Distal wound complications following pedal bypass: analysis of risk factors

Wound complications of the pedal incision continue to compromise successful limb salvage following aggressive revascularization. Significant distal wound disruption occurred in 14 of 142 (9.8%) patients undergoing pedal bypass with autogenous vein for limb salvage between 1986 and 1993. One hundred forty-two pedal bypass procedures were performed for rest pain in 66 patients and tissue necrosis in 76. Among the 86 men and 56 women, 76% were diabetic and 73% were black. All but eight patients had a history of diabetes and/or tobacco use. Eight wounds were successfully managed with maintenance of patent grafts from 5 to 57 months. Exposure of a patent graft precipitated amputation in three patients, as did graft occlusion in an additional patient. One graft was salvaged by revision to the peroneal artery and one was covered by a local bipedicled flap. Multiple regression analysis identified three factors associated with wound complications at the pedal incision site: diabetes mellitus (p = 0.03), age > 70 years (p = 0.03), and rest pain (p = 0.05). Ancillary techniques ("pie-crusting") to reduce skin tension resulted in no distal wound problems among 15 patients considered to be at greatest risk for wound breakdown. Attention to technique of distal graft tunneling, a wound closure that reduces tension, and control of swelling by avoiding dependency on and use of gentle elastic compression assume crucial importance in minimizing pedal wound complications following pedal bypass.

Upregulation of b-FGF receptor expression after carotid bypass

Basic fibroblast growth factor (b-FGF) appears to be an important positive modulator of the neointimal hyperplasia that occurs after prosthetic vascular graft implantation through its effects on vascular myointimal/smooth muscle cell migration and proliferation. The distribution and extent of b-FGF receptor (b-FGFR1) expression was compared using immunohistochemical techniques in normal porcine carotid arteries and at various times up to 6 weeks following implantation of small caliber prosthetic vascular grafts. At the time of graft harvest, specimens were infused with OCT medium at 100 mm Hg and rapidly frozen in liquid nitrogen. Transverse sections of the perianastomotic arterial tissues were labeled with primary mouse monoclonal antibody directed toward the extracellular domain of the receptor, followed by goat-anti mouse IgG and rabbit anti-goat IgG conjugated to horseradish peroxidase. The b-FGFR1-positive cells were identified by peroxidase activity within the Golgi complex of smooth muscle cells. Normal porcine carotid arteries showed no evidence of staining for b-FGFR1. However, at 6 weeks cells in the perianastomotic area clearly showed significant b-FGFR1 localization. Anti-muscle actin labeling confirmed these to be smooth muscle cells. The observed upregulation of b-FGFR1 expression supports the concept of positive feedback by cytokines as a contributing factor to the hyperplastic response of smooth muscle cells after prosthetic vascular graft implantation. This finding further supports a potential strategy to specifically target activated smooth muscle cells through use of mitotoxin therapy.

Aortic dissection originating in the suprarenal abdominal aorta

Spontaneous dissection of the abdominal aorta originating from the suprarenal aorta is very rare. Previous reports attest to the lethal nature of this disorder. This case represents the first report of successful repair of a spontaneous suprarenal abdominal aortic dissection by graft insertion with obliteration of both the entrance tear and the false lumen with reimplantation of the visceral vessels.

Limitations of peroneal artery bypass grafting for limb salvage

PURPOSE

The purpose of this study was to compare the results of peroneal bypass grafting for limb salvage with the results of other tibial and pedal bypass grafts performed concurrently.

METHODS

Thirty-four peroneal bypass grafts with autologous vein were performed for limb salvage between September 1986 and June 1992. These constituted 18% of an overall experience of 194 tibial or pedal bypasses performed during that time. Preoperative and intraoperative arteriograms were reviewed to identify anatomic characteristics associated with successful limb salvage.

