Biomedical subjects

R M Green

Publications and source records attributed to R M Green.

At least 55 records · Page 3Linked to original sources

PubMed2000

Claviculectomy for subclavian venous repair: long-term functional results.

OBJECTIVES: The purpose of this study was to determine the long-term functional results after medial claviculectomy and venous patch angioplasty or bypass grafting using internal jugular vein after incomplete thrombolysis of effort thrombosis of the subclavian vein. METHODS: The records of 11 patients with effort thrombosis who were treated over the past 9 years were reviewed. Patients have been followed up between 3 and 9 years at 6-month intervals with duplex imaging and contrast venography when indicated and have had an orthopedic evaluation of their shoulder function. RESULTS: All reconstructed veins are patent, and only one patient complains of any arm swelling after prolonged usage. This patient is one of three with postphlebitic changes at the site of repair and has similar findings in her basilic vein. All patients have returned to their prethrombosis vocation without limitation. Four of the 11 patients have jobs requiring heavy physical labor. No patient describes any limitations of shoulder function, but one man who works as a diesel mechanic complains of shoulder aching with overuse with repetitive pulling. Three patients describe upper extremity paresthesias when lying on the operated side. Two patients (one man and one woman) are bothered by the large scar and indentation at the site of the incision. Every patient considers the overall result completely successful from a functional standpoint. CONCLUSIONS: Early subclavian venous repair performed through a medial claviculectomy is a durable operation with excellent long-term functional results. Half of the patients noted minor but significant symptoms, but all are uniformly able to return to normal function.

Adolescent↗

PubMed2000

Eversion endarterectomy of the carotid artery: technical considerations and recurrent stenoses.

PURPOSE: The purpose of this study was to examine the characteristics of residual and recurrent lesions after eversion endarterectomy of the carotid artery (E-CE) and compare these results with those following endarterectomy and patch closure (CE-P). METHODS: We reviewed 274 patients who underwent carotid endarterectomy in 1998 with electroencephalographic monitoring, general anesthesia, completion duplex scan, and 1-year follow-up. CE-P was preferred for patients who required temporary shunting. In the E-CE group an additional proximal 2-cm arteriotomy was made in the common carotid artery (CCA) in 79 patients, a longer arteriotomy was made for extensive involvement of the CCA in 14 patients, and the internal carotid artery was advanced proximally as a patch for the CCA arteriotomy closure in 14 patients. Stenoses of > 50% that were present at 1 month were considered residual, and those of > 50% that were present at 1 year but not at 1 month were considered recurrent. RESULTS: There were five (1.8%) postoperative strokes (four after CE-P and one after E-CE, P = not significant). At 30 days there were 28 patients (10.2%) with residual stenoses > 50% (11 patients [10.2%] in the E-CE group and 17 patients [10.1%] in the CE-P group; P = not significant). The incidence of recurrent lesions of more than 50% was similar (4.6% for E-CE vs 4.7% for CE-P). CONCLUSION: The pattern of residual lesions and recurrent stenoses differs with each technique of endarterectomy. Proximal stenoses are more common after E-CE, and distal stenoses are more common after CE-P at both 1 month and 1 year. The frequency of proximal lesions is reduced in E-CE when either the internal carotid artery is advanced proximally onto the CCA or a long CCA arteriotomy is made. Distal recurrences do not seem to be a problem after eversion endarterectomy.

Angiography↗

PubMed2000

A peptide permease mutant of Mycobacterium bovis BCG resistant to the toxic peptides glutathione and S-nitrosoglutathione.

