Infrainguinal Reconstruction Research Articles

Choice of hybrid interventions for iliac-femoral arterial lesions

To compare the short-term and long-term outcomes of hybrid interventions after various infrainguinal reconstructions (restoration of blood flow through superficial femoral artery and pulsatile blood flow through deep femoral artery) in patients with iliac-femoral arterial disease. A retrospective analysis included patients after hybrid iliac-femoral interventions between 2014 and 2018. These interventions included stenting of iliac arteries and various open infrainguinal reconstructions. The first group (n=41) consisted of patients who underwent reconstruction of superficial femoral artery, the second group (n=88) - restoration of pulsatile blood flow in deep femoral artery. We analyzed the Rutherford score, perioperative complications, primary patency rates and limb salvage rates after 12 months in both groups. Significant improvement (Rutherford score +3) was achieved in 28 (70%) and 14 (15.9%) patients, respectively (p<0.05). There were no significant between-group differences in the number of postoperative complications. Surgery time was longer in the first group (median 160 and 130 min, respectively, p<0.05). However, intraoperative blood loss was similar. Primary patency rates after 12 months were 82.4% and 95.1%, respectively (p=0.054). Limb salvage rates after 12 months were 94.7% and 100%, respectively (p<0.05). This study highlights the potential advantages of restoring pulsatile blood flow through the deep femoral artery in hybrid interventions. Higher primary patency and limb salvage rates in the second group indicate better long-term outcomes after restoration of blood flow through the deep femoral artery. Further prospective studies are needed to confirm these results and determine the underlying mechanisms of differences.

Evaluation of Arterial and Venous Allografts in Subinguinal Bypasses

Autologous saphenous vein (ASV) is the preferred conduit for below-the-knee bypasses in patient with critical limb-threatening ischemia (CLTI). Alternative graft must be considered for patients without (ASV). The aim of this work is to evaluate the mid-term performance of arterial (AA) and venous allografts (VA) used as an alternative conduit. This retrospective study included patients with CLTI, with or without a history of homolateral femoropopliteal bypass and no autologous veins were available who underwent infra-inguinal arterial reconstructions using VA or AA from 2008 to 2018. Patients undergoing revision operations for infected bypasses were excluded. Primary patency (PP), primary assisted patency (PAP), secondary patency (SP), major amputation and death from any cause were the endpoints. For each event, a set of analyses were performed. Overall, 111 patients (63 VA and 48 AA) were included, with 108 having below-the-knee bypass. The median follow-up time was 27.8 months [15.6; 37.4]. The difference in PP between the two allograft types was significant (p=0.049) with 65.9% [43.7; 81.0], 44.1% [24.2; 62.3] and 44.1% [24.2; 62.3] in the AA group respectively at 6, 12 and 18 months while 55.6% [40.0; 68.6], 46.0% [30.6; 60.2] and 33.2% [18.2; 49.0] in the VA group. The choice of an AA over a VA was an independent factor associated with patency (for PP: HR=0.43 [0.24; 0.75] (p=0.003), PAP: HR=0.52 [0.30; 0.89] (p=0.018), SP: HR=0.49 [0.27; 0.88] (p=0.016). The allograft type did not affect neither the incidence of major amputation nor death from any cause (respectively, HR=1.20 [0.49; 2.93], and 0.88 [0.37; 2.14]). The nature of the allograft appears to influence the patency of infra-inguinal reconstruction, but not the course of the disease. Performant alternative grafts answering infectious issues are needed.