RESULTS

Secondary patency rates for peroneal bypass grafts (70%) compared with the other tibial and pedal bypass grafts (65%) did not differ significantly at 48 months by life-table analysis. Limb salvage achieved by peroneal artery bypass grafting was significantly worse (55%) than that achieved by the remaining tibial and pedal bypasses (67%) at 48 months. Limb salvage was 33% at 7 months for those undergoing peroneal artery bypass grafting as opposed to 57% at 48 months for patients undergoing other tibial or pedal revascularizations with tissue necrosis. Four anatomic features were identified that were associated with failure after peroneal artery bypass grafting. These were peroneal length less than 10 cm (p = 0.012), peroneal artery diameter less than 2 mm (p = 0.035), absence of arteriographically demonstrated collaterals perfusing the foot (p = 0.0001), and little or no visualization of the pedal arch (p = 0.008).

CONCLUSIONS

Although successful grafts may avoid amputation in carefully selected cases, alternatives to peroneal artery bypass grafting should be considered when less than favorable anatomic conditions are encountered, particularly in the presence of forefoot tissue necrosis.

Traumatic aneurysm associated with fibrointimal proliferation of the common carotid artery following blunt trauma: case report

Late neurologic symptoms following blunt trauma to the neck and upper torso were evaluated with duplex scanning of the carotid arteries and the diagnosis of a traumatic aneurysm of the common carotid artery with an associated stenosis was made. Resection and an end-to-end anastomosis resulted in an excellent outcome. Carotid aneurysm following blunt trauma is unusual and duplex scanning facilitated the diagnosis. Duplex scanning is useful in the evaluation of the carotid arteries in patients with posttraumatic neurologic symptoms.

Limitations of subfascial ligation for refractory chronic venous stasis ulceration

Eighteen subfascial ligations of deep venous perforators were performed on 17 patients with refractory venous stasis ulceration. Thirteen patients also required concomitant or subsequent split thickness skin grafting. Primary indications included: (1) recurrence of ulceration during adequate support therapy with failure to heal using conservative measures (10 cases--55%) and (2) failure to heal with support therapy alone (eight cases 45%). Five limbs had ulcers greater than 30 cm2 and two had giant ulcers (greater than 50 cm2). Most extremities had evidence of venous reflux by photoplethysmography or Doppler ultrasound (10 of 11) or chronic deep venous thrombosis by venography (six of seven). Mean hospital stay was 23 days +/- 17, range six to 68 days. Early complications, including incisional breakdown or partial skin graft loss, were common and occurred in 10 patients. With a mean follow-up interval of 28 months (range nine to 49 months), most limbs (N = 10) were judged cured, including both with giant ulcers, and three significantly improved. By life table analysis, 63% were free from significant ulcer recurrence at 42 months. Four limbs were not significantly improved following surgery. Most patients with refractory venous ulceration will benefit from subfascial ligation of deep venous perforators and skin grafting, although recurrent or persistent ulceration remains problematic for a significant number of patients.

The influence of groin sepsis on extraanatomic bypass patency in patients with prosthetic graft infection

Twenty-seven vascular prosthetic graft infections in 25 patients were managed from 1981 through 1990 using the principles of extraanatomic bypass through uncontaminated fields and removal of the infected prosthesis. This experience included 18 aortic, three femoral-femoral, three femoral-popliteal, two axillofemoral grafts, and one popliteal endarterectomy patch. The predominant organism was Staphylococcus epidermidis (26%). Mean follow-up was 36 months. There was only one early and one late death, with two late amputations. Extraanatomic bypass grafts were placed in 21 of 25 patients including all 18 infected aortic grafts. Of these 21 patients, 11 (52%) experienced at least one extraanatomic bypass failure within 15 months, resulting directly in two major lower extremity amputations and two graft reinfections. Axillounifemoral bypass had a higher incidence of failure than axillobifemoral bypass (54% versus 29%). More importantly, however, extraanatomic graft failure was also associated with the presence of groin sepsis. The revision rate was 63% when the graft required circuitous tunneling to avoid groin sepsis, in contrast to a revision rate of only 17% when the graft could be anastomosed directly to the common femoral artery. Of extraanatomic bypass grafts that failed once, 63% had multiple failures. Graft removal and extraanatomic revascularization produced excellent overall results when not involving the groin. Late complications occurred more frequently when groin sepsis was present. These results suggest that, to reduce the incidence of late graft failure and amputation, more aggressive early direct reconstruction should be performed in lieu of atypical graft tunneling, especially if the extraanatomic graft has failed once and the causative organism is Staphylococcus epidermidis.

