Arterial Reconstruction In Patients Research Articles

EP.WE.567Regional anaesthesia for infra-inguinal revascularisation in patients with symptomatic peripheral arterial disease

IntroductionGeneral anaesthesia is considered to be an aerosol generating procedure. The global Covid-19 pandemic has resulted in review of practice to reduce risk to both patients and health care workers. The outcome of regional anaesthesia (RA) for infra-inguinal arterial reconstruction in patients with symptomatic occlusive atherosclerotic has been explored and compared with patients managed with general anaesthesia (GA).MethodsPatients undergoing infra-inguinal revascularisation between 2019-2020 were identified from a prospectively maintained administrative theatre dataset. Case-linkage was used to complete the dataset. Specific end points included to critical care admission and peri-operative mortality.ResultsThere were 204 patients identified (46 RA and 158 GA). The mean age of patients in both groups was 67-years and procedures were commonly performed in male patients (although the male:female ratio was higher in the RA group 2.8:1 than in the GA group 1.4:1). More patients in the RA had intervention for chronic limb threatening ischaemia (80% versus 59%). The interventions performed were comparable in both groups. The mean length of procedure was less in the RA group (142-minutes versus 160-minutes). No patients in the RA required admission to critical care (10 patients managed with GA required admission to critical care). The 30-day mortality was comparable in the RA and GA groups (2.2% and 1.9% respectively).ConclusionsRegional anaesthesia would appear to be feasible for patients undergoing infra-inguinal arterial reconstruction with a reduction in operating time and critical care admission without increased peri-operative risk.

Late Outcomes After Pulmonary Arterial Reconstruction in Patients With Arterial Tortuosity Syndrome

BackgroundSurgical pulmonary artery reconstruction in patients with arterial tortuosity syndrome has excellent outcomes. In this study, we report our late outcomes after more than a decade of experience with such complex interventions. MethodsWe conducted a retrospective review of 33 arterial tortuosity syndrome patients who underwent pulmonary artery reconstruction. The mean preoperative right ventricular to left ventricular pressure ratio was 1.19 ± 0.2. Our surgical approach included either a single-stage complete repair through a median sternotomy (17 patients) or a two-stage repair through sternotomy/left thoracotomy (16 patients), depending on the degree of distal involvement in the left pulmonary artery. ResultsMedian age was 36 months. All patients had distal segmental peripheral pulmonary artery stenosis. Thirty patients (90.1%) were symptomatic before surgery. There was one hospital death due to viral pneumonia 78 days after the surgery (in-hospital mortality 3%). The mean right ventricular to left ventricular pressure ratio decreased to 0.31 ± 0.07 early postoperatively (P < 0.001), representing a 74% reduction compared with preoperative values. Follow-up was 100% complete for all hospital survivors (32 of 33) with a mean follow-up of 70.42 ± 43.32 months (range, 2 to 143). There was no late mortality or need for reintervention (surgical or catheter based) after hospital discharge. In late postoperative catheterization, the mean right ventricular to left ventricular pressure ratio was 0.27 ± 0.05 (P = .003 compared with early postoperative value). All patients were asymptomatic on their most recent follow-up. ConclusionsA strategy of complete surgical reconstruction of all stenotic pulmonary artery segments in patients with arterial tortuosity syndrome is recommended for sustainable successful outcomes more than a decade later.

Arterial reconstruction with human bioengineered acellular blood vessels in patients with peripheral arterial disease

