeter was used on 36 patients with ischaemic heart disease to measure myocardial blood flow before and after revascularization. Flow was measured in the right and left ventricles while patients were in a haemodynamically stable state as determined by electrocardiography, heart rate, blood pressure and double product (heart rate × systolic blood pressure). No significant difference was found between the mean (s.e.m.) preoperative and postoperative flow volume at the anterior wall of the right ventricle (77(15) versus 81 (12) ml/min per 100g), which did not undergo revascularization, but mean (s.e.m.) myocardial blood flow at the ischaemic left ventricle increased significantly (from 68(15) to 88(13) ml/min per 100 g; P<0.01). There was also no significant difference between preoperative and postoperative values of haemodynamic parameters of coronary blood flow. In conclusion, a means to measure myocardial blood flow with He-Ne laser Doppler flowmetry has been devised which shows coronary artery bypass grafting to increase myocardial blood flow in the ischaemic myocardium.

From 1986 to 1989, seven children ranging in age from 5 months to 16 years underwent surgical treatment for the Wolff-Parkinson—White syndrome at the Shiga University of Medical Science. None of the patients had any other associated congenital heart disease. There was a right free wall accessory pathway in four patients and a left free wall accessory pathway in three. Surgical ablation of these accessory pathways was performed on eight occasions, using the endocardial approach three times and the epicardial approach five. All the children are alive and none has since had episodes of tachycardia. Only one patient had a recurrent delta wave, which was noted 18 months after the operation. Surgical ablation of the accessory pathway for the Wolff-Parkinson—White syndrome can be performed safely, even in infants and children; it is concluded that this useful procedure is capable of improving a patient's quality of life.

Because of unsatisfactory long-term results with current DeVega tricuspid annuloplasty, 43 patients with secondary tricuspid regurgitation associated with mitral disease were treated with a modified DeVega operation. This procedure continues the suture line to the tendon of Todaro, resulting in almost circumferential traction of the tricuspid annulus. The suture is tied securely around a 29-mm or 31-mm (for women and men, respectively) ball-shaped obturator. Atrioventricular block was not observed. One patient died during the early postoperative period. During a mean(s.d.) follow-up of 5.0(2.0) years, one patient died from causes unrelated to tricuspid regurgitation 2 years after surgery. The mean(s.d.) functional class (New York Heart Association) was 3.1(0.5) on admission and improved to 1.2(0.4) at the end of follow-up The mean(s.d.) cardiothoracic ratio improved from 67(6) to 60(5)% at 1 month after operation and was 59(5)% at the final examination. Preoperative Doppler echocardiography revealed a mean(s.d.) regurgitation grade of 2.7(0.7). (Grades 1–4 are equivalent to mild, moderate, severe and massive regurgitation, respectively.) At 1 month, regurgitation was corrected almost completely in all patients (grade 0.2(0.4)) and remained significantly improved at follow-up (grade 0.5(0.6)). The actuarial freedom rate at 5 years for moderate or severe reguritiation (> grade 2) was 93%. This modification of the DeVega technique substantially improved early and late tricuspid valve competence.

A mouse monoclonal antibody 1A29, which binds to the rat intercellular adhesion molecule-1 (ICAM-1), was studied for its effect on cardiac allograft survival. Expression of ICAM-1 was detectable only on vascular endothelium in normal heart, but was induced on myocardium associated with interstitial mononuclear cell infiltration during acute rejection. Treatment with monoclonal antibody 1A29 for 10 days after transplantation in 15 rats significantly prolonged allograft survival (mean(s.d.) 18(2) days; P<0.001), as compared with 15 isotype-matched control monoclonal antibody (mean(s.d.) 10(1) days) recipients. Five-day treatment with monoclonal antibody 1A29, when started at 5 days after transplantation (the time for which acute rejection is ongoing), also significantly extended the survival (mean(s.d.) 12(1) days; P<0.01) in seven rats. On histological examination, treatment with monoclonal antibody 1A29 reduced the degree of T-cell infiltration of both CD4+ and CD8+ subsets, and greatly reduced myocardial necrosis, vascular injury and intravenous thrombi. These results indicate that an anti-ICAM-1 monoclonal antibody can be used to prevent or treat acute rejection in the rat cardiac allograft model and suggest that human ICAM-1 is an important target for immunosuppression in clinical organ transplantation.

