Autogenous Saphenous Vein Research Articles

Use of autogenous saphenous vein as a conduit for mesenterico-left portal vein bypass

The authors describe a case of extrahepatic portal vein (EHPV) thrombosis and portal hypertension treated with a variant of mesenterico-left portal vein bypass (MLPVB) or Rex shunt. In this case, a segment of autogenous greater saphenous vein was used to bridge the distance between the left gastric vein inflow and the left portal vein. Use of such nontraditional conduit in similar circumstances may expand the application of portal revascularization/decompression procedures in treating these patients.

Revascularization after segmental resection of lower extremity soft tissue sarcomas

Limb salvage surgery combined with vascular reconstruction has replaced amputation as the preferred treatment of soft tissue sarcomas involving major vascular structures of the extremities. We describe our experience with soft tissue sarcomas involving major vascular structures and examine outcomes according to the type of graft selected for arterial reconstruction. We also examine the effect of venous reconstruction on post-operative edema. This retrospective review includes 14 patients with lower extremity soft-tissue sarcomas that encased major vessels, requiring combined limb-preserving tumor resection and revascularization with a synthetic or autogenous saphenous vein graft. Edema in patients with and without venous reconstruction was compared. The incidence of infection, wound dehiscence, and graft thrombosis were compared according to arterial graft type. There was no significant difference in edema in patients with venous reconstruction and those without. There was also no significant difference in infection and graft thrombosis in patients with synthetic grafts and those with autogenous saphenous vein grafts. Wound dehiscence occurred more often in patients with synthetic grafts (P = 0.029). Although this study was small, these results suggest that further studies are needed to determine the roles that vascular graft selection and venous reconstruction play in clinical outcome.

A Comparison of Bilateral with Single Internal Mammary Artery Grafts on Postoperative Mediastinal Drainage and Transfusion Requirement

The superiority of the left internal mammary artery (LIMA) graft over autogenous saphenous vein as a bypass conduit in coronary artery bypass surgery has been well established. Early and late patency rates of bilateral internal mammary artery (BIMA) grafts exceed those of vein grafts, and patients who receive BIMA have improved long-term survival rates and more freedom from reoperations and other cardiac events. But because of other concerns, particularly the question of increased risk of postoperative bleeding, controversy still surrounds the perioperative period. In the present study we sought to determine whether BIMA grafting was an independent risk factor of postoperative bleeding and of blood product use in patients undergoing primary elective coronary artery revascularization. For this purpose, 33 consecutive patients scheduled for BIMA grafting were matched with 66 patients operated on by single LIMA grafting. Patients in the LIMA group had significantly less postoperative mediastinal drainage than those in the BIMA group (median: 722 vs 920 mL, P = 0.0001). Fifty-six patients received blood products (56% vs 51% in LIMA and BIMA groups, respectively; P = 0.67). In multivariate analysis, BIMA and operative duration were independent predictors of increased postoperative drainage. Nevertheless, in logistic regression, BIMA was not significantly associated with blood product use, unlike precardiopulmonary bypass hematocrit and duration of surgery (OR and 95% CI: 0.89 [0.80-0.96] P = 0.01; 1.009 [1.001-1.019] P = 0.04, for an increase of 1% in hematocrit and 1 min in duration of surgery, respectively). In conclusion, these data support the idea that BIMA graft slightly increases postoperative drainage but not transfusion requirement.

Management of distal femoral and popliteal arterial injuries: an update

Background The management of combined arterial and musculoskeletal injuries to the lower extremity remains controversial, particularly with regard to the initial order of intervention and the use of intravascular shunting. In this study, we review the contemporary management and outcome of patients treated for acute traumatic distal femoropopliteal arterial injuries. Methods From January 2001 to January 2006, we repaired 57 acute traumatic lower-extremity arterial injuries in a level 1 trauma center. Our approach was to perform surgical revascularization without intraluminal shunting as soon as the arterial injury was recognized. There were 44 men (77%). Mean age was 31 years (range, 5-68). The mechanism of injury was blunt in 42 of 57 (74%) patients. Vascular reconstruction was achieved by using an autogenous saphenous vein graft in 52 of 57 (91%), a vein patch in 3 of 57 (5%), or primarily in 2 of 57 (4%) patients. Results The limb-salvage rate was 92% (53/57). Thirty-six patients (63%) had associated orthopedic fixation: 12 of 36 (33%) before and 24 of 36 (67%) after revascularization. Twenty-one of 57 patients (37%) had vascular repair only without orthopedic fixation. Thirty-four patients (60%) required fasciotomy. Four patients had subsequent above-knee amputation: 3 because of wound complications despite successful revascularization and 1 because of failed revascularization. There were no complications related to the arterial repairs that were performed before orthopedic fixation. Conclusion Our study shows that arterial reconstruction for acute traumatic lower-limb injuries results in a good limb-salvage rate. We advocate prompt vascular repair before orthopedic intervention for combined vascular and skeletal injuries of the lower extremity, without using intravascular shunting.