ObjectiveVascular conduit is essential for arterial reconstruction for a number of conditions, including trauma and atherosclerotic occlusive disease. We have developed a tissue-engineered human acellular vessel (HAV) that can be manufactured, stored on site at hospitals, and be immediately available for arterial vascular reconstruction. Although the HAV is acellular when implanted, extensive preclinical and clinical testing has demonstrated that the HAV subsequently repopulates with the recipient's own vascular cells. We report a first-in-man clinical experience using the HAV for arterial reconstruction in patients with symptomatic peripheral arterial disease. MethodsHAVs were manufactured using human vascular smooth muscle cells grown on a biodegradable scaffold. After the establishment of adequate cell growth and extracellular matrix deposition, the vessels were decellularized to remove human cellular antigens. Manufactured vessels were implanted in 20 patients with symptomatic peripheral arterial disease as above-knee, femoral-to-popliteal arterial bypass conduits. After HAV implantation, all patients were assessed for safety, HAV durability, freedom from conduit infection, and bypass patency for 2 years. ResultsTwenty HAVs were placed in the arterial, above-knee, femoral-to-popliteal position in patients with rest pain (n = 3) or symptomatic claudication (n = 17). All HAVs functioned as intended and had no evidence of structural failure or rejection by the recipient. No acute HAV infections were reported, but three surgical site infections were documented during the study period. Three non-HAV-related deaths were reported. One vessel developed a pseudoaneurysm after suspected iatrogenic injury during a balloon thrombectomy. No amputations of the HAV implanted limb occurred over the 2-year period, and no HAV infections were reported in approximately 34 patient-years of continuous patient follow-up. ConclusionsHuman tissue engineered blood vessels can be manufactured and readily available for peripheral arterial bypass surgery. Early clinical experience with these vessels, in the arterial position, suggest that they are safe, have acceptable patency, a low incidence of infection, and do not require the harvest of autologous vein or any cells from the recipient. Histologic examination of tissue biopsies revealed vascular remodeling and repopulation by host cells. This first-in-man arterial bypass study supports the continued development of human tissue engineered blood vessels for arterial reconstruction, and potential future expansion to clinical indications including vascular trauma and repair of other size-appropriate peripheral arteries.

Simultaneous SFA Angioplasty/Stent Plus Popliteal Distal Bypass for Limb Salvage

Introduction: Treatment of severe critical limb ischemia (CLI) due to Superficial Femoral Artery (SFA) and below-the-knee (BTK) vessels' involvement could be compromised by the lack of a Great Saphenous Vein (GSV) suitable in its entire length. The purpose of this study is to assess the efficacy of a hybrid endovascular and open lower limbs arterial reconstruction in these patients with multilevel, advanced CLI. We combined two different techniques, each one largely validated for different level of intervention (endovascular for SFA, surgical for BTK), and we aimed to assess the efficacy of such an hybrid arterial reconstruction in patients with multilevel CLI in the lack of suitable autologous vein. Methods: From 2005 to 2019, we performed hybrid endovascular and surgical treatment for limb salvage in SFA-BTK CLI. This consisted of percutaneous transluminal angioplasty (PTA) with or without stenting of the SFA, along with distal origin vein graft bypass. Inclusion criteria were: Rutherford category 5 or 6, lack of a suitable GSV, patency of the popliteal artery, steno-obstructive lesions of the SFA, lesions of the three crural vessels > 5 cm in length each. The follow-up was performed with duplex scan surveillance of both the bypass graft and PTA sites. Results: The hybrid treatment was performed in 34 patients. 56% of the SFA steno-obstructive lesions were treated with simple PTA, except for the application of a bare metal stent in one patient (3%), while in all the SFA occlusions PTA was completed with covered stents (41%). Thirty-four popliteal-to-distal vein bypass grafts have been performed. There were no perioperative PTA or bypass graft failures. Clinical improvement was achieved in 26 (76%) patients. Overall, primary, assisted primary and secondary patency, limb salvage, and survival rates were 65%, 70%, 68%, and 75% at 5 years, respectively (Graph 1 and Graph 2). Conclusion: A hybrid strategy in multilevel SFA-BTK CLI is a well established approach. Additional studies are warranted to validate these results.Graph 2View Large Image Figure ViewerDownload Hi-res image Download (PPT) Disclosure: Nothing to disclose

CD8+ T Cells Protect During Vein Graft Disease Development.

