Inflow Reconstruction Research Articles

Perioperative outcomes of elective inflow revascularization for lower extremity claudication in the American College of Surgeons National Surgical Quality Improvement Program database

BackgroundWe compared the early postoperative morbidity and mortality rates of contemporary aortofemoral bypass (AFB) and other inflow procedures for claudication. MethodsWe identified 1974 claudicants who underwent elective AFB (n = 566) or non-AFB (nonaortofemoral bypass [NAFB]; n = 1408) inflow reconstruction using the ACS-NSQIP database (2005 to 2012). Stent placement was not routinely captured. In propensity score–matched cohorts, we analyzed the association between type of inflow surgery and 30-day postoperative outcomes. ResultsAmong 824 propensity score–matched patients (AFB, n = 412; NAFB, n = 412), the 30-day mortality rate was 2.7% for AFB and .0% for NAFB (P = .0008). NAFB conferred significantly lower rates of major cardiac (.2% vs 2.4%, P = .0063), respiratory (.7% vs 10.9%, P < .0001), renal (.2% vs 1.9%, P = .0380), and septic (.5% vs 3.6%, P = .0014) complications, and fewer returns to the operating room (4.6% vs 9.9%, P = .0032), compared with AFB. Rates of major venous thrombosis, wound complications, peripheral nerve injury, and graft failure were similar between the groups. ConclusionsThis study reports a higher contemporary short-term complication rate with AFB compared to alternative inflow revascularization, against which future study of long-term durability may be weighed.

Preliminary December–January inflow and streamflow reconstructions from tree rings for western Tasmania, southeastern Australia

AbstractProjected decreases and changes in the seasonal distribution of precipitation will have profound impacts on southeastern Australia, including its ability to generate renewable hydroelectricity. Recent decreases in precipitation over the region may be significant in the context of instrumental records, but the question of whether these decreases are within long‐term natural variability remains. To help address this issue, we present December–January streamflow and dam inflow reconstructions for southeastern Australia. These reconstructions for the Tasmanian west coast are based solely on local tree ring chronologies and span up to 1600 years. Nonparametric estimates, however, indicate good model skill for the last 458 years (streamflow) and 478 years (dam inflow). The reconstructions indicate that twentieth century conditions were well within the range of historical variability, and were in fact relatively wet. The period from approximately 1600 to 1750 CE was one of the enhanced variability and a high proportion of low and high flow events occurred in the seventeenth century. There are significant relationships between streamflow and inflow reconstructions and large‐scale ocean‐atmosphere processes such as ENSO and the Southern Annular Mode. Critically, our two reconstructions rely heavily on new tree ring chronologies based on properties such as tracheid radial diameter, cell wall thickness, and density, underscoring the importance of these different types of chronologies in reconstructions.

Reprint of: Reconstruction of inflow of Atlantic Water to Isfjorden, Svalbard during the Holocene: Correlation to climate and seasonality

The distribution patterns of benthic foraminifera faunas, stable isotopes and ice rafted debris (IRD) have been studied in piston core JM98-845-PC from Isfjorden, western Svalbard to reconstruct changes in the flow of Atlantic Water during the Holocene interglacial. The paleoenvironmental conditions in Isfjorden and the inflow of the Atlantic Water followed closely the changes in insolation with strong seasonality in the early Holocene and weaker seasonality in the middle to late Holocene. A summer temperature maximum of the bottom water occurred in the early Holocene 10,500–c. 8200 years BP. Cooling began at 9000 years BP with stepwise coolings at c. 8200, 7400 and 4000 years BP. The cooling correlated with an increase in ice rafting and increased influence of polar water and seasonal sea ice cover. Between 4000 and 2000 years BP bottom water temperatures reached a minimum. After 2000 years BP episodic inflow of warmer Atlantic Water at the bottom of the fjord occurred and conditions became more unstable. The data indicate close interaction of the flow of Atlantic Water with the development of the terrestrial climate and the amount of polar meltwater and sea ice.

