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G W Gibbons

Publications and source records attributed to G W Gibbons.

At least 37 records · Page 2Linked to original sources
PubMed1996

Results of a policy with arm veins used as the first alternative to an unavailable ipsilateral greater saphenous vein for infrainguinal bypass.

PURPOSE: Aggressive policies for distal bypass and coronary revascularization increase the need to identify alternatives to autologous saphenous vein grafts. We examined the performance of arm vein as the primary alternative to contralateral saphenous vein when the ipsilateral saphenous vein was not available. METHODS: A total of 250 arm vein grafts were studied retrospectively in 224 patients (143 men, 81 women, 82.6% with diabetes, mean age 68.3 years) from February 1989 to April 1994. Intraoperative angioscopy was carried out to observe valve lysis, remove abnormalities, and select optimal vein segments. RESULTS: A total of 85 primary, 103 repeat, and 62 graft revision procedures were done for limb salvage in 99.2% of the patients. A total of 41 femoropopliteal, 114 femorotibial-pedal, 33 popliteodistal, and 62 jump or interposition grafts were constructed. A total of 199 grafts were single vein, and 51 were composite vein. The source was cephalic vein alone in 50.4%, cephalic and basilic vein in 35.6%, and basilic vein only in 14%. The contralateral saphenous vein as an alternative conduit was available in 97 (38.8%) instances. Interventions guided by angioscopy to "upgrade" the graft were necessary in 51.6%. Overall early patency (< or = 30 days) was 94.8% (n = 13 occlusions). The cumulative primary patency rate at 1 year was 70.6%, the secondary patency rate was 76.9%, and the limb salvage rate was 88.2%. The 3-year patency rate (limb salvage) was 51.9% (92.4%) for primary grafts, 56.7% (67.1%) in revision grafts, and 42.4% (79.9%) in repeat grafts. In 22.7% (22 of 97) the available contralateral saphenous vein was used for distal revascularization within the follow-up period. CONCLUSIONS: Arm veins are an easily accessible autologous conduit of sufficient length to reach the midtibial level. Excellent patency rates allow durable limb salvage in otherwise difficult circumstances. Vein configuration and splicing do not affect patency rates, but vein quality and repeat operations do. Angioscopy is a valuable adjunct to upgrade graft quality. The contralateral saphenous should be saved for subsequent contralateral revascularization or coronary artery bypass grafting.

Adult↗
PubMed1996

Infrapopliteal bypasses to severely calcified, unclampable outflow arteries: two-year results.

PURPOSE: Although severe, circumferential calcification of distal outflow vessels is frequently encountered, its effect on bypass graft patency rates has not been well established. METHODS: Using a computerized vascular registry database, we conducted a retrospective review of 1957 bypass grafts with distal anastomoses to infrapopliteal vessels performed at a single institution between 1990 and 1995. Of these cases, 101 procedures involved outflow arteries classified by the operating surgeon as severely calcified and unclampable (requiring intraluminal occluders for vascular control), whereas in 105 cases the outflow arteries had no calcification present at the distal anastomotic site. The remaining cases had varying intermediate degrees of calcification and were not analyzed. Indication for bypass procedure was limb-threatening ischemia in 90% of severe calcification cases and in 84% of cases without calcification. Atherosclerotic risk factors were similar except for the presence of diabetes (92% vs 74%, p < 0.001), creatinine level > 2.0 mg/dl (21% vs 8%, p < 0.01), and dialysis dependency (17% vs 3%, p < 0.001), all of which were more prevalent in the severe calcification group. Infrapopliteal distal anastomotic location and type of conduit ( > 90% autogenous vein) were comparable between groups. RESULTS: Primary patency, secondary patency, and foot salvage rates at 24 months were 60%, 65%, and 77% for the severe calcification group and 74%, 82%, and 93% for the no calcification group, respectively. With secondary procedures comprising 26% of cases in each group, data from the 150 primary procedures were reanalyzed separately. In this primary procedure group, 24-month primary patency, secondary patency, and foot salvage rates were 66%, 69%, and 77% for the severe calcification group and 84%, 90%, and 96% for the no calcification group, respectively. Although patency and salvage rates were consistently lower for the severe calcification group in all analyses, these differences did not achieve significance by log-rank life-table analysis at 2-year follow-up. Perioperative 30-day mortality (0.99% severe calcification vs 0.95% no calcification) and 24-month survival rates (84% severe calcification vs 83% no calcification) were also similar between groups. CONCLUSION: These data suggest that effective techniques exist to perform infrapopliteal bypasses to severely calcified, unclampable outflow arteries with results comparable with those obtained with clampable, uncalcified vessels. The finding of severe, circumferential calcification of outflow target arteries should not dissuade vascular surgeons from distal bypass for limb salvage indications.