Oligopeptides play important roles in bacterial nutrition and signaling. Using sequences from the available genome database for Mycobacterium tuberculosis H37Rv, the oligopeptide permease operon (oppBCDA) of Mycobacterium bovis BCG was cloned from a cosmid library. An opp mutant strain was constructed by homologous recombination with an allele of oppD interrupted by kanamycin and streptomycin resistance markers. The deletion was complemented with a wild-type copy of the opp operon. Two approaches were taken to characterize the peptide transporter defect in this mutant strain. First, growth of wild-type and mutant strains was monitored in media containing a wide variety of peptides as sole source of carbon and/or nitrogen. Among 25 peptides ranging from two to six amino acids in length, none was capable of supporting measurable growth as the sole carbon source in either wild-type or mutant strains. The second approach exploited the resistance of permease mutants to toxic substrates. The tripeptide glutathione (gamma-glutamyl-L-cyteinylglycine [GSH]) is toxic to wild-type BCG and was used successfully to characterize peptide uptake in the opp mutant. In 2 mM GSH, growth of the wild-type strain is inhibited, whereas the opp mutant is resistant to concentrations as high as 10 mM. Similar results were found with the tripeptide S-nitrosoglutathione (GSNO), thought to be a donor of NO in mammalian cells. Using incorporation of [(3)H]uracil to monitor the effects of GSH and GSNO on macromolecular synthesis in growing cells, it was demonstrated that the opp mutant is resistant, whereas the wild type and the mutant complemented with a wild-type copy of the operon are sensitive to both tripeptides. In uptake measurements, incorporation of [(3)H]GSH is reduced in the mutant compared with wild type and the complemented mutant. Finally, growth of the three strains in the tripeptides suggests that GSH is bacteriostatic, whereas GSNO is bacteriocidal.

Cloning, Molecular↗

PubMed2000

An endoluminal method of hemorrhage control and repair of ruptured abdominal aortic aneurysms.

PURPOSE: To report our initial experience with endovascular grafting to treat ruptured abdominal aortic aneurysms (AAAs). METHODS: Three consecutive patients with severe comorbid illnesses and symptoms of aneurysm rupture and hemodynamic instability were treated with aortomonoiliac grafts. The Z-stent-based devices were implanted with the assistance of an occlusion balloon placed in the distal descending thoracic aorta. RESULTS: All patients survived the procedure with successfully excluded AAAs. Two patients had relatively short hospital stays (4 and 14 days), while the third required prolonged treatment for pre-existing conditions. All patients required blood transfusions; 2 developed significant coagulopathies. Definitive management was delayed significantly by imaging protocols and graft construction. CONCLUSIONS: Endovascular repair of ruptured aortic aneurysms is feasible. Proximal aortic control is readily attainable with the use of an aortic occlusion balloon placed through the left axillary artery. The absence of a laparotomy, extensive retroperitoneal dissection, and aortic cross-clamping likely contributes to patient survival; however, the delay in operative therapy to obtain adequate imaging and construct an endograft could be a hindrance to the ultimate success of this approach. The concepts of alternative aortic imaging techniques and endograft design, construction, and storage must be addressed.

Aged↗

PubMed2000

Unrecognized carotid artery stenosis discovered by calcifications on a panoramic radiograph.

BACKGROUND: Approximately 730,000 strokes occur each year in the United States, costing an estimated $40 billion annually. One-half of all strokes are the result of atherosclerotic plaques found in the carotid artery. Such plaques frequently are heavily calcified and can be identified on a panoramic radiograph by the incidental finding of calcifications overlying the carotid bifurcation. CASE DESCRIPTION: The authors found that a 67-year-old asymptomatic woman had calcium deposits overlying both carotid bifurcation regions on a panoramic radiograph. Subsequent duplex ultrasonic examination indicated bilateral, high-grade carotid arterial stenoses. The patient underwent uneventful bilateral carotid endarterectomy. CLINICAL IMPLICATIONS: The patient had critical carotid arterial stenoses associated with significant risk of stroke that had not been identified otherwise. The findings on the panoramic radiograph led to appropriate and potentially life-saving treatment. While the positive predictive value of this finding has yet to be defined, the authors believe that calcifications overlying the carotid system region seen on panoramic radiography in an asymptomatic patient should be followed by formal evaluation of the carotid bifurcation.

Aged↗

PubMed2000

Prosthetic above-knee femoropopliteal bypass grafting: five-year results of a randomized trial.