Results of infrainguinal reconstructions with distal anastomosis below the knee joint fissure in patients with critical ischemia when using various prosthetic materials

Aim. To cоmpare the results оf infra-spinal reconstructions of the lower extremities with the formatiоn of a distal anastomоsis below the knee joint fissure with the use of a bioprosthesis and autovein in critical limb ischemia (CLI).Methods. The hospital results of revascularization were retrospectively analyzed in 53 patients with CLI who underwent primary prosthetics of the femoral-popliteal segment with the fоrmation of a distal anastomоsis belоw the knee joint gap. All patients, depending on the prоsthetic material used, were divided into two groups: 1) autovein was used as a prosthesis (39.6%, n = 21)) and 2) a bioprosthesis was used (“KemAngioprosthesis” closed joint-stock company “NeoCor” Kemerovo, Russia) (60.4%, n = 32).Results. In the early postoperative period, thrombosis developed in group 1 in 7 cases (33.3%): in 5 patients – on the first day after the surgery; 2 out of 5 patients were with chronic arterial insufficiency (CAI) of the fourth degree, 1 was with acute arterial insufficiency of the first degree, and 2 patients with the third degree of CAI. In group 2, there were 6 prosthetic thrombosis (18.7%), 4 cases of which developed thrombosis on the first day, 3 patients with CAI of the fourth degree and 1 case with acute arterial insufficiency of the second degree.Conclusion. The application of infra-lingual reconstructions using bioprostheses is quite effective and safe in patients with CLI, in particular with purulent-necrotic trophic processes when a suitable autovein to be used as a prosthetic material is absent.

Infrainguinal bypass under triple nerve block in patients with severely compromised left ventricular ejection fraction and chronic limb-threatening ischemia

A severely compromised left ventricular ejection fraction (LVEF) is a major limitation for lower extremity bypass reconstruction both under general anesthesia or neuraxial anesthesia (NA). A series of eight infrainguinal bypass procedures were performed under peripheral nerve block in five patients (three males and two females; median age, 67 years) with chronic limb-threatening ischemia and a preoperative LVEF of 35% or less (median, 27%; range, 20%-35%). There were no conversions to neuraxial anesthesia/general anesthesia or early postoperative complications. This study showed that open infrainguinal reconstructions can be performed safely under peripheral nerve blockade in this vulnerable category of patients.

Remote results of infrainguinal bypass graft procedures for critical lower limb ischaemia

The study was aimed at assessing the remote results of infrainguinal reconstructions in patients with critical lower limb ischaemia depending upon the bypass graft material used. Analysed herein are the results of 237 infrainguinal bypass procedures performed over a 9-year period from January 1st, 2010 to December 31st, 2018. The patients were divided into three groups depending on the level of the distal anastomosis. Each group was then subdivided into subgroups based on the bypass graft material. Group One comprised 40 patients having endured femoral-proximal-popliteal bypass grafting. Group Two was composed of 77 patients after femoral-distal-popliteal bypass graft operations. Group Three included 120 patients after femorotibial bypass graft procedures. The comparative analysis was carried out in the first group between autovenous and synthetic grafts, in the second group - between autovenous, synthetic grafts and xenografts, and in the third group - between autovenous, composite grafts and xenografts. The primary patency rates at 1, 3, and 5 years in the first group amounted to 92, 88, and 73%, in the second group to 68, 60, 45% and in the third group - to 58, 49, and 43%, respectively. The 1-, 3-, and 5-year limb salvage rates in the first group were 100, 100, and 87%, in the second group - 90, 85, 73%; and in the third group - 90, 80, and 79%, respectively. Statistically significant differences were observed only when comparing the femoral-proximal and tibial grafts (p=0.039). Patients' survival at 1, 3, and 5 years in all groups turned out to be approximately similar, amounting in the first group to 92, 84, and 61%, in the second group to 96, 91, 71%, and in the third group to 88, 77, and 69%, respectively (p=0.87). In the first group, there were no significant differences between autovenous and synthetic grafts for any of the parameters studied. In the second group, the synthetic grafts (20%) were significantly inferior by the 5-year patency to autovenous grafts (65%) and xenografts (56%), as well as by the limb salvage rate to autovenous grafts (47 versus 84%). In the third group, the 5-year patency was the worst for the subgroup of composite grafts (15%), with the patency of xenografts being slightly inferior to that of autovenous grafts (33 vs. 55%). In patients presenting with critical ischaemia and requiring infrainguinal bypass grafting, as an alternative to an autovein if unavailable may serve synthetic prostheses when shunting to the proximal portion of the popliteal artery, or xenografts when shunting to the distal portion of the popliteal artery or tibial arteries. Despite worse patency, with their help it is possible to achieve regression of critical ischaemia and an acceptable limb salvage rate, which is comparable to the results of autovenous grafts.