Aged↗
PubMed1996

Vascular disease of the lower extremities in diabetes mellitus.

Vascular disease, neuropathy, and infection act synergistically to cause diabetic foot ulceration. Appropriate care is hindered by misconceptions about microvascular disease. Recent advances and success with extreme distal revascularization combined with surgical management of infection have greatly improved salvage of the diabetic foot. Success is enhanced by a multidisciplinary team approach.

Diabetes Complications↗
PubMed1996

Cardiac outcome after peripheral vascular surgery. Comparison of general and regional anesthesia.

BACKGROUND: Despite evidence that regional anesthesia may be associated with fewer perioperative complications than general anesthesia, most studies that have compared cardiac outcome after general or regional anesthesia alone have not shown major differences. This study examines the impact of anesthetic choice on cardiac outcome in patients undergoing peripheral vascular surgery who have a high likelihood of associated coronary artery disease. METHODS: Four hundred twenty-three patients, between 1988 and 1991, were randomly assigned to receive general (n = 138), epidural (n = 149), or spinal anesthesia (n = 136) for femoral to distal artery bypass surgery. All patients were monitored with radial artery and pulmonary artery catheters. Postoperatively, patients were in a monitored setting for 48-72 h and had daily electrocardiograms for 4-5 days and creatine phosphokinase/isoenzymes every 8 h x 3, then daily for 4 days. Cardiac outcomes recorded were myocardial infarction, angina, and congestive heart failure. RESULTS: Baseline clinical characteristics were not different between anesthetic groups. Overall, the patient population included 86% who were diabetic, 69% with hypertension, 36% with a history of a prior myocardial infarction, and 41% with a history of smoking. Cardiovascular morbidity and overall mortality were not significantly different between groups when analyzed by either intention to treat or type of anesthesia received. In the intention to treat analysis, incidences of cardiac event or death for general, spinal, and epidural groups were 16.7%, 21.3%, and 15.4%, respectively. The absolute risk difference observed between general and all regional anesthesia groups for cardiac event or death was -1.6% (95% confidence interval -9.2%, 6.1%) This reflected a nonsignificant trend for lower risk of postoperative events with general anesthesia. CONCLUSIONS: The choice of anesthesia, when delivered as described, does not significantly influence cardiac morbidity and overall mortality in patients undergoing peripheral vascular surgery.

Aged↗
PubMed1995

Probing to bone in infected pedal ulcers. A clinical sign of underlying osteomyelitis in diabetic patients.

OBJECTIVE: To assess a bedside technique for diagnosing osteomyelitis. DESIGN: We prospectively assessed infected pedal ulcers for detectable bone by probing with a sterile, blunt, stainless steel probe. We then examined the relationship between detection of bone and the presence or absence of osteomyelitis that was defined histopathologically and/or clinically. SETTING: A tertiary care center. PATIENTS: Seventy-five hospitalized diabetic patients with a total of 76 infected foot ulcers were studied. RESULTS: Osteomyelitis was diagnosed in 50 instances (66%) and was excluded in 26 instances. Bone was detected by probing in 33 of 50 ulcers with contiguous osteomyelitis; in contrast, bone was probed in only four of 26 ulcers without contiguous osteomyelitis (P < .001). Bone detected on probing was visible in only three instances. Palpating bone on probing the pedal ulcer had a sensitivity of 66% for osteomyelitis, a specificity of 85%, a positive predictive value of 89%, and a negative predictive value of 56%. CONCLUSIONS: Palpation of bone in the depths of infected pedal ulcers in patients with diabetes is strongly correlated with the presence of underlying osteomyelitis. If bone is palpated on probing, specialized roentgenographic and radionuclide tests to diagnose osteomyelitis are unnecessary. Probing for bone should be included in the initial assessment of all diabetic patients with infected pedal ulcers.