The Relationship between Gestational Age and Compliance in Human Umbilical Vein and Its Possible Application in Vascular Grafting

The aim of this study was to provide a theoretical basis, using biomechanical properties, for the clinical application of human umbilical vein (HUV) as material for vascular grafting. This was a nonrandomized, non-controlled in vitro study. The experiment was conducted in the Laboratory of Medical Biomechanics, Yunyang Medical College. HUVs of 50 normal fetuses were collected on spontaneous miscarriage or labor with the pregnant women's permission by the Department of Obstetrics and Gynecology, Taihe Hospital, Shiyan, Hubei Province. Gestational aged ranged 24-42 weeks, and parturients were 20-30 years old. The pressure-volume (P-V) relationship of HUV was measured on the biomechanical experiment stand for soft tissues, and then compliance was calculated. The P-V relationship of HUV corresponded to a parabolic curve. The compliance of HUV increased gradually with gestational age [24-27 weeks (2.22+/-0.34) x 10(-4) mL/(kPa * cm), 28-32 weeks (3.65+/-0.46) x 10(-4) mL/(kPa * cm), 33-36 weeks (4.22+/-0.55) x 10(-4) mL/(kPa * cm), 37 weeks (7.63+/-0.48) x 10(-4) mL/(kPa * cm), 38 weeks (8.32+/-0.76) x 10(-4) mL/(kPa * cm)]. However, after 39 weeks of gestation, compliance decreased gradually with gestational age [39 weeks 7.61+/-0.46) x 10(-4) mL/(kPa * cm), 40 weeks (7.53+/-0.72) x 10(-4) mL/(kPa * cm), 41 weeks (4.13+/-0.35) x 10(-4) mL/(kPa * cm), 42 weeks (2.25+/-0.62) x 10(-4) mL/(kPa * cm)]. The compliance of HUVs collected at 37-40 weeks of gestational age was similar. When the HUVs older than 42 weeks or under 28 weeks were compared, there was significant difference in their compliance (F=65.84-86.52, p<0.01). The results of the present study suggest that HUVs collected at 37-40 weeks of gestational age have good compliance, i.e., a good P-V relationship, and therefore may be a suitable material for vascular grafting. HUV is one of several graft materials that may be used when autogenous saphenous vein is absent or inadequate. HUV is very biocompatible and shows promise for use in orthopedic implants.

Impact of Duplex Arteriography in the Evaluation of Acute Lower Limb Ischemia from Thrombosed Popliteal Aneurysms

Acute limb-threatening ischemia from thrombosis may be the initial presentation of popliteal artery aneurysms (PAA) and is associated with amputation rates of 20-30%. Since contrast angiography may miss the diagnosis, the authors suspect that thrombosis of PAA may be an underappreciated cause of acute ischemia. Routine use of duplex arteriography (DA) may aid in the diagnosis and may help identify the outflow vessels with improved results. One hundred and nine patients (group 1) from 1994 to 1997 and 201 patients from 1998 to 2001 (group 2) presenting with acute limb-threatening ischemia were studied. None of the group 1 patients underwent preoperative DA and no diagnosis of acute popliteal artery aneurysm thrombosis was made. Ten patients with acute ischemia due to thrombosed popliteal artery aneurysms were identified in group 2 when preoperative DA was routinely performed. Urgent revascularization based on the results from DA was performed with use of autogenous saphenous vein in all patients. Six patients had functioning bypasses with a mean follow-up of 15.6 months. There were 3 deaths, 2 within 30 days and 1 after 2(1/2) years with functioning grafts. One patient was lost to follow-up. No major amputations were performed. Incidence of thrombosed popliteal artery aneurysms as the cause of acute limb-threatening ischemia is probably underestimated. Routine use of DA may provide the diagnosis and identifies the available outflow vessels. Contrary to previously published reports, urgent revascularization of an acutely ischemic extremity from thrombosed popliteal aneurysm can provide excellent rates of limb salvage.

