Venous Autografts Research Articles

Repair of an infected aortic aneurysm using an aortic allograft and a venous autograft: Report of a case

We describe the successful surgical treatment of an unusual type of infected aortic aneurysm. The aneurysm emerged around the distal part of the ascending aorta and the proximal part of the arch and involved the innominate artery. The infection was attributed to prolonged catheter placement in the right jugular vein for intravenous hyperalimentation several years earlier. We repaired the aneurysm using an aortic allograft and a venous autograft under antegrade selective cerebral perfusion with deep hypothermia. Pathological examination revealed a pseudoaneurysm. The patient recovered well and has shown no sign of recurrence of the infection.

Comparing the saphenous vein with the Gore-tex bridge fistula in thigh for chronic hemodialysis

BACKGROUND: Performing chronic hemodialysis in patients suffering from end stage renal disease needs a suitable vascular access like A–V fistula in upper limbs, bridge fistula in upper or lower limbs, and use of permanent and temporary catheters. The purpose of this study is to compare the saphenous vein loop fistula as a venous autograft versus using the synthetic Gore-tex vascular graft for creating loop A–V fistula in thigh for hemodialysis. METHODS: In the context of a prospective randomized study, seventy patients needing bridge fistula for dialysis access were randomly divided into two groups. We performed the loop saphenous A-V fistula in the test group and the Gore-tex loop bridge fistula in the control group. An assessment was made of the function criteria (fistula thrill and murmur) and complications (infection and thrombosis) in planned intervals. At the end of a year of follow-up the flow rate of all fistulas were assessed by means of Doppler sonography. These data were compared with each other. RESULTS: Comparing the function criteria (fistula murmur and thrill) of the loop saphenous A–V fistula and the Gore-tex method showed no significant differences (p < 0.8). There was no significant difference between the two groups in thrombosis (p < 0.8). The infection rate of the Gore-tex method was significantly high (p < 0.05). However, the flow rates showed no significant differences (p < 0.8). CONCLUSIONS: Essentially we showed that arteriovenous fistula was an acceptable alternative for arteriovenous graft in the thigh for performing chronic hemodialysis and that saphenous vein loop arteriovenous fistula was superior to Gore-tex loop arteriovenous graft from some aspects.

Modulation of Graft Arteriosclerosis in a Rat Carotid Transplantation Model

Venous autografts used in cardiovascular surgery tend to deteriorate over time due to arteriosclerotic complications. Cadaveric vascular allografts represent a possible alternative for this application, but donor endothelial cells (ECs) and antigen presenting cells of the graft trigger alloresponses mediated by MHC class I (MHC I) antigen, leading to graft failure. Vascular allograft rejection might be prevented by reducing cell surface expression of MHC I and thereby lowering the immunogenicity of the grafts. An Intrabody approach was used to reduce MHC I expression in vascular allografts. The efficacy of an adenovirus (Ad) carrying an anti-MHC I Intrabody gene (Ad-Intrabody) was first tested in vitro using rat aortic ECs. The effect of the Ad-Intrabody was then studied in vivo by a model of rat carotid artery transplantation. Grafts were analyzed 7 and 28 days after transplantation by immunohistochemistry and real time reverse transcriptase-polymerase chain reaction. Ad-Intrabody gene transfer reduced MHC I surface expression of rat ECs and inhibited in vivo alloimmune responses to carotid allografts. Decreased T cell and macrophage infiltration was observed within Ad-Intrabody transduced arterial allografts at day 28. This was associated with an inhibition of intimal thickening formation. Analysis of mRNA showed diminished levels of T cell markers and Interferon-gamma expression in the Ad-Intrabody-treated group compared with control groups. Ex vivo adenoviral gene transfer of an Intrabody against MHC I into rat carotid arteries prior to transplantation reduced both graft arteriosclerosis and inflammation in the absence of any systemic immunosuppression.

