Autogenous Saphenous Vein Research Articles

Comparative outcomes between cryopreserved cadaveric saphenous vein and spliced autogenous vein for infrainguinal bypass

Objective Cryopreserved greater saphenous vein (CV) and spliced autogenous veins (SV) serve as alternative conduits for lower extremity revascularization when a single-segment autogenous saphenous vein is not available. This study compares the outcomes of infrainguinal bypasses using CV and two-segment SV as conduits. Methods We conducted a retrospective review of data on all lower extremity bypasses performed using CV or SV at our institution. Patients undergoing revascularization for atherosclerotic occlusive disease were included in the statistical analysis, while those with primary acute embolic and/or traumatic causes were excluded. Primary outcomes included limb loss. Secondary outcomes included primary, primary assisted, and secondary patency at one and 3 years. Results 56 patients were included in the analysis, 25 had CV bypass and 31 had SV. The groups did not significantly differ in demographics and comorbidities except for age (mean age 68 CV vs 62 SV, p = .03), and prior coronary artery bypass graft (32% CV vs 6.5% SV, p = .01). There was no statistically significant difference between CV and SV at one- and three-years in limb salvage (54.4% CV vs 61.7% SV, p = .96 and 48.3% CV vs 50.2% SV, p = .94), and bypass abandonment (44.2% CV vs 61.7% SV, p = .83 and 44.2% CV vs 44% SV, p = .85). Despite lower one and 3-year primary patency for CV compared to SV (33.3% CV vs 54.9% SV, p = .29, and 27.7% CV vs 48% SV, p = .27), the difference was statistically not significant. CV and SV had also similar one and 3-year primary assisted (41.8% CV vs 57.8% SV, p = .72 and 41.8% CV vs 44.9% SV, p = .71), and secondary patency (43.9% CV vs 61.7% SV, p = .8 and 43.9% CV vs 44% SV, p = .88), with no statistically significant difference. Conclusion In patients for whom single-segment autologous saphenous vein bypass is not an option, CV and SV show comparable limb salvage up to 3 years. SV may be a more durable option with higher patency, this was however not statistically significant in our cohort likely due to sample size.

Systematic review and meta-analysis comparing the autogenous vein bypass versus a prosthetic graft for above-the-knee femoropopliteal bypass surgery in patients with intermittent claudication.

According to guidelines, the autogenous saphenous vein (ASV) is the preferred conduit for femoropopliteal bypass surgery in all patients with peripheral artery disease. However, in contrast to patients with critical limb ischemia (CLI), patients with intermittent claudication (IC) only, tend to have milder disease, and thus a prosthetic graft may be as good as a vein conduit. The objective of this study was to compare patency rates of the ASV and a prosthetic graft in femoropopliteal bypass surgery in patients with IC. A systematic literature search was performed in the PubMed, Embase, and Cochrane databases to identify randomized controlled trials comparing prosthetic graft versus ASV in patients with IC. Articles with a mixed IC and CLI study population were included if more than 50% of the study cohort was treated for IC. Primary analysis was performed on IC patients only. Secondary analysis was performed on the mixed group. The primary endpoint was short- and long-term patency and secondary endpoints were complications, limb salvage, and mortality. In total, six studies with 524 patients were included. Only two studies reported solely on patients with IC. All these patients underwent above-the-knee bypasses and average patency rates at one and 5years were 88% and 76% vs 81% and 68% in the ASV and the PTFE groups, respectively. One and five-year patency was not statistically different between the groups (OR 5.21; 95% CI 0.60-45.36 and OR 2.10; 95% CI 0.88-5.01). In a mixed population of patients with IC and CLI (84% IC patients), 1year patency was comparable (OR 1.40; 95% CI 0.87-2.25). However, after a follow-up of over 3years, this mixed group had significantly higher patency rates in favour of the ASV (OR 2.06; 95 % CI 1.30-3.26). Complication and amputation rates were comparable in both groups. Limited data are available for patients receiving above-the-knee femoropopliteal bypass for intermittent claudication. The ASV remains the conduit of choice for femoropopliteal bypass surgery. However, the prosthetic conduit seems a feasible alternative for patients with intermittent claudication in whom the ASV is not present or unsuitable.