Arteriovenous grafts for vascular access in haemodialysis

The outcome of 68 arteriovenous grafts placed in 46 patients requiring haemodialysis was studied over a period of 3.5 years. The biological grafts included autogenous saphenous vein, modified bovine carotid artery and human umbilical cord vein allograft, whereas the synthetic grafts comprised Sparks Dacron mandril, expanded reinforced polytetrafluoroethylene and knitted Dacron velour. These subcutaneous grafts were arranged as looped or straight configurations in the forearm or thigh. Of 59 grafts evaluated in patients with end-stage renal failure, only 48 per cent of the forearm grafts performed well, compared with 85 per cent of the thigh grafts. Although only 38 per cent of the looped grafts were successful, 78 per cent of the straight grafts functioned satisfactorily. Synthetic grafts suffered less serious complications than the commercial biological grafts.

The mechanical properties of glutaraldehyde stabilized human umbilical vein measured in vivo.

Vascular prostheses, when used to bypass the femoral and popliteal arteries, and particularly if the bypass is made to the distal part of the tibial arteries, seldom remain patent, or if they do then for only a limited period of time. Femorotibial bypass with modified human umbilical vein is relatively successful in selected patients and one explanation may be that it resembles human arteries more than other prostheses. We have developed a method of calculating the asymptotic phase speed, from the propagation constant and from this the characteristic impedance of a bypass (all of which characterize viscoelastic behaviour). Calculations were made on measurements of pressure made in vivo. Twenty patients who had a femorotibial bypass, using glutaraldehyde stabilized umbilical vein, were studied and, from measurements of pressure made at operation, we calculated the asymptotic phase speed and the characteristic impedance of the prostheses. Results show that the viscoelastic properties of newly implanted umbilical vein are comparable to those of autogenous saphenous vein.

Reduction of thrombus formation in vivo using a thrombolytic agent targeted at damaged endothelial cells.

Endothelial damage in saphenous vein harvested before coronary artery and peripheral vascular surgery has been well documented. Autogenous saphenous vein grafts are subject to early thrombotic occlusion, a process that is related to injury of this endothelial monolayer. A monoclonal antibody that binds to areas of endothelial damage (P14G11) and a non-specific immunoglobulin G (IgG) have been linked to urokinase. These conjugates were investigated in vivo using a rat vena cava model. The P14G11-urokinase conjugate significantly reduced thrombus formation compared with controls and non-conjugated urokinase (P < 0.02). No reduction in thrombus formation was seen with the IgG-urokinase conjugate. This shows that thrombus formation after endothelial damage in an in vivo model can be reduced with a targeted thrombolytic agent. Conjugates such as this may have a role in preventing early thrombotic occlusion in vein grafts.

Sparks mandril, velour Dacron and autogenous saphenous vein grafts in femoropopliteal bypass

Ninety-nine consecutive vascular reconstructions with femoropopliteal bypass performed during 1973--6 have been reviewed. A Sparks mandril was used in 11 patients, reversed autogenous saphenous vein in 30 and velour Dacron prostheses in 58. The indication for operation was severe ischaemia in 79 per cent. The overall patency rate at 12 months was 70 per cent for autogenous vein, 46 per cent for velour Dacron prosthesis and 18 per cent for Sparks mandril. When the distal anastomosis was located above the knee the patency rate was 100 per cent and 87 per cent for autogenous vein and velour Dacron graft respectively, while the corresponding figures for distal anastomosis below the knee were 58 per cent and 11 per cent. At follow-up 60 per cent of the patients showed improvement owing to the vascular reconstruction.

Distal lower limb arterial reconstruction with modified allograft saphenous veins.

Cadaveric donor saphenous veins subjected to proteolytic enzymatic digestion, crossbonding and heparin bonding were used for arterial reconstruction in the legs of 13 patients threatened with amputation and without suitable autogenous saphenous veins. Distal anastomoses were to the tibial and peroneal vessels. Twelve patients (92 per cent) were discharged from hospital with functioning grafts; 9 grafts (69 per cent) continue to function 2-16 (average 8) months after operation. Amputation was avoided in 11 patients (85 per cent). Although early results are encouraging, late results are yet to be determined.