Dobutamine-201Tl imaging. Assessing cardiac risks associated with vascular surgery

The prevalence of coronary artery disease among patients considered for vascular surgical reconstructive procedures is appreciable though often clinically not apparent. One hundred and twenty-six patients underwent dobutamine-201Tl imaging (DTI) in preparation for vascular reconstruction. Fifty-four patients (43%) had a normal study and underwent vascular reconstruction, with one postoperative myocardial ischemic event (1.8%). 30 patients (24%) had a fixed defect present on DTI, which was indicative of prior infarction. Twenty-eight of these 30 patients underwent vascular reconstruction, with three postoperative myocardial ischemic events (11%, p = NS). The presence of a fixed defect on DTI did not significantly increase the risk of ischemic events in patients undergoing vascular procedures. Forty-two (33%) patients had reperfusion of their defects on DTI, which was indicative of myocardial ischemia. Fifteen of these 42 (36%) were denied vascular reconstruction. Nine of the 42 (21%) had either coronary artery bypass graft surgery or coronary angioplasty performed before vascular reconstruction without any postoperative myocardial ischemic events. The remaining 18 patients with reversible ischemia identified by DTI underwent vascular reconstruction without preoperative cardiac intervention, and nine of these 18 (50%) suffered a postoperative myocardial ischemic event (p less than 0.0001). Although there was a difference in the incidence of ischemic events among patients undergoing peripheral vascular compared with aortic reconstruction (71% versus 36%), if there was reversible ischemia identified on DTI this did not reach statistical significance. DTI is a reliable screening test that allows for an accurate means of predicting cardiac risks associated with vascular reconstruction, as well as identifying patients that might benefit from further cardiac evaluation and preoperative intervention.

Does postoperative surveillance with duplex scanning identify the failing distal bypass?

Duplex scanning used to determine graft flow velocities is an effective means of identifying lower extremity bypass grafts at risk for failure before they occlude. We implemented a graft surveillance protocol using duplex scanning and over a two-year interval evaluated fifty-four lower extremity bypasses utilizing graft flow velocities, ankle/brachial indices, and toe pressure measurements. Three patients were identified with grafts at risk for thrombosis. Of these patients, one had no evidence of arteriographic stenosis, one patient had clinical symptoms of reduced flow velocity measurements, and one's graft subsequently occluded during follow-up. Eight patients with graft flow velocities of greater than 45 cm/sec subsequently developed occlusion or were noted to have a severe associated stenosis. Six patients developed unheralded graft occlusion less than three months following determination of the graft flow velocity. Four of these patients (67%) had bypasses to the dorsalis pedis artery. Graft flow velocity measurements do not always predict an impending graft failure, and other factors may contribute to the sudden occlusion of patent distal bypasses, especially to the pedal arteries. Although the concept of hemodynamic monitoring to identify impending graft failure is an attractive one, more sensitive or refined measurements (especially to the pedal vessels), are required.