Introducing the efficient technique and experience of femoropopliteal bypass surgery: Our 10-Year experience using autogenous saphenous vein

Introducing the efficient technique and experience of femoropopliteal bypass surgery: Our 10-Year experience using autogenous saphenous vein

Immunological Aspects Involved in the Degeneration of Cryopreserved Arterial Allografts.

Introduction: Cryopreserved arterial allografts have remained an option in patients requiring distal revascularization or associated with vascular infection, in the absence of a valid autogenous saphenous vein. The objective of this study is to describe the different clinical, anatomopathological, and immunological findings related to vascular transplant rejection.Methods: In a prospective trial, 35 patients who underwent cryopreserved allogeneic arterial bypass were studied, including demographics and conduit patency. Anti-HLA antibody production was stablished prior to the surgery, 7 days, 1, 3 months, and every 3 months since. Clinical and ultrasound evaluation was added after the first month. Donor HLA-typing was retrieved whenever available, allowing for the characterization and quantification of donor specific antibodies. Cytotoxic crossmatch test was also performed. A second group of patients with allograft degenerations registered during the follow up period was studied. In this group, exclusively for aneurysm description and histopathological analysis, they were included those degenerated vascular transplants from the original series, but also those implanted prior to the beginning of the study and degraded during follow up.Results: All patients studied displayed an increase in anti-HLA antibodies one month after the intervention, regarding bypass patency. In total, 14 patients fulfilled requirements for the study of donor specific antibodies, equally showing IgG production detectable one month after surgery. The presence of complement-fixing antibodies was also confirmed. Antibody levels were not related to graft degeneration. No specific immune markers able to predict aneurysmal development and evolution were found. From the original group, 3 patients suffered aneurysmal degeneration during follow up, together with 9 bypasses previously implanted. Average time until the first degeneration was 33 ± 19.7 months, with 30.6 ± 17.7 and 54.5 ± 2.5 months for a second and third degeneration, when occurring. Therefore, subsequent vascular transplants frequently augmented the time for new degenerations, despite increasing sensibilization. Samples from eight degenerated allografts were available for analysis, unexpectedly showing inflammatory infiltrate in only four cases and immune complex deposition in 7.Conclusions: Immune response against vascular transplants was confirmed in all cases, but chronic rejection did not necessarily provoke bypass degradation or reduced the time for new aneurysms to develop in subsequent allografts.

Analysis of the effect of one-stage revascularization with internal carotid artery resection on cervical metastatic carcinoma in advanced head and neck carcinomas

Objective:To analyze the therapeutic effect of internal carotid artery resection and one-stage revascularization in advanced cervical metastatic carcinoma. Method:Twenty-one patients with advanced head and neck malignant tumors who underwent internal carotid artery resection and one-stage revascularization were analyzed retrospectively. Among those, 11 patients suffered from hypo-pharyngeal carcinomas, 5 laryngeal carcinomas, 2 external auditory carcinomas, 1 middle ear carcinoma, and 2 parotid gland carcinomas. All patients received CT, MRI, DSA and other examinations before operation. It was found that all the internal carotid artery walls had been invaded by tumors, and there were different degrees of lumen stenosis. Autogenous saphenous vein grafts were used in 18 cases; artificial vessels were used in 3 cases. After revascularization, pedicled or free flaps were used to protect the anastomotic areas. All patients were treated with radiotherapy and chemotherapy according to different situations. Result:Among the 21 cases, 16 cases underwent reconstruction of cervical segment internal carotid and 5 cases were the skull base segment internal carotid. Twenty patients were successfully reconstructed in the first stage, and no vascular reconstruction-related nervous system complications occurred after operations. Postoperative imaging showed that the reconstructed blood vessels were well recanalized, with a success rate of 95.2%（20/21）. Only 1 case received ligation of internal carotid artery after the failure of vascular reconstruction. Among all the cases, the 1-year survival rate and 3-year survival rate were 90.5% and 40.4%, respectively. Conclusion:In patients with advanced head and neck malignant tumors with cervical metastatic cancer invading the internal carotid artery, one-stage revascularization after radical resection of the tumor and the internal carotid can achieve good therapeutic effect. Careful preoperative evaluation, proficient vascular anastomosis technology, adequate risk assessment and prevention are the key to the success of the operations.

