In situ bypass: technical considerations. Preoperative evaluation of veins.
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Arteriovenous Shunt, Surgical↗
Biomedical subjects
R C Darling
Publications and source records attributed to R C Darling.
Optimal outcome after tibial arterial bypass.
To evaluate factors for the optimal outcome after tibial arterial bypass for lower extremity ischemia, we analyzed our experience with 1,359 such bypasses during the last ten years. There were 869 males and 490 females, of whom 739 patients (54 percent) had diabetes. The average age was 68 years. One thousand and twenty-four bypasses were performed using the atraumatic valve incision in situ technique, 281 bypasses using free vein grafts and 54 bypasses with synthetic materials. These bypasses were taken to the anterior tibial (312 patients), posterior tibial (341 patients), peroneal (520 patients) and dorsalis pedis arteries (125 patients). Inflow arteries included external iliac (two patients), common (435 patients), superficial (472 patients) and profunda femoris arteries (259 patients). In certain instances, popliteal and tibial arteries were used for inflow (short bypasses). Limb salvage was the significant indication (95 percent). The overall cumulative primary patency rate at five years was 68 percent and secondary patency was 76 percent. In situ bypasses had the best secondary patency rate of 80 percent at five years followed by free vein grafts of 70 percent and synthetic bypasses of 33 percent. The choice of inflow or outflow arteries did not influence the patency rate in any category. The overall limb salvage rate was 94 percent at five years. Short bypasses using free vein grafts had a similar patency to long free vein graft but lower patency than long in situ bypasses. These data demonstrate that bypasses to tibial arteries, using autogenous vein for ischemia of the lower extremity and limb salvage, have long term durability. In situ bypass with a complete saphenous vein is the best conduit for such reconstructions. We suggest that tibial arterial bypass should be strongly considered in all instances for limb salvage when autogenous vein is available before resorting to primary amputation.
Aged↗
A case of nutcracker syndrome: treatment by mesoaortic transposition.
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Adolescent↗
Long-term follow-up of poor-risk patients undergoing small-diameter portacaval shunts.
The small-diameter portacaval H-graft has been shown to be a reliable method of controlling variceal hemorrhage. However, little has been written about the long-term follow-up of poor-risk patients treated by this method. Over the last 11 years, we have performed 38 portacaval H-grafts; 79% of the patients were Child's B or C, and 79% were alcoholic. The mean age was 52 years, and the mean period of follow-up was 44 months. Over 37% of the grafts were performed in patients who were bleeding at the time of operation. Our 30-day operative mortality was 13%. Postoperatively, the small-diameter H-graft was associated with mild to moderate encephalopathy in 33% of the patients and ascites in 42%. Both these conditions were easily controlled with diet and medication. Early recurrent variceal bleeding was seen in 13% of patients. However, on late follow-up, recurrent hemorrhage and encephalopathy have been seen in only 12% and 14% of patients, respectively. We conclude that the portacaval H-graft is a reliable and lasting method for controlling variceal bleeding with an acceptable postoperative morbidity and mortality.
Adolescent↗
Femoropopliteal reconstruction with knitted, nonvelour Dacron versus expanded polytetrafluoroethylene.
No ideal prosthetic conduit exists for femoropopliteal reconstruction. Expanded polytetrafluoroethylene (PTFE) has gained much greater popularity than the less expensive Dacron, despite disappointing long-term patency for each material. Few direct comparisons of results with the two materials have been performed. The concurrent experience of a single surgeon with femoropopliteal reconstructions of PTFE (n = 85) or knitted, nonvelour Dacron (KNVD, n = 38) was reviewed. Risk factors were comparable in the two groups. Overall patency was significantly better for KNVD than for PTFE (p = 0.0096 by log rank; p = 0.039 by Cox proportional hazards; 48% vs 27% at 5 years). Since in this series the overall performance of KNVD was significantly better than PTFE, a reassessment of the prosthetic materials used in femoropopliteal reconstruction is necessary. These results justify a prospective comparison of PTFE and KNVD.
Aged↗
The current surgical management of carotid body paragangliomas.