Preoperative evaluation of cardiac risk using dobutamine-thallium imaging in vascular surgery

Coronary artery disease is frequently present in patients undergoing evaluation for reconstructive peripheral vascular surgery. Dobutamine-thallium imaging has been shown to be a reliable and sensitive noninvasive method for the detection of significant coronary artery disease. Eighty-seven candidates for vascular reconstruction underwent dobutamine-thallium imaging. Forty-eight patients had an abnormal dobutamine-thallium scan. Twenty-two patients had infarct only, while 26 had reversible ischemia demonstrated on dobutamine-thallium imaging. Fourteen of 26 patients with reversible ischemia underwent cardiac catheterization and 11 showed significant coronary artery disease. Seven patients underwent preoperative coronary bypass grafting or angioplasty. There were no postoperative myocardial events in this group. Three patients were denied surgery on the basis of unreconstructible coronary artery disease, and one patient refused further intervention. Ten patients with reversible myocardial ischemia on dobutamine-thallium imaging underwent vascular surgical reconstruction without coronary revascularization and suffered a 40% incidence of postoperative myocardial ischemic events. Five patients were denied surgery because of presumed significant coronary artery disease on the basis of the dobutamine-thallium imaging and clinical evaluation alone. Thirty-nine patients with normal dobutamine-thallium scans underwent vascular reconstructive surgery with a 5% incidence of postoperative myocardial ischemia. Dobutamine-thallium imaging is a sensitive and reliable screening method which identifies those patients with coronary artery disease who are at high risk for perioperative myocardial ischemia following peripheral vascular surgery.

Aortic reconstruction in high-risk pulmonary patients

Seventeen patients with clinical chronic obstructive pulmonary disease (COPD) who required aortic reconstruction underwent preoperative pulmonary function testing that categorized them as extremely high risk for pulmonary complications. Ten patients (Group 1) received perioperative steroids and seven patients (Group 2) received no perioperative adjunctive steroids. The mean forced expiratory volume (FEV 1) was 45% of the predicted value in Group 1 patients and 47% in Group 2 patients. The forced expiratory flow (25% to 75%) was severely restricted in both groups: 0.47 liters per second in Group 1 (16% +/- 6% predicted value) and 0.53 liters per second (20% +/- 7% predicted value) in Group 2 patients. Using a regimen consisting of preoperative pulmonary physiotherapy, optimization of theophylline levels, and early postoperative extubation with initiation of postoperative physiotherapy resulted in survival in all cases. There did not appear to be a clear advantage to the use of adjunctive perioperative steroids. The overall incidence of pulmonary complications was 22%. Four patients died during the follow-up interval. The remaining 13 patients were alive at a mean follow-up interval of 35 months. Using a number of adjunctive techniques, successful aortic reconstruction can be accomplished in many patients with severe COPD, and the majority will survive for extended periods after operation despite their impaired pulmonary function.

The inherent limitations of sequential arterial bypass grafts: a hemodynamic study

While proximal bypass graft flows are known to increase by the sequential technique, the possibility of a "steal phenomenon" caused by the intermediate anastomosis has been raised. We compared graft and distal flow rates using simple reversed vein versus sequential bypass grafts in a canine model. A blind segment was created by occluding the common iliac artery above and the superficial femoral artery below a profunda femoris artery equivalent, which served as runoff from the blind segment. Reversed saphenous vein harvested from the contralateral thigh in seven anesthetized dogs was used to perform a simple common iliac artery to superficial femoral artery bypass. Graft and distal superficial femoral artery flow were measured with a calibrated flow probe of appropriate diameter (3-5 mm). A sequential side-to-side vein graft to arterial blind segment anastomosis was then added and flow measurements repeated after equilibration. Mean graft flow increased by 20 cc/min with the sequential technique (p = 0.05), while distal flow actually decreased by 1 cc/min (NS). Although no "steal phenomenon" was demonstrated, distal flow was not significantly improved by the sequential technique. We conclude that no convincing case based on presumed hemodynamic superiority can be made for performing sequential bypass in preference to standard reversed vein bypass. The increased potential for technical error introduced by the additional anastomosis and the lack of any demonstrable augmentation in distal flow suggest inherent limitations of the technique, and caution against its widespread use.

