Aortofemoral Bypass Grafting Research Articles

Spasme coronarien lors d'anesthésies itératives

Coronary arterial spasm observed during the course of two repeated anaesthesias in a patient having undergone aorto-femoral bypass grafting is reported by the authors. Such complications are accompanied by serious ventricular arrhythmias, though transient and healing without sequelae. Clinical and electrocardiographic characteristics of peroperative coronary arterial spasm are underlined. In patients prone to developing such spasm, peroperative alcalosis, hypothermia and parasympathetic stimuli should be avoided. Are emphasized the efficiency of preventive treatment with calcium antagonists and that of intravenous nitroglycerin in the treatment of peroperative coronary arterial spasm when it does occur.

Application of intestinal staplers to aortoiliac surgery

Although intestinal stapling devices have become an accepted part of the contemporary gastrointestinal surgeon's armamentarium, little attention has been given to their application to vascular surgical operative techniques. We have found the TA stapler helpful in surgery of the abdominal aorta, the iliac arteries, and their branches. It is most applicable to aortic bypass surgery for both atherosclerotic occlusive and aneurysmal disease. The TA 30, 50, and 90 devices designed to introduce a double row of overlapping staples effect a secure, hemostatic, and watertight bowel closure. These staples can likewise achieve a secure, bloodtight closure when used appropriately in aortic surgery. In aortofemoral bypass grafting performed with a proximal end-to-end anastomosis, the TA 30 or 55 is ideal for expeditious closure of the transected, distal aortic stump. The stapling technique also greatly simplifies obliteration of common, external, and internal iliac aneurysms to prevent back-bleeding when these aneurysms are excluded from the main reconstructed arterial stream. In the resection of abdominal aortic aneurysms associated with multiple iliac branch aneurysms, the technique eliminates the necessity of placing sutures in deep, inaccessible areas. Tangential staple occlusion of common iliac aneurysms, allowing retrograde flow from the distal femoral anastomosis into the internal iliac artery, preserves pelvic visceral perfusion. Our experience in approximately 50 cases, employing the TA stapling device in a variety of aortoiliac artery operative situations, is outlined.

Prospective randomized study of concomitant lumbar sympathectomy with aortoiliac reconstruction

Ninety-three consecutive patients for aortofemoral bypass grafting were studied to determine the effect of sympathectomy on early and late patency, the need for subsequent distal procedures, amputation rate, and ankle-brachial Doppler systolic pressure indexes. Sixty-seven patients completed the study. Fifty-three limbs were randomized to receive sympathectomy and 81 no sympathectomy. The mean length of follow-up postoperatively was 11 ± 2.53 months (maximum 24). Five grafts occluded, two early and three late. Both early occlusions occurred in the nonsympathectomy group and all three late occlusions ensued in the sympathectomy group. Subsequent distal procedures were necessary early (within 30 days) in five limbs, all in the nonsympathectomy group. Nine limbs required distal procedures late, four (5 percent) in the nonsympathectomy group and five (9.5 percent) in the sympathectomy group (p > 0.05). Altogether, distal bypass was required in 11 percent of the patients in the nonsympathectomy group versus 9.4 percent in the sympathectomy group (p > 0.05). Five limbs were amputated 4 to 14 months after aortofemoral bypass, four (5 percent) in the nonsympathectomy and one (2 percent) in the sympathectomy group (p > 0.05). The ankle-brachial pressure index increased significantly after aortofemoral bypass in both groups (p < 0.05). The mean increase after aortofemoral bypass was more marked in the sympathectomy group (p > 0.05). Thus, at a mean follow-up time of 11 months after aortofemoral bypass, there was no significant difference in graft patency, need for subsequent distal bypass, or amputation rate between the sympathectomy and nonsympathectomy groups.

Aortofemoral bypass for severe limb ischemia: Long-term survival and limb salvage

Long-term survival, graft patency and limb salvage in 74 patients with 96 severely ischemic limbs after aortofemoral bypass grafting is presented. Results in 73 limbs reconstructed for rest pain and 23 limbs reconstructed for ulceration or gangrene were compared by life table analysis, with follow-up of up to 98 months. The operative mortality was 4 percent. Overall 5 and 8 year survival was 74.8 and 52.3 percent, respectively. Overall graft patency at 5 years was 80.8 percent (rest pain 74.4 percent versus ulceration or gangrene 100 percent). Overall limb salvage was 76.7 percent at 5 years (rest pain 83 percent versus ulceration or gangrene 55 percent) (p < 0.001) and 68 percent at 8 years. Distal reconstructions were necessary in 19 limbs (21 percent); limbs with ulceration or gangrene required further attempts at salvage more often (34 percent versus 16 percent for rest pain) (p < 0.01). Aortofemoral bypass for impending limb loss yields satisfactory long-term results, and the extent of tissue loss preoperatively is an important prognostic factor. Prognosis for survival and limb salvage is worse and the need for additional distal reconstruction greater in patients with ischemic ulcer or gangrene.