Extra anatomic hepatic artery reconstruction in deceased donor liver transplantation – Feasibility and outcome

BackgroundHepatic arterial inflow to the liver graft following liver transplantation is critical to graft survival. When recipient hepatic artery is not available due to injury or recipient hepatic artery flow is inadequate extra anatomic hepatic arterial reconstruction during deceased donor liver transplantation is required to ensure adequate hepatic arterial blood flow to the graft. The outcome in such patients is analyzed and compared with patient with standard hepatic artery reconstruction. MethodsRetrospective analysis of 30 patients who underwent Deceased Donor Liver Transplantation (DDLT) from March 2007 to May 2010 was done to assess the outcome of extra anatomic arterial inflow reconstruction. DDLT with standard end to end Hepatic Artery anastomosis performed in 24 patients (n = 24) served as control. Extra anatomic hepatic arterial reconstruction (EAHAR) was performed in 6 patients. The preferred choice of EAHAR was to fashion an infrarenal aortic conduit using stored donor iliac artery graft routed through the base of the transverse mesocolon. ResultsExtra anatomic hepatic arterial reconstruction is not associated with increased morbidity, mortality, blood loss, operating room time or thrombosis. ConclusionExtra anatomic hepatic arterial reconstructions are associated with excellent long-term outcomes and provide acceptable alternatives for arterial reconstruction.

Upper limb ischaemia after formation of dialysis fistula

Limb ischaemia caused by formation of dialysis fistula is rare but serious complication. The severity of symptoms may vary but rest pains and necrotic lesions are observed in most advance cases. In these patients different invasive procedures for treatment are performed - from simplest dialysis fistula ligation to complicated vascular reconstructions. The aim of the study was to evaluate treatment results of upper limb ischaemia triggered by dialysis fistula. We have analysed methods and results of treatment of 14 patients with symptomatic upper limb ischaemia caused by dialysis fistula treated in our department between 1st January, 2006 and 30th June, 2013. Treatment was subject to anatomical situation and clinical symptoms. In three patients the ligation of dialysis fistula was performed, four patients underwent inflow reconstruction - in one case by ligation of ligation of vein branch, in three patients by cephalic transfer of arterial anastomosis. In 2 patients hyperkinetic fistula aneurysm was excised and replaced by PTFE bypass, in three patients fistula reconstruction with DRIL method (distal revascularization - interval ligation) was performed, in one patient surgical operation of brachial artery stenosis was conducted. One patient underwent brachial artery angioplasty. Rest pains occurred in all patients (100%), regressive changes in 10 patients (71.4%). Eight patients (57.2%) had concomitant diabetes, seven (50%) ischaemic heart disease, five (35.5%) chronic lower limb ischemia and hyperparathyroidism was observed in fivepatients (35.5%). The imaging studies in all patients revealed pathological steal syndrome (stealing blood to the fistula), in majority concurrent with other pathologies - obstruction stenosis of peripheral artery, defects in blood out flow from the limb. As a result of the surgical treatment, symptoms of limb ischaemia subsided in all patients. Critical limb ischaemia caused by dialysis fistula is a dangerous complication. In most cases there are several causes of ischaemia. Treatment methods should be selected individually for each patient and clinical situation. Clinical symptoms should subside as a result of optimal choice of treatment and, if possible, maintaining of dialysis access.

Reconstruction of inflow of Atlantic Water to Isfjorden, Svalbard during the Holocene: Correlation to climate and seasonality

Abstract The distribution patterns of benthic foraminifera faunas, stable isotopes and ice rafted debris (IRD) have been studied in piston core JM98-845-PC from Isfjorden, western Svalbard to reconstruct changes in the flow of Atlantic Water during the Holocene interglacial. The paleoenvironmental conditions in Isfjorden and the inflow of the Atlantic Water followed closely the changes in insolation with strong seasonality in the early Holocene and weaker seasonality in the middle to late Holocene. A summer temperature maximum of the bottom water occurred in the early Holocene 10,500–c. 8200 years BP. Cooling began at 9000 years BP with stepwise coolings at c. 8200, 7400 and 4000 years BP. The cooling correlated with an increase in ice rafting and increased influence of polar water and seasonal sea ice cover. Between 4000 and 2000 years BP bottom water temperatures reached a minimum. After 2000 years BP episodic inflow of warmer Atlantic Water at the bottom of the fjord occurred and conditions became more unstable. The data indicate close interaction of the flow of Atlantic Water with the development of the terrestrial climate and the amount of polar meltwater and sea ice.