Aims: Vein grafts are frequently used conduits for arterial reconstruction in patients with cardiovascular disease. Unfortunately, vein graft disease (VGD) causes diminished patency rates. Innate immune system components are known to contribute to VGD. However, the role of T cells has yet to be established. The purpose of this study was to investigate the role of T cells and T cell activation pathways via the T cell receptor (TCR), co-stimulation and bystander effect in VGD.Methods and results: Here, we show upon vein graft surgery in mice depleted of CD4+ T cells or CD8+ T cells, that CD8+ T cells are locally activated and have a major protective role for vein graft patency. In presence of CD8+ T cells vein grafts appear patent while CD8+ T cell depletion results in occluded vein grafts with increases apoptosis. Importantly, the protective effect of CD8+ T cells in VGD development was TCR and co-stimulation independent. This was demonstrated in vein grafts of OT-I mice, CD70−/−, CD80/86−/−, and CD70/80/86−/− mice compared to C57BL/6 mice. Interestingly, cytokines including IL-15, IL-18, IL-33, and TNF are up-regulated in vein grafts. These cytokines are co-operatively capable to activate CD8+ T cells in a bystander-mediated fashion, in contrast to CD4+ T cells.Conclusions: T cells are modulators of VGD with a specific protective role of CD8+ T cells, which are locally activated in vein grafts. CD8+ T cells may protect against occlusive lesions by providing survival signals, and concert their protection independent of TCR and co-stimulation signaling.

Graft type for femoro-popliteal bypass surgery.

Graft type for femoro-popliteal bypass surgery.

Визначення ступеню важкості ураження гемомікроциркуляторного русла у хворих на цукровий діабет з критичною ішемією нижньої кінцівки

Aim.&nbsp;To determine the quantitative characteristics of lesions of the hemomycrocirculatory channel of the skin and muscles in patients with diabetes mellitus with critical ischemia of the lower limb. And to develop a method for calculating the degree of diabetic microangiopathy.&nbsp; Material and Methods.&nbsp;Samples of paraffin blocks of skin and muscles of 49 patients (experimental group) with diabetes mellitus, type II with chronic critical ischemia of the lower limb, against a background of combined&nbsp;stenotic-occlusive lesions of the arteries of the femoral and pediculophagomic segments, in combination with ulcerative-necrotic foot lesions, who were treated at the Center for Vascular Surgery at the Clinical Hospital "FEOPHANIA" of the State Department of Affairs during 2013 - 2016 were selected. A comparison group included the selected samples of skin and muscles of 20 patients without systemic diseases. Histologic and immunohistochemical studies were conducted to detect collagen IV - the marker of the basal membranes, VEGF - the vascular endothelial germ factor; CD 31 - the endothelial factor; and smooth muscle actin. The diameters of the blood vessels of the hemomicrocirculatory channel of skin of and muscles and the density of the capillaries were measured and compared. On the basis of the obtained data, the calculation of the degree of diabetic microangiopathy was performed. Results and Discussion.&nbsp;Characteristic changes were observed in the morphometric indices of blood vessels in the hemomicrocirculatory channel of the skin and muscles in patients with diabetes mellitus, type II with chronic critical ischemia of the lower limb. The method of calculating the degree of diabetic microangiopathy was developed. The correlation between the degree of diabetic microangiopathy and the probability of thrombosis after hybrid arterial reconstruction was revealed, and the algorithm of patient examination in the postoperative period was developed. Conclusions.&nbsp;The quantitative indicators that vary depending on the course and compensation of diabetes mellitus were identified: the vascular density of the hemomicrocirculatory channel in the papillary layer of the skin; the thickness of basal membranes of the vessels of the hemomicrocirculatory channel; the diameter of the lumen of the vessels of the hemomicrocirculatory bed. The characteristic qualitative changes in tissues are: the smoothing of the basement membrane of the epidermis, its dissolution in separate areas; the increased expression of VEGFR-1; the increase of expression of actin in blood vessels, including in capillaries; the unequal expression of CD31 in blood vessels. The collection of the data on qualitative and quantitative changes in the hemomicrocirculatory channel of the skin and muscles allowed to develop criteria for the calculation of the degree of diabetic microangiopathy. There was a correlation revealed between the severity of diabetic microangiopathy and the probability of thrombosis after the hybrid arterial reconstruction. Determining the severity of diabetic microangiopathy can be used in determining the algorithm of examination with possible implementation of preventive operations prior to the occurrence of thrombosis of the arterial reconstruction area and the nature of conservative treatment after arterial reconstruction in patients with diabetes with chronic critical ischemia of the lower limb.