PURPOSE: This trial was designed to identify factors affecting patency rates of primary prosthetic above-knee femoropopliteal bypass grafts at 5 years. METHODS: A multi-institutional, prospective trial randomized 240 patients to compare patency rates of Gore-tex and Hemashield above-knee femoropopliteal bypass grafts at 5 years. Univariate comparisons of patency between levels of each prognostic variable were made with the Kaplan-Meier method. Variables that had a univariate P value less than.25 or those known to be important were submitted to a Cox regression analysis. RESULTS: The patient survival rate at 5 years was 59.4%. There were no differences in primary or secondary patency rates at 5 years between the two graft materials (primary, 45% vs 43% and secondary, 68% vs 68%). The risk for graft occlusion was significantly increased for patients younger than 65 years (2.1; P =.001) and for grafts with a diameter less than 7 mm (1.65; P =.0219). Variables with no apparent independent effect on patency rates were smoking status, runoff, diabetes mellitus, sex, presenting symptoms, and postoperative treatment with aspirin or Coumadin. Noninvasive test results were not predictive of subsequent graft function. CONCLUSION: Although the type of prosthetic used for above-knee femoropopliteal bypass grafts does not affect 5-year patency rates, age and graft size do influence results. These factors should be considered before a prosthetic bypass grafting procedure. Furthermore, these data should serve as a contemporary standard, with which evolving and conventional procedures can be compared.

Aged↗

PubMed2000

Mammary tuberculosis: rare but still present in the United Kingdom.

Mammary tuberculosis (TB) is rare and usually affects women from the Indian sub-continent and Africa. It may be mistaken clinically for carcinoma or pyogenic abscess. Tuberculosis (particularly drug-resistant TB) is on the increase in areas of the UK with rising numbers of immigrants, some of whom may present with breast lesions of uncertain aetiology. Between 1978 and 1997 there were 436 cases of TB notified for Indian Sub-continent females aged 15-49 years in Blackburn, Hyndburn and Ribble Valley, Lancashire, UK. Ten cases were mammary TB (10/436 = 2.3%) which was clinically suspected in only three patients preoperatively, despite the area having large numbers of immigrants. Mammary TB should be included in the differential diagnosis of breast lesions in women from those ethnic groups at increased risk of TB. Pus and/or breast tissue samples should be subjected to TB culture and histological examination for both diagnosis of TB and determination of drug sensitivities.

Abscess↗

PubMed2000

Functional expression of a high affinity mammalian hepatic choline/organic cation transporter.

Uptake by the liver of the organic cation and essential nutrient choline is required for the hepatic synthesis of phosphatidylcholine. Uptake of other organic cations is also important for the metabolism and secretion of numerous endobiotics and drugs. Although a high affinity mammalian hepatic choline transporter has been kinetically defined, it has not been previously identified. We have developed stable transfectants of BALB/3T3 cells, using a murine member of the organic cation transporter gene family (mOct1/Slc22a1), and used these cells to characterize the transport of the organic cation choline and model organic cation tetraethylammonium (TEA). Functional expression of mOct1/Slc22a1 in BALB/3T3 cells confers the saturable, temperature-dependent uptake of choline with a K(m) of 42 micrometer, and uptake of TEA with a K(m) of 43 micrometer. We subsequently used our cell culture uptake system to kinetically define in HepG2 cells a high affinity choline uptake process, which transports choline with a K(m) similar to that of mOct1/Slc22a1 protein. We also demonstrated that organic cation transport by mOct1/Slc22a1 is inhibited by several organic cations, and that the gene is expressed in the perinatal period, at a time when phosphatidylcholine synthesis increases. We conclude that mOct1/Slc22a1 encodes a high affinity mammalian hepatic choline/organic cation transporter. This transporter may be important for hepatic phosphatidylcholine synthesis, and for the metabolism and secretion of many organic cationic drugs.

3T3 Cells↗

PubMed1999

Cloning, tissue-specific expression, gene structure and chromosomal localization of human phosphatidylcholine transfer protein.

Phosphatidylcholine transfer protein (PC-TP) is a cytosolic protein that catalyzes intermembrane transfer of phosphatidylcholines in vitro. We have cloned a cDNA encoding the human ortholog of PC-TP and have determined its tissue-specific expression as well as genomic organization. Radiation hybrid mapping localized the human gene, PCTP, to chromosome 17q21-22 and PCR-based single strand conformation polymorphism analysis of an interspecific backcross assigned mouse Pctp to the region of syntenic conservation on chromosome 11.

Amino Acid Sequence↗

PubMed1999

The protein kinase CK2 is involved in regulation of circadian rhythms in Arabidopsis.