Review of Various Techniques of Pancreas Transplantation in Rat Model

Pancreas transplantation (PTx) is being applied with increasing frequency in the treatment of diabetes mellitus Type 1 and selected cases of Type 2. It is known that PTx can consistently establish normoglycemic insulin-independent state. Due to the increased use of different PTx models in rats for studying the metabolic function of the transplanted pancreas, reviewing the various techniques in PTx seemed to be necessary. A review of the literature of PTx in rat models showed that different techniques or modifications have been described. Each modification is the result of a change or simplification of three main points: the arterial inflow, the venous outflow, and the management of the exocrine secretory part of the gland. The techniques of PTx vascularization in rats are based on two cardinal models, which include the microsuture and non-suture cuff techniques. In arterial inflow reconstruction, an aortic segment is used. Venous drainage is accomplished by systemic or portal drainage (porto-caval or porto-portal anastomosis). Management of the exocrine part has the most variations. Enteric and urinary diversion, as well as duct ligation or obstruction, are the most important techniques for the management of exocrine part. Regarding vascular anastomosis, the microsuture technique is more popular than the cuff technique. However the cuff technique seems to be simpler. Grafts with portal venous drainage show a lesser probability of hyperinsulinemia and a high level of lipoproteins. In the management of the exocrine part, enteric exocrine drainage is more similar to the physiological setting and is associated with a significant reduction in the incidence of acidosis and dehydration. However, enteric diversion is more prone to intestinal bleeding and ileus as well as to bacterial contamination. The technique for PTx in rat varies according to surgeons' experiences and preferences as well as their research objectives.

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.

Staged in situ bypass

Abstract Background After femoral revascularization, following embolectomy or proximal reconstruction, the need for additional distal revascularization may be unpredictable. This dilemma may be addressed by anastomosing the detached upper end of the long saphenous vein to the femoral arteriotomy, as for in situ bypass, permitting some outflow into proximal vein tributaries. Later, if ischaemia persists, distal arterial flow can be established by closed retrograde saphenous valvulotomy. Methods Over 12 years this technique was employed in 26 legs in 22 patients, following inflow reconstruction in 15 and femoral embolectomy in seven. Postoperative observation showed persisting distal ischaemia in 14 legs and distal bypass was completed after 1–9 days, using local anaesthesia without femoral re-exposure. One patient died at 15 days and 13 grafts were patent on discharge from hospital. Results In 12 legs in 11 patients, limb perfusion was deemed adequate after operation. Four patients (five legs) died in hospital and seven were discharged. No further procedure was required in five and the proximal long saphenous vein presumably thrombosed. In two legs the whole long saphenous system had become pulsatile at 7 and 8 months, and a distal bypass was completed. No amputations were required in this series. Conclusion Staged in situ bypass can avoid prolonged and complex reconstructions in frail patients and facilitates the use of local anaesthesia, where necessary.

Impact of inflow reconstruction on infrainguinal bypass

Purpose: This study assessed whether multisegmental disease that is severe enough to require an inflow procedure adversely affects infrainguinal bypass patency, limb salvage, or patient survival rates. Methods: The records of 495 patients who underwent 551 infrainguinal bypass grafting procedures were reviewed. Saphenous vein and prosthetic grafts were evaluated separately. Graft patency rates, patient limb salvage rates, and patient survival rates in those grafts that arose from a reconstructed inflow source were compared with those that arose from normal, nonreconstructed inflow sources. When grafts had either hemodynamic failure or occlusion, the cause of failure was identified. Results: Four-year primary patency rates in vein grafts that arose from a reconstructed inflow sources were lower than those in grafts that arose from nonreconstructed inflow sources (41% vs 54%; p = 0.006). Assisted primary patency rates and secondary patency rates, however, were similar (62% vs 74% and 64% vs 77%, respectively). The 4-year primary patency rate (45% vs 55%), assisted primary patency rate (60% vs 60%), and secondary patency rate (60% vs 61%) in prosthetic grafts did not vary based on inflow source. The most common cause of graft failure was inflow failure, except in the vein grafts that did not require an inflow procedure, in which the most common cause of failure was graft failure. Inflow failure occurred in 24% and 22% of the vein and prosthetic grafts with multisegmental disease, respectively, but in only 7% ( p < 0.001) and 10% ( p < 0.05), respectively, of those that arose from normal nonreconstructed inflow. The presence of an inflow procedure did not affect limb salvage rates or patient survival rates, regardless of graft material. Conclusions: Long-term patency rates, patient limb salvage rates, and survival rates in patients with a reconstructed inflow source were similar to those of patients with a normal nonreconstructed inflow. A major cause of occlusion is inflow failure, and this occurs in a greater proportion of patients with multisegmental disease. These patients, in particular, may benefit from patient surveillance to screen for progression of their inflow disease and to allow for intervention before infrainguinal graft occlusion. (J Vasc Surg 1997;26:928-38.)