Aged↗
PubMed1995

The upper arm basilic-cephalic loop for distal bypass grafting: technical considerations and follow-up.

PURPOSE: The performance of a graft created from the upper arm basilic and cephalic veins in continuity was investigated. METHODS: Retrospective analysis of 50 patients, who underwent 54 distal reconstructions with an upper arm vein loop graft between February 1989 and October 1993 (male-to-female ratio of 30/20; mean age of 69.2 years, range 39 to 87; 74% had diabetes) was undertaken. Vein grafts were harvested through a near continuous incision, leaving a skin bridge in the cubita. Intraoperative angioscopy was used to exclude endoluminal disease and to directly observe valvulotomy of the nonreversed part of the graft. RESULTS: Operations were performed for limb salvage in 98.2% of 17 primary and 37 reoperative procedures. Eleven femoropopliteal, 33 femorotibial-pedal, seven popliteal-distal, and two outflow jump grafts were performed. The ipsilateral saphenous vein was unavailable because of previous infrainguinal bypass in 35, coronary artery bypass grafting in 14, and unsuitable quality in 5 cases. Thirty-eight grafts were used in continuity, and 16 grafts required repair or splicing with additional vein segments. Primary 30-day patency rate was 92.6% (n = 4 occlusions). No operative deaths occurred. The cumulative patency rate at 1 year was 74.4%, the limb salvage rate 90.7%. CONCLUSIONS: The upper arm vein loop is a durable graft with excellent short-term and midterm patency rates. Sufficient vein length can be obtained to reach the below-knee and midtibial levels. Angioscopic quality assessment is a valuable adjunct to exclude endoluminal disease most commonly occurring in the median cubital vein. Straightening the curve of the median cubital vein and valvulotomy do not influence patency rates. This is a valuable technique for vascular surgeons that enables rescue of ischemic limbs under otherwise difficult circumstances.

Adult↗
PubMed1995

Return to well-being and function after infrainguinal revascularization.

PURPOSE: The purpose of this study was to assess functional status, well-being, and symptom relief of patients after infrainguinal revascularization for severe peripheral vascular disease. METHODS: Two questionnaires were used to assess symptoms, functional status, and well-being before operation and 6 months after operation. Sociodemographics, comorbidities, indications for surgery, graft location, and morbidity, mortality, patency, and limb salvage rates were obtained via vascular registry. RESULTS: Of 318 patients who underwent revascularization over a 1-year period, 276 patients were asked to complete the questionnaires. Of the 156 patients who completed both questionnaires, mean age was 66 years, 67% were men, 84% had diabetes mellitus, and 83% had various heart-related conditions. Mean length of stay was 15.3 days. Distal graft sites were popliteal (29%), tibial/peroneal (40%), and pedal/plantar (31%). The operative morbidity rate was 21%, the cumulative primary graft patency rate was 93%, the cumulative secondary graft patency rate was 95%, and the limb salvage rate was 97% at 6 months. At follow-up, improved functioning of instrumental activities of daily living, mental well-being, and vitality were reported. Symptoms of calf cramping and toe or foot pain when walking and at rest were also improved. Sores or ulcers improved, but leg swelling did not. The only independent predictor of improved function and well-being was the patients' perception of their status at baseline: those patients who functioned better before operation reported improved function and well-being at 6 months. Only 45% of patients reported feeling "back to normal" at 6 months. CONCLUSION: Reported health status at baseline was a predictor of improved function, mental well-being, and resolution of symptoms after infrainguinal revascularization. Expected return to "normal" may take longer than 6 months.

Activities of Daily Living↗
PubMed1995

Dorsalis pedis arterial bypass: durable limb salvage for foot ischemia in patients with diabetes mellitus.