Evaluation of peripheral vascular injuries treated with surgery: A retrospective cohort study

Aim: Vascular injuries constitute 2-3% of the total injuries. Early diagnosis and emergent management of peripheral vascular injuries, which have high mortality and morbidity rates if inadequately managed, are particularly important. In this study, we aimed to evaluate the etiology and treatment results of patients who underwent surgical treatment due to peripheral vascular injury. Methods: This research was designed as a retrospective cohort study. The etiologies, localizations, accompanying injuries, surgical methods, and results of 57 cases operated due to peripheral arterial injury in Yozgat State Hospital and Bozok University Research Hospital between 2012 and 2019 were evaluated. Results: Fifty-two patients were male (91.23%) while 5 were female (8.77%). The mean age of all patients was 27.6 (10.5) years (range: 4 - 63 years). Among etiologies, injury due to sharp objects and firearms were significantly higher (n=34 (59.6%) and n=16 (28%), respectively). Traffic accidents were the cause in 5 (8.7%) cases and occupational accidents had occurred in 2 (3.5%) patients. Arterial injuries were detected in 33 (56.89%) upper extremities and 24 (41.87%) lower extremities. End-to-end anastomoses were performed in 29 cases, lateral arteriorrhaphy (primary repair) was performed in 24, autogenous saphenous vein interposition in 4 and ligation was performed in one patient. No cases required fasciotomy or amputation and one patient with a multi-trauma died. A secondary operation was needed for hematoma, thrombectomy, and anastomosis revision in seven, five and three cases, respectively. Conclusion: In vascular injuries, after ensuring hemodynamic stability, the primary aim is providing the accurate operation approach in the shortest time to reduce morbidity and mortality.

Blunt Handlebar Injury of the Common Femoral Artery in a Pediatric Patient: Case Report

Introduction - Vascular non-iatrogenic trauma in pediatric population is rare. Generally, they are associated to bone fractures, stab or cut wounds. Less common is the blunt trauma as a cause of a vascular lesion. There are implications in the treatment of this kind of lesion associated to the pediatric anatomy, physiology and the growth potential of the pediatric patient. Mainly by the small size of the vessels, thickness of the veins wall or the vascular spasm of the arteries. It’s still controversial which is the best treatment option in these cases, with a wide range of options from medical treatment, direct repair, autogenous saphenous vein graft, ligation and endovascular stenting. Methods - We describe a case of a 9-year-old boy with a very small groin hematoma and an acute left limb ischemia grade IIa after a handle bike trauma 24 hours ago. Ultrasound and CT scan showed a common femoral artery occlusion as well as an absence of femoral vein thrombosis. Results - A surgical treatment was chosen. A common femoral artery approach showed a focal contained artery transection with thrombosis. An autologous panel saphenous vein graft interposition was performed to avoid graft size mismatch. An uneventful postoperative course was developed, and he was discharged 72 hours later. Conclusion - Blunt vascular trauma is a rare condition in pediatric population and clinical suspicion is necessary to avoid a diagnosis delay. The handlebar pressure on the femoral artery against femur or pubis bone may be a traumatic weapon even in not severe bike trauma. Special considerations and technical difficulties should be considerate in the surgical and medical pediatric treatment. There are different options of treatment that depends on the type of injury and the clinical situation. References1Sarfati MR, Galt SW, Treiman GS, Kraiss LW. Common femoral artery injury secondary to bicycle handlebar trauma. J Vasc Surg. 2002 Mar;35(3):589-91.2Mommsen P, Zeckey C, Hildebrand F, Frink M, Khaladj N, Lange N, Krettek C, Probst C. Traumatic extremity arterial injury in children: epidemiology, diagnostics, treatment and prognostic value of Mangled Extremity Severity Score. J Orthop Surg Res. 2010 Apr 15;5:25. doi: 10.1186/1749-799X-5-25.