A multidisciplinary approach to reducing morbidity and operative blood loss during resection of carotid body tumor

Seven carotid body tumors in six patients were successfully managed using a multimodality approach that included the vascular surgeon, head and neck surgeon and angiographer. Five tumors were managed with preoperative subselective embolization of tumor vessels. Two required vascular reconstruction. The mean operative blood loss was 332 milliliters. All of the patients survived, and the only morbidity was one instance of transient vocal cord paresis. Surgical resection remains the treatment of choice for carotid body tumors. After angiographic embolization, a combined surgical approach by both the vascular surgeon and the head and neck surgeon reduces the associated morbidity and blood loss during resection.

Special problems after iatrogenic vascular injuries

Iatrogenic vascular injuries occurring at our institution were reviewed and several special problems not previously well described were found. These include carotid and femoral pseudoaneurysms, occult hemorrhage and knotting of the angiographic catheter. These problems are exemplified in four patient reports to illustrate how appropriate planning of operative approach and adherence to vascular surgical principles can optimize results.

Minimizing mortality and morbidity from iatrogenic arterial injuries: the need for early recognition and prompt repair

Seventy-one cases of iatrogenic arterial injury requiring repair at our institution from 1972 through 1984 were retrospectively analyzed. Cardiac catheterization accounted for most of the injuries (62%). Ten injuries (14%) resulted from angiography or percutaneous transluminal angioplasty; four injuries (5.6%) occurred after invasive monitoring devices were inserted. Six injuries (8.45%) stemmed from complications of intra-aortic balloon pump insertion, whereas the remainder occurred during various surgical procedures. Most injuries were in the femoral (42.3%) and brachial (38.1%) locations. Thrombectomy (23.9%) and resection with end-to-end anastomosis (35.2%) were the repairs most commonly performed. Morbidity and mortality were low; only one case resulted in limb loss, and neither of the two deaths resulted from the vascular repair itself. On the basis of our experience, we can make certain recommendations with regard to specific injuries. First, the conservative approach to brachial artery thrombosis occurring after catheterization is early exploration and repair. Second, although most injuries can be managed simply with thrombectomy and primary repair, iliofemoral injuries are more likely to require complex reconstructive techniques. Third, large-bore catheter injuries to the carotid artery require immediate exploration and repair to prevent thrombosis, pseudoaneurysm, and cerebral embolism. Fourth, symptoms of nerve compression after transaxillary arteriography require prompt exploration. Our results indicate that, depending on the site of injury, individualized techniques of varying complexity are required for repair. In general, serious sequelae can be minimized by early recognition, prompt operation, and adherence to sound vascular surgical principles.

Popliteal artery pseudoaneurysm following arthroscopy

An 18-year-old male presented with left foot ischemia secondary to emboli from a pseudoaneurysm of the left popliteal artery. His past history was significant only for two arthroscopies of his left knee. After evaluation, the patient was successfully treated with obliteration of the aneurysm and a reverse saphenous vein bypass graft.

Lower extremity arterial disease in young adults. A systematic approach to early diagnosis

General and vascular surgeons are consulted occasionally to evaluate young adults with ischemia of the lower extremity. Between 1975 and 1985, 51 adults under 40 years of age who had arterial occlusive disease of the lower limb were managed. Although premature atherosclerosis was the most common problem (50%), claudication or limb-threatening ischemia also resulted from other sources (thromboembolism, popliteal artery entrapment, Buerger's disease, collagen vascular disease, and Takayasu's arteritis). Identifying the exact cause was sometimes difficult. The authors were impressed with the number of young adults who had delay in diagnosis and treatment (30 patients, 59%) before referral for a surgical opinion. In this paper, the attempt has been made to uncover the reasons for delayed diagnosis and to suggest a systematic approach that should lead to early recognition of lower extremity ischemia in this age group.