Commentary on “Cryopreserved Cadaveric Arterial Allograft for Arterial Reconstruction in Patients with Prosthetic Graft Infection”

Commentary on “Cryopreserved Cadaveric Arterial Allograft for Arterial Reconstruction in Patients with Prosthetic Graft Infection”

MicroRNA expression profiling analysis and target gene validation in human restenosis after arterial reconstruction

Objective To identify artery-specific mircoRNAs (miRNAs) in restenosis after arterial reconstruction in patients with atherosclerosis obliterans (ASO) and validate the target gene of aberrantly expressed miRNA.Methods Superficial femoral artery tissue samples were collected from six patients with ASO and three normal controls who underwent above-knee amputation for limb injury (Group N).The six patients were divided into two groups based on prior arterial reconstruction:Group A,ASO without revascularization ( n =3) and Group R,restenosis following revascularization ( n =3 ).MiRNA expression profiling of all samples was performed using miRNA microarray analysis,the selected aberrantly expressed miRNAs were validated using real-time reverse transcription-polymerase chain reaction (real-time RT-PCR ) analysis and the predicted target gene was assessed using dual-luciferase reporting assays.Results MiRNA microarray analysis showed that miRNA-1 and miRNA-335 were down-regulated whereas there was no miRNA up-regulated in arteries from patient group ( Group A and Group R) as compared to those from Group N.In subgroup analyses,miRNA-1 and miRNA-335 were down-regulated whereas there was no miRNA up-regulated as compared to those from Group N; there were 17 miRNAs down-regulated while only hsa-miR-623 up-regulated in arteries from Group R as compared to those from Group N; there were 17 miRNAs up-regulated and 9 miRNAs down-regulated in arteries from Group R as compared to those from Group A.Among all down-regulated miRNAs,down-regulation of miRNA-1 was the largest,and it was confirmed by real-time RT-PCR (P ＜ 0.05 ).At the same time,dual-luciferase reporting assay data demonstrated that miR-1 targets a putative binding site in the 3' -UTR of kruppel like factor 4 ( KLF4,P ＜ 0.05).Conclusion MiRNAs may play important roles in human restenosis following arterial reconstruction,and they may have therapeutic applications in the prevention of neointimal hyperplasia.MiRNA-1 might play a pivotal role in the pathogenesis of both atherosclerotic ASO and restenosis. Key words: Restenosis; Atherosclerosis obliterans; MicroRNA ; Kruppel like factor 4

Early Outcomes of Total Pulmonary Arterial Reconstruction in Patients With Arterial Tortuosity Syndrome

Arterial Tortuosity Syndrome (ATS) is an autosomal recessive connective tissue disease that can present with complex pulmonary arterial stenosis, causing right ventricular (RV) hypertension and dysfunction. In this study, we review our experience and early outcomes with single stage surgical repair. From 2008 to 2010, 7 patients with ATS and severe bilateral pulmonary artery stenosis underwent surgical repair that involved extensive reconstruction of the pulmonary arterial tree bilaterally, including the central, lobar and segmental branches. The clinical records of these patients were reviewed for preoperative data, repair techniques and early clinical outcomes, including reinterventions and recent echocardiographic studies. All 7 patients had bilateral peripheral and central pulmonary artery stenosis with systemic to supra-systemic RV pressure and severe RV dysfunction. Median age at the time of operation was 72 months (range=7 to 120 months). All patients had low RV pressure (≤40% systemic) after the procedure with significant improvement in RV function to normal before hospital discharge. The mean right ventricular/left ventricular pressure ratio decreased from 1.27±0.19 to 0.31±0.06 postoperatively (p<0.001). There was no mortality. All patients continued regular follow-up at our institution for a mean follow-up period of 17.6±9.1 months. All patients were alive and asymptomatic with normal RV function and no evidence of elevated RV pressure on most recent echocardiography. Complete surgical reconstruction of the pulmonary arterial tree in advanced cases of ATS is a successful intervention with excellent early clinical and hemodynamic outcomes.