A simple angiographic method for assessing aorto-femoral bypass grafts

Direct puncture of femoral bypass grafts in the groin with retrograde injection of contrast was employed to assess the lower abdominal aorta, iliac and lower limb arteries. The technique was effective, simple, quick and safe.

Aortic grafting procedures: tailoring the options.

Records from 165 patients who had received aortoiliac or aortofemoral bypass grafts were reviewed. The overall five-year patency rate was 88%. There was no significant difference in operative duration, amount of blood transfused, postoperative complications, and life table patency rates when comparisons were made of unilateral and bilateral grafts, of patients who underwent sympathectomy and those who did not, or of aortofemoral and aortoiliac grafts. When bypass grafting included an additional procedure, the amount of blood transfused and the number of postoperative complications increased significantly. We conclude that (1) the decision to operate should be based on symptoms, (2) the site of anastomosis should be chosen from anatomic characteristics, and (3) other procedures should not be performed except to achieve obvious therapeutic goals and to assure graft patency.

Ureteral Obstruction Secondary to Bifurcated Aortic Grafts

We report three cases of ureteral obstruction producing hydronephrosis following aortofemoral bypass graft. In each case, the obstruction occurred in the area where in the ureter crossed over the limb of a Dacron graft. Ureterolysis relieved the obstruction. Most of the previously reported cases of this complication of bypass surgery occurred when the ureter was situated between the limb of a graft and the patient's own iliac artery. Various methods of surgical appraoch are listed. In some cases, ureterolysis is a suitable alternative to division and reanastomosis of the ureter to relieve obstruction.

Autogenous Profundaplasty

The records of 281 patients undergoing aortic grafting to 522 femoral arteries over a period of 18 years were reviewed. Fifty-four patients suffering graft limb occlusion to 71 femoral arteries requiring subsequent secondary repair were identified for detailed analysis. Occlusive disease of the profunda femoris artery was identified as the primary cause of thrombosis. Repair consisted of profunda femoris angioplasty, and transfemoral retrograde graft thrombectomy was possible in all but three instances which were managed by cross-over femoral-femoral bypass. In no instance was laparotomy and abdominal graft replacement necessary. The 30 day operative survival and graft patency were 100%. Analysis of factors that have influenced late graft patency demonstrated that the key factors were the method of profundaplasty and the association of diabetes mellitus. When autogenous profundaplasty (on-lay arterial patches, saphenous vein, or limited endarterectomy) was employed, the overall patency combining diabetics and non-diabetics was two and one-half times greater than when profundaplasty was performed with an on-lay Dacron((R)) patch. If diabetics were separated from nondiabetics in the autogenous angioplasty group, the 36 month patency for non-diabetics was 85%, and 0% for diabetics. We conclude that autogenous profundaplasty provides considerable advantage from the standpoint of long-term patency and that the diabetic patients are relatively poor candidates for secondary arterial repair of an occluded aortofemoral bypass graft.

Case 41-1977

Presentation of CaseA 68-year-old man was admitted to the hospital because of dehydration.There was a long history of peripheral vascular disease. Fifteen years before entry bleeding occurred from a peptic ulcer. Eight years later a right nephrectomy was performed at another hospital because of a perinephric abscess. Six years before admission ischemic ulcers appeared on the right foot. He was admitted to this hospital, where aortoiliac occlusion was found, and a Dacron aortofemoral bypass graft was inserted. Two months later, becase of persistent pain and ischemic ulcers on the right foot, a right-saphenous-vein femoral-popliteal bypass graft was performed. . . .

The profunda femoris-popliteal artery bypass.