Searching for the Optimal Predictors’ Model for Occlusion of the Femoral-popliteal and Femoral-tibial bypasses

Risk factors affecting the patency of shunts after infrainguinal reconstructions have been known for a long time. But so far, no effective model has been proposed, that allows to predict in a particular patient at what time and with what combination of risk factors bypass occlusion will occur. A statistical analysis of the risk factors for occlusion of such bypasses was made and developed a reliable prognostic model based on the regression function. A retrospective analysis of 136 cases of femoral-popliteal bypasses and femoral-tibial bypasses was carried out at the Department of Vascular Surgery of the Orel Regional Clinical Hospital from 2008 till 2018. Statistical data analysis was performed using Spearman’s rank correlation, binary logistic regression, ROC-curve and Kaplan-Meier survival graphs using IBM SPSS Statistics 22. A correlation was found between almost all analyzed factors and primary permeability. Based on the logistic regression, a reliable model of a combination of ischemia, superficial femoral artery patency, diabetes history, pre-operative INR data and hemoglobin level, with high prognostic significance, specificity, sensitivity and informativeness, was compiled. The constructed Kaplan-Meier survival graphs showed the dependence of the degree of ischemia and trophic disorders, history of diabetes, and the use of clopidogrel, atorvastatin / rozuvastatin, pentoxifylline, actovegin in the postoperative period from the primary patency over the time. To the patients, who have occlusion risk factors proposed in the developed model, should prolonged atorvastatin/rosuvastatin, clopidogrel, pentoxifylline, actovegin intake (more than 1 year, ideally for life) first be advised, and also they should appoint a periodic preventive examination of a vascular surgeon after 1 month, 3 months, 6 months, 1 year and 2 years after surgery with an ultrasound scan of the lower limb arteries and a bypass, as well as a complete blood count analysis (leukocytes and platelets).

Усовершенствование хирургического доступа при аутовенозных инфраингвинальных реконструкциях по методике «in situ»

Усовершенствование хирургического доступа при аутовенозных инфраингвинальных реконструкциях по методике «in situ»

Large vein reconstructions in the endovascular era

SummaryMax Ratschow was a remarkable physician and an international authority in the field of angiology and the Ratschow lectureship helps to fulfill this pioneer’s life purpose: to advance evaluation and treatment of vascular diseases. The 2017 Max Ratschow lecture covers some recent advances and controversies in venous diseases. Phlebology, once a neglected field of angiology, is a discipline that has been in constant progress during the past decades. Endovascular techniques revolutionized treatment of patients with large vein obstruction and provided safe, minimally invasive procedures with excellent long term results. Attention now need to focus on comparative studies to provide scientific evidence of efficacy of venous angioplasty and stenting with properly organized randomized controlled trials. Further attempts are needed to develop special venous stents and to decrease thrombotic complications and formation of pseudointima that cause in-stent restenosis. Open and hybrid reconstructions are safe and durable, but the number of procedures in general is small and special training and expertise for reconstructive venous surgery is recommended. Autologous vein should be used for infrainguinal reconstructions and for treatment of unilateral iliac vein obstruction with a femoro-femoral cross-over bypass (Palma procedure). IVC and iliac vein reconstructions with ePTFE grafts provide superb result in patients who need excision of malignant tumors invading large veins. Open and hybrid reconstructions are here to stay and they remain excellent options for those patients who are unsuitable for or fail endovascular repair.