A wide range of processes in plants, including expression of certain genes, is regulated by endogenous circadian rhythms. The circadian clock-associated 1 (CCA1) and the late elongated hypocotyl (LHY) proteins have been shown to be closely associated with clock function in Arabidopsis thaliana. The protein kinase CK2 can interact with and phosphorylate CCA1, but its role in the regulation of the circadian clock remains unknown. Here we show that plants overexpressing CKB3, a regulatory subunit of CK2, display increased CK2 activity and shorter periods of rhythmic expression of CCA1 and LHY. CK2 is also able to interact with and phosphorylate LHY in vitro. Additionally, overexpression of CKB3 shortened the periods of four known circadian clock-controlled genes with different phase angles, demonstrating that many clock outputs are affected. This overexpression also reduced phytochrome induction of an Lhcb gene. Finally, we found that the photoperiodic flowering response, which is influenced by circadian rhythms, was diminished in the transgenic lines, and that the plants flowered earlier on both long-day and short-day photoperiods. These data demonstrate that CK2 is involved in regulation of the circadian clock in Arabidopsis.

Amino Acid Sequence↗

PubMed1999

Loss of the circadian clock-associated protein 1 in Arabidopsis results in altered clock-regulated gene expression.

Little is known about plant circadian oscillators, in spite of how important they are to sessile plants, which require accurate timekeepers that enable the plants to respond to their environment. Previously, we identified a circadian clock-associated (CCA1) gene that encodes an Myb-related protein that is associated with phytochrome control and circadian regulation in plants. To understand the role CCA1 plays in phytochrome and circadian regulation, we have isolated an Arabidopsis line with a T DNA insertion that results in the loss of CCA1 RNA, of CCA1 protein, and of an Lhcb-promoter binding activity. This mutation affects the circadian expression of all four clock-controlled genes that we examined. The results show that, despite their similarity, CCA1 and LHY are only partially redundant. The lack of CCA1 also affects the phytochrome regulation of gene expression, suggesting that CCA1 has an additional role in a signal transduction pathway from light, possibly acting at the point of integration between phytochrome and the clock. Our results indicate that CCA1 is an important clock-associated protein involved in circadian regulation of gene expression.

Arabidopsis↗

PubMed1999

A novel putative transporter maps to the osteosclerosis (oc) mutation and is not expressed in the oc mutant mouse.

The phenotype of mice homozygous for the osteosclerosis (oc) mutation includes osteopetrosis, and a variety of studies demonstrate that osteoclasts in these mice are present but nonfunctional. We have identified a novel gene that has homology to a family of 12-transmembrane domain proteins with transport functions and maps to proximal mouse chromosome 19, in a region to which the oc mutation has been previously assigned. The putative transporter is abundant in normal kidney, but its expression is markedly reduced in kidneys from oc/oc mice when tested using Northern and Western analyses. Southern analysis of this gene, which we call Roct (reduced in oc transporter), demonstrates that it is intact and unrearranged in oc/oc mice. In situ studies show that Roct is expressed in developing bone. We propose that the absence of Roct expression results in an osteopetrosis phenotype in mice.

Amino Acid Sequence↗

PubMed1999

Cloning and functional expression of a mouse liver organic cation transporter.

Hepatic uptake of organic cations is essential for the metabolism and secretion of numerous endobiotics and drugs. Several hepatic organic cation transporters have been kinetically defined, yet have not been isolated or cloned. We have isolated a complementary DNA (cDNA) from both murine liver and kidney cDNA libraries (mOct1/Slc22a1), and have functionally expressed it in Xenopus laevis oocytes. Although mOct1/Slc22a1 is homologous to previously cloned rat and human organic cation transporters, organic cation transport kinetics differed markedly. mOct1/Slc22a1-RNA injection of oocytes resulted in the saturable, time- and temperature-dependent uptake of the quaternary organic cation [14C]-tetraethylammonium ([14C]-TEA), with a Km of 38 micromol/L. TEA uptake was inhibited by several other organic cation drugs, but was not inhibited by the organic cation n-methyl-nicotinamide (NMN), being instead stimulated by it (fourfold). [14C]-TEA uptake was also stimulated by an inside-outside proton gradient. mOct1/Slc22a1-injected oocytes transported the organic cations [3H]-1-methyl-4-phenylpyridium and [3H]-choline chloride, but did not transport other classes of organic compounds. mOct1/Slc22a1 encodes for a hepatic and renal organic cation transporter which may be important for the uptake and secretion of cationic drugs and endobiotics.

1-Methyl-4-phenylpyridinium↗

PubMed1999

A volumetric index for the quantification of deep venous thrombosis.