Kyste mucoïde adventitiel de l'artère radiale associé à un kyste arthrosynovial radiocarpien de la gouttière du pouls. À propos d'un cas

The authors report a rare case of a 51-years old woman presenting with cystic mucoid adventitial disease of the radial artery associated with a volar wrist ganglion. Imaging namely doppler sonography, magnetic resonance scanning and angio-MR was performed preoperatively because of a history of radial artery aneurysm in the opposite wrist. The radial artery was resected and the defect bridged by a venous autograft; the volar wrist ganglia was removed. Postoperative histological analysis confirmed mucoid adventitial cyst without communication with the volar wrist ganglion. Surgeons ought to be aware of this rare differential diagnosis (less than ten cases in the literature) in cases of preoperative or peroperative diagnostic doubt.

Utilização da veia glicerolada na regeneração neural: Estudo experimental em ratos

A auto-enxertia de nervo é o tratamento de escolha para grandes perdas de tecido neural que não podem ser reparadas por meio de rafia primária. A utilização do enxerto venoso previamente conservado em glicerol seria uma alternativa para diminuir o tempo operatório e a morbidade cirúrgica nesses casos. Os vasos preservados em glicerol não apresentam destruição de sua estrutura, o que permite seu uso na microcirurgia vascular, tendo a vantagem de diminuir a imunogenicidade do enxerto. O objetivo deste trabalho experimental foi comparar o grau de reparação nervosa, utilizando análise histológica, contagem do número de axônios mielinizados regenerados e análise funcional, obtida com a interposição de enxerto autógeno (grupo A) e de tubo de veia glicerolada (grupo B) em defeitos de 5 mm no nervo fibular de ratos Wistar. Somente no grupo A foi observado a formação de neuroma. O grupo B apresentou padrões histológicos compatíveis com diminuição quantitativa do número de axônios mielinizados regenerados em menor número em relação ao grupo A (controle). Na recuperação funcional, não houve diferença estatisticamente significativa entre os dois grupos.

Reoperations for occluded arterial bypasses in the lower limbs

We reviewed the outcomes of reoperations for 29 patients (30 limbs) who had undergone occluded arterial bypass in the lower limbs from May 1996 to September 2005. The 30 lower limbs of the 29 patients with arteriosclerotic obstruction received 44 reoperations, including thrombectomy alone (group T, 27) and inflow or outflow reconstruction plus thrombectomy (group C, 17). Among the 17 operations in group C, 17.6% (3/17) were inflow reconstructions involving the axillary-femoral (1), aorta-iliac (1) and aorta-femoral (1) arteries, and 76.4% (13/17) outflow reconstructions involving the femoral-popliteal bypass-tibial (8), femoral-tibial (1), femoral-popliteal bypass-popliteal arteries below the knee (2), and the femoral-popliteal bypass-tibial-peroneal trunk (2). One patient (1 limb) underwent both inflow and outflow reconstructions with an iliac arterial stent and a graft-popliteal anastomosis patch. Polytetrafluoroethylene (PTFE) grafts were used in the inflow or outflow reconstructions above the knee. Autovenous grafts or autovenously combined PTFE grafts were used in the outflow reconstructions below the knee. The percentages of Fontaine stage III and IV before primary operation and reoperation were 60% (18/30) and 86.7% (26/30), respectively (P < 0.05). Four patients died of heart attack (2), stroke (1) and multiple organ failure (1) after reoperations. Among them, only 1 patient underwent occluded bypass, and others, patent bypass. Five patients after patent bypass are still alive. The accumulative patent rate was 28.6% (8/28). The average duration of patency in groups T and C was (4.16 +/- 5.68) (0.13 - 24) months and (7.14 +/- 6.37) (0.26 - 21) months, respectively (P > 0.05). Among 42 reoperations, 19 failed within 1 month in groups T (16) and C (3) (P < 0.01). Nine patients had limb amputated (10/28 limbs, 35.71%) because of graft infection (2 limbs), pseudo aneurysm at anastomosis (1 limb), and gangrene caused by failed grafts (7 limbs). The amputation was performed on 6 limbs within 1 month and on 4 limbs 1 month after reoperation (P > 0.05). The rate of limb salvage was 64.29% (18/28). The percentages of Fontaine stage III and IV before reoperation may be much higher than those before primary operation. Thrombectomy plus inflow/outflow reconstruction creates patency better than thrombectomy alone for re-occluded bypass.