A New Venous Conduit Utilizing the Recipient Portal Vein Branches for Segment V in Adult Partial Liver Transplantation

Right anterior-medial lobe congestion due to temporary clamping of segment V and/or VIII is common in the operative theater during adult donor right lobe liver transplantation, the most common procedure in our institute. We have used an autogenous saphenous vein conduit to recipient portal vein tributaries in 15 cases, as a “Y-to-I venoplasty” since January 2004. The recipient portal vein is transected 5 mm proximal to its bifurcation and extended to both sides with partial hepatic dissection. The “Y-to-I venoplasty” is made by suture closure of the portal vein transversely to form a tube. The average length is 7.5 cm with a 1.3 cm width. One end of “Y-to-I venoplasty” conduit is anastomosed to the donor segment V branch on the back table. And the other end is anastomosed directly to the IVC via a new window or the middle hepatic vein stump in recipient. The phase distension of the conduit with respiration is noted in the operative field. A 6/15 (40%) patency rate, was observed by CT angiography at the second postoperative week. All-patient conduits showed good flow on serial examinations at the 60th postoperative day. This new venous graft, made of recipient portal vein is a good conduit for segment V decongestion in adult right lobe partial liver transplantation.

Operative Repair of Popliteal Aneurysms: Effect of Factors Related to the Bypass Procedure on Outcome

The objective of this study was to compare patency rates following the repair of popliteal aneurysms according to the site of inflow, material of bypass graft and quality of distal runoff. Seventy bypasses were performed over an 11-year period. Autogenous saphenous vein was used in 53 procedures (75.7%) and prosthetic material was used in 17 (24.3%). Early mortality was 2.8%. Early primary and secondary patency rates were 95.7% and 97.1%, respectively. Autogenous vein showed better 10-year patency than prosthetic material (86% vs. 57%; p = 0.02). No significant differences in patency were observed according to the inflow site (87.8% groin vs. 74.7% supragenicular). Bypasses that originated in the groin showed improved patency when a saphenous vein was used (84.8% vs. 43.7%; p = 0.01). However, no influence of the graft material was noted in supragenicular bypasses (90.4% vs. 84.8%; p = 0.6). Bypasses in extremities with good runoff showed better patency than those in limbs showing poor runoff (86% vs. 55%; p = 0.003). The use of saphenous vein for the repair of popliteal aneurysms showed better results than those with prosthetic material, although in bypasses originating from the distal superficial femoral or above-knee popliteal artery, no significant differences in patency were observed. Good distal runoff was associated with improved overall outcome.

Revascularization Procedures for Chronic Lower Limb Ischaemia in TU Teaching Hospital

A retrospective review of various revascularization procedures performed for the management of chroniclower limb ischaemia in Tribhuvan University Teaching Hospital (TUTH) during the last three and halfyears was done. A total of 37 revascularization procedures were done in 30 patients. Mean age of thepatients was 53.10+15.34 (range 20-88) years. Except 3, all the patients were male. Atherosclerosispredominated as the cause of arterial occlusion. Superficial femoral artery was the commonest site of occlusionfollowed by external iliac artery. Femoropopliteal bypass was the commonest procedure done (62 per cent).Vascular prosthesis was used only in 7 patients, rest were managed using autogenous saphenous vein tobypass the occluded segment. Endarterectomy (10 per cent) and thrombectomy (8 per cent) were otherprocedures done for revascularization. There was 91% immediate limb salvage rate. Late limb salvage ratewas 88% till the time of this writing.Key Words: Revascularization, chronic leg ischaemia, bypass, graft.

Diabetic revascularization: improving limb salvage in the absence of autogenous vein.

Summary Diabetic patients can be offered opportunities for lower extremity revascularization with the expectation of results equal to those in the nondiabetic population. For those diabetics in danger of limb loss without adequate saphenous vein, alternatives exist for distal bypass resulting in acceptable long-term patency and limb salvage. As the population ages and approaches toward limb salvage become more aggressive, vascular surgeons will require alternative conduits to autogenous saphenous vein in a certain subset of patients. A PTFE graft with a distal vein patch may prove an acceptable alternative in the absence of saphenous vein. A multicenter prospective randomized trial may be of benefit to address the question of the best alternative for the patient without suitable autogenous saphenous vein for limb salvage. Until then, we will offer the patient without adequate vein PTFE bypasses to tibial arteries for limb salvage with the addition of a distal vein patch.

Diabetic revascularization: Improving limb salvage in the absence of autogenous vein

Summary Diabetic patients can be offered opportunities for lower extremity revascularization with the expectation of results equal to those in the nondiabetic population. For those diabetics in danger of limb loss without adequate saphenous vein, alternatives exist for distal bypass resulting in acceptable long-term patency and limb salvage. As the population ages and approaches toward limb salvage become more aggressive, vascular surgeons will require alternative conduits to autogenous saphenous vein in a certain subset of patients. A PTFE graft with a distal vein patch may prove an acceptable alternative in the absence of saphenous vein. A multicenter prospective randomized trial may be of benefit to address the question of the best alternative for the patient without suitable autogenous saphenous vein for limb salvage. Until then, we will offer the patient without adequate vein PTFE bypasses to tibial arteries for limb salvage with the addition of a distal vein patch.