To determine if recent trends in evaluation and therapy have contributed to the successful surgical management of carotid body paragangliomas, we reviewed our experience over the past decade. Nineteen carotid body paragangliomas were identified in 17 patients. Eleven patients underwent complete, preoperative embolization of their afferent arteries with one complication. Calculated carotid body paragangliomas surface areas did not differ between the embolized 64.6 +/- 43.3 cm2 and nonembolized 63.0 +/- 57.9 cm2 lesions. Intraoperative blood loss was lower (p = 0.02) in the patients treated with embolization (372 +/- 213 ml) compared with their cohorts (609 +/- 564 ml). However, the operative times were equivalent 4.1 hours versus 4.5 hours in both groups. Intraoperative electroencephalographic (EEG) monitoring was used in 10 patients; in one patient the EEG indicated intraoperative thrombosis of the carotid artery, which was successfully treated by thrombectomy without complications. Two patients required carotid bifurcation resection and vascular reconstruction to remove the entire tumor; a late stroke manifested by contralateral hand weakness developed in one of these patients. The incidence of cranial nerve injury was low at 16%, with one transient ramus mandibularis paresis and two instances of vocal cord dysfunction. Two additional patients had a postoperative Horner's syndrome. We conclude that by diminishing intraoperative blood loss through complete and careful preoperative embolization and use of intraoperative EEG monitoring along with careful surgical technique, the complications associated with this challenging operation are facilitated and diminished.
Adult↗
Retroperitoneal in-line aortic bypass for treatment of infected infrarenal aortic grafts.
Since 1970, we have treated 43 patients with infected aortic grafts. Early in the series, four patients were treated with resection of the fistula or erosion and systemic and topical antibiotics without removal of the graft. All four patients died. Thirty-two patients were treated by conventional therapy; there were 13 deaths (40 percent). More recently, seven patients were managed by the left retroperitoneal placement of a new in-line polytetrafluoroethylene (PTFE) aortic graft through clean tissue planes, followed by the immediate transperitoneal removal of the infected graft without cross-contamination. Patients were maintained postoperatively on antibiotics for a minimum of two weeks. All seven patients survived without septic complications, with a mean follow-up time of 36 months (six months to four years). The surgical technique consists of initial suprarenal control of the aorta, followed by infrarenal division and oversewing of the distal aorta. A PTFE bifurcation graft is placed connecting the proximal aorta and the appropriate femoral vessels, the right limb tunneled through the space of Retzius. After closure of the incisions, through the space of Retzius. After closure of the incisions, the patient is placed in the supine position and the infected graft is removed transperitoneally. We believe that retroperitoneal in-line aortic bypass for treatment of an infected aortic graft offers a favorable alternative to conventional therapy by avoiding the use of an extra-anatomic bypass and associated risk of stump blowout.
Anti-Bacterial Agents↗
Is long vein bypass from groin to ankle a durable procedure? An analysis of a ten-year experience.
Long vein bypass from the femoral artery to the level of the ankle may be performed with good initial success despite extreme bypass length and limited outflow tracts. However, the long-term performance of these bypasses remains to be defined. During the last 10 years we have performed single greater saphenous vein in situ bypass to the ankle level in 270 patients. There were 187 male and 83 female patients, and 61% of the patients were diabetic. The operative mortality rate was 3.7%. Cumulative bypass patency was 79% at 3 years and 73% at 5 years. In a similar manner, limb salvage was 93% at 3 years and 89% at 5 years. The patency rate was similar for various inflow arteries (common femoral, 88 cases; proximal superficial femoral, 135 cases; and deep femoral, 41 cases) and outflow tracts (dorsal pedal, 72 cases; anterior tibial, 59 cases; posterior tibial, 72 cases, and peroneal, 67 cases). Short bypasses, composite bypasses, free-vein grafts, and bypasses proximal to 10 cm above the ankle were excluded from this analysis. These data show that a long bypass to the ankle level for limb salvage is a durable procedure. The basic concept of bypassing all occlusive disease to the distal open artery in patients undergoing limb salvage should be an acceptable dictum. Excellent long-term patency and limb salvage rates are achievable by following this principle.
Adult↗
Delayed presentation and treatment of popliteal artery embolism.
In the course of reviewing a 10-year experience with popliteal artery embolism (PAE), two distinct patterns of clinical presentation were identified. In addition to those patients presenting with typical acute (symptom duration less than 7 days) arterial ischemia, a second group was identified who presented with more chronic symptoms. The present study was conducted to contrast the clinical factors and treatment of these two temporal patterns of presentation with PAE. Sixty PAEs in 58 patients were documented by the combination of angiography and/or exploration of the popliteal artery. Acute presentation (AP) was seen in 41 (68%) of these and delayed presentation (DP) was noted in 19 (32%) patients. Delayed presentation patients typically presented with a history of sudden onset of claudication or rest pain and a median symptom duration of 30 days. Eighty per cent of AP patients presented with immediately threatened limbs. Angiography was generally diagnostic of chronic popliteal embolism. In the acute group, 90% were treated with embolectomy alone, while 20% of the DP group required bypass grafting. However in two thirds of the DP group, embolectomy alone performed through a direct popliteal approach was possible. Current results with overall limb salvage (92%) and mortality (7%) represents a substantial improvement compared to the authors' previous experience with PAE. The current study suggests that as many as one third of patients with popliteal artery embolism may present in delayed fashion with chronic symptoms. Furthermore most of these patients can be treated with direct popliteal embolectomy alone with favorable results.