Functional outcome after surgical treatment for intermittent claudication

Although patency data for lower extremity bypass grafts are readily available, few reports have focused on patients' satisfaction after surgical reconstruction for claudication. We reviewed our experience with surgical treatment for claudication, focusing on late outcome from the patients' perspective to further refine surgical decision making in patients with intermittent claudication. From February 1987 through April 1994, 114 consecutive patients underwent surgical bypass for intermittent claudication. Nine patients were lost to follow-up, leaving the study cohort composed of 105 patients with a mean age of 63 years (range 42 to 82 years). Sixty-two percent of the procedures were inflow reconstructions, and the remainder were infrainguinal bypasses. Clinical and demographic data were gathered from record review, and late follow-up was obtained by return visit or telephone interview. Patient satisfaction and level of function were assessed by a simple five-point questionnaire administered by a research nurse. Actuarial methods were used to calculate late graft patency and survival. Cox regression analysis was used to identify clinical and anatomic factors predictive of late survival and favorable outcome. Cardiac risk assessment revealed that 75% of patients either had no clinical markers for cardiac disease or had been treated with previous coronary artery bypass grafting or percutaneous transluminal angioplasty; despite this 61% of patients underwent specific preoperative cardiac testing. Most (68%) inflow procedures were aortobifemoral bypass grafts, and 93% of outflow procedures were femoropopliteal bypass grafts. Two thirds of infrainguinal grafts were performed with autogenous conduits, with prosthetic femoropopliteal bypass grafts performed only to the above-knee popliteal artery. Early graft failure with successful immediate revision occurred in 5% of patients. No operative deaths or early or late amputations occurred. At a mean follow-up of 4.5 years 96% of surviving patients had a patent graft. However, primary unassisted patency at 4 years was superior for inflow (92% +/- 4%) versus outflow (81% +/- 6%) procedures (p = 0.009). Late readmission for cardiac-related events occurred in 12%, and late cardiac-related death occurred in 5%. Actuarial survival at 5 years was 80% +/- 5%, with diabetes being the only negative survival predictor (risk ratio 2.6, 95% confidence interval 1 to 7, p = 0.049); 60% of late deaths were cancer-related. Satisfactory late results were reported by 82% of patients, with age < or = 70 years (odds ratio 4.01, 95% confidence interval 1.2 to 13.7, p = 0.026) and normalization ( > or = 0.85) of ankle/brachial index (odds ratio 5.7, 95% confidence interval 1.6 to 20, p = 0.008) being powerful independent predictors of patient satisfaction. After considering cardiac-related short- and long-term prognosis, we conclude that lower extremity bypass grafting for intermittent claudication will produce optimal results when restricted to younger ( < 70 years) nondiabetic patients in whom near normalization of the postoperative ankle/brachial index can be anticipated.

Retrograde iliofemoral endarterectomy facilitated by balloon angioplasty.

The purpose of this study was to explore the feasibility of iliofemoral endarterectomy performed through a single groin incision. Thirty-two patients aged 34 to 75 years (mean age 63.4 years) with a male/female ratio of 20:12 underwent 36 lower extremity inflow reconstructions from July 1989 to September 1994. Surgical indications were for limb-threatening ischemia in 24 patients and for claudication in eight patients. The procedures were done for occlusive disease of the external iliac artery and common femoral artery with patients under either spinal (n = 24) or local (n = 12) anesthesia. Intraoperative balloon angioplasty with fluoroscopic guidance preceded open retrograde iliofemoral endarterectomy. Adjunctive procedures included 18 profundaplasties, eight femorofemoral, nine femoropopliteal, and one femorotibial bypasses. Thirty-three of the 36 cases were initially successful. The three failures were in patients with extensive calcification. The mean follow-up has been 36.4 months, and the patency rate was 80.5% at 3 and 4 years. The four failures noted on follow-up were caused by three common iliac artery stenoses and one iliac system occlusion. The former group was successfully treated with balloon angioplasty/stent, and the latter patient required an aortofemoral bypass. No operative deaths or limb loss occurred in this series. Retrograde iliofemoral endarterectomy facilitated by balloon angioplasty is a safe, easy-to-perform, and viable option for patients with combined external iliac artery and common femoral artery occlusive disease. Midterm results (36.4 months) are favorable, and most hemodynamic failures are easy to correct with standard endovascular techniques.

