Repeat Graft Research Articles

Surgical and endovascular revision of infrainguinal vein bypass grafts: Analysis of midterm outcomes from the PREVENT III trial

Data supporting the utility of percutaneous treatment to maintain vein graft patency have been limited to a collection of single-institution, retrospective analyses. Using the prospective, multi-institutional PREVENT III database, we sought to define the outcomes for endovascular vs surgical vein bypass graft revision and to define predictors for the success or failure of these interventions. A nested cohort study of 1404 patients in the PREVENT III trial who underwent infrainguinal vein bypass grafting for critical limb ischemia was performed to identify those patients who underwent either open surgical or endovascular graft revision. All patients in PREVENT III were followed up for 1 year from the initial bypass operation. The following were modeled as end points from the time of the initial open surgical or endovascular revision: freedom from graft reintervention, occlusion, amputation, and death. A total of 156 open surgical and 134 endovascular reinterventions were performed, with a mean follow-up after revision of 193 and 151 days, respectively. Although the demographics for each group were similar, the choice of repair was influenced by the interval between the index graft placement and the initial revision, with a high percentage of the early graft revisions treated with an open surgical procedure (0-1 months: 84% open surgical vs 16% endovascular; P < .001). The primary end point (ie, failure resulting in repeat graft revision, graft occlusion, or major amputation) was reached in 30.2% of the endovascular and 26.2% of the open surgical individuals, with significant improvements in the durability of graft revisions noted in the open surgical group (12-month amputation-/revision-free survival of 75% for the open surgical and 56% for the endovascular group; hazard ratio, 2.2; 95% confidence interval, 0.92-5.26; P = .043). Furthermore, subgroup analysis revealed this benefit to be most profound within the subset of thrombosed grafts undergoing salvage (P = .006). For revisions performed to treat graft stenosis, early outcomes were similar, with a trend favoring the open surgical group developing beyond 6 months. Although 80% of open surgical and 64% of endovascular-revised grafts required no further intervention, endovascular revisions necessitated significantly more reinterventions to maintain patency. The mean hospital lengths of stay (open surgical, 2.1 days; endovascular, 1.7 days) and quality of life at completion of the study (VascuQoL: open surgical, 4.72; endovascular, 4.76) were similar between the groups. Open surgical revision of infrainguinal vein grafts provides an increased freedom from further reinterventions or major amputation, but early success rates for endovascular procedures were similar, particularly for nonoccluded grafts. With time, endovascular revisions necessitate an increasing number of reinterventions and manifest higher rates of failure.

Corneal Transplants for the Treatment of Congenital Corneal Opacities

To describe the results of corneal transplants in infants and young children with congenital corneal disorders. The charts of 38 children who underwent corneal transplantation for congenital corneal opacities from 1988 to 1999 at the Hospital for Sick Children, Toronto, Ontario, were reviewed. Parameters reviewed included indication, age at diagnosis and surgery, graft size, graft clarity, repeat surgery, glaucoma pre- and postsurgery, visual acuity, and refraction. Thirty-eight children (63 eyes) underwent 86 corneal transplants. The four most common indications for surgery included posterior polymorphous dystrophy, Peters anomaly, congenital glaucoma, and sclerocornea. Mean follow-up was 40.4 +/- 30.2 months (range, 2-111 months). Seventy-eight percent of the grafts were clear at the final follow-up visit. There were 23 repeat grafts in the entire group. The overall success rate of graft clarity was 78% for children undergoing corneal transplantation for congenitally opaque corneas. Best results were achieved in patients with posterior polymorphous dystrophy, followed by patients with Peters anomaly. Sclerocornea and congenital glaucoma carried a 50% chance of success, with repeated transplants needed for many of the eyes.

Experience with cyclosporine in 1519 kidney transplantations from living donors in a national transplant programme, 1983–2002

