Autogenous Vein Bypass Research Articles

下肢血行再建術における自家静脈グラフトと代用血管グラフトの手術成績の比較

下肢血行再建術における自家静脈グラフトと代用血管グラフトの手術成績の比較

Management of Recurrent Superior Vena Caval Syndrome with an Externally Supported Femoral Vein Bypass Graft

Management of superior vena caval syndrome with an autogenous vein bypass graft can be complicated by occlusion of the bypass graft. The case of a patient with recurrent superior vena caval syndrome due to occlusion of a spiraled saphenous vein graft who was managed with a femoral vein graft supported externally by a sleeve of ringed polytetrafluoroethylene is presented. A venogram demonstrated patency of the graft 11 months postoperatively, and the patient remains free from clinically apparent superior vena caval obstruction 18 months postoperatively.

SURGICAL MANAGEMENT OF ARTERIOSCLEROTIC BILATERAL FEMORAL AND RIGHT POPLITEAL ANEURYSMS

Multiple peripheral arterial aneurysms have been considered a relatively rare disease. A case is reported of a 70-year old man whose chief complaint was spontaneous pain in the right calf. Preoperative diagnosis by angiography and echography suggested bilateral common femoral and right popliteal aneurysms.The bilateral common femoral arterial aneurysms were treated by excision and Cooley double velour prosthetic interposition for resected aneurysms. In addition, the right popliteal arterial aneurysm was treated by the use of autogenous saphenous vein bypass grafting from above the aneurysm to below, with ligation of the aneurysm to prevent further embolization. Pathological examination indicated atherosclerotic aneurysm. The patient has been well for more than four years after surgery.Elective surgery is considered appropriate in the management of multiple peripheral arterial aneurysms when the surgical risk is reasonable, because of the high morbidity associated with femoral and popliteal arterial aneurysms.

Management of Pediatric Visceral Arterial and Aortic Coarctation

Two unusual pediatric vascular problems have been managed surgically. The first patient is a five-and-a half-year old girl who presented with renal artery stenosis and aneurysm and renovascular hypertension. This was treated by excision of the aneurysm and reimplantation of the right renal artery. The second patient is a two-year old girl with atresia of the abdominal aorta, superior mesenteric artery (SMA) and both renal arteries. She was treated by PTFE patch graft angioplasty of the aorta, SMA reimplantation and bilateral aorto-renal autogenous saphenous vein bypass.

A metropolitan experience with infrainguinal revascularization: Operative risk and late results in northeastern Ohio

Despite being of fundamental importance, the late results of major arterial reconstruction rarely have been documented throughout a large metropolitan area. In this study of 932 patients entered into the computer registry of the Cleveland Vascular Society, 19 surgeons representing 13 community hospitals and referral centers in Cleveland and Akron report the intermediate-term outcome during a mean interval of 35 months after infrainguinal lower extremity revascularization performed in northeastern Ohio from 1978 through 1982. Operative risk (5%), the early amputation rate (7%), and actuarial 5-year survival (48% to 55%) for patients with rest pain or tissue necrosis were significantly worse (p < 0.05) than comparable figures (0.6%, 0%, and 77%, respectively) for others who underwent procedures for disabling claudication. Although both materials had similar success above the knee, the cumulative 3-year patency rate of autogenous vein bypass to the distal popliteal (69% to 88%; p < 0. 05) and tibioperoneal arteries (43%; 0. 05 < p < 0. 1) was superior to the results of polytetrafluoroethylene grafts (32% to 50% and 19%, respectively). Moreover, polytetrafluoroethylene grafts required reoperations at three times the rate of vein grafts to maintain limb salvage.

Autogenous reversed vein bypass for lower extremity ischemia in patients with absent or inadequate greater saphenous vein

This report has presented the results of 329 reversed vein bypasses performed for lower extremity ischemia over a 6 3 4 year period. One hundred eighty-nine bypasses were formed from intact ipsilateral greater saphenous veins of adequate size and length. One hundred forty bypasses were formed in patients in whom the ipsilateral greater saphenous vein was absent or of inadequate size or length to complete the bypass. The grafts in these patients were accomplished using a variety of techniques including distal graft origin, use of arm veins and lesser saphenous veins, and use of vein splicing. The patency rates of these grafts were equivalent to those achieved using adequate intact ipsilateral greater saphenous vein. In view of these results, we conclude that the absence of a greater saphenous vein does not preclude successful autogenous lower extremity vein bypass and that prosthetic bypass is rarely justified.