A total of 44 patients undergoing isolated aortic valve replacement received either anterograde (20 patients) or retrograde (24 patients), cold St Thomas's Hospital cardioplegia. The patients were similar with respect to age, sex, left ventricular ejection fraction, left ventricular-aortic pressure gradient, cross-clamping time and mean dose of cardioplegia. After surgery, there were no differences in enzyme release, low cardiac output syndrome, rhythm disturbances or clinical outcome between the two groups. Analysis of the postoperative haemodynamic data, however, suggests better preservation of left ventricular contractility with retrograde delivery of cardioplegic solution.

Fifty consecutive patients undergoing coronary artery bypass grafting surgery were studied to evaluate the effects of intermittent anterograde cold cardioplegia (IACCH) and intermittent combined anterograde-retrograde cold cardioplegia (IRCCN) on left ventricular function using transesophageal echocardiography. Global function did not significantly change in both groups, but significantly more inotropes were required in IACCH. Newly developed abnormalities of regional wall motion after cardiopulmonary bypass, which were indicative of ischemic myocardium, were detected in the segments supplied by the right coronary artery in both groups (IACCH, 20%; IRCCN, 16%), by the left circumflex coronary artery only in IACCH (12%) and by the left anterior descending coronary artery only in IRCCN (12%). It is concluded that although global evaluation of left ventricular function did not show any significant change after IACCH and IRCCN under routine management, analysis of abnormalities of regional wall motion provided specific information. In both groups, complete protection of the myocardium was not achieved, and the characteristics of poorly protected areas were dependent on the difference in the two methods. Myocardium supplied by the right coronary artery seemed to be particularly vulnerable, and a special effort to protect these segments is mandatory for a successful outcome.

Between January 1985 and March 1990, isolated Omnicarbon valve replacement operations were performed on 90 patients aged 25–72 years. There were 53 aortic valve replacements (AVR) and 37 mitral valve replacements (MVR). The cumulative follow-up was 320 patient-years, with a mean(s.d.) follow-up of 3.7(1.4) years. There were three operative and hospital deaths (3.3%) resulting from retrograde aortic dissection during cardiopulmonary bypass, postoperative renal failure and postoperative mediastinitis. Seven patients died during the late postoperative period, four from valve-related causes. Two of these patients died from prosthetic valve endocarditis, and the others died from thromboembolism and valve thrombosis. The mean(s.d.) actuarial survival rate at 6 years was 86.2(4.3)% (98.8(0.8)% for AVR, 82.1(4.8)% for MVR). The mean(s.d.) actuarial survival rate of freedom from all valve-related mortality at 6 years was 93.5(2.6)% (100% for AVR, 88.1 (2.9)% for MVR). There were two thromboembolic events (one mesenteric artery thrombosis and one valve thrombosis). The standardized incidence of thromboembolism was 0.63% per patient-year. Prosthetic valve endocarditis occurred in three patients (0.94% per patient-year). One patient (0.31% per patient-year) was found to have a paravalvular leak resulting from aortitis syndrome. The mean(s.d.) actuarial rate of freedom from all valve-related complications at 6 years was 89.2(2.0)% (98.6(1.0)% for AVR, 86.4(2.2)% for MVR). There were no instances of anticoagulant-related haemorrhage, valve-related haemolysis, or structural failure. Results of a follow-up period of 6 years indicated that good clinical results and a low incidence of valve-related complications can be demonstrated with the Omnicarbon valve.

A case report of a 73-year-old woman with mitral regurgitation secondary to papillary fibroelastoma and prolapse of the mitral valve is described. The tumor was excised, and the valve repaired with a Duran annuloplasty ring. The clinicopathologic features and the surgical management of this rare tumor are reviewed.

Forty-seven cases of cervical aortic arch have been reported in the literature. Eleven of these patients had congenital cardiac defects, including tetralogy of Fallot in three. An additional case of cervical aortic arch and tetralogy of Fallot is presented along with a brief review of the literature pertaining to this rare condition.

A patient with isolated pulmonary valve infective endocarditis without congenital heart disease was diagnosed at an early stage. Simple valvulectomy without replacement was successfully performed during the active stage of infection.

Between 1977 and 1992, four infants with an anomalous left pulmonary artery and subsequent compression of the tracheobronchial tree were operated on at the University Hospital Zurich. The operation consisted of mobilization of the abnormal left pulmonary artery with reimplantation into the main pulmonary trunk in three patients; the left pulmonary artery was transected and restored in front of the trachea by end-to-end anastomosis in one. Mean follow-up was 7 years (range 2 months to 14.3 years). There were no early and no late deaths. All patients have shown significant symptomatic improvement without respiratory infection or disturbance of normal life activities. Surgical therapy in this rare condition can be safely undertaken with good long-term results. In symptomatic patients the operation should be performed early before occurrence of severe respiratory symptoms and bronchial collapse.