Statistical determinants of success and complications of thrombolytic therapy for arterial occlusion of lower extremity

In this prospective study, we have documented the limited usefulness of thrombolytic therapy in the management of all patients with arterial occlusion of the lower extremities. We have also emphasized the significant rate of recurrent thrombosis unless an underlying obstructive lesion is corrected surgically after clot dissolution. Because thrombolytic drugs can lyse clots of a duration of several weeks, we recommend consideration of fibrinolytic therapy for subacute graft occlusions and segmental arterial thromboses. In such instances, thrombolysis is likely to reveal a focal underlying lesion that is correctable by a limited anastomotic revision or balloon angioplasty. Without fibrinolytic therapy, these older occlusions generally require more extensive bypass grafting or graft replacement. In contrast, we are less enthusiastic about thrombolytic therapy for distal small vessel thrombosis or embolism because complete clot lysis was achieved in only one of five patients. The primary problems with regional arterial low dosage thrombolytic infusions are bleeding at the angiographic catheter entry site and distal thromboemboli of the lysing clot. These difficulties may discourage wide acceptance of fibrinolytic therapy. However, they can be minimized by careful technique. Although its usefulness is limited and complications are common, catheter directed arterial low dosage thrombolytic therapy can be an important initial step in the diagnosis and treatment of selected arterial occlusion of the lower extremities.

The fate of polytetrafluoroethylene grafts in lower limb bypass surgery: a six year follow-up

The success of lower limb bypass surgery depends, in the major part, on the availability of autologous saphenous vein as the most satisfactory arterial substitute known to date. Although various prosthetic conduits, used in the absence of saphenous vein, have shown promising success on short term follow-up, more long-term comparative data are required for adequate assessment. This study analyses, by life table method, the results of 134 infra-inguinal bypass grafts using polytetrafluoroethylene (PTFE) over a 6 year period. The results reconfirm the superior long-term patency of vein bypasses compared with such prosthetic grafts. Analysis suggests that, while PTFE may give acceptable results in the immediate and short-term follow-up period, 6 year patencies approach 20-30 per cent.

The angiographic evaluation of lower-extremity arterial disease in the young adult

The angiographic evaluation of 38 patients younger than 40 years of age with lower-extremity arterial disease is reviewed. Although atherosclerosis was the most common diagnosis, other etiologies included thromboembolism, popliteal artery entrapment, Buerger's disease, collagen vascular disease, and arteritis. The two features of the angiographic workup that proved most helpful in establishing an accurate diagnosis were biplane aortography and runoff exams designed to demonstrate possible popliteal artery entrapment.

Survival following aggressive treatment of secondary aortocolonic fistula

Secondary aortocolonic fistula is an uncommon complication of prosthetic aortic grafts; apparently there have been only two previously described long-term survivors. We describe a long-term survivor with this complication in which preoperative computed tomographic scanning and percutaneous abscess drainage allowed early diagnosis and intervention and contributed to optimal treatment and survival. Adherence to time-honored principles of abscess drainage and graft removal, followed by extra-anatomic bypass when indicated, are essential to successful treatment.

Utility of transcutaneous oxygen tension measurements in peripheral arterial occlusive disease

The use of transcutaneous oxygen tension (TCpO2) measurements to objectively and noninvasively diagnose peripheral arterial occlusive disease (PAOD) and to aid in the planning of vascular surgery was investigated. Thirty-two normal subjects and 100 patients with PAOD were studied. TCpO2 values decreased with age; when normalized by measurements on the chest, they did not. Absolute and normalized values of TCpO2 were equally effective in identifying the presence of PAOD and accurately characterized different degrees of severity (claudication vs. rest pain vs. impending gangrene; p less than 0.001). This was true even in diabetic patients, in whom tests based on hemodynamic function were less reliable. Healing of amputations was observed when TCpO2 greater than or equal to 38 mm Hg either preoperatively or after reconstruction; failure to heal in the absence of infection was associated with TCpO2 less than or equal to 38 mm Hg. The need for revascularization was associated with TCpO2 less than 30 mm Hg. A similar distribution of TCpO2 values was associated with success vs. failure of ulcer healing. TCpO2 is a useful complement to standard hemodynamic tests in the diagnosis and management of PAOD and, in addition, provides some distinct advantages.