Postoperative Pseudomonas urinary tract infections as a source of bacterial contamination of an autogenous vein graft

The infection of autogenous vascular grafts from blood-borne contaminants is distinctly unusual. Two cases are reported in which a urinary tract infection caused by Pseudomonas aeruginosa occurred after autogenous saphenous vein bypass grafting. Despite appropriate intravenous antibiotic therapy for 10 days with clearing of both blood and urine, the patients subsequently had significant complications from graft infections. The factors thought to have contributed to this are discussed and the literature reviewed. Recommendations are made concerning the modification of the standard therapy in this situation.

Present status of reversed vein bypass for lower extremity revascularization

During the past 4 years we have performed 239 reversed vein bypasses for leg ischemia in 196 patients including 45 to the above-knee popliteal artery, 118 to the below-knee popliteal artery, and 76 to infrapopliteal arteries. The cumulative primary patency results by the life-table method through 24 months are 97% at 6 months, 91% at 1 year, and 88% at 2 years. No difference was evident in patency rates with respect to site of distal anastomosis or reason for graft performance (i.e., for claudication [31%] or for limb salvage [69%]). Twenty-two percent of these patients did not have an intact ipsilateral greater saphenous vein. By a variety of techniques including the use of cephalic and lesser saphenous veins, vein splicing, and proximal superficial femoral endarterectomy, we have been able to perform autogenous vein bypass in 94% of all patients who require lower extremity revascularization. The patency of bypasses made from conduits other than greater saphenous vein does not differ from that of the entire series. Both the graft patency and vein utilization rates in the present report are equal to those of recently published series of in situ saphenous vein bypasses and are clearly better than the published results with reversed vein bypass a decade and more ago. We conclude that, although in situ saphenous vein bypass is a good procedure, it is not superior to reversed vein bypass performed in the same time period. This report again emphasizes the hazards of evaluating any new treatment by the use of historic controls.

Flow- and pressure-adapted portal arterialization in dogs.

The effects of portal arterialization after portacaval shunt were studied in dogs. Flow- and pressure-adapted portal arterialization was performed by mounting a Teflon cuff on an autogenous vein bypass graft between the hepatic stump of the portal vein and the right renal artery. Immediately following operation, the total hepatic blood flow and intrahepatic portal venous pressure were within normal range. Eight weeks after operation, the intrahepatic portal venous pressure remained within the preoperative range, while total hepatic blood flow had increased double or triple. However, structural change due to increased flow was absent in the liver, even sixteen months after operation. Body weight, liver enzyme chemistry, ICG clearance rate, and amino acid metabolism were well maintained for the entire period of investigation. These findings suggest that sequelae such as hepatic encephalopathy and impaired hepatic metabolism after portacaval shunt can be avoided by portal arterialization, in the presence of an appropriate flow and pressure.

B-10 非逆転遊離自家静脈バイパスグラフトの長期遠隔成績と問題点について

B-10 非逆転遊離自家静脈バイパスグラフトの長期遠隔成績と問題点について

Vein graft angioplasty with nonballoon catheters.

Percutaneous transluminal angioplasty that was performed in five patients who had autogenous vein bypass graft stenosis using 6-French to 10-French teflon catheters was initially successful in all patients. One graft was patent at the time of death 15 months after angioplasty. In two patients grafts are patent 14 months and 13 months, respectively, after dilatation. One stenosis recurred at four months and again at eight months and was redilated on both occasions. Graft occlusion occurred at 11 months, and although it was redilated and lysed with streptokinase, the patient required an operation during which he died. One graft occluded at two months. No complications occurred from the angioplasties.