PURPOSE: Although the technical feasibility of pedal artery bypass for limb salvage is now well established, questions remain about its most appropriate use and its long-term durability. METHODS: We reviewed our experience over an 8-year period in 367 consecutive patients undergoing 384 vein bypass grafts to the dorsalis pedis for limb salvage. RESULTS: Ninety-five percent of the patients had diabetes mellitus. Infection complicated ischemia at initial presentation in 55.2% of patients. The preoperative arteriogram demonstrated a patent dorsalis pedis in 362 extremities (92.8%). Four hundred two patients underwent exploration for bypass, including 29 patients without demonstrated arteries on the arteriogram but audible pedal Doppler signals. Successful bypasses were carried out in 357 of 362 cases, where preoperative arteriography demonstrated a patent dorsalis pedis artery (98.6%), 16 of 28 cases explored on the basis of a Doppler signal alone (57%), and 11 of 12 patients where angiographic status was unknown. All procedures were performed with vein: in situ 38.5%, reversed 29%, nonreversed 18%, arm vein 7%, and composite vein 8%. Inflow was taken from the common femoral artery in 34%, superficial femoral or popliteal arteries in 60%, a previously placed graft in 5%, and a tibial artery in 1%. There were seven perioperative deaths (1.8%) and 21 myocardial infarctions (5.4%). Twenty-nine grafts failed within 30 days (7.5%), but 19 were successfully revised. Eight of the 10 failed grafts resulted in major amputation (80%). Over the remaining study period, there were 39 additional graft failures, of which 17 were successfully revised, and 17 additional major amputations. Actuarial primary and secondary patency and limb salvage rates were 68%, 82%, and 87%, respectively, at 5 years' followup. The actuarial patients survival rate was 57% at 5 years. Patency rates were similar for in situ and translocated saphenous vein grafts. CONCLUSIONS: Dorsalis pedis arterial bypass is an effective limb salvage procedure with long-term durability comparable to distal vein grafts placed into more proximal arteries.

Arteries↗
PubMed1995

Diabetic foot infections. Anatomy and surgery.

Sensory and motor neuropathy result in foot deformities highly susceptible to unrecognized trauma resulting in ulceration. Early, aggressive surgical debridement, adjunctive antibiotics, dressings, rest of the injured area, correction of ischemia, and control of diabetes are essential to prevent amputation.

Bandages↗
PubMed1994

Assessment and management of foot disease in patients with diabetes.

Limb- or life-threatening complications in patients with diabetes can be prevented with an integrated, multidisciplinary approach. Most patients seen in clinical practice are in the early stages of the disease process. Glycemic control retards the progression of neuropathy, which is the most important risk factor for ulceration. Early detection of the loss of protective sensation and implementation of strategies to prevent ulceration will reduce the rates of limb-threatening complications. Clinicians should routinely examine the feet of diabetic patients. Education in foot care, proper footwear, and close follow-up are required to prevent or promptly detect neuropathic injury. If ulceration occurs, removal of pressure from the site of the ulcer and careful management of the wound will allow healing in most cases. The failure to heal despite these measures should prompt a search for associated arterial insufficiency. If infection is present, appropriate antimicrobial therapy combined with immediate surgical intervention, including revascularization when necessary, will increase the chances of saving the limb. With this comprehensive approach, it is possible to achieve the goal of a 40 percent decrease in amputation rates among diabetic patients by the year 2000.

Anti-Bacterial Agents↗
PubMed1994

Role of angioscopy in reoperation for the failing or failed infrainguinal vein bypass graft.

The purpose of this retrospective study is to review our ongoing experience with the use of angioscopy during reoperation for failed or failing infrainguinal vein bypass grafts and define the role of angioscopy in the management of this clinically demanding patient group. All hospital records, arteriograms, and intraoperative angioscopic video recordings of 79 consecutive failed or failing grafts (76 patients) examined with angioscopy during reoperation between 1987 and 1993 were reviewed. Clinical and intraoperative data, comparison of the preoperative arteriogram and intraoperative angioscopic findings, and surgical decisions or interventions resulting from the additional angioscopic findings were collated and analyzed according to a predetermined protocol. Sixty-six additional angioscopic findings were noted during the 79 reoperations and resulted in 61 additional interventions and surgical decisions with salvage of all or part of the graft in 90.9% in the early (< 30 day) failed (group 1), 84.6% in the late (> 30 day) failed (group 2), and 90.3% in the late (> 30 day) failing grafts (group 3). The amount of residual thrombus within the graft, as assessed by angioscopy after all interventions, was the critical determinant for overall early graft patency (p < 0.001) and long-term patency for all the subgroups after reoperation (group 1, p < 0.001; group 2, p = 0.0016; and group 3, p = 0.0194). Intraoperative angioscopy has an important role in these challenging procedures. It provides additional and useful information that not only influences the conduct and extent of the reoperative surgery but may provide insights into the pathogenesis of graft failure.