Following the introduction of cyclosporine as basic immunosuppression in our national transplant programme in 1983, the pool of grafts from living donors (LDs) was expanded 2 years later by also accepting LDs mismatched for 2 HLA haplotypes and living unrelated donors (LURDs), mostly spouses. A policy of approaching family members to promote donation was consistently pursued. During 1983 through 2002, nephrectomy was performed on 1519 LDs without mortality. From 1983 through 1988, our learning phase in managing cyclosporine-immunosuppression, 382 patients received first grafts from LDs. One-year graft survival (GS) rates were 94.4%, 90%, 89%, and 82% in 71 HLA identical, 260 haploidentical, 18 2-haplotypes disparate, and 33 LURD graft recipients, respectively. Corresponding half-lives were 15.8, 10.3, 11, and 9.1 years, respectively. Results improved in 1028 patients receiving first LD grafts from 1989 through 2002. Corresponding 1-year GS rates were 96.6% (n = 117), 93.5% (n = 650), 90.4% (n = 73), and 88.8% (n = 188), and half-lives were 30, 13.3, 13.5, and 12.3 years, respectively. Similar GS rates were observed in 109 recipients of repeat grafts from LDs. LDs contributed 44% and 21.6% of all first and repeat grafts transplanted, providing grafts to 11 patients (in 1983) increasing to 23 patients (in 2002) per million population per year (pmp/y). When added to grafts from cadaveric donors, 40 to 48 pmp/y were provided with a first or repeat graft since 1990, thus covering at least 65% of the national need for kidney transplantations.

Technique of split skin graft fixation using hypafix: a 15-year review.

The technique of graft fixation with Hypafix was introduced in 1986 and has since been adapted for use in all sites to become the standard technique in the management of paediatric burns at the Women's and Children's Hospital Burn Unit. The technique is versatile, safe, simple, reliable and inexpensive, and has proven to be effective in over 700 burn patients, with 18 patients (2%) requiring repeat grafts. The patient's care is continued in a designated Burn Scar Assessment Clinic with a range of 'contact media', including Hypafix, Elastofix, silicone gel and Elastomer products, being applied as necessary.

Indications for and outcomes of penetrating keratoplasty performed by resident surgeons

PurposeTo analyze the indications for and outcomes of penetrating keratoplasty (PKP) performed by resident surgeons at both county hospital and Veterans Affairs facilities. DesignObservational case series MethodsRetrospective review of 79 eyes from 61 patients undergoing PKP from January 1, 1997, through December 31, 2001, to determine indications for surgery and outcomes, including graft clarity and final visual acuity. ResultsThere were 52 (65.8%) primary and 27 (34.2%) repeat transplants performed. Follow-up after surgery averaged 21.9 months. Indications for PKP included failed graft, 23 (29.1%), bullous keratopathy, 17 (21.5%), keratoconus, 16 (20.3%), corneal scar, 15 (19.0%), corneal perforation from infection, 5 (6.3%), and Fuchs endothelial dystrophy, 3 (3.8%). Twenty-one eyes had pre-existing ocular disease limiting final acuity. Overall, 51 grafts (64.6%) remained clear. More primary than repeat grafts remained clear (75% vs 44.4%, P = .012) and achieved 20/40 or better final acuity (30.8% vs 11.8%, P = .05). Excluding failed grafts or eyes with limited visual potential, final acuities achieved were: 19 (47.5%) 20/40 or better, 18 (45%) 20/50 to 20/150, 3 (7.5%) 20/200 or worse. Grafts remaining clear by indication were: failed graft, 9 (39.1%); keratoconus, 14 (87.5%); bullous keratopathy, 13 (76.5%); corneal scar, 10 (66.7%); corneal perforation, 2 (40%); Fuchs, 3 (100%). Eyes achieving final acuity of 20/40 or better by indication were: keratoconus, 9 (56.2%); failed graft, 3 (13%); bullous keratopathy, 3 (17.7%); corneal scar, 2 (13.3%); corneal perforation, 0 (0%); Fuchs, 2 (66.7%). ConclusionsCounty hospital and Veterans Affairs facilities provide a challenging subset of patients for penetrating keratoplasty. Failed graft was the leading indication for transplantation for our population. Graft clarity and final visual acuity varied by indication for transplantation. Resident surgeons can achieve favorable results for penetrating keratoplasty performed at these venues, especially for primary transplants.