Anatomical bases of the bypass-flap: study of the thoracodorsal axis

Cutaneous tissue loss in patients with lesions on the arterial axes remains difficult to treat. Currently, combined surgery associating distal bypass and free flap seems to be the technique that yields the best results. The hemodynamic advantages of this technique, recently demonstrated, are the distal resistance and the increase in bypass flow. Nevertheless, it is complex and its indications limited. Two major drawbacks can be noted: The increasing risk of thrombosis due to the multiplication of anastomoses on the same arterial axis and the deterioration in venous autograft. To overcome these inconveniences we propose a new technique that we call bypass-flap (BF): the graft of an anatomical entity comprised of one artery and one flap. This graft secures the cover of tissue loss and the revascularization of the limb. Apart from its combined nature this technique presents three major advantages. The arterial autograft is superior to the venous graft, the gradually decreasing diameter of the artery secures the congruence of the anastaomoses, and the arterial flow of the graft is higher than a simple bypass due to the joint vascularization of the flap. The arterial graft includes the subscapular and the thoracodorsal arteries. The free flap is composed of serratus anterior muscle supplied by branches of the graft. This investigation studied the feasibility of the bypass flap and determined the length and diameter of the arterial graft and its muscular branch. Forty anatomical preparations were performed on 20 cadavers. The dissections were performed after injection of Rhodorsil. The anatomical feasibility of the bypass flap was confirmed in 37 cases. The total length of the arterial graft that preserved an external diameter above 2 mm was measured at 13 cm (8.5-15.5). This includes the subscapular artery and the thoracodorsal artery with its intramuscular part (if external diameter of that part always above 2 mm). The length of the pedicle of the serratus anterior flap was measured at 7.5 cm (3.0-12.5 cm).

Place de la chirurgie dans le traitement de l’hypertension réno-vasculaire de l’enfant

The aim of this retrospective study was to report our experience of the surgical treatment of renovascular hypertension in children and to define the role of surgery in the treatment of this form of hypertension. The author's series included 83 patients (49 girls, 34 boys), 28 months to 18 years of age (mean: 10.3) operated on from 1970 to 2001. All patients had elevated blood pressure and underwent the investigations usually performed in patients with hypertension. Lesions were bilateral in 28 cases. The operation was decided after failure of percutaneous angioplasty in the patients treated since 1982. Due to bilateral procedures and to secondary or late re-operations, the number of surgical procedures was 114 (15 nephrectomies and 99 arterial repairs). The repairs were performed by extracorporeal surgery in 25 cases and by conventional in situ surgery in 74 cases. Whenever an arterial substitute was necessary, an arterial autograft was preferred since this material does not undergo late degenerative changes with time. Fibrodysplasia of the renal artery was the prevailing pathologic finding (70%). Associated lesions were observed in 59% of the patients: coarctation of the abdominal aorta (23 patients), stenoses, obstructions or aneurysms of splanchnic arteries (23 lesions in 17 patients), pheochromocytoma (2 patients), arterial lesions of distant arterial territories in patients with Takayasu's aortitis (7 patients). There was no postoperative death in this series. Seven postoperative thromboses occurred (7% of the repairs). In the long-term follow-up, three recurrent stenoses and two aneurysms of a venous autograft were repaired surgically. In two patients, a stenosis of the opposite artery occurred and was also repaired. In two patients, a stenosis of the abdominal aorta worsened and required an aortic by-pass 3 and 12 years after the renal artery repair. In patients with Takayasu's disease, operations in other arterial territories (supra-aortic trunks, coronary arteries) were required in two patients. The complete cure of arterial hypertension was obtained in 82% of the patients. In young children, growth of the repairs was normal when age increased. Surgery still keeps a major place in the treatment of renovascular hypertension in children. Its prognosis is favourable since atheroma, visceral or renal lesions are usually lacking.