Adult↗
PubMed1994

Use of ampicillin/sulbactam versus imipenem/cilastatin in the treatment of limb-threatening foot infections in diabetic patients.

In a double-blind randomized trial, imipenem/cilastatin (I/C; 500 mg every 6 hours) and ampicillin/sulbactam (A/S; 3 g every 6 hours) were compared in regard to their efficacy for initial empirical and definitive parenteral treatment of limb-threatening pedal infection in diabetic patients. The major endpoints of treatment were cure (resolution of soft-tissue infection), failure (inadequate improvement, necessitating a change in antibiotic therapy), and eradication (clearance of all pathogens from the wound and any bone cultures). Patients in the two treatment groups were similar in regard to the severity of diabetes; presence of neuropathy and peripheral vascular disease; site and severity of infection; pathogen isolated; and frequency of osteomyelitis (associated with 68% of the 48 A/S-treated infections and 56% of the 48 I/C-treated infections). After 5 days of empirical treatment, improvement was noted in 94% of the A/S and 98% of the I/C recipients. At the end of definitive treatment (days' duration [mean +/- SD]: 13 +/- 6.5 [A/S], 14.8 +/- 8.6 [I/C]), outcomes were similar: cure, 81% (A/S) vs. 85% (I/C); failure, 17% (A/S) vs. 13% (I/C); and eradication, 67% (A/S) vs. 75% (I/C). Treatment failures were associated with the presence of antibiotic-resistant pathogens and possible nosocomial acquisition of infections. The number of adverse events among patients in the two treatment groups was similar: 7 in the A/S group (4 had diarrhea and 3 had rash) and 9 in the I/C group (5 had diarrhea, 2 had severe nausea, 1 had rash, and 1 had seizure). Efficacy of A/S and I/C is similar for initial empirical and definitive treatment of limb-threatening pedal infection in patients with diabetes.

Adult↗
PubMed1994

Maximizing foot salvage by a combined approach to foot ischemia and neuropathic ulceration in patients with diabetes. A 5-year experience.

OBJECTIVE: The combination of peripheral neuropathy and arterial insufficiency in patients with diabetes frequently results in chronic non-healing foot ulcers. These patients often have a protracted course that commonly ends in limb amputation. RESEARCH DESIGN AND METHODS: Since 1987, 39 diabetic patients presented with 42 neuropathic ulcerations beneath the lesser metatarsal heads, complicated by severe arterial insufficiency. A variety of vascular reconstructions were performed to improve circulation to the foot. After successful vascular reconstruction, 14 patients with deep ulcers underwent resection of the involved bone or joint through a plantar elliptical incision with excision of the ulcer and primary closure (33%). Five patients required a simultaneous panmetatarsal head resection (12%). For fifteen superficial ulcers, metatarsal osteotomy through a dorsal approach was performed (36%). Eight patients underwent a fifth metatarsal head resection through a dorsal approach (19%). RESULTS: In follow-up of 2-64 months (mean 21.2 months), 35 extremities with patent bypass grafts achieved and maintained primary healing of their local foot procedure (83%). Two feet required subsequent revision but ultimately healed (5%). Three feet (7%) developed a new plantar ulceration adjacent to the original one. In two extremities, the foot remained healed in spite of thrombosis of their grafts (5%). One patient with a thrombosed graft required a below-knee amputation. One patient died before the foot healed with a patent bypass graft. Overall, 40 of 42 extremities (95%) ultimately healed over the course of the follow-up period. CONCLUSIONS: We conclude that complex neuropathic ulcers in diabetic patients can be successfully treated by an aggressive surgical approach that removes infected bone and ulcers and corrects underlying structural abnormalities provided arterial insufficiency is corrected first.

Aged↗
PubMed1993

Improved quality of diabetic foot care, 1984 vs 1990. Reduced length of stay and costs, insufficient reimbursement.