Can the deep femoral artery be used reliably as an inflow source for infrainguinal reconstruction? Long-term results in 563 procedures

Purpose: Historically, most infrainguinal bypasses originated from the common femoral artery. In spite of sporadic reports of the use of the deep femoral artery as an inflow source, its durability has not been critically reviewed.Methods: From 1977 to 1994, 2829 infrainguinal reconstructions have been performed. Of these, 563 (20%) procedures have been performed with the deep femoral artery used as the inflow source. The indication for operation was limb salvage in 91.5% of cases. Four hundred eleven procedures were performed with use of the saphenous vein in situ, 48 were performed with partial in situ vein, and 75 were performed with excised (translocated) vein (29 other). When the deep femoral artery was relatively disease free, it was accessed through a lateral or standard inguinal approach. Reasons given for the use of the deep femoral artery were inadequate vein length, concomitant inflow procedures, prior groin dissections, and occluded superficial femoral artery.Results: The 1- and 5-year secondary patency rates for all bypasses with the deep femoral artery were 90.4% and 76.9%, respectively, as compared with 88% and 73.3% for common femoral artery-based bypasses. Sixty-five patients (11.5%) had concomitant inflow procedures. All patients were monitored with serial noninvasive examinations, and data were collected from the vascular registry. Only eight patients (1.6%) required further inflow reconstructions for salvage of bypasses.Conclusions: The hemodynamically unobstructed deep femoral artery is a reliable and durable inflow source for patients requiring infrainguinal bypasses. Its patency rates are comparable to those of the common femoral artery-based reconstructions in our experience.

The role of the deep femoral artery as an inflow site for infrainguinal revascularization.

Although the deep femoral artery (DFA) is well acknowledged as an outflow vessel for inflow reconstruction, data are lacking concerning the suitability of the DFA as an inflow site for distal bypass. From 1986 to 1992 we performed 268 consecutive infrainguinal reversed vein bypasses, of which 56 (21%) originated from the middle or distal DFA. The indications for DFA-origin grafts included inadequate vein length, need for concomitant extended profundaplasty, and avoidance of groin scarring from previous reconstruction or infection. The surgical approach to the DFA (standard, posteromedial, or lateral) was tailored to the patient. All grafts were monitored with serial duplex scanning surveillance. Primary and secondary patency rates of DFA origin grafts were 78% and 96% at 3 years. These patency rates were no different from those grafts originating from the common femoral artery (66%; 89%), the superficial femoral artery (69%; 87%), or the popliteal artery (66%; 87%). Hemodynamic failure was detected in seven DFA-origin grafts, but only one resulted from disease in the common femoral artery or DFA proximal to the origin of the vein graft. Direct lateral and posteromedial approaches to the DFA were used extensively in repeat operative situations, avoiding dissection in a scarred groin and shortening the length of vein required to perform an autogenous bypass. We conclude that in appropriately selected patients, the DFA origin technique increases the versatility of lower extremity vein bypass grafting without sacrificing durability.

The role of the deep femoral artery as an inflow site for infrainguinal revascularization

Purpose: Although the deep femoral artery (DFA) is well acknowledged as an outflow vessel for inflow reconstruction, data are lacking concerning the suitability of the DFA as an inflow site for distal bypass.Methods: From 1986 to 1992 we performed 268 consecutive infrainguinal reversed vein bypasses, of which 56 (21%) originated from the middle or distal DFA. The indications for DFA-origin grafts included inadequate vein length, need for concomitant extended profundaplasty, and avoidance of groin scarring from previous reconstruction or infection. The surgical approach to the DFA (standard, posteromedial, or lateral) was tailored to the patient. All grafts were monitored with serial duplex scanning surveillance.Results: Primary and secondary patency rates of DFA origin grafts were 78% and 96% at 3 years. These patency rates were no different from those grafts originating from the common femoral artery (66%; 89%), the superficial femoral artery (69%; 87%), or the popliteal artery (66%; 87%). Hemodynamic failure was detected in seven DFA-origin grafts, but only one resulted from disease in the common femoral artery or DFA proximal to the origin of the vein graft.Conclusions: Direct lateral and posteromedial approaches to the DFA were used extensively in repeat operative situations, avoiding dissection in a scarred groin and shortening the length of vein required to perform an autogenous bypass. We conclude that in appropriately selected patients, the DFA origin technique increases the versatility of lower extremity vein bypass grafting without sacrificing durability.