Treatment of Vein Graft Stenosis by Balloon Catheter Dilation

Percutaneous balloon catheter dilation was used to treate 12 high-grade stenoses in ten autogenous vein bypass grafts since September 1978. Four lesions occurred in femoropopliteal grafts, seven in femorotibal grafts, seven in femorotibial grafts, and one in an axillofemoral graft. Balloon catheter dilation was successful and surgery avoided in 11 of the 12 lesions. Pedal pulses were restored in eight of the ten patients, and the pulse in a femorotibial bypass graft was improved in another. Postdilation arteriography demonstrated a substantial increase in luminal diameter, and ankle pressure indexes were improved in all successful cases. The tenth had an operative correction of the stenosis. There were no complications with the procedure. Percutaneous balloon catheter dilation appears to be an effective method of treating stenosis in autogenous vein grafts and a useful alternative to surgical revision.

Vein bypass to the tibial, peroneal and dorsalis pedis arteries for limb ischaemia.

Fifty-nine autogenous vein bypass grafts were performed to the distal leg arteries in 57 patients for limb salvage over a 10 year period.Analysis of results by the Life Table showed a cumulative patency of 74% at 1 month and 59% patency at 6 years. Failure of the vein graft in the early post-operative period resulted in amputation, and in almost 50% of cases, at an aboveknee level. Of 18 patients whose grafts thrombosed, 16 required major amputation, and infection in another 6 patients with patent grafts resulted in limb loss. With these exceptions, all the patients with patent grafts had viable and functional limbs. Of 37 diabetic patients subjected to operation, 17 lost their limbs during follow-up. There was no significant difference in patency of grafts inserted proximally or distally into the tibial vessels. The hospital mortality was 8% and one-fourth of patients subjected to operation died of causes related to atherosclerosis during follow-up.Reduction of the early post-operative failure rate by careful patient selection and meticulous operative technique makes arterial bypass operations to the distal tibial vessels beneficial to many patients who are otherwise doomed to amputation.

血行再建術, とくに合併症と代用血管の現況について

Three hundred and eighty patients with various peripheral arterial occlusive diseases have been encountered at our department during the last 15 years. The most frequent clinical entity among them were thromboangitis obliterans (TAO), 145 cases and arteriosclerosis obliterans (ASO), 125 cases. Arterial occlusion in TAO occurs usually at the peripheral level of the limb artery where the conventional reconstructive surgery is hardly applied. On the contrarily, reconstructive surgery was able to apply to the most cases of ASO. Thus it was applied to 38 cases, or 26 per cent in TAO and 78 cases, or 64 per cent in ASO.Results of reconstructive surgery (38 cases, 43 limbs and 52 operations in TAO, and 78 cases, 91 limbs and 100 operations in ASO) were analysed with special reference to operative procedures and complications. Results in TAO were not so favorable. Early patency rates of thromboendarterectomy (TEA), prosthetic graft bypass and autogenous vein bypass in TAO were 41 per cent, 33 per cent and 65 per cent, respectively, Late patency rates were 23 per cent, 0 per cent and 48 per cent, respectively. Those figures are well contrasted with the figures in ASO groups where early patency rate was 85 per cent and late patency rate was 69 per cent. Difference of results among the procedures is not so apparent, TEA and prosthetic graft bypass procedures proved to be unfavorable in TAO. Vein bypass was the single procedure applicable to obtain resonable results.Most frequent complications were early thrombosis which occured 14 per cent in ASO and 46 per cent in TAO. Late occlusions were observed 16 per cent in ASO and 20 per cent in TAO. Infection was complicated in 3.3 per cent. Anastomotic aneurysm was observed in 2.6 per cent.

Composite Graftを用いた下肢(below knee)血行再建術

Composite Graftを用いた下肢(below knee)血行再建術

Chronic mesenteric arterial insufficiency: results of revascularization in 33 cases.

The symptoms of mesenteric arterial insufficiency and the advantages of surgical revascularization have become widely recognized in recent years. Follow-up data are accumulating on patients who have had surgery for revascularization. In this study we report on 33 patients who had mesenteric revascularization for intestinal angina. Twenty-nine patients presented with postprandial pain; most had weight loss. Abdominal bruits were heard preoperatively in 26 patients. Aortogram demonstrated involvement of one mesenteric vessel in 13 (39%) patients and two or more vessels in 20 (61%). Revascularization was accomplished with the use of a Dacron graft or an autogenous vein bypass graft to 48 vessels. Endarterectomy and patch angioplasty were done once. One patient died in the early postoperative period. Of the other 32 patients, 30 (94%) had relief of symptoms. Eight patients died from 8 to 135 months after operation, but only one died from mesenteric vascular occlusion and bowel infarction. Five years after operation, 83% of the patients were alive; in ten years, 62%.