Massive hematuria due to an autogenous saphenous vein graft and urinary bladder fistula in an extra-anatomic iliofemoral bypass: a case report

IntroductionGross hematuria caused by rupture of an artery in the urinary tract is a rare but potentially fatal condition. Iliac artery aneurysms, pelvic surgery with radiation, vascular reconstructive surgery, surgery for stenosis of the ureteropelvic junction, and transplantation are reported to be associated with this condition. In the vascular reconstructive surgery group, the most common etiology is rupture of the degenerated artery or synthetic graft in the ureter.Case presentationWe present a case of rupture of the small anastomotic pseudoaneurysm at the proximal anastomosis of a right iliofemoral autogenous vein extra-anatomic graft in the urinary bladder. To our knowledge, this is the first report of a rupture of an autogenous vein graft in the urinary bladder. Our patient, a 24-year-old Albanian farmer, was admitted to the emergency department in severe hemorrhagic shock induced by exsanguinating hematuria. He underwent immediate surgery, during which direct sutures to the bladder were placed and the saphenous graft was replaced with a synthetic one. The patient recovered completely, was free of hematuria, and showed no signs of pathological communication between the urinary and arterial tracts on postoperative cystoscopy and computed tomographic angiography during 2 years of follow-up.ConclusionThe incidence of artery-to-urinary tract fistulas is growing due to the increasing use of urologic and vascular surgery, pelvic oncologic surgery, and radiation therapy. In addition to fistulas involving a degenerated artery and ureter or synthetic grafts and ureter, they can also involve an autogenous vein graft and the urinary bladder. In our patient, the fistula was a result of erosion of the bladder from a pseudoaneurysm at the proximal anastomosis of an autogenous vein iliofemoral bypass in an extra-anatomic position. Open surgery remains the best treatment option, although there is increasing evidence of successful endovascular treatment.

Clinical efficacy of Da Vinci robot-assisted iliofemoral vein bypass grafting

Objective To explore the clinical efficacy of Da Vinci robot-assisted iliofemoral vein bypass grafting. Methods The retrospective descriptive study was conducted. The clinical data of one 66-year-old male patient who underwent Da Vinci robot-assisted iliofemoral vein bypass grafting in the First Affiliated Hospital of Army Military Medical University in March 2019 were collected. The patient was failed to recanalize iliofemoral vein stent thrombosis by endovascular measures and underwent Da Vinci robot-assisted iliofemoral vein bypass grafting after balloon occlusion preset in the common iliac vein. Observation indicators: (1) intra- and post-operative situations; (2) follow-up and survival situations. Follow-up using outpatient examination was performed to detect the patient′s postoperative survival and swelling reduction of affected extremity up to April 2019. Results (1) Intra- and post-operative situations: the patient underwent Da Vinci robot-assisted iliofemoral vein bypass grafting successfully. The operation time of balloon occlusion preset by digital subtraction angiography was 35 minutes. The operation time of Da Vinci robot-assisted iliofemoral vein bypass grafting was 502 minutes (50 minutes of exposure time of femoral vein, 80 minutes of exposure time of iliac vein, 40 minutes of great saphenous vein harvesting time, 70 minutes of end to side anastomosis between autogenous great saphenous vein and femoral vein, 10 minutes of subcutaneous tunnel construction, 90 minutes of end to side anastomosis between autogenous great saphenous vein and iliac vein, 60 minutes of suturing except vessel closure, 102 minutes of preparation time, check and washing time). The volume of intraoperative blood loss was 500 mL and no intraoperative complications occurred. The autogenous great saphenous vein graft was well filled and no bleeding was found at both proximal and distal anastomoses after iliofemoral vein bypass grafting. There were 4 abdominal Trocar holes including 2 of 1.2 cm and 2 of 0.8 cm. The incisional length of right groin and left great saphenous vein harvesting region was 5.0 cm and 15.0 cm, respectively. At the discharge time, the patient had swelling subsided partially at right lower extremity and skin tesion reduced significantly compared with the admission. The perimeters at 15 cm above right knee joint and left knee joint were 53.5 cm and 48.0 cm. The maximum perimeters of right calf and left calf were 41.0 cm and 38.0 cm. No postoperative complications occurred. Duration of hospital stay after surgery was 3 days. (2) Follow-up and survival situations: the patient was followed up for 1 month, with good survival. The patient had swelling subsided of affected extremity. The perimeters at 15 cm above right and left knee joint were 52.0 cm and 48.0 cm. The maximum perimeters of right calf and left calf were 40.0 cm and 38.0 cm. Conclusion The Da Vinci robot-assisted iliofemoral vein bypass grafting is safe and feasible, with good short-term outcomes. Key words: Vein thrombus; Da Vinci robotic surgical system; Vein; Bypass grafting; Minimally invasive surgery

Risk Factors of Amputation in Lower Extremity Trauma with Combined Femoropopliteal Arterial Injury.