Chemical and microbiological analysis of cosmetics for hair dyeing and body painting

Biosynthetic prosthesis has become the trend to carry out arterial reconstruction in infected sites since considered to be resistant to infection. Late graft occlusion is the only complication reported in literature so far. We report a case of biosynthetic graft infection which led to early detachment of the femoral anastomosis of a femoral-popliteal above-knee bypass.A 76-year-old man developed groin infection 3 months later after performing an ePTFE femoral-popliteal above-knee bypass for critical limb ischemia. He was re-admitted for groin infection involving the vascular structures. Explantation of the existing bypass and its replacement with a biosynthetic graft (omniflow II) was performed. Detachment of the proximal anastomosis occurred 6 days later leading to groin haematoma. Consequently, retroperitoneal access was performed for clamping the external iliac artery so as to control haemorrhage followed by explantation of the biosynthetic graft. An external iliac-popliteal above-knee bypass was tailored in order to save the limb and it was performed using a transobturator approach avoiding the infected site. In both cases bacterial cultures resulted positive for Morganella Morganii. The groin wound was treated separately with negative pressure medication healing definitively within 20 days and after 3-month follow-up the bypass was still patent.This is the first report of biosynthetic graft infection used for infrainguinal reconstruction leading to haemorrhage due to anastomosis disrupture. Using an extra-anatomical access for providing blood inflow to the leg avoiding the infected site and treating safely the groin wound with VAC therapy revealed to be a valid approach.

Society for Vascular Surgery limb stage and patient risk correlate with outcomes in an amputation prevention program

Clinical decision making and accurate outcomes comparisons in advanced limb ischemia require improved staging systems. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System (Wound extent, Ischemia, and foot Infection [WIfI]) was designed to stratify limb outcomes based on three major factors-wound extent, ischemia, and foot infection. The Project or Ex-Vivo vein graft Engineering via Transfection III (PREVENT) III (PIII) risk score was developed to stratify patients by expected amputation-free survival (AFS) after surgical revascularization. This study was designed to prospectively assess limb and patient-based staging for predicting outcomes of hospitalized patients in an amputation prevention program. This study undertook a retrospective analysis of prospectively gathered registry data of consecutive patients with limb-threatening conditions admitted to a fully integrated vascular/podiatry service over a 16-month period. Upon admission, limb risk was stratified using the WIfI system and patient risk was categorized using PIII classification. Patients were assessed for perioperative and postdischarge outcomes, and their relationship to staging at admission was analyzed. There were 174 threatened limbs (143 hospitalized patients) stratified by WIfI stage (1%-12%, 2%-28%, 3%-24%, 4%-28%, 5%-3%, unstaged-5%) and PIII risk (34% low, 49% moderate, and 17% high risk). Diabetes and end-stage renal disease were associated with WIfI stage (P= .006 and P= .018) and PIII risk (P= .003 and P< .001). Perioperative (30-day) events included 3% mortality, 8% major adverse cardiovascular events and 2.4% major amputation. There were 119 limbs (71%) that underwent revascularization, including 108 infrainguinal reconstructions (endovascular or open revascularization). Rate of revascularization increased with WIfI stage (P< .001), concomitant with the number of podiatric procedures, minor amputations, and initial hospital duration of stay (all P< .001). Increased WIfI stage was associated with major adverse limb events (P= .018), reduced limb salvage (P= .037), and decreased AFS (P= .048). In contrast, PIII risk category was associated with mortality (P< .001) and AFS (P< .001). Among infrainguinal reconstruction procedures, there was a similar distribution of endovascular (46%) and surgical (54%) interventions. Freedom from major adverse limb events was best for autogenous vein bypass (P= .025), and surgical revascularization was associated with improved limb salvage among the most severely threatened limbs (WIfI stage 4: 95% limb salvage for open bypass vs 68% limb salvage for endovascular; P= .026). Among patients hospitalized with limb-threatening conditions and treated by a multidisciplinary amputation prevention team, PIII risk correlates with mortality whereas WIfI stage strongly predicts initial hospital duration of stay, and key mid-term limb outcomes. Surgical revascularization performed best in the limbs at greatest risk (WIfI stage 4), and autogenous vein bypass was the preferred conduit for open bypass. These data support the use of WIfI and PIII as complementary staging tools in the management of chronic limb-threatening ischemia.