B-Cell crossmatching and kidney allograft outcome in 9031 United States transplant recipients

The predictive power of a positive B-cell crossmatch remains controversial due to the presence of cofactors, such as sensitization and human leukocyte antigen (HLA) mismatch levels. UNOS OPTN/Scientific Registry data were analyzed on 9031 cadaveric kidney graft recipients who were B-cell crossmatched during 1994 and 1995 for graft outcome. This 2-year time period was chosen so that most US transplant recipients in this study would have had a similar regimen of immunosuppression consisting of prednisone, Sandimmune, and azathioprine The two patient groups that were analyzed were B-pos (n = 336) and B-neg (n = 8,695). All T-cell crossmatches were negative. Data analyzed included donor-recipient demographics, sensitization levels, B-cell crossmatch techniques, histocompatibility mismatching, graft rejection incidence, early graft loss, cause of graft failure, and statistical analyses (univariate and multivariate) in primary and repeat graft recipients. Significant factors in both crossmatch groups included pretransplant transfusions, peak and most recent class I PRA levels, a previous kidney graft, histocompatibility mismatching at HLA-A plus -B, urine in first 24 h, and rejection incidence between discharge and 6 months post-transplantation. Class II antibody specificities and panel reactive antibody (PRA) levels were not available from the UNOS database. Fifty-seven percent of 15,896 (1994–1995) transplant recipients (n 9031) were B-cell crossmatched, and 336 of 9031 recipients (3.7%) were transplanted with a B-pos crossmatch. Sixteen percent of B-pos recipients experienced early graft loss (< 6 months) compared with 11% of B-neg recipients (p < 0.001). Both primary and repeat grafts with B-pos crossmatches experienced an increase in rejection incidence (p = 0.023) and early graft loss (p < 0.001). In the sensitized (PRA > 10%) recipient subset (n = 2,789), both primary (n = 93) and regraft (n = 52) recipients with B-pos crossmatches had a higher incidence of early graft loss at 3 months, p < 0.001 and p = 0.016, respectively. HLA-DR mismatch levels in both patient groups were not different (p = 0.109). There was a 68% increase in the odds of 3-month graft loss in B-pos versus B-neg recipients (multivariate logistic regression analysis p = 0.054, 95% confidence interval 0.99–2.85). In conclusion, a B-pos crossmatch in primary and regraft recipients, including a sensitized subset, is predictive of inferior kidney graft outcome.

UROLOGICAL COMPLICATIONS AFTER RENAL TRANSPLANTATION USING URETEROURETERAL ANASTOMOSIS IN CHILDREN

Ureterovesical reimplantation is most often performed for renal transplantation in children. We reviewed our experience to evaluate the safety and efficacy of ureteroureteral reimplantation in pediatric renal transplantation. We retrospectively evaluated the charts of 92 boys and 72 girls who underwent a total of 166 ureteroureteral anastomoses for renal transplantation from January 1990 to December 1999. Spatulated end-to-end anastomosis was performed between recipient and graft ureters without stenting and with a bladder catheter for at least 10 days. Mean patient age at transplantation was 11.2 years (range 1 to 21.5). There were 22 living related donor and 144 cadaveric grafts. Urological anomalies and nephropathy were the cause of end stage renal disease in 146 and 20 patients, respectively. Urological complications were noted in 14 of the 166 transplantations (8.4%) in 10 boys and 4 girls, including 12 initial and 2 repeat grafts from 2 living related and 12 cadaveric donors. Five of these patients had undergone previous urological surgery. The 2 children (1.2%) with acute ureteral obstruction underwent repeat intervention after stent failure. Anastomotic leakage in 7 cases (4.2%) was treated conservatively in 1 and with a Double-J stent (Medical Engineering Corp., New York, New York) only required in 3. Reoperation was required in 3 cases. One patient (0.6%) with late ureteral stenosis underwent repeat anastomosis, 1 (0.6%) required reimplantation for recurrent pyelonephritis due to vesicoureteral reflux in the graft, 1 (0.6%) with a valve bladder required bladder augmentation and ureteral reimplantation, and 1 (0.6%) with lymphocele and 1 (0.6%) with lithiasis were successfully treated conservatively. Complications were associated with acute rejection in 6 cases. Mean followup without graft loss in patients who presented with versus without complications was 58.3 months (range 1 to 112) versus 75 (range 1 to 118). In the former patients with a mean age of 16 years 9 months versus those without urological complications mean serum creatinine was 116 and 108 mol./l., respectively. Two grafts were lost in patients with urological complications, including 1 who died of pulmonary embolism and 1 with refractory chronic rejection. Seven patients were lost to followup after 54 months (range 12 to 113) of adequate graft function. Ureteroureteral anastomosis is a safe and effective technique for pediatric renal transplantation with a low complication rate, which may be due to better vascularization of the shorter ureteral end of the graft. Our results should encourage the use of this technique in pediatric renal transplantation. Efforts to preserve the recipient ureters should be made at nephrectomy.