PurposeThe clinical characteristics and results of femoropopliteal artery injury (FPAI) remain unclear. In this study, we evaluated the outcomes and risk factors of limb loss in patients treated for FPAI.Materials and MethodsWe retrospectively reviewed data from a database of patients who underwent revascularization for an FPAI at a single institution between January 2013 and December 2017. We reviewed and analyzed the characteristics, postoperative results, and factors that influence amputation rates.ResultsTwenty-four femoropopliteal arterial reconstructions in 24 patients were included in this study. Among the patients were 20 (83.3%) male with a first-quartile age of 28 years and a third-quartile age of 45 years (range, 15–68 years). The mean injury severity score (ISS) was 16 (range, 4–55), and 5 patients (20.8%) had ISSs of >20 points. The mean mangled extremity severity score (MESS) was 3.8 (range, 1–11), and 8 patients (33.3%) had MESSs of >5 points. In terms of arterial reconstruction methods, autogenous saphenous vein grafting, vein patching, and primary closure were performed in 9 patients (37.5%), 4 patients (16.7%), and 11 patients (45.8%), respectively. Despite arterial reconstruction, 5 patients (20.8%) underwent above-knee amputation. ISSs of >20, MESSs of >7, and orthopedic fixation were statistically significant factors associated with amputation.ConclusionIn cases of FPAI with ISSs of >20, MESSs of >7, and orthopedic fixation, amputations should be considered. We were also careful to attempt limb salvage in such cases.

Successful Treatment for End—Stage Hepatic Alveolar Echinococcosis With ex vivo Liver Resection and Autologous Liver Transplantation: A Case Report

3045_A.tif Figure 1: Preoperative 3D imaging analysis system revealed the retro—hepatic IVC was involved (arrow)3045_B.tif Figure 2: The irregular outflow of right/short hepatic vein reconstruction (A: great saphenous veins; B—C: right/short hepatic vein reconstruction using the great saphenous veins wall)Objective To explore the surgical process of ex—vivo liver resection and autologous liver transplantation (ERAT) for end—stage hepatic alveolar echinococcosis (HAE) and evaluate the therapeutic effect and surgical benefit. Methods The clinical data of one end—stage HAE patient treated with ERAT combined complicated hepatic vein reconstructionwas analyzed retrospectively. Preoperative examination and intraoperative exploration revealed the second hepatic portal was involved. We successfully initiated an operation through ex—vivoliver resection, hepatic vein reconstruction with the autogenous saphenous vein, and subsequent piggyback autologous liver transplantation by wide—mouth hepatic vein—artificial inferior vena cava anastomosis (end to side). Results This patient discharged uneventfully 14 days after the operation. The injection of low—molecular—weight heparin sodium and consequent oral warfarin sodium tablets were administered for anticoagulant therapy. Regular autograft ultrasound examination revealed no tarombokinesis in autologous liver and inferior vena cava. Conclusion ERAT is an ideal surgical method for end—stage HAE. Wide—mouth hepatic vein reconstruction using an autogenous saphenous vein is the key procedure. Postoperative anticoagulant therapy is significant for the improvement of transplanted liver function.3045_C.tif Figure 3: Piggyback autologous liver transplantation (A—C)