Tibial and Peroneal Bypass in Severe Occlusive Disease of the Lower Extremities

Symptomatic arteriosclerotic occlusive disease involving the femoral and proximal popliteal arteries is currently best treated by reversed autogenous saphenous vein bypass graft. Severe occlusive disease frequently includes the popliteal and/or origin of the trifurcation vessels with reconstitution of one or more of the vessels in the lower leg. We have used distal bypass 97 times in 90 patients during the past decade. There was only one postoperative death in the series in spite of the advanced age and concurrent disease in the majority of the patients. Our indications for operation continue to be relief of pain or salvage of an extremity. We rely on high quality preoperative angiograms for selection of vessels to receive the bypass. The posterior tibial artery was used in 63 of the cases, while the anterior tibial and peroneal were used in 24 and 10 cases, respectively. There were 11 immediate inhospital failures in this series of 97 cases requiring amputation in five. Three additional patients had amputations during the ensuing several months. Of the 85 grafts functioning at the time of discharge from the hospital, 16 or (18.8%) failed during the first years. Grafts that remained patent for one year have a high incidence of long term patency which is in keeping with other reported series.

Bypass vein grafts in patients with distal popliteal artery occlusion

The results obtained by placing reversed autogenous saphenous vein bypass grafts in either isolated popliteal artery segments or tibial vessels distal to the popliteal artery are compared. Fifty-five patients with arteriosclerotic peripheral vascular disease who were threatened with limb loss were followed up from six months to nine years prior to this report. The success rate at one year was 94 per cent for the isolated popliteal segment grafts and 73 per cent for the tibial vessel grafts. The success rate after four years was 70 per cent for the isolated popliteal segment grafts and 63 per cent for the tibial vessel grafts. The clinical factors associated with the success of isolated popliteal segment bypass grafts and the factors apparently associated with failure of vein grafts in both of these groups with very poor distal arterial outflow are discussed. Our results suggest that either an isolated popliteal artery segment graft or a tibial vessel graft is a satisfactory means of treating these patients; however, a graft to an isolated popliteal segment is probably preferable to a graft to a tibial artery.

Hydraulic and morphologic study of fibrous intimal hyperplasia in autogenous saphenous vein bypass grafts

In certain patients who have had aorto-coronary bypass, the grafts are found to have concentric stenosis at the time of reinvestigation. Subsequent morphologic examination of the excised vein has shown marked intimal fibrous hyperplasia. A simplified aorto-coronary bypass system was simulated by a mathematical computer model, through which the entrance effect of various angles by the anastomosis on the flow in the side branch was studied. By matching the coronary impedance to the aortic pressure wave over a cardiac cycle, the model predicted that the optimal angle to obtain the maximum efficiency is 90 degrees. The pathological findings in a group of 108 patients who underwent aorto-coronary bypass grafting with the saphenous vein were correlated with the clinical course, angiographic findings, and hydraulic features. All four categories of data were available in 8. In all but 1 of the 8 patients who underwent reoperation, there was clinical recurrence of angina an average of 10.6 months after the first operation. Repeat angiography revealed severe narrowing of the vein graft in 6 patients and complete occlusion in 2. The angle 0*** subtended by the vein graft with the aorta was estimated at an average of 45.8 degrees.

Reversed autogenous saphenous vein by-pass from the common to the deep femoral (profunda femoris) artery.

Abstract Extended deep femoral angioplasty is an invaluable method of saving a limb especially where a femoro-popliteal vein by-pass is not possible because of a poor run-off. Atherosclerosis in the deep femoral artery often extends for more than 10 cm. In such cases we have preferred to perform a short vein by-pass than an extensive endarterectomy and patch graft. Our experience is described of 6 such cases, in 5 of whom amputation was avoided.