The profunda femoris artery can be used for the origin of a femoropopliteal bypass in cases of previous aorto femoral bypass graft, short saphenous vein, and other less common conditions that render the common femoral artery unsuitable for proximal anastomosis. Fourteen profunda-popliteal bypass procedures were performed in 12 patients between 1973 and 1976. The indications for surgery were incapacitating claudication in seven, and rest pain or tissue necrosis in five patients. Electromagnetic flow measurements at operation in ten patients indicated a mean graft blood flow of 146 +/- 51 ml/min. The mean Doppler ankle/wrist pressure ratio improved from 0.48 +/- 0.11 preoperatively to 0.87 +/- 0.14 postoperatively, while the plethysmographic mean pulse volume increased from 1.1 +/- 0.6 microliter to 2.4 +/- 0.4 microliter. Thirteen of the 14 grafts remain patient at one to three years' follow-up. The profunda-popiteal bypass is an effective alternative to standard femoropopliteal bypass in cases where the common femoral artery is not available for proximal graft anastomosis.

Stenosis of the deep femoral artery: an evaluation of the accuracy of single-plane, anteroposterior arteriograms

Pre-operative evaluation of the deep femoral artery is important in determining surgical treatment of aortofemoral disease. We reviewed 16 years' experience in bilateral aorto-femoral by-pass grafting and found that 63.2% of stenoses of the deep femoral arteries seen at surgery had been missed on conventional antero-posterior arteriograms. These findings demonstrate the inadequacy of a single, antero-posterior projection and the need for supplementary views in assessing lesions of the deep femoral artery.

The complication rate of catheter angiography by direct puncture through aorto-femoral bypass grafts

A search of the literature revealed no documentation of the complication rate associated with percutaneous catheterization of aorto-femoral bypass grafts in the arteriographic evaluation of graft patency. The authors compared the complication rates of 29 consecutive arteriograms performed through grafts (Group I) with 40 arteriograms performed on non patients (Group II). Neither group had any significant complications, indicating the safety of percutaneous catheterization of the graft site.

The natural history of bilateral aortofemoral bypass grafts for ischemia of the lower extremities.

Analysis of the immediate and long-term results in 180 patients undergoing aortofemoral bypass grafts for occlusive disease of the lower extremities showed the immediate graft limb patency in 360 graft limbs to be 99.2%. The cumulative ten-year graft limb patency was 66%. Factors associated with thrombosis of the graft limb revealed correlations for localized atherosclerotic disease of either the profunda femoris artery or the tibial trifurcation vessels. The highest correlation for graft limb thrombosis was with simultaneous lesions involving both the profunda femoris artery and tibial trifurcation vessels. The acute lower extremity salvage rate was 94%, and the ten-year cumulative extremity salvage for legs at risk of amputation was 85%. Postoperative symtpoms correlated well with patency. Overall operative mortality was five patients out of 180 (2.5%).

Sexual function after aorto-lliac surgery.

Patients undergoing aorto-iliac operations frequently suffer severe physical and psychological problems as a consequence of postoperative sexual disability. In an attempt to reduce this symptom complex, careful preoperative and postoperative evaluations were performed on 20 patients undergoing such procedures. Their average age was 64 years. Patients were divided into groups distinguished by type of operative procedure and extent of sexual function, then carefully evaluated for changes related to technical aspects of the vascular reconstruction. Data were accumulated pertaining to preoperative and postoperative frequency of sexual intercouse, ability to achieve and maintain an erection, occurrence of retrograde ejaculation, and other symptoms of genitourinary dysfunction. Significant and disabling sexual dysfunction, found to occur after routine abdominal aneurysmectomy, aorto-femoral bypass grafting, and aorto-iliac endarterectomy, is believed to be related to type of operation and technical aspects of the procedure. The incidence of postoperative retrograde ejaculation and impotence was significant.

Extended endarterectomy of the profunda femoris artery.

In eight limbs with femoral or popliteal artery occlusions due to arteriosclerosis profunda, endarterectomy was used as all (two patients) or part of the reconstructive procedure. In five patients aortofemoral bypass grafts were used concomitantly, and in one a femoropopliteal vein bypass was performed also. All were improved clinically and no amputations followed. Where blood flows were measured by the electromagnetic flowmeter before and after operation, all increased, most by over 100 ml/min. In some limbs popliteal pulses returned. The endarterectomy technique was a closed one and clearance was always carried to the second or third perforating branch.

ARTERIAL SURGERY FOR AORTO-ILIAC OCCLUSIVE VASCULAR DISEASE EARLY AND LATE RESULTS IN 238 PATIENTS

The results of direct arterial surgery in 238 patients with aorto-iliac disease have been analysed. The two procedures used were endarterectomy and aortofemoral bypass graft. The 91% early and 80% late patency-rates are encouraging. In-hospital mortality was 6·3%. Late mortality was high principally due to the sequelæ of atheroma. These sequelæ have been analysed in both non- diabetic and diabetic patients with regard to mortality as well as durability of the definitive procedures.