Surgical treatment for chronic lower limb ischemia: A report of 60 cases

Objective To explore the clinical characteristics and treatment strategy of chronic lower limb arterial ischemic. Methods The clinical data of 60 patients with chronic lower limb arterial ischemic-treated from January 2017 to May 2017 were analyzed retrospectively (63 affected limbs). According to the patient's physical condition, clinical symptoms and pathological features, individualized surgical treatment was selected, including autogenous great saphenous vein or artificial blood vessel bypass grafting, artery intima stripped, balloon dilatation, stenting, intracavity volume reduction, or hybrid procedures. The ankle brachial index of preoperative and postoperative 3 months was monitored, and patients were classified according to the Rutherford classification standard. Results Sixty cases were underwent surgery treatment, three patients were treated with bilateral lower limbs in the same period, successfully 58 cases and success rate reached 96.67%. One case was subjected to amputation, and 1 case died (cardiovascular disease). Postoperative 3 month follow-up, the Rutherford grading of 59 affected limbs was improved markedly, average ankle brachial index of postoperative was higher than preoperative (P<0.05). Six cases of patients with ulcer were cured, the ulcer surface of 2 cases were significantly narrowed. Conclusions The incidence of chronic lower limb arterial ischemic is increasing year by year, the treatment ideas are constantly updated. It is safe and effective to select individualized treatment according to the patients' physical condition, clinical symptoms and pathological feature. However it still needs to enlarge the sample and extend the time of follow-up to verify this point. Key words: Ischemia/SU; Lower extremity/PA

Treatment of severe cerebral ischemia in takayasu's disease with arterial reconstruction

Objective To explore the effect of surgical bypass and the role of transcranial doppler (TCD) during the bypass operation. Methods A retrospective analysis was performed for the surgical data of cerebral ischemic Takayasu disease from January 2003 to December 2012 in single center. Forty one patients were divided into two groups: Group A with TCD during operation (n=22) and Group B without TCD (n=19). For group A, the main operation methods were 10 ascending aorta-biliteral axillary (brachial)/subclavian artery artificial vascular graft bypass-unilateral internal carotid autologous great saphenous vein grafting, 7 ascending aorta (aortic arch)-biliteral axillary (brachial)/subclavian artery artificial vascular bypass grafting, 3 ascending aorta-unilateral subclavian and unilateral carotid artery artificial graft bypass, and 2 ascending aorta-unilateral internal carotid artery autogenous saphenous vein grafting. For group B, the corresponding number was 8, 9, 1, and 1 case, respectively. On the basis of above-mentioned ascending aorta-biliteral axillary artery graft, there were 5 artificial graft-unilateral internal carotid saphenous vein-grafting in both groups. Results All operations were successful with a success rate of 100% and without death.All grafts remained patency when discharged, and all patients had improved cerebral ischemic symptoms. The effective rate of treatment was 100% in both groups, without statistical significance between two groups (P>0.05). Complications were reversible tongue for 5 cases in group A and 4 in group B (P>0.05), dizziness for 2 cases in group A and 9 in group B (P 0.05), eye swelling for 7 cases in each group (P>0.05), and cerebral hemorrhage for 0 cases in group A and 2 in group B (P>0.05). All patients were followed-up 3.5 to 13.5 years, mean (8.5±2.0)years. Symptom recurrence was 2 cases in group A and 1 in group B, and the recurrence rate of two groups had no difference (P>0.05). Conclusions Cervical arterial blood flow reconstruction is a safe and effective treatment for cerebral ischemia caused by Takayasu arteritis. TCD intraoperative monitoring can reduce postoperative complications caused by hyperperfusion significantly. Key words: Arteritis/SU; Carotid arteries/SU; Blood vessel prosthesis/AE; Brain ischemia/ET; Ultrasonography, doppler, transcranial

Simulation of Anastomosis in Coronary Artery Bypass Surgery.

Developing cardiac surgical skills and experience takes years of practice. Cardiac trainees need to develop technical proficiency in order to enhance quality of care and patient safety. Simulation-based models are common resources for teaching procedural skills in both undergraduate and postgraduate medical education. Suitable and accessible educational platforms can play a progressively important role in the training process for young surgeons in the area of cardiac surgery. Coronary artery bypass graft (CABG) surgery consists of a wide range of pathologic anatomies and surgical techniques. In this paper we introduce a novel, synthetic, biomimetic platform that allows for the realistic practice of the CABG surgery. The prototype uses a polyvinyl alcohol hydrogel which has been designed to mimic the geometric properties of vasculature. The proposed models look and feel like human tissue and possess somewhat consistent mechanical properties. In this study, we apply the platform to simulate a case of autogenous saphenous vein bypass grafting of a patient. An autogenous saphenous vein graft is placed from the aorta to the left anterior descending coronary artery. The standard procedures of the coronary artery bypass surgery were successfully simulated. Using the proposed technology, other complicated surgeries such as end to end, side to end, and sequential anastomoses can be simulated such that these models lend themselves very well to various types of anastomoses.