Amputation, Surgical↗
Intestinal ischemia complicating abdominal aortic surgery.
A 9-year experience with 2137 patients undergoing infrarenal abdominal aortic reconstruction was reviewed to determine both the incidence of intestinal ischemia and the clinical, anatomic, and technical factors associated with this complication of aortic surgery. A total of 24 (1.1%) patients had overt intestinal ischemia, documented by reoperation or endoscopic findings. Of these, colon ischemia occurred in 19 (0.9%) and small bowel ischemia developed in 5 (0.2%) patients. The incidence after elective operation for aneurysmal or occlusive disease did not differ, but patients with ruptured aneurysms and those undergoing reoperative procedures for total graft replacement were at higher risk. Preoperative angiography was most helpful in ascertaining risk. Ligation of a patent inferior mesenteric artery was the most common (74%) feature in patients with colon ischemia. With preexisting inferior mesenteric artery occlusion, impairment of collateral circulation was attributable to superior mesenteric artery disease, dissection or retractor injury, prior colon resection, or exclusion of hypogastric perfusion. Bloody diarrhea was the most frequent postoperative symptom and colonoscopy the most reliable means of diagnosis. One half of patients with colon ischemia required resection after late recognition of perforation. All cases of small bowel ischemia were related to superior mesenteric artery disease or injury or use of suprarenal clamping. The overall mortality rate was 25% but rose to 50% if bowel resection was required. Intestinal ischemia remains an infrequent but serious complication of aortic surgery. Despite a multifactorial cause, identification of patients at increased risk can lead to operative strategies to reduce its occurrence.
Aged↗
Aortocaval and iliac arteriovenous fistulas: recognition and treatment.
Despite the well characterized physiologic effects of aortocaval or iliac arteriovenous fistulas, patients with such uncommon lesions may manifest a diverse array of symptoms, and diagnosis is often delayed or overlooked. To examine clinical features that facilitate recognition and allow successful repair, a 30-year experience with 20 such fistulas was reviewed. Fourteen fistulas were caused by aneurysm erosion, four followed iatrogenic injury during lumbar disk surgery, and two developed from abdominal gunshot wounds. The interval from presumed occurrence to diagnosis ranged from 3 hours to 8 years. The diagnosis was not recognized before surgery in five (25%) patients. Back pain (70%) was the most common symptom. The presence of a typical abdominal bruit (80%) was the most reliable physical finding, but its significance was occasionally overlooked or misinterpreted. Congestive heart failure was prominent in only seven (35%) patients. Severe lower extremity edema and mottling was the primary manifestation in eight cases, often causing initial confusion with venous thrombosis. Hematuria (5 patients) and oliguric renal failure (4 patients), both fully reversible after fistula repair, also caused diagnostic uncertainty. The mean preoperative cardiac output was 12.2 L/min, falling to 5.4 L/min with fistula repair. Mean blood loss was 5960 ml, supporting use of intraoperative autotransfusion. Two operative deaths (10%) occurred, both in patients not correctly diagnosed before surgery. Despite varied modes of presentation, prompt recognition and use of appropriate operative techniques should achieve successful repair.
Adult↗
Combining clinical and thallium data optimizes preoperative assessment of cardiac risk before major vascular surgery.