An updated meta-analysis of infrainguinal arterial reconstruction in patients with end-stage renal disease

A previous meta-analysis reported on the mid-term outcomes of infrainguinal bypass grafts in patients with critical limb ischemia and end-stage renal disease. Given the competing interest in endovascular procedures, the results of bypass surgery must be assessed as precisely as possible for future comparison. In this study, the original meta-analysis was refined and updated by increasing the number of studies reviewed, estimating primary graft patency, extending follow-up time, and investigating the problem of early amputation despite a patent graft. Studies published from 1987 through 2005 were identified from two electronic databases. Two investigators independently extracted the survival data from life tables, survival curves, and texts. Pooled survival curves were then constructed for graft patency, limb salvage, and patient survival according to a random-effects protocol for meta-analysis. Of 28 articles included, 18 reported amputation despite a patent graft in 84 (10%) out of 844 limbs, and 25 described a perioperative mortality of 88 (8.8%) out of 996 patients. The 5-year pooled estimate (SE) was 50.4% (15.4%) for primary patency, 50.8% (19.0%) for secondary patency, 66.6% (11.2%) for limb salvage, and 23.0% (11.7%) for patient survival. No publication bias was detected. Limb salvage can be achieved in most end-stage renal disease patients who undergo bypass surgery for critical ischemia, but survival is poor. To avoid early amputation despite a patent graft, bypass grafting should not be offered to patients with a great amount of tissue loss or extensive infection.

Outcome of infrainguinal revascularization for critical limb ischemia in diabetics with end stage renal disease

End stage renal disease [ESRD] and diabetes have a negative effect on outcome of arterial reconstructions, because they are associated with a vulnerability to infection, an infrageniculate arterial occlusive disease and an increased perioperative risk. The combination of both in critically ischemic patients is traditionally considered a great threat to their limb or life. The risk/benefit ratio of revascularization in this clinical setting is marginal and therefore the decision making is controversial. This study was undertaken to determine the results of arterial reconstruction in patients with end-stage renal disease and diabetes mellitus. The outcome of 97 patients undergoing 121 arterial reconstructions due to lower limb threatening ischemia were reviewed. Primary and secondary patency rates as well as survival and limb salvage were estimated. Thirty-day operative mortality rate was 10.3%. At one month, one year and 2 year follow-up, the survival rate was 89.7%, 77.6% and 44.2% respectively. Limb salvage at 6 months was 85.6%, at 12 months 75.3% and at 2 years 56.3%. The primary and secondary patency was 92.4% and 93.2% at 6 months and 71.7% and 72.7% at 12 months, respectively. Diabeticpatients with ESRD attained an acceptable graft patency and limb salvage but they sustained higher perioperative mortality and morbidity and reduced survival.

Arterial reconstruction with donor iliac vessels during pancreas transplantation: an intraoperative approach to arterial injury or inadequate flow

Outcome of pancreas transplantation (PTX) has improved because of use of novel immunosuppression and advances in surgical technique. It is not uncommon for severe atherosclerosis in patients with type 1 insulin-dependent diabetes mellitus or the presence of a previously transplanted organ to limit the options for vascular anastomosis. Herein we report the novel application of donor iliac arterial interposition grafts for arterial reconstruction in patients with severe iliac artery arteriosclerosis, and/or previous transplant who develop an arterial injury or stenosis during surgery. In five patients undergoing PTX, the external iliac artery was severely atherosclerotic and/or occupied by a previous vascular anastomosis. In four of the five patients, an arterial intimal dissection became apparent. The external iliac artery was excised and reconstructed with donor iliac artery interposition graft (end-to-end anastomosis). Pancreas or kidney was engrafted onto this arterial interposition graft (end-to-side anastomosis). There was no operative morbidity related to this surgical approach. All grafts functioned well after transplantation. Distal lower extremities have no evidence of vascular insufficiency with mean follow-up of 26 months (7-45 months). This surgical technique is an acceptable option during PTX for the patient with severe iliac artery arteriosclerosis with intraoperative intimal dissection or stenosis, or perhaps those with challenging arterial access.