PURPOSE: The evaluation of treatment strategies for deep venous thrombosis (DVT) is assessed through the use of a reliable method of quantifying the extent of the thrombotic process. Previous indices of thrombus burden have suffered from various limitations, including lack of clinical relevance, poor correlation with actual thrombus mass, and failure to include important venous segments in the methodology. The use of a novel scheme of quantifying venous thrombus was evaluated as an alternative method that would avoid some of the drawbacks of existing indices. METHODS: The volumes of 14 venous segments (infrarenal inferior vena cava, common iliac, hypogastric, external iliac, common femoral, profunda, superficial femoral, and popliteal and six tibial veins) were calculated from computed tomography (pelvic vein diameter), duplex ultrasound scan (infrainguinal vein diameter), and contrast venography (length of all segments) measurements. A venous volumetric index (VVI) was assigned with the normalization of the values to the volume of a single calf vein. The VVI was validated with the assessment of the ability to discriminate between asymptomatic and symptomatic DVT and between those DVT that were associated with pulmonary emboli and those that were not. RESULTS: With the imaging data, the VVI ranged from 1 for a single calf vein thrombus to 26 for the infrarenal inferior vena cava. Each VVI unit represented 2.3 mL of thrombus, with a maximum possible score of 63 representing a thrombus burden of 145 mL for a single extremity, including the infrarenal inferior vena cava. In 885 patients with DVT, the VVI ranged from 1 to 56, averaging 3.9 +/- 0.2 in patients who were asymptomatic and 8.7 +/- 0.3 in patients who were symptomatic (P <.001). The VVI was similar in the patients with pulmonary emboli as compared with those without (9.6 +/- 1.2 vs 7.7 +/- 0.2, respectively). In comparison with the three existing methods of quantifying venous thrombus burden, the receiver operating characteristic curve analysis results suggested that the VVI and the Venous Registry index were better than the other two indices in the discrimination of patients with symptomatic and asymptomatic DVT (P <.001). CONCLUSION: A novel index of venous thrombus burden, on the basis of actual venous volume measurements, was more accurate than present indices in the differentiation between clinical categories of patients with DVT. As such, it offers an acceptable alternative to current scoring systems.

Diagnostic Imaging↗

PubMed1999

Photoplethysmography and calf muscle pump function after subfascial endoscopic perforator ligation.

OBJECTIVE: Subfascial endoscopic perforator surgery (SEPS) results in acceptable healing and recurrence rates. The role of hemodynamic venous testing in this situation, however, is poorly understood and inconsistently used. Our ongoing experience was reviewed to explore how SEPS affects the photoplethysmographic assessment of the leg. METHODS: Preoperative and postoperative venous refill times (VRTs) were measured with photoplethysmography in 30 limbs in 28 patients who underwent SEPS and superficial ablation, when indicated, with complete clearing of the anterolateral surface of the tibia, thus opening the deep posterior compartment from mid calf to close to the malleolus. Postoperative healing and duplex scanning were used to assess clinical and anatomic success, respectively. The VRTs were classified as "interpretable" if the leg emptied or "uninterpretable" if the calf could not empty. The "interpretable" study results were further classified as "normal" if the refill took 20 seconds or more or "abnormal" if less. RESULTS: Before the patients underwent SEPS, six study results (20%) showed inability of the calf to empty and thus were judged uninterpretable. After the patients underwent SEPS, 12 study results (40%) were uninterpretable (NS; P =.09 with the chi(2) test). Of the 24 preoperative interpretable study results, two (8%) were normal, and of the 18 postoperative interpretable study results, seven (39%) were normal (P <.03). With the consideration of only interpretable study results, the mean VRT increased slightly from 12.0 +/- 5.1 seconds (mean +/- standard deviation) to 14.3 +/- 8.1 seconds (NS). Seventeen of 19 ulcers (89%) had healed at a mean follow-up period of 8.6 +/- 4.8 months. CONCLUSION: Although VRT is unpredictably affected by SEPS, the most consistent finding is the inability of the calf to empty, which invalidates the remainder of the test. In addition, most ulcers heal, even with uninterpretable or abnormal postoperative VRTs. This suggests that photoplethysmography is a poor method of assessment of venous reflux after SEPS.

Adult↗

PubMed1999

Intracerebral hemorrhage after carotid endarterectomy: incidence, contribution to neurologic morbidity, and predictive factors.