STUDY OBJECTIVE: To determine whether clinical markers and preoperative dipyridamole-thallium imaging are both useful in predicting ischemic events after vascular surgery. DESIGN: Retrospective, observational study. SETTING: University medical center. PATIENTS: Two hundred fifty-four consecutive patients referred to a nuclear cardiology laboratory before surgery. Forty-four patients had surgery cancelled or postponed after clinical evaluation and dipyridamole-thallium imaging. Surgery was not confirmed for ten. Two hundred patients receiving prompt vascular surgery were the study group. MEASUREMENTS AND MAIN RESULTS: Thirty patients (15%) had early postoperative cardiac ischemic events, with cardiac death in 6 (3%) and nonfatal myocardial infarction in 9 (4.5%). Logistic regression identified five clinical predictors (Q waves, history of ventricular ectopic activity, diabetes, advanced age, angina) and two dipyridamole-thallium predictors of postoperative events. Of patients with none of the clinical variables (n = 64), only 2 (3.1%; 95% CI, 0% to 8%) had ischemic events with no cardiac deaths. Ten of twenty (50%; 95% CI, 29% to 71%) patients with three or more clinical markers had events. Eighteen of one hundred sixteen (15.5%; 95% CI, 7% to 21%) patients with either 1 or 2 clinical predictors had events. Within this group, 2 of 62 (3.2%; 95% CI, 0% to 8%) patients without thallium redistribution had events compared with 16 events in 54 patients (29.6%; 95% CI, 16% to 44%) with thallium redistribution. The multivariate model using both clinical and thallium variables showed significantly higher specificity at equivalent sensitivity levels than models using either clinical or thallium variables alone. CONCLUSIONS: Preoperative dipyridamole-thallium imaging appears most useful to stratify vascular patients determined to be at intermediate risk by clinical evaluation. For patients with one or two clinical predictors, thallium redistribution correlates with substantial change in probability of events. For nearly half the patients, however, thallium imaging may have been unnecessary because of very high or low cardiac risk predicted by clinical information alone.
Age Factors↗
Recent experience with thoracoabdominal aneurysm repair.
Thoracoabdominal aneurysm repair was carried out in 55 patients during the period from January 1978 to June 1988. Considering the volume of experience and application of a routine for preoperative and intraoperative management, the experience was divided as follows: group 1 1978 to 1985 (26 patients) and group 2 1985 to 1988 (29 patients). Clinical features of the two groups differed only in the incidence of emergency operations (group 1 [6/18, 30%] vs group 2 [2/29, 8%]). Operative mortality in elective operations improved substantially in recent experience (group 1 [50%] vs group 2 [7.4%]). Significant reductions in total operative time, operative blood loss, and total aortic cross-clamping times paralleled and, in part, explained the improvement in overall surgical results seen in group 2 patients. Spinal cord injury occurred in 7.2% of the entire cohort. Nonfatal but major complications occurred in 25% of group 2 patients, with the most common being prolonged ventilatory assistance (12%). Current results with thoracoabdominal aneurysm repair both establish its safety and help to provide guidelines in selecting patients for elective repair.
Acute Kidney Injury↗
Are familial abdominal aortic aneurysms different?
A 9-year prospective study of 542 consecutive patients undergoing operation by one of the authors for abdominal aortic aneurysms was undertaken to define the incidence, clinical behavior, and anatomic characteristics of familial abdominal aortic aneurysms. Eighty-two (15.1%) patients having surgery for abdominal aortic aneurysms were found to have a first-degree relative with an aneurysm, as compared to nine (1.8%) of a control group of 500 patients of similar age and sex without aneurysmal disease (p less than 0.001). Detailed analysis was next performed of the pedigree charts of patients with a positive family history of aneurysm who underwent repair of abdominal aortic aneurysms by all authors over the 9-year study period. This review identified a total study population of 86 families with 209 first-degree relatives with abdominal aortic aneurysms. Clinical and anatomic features of this familial group were compared to those of 460 patients operated on for abdominal aortic aneurysms who had no family history of abdominal aortic aneurysms. Patients with familial abdominal aortic aneurysms were more likely to be women (35% vs 14%), and men with familial abdominal aortic aneurysms tended to be about 5 years younger than the women. There was no significant difference between the patients with nonfamilial and familial abdominal aortic aneurysms in anatomic extent of aneurysmal disease, multiplicity of aneurysms, associated occlusive disease, or blood type. There was a history of aneurysm rupture in 35 of 86 (40.7%) families with familial abdominal aortic aneurysms.(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
Long-term results of combined iliac balloon angioplasty and distal surgical revascularization.