The Role of Distal Arterial Reconstruction in Patients With Diabetic Foot Ischemia

The diabetic foot, a common complication that affects patients with diabetes mellitus, is a therapeutic challenge. It places an increasing burden on society; the patient and caregivers as well as health care systems and clinicians are touched by this problem. The management of the diabetic foot with ischemia consequent to peripheral arterial disease is vexing, often leading to successive amputations. Surgical reconstruction of the peripheral arteries has always been a consideration, although the concept of coexistent small vessel disease has prejudiced the notion of offering reconstructive surgery to these patients. This article examines some of the literature relating to bypass surgery with a view to addressing the aforementioned notion. An appraisal of the literature suggests that vascular reconstructive surgery offers benefits to the diabetic patient, albeit these papers have weaknesses related to study design and methodology. Improved studies are indicated to address the role of bypass surgery to help the diabetic patient with foot complications; it is reasonable to hope that our understanding of the fundamental concepts of the pathogenesis of diabetic foot disease will also improve.

Comparison of Precuffed and Vein-Cuffed Expanded Polytetrafluoroethylene Grafts for Infragenicular Arterial Reconstructions: A Case-Matched Study

Distal vein cuff interposition is often added to prosthetic infragenicular arterial reconstruction in an attempt to improve hemodynamics and patency rates. The purpose of this study was to compare the outcome of a precuffed expanded polytetrafluroethylene (ePTFE) graft with a vein-cuffed ePTFE graft for infragenicular bypass. We reviewed the clinical outcome of 77 patients with critical limb ischemia without available autologous vein conduits who underwent arterial reconstruction of 80 limbs to below-knee popliteal or tibioperoneal vessels using either ePTFE precuffed graft (precuffed group, 38 patients 40 limbs) or ePTFE vein-cuffed graft (vein-cuffed group, 39 patient, 40 limbs). Precuffed group patients were enrolled in a prospective cohort study. Vein-cuffed group patients consisted of consecutive case-matched patients operated on during the same study period. End points were primary graft patency and limb salvage rates. There were 42 males and 35 females with a mean age of 73.4 years (range, 44-92 years). Both groups were matched to demographics, risk factors for atherosclerosis, previous ipsilateral reconstruction, and location of the distal anastomosis. Proximal anastomosis was to the common (n = 68) or superficial (n = 12) femoral arteries. Distal anastomosis was to the below-knee popliteal (n = 28), anterior tibial (n = 12), posterior tibial (n = 15) and peroneal (n = 25) arteries. Operative mortality was 1.3%. Graft patency at dismissal was 90% and 95% in the precuffed and vein-cuffed groups, respectively. The mean follow-up was 25.7 months (range, 2.4-61 months). Primary patency rates at 1 and 3 years were 70% and 57% in the precuffed group, and 78% and 54% in the vein-cuffed group (p = 0.32). Limb salvage rates at 1 and 3 years were 97% and 70% in the precuffed group, and 95% and 81% in the vein-cuffed group (p = 0.49). Overall patient survival at 1 and 3 years was 81 % and 57%, respectively. In this case-control study, results of precuffed ePTFE graft were similar to those obtained with vein-cuffed ePTFE grafts. The precuffed ePTFE graft is an adequate alternative conduit for infragenicular arterial reconstruction in patients with critical limb ischemia and no available autologous veins.

A Meta-analysis of Infrainguinal Arterial Reconstruction in Patients with End-stage Renal Disease

to determine graft patency, limb salvage, and patient survival following infrainguinal bypass grafting in patients with end-stage renal disease (ESRD). studies published from 1987 through 2000 were identified from the PUBMED database and pertinent original articles. Sixteen studies were found that used survival analysis to report the outcomes of interest. Two investigators independently extracted the data from standard life-tables, survival curves and texts. A new method was developed for meta-analysis of uncontrolled studies that use survival analysis with different follow-up intervals. random-effects modelling yielded the following summary estimates at one- and two-year follow-up: 79% (95% CI, 70-87%) and 74% (63-85%) for graft patency; 77% (69-84%) and 73% (64-81%) for limb salvage; and 59% and 42% for patient survival. despite a severely limited life span, infrainguinal bypass grafting for the treatment of critical ischaemia is worthwhile in selected patients with ESRD.