Ischemic foot ulceration in the diabetic patient is a source of great physical and emotional strain for the patient and represents a significant financial burden for the health care system responsible for the cost of such care. Limb salvage remains the primary therapeutic goal; yet, fiscal constraints imposed by diagnosis related group-based reimbursement systems require maximal cost efficiency in the care process. Between 1984 and 1990, the changes in our team management approach to this problem, emphasizing aggressive surgical revascularization of threatened limbs, have improved the quality of care and dramatically reduced the major and minor amputation rate. In the process, we have reduced the length of hospital stay and the overall cost of care. Despite this improvement in outcome and efficiency, Medicare reimbursement remains insufficient, with an average loss of $7480 per admission.

Aged↗
PubMed1993

Comparison of angioscopy and angiography for monitoring infrainguinal bypass vein grafts: results of a prospective randomized trial.

PURPOSE: This study was designed to determine whether, in primary infrainguinal bypass grafts in which only saphenous vein is used as the graft conduit, routine monitoring with intraoperative angioscopy can improve early graft patency as compared with standard monitoring with intraoperative completion angiography; and to delineate the advantages and disadvantages of these two modalities and their respective roles for the routine monitoring of the infrainguinal bypass graft. METHODS: A total of 293 patients undergoing primary saphenous vein infrainguinal bypass grafting were prospectively randomized and monitored with either completion angioscopy or completion angiography. Clinical parameters, indications for operation, graft anatomy, and configuration were evenly matched in both groups. Forty-three bypasses were excluded from the study after randomization, including 12 veins randomized to angiogram, deemed inferior, and prepared with angioscopy. RESULTS: In the 250 bypass grafts (angioscopy 128, angiography 122) there were 39 interventions (conduit, 29; anastomosis, 8; distal artery, 2), 32 with angioscopy and 7 with angiography (p < 0.0001). Twelve (4.8%) of the 250 grafts failed in less than 30 days, four (3.1%) of 128 in the angioscopy group and eight (6.6%) of 122 in the angiography group (p = 0.11 by one-sided hypothesis test). CONCLUSION: Although no statistical improvement in the proportions of failures in primary saphenous vein bypass grafts routinely monitored with completion angioscopy rather than the standard completion angiogram was demonstrated, the study delineates a trend that favors completion angioscopy for routine vein graft monitoring and demonstrates the advantages of angioscopy in preparing the optimal vein conduit.

Aged↗
PubMed1993

Angioscopically directed interventions improve arm vein bypass grafts.

PURPOSE: Our purpose was to determine the incidence and segmental distribution of intraluminal disease in the arm veins of patients in whom saphenous vein was unavailable or inadequate for bypass, determine whether angioscopic evaluation and directed interventions can upgrade the quality of arm vein conduit and improve early graft patency, and describe the angioscopic technique of in situ retrograde arm vein inspection. METHODS: Retrospective review of 109 infrainguinal arm vein bypass grafts in 104 patients performed with intraoperative angioscopic vein preparation and monitoring between August 1989 and March 1992 was undertaken. Four additional arm veins harvested were discarded because of diffuse disease. RESULTS: Intraluminal disease was noted in 71 (62.8%) of 113 arm veins, "webs" in 61 (54%), vein sclerosis in 25 (22.1%), localized stenosis in 11 (9.7%), and thrombus in 7 (6.2%). Intraluminal disease was most common in the cephalic (forearm 49.2%; arm 35.1%) and median cubital (33.3%) veins and least common in the basilic vein (11.7%). Eighty-three angioscopically directed interventions in 68 of 71 abnormal arm veins resulted in upgraded vein conduit quality in 47 (66.1%) of 71. Primary patency (< 30 days) was 99 (90.8%) of the 109 grafts, 85 (95.5%) of 89 grafts with normal or upgraded quality conduits, and 14 (70%) of 20 inferior-quality grafts (p = 0.0024). These differences persisted through 1 year by life-table analysis, (p < 0.001). CONCLUSIONS: Not only is the routine use of the angioscope in arm vein bypass grafting a sensitive technique to detect the intraluminal diseases so prevalent in arm veins but it can also direct endoluminal and surgical interventions that upgrade the quality of the vein conduit and improve early graft patency.

Adult↗