Clinical Significance of Venous Graft Size and Run-Off Segment for Peripheral Bypass Patency

Aim: To analyze the one-year-patency of infrainguinal arterial reconstructions in relation to venous graft diameter and length and the run-off segment, when arteries above the proximal anastomosis of the reconstruction are not diseased. Material and Methods: We compared retrospectively for two-year period the diameter, the length of the used vein and the run-off segment in 107 consecutively constructed infrainguinal autovenous bypasses – 54 patent (not less than 1 year) and 53 failed bypasses Diameter of the vein was measured at the narrowest part of the vein (in all cases this was the area of the distal anastomosis). Аll bypassеs are made with translocated nonreversed vein and the length of the vein was measured after the completion of reconstruction. Volume and pressure of blood flow were measured below the distal anastomosis by the means of ultrasound transit-time flowmetry. For the assessment of run-off segment Fourier analyses of flow and pressure were used and alteration of the amplitudes after intragraft infusion of Prostaglandines was calculated. Results: We compared the alteration in amplitudes in failed and patent for at least 1 year bypasses and estimated that ratio below 2 before and after medicamentous vasodilatation, sets the reconstruction in the group of threatened, as well as graft diameter below 3.5 mm and length over 40 cm. Conclusion: Hemodynamic assessment of blood flow below distal anastomosis defines the necessary vein lenght, that is why run-off segment has the most important significance for the patency of the infrainguinal autovenous reconstructions. Shorter grafts with diameter over 3.5 mm do not guarantee longer patency if distal anastomosis is constructed above diseased run-off segment.

Mortality Can Be Reduced in Infrainguinal Reconstruction Even With an Aggressive Open Surgical Approach in the Endovascular Era: The Benefits of a Standardized Approach and Regionalization of Care

Mortality Can Be Reduced in Infrainguinal Reconstruction Even With an Aggressive Open Surgical Approach in the Endovascular Era: The Benefits of a Standardized Approach and Regionalization of Care

Clinical Significance and Prognostic Value of Preoperative Angiographic Assessment in Infrainguinal Arterial Reconstructions

Objective. To assess the practical implementation of the modified Schwierz T. system for angiographic scoring of the arteries below the distal anastomosis (run-off) after infrainguinal reconstructions. Methods. We used the modified Schweierz T. score, which is readily practically applied in each patient for assessment of the run-off segment, independently from the planned level of distal anastomosis. 97 consequently treated patients who underwent infrainguinal arterial reconstructions were followed up during a 12-month period, and we retrospectively compared the results of two groups—48 of failed and 49 of patent bypasses; as for the long term patency there were some discrepancies with the expected good results. Measurements of the flow volume were performed below distal anastomoses in peripheral bypass operations with flowmeter VeriQ, Medistim, Oslo, Norway. Flowmetry was performed before and after a 5-minute infusion of Prostavasin or Ilomedin, causing peripheral vasodilatation. The resulting values were averaged and compared to the beforehand calculated according to the Schwierz score minimal expected flow. Results. Schwierz score gives orientation immediately after the reconstruction about the early patency of the bypass. Control angiographies and revisions in cases with inadequate minute blood flow identify some mistakes, the correction of which (if possible) in one operation time improves the results and the early patency. 9% of the failed bypasses in the first month had blood flow above the expected and 37% of the failed bypasses in the eighth month had flow above the expected. Mismatch in the patent bypasses was observed in 6%, probably due to subjective underestimation of some collateral vessels. Conclusion. Quantification of the distal flow is very important. The suggested model of assessment must determine as exactly as possible minimal flow to be reached at the end of the operation. We consider the preoperative angiographically calculated expected blood flow, good additional criteria for the quality of the newly constructed bypass. Intraoperative registration of low blood flow has the significance of screening for further assessment through intraoperative arteriography for the morphological identification of the cause. Having in mind the subjective nature of the angiographic scoring system and its dependence on the quality of the image, we consider the preoperative angiographic estimated expected volume of flow referring to the early patency adequate and inappropriate for long term prediction, but useful as an accessory orientation measurement of the state of the run-off arteries and the result of the surgery.