Hand-assisted laparoscopic aortobifemoral bypass grafting.

Aortobifemoral bypass grafting is a durable operation for arterial reconstruction in patients with symptomatic aortoiliac occlusive disease. In several small laparoscopic series technically demanding aortic operations have been described that have not gained widespread acceptance or applicability. To simplify the laparoscopic approach to the aorta, we have developed a technique of aortobifemoral bypass grafting that uses hand-assisted laparoscopic surgery (HALS) to minimize the complexity of aortic dissection and reconstruction. Five patients with symptomatic aortoiliac occlusive disease underwent successful HALS aortobifemoral bypass grafting. With the use of a specialized sleeve device (Hand-Port), an operative hand was introduced into the laparoscopic field while pneumoperitoneum was maintained. Laparoscopic dissection of the infrarenal aorta was then performed with retraction provided by the operative hand. Proximal aortic anastomosis was performed with an open technique through the same 7.5-cm Hand-Port incision, and femoral anastomoses were performed in the standard fashion. Five hand-assisted laparoscopic aortobifemoral bypass grafts were performed (two end-to-end, three end-to-side proximal anastomoses). Mean operative time was 231 minutes. Mean blood loss was 440 mL. All patients underwent extubation immediately after surgery, were ambulatory on postoperative day (POD) 1, and were tolerating their diet by POD 3. The mean length of hospital stay was 3.8 days. One patient was discharged on POD 5 and started a clear liquid diet after a self-limiting postoperative ileus. All patients were asymptomatic and back to full activity/work by 14.6 days postoperatively, on average (range, 11-20 days). The HALS offers the advantages of tactile feedback, flexible retraction, and the introduction of conventional surgical instruments, all of which extend laparoscopic surgery and its established benefits to a wide array of more complex surgical problems, including major vascular surgery. Ease of performance, shorter hospital stays, and faster recovery times all suggest that HALS may become a valuable adjunct to conventional aortobifemoral bypass grafting.

Hand-assisted laparoscopic aortobifemoral bypass grafting

Objective: Aortobifemoral bypass grafting is a durable operation for arterial reconstruction in patients with symptomatic aortoiliac occlusive disease. In several small laparoscopic series technically demanding aortic operations have been described that have not gained widespread acceptance or applicability. To simplify the laparoscopic approach to the aorta, we have developed a technique of aortobifemoral bypass grafting that uses hand-assisted laparoscopic surgery (HALS) to minimize the complexity of aortic dissection and reconstruction.Methods: Five patients with symptomatic aortoiliac occlusive disease underwent successful HALS aortobifemoral bypass grafting. With the use of a specialized sleeve device (Hand-Port), an operative hand was introduced into the laparoscopic field while pneumoperitoneum was maintained. Laparoscopic dissection of the infrarenal aorta was then performed with retraction provided by the operative hand. Proximal aortic anastomosis was performed with an open technique through the same 7.5-cm Hand-Port incision, and femoral anastomoses were performed in the standard fashion.Results: Five hand-assisted laparoscopic aortobifemoral bypass grafts were performed (two end-to-end, three end-to-side proximal anastomoses). Mean operative time was 231 minutes. Mean blood loss was 440 mL. All patients underwent extubation immediately after surgery, were ambulatory on postoperative day (POD) 1, and were tolerating their diet by POD 3. The mean length of hospital stay was 3.8 days. One patient was discharged on POD 5 and started a clear liquid diet after a self-limiting postoperative ileus. All patients were asymptomatic and back to full activity/work by 14.6 days postoperatively, on average (range, 11–20 days).Conclusion: The HALS offers the advantages of tactile feedback, flexible retraction, and the introduction of conventional surgical instruments, all of which extend laparoscopic surgery and its established benefits to a wide array of more complex surgical problems, including major vascular surgery. Ease of performance, shorter hospital stays, and faster recovery times all suggest that HALS may become a valuable adjunct to conventional aortobifemoral bypass grafting.

Arterial reconstruction: justified for patients with intermittent claudication?