Reinterventions for Recurrent Ischemic Heart Disease following a Successful First Re-Do Myocardial Revascularization: Predictors, Indications and Results

Predictors for a reintervention following a successful first re-do surgical revascularization (CABG) were examined. Success and limitations of the reintervention procedures were evaluated. Between 3/88 and 3/95, 16.81% (302/1796) patients who had undergone a first re-do CABG surgery in the authors' center, required a reintervention. Graft angioplasty was performed in 158 (52.32%) patients and a second re-do CABG in 47.68% ( n = 144). Graft angioplasty was preferred over surgery in patients aged 70 years or older (43% versus 24.3%, P &lt; 0.001) and in patients with unstable angina (55.6% versus 33.3%. NS) or a Left Ventricular Ejection Fraction (LVEF) &lt; 30% (34.8% versus 20%, P &lt; 0.05). Re-do CABG was preferred over graft angioplasty for multivessel revascularization (3 ± 0.3 versus 1 ± 0.6, P &lt; 0.001), proximal occlusive disease ( P &lt; 0.001) and for graft disease of a longer duration (7.18 ± 1.7 years versus 3 ± 0.6 years, P &lt; 0.01). The independent predictors of a reintervention were (i) lack of arterial revascularization and (ii) inability to achieve a complete revascularization in a previous operation. The predictors of a failed graft angioplasty were diameter stenosis &gt; 70% long occlusive lesions (multivariate), angulation, calcification and asymmetrical lesions (univariate). Failed graft angioplasty required a re-do CABG ( n = 48: early 21. late 27). repeat graft angioplasty ( n = 34: early 8. late 26) or transplant ( n = 1). Recurrent symptoms following a second re-do CABG required a graft angioplasty ( n = 6: early 2, late 4), a subsequent re-do CABG ( n = 32) or a transplant ( n = 4). Cumulative incidence of cardiac events at 1 month, and 1 and 8 years were: 20, 40.45 and 66.44% following graft angioplasty and 5.5, 10 and 56.55% following a second re-do CABG, respectively ( P &lt; 0.05). Actuarial survival at 1 month and 6 years following graft angioplasty were 97.15 and 77.22%, and 94.7 and 83.26% after a second re-do CABG, respectively (NS). Re-do CABG was more effective and durable. Graft angioplasty provided a good palliation in suitable cases and also postponed the need for a high-risk surgical intervention for more favorable conditions.

Reinterventions for recurrent ischemic heart disease following a successful first re-do myocardial revascularization: predictors, indications and results

Predictors for a reintervention following a successful first re-do surgical revascularization (CABG) were examined. Success and limitations of the reintervention procedures were evaluated. Between 3/88 and 3/95, 16.81% (302/1796) patients who had undergone a first re-do CABG surgery in the authors' center, required a reintervention. Graft angioplasty was performed in 158 (52.32%) patients and a second re-do CABG in 47.68% ( n=144). Graft angioplasty was preferred over surgery in patients aged 70 years or older (43% versus 24.3%, P<0.001) and in patients with unstable angina (55.6% versus 33.3%, NS) or a Left Ventricular Ejection Fraction (LVEF) <30% (34.8% versus 20%, P<0.05). Re-do CABG was preferred over graft angioplasty for multivessel revascularization (3±0.3 versus 1±0.6, P<0.001), proximal occlusive disease ( P<0.001) and for graft disease of a longer duration (7.18±1.7 years versus 3±0.6 years, P<0.01). The independent predictors of a reintervention were (i) lack of arterial revascularization and (ii) inability to achieve a complete revascularization in a previous operation. The predictors of a failed graft angioplasty were diameter stenosis>70%, long occlusive lesions (multivariate), angulation, calcification and asymmetrical lesions (univariate). Failed graft angioplasty required a re-do CABG ( n=48: early 21, late 27), repeat graft angioplasty ( n=34: early 8, late 26) or transplant ( n=1). Recurrent symptoms following a second re-do CABG required a graft angioplasty ( n=6: early 2, late 4), a subsequent re-do CABG ( n=32) or a transplant ( n=4). Cumulative incidence of cardiac events at 1 month, and 1 and 8 years were: 20, 40.45 and 66.44% following graft angioplasty and 5.5, 10 and 56.55% following a second re-do CABG, respectively ( P<0.05). Actuarial survival at 1 month and 6 years following graft angioplasty were 97.15 and 77.22%, and 94.7 and 83.26% after a second re-do CABG, respectively (NS). Re-do CABG was more effective and durable. Graft angioplasty provided a good palliation in suitable cases and also postponed the need for a high-risk surgical intervention for more favorable conditions.