Lower and Upper Extremity Arterial Bypasses in 38 Preadolescent Children

Results: 312 patients underwent revascularization; 194 with open and 118 with endoscopic GSV harvest. There were no differences between groups in age, medical comorbidities, smoking status, prior interventions, treatment indication (CLI: 81% OVH, 83% EVH), or proximal/distal anastomotic site. Mean operative times were 262 minutes for OVH and 323 minutes for EVH (P < .001). Mean follow-up was 556 days (OVH) and 595 days (EVH). 18% of OVH grafts and 28% of EVH grafts had an intervention during follow-up (P 1⁄4 .048). Median time to intervention was 201 days (OVH) vs 126 days (EVH) (P 1⁄4 .192). Amongst interventions, there was no difference in the number that were surgical: 51.4% (OVH) vs 63.6% (EVH) (P 1⁄4 .337). Mean number of stenoses treated per intervention was 1.1 (OVH) vs 1.2 (EVH) (P 1⁄4 .552). Median stenosis length was 2.1 cm (OVH) vs 2.6 cm (EVH) (P 1⁄4 .724). Three-year primary patency was 51% (OVH) vs 41% (EVH) (P 1⁄4 .057). Secondary patency at three years was 72% (OVH) vs 63% (EVH) (P 1⁄4 .325). Overall and harvest related wound complications were 44.8% and 28% (OVH) vs 33.9% and 10.8% (EVH) (P 1⁄4 .059 and P < .001). Limb salvage for CLI was 88.9% (OVH) and 91.2% (EVH) at 3 years (P 1⁄4 .646). Conclusions: OVH and EVH have similar long-term patency, failure mechanisms and limb salvage. Harvest related wound complications are less with EVH but overall wound complications are similar and operative times are longer for EVH and more interventions are required for EVH to maintain patency. Open GSV harvest is preferred to EVH for infrainguinal reconstructions in a predominantly CLI population.

Recent Advances in Endovascular Treatment of Aortoiliac Occlusive Disease

The rate of endovascular interventions for iliac occlusive lesions is continuously growing. The evolution of the technology supporting these therapeutic measures improves the results of these interventions. We performed a review of the literature to report and appreciate short- and long-term results of endovascular stenting of iliac artery occlusive lesions. The Medline database was searched to identify all the studies reporting iliac artery stenting for aortoiliac occlusive disease (Trans Atlantic Inter-Society Consensus [TASC] type A, B, C, and D) from January 2006 to July 2012. The outcomes were technical success, long-term primary and secondary patency rates, early mortality, and complications. Technical success was achieved in 91% to 99% of patients as reported in all the analyzed articles. Early mortality was described in 5 studies and ranged from 0.7% to 3.6%. The most common complications were access site hematomas, distal embolization, pseudoaneurysms, and iliac artery ruptures. The complications were most often treated conservatively or using percutaneous techniques. The 5-year primary and secondary patency rates ranged from 63% to 88% and 86% to 93%, respectively; and the 10-year primary patency rates ranged from 68% to 83%. In this article, combined percutaneous endovascular iliac stenting and infrainguinal surgical reconstructions and new techniques in the treatment of iliac stent restenosis are discussed. Iliac stenting is a feasible, safe, and effective method for the treatment of iliac occlusive disease. Initial technical and clinical success rates are high; early mortality and complication rates are low. Long-term patency is comparable with that after bypass surgery.