Neovascularization and other histopathologic findings in an autogenous saphenous vein wrap used for recalcitrant carpal tunnel syndrome: A case report

A patient suffering from recalcitrant carpal tunnel syndrome despite 4 surgical decompressions was treated successfully with revision carpal tunnel release, neurolysis, and autogenous saphenous vein wrapping of the median nerve. When he subsequently developed compression of the common digital nerve to the middle finger his carpal tunnel was re-explored and the previously applied vein graft underwent a biopsy examination. Histopathologic analysis of the biopsy specimen was remarkable for neovascularization of the vein graft and structural transformation of the vein endothelium, neither of which has been reported in vein wrapping of the upper extremity. (J Hand Surg 2003;28A:262-266. Copyright © 2003 by the American Society for Surgery of the Hand.)

Postoperative Complications of Carotid Patching: Pseudoaneurysm and Infection

Patch angioplasty after carotid endarterectomy has been advocated to improve results by decreasing the incidence of recurrent stenosis and postoperative carotid thrombosis. Aneurysmal and infectious complications may be secondary to use of prosthetic materials in arterial reconstruction. We report four patients who developed late operative site complications related to carotid patching. All four of our patients had delayed pseudoaneurysms and three had infection related to the Dacron patch. In a typical case, a 57-year-old who had a right carotid endarterectomy in 1994 presented with a 1-month history of an enlarging right neck mass 7 years later. Imaging revealed a 6 x 4 cm pseudoaneurysm originating from an opening between the patch graft and the old endarterectomized carotid wall. Analysis of the literature disclosed an additional 45 patients who had pseudoaneurysms and/or infection related to carotid patching, most frequently with Dacron. We postulate that a low-grade Staphylococcus epidermidis infection of the foreign body patch may be the etiology. Autogenous saphenous vein interposition graft and antimicrobials effective against gram-positive organisms corrected the pseudoaneurysm. Although the benefits of routine carotid patching may include a decrease in restenosis, this advantage must be weighed against the risk of late pseudoaneurysm and/or infection when a prosthetic patch is used to closed the endarterectomy site.

Methicillin-resistant Staphylococcus aureus (MRSA) and Autogenous Saphenous Vein Grafts in Femoropopliteal Bypass Procedures

Abstract: Do autogenous vein grafts provide resistance to graft infection in MRSA (Methicillin resistant Staphylococcus aureus) patients undergoing vascular surgery? This paper presents two MRSA patients, who underwent femoral popliteal bypass procedure with autogenous saphenous vein grafts. Despite prophylactic measures and all necessary care, both patients had graft infections and died as a result of MRSA septicaemia. Our conclusion is that autogenous vein grafts do not provide resistance to MRSA infection.

Development and evaluation of a novel decellularized vascular xenograft

Although autogenous saphenous vein remains the standard for coronary and infrapopliteal bypass, many patients do not have a suitable vein. Attempts at developing a small-caliber vascular graft have failed largely due to occlusion, neointimal hyperplasia, or aneurismal degradation. We have designed and characterized a novel small-caliber vascular xenograft that may overcome these failure modes. To reduce immune reactions, porcine common carotid arteries were decellularized by enzymatic and detergent treatments. Histology and electron microscopic examination showed complete removal of cellular components while the extracellular matrix structure remained intact. To reduce thrombogeneity, decellularized vascular grafts were covalently linked with heparin. The efficiency of heparin linkage was demonstrated with toluidine blue staining and the antithrombogeneity of the heparin-treated grafts was demonstrated with a clot time test. Mechanical testing of the graft was performed. Decellularized-heparin-treated grafts were similar in compliance to fresh vessels and burst testing showed grafts to withstand pressures exceeding 10 times physiologic blood pressure. There was no difference in suture retention strength between fresh vessels and decellularized-heparin-treated grafts. Decellularized, heparinized grafts were implanted in dogs as carotid artery bypass grafts and showed smooth muscle cells densely populating the wall, and endothelial cells lining the lumen by two months. This study provides a new strategy to develop a small-caliber vascular graft with excellent mechanical properties, antithrombogeneity, and tissue compatibility.