Long-term results of combined use of iliac artery percutaneous transluminal angioplasty (PTA) and distal surgical revascularization for the management of multilevel occlusive disease were evaluated over a 12-year period. A total of 79 combined procedures were performed in 75 patients. All patients had tandem occlusive disease, with the inflow lesion felt to preclude a distal revascularization procedure alone. Revascularization was performed for incapacitating claudication in 17 (22%) and limb salvage indications in 62 (78%) cases. A mean resting iliac artery pressure gradient of 29 +/- 11 mmHg pre-PTA was reduced to 0.9 +/- 0.4 post-PTA. Major complications of PTA occurred in five (6%) cases, but four were successfully corrected at the time of the distal surgical procedure without alteration of the operative plan. Infrainguinal operations included 55 femoropopliteal or tibial bypass grafts, 18 femorofemoral grafts, and 6 profundaplasties. Mean follow-up was 43 months. By life table analysis, the 5-year primary patency rate of the distal surgical procedures was 76%; a secondary patency of 88% at 5 years was achieved by various means of reintervention. Mean pretreatment ankle/brachial index of 0.31 +/- 0.14 increased to 0.80 +/- 0.16 after operation (p less than 0.0001). The 5-year limb salvage rate was 90%. There were no operative deaths. We conclude that in carefully selected patients, combined use of iliac PTA and distal surgical reconstruction is effective and durable, safely reducing the extent of surgical intervention while reliably increasing the comprehensiveness of revascularization.
Actuarial Analysis↗
Vascular complications associated with spontaneous aortic dissection.
Three hundred twenty-five cases of spontaneous aortic dissection seen at two institutions between 1965 and 1986 were reviewed to assess the incidence, morbid sequelae, and specific management of aortic branch compromise. Noncardiac vascular complications occurred in 33% of the study group, and in these patients the overall mortality rate (51%) was significantly (p less than 0.001) higher than in patients without (29%) such complications. Although aortic rupture was the strongest correlate of mortality (90%), death specifically related to vascular occlusion was common when such occlusion occurred in the carotid, mesenteric, and renal circulation. There was a strong correlation between stroke and carotid occlusion (22/26 cases), yet specific carotid revascularization was only used during the chronic phase of the disease. Similarly, peripheral operation was ineffective in reducing the mortality rate in the setting of mesenteric (87%) and renal (50%) ischemia. Fifteen patients required either fenestration or graft replacement of the abdominal aorta for acute obstruction, rupture, or chronic aneurysm development. Thirty-eight patients (12%) demonstrated some degree of lower extremity ischemia, and one third of these required a direct approach on the abdominal aorta or iliofemoral segments to restore circulation. Selected patients with acute aortic dissection may require peripheral vascular operation in accordance with a treatment strategy that directs initial attention to the immediate life-threatening complications.
Aged↗
Use of the gastroduodenal artery in right renal artery revascularization.
Of 15 patients having revascularization of the right renal artery with the use of the hepatic circulation from May 1984 through March 1987 at the Massachusetts General Hospital, eight patients had this accomplished with end-to-end anastomosis of the gastroduodenal artery and right renal artery. Operative indications were acute azotemic renal failure (three patients), poorly controlled renovascular hypertension (four patients), and staged repair of bilateral renal artery disease (one patient). All revascularizations were successful in restoring renal function or rendering hypertension manageable and were assessed by means of renal flow scans, celiac angiography, or return of function in those patients with a solitary, functioning kidney. All patients survived the operation with one late death caused by myocardial infarction after abdominal aortic aneurysm repair. The gastroduodenal artery may be used as the source for arterial inflow in revascularization of the right renal artery by end-to-end anastomosis in approximately 50% of instances, conferring the advantage of the use of only one anastomosis and obviating the long-term possibility of vein graft failure.
Anastomosis, Surgical↗
Dipyridamole-thallium scanning in patients undergoing vascular surgery. Optimizing preoperative evaluation of cardiac risk.
Dipyridamole-thallium imaging has been suggested as a method of preoperatively assessing cardiac risk in patients undergoing major surgery. To define more clearly its proper role in preoperative assessment, we prospectively evaluated 111 patients undergoing vascular surgery. In the first set of 61 patients, our data confirmed the value of preoperative dipyridamole-thallium scanning in identifying the patients who suffered postoperative ischemic events. Events occurred in eight of 18 patients with reversible defects on preoperative imaging, compared with no events in 43 patients with no thallium redistribution (confidence interval for the risk difference: 0.624, 0.256). The results also suggested that clinical factors might allow identification of a low-risk subset of patients. To test the hypothesis that patients with no evidence of congestive heart failure, angina, prior myocardial infarction, or diabetes do not require further preoperative testing, we evaluated an additional 50 patients having vascular procedures. None of the 23 without the clinical markers had untoward outcomes, while ten of 27 patients with one or more of these clinical markers suffered postoperative ischemic events (confidence interval for the risk difference: 0.592, 0.148). In the clinical high-risk subset, further risk stratification is achieved with dipyridamole-thallium scanning.
Aged↗