Reconstructive surgery for complex aortoiliac occlusive disease in young adults

Although aortoiliofemoral bypass grafting is the optimal revascularization method for patients with severe aortoiliac occlusive disease (AIOD), previous studies have documented poor patency rates in young adults. This study investigated whether young patients with AIOD have worse outcomes in patency, limb salvage, and long-term survival rates after reconstructive surgery than their older counterparts. Patients aged≤50 years undergoing reconstructive surgery at our institution for AIOD between 1995 and 2010 were compared with a cohort of randomly selected patients aged≥60 years (two for each of the young patients, matched for year of operation), analyzing demographics, risk factors, indications for surgery, operative details, and outcomes. Among 927 consecutive patients undergoing primary surgery for AIOD, 78 (8.4%) aged≤50 years (mean age, 48.4 years) and 156 older control patients (mean age, 71.2 years) were identified. The younger patients were mainly men (81%) and 59% had surgery for limb salvage and 41% for disabling claudication (P=.02). Compared with older patients, they were significantly more likely to be smokers (90% vs 72%; P=.002) and had previously needed significantly more inflow procedures (28% vs 16%; P=.03). Only one death occurred perioperatively (30-day) among the control patients, and no major amputations or graft infections occurred in either group. The need for subsequent infrainguinal reconstructions was greater in the younger patients (18% vs 7%; P=.01). The primary patency rates were inferior in the younger patients at 5 years (82% and 75%) and 10 years (95% and 90%; P=.01), whereas assisted secondary patency (89% and 82% vs 96% and 91%; P=.08), secondary patency (93% and 86% vs 98% and 92%; P=.19), limb salvage (88% and 83% vs 95% and 91%; P=.13), and survival rates (87% and 76% vs 91% and 84%; P=.32) were comparable in the two groups. This study shows that despite a higher primary graft failure rate than that in older patients, aortoiliofemoral revascularization for complex AIOD is a safe procedure for younger patients with disabling claudication or limb-threatening ischemia, providing they are willing to follow a regular protocol to complete their postoperative surveillance and to undergo graft revision as necessary.

Aneurysm formation in bovine mesenteric vein grafts after infrainguinal reconstructions

The use of autologous vein graft in infrainguinal arterial bypass grafting (IABG) is the gold standard. However, expanded polytetrafluoroethylene (ePTFE)/heterografts can be also used in cases where the use of autologous vein graft is inappropriate. Biological vascular grafts have been used for many years in the treatment of peripheral arterial diseases. In this report, we present a 62-year-old male who was admitted to our clinic with the symptoms of left lower leg ischemia and diagnosed with left superficial femoral artery occlusion. The patient who did not have an appropriate autologous vein graft underwent femoropopliteal bypass grafting (FPBG) surgery via bovine mesenteric vein graft. At eight months, the patient revisited our clinic with the complaint of a pulsatile mass on the grafting site of the left leg. Aneurysmal dilatation of graft was detected in the patient and aneurysmatic bovine mesenteric vein graft was replaced by ePTFE graft. The patient was discharged on day 8 following uneventful surgery.

Factores de riesgo para el desarrollo de infección de injerto protésico infrainguinal en un Servicio de Cirugía Vascular en Medellín (Colombia)

Vascular graft infection has high mortality and morbidity among patients with peripheral arterial disease undergoing limb artery bypass. Due to there being little information available in Latin American centers on this complication, it is important to identify risk factors associated with infrainguinal prosthetic graft infections. Vascular graft infections are a serious complication, with reports of up to 17% mortality and a morbidity of 41%, the loss of the limb being the most frequent outcome (1).Although the incidence of vascular graft infection is reported to be from 1% to 6% in most series, some studies in Latin American centers show incidences between 4% and 11.6% Methods A retrospective case-control study was conducted on patients undergoing infrainguinal reconstruction with prosthetic graft at the Hospital Universitario San Vicente Fundacion, Medellín, taking as case patients who developed an infection; and controls, patients who did not, according to the classification of Szilagyi. Results A total of 34 cases and 34 controls, no differences in gender distribution or age, were obtained over a period of 10 years. The most frequently isolated microorganism was S. aureus, with a significant proportion of methicillin resistant S. aureus. The variables found to be associated with significant vascular graft infection in the bivariate analysis were, the presence of wound complications (OR: 77.7, 95% CI; 15.9 to 375, P = .000), re- interventions (OR 7.23, 95% CI; 1.84 to 28.40, P = .002), smoking (OR 4.04, 95% CI; 1.37 to 11.86, P = .009), surgical time greater than 75 percentile for the population studied (OR 6.61, 95% CI; 1.2 to 2.82, P = .012). Variables such as comorbidities, type of graft or concomitant surgery had no influence of the appearance of infections in the population studied. Conclusion Surgical wound complications, re-interventions, longer operating time, and smoking are associated with an increased risk of suffering from a vascular graft infection in the population studied.