Mycotic aneurysm of common carotid artery induced by Staphylococcus aureus infection after cervical reoperation.

The objective of this study was to define a novel type of mycotic aneurysm of the carotid artery arising after cervical reoperation. We retrospectively analyzed all staphylococcal mycotic aneurysms of the common carotid artery. These aneurysms had developed after reoperative thyroid or parathyroid surgery, including resection of the central lymph node compartment and cervical reexploration. Mycotic aneurysms were found in three patients, with an incidence of 0.77% (2/261) and 0.62% (1/161) for thyroid and parathyroid reoperations, respectively. Postoperatively, a lymphatic fistula and cervical hematoma emerged in all patients, as did cervical wound infections on days 3, 4, and 6. Deep wound infections were noted on surgical revision. Cultures grew exclusively Staphylococcus aureus, which was resistant to methicillin (MRSA) in one patient. Mycotic aneurysms were identified 1 week after cervical reoperation. One aneurysm was discovered incidentally on planned lavage. The other two aneurysms presented as severe arterial hemorrhages, resulting in exsanguination in one patient. The other two patients had their aneurysms replaced by saphenous venous autografts. There seems to be accelerated arterial media destruction with formation of mycotic aneurysms in staphylococcal wound infections after cervical reoperation. It is important to recognize this novel type of mycotic aneurysm, as it must be repaired immediately to anticipate imminent rupture.

The Past 50 Years of Cardiovascular Surgery

The Past 50 Years of Cardiovascular Surgery

Traitement chirurgical des lésions artérielles rénales chez l'enfant

Purpose The aim of this retrospective study was to report the modalities and results of the surgical treatment of renal artery lesions in children. Patients and methods The series included 78 patients (43 girls, 35 boys), 16 months to 18 years of age, operated on from between 1975 to 1998. Lesions were bilateral in 24 cases. Due to bilateral procedures and to secondary or late re-operations, the number of surgical procedures was 106 (91 repairs and 15 nephrectomies). The repairs were performed by extracorporeal surgery in 22 cases and by in situ surgery in 69 cases. Whenever an arterial substitute was necessary, an arterial autograft was preferred Results Fibrodysplasia of the renal artery was the prevailing pathologic finding (63%). Associated lesions were observed in 64% of the patients: coarctation of the abdominal aorta ( n=20), stenoses, obstructions, or aneurysms of splanchnic arteries ( n=15), and pheochromocytoma ( n=2). There was no postoperative death in this series. Seven postoperative thromboses occurred (7.7%). In the long-term follow-up, three recurrent stenoses, two stenoses of the opposite artery, and one aneurysm of a venous autograft were repaired surgically. In two patients, a stenosis of the abdominal aorta worsened and required an aortic by-pass at 3 and 12 years. A complete cure of arterial hypertension was observed in 87% of the patients. In young children, growth of the repairs appeared normal when age increased. Conclusions Surgery still has a prominent role in the treatment of these lesions. The prognosis is favorable since atheroma, visceral or renal lesions are usually lacking.