PURPOSE: With a diminishing rate of cardiac and neurologic events after carotid endarterectomy, intracerebral hemorrhage is gaining increasing importance as a cause of perioperative morbidity and mortality. To date, information has been largely anecdotal, and there has been no comparison with a control group of patients. METHODS: The records of all patients experiencing symptomatic intracerebral hemorrhage after carotid endarterectomy were reviewed and compared with data from 50 randomly selected patients who did not experience intracranial bleeding. Univariate analyses were performed, using the Fisher exact test for dichotomous data and the Student t test for continuous data. RESULTS: During a 6-year period, symptomatic intracranial hemorrhage developed in 11 (0.75%) of 1471 patients undergoing carotid endarterectomy, accounting for 35% of the 31 total perioperative neurologic events. Hemorrhage occurred a median of 3 days postoperatively (range, 0 to 18 days). Signs and symptoms included hypertension in all 11 patients, headache in 7 conscious patients (64%), and bradycardia in 6 patients (55%). Massive hemorrhage with herniation and death occurred in 4 patients (36%). Moderate hemorrhage developed in 5 patients (45%); 3 of these patients had partial recovery, and 2 had complete recovery. Petechial hemorrhage occurred in the remaining 2 patients (18%), 1 with partial and 1 with complete recovery. In comparison with the control group, there were no differences in respect to sex, indication for operation, smoking or diabetic history, and antiplatelet therapy or perioperative heparin management. Patients with intracranial hemorrhage were, however, younger, more frequently hypertensive, had a higher degree of ipsilateral and contralateral carotid stenosis, and had a higher rate of contralateral carotid occlusion. CONCLUSION: Intracranial hemorrhage occurs with notable frequency after carotid endarterectomy and accounts for a significant proportion of neurologic morbidity and mortality. Younger patients, hypertensive patients, and patients with severe cerebrovascular occlusive disease appear to be at greatest risk for the complication.

Age Factors↗

PubMed1999

Azoxymethane-induced fulminant hepatic failure in C57BL/6J mice: characterization of a new animal model.

Without transplantation, approximately 50-90% of all patients with fulminant hepatic failure (FHF) die. This poor outcome is due in part to the absence of an appropriate animal model, which would allow for a greater understanding of the pathophysiology of this syndrome. Given the reports of liver injury in humans and livestock fed cycad palm nuts on the island of Guam, we hypothesized that the active ingredient azoxymethane (AOM) could cause FHF. We therefore evaluated AOM in C57BL/6J mice. Histologically, we observed microvesicular steatosis 2 h, sinusoidal dilatation 4 h, and centrilobular necrosis 20 h after AOM administration, and transmission electron microscopy showed that this agent causes mitochondrial injury. FHF was associated with all four stages of encephalopathy, as well as by a prodromal period of decreased eating and drinking lasting approximately 15 h before the development of stage I encephalopathy (i.e., loss of scatter reflex). Late encephalopathy was associated with increased arterial ammonia, decreased serum glucose, and evidence of brain edema (astrocyte swelling). We show that AOM-induced FHF is highly reproducible, without evidence of lot-to-lot variability, and is dose dependent. These findings therefore suggest that AOM is an excellent agent for the study of FHF, as well as indicate that Guamanian FHF may be due to AOM found in unwashed cycad palm nuts.

Animals↗

PubMed1999

Prosthetic above-knee femoropopliteal bypass.

One of the classic and as yet unresolved arguments in vascular surgery is whether using prosthetic for a first-time above-knee femoropopliteal bypass, to "save the vein" for a later, more distal bypass, is of net benefit. Most of the arguments supporting use of prosthetic for a first bypass in this situation are, in fact, not supported by the literature, whereas most of the arguments in favor of using vein first are. In addition, decision analysis shows that overall amputation-free survival and number of operative procedures required are clearly better if vein is used first under essentially all conditions--the overwhelmingly strongest determinant of outcome is patency of the first bypass, and the superior patency of initial bypass with vein mathematically outweighs the ability of the "preserved" vein to salvage failures after an initial bypass with prosthetic. Theoretical, empirical, and mathematical arguments all strongly favor preferential use of vein for a first bypass to the above-knee popliteal artery.

Blood Vessel Prosthesis Implantation↗