Acute limb-threatening ischemia following rupture of a brachial A-V fistula pseudoaneurysm

We present a case of acute limb-threatening ischemia following contained rupture of a pseudoaneurysm at brachial arterio-venous fistula site. The rapid progression of the clinical ischemia with impending external rupture of the pseudoaneurysm made the presentation unique. Emergent salvage surgery was performed with autogenous saphenous vein reconstruction of the brachial artery. We believe that emergent surgery with autogenous reconstruction of the artery would give the best results considering the strong probability of infection as the etiology.

Management of traumatic popliteal vascular injuries in a level I trauma center: A 6-year experience

IntroductionPopliteal vascular trauma remains a challenging entity, and carries the greatest risk of limb loss among the lower extremity vascular injuries. Operative management of traumatic popliteal vascular injuries continues to evolve. We aim at describing our experience with such complex injuries, with associated patterns of injury, diagnostic and therapeutic challenges, and outcomes. MethodsFrom January 2006 to September 2011, 191 adult trauma patients presented to an urban level I trauma center in Miami, Florida with traumatic lower extremity vascular injuries. Variables collected included age, gender, mechanism of injury, and clinical status at presentation. Surgical data included vessel injury, technical aspects of repair, associated complications and outcomes. ResultsForty-seven (24.6%) patients were diagnosed with traumatic popliteal vascular injuries. Mean age was 38.1 ± 16.1 years, and the majority of patients were males (43 patients, 91.4%). There were 21 (44.7%) penetrating injuries, and 26 (55.3%) blunt injuries. Vascular repair with saphenous venous interposition graft and PTFE (polytetrafluoroethylene) grafting were performed in 36 (70.7%) and 2 (3.9%) patients, respectively. Blunt popliteal injuries were significantly more associated with major tissue loss, and length of hospital and intensive care unit (ICU) stays. The risk for amputation is increased with longer ICU stays and the use of PTFE grafting for vascular repair. The overall mortality rate in this series was 8.5%. ConclusionsBlunt popliteal vascular injuries are associated with increased morbidity compared to penetrating trauma. Early restoration of blood perfusion, frequent use of interposition grafts with autogenous saphenous vein, and liberal use of fasciotomies play important role to achieve acceptable outcomes.

Bypass and embolization for a vertebral artery aneurysm in a patient with Marfan syndrome.

Extracranial vertebral artery aneurysms represent an uncommon presentation of collagen vascular disease. We performed staged proximal embolization of large left vertebral artery aneurysm after distal common carotid-to-vertebral bypass at C2 in a young adult patient with Marfan syndrome and a hypoplastic contralateral vertebral artery. Dilation of the autogenous saphenous vein graft occurred at 1 year with proximal graft stenosis requiring operative revision. Subsequent dilation of the basilar artery led to symptoms of pontine compression at 18 months that have resolved at 31 months of follow-up.

Long-term patency of autogenous saphenous veins vs. PTFE interposition graft for prosthetic hemodialysis access.

Prosthetic vascular access is the other choice when the superficial venous system is inadequate to perform a simple radio-cephalic and brachio-cephalic fistula. This paper reports the outcomes of a prospective cohort study of 54 patients who underwent either saphenous vein (SVI Group, n=29) or PTFE graft (PTFE Group, n=25) interposition surgery for prosthetic hemodialysis access. All patients were evaluated via color Doppler ultrasonography during preoperative course and superficial venous systems of these patients were found inadequate to perform simple radial/brachial artery-cephalic vein anastomosis. Follow-up was performed for every 6-months period. Kaplan-Meier analysis and Log Rank test was used for estimation and comparison of the patency. In SVI group access failure was observed in 5 of 29 patients (17.2%). In PTFE group, access failure was observed in 13 of the 25 patients (52%). Primary patency rate was 93% in 12th month and 82% in 24th month in SVI group while it was 88% in 12th month and 56% in 24th month in PTFE group. According to the Kaplan-Meier method, mean time of primary patency was significantly higher in SVI group when compared to PTFE group (33.03±1.32 months vs. 28.16±1.91 months, Log Rank chi-square value: 7.01, df:1, p=0.008). Secondary patency rate was 96% in 12th month and 93% in 24th month for SVI group while 96% in 12th month and 84% in 24th month for PTFE group. According to the Kaplan-Meier method, mean time of secondary patency was significantly higher in SVI group when compared to PTFE group (34.27±0.95 months vs. 31.16±1.40 months, Log Rank chi-square value: 7.33, df:1, p=0.007). Autologous saphenous vein can be preferably chosen as a prosthetic hemodialysis access graft due its higher primary and secondary patency, lower complication rate and cost when compared with PTFE grafts.