Chirurgie extracorporelle de l'artère rénale

Purpose: The aim of the study was to assess the shortand long-term results of ex situ renal artery repair in a homogeneous series of patients operated on for complex lesions of this artery. Material and methods: Seventy-seven patients (38 males and 39 females) underwent 80 extracorporeal repairs of the renal artery The operated lesions were: aneurysms of the artery and/or of its branches with or without associated dysplasia (30 cases), extensive fibrodysplasia extending to distal branches (31 cases), spontaneous dissection of the artery with extension to the branches (nine cases), reoperation on the renal artery (six cases), miscellaneous (four cases). In all cases, the kidney was exteriorized after transsection of its vessels and cooled by perfusion of cold Collin's solution. After repair, it was reimplanted in the lumbar (36 cases) or iliac fossa (44 cases). An arterial substitute was used in 59 cases. Result: No mortality was observed in this series. Five postoperative thromboses occurred leading to kidney loss (6.25%). Segmental thrombosis leading to partial atrophy of the kidney occurred in three cases (3.75%). During the long-term follow-up, one repeat stenosis and four fusiform dilations of venous autografts were observed. All other repairs were successful (89.3%). Results on blood pressure control were favourable in 88.7% of the cases. Conclusions: Ex situ repair must be reserved to lesions involving several branches of the artery whose repair requires prolonged circulatory arrest and lesions profoundly situated in the renal sinus whose repair is difficult by conventional in situ surgery.

Expected and Unexpected Changes in Venous Autografts Used as Aortocoronary Conduits

(1997). Expected and Unexpected Changes in Venous Autografts Used as Aortocoronary Conduits. Baylor University Medical Center Proceedings: Vol. 10, No. 2, pp. 79-84.

Surgical treatment of isolated left anterior descending coronary stenosis: Comparison of left internal mammary artery and venous autograft at 18 to 20 years of follow-up

To assess the long-term results of the surgical treatment of isolated left anterior descending coronary artery stenosis and compare surgical strategies for graft selection, we reviewed 100 consecutive patients receiving left internal mammary artery–to–left anterior descending artery grafts and 100 consecutive patients who received a saphenous vein autograft to the left anterior descending artery. All patients underwent operation from 1971 through 1973. The internal mammary artery and saphenous vein graft groups were equivalent with regard to preoperative clinical and angiographic variables, except that patients receiving left internal mammary artery grafts had a higher prevalence of noncritical disease (less than 50% stenosis) in the circumflex and right coronary arteries than did the saphenous vein graft group. Mean follow-up for the internal mammary artery and saphenous vein graft groups was 18.7 years and 20.7 years, respectively. The 18-year outcome was superior for the internal mammary artery group. Cox regression analysis confirmed that patients with left internal mammary artery grafts had superior survival, intervention-free survival, and event-free survival (all p < 0.01). The presence of noncritical disease in other vessels adversely affected intervention-free survival and event-free survival for both groups (all p < 0.03) and decreased survival for the saphenous vein graft group ( p = 0.01) but not for the internal mammary artery group ( p = 0.24). We conclude that in long-term follow-up of surgically treated isolated left anterior descending artery stenosis (1) the left internal mammary artery consistently yields better overall and intervention-free survival than does the saphenous vein graft, (2) outcome is influenced by the presence of noncritical disease in other vessels at the initial operation, and (3) deployment of the left internal mammary artery in the treatment of isolated left anterior descending artery stenosis yielded 18 years of intervention-free survival of 60.5% and provides a standard for comparison with other forms of therapeutic intervention. (J THORAC C ARDIOVASC S URG 1994;107:657-62)

Lymphedema: is there a treatment?

More than hundred medical treatments for lymphedema have been described. This very high number shows the evidence of difficulties: lymphatics are very small vessels, under low pression and velocity respondent to spontaneous quiet lymphatic contractions. The treatments can be listed in 3 groups: 1) physiotherapeutic methods, increasing lymphatic flow: cold, field stimulation, manual lymph drainage, intermittent compression, heat; 2) drugs: venous agents (flavone, benzo-pyrone), and intraarterial lymphocytes injection, promoting lymphatic flow or increasing normal proteolysis by macrophages in order to remove trapped proteins from interstitial fluid; 3) surgical procedures subdivided in 2 groups: excisional techniques and bridging drainage techniques; radical or partial excision removes involved subcutaneous tissue, recently by the way of liposuction; Efforts to drain lymphedema by subcutaneous implants, pedical flaps, myocutaneous flaps, omental transposition and intestinal flaps are historical. Microsurgical lymphatic anastomosis to vein (nodo-venous then lymphovenous), and to lymphatic themselves are now performed: lymphatic collectors or venous autografts are interpositioned to by-pass lymphatic blockade with end-to end anastomosis. The free transplantation of a lymphatic flap with its own vascularisation from healthy inguinal nodes to axillary blockade is the last described procedure. Lymphatic anastomosis are not needed. Actually, physiotherapy is always first indicated. Benzo-pyrones are additive drugs. Excisional procedures concern monstruous lymphedema. Microsurgical bridging procedures can be attempted only for secondary lymphedemas. They could be of benefit if physiotherapy and elastic bandages, stockings or sleeves, could then be avoided. Studies assessing independently the efficiency of each procedure are needed.