The retroperitoneal, left flank approach to the supraceliac aorta for difficult and repeat aortic reconstructions

Between 1986 and 1990, 11 patients with relative or absolute contraindications to standard infrarenal reconstructions underwent supraceliac aortofemoral bypass. The operation was performed through a left-flank incision extended into the eleventh intercostal space with retroperitoneal and extrapleural dissection. Indications included multiple failed infrarenal reconstructions in four patients, previous removal of infected aortofemoral bypass graft with failure of extra-anatomic bypass in five patients, prior para-aortic lymph node dissection and radiotherapy in one patient, and aortic aneurysmal disease proximal to the renal arteries in one patient. Bypass conduits included either a bifurcated Dacron graft or a tube graft to the left femoral artery with a femorofemoral cross-over graft; concomitant left renal artery reconstruction was performed in three patients. The mean supraceliac cross-clamp time was 24 minutes, and only one patient experienced transient postoperative acute tubular necrosis. There was no operative mortality. The graft limb patency was 95% after mean follow-up extending to 17 months (range: 5 months to 5 years). We conclude that the supraceliac aorta is a useful inflow source for aortofemoral reconstruction in difficult repeat cases. It can be approached easily without thoracotomy and avoids difficult infrarenal aortic dissection in a scarred field. The tunneling is easier than with descending thoracic aorta or ascending aorta inflow sources. In addition, this bypass is likely to be more durable than inflow reconstructions based on the axillary artery.

Femoro-femoral or ilio-femoral bypass for unilateral inflow reconstruction?

Femoro-femoral and ilio-femoral bypass are two popular options for unilateral inflow reconstruction. In order to evaluate these alternative approaches, the records of 70 consecutive patients who underwent either femoro-femoral (n = 50) or ilio-femoral (n = 22) grafts were retrospectively reviewed. There were 46 men and 24 women, ranging in age from 27 to 84 years (mean: 66 years). Operative mortality was 10% for all femoro-femoral procedures, including 50% for emergent, 14% for synchronous, and 0% for solitary procedures; mortality was 9% for all ilio-femoral grafts including 20% for synchronous and 6% for solitary procedures. Among the elective solitary procedures, there was no significant difference with respect to operative time, blood loss, fluid requirement, time until resuming an oral diet, or duration of postoperative course for the two procedures. Five-year patency was 93% for all ilio-femoral and 57% for all femoro-femoral grafts. Although femoro-femoral bypass has been the more popular option for unilateral inflow reconstruction in this and other institutions, these findings justify the more wide-spread use of ilio-femoral bypass.

Failure of PTFE Infrainguinal Revascularization: Patterns, Management Alternatives, and Outcome

This review identifies the causes of PTFE infrainguinal bypass graft failure and compares the results of management alternatives. In 322 infrainguinal reconstructions 111 failures occurred over a ten year interval (1978-1988). Sixty-four percent of all failures occurred within the first year, most within the first six months due to severity or progression of distal disease (56%), which suggests that patient selection is an important factor. Only 8% of cases had intimal hyperplasia as a cause of failure without evidence of distal disease progression, and all occurred within the first twelve months. Progression of inflow disease occurred in 25% of instances and was most commonly seen as progression of iliac disease in patients operated upon to relieve claudication and thrombosis of inflow reconstructions in limb salvage patients. Infection was the cause of failure in 5.5% of failed grafts (1.8% of the series) and was associated with multiple reoperations. Management consisted of conservative treatment in 15 cases, with amputation resulting in seven (46%) of these. Operative treatment consisted of (A) thrombectomy with or without patch (N = 56); (B) extension with vein (N = 12); (C) replacement with vein (N = 11); or (D) extension or replacement with PTFE (N = 17). Primary patency and limb salvage of secondary procedures at 30 months after the reoperation was (A) 40%/45%; (B) 32%/43%; (C) 55%/72%; and (D) 30%/38%, respectively. Patients in Group C (replacement with vein) had an 88% 30-month patency when this was the first procedure after the failure, with limb salvage in all cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Arterial Graft Infections

We evaluated the treatment and clinical outcome of 20 patients with major abdominal vascular graft infections and found that immediate reconstruction of arterial inflow to the lower extremities after complete removal of contaminated graft material may not always be necessary or advisable. Patients were treated by the following categories: group 1, graft removal with immediate vascular reconstruction (seven patients, two aortoiliac and five aortofemoral grafts); group 2, graft removal with delayed vascular reconstruction (13 patients, three aortoiliac, five aortofemoral, and five extra-abdominal grafts). The mortality (57%) and the incidence of major amputation (14%) were highest when immediate vascular reconstruction was attempted. Patient survival, the incidence of recurrent graft infection, and the need for major amputation were favorably altered with delayed reconstruction even when prosthetic material was used.