The role of peripheral vascular resistance in determining the infrainguinal arterial reconstruction patency

To find if there is any correlation between the peripheral vascular resistance, its change following an intragraft prostaglandin infusion and the infrainguinal reconstruction patency. Ninety-seven patients with infrainguinal reconstructions were included in the study: in 48 patients they were compromised (32 with graft thrombosis and 16 with stenosis of the distal anastomoses); 49 patients had their bypasses patent for no less than 12 months. Intraoperative flowmetry was performed on the target artery under the distal anastomosis, after declamping, and after a five-minute intragraft prostaglandin infusion. We measured the peripheral vascular resistance (PVR) by two methods - as a ratio of the invasively measured average pressure to the average blood flow volume (mmHg/ml/min. = peripheral resistance unit [PRU]) and by using the readings by the flowmeter (ohms). The decrease of peripheral resistance was calculated in the functioning and the compromised reconstructions after administration of prostaglandin. We found that if PVR decreases 4.5 times (in ohms) the prognosis is good; we can make the same positive prognosis when the ratio of the mean invasively measured pressure to the mean blood flow volume (Pmean/Qmean) decreases more than four times. Values greater than 1.07 ohms, after peripheral vasodilatation, are indicative of high peripheral vascular resistance, at a level of specificity of 86%, and values greater than 0.57 PRU - at a level of specificity of 87%. Although PVR measurements cannot predict with absolute certainty that bypasses under the inguinal ligament shall stay patent for a long time, it is a valuable indicator showing the immediate outcome of reconstruction work carried out with the patient on the operating table. Finding Any technical errors and dealing with them saves time and money, as well as prevents the stress on the part of patients caused by the required additional revisions and multiple operations.

Assessment of Donor-Site Morbidity following Rectus Femoris Harvest for Infrainguinal Reconstruction

Advantages of the pedicled rectus femoris myofascial flap for groin wound coverage include a sufficient arc of rotation to reach the groin and inguinal region, a dependable vascular pedicle, and low donor-site morbidity. The authors aim to demonstrate the functional deficit resulting from use of the rectus femoris flap in groin wound reconstruction. One hundred six rectus femoris flaps were performed for groin wound reconstruction over a 10-year period. From this cohort, consent was successfully obtained from 20 patients for testing of thigh function. Testing included both a subjective questionnaire eliciting patient assessment of postoperative thigh strength, and objective muscle strength testing using isometric dynamometer analysis. An age- and sex-matched control group of 20 subjects with no operative history or known discrepancy of thigh strength underwent identical testing. : Subjects were tested an average of 33 months postoperatively. Dynamometer studies demonstrated a mean nonoperative and operative thigh peak torque of 135 ft-lb and 104 ft-lb, respectively, or a 21 percent difference in isometric knee extensor strength favoring the dominant leg (p = 0.02). Similarly, the control group exhibited a 17 percent strength difference between both thighs (p = 0.04). Operative subjects exhibited a lower peak torque generated by the operative leg relative to the nonoperative leg. However, a similar difference was observed in the matched control cohort. Thus, there is little isolated deficit in quadriceps strength as a result of rectus femoris harvest.