Experimental Evaluation of the length of microvenous grafts under normal tension

Four groups of microvenous grafts of 2, 4, 6, and 10 cm were used to determine whether length under normal tension affects patency rates in bridging arterial defects. Tension was evaluated by allowing the grafts to assume their normal orientation and length by filling them with blood, under physiological pressure, after the completion of the proximal anastomosis. The length was estimated through the normal range of motion such that the graft would not be too loose and/or tortuous following final anastomosis. The patency rates in the four length groups of this study ranged between 80% and 83%, with no statistical difference between groups. No statistically significant correlation was found between graft length and patency rate. It was concluded that the length of venous autografts does not affect patency.

Comparison of Lymphatic and Venous Interpositional Autografts in Experimental Microsurgery of the Canine Lymphatics

Comparison of Lymphatic and Venous Interpositional Autografts in Experimental Microsurgery of the Canine Lymphatics

Comparison of Lymphatic and Venous Interpositional Autografts in Experimental Microsurgery of the Canine Lymphatics

In mongrel dogs, 56 autologous lymphatic and vein grafts were interpositioned to bridge a defect in the femoral collecting lymphatics. In one group, 26 lymphatic autografts were interpositioned with good results. No obstruction was observed over 6 months. In another group, 20 venous autografts were interpositioned after irrigation with heparinized saline and another 10 autografts were interpositioned without irrigation. After 1 week, four irrigated grafts were partially occluded with a red thrombus; after 6 months, all grafts were totally occluded. In a third group, 15 lymphaticolymphatic anastomoses were enveloped by a silicone sheet to provoke prolonged devascularization. None of the vessels was patent. Anastomotic patency was inspected in vivo postoperatively. The specimens were studied with light microscopy and scanning and transmission electron microscopy. Prolonged devascularization damaged the endothelial cells. The results show that the lymphatic vessel autograft is the best choice for an interpositional autografting to bridge a defect in lymphatic vessels.

The orthograde venous autograft and allograft. Presidential address.

Nature's Laws Are God's Thoughts . This imposing motto crowned the entrance to the biology building at Bowdoin College, Brunswick, Me, in the fall of 1940. It remains among my four favorite aphorisms. Mounted on the wall of the histology room in the Anatomy Department at Harvard Medical School, Boston, in 1943, an old Dutch couplet, translated by Charles Minot, admonished: What good will light or lenses be, if owlets look but will not see? Around the ceiling of the foyer in the Vanderbilt Hall Dormitory at Harvard was Louis Pasteur's dictum: Dans les champs de l'observation, le hasard favorise les esprits prepare . In short: cultivate insight, make accurate observations, and evaluate critically the significance of ideas. During my two years at the Naval Medical Research Institute in Bethesda, Md, 1947 to 1949, a homograft bank was established and the plaque over the entrance to the room announced: Ex Morte, Vita.

Method of autovenous graft preparation

The method of autovenous bypass grafting is widespread and is considered as one of the optimal options for surgical rehabilitation of regional circulation in occlusive lesions of the lower limb arteries. The use of augmentation to restore the transport function of the main arteries yields satisfactory immediate and long-term results. Thus, according to a number of authors, the use of bypass autovenous shunting in the femur-sacral segment, as well as in the arteries of the lower leg and foot allows avoiding amputation in 43-73% of cases.