The objective of this study was to evaluate the effects of arterial reconstruction in patients with intermittent claudication. A total of 243 patients (305 limbs) underwent lower extremity vascular reconstruction at our institution from 1979 to 1995. They were assessed by physical examination, pulse volume recordings, segmental pressure, Duplex ultrasonography, and intravenous subtraction arteriography to evaluate the effects of arterial reconstruction. Surviving patients (220 limbs) were enrolled for evaluation of outcome during the follow-up period. There were 59 deaths during the follow-up period. The cumulative life-table 5-year patency rates were 90% +/- 3%, 73% +/- 6%, and 74% +/- 10% for aortoiliac, infrainguinal, and aortofemorodistal arterial reconstructions, respectively. Among 129 repairs in the aortoiliac region, Fontaine stages I, II, and III were found in 109 limbs (84.5%), 17 limbs (13.2%), and 2 limbs (1.5%), respectively. There was one (0.7%) minor amputation. There was Fontaine stage I in 50 limbs (76.9%), Fontaine stage II in 14 limbs (21.5%), and Fontaine stage III in 1 limb (1.5%) for repairs in the infrainguinal region. Among the 26 aortofemorodistal repairs, there was Fontaine stage I in 21 limbs (81%) and Fontaine stage II in 5 limbs (19%). There was a statistically significantly higher incidence of Fontaine stage I than Fontaine stage II or III in aortofemoral, infrainguinal, and aortofemorodistal arterial reconstructions (p < 0.0001). Arterial reconstruction for patients at Fontaine stage II offered benefits and improved quality of life at follow-up. Arterial reconstruction for patients at Fontaine stage II offers benefits and improved quality of life at follow-up. It was concluded that the significant improvement in quality of life after arterial reconstruction warrants continued use of the procedure in patients with intermittent claudication.

Enhancement of nitric oxide production after arterial reconstruction in patients with arteriosclerosis obliterans.

Nitric oxide (NO) not only relaxes vascular smooth muscles, but it also reduces platelet adhesion and is itself a potent antiaggregatory substance. Experimental studies have shown that the release of NO is modulated by the blood flow. However, little clinical information is available about the effects of hemodynamic changes after arterial reconstruction on NO production. We therefore examined whether the plasma levels of nitrite (NO2-) and nitrate (NO3-) ions increased after arterial reconstruction in patients with arteriosclerosis obliterans (ASO). Blood samples were obtained from the femoral artery in seven patients who underwent arterial reconstruction and seven healthy individuals (control). NO2- and NO3- levels were measured using high-performance liquid chromatography before the operation and 1 hour and 14 days after the operation. In addition, the mean femoral artery blood flow and ankle-brachial pressure index (ABI) were also measured using a duplex and Doppler velocimeter both before and after the operations. In the control subjects, the mean plasma NO2-, NO3-, and NOx (NO2- plus NO3-) levels in the femoral artery were 0.37 +/- 0.15 mumol/L, 45.6 +/- 10.8 mumol/L, and 46.0 +/- 10.9 mumol/L, respectively. Before the operation in the patients with ASO, the mean plasma NO3- (23.8 +/- 2.2 mumol/L) and NOx levels (24.0 +/- 2.3 mumol/L) were significantly lower than those in the control subjects, whereas the plasma NO2- levels (0.27 +/- 0.04 mumol/L) were comparable between the two groups. At 14 days after operation, the mean plasma NO3- and NOx levels in the femoral artery were significantly increased to 42.8 +/- 5.6 mumol/L and 43.4 +/- 5.6 mumol/L compared with those before the operation, whereas the mean plasma NO2- levels (0.50 +/- 0.05 mumol/L) changed significantly. The mean ABI and the mean flow rate before the operation were 0.32 +/- 0.07 and 344 +/- 145 ml/min, respectively. Both the ABI and the mean flow rate significantly increased to 1.04 +/- 0.06 and 627 +/- 141 ml/min after the operation. In patients who have ASO, the mean plasma level of NO is significantly lower than that of healthy individuals. In patients with ASO, the mean blood flow increased significantly after arterial reconstruction. This hemodynamic improvement may thus enhance NO production and may also help to maintain the patency of the bypass graft or native artery.