Cryopreserved saphenous vein graft in infrainguinal bypass

Autogenous saphenous vein is the ideal conduit for lower extremity revascularization. Unfortunately, autogenous vein is unavailable in up to 20% of patients. Synthetic grafts provide an alternative; however, their use in distal revascularization has shown varying results. In addition, infected surgical sites preclude their use. Currently, there are limited outcome data for cryopreserved saphenous vein use in regard to long-term patency and limb salvage rates. Cryopreserved saphenous vein allograft use in infrainguinal bypass was studied retrospectively in a community setting. End points included primary patency, limb salvage, and early complications. Records of patients receiving cryopreserved allografts by nine vascular surgeons within one hospital system from 2006 to 2012 were reviewed. Fifty-three patients, mean age 69years (standard deviation, 12.3; range, 28-90years), underwent 60 operations. Indications for surgery included limb-threatening ischemia (48%), tissue loss (30%), previous graft or site infection (10%), claudication (7%), or other (5%). The mean follow-up period was 23.9months (standard deviation, 21.0; range, 0-64months). Primary patency was maintained in 53% of patients at 1year and in 22% at 3years. Limb salvage was achieved in 74% of patients at 1year and in 70% at 2years. Thirteen early complications included 8 thromboses, 2 deaths, 2 amputations, and 1 anastomotic disruption. Fifteen patients (28%) underwent additional ipsilateral operations with use of synthetic conduits after initial cryopreserved allografts failed. Cryopreserved vein allografts displayed poor short-term and long-term patency, whereas limb salvage rates at 1 and 2years remained acceptable. However, >25% of patients required additional ipsilateral operations with use of synthetic conduits after previous failed cryopreserved allograft use. Our data indicate that cryopreserved vein graft is a suboptimal choice of conduit in a noninfected field.

Missed vascular injuries: presentation and outcome.

To describe the different presentation, diagnostic evaluation, management and outcome of complications of missed vascular injuries. A case series. Combined Military Hospital, Rawalpindi and Combined Military Hospital, Kharian Cantt, from June 2009 to June 2012. All the patients with vascular injuries missed at the time of causative trauma who reported during this study period were included. Patients presented with acute vascular injuries and iatrogenic aneurysm at the vascular anastomosis site were excluded. All cases were evaluated with either CT or conventional angiography and managed with various open vascular surgical techniques and their results were assessed. Twenty eight patients with missed vascular injury underwent various vascular repairs. Age of patients ranged from 16 to 78 years (mean = 33.7 ± 15.4 years). Male to female ratio was 6:1. Twelve (42.8%) patients presented with pseudoaneurysm alone, 10 (35.7%) with traumatic arteriovenous fistulae, 4 (14.3%) with post-traumatic thrombosis and occlusion and 2 (7.1%) with pseudoaneurysm and hemorrhage. Penetrating injuries were the commonest cause in 19 (67.8%). The time interval between injury and presentation in hospital ranged from 2 to 1300 weeks (mean 228 weeks). Lower limb vessels were affected in 20 (71.4%), the upper limb in 5 (17.8%) and neck vessels in 3 (10.7%). Superficial femoral artery was the most frequently involved artery in 9 (32.1%) cases. Interposition reverse autogenous saphenous vein graft was most common type of repair in all types of missed vascular injuries. One (3.5%) patient had amputation after secondary hemorrhage. Low velocity penetrating trauma was the common cause of missed vascular injury. Pseudoaneurysm was the most common presentation.