Porcine small intestinal submucosa as a dural substitute

BACKGROUND The continuing search for the ideal dural substitute is currently directed toward collagen preparations. Xenogeneic porcine small intestinal submucosa (SIS), a naturally occurring extracellular matrix rich in collagen, has been successfully used as a soft tissue graft in several body organ systems, including preliminary studies as a dural substitute in the rat. METHODS Eight dogs underwent temporoparietal craniotomy and dural resection with replacement by SIS. Five dogs had contralateral procedures without SIS grafting. Three dogs had contralateral SIS grafts placed 2 months after the initial procedure. Histologic assessment was obtained at 7, 30, 60, 90, and 120 days. Cerebrospinal fluid (CSF) cytological examination and routine serum chemistry preceded sacrifice. RESULTS Histologic evaluation showed initial graft infiltration by mononuclear round cells, spindle-shaped cells within an eosinophilic staining extracellular matrix, and neovascularity. Complete resorption of the graft was evident by 60 days. This pattern is consistent with the previously described incorporation and remodeling of the SIS graft at other sites. CSF cytology and routine serum chemistry at the time of sacrifice were normal. Response to repeat grafting was identical to that of initial exposure. There was no clinical or histologic evidence of sensitization or graft rejection. No evidence of adverse effect on the underlying cerebral cortex was observed. CONCLUSIONS Porcine small intestinal submucosa demonstrates a favorable biologic response as a dural substitute in the canine model. It is a promising biomaterial for dural replacement.

PRIMARY LYMPHEDEMA OF THE GENITALIA IN CHILDREN AND ADOLESCENTS

Purpose Congenital lymphedema is a rare disorder that may result in disfiguring edema of the male genitalia. We reviewed our experience with 5 cases to advance our understanding of this challenging problem. Materials and Methods Four boys with significant lymphedema underwent excision of the involved subcutaneous genital tissue and coverage with local skin flaps. Two boys in whom this approach failed later underwent complete excision of the involved subcutaneous tissue and skin, and coverage with split thickness skin grafts. The boy with minimal edema was observed. Results Two of the 4 boys who underwent subcutaneous genital tissue resection and coverage with local skin flaps are markedly improved, although 1 requires further revision. In the other 2 boys treatment failed, necessitating repeat genital tissue excision and grafting. While there have been no recurrences in the grafted areas, each patient has required additional operations to manage recurrent edema in adjacent tissues of the perineum and inguinal region, and in 1 significant contraction of the grafted skin developed. Mild genital lymphedema in the remaining patient has remained stable during 10 years of followup. Conclusions Congenital lymphedema of the genitalia is a challenging problem. Recurrences requiring multiple operations are common. We recommend expectant management of mild cases. In more severe cases excision without grafting should be attempted. While skin grafting may be the most definitive solution, it does not prevent recurrence in adjacent regions, and it carries the risk of skin contraction. Skin grafts should only be used when other techniques have failed.

P-3-372 - Expanded polytetrafluoroethylene surgical membrane as a substitute for the dura mater

BACKGROUNDThe continuing search for the ideal dural substitute is currently directed toward collagen preparations. Xenogeneic porcine small intestinal submucosa (SIS), a naturally occurring extracellular matrix rich in collagen, has been successfully used as a soft tissue graft in several body organ systems, including preliminary studies as a dural substitute in the rat.METHODSEight dogs underwent temporoparietal craniotomy and dural resection with replacement by SIS. Five dogs had contralateral procedures without SIS grafting. Three dogs had contralateral SIS grafts placed 2 months after the initial procedure. Histologic assessment was obtained at 7, 30, 60, 90, and 120 days. Cerebrospinal fluid (CSF) cytological examination and routine serum chemistry preceded sacrifice.RESULTSHistologic evaluation showed initial graft infiltration by mononuclear round cells, spindle-shaped cells within an eosinophilic staining extracellular matrix, and neovascularity. Complete resorption of the graft was evident by 60 days. This pattern is consistent with the previously described incorporation and remodeling of the SIS graft at other sites. CSF cytology and routine serum chemistry at the time of sacrifice were normal. Response to repeat grafting was identical to that of initial exposure. There was no clinical or histologic evidence of sensitization or graft rejection. No evidence of adverse effect on the underlying cerebral cortex was observed.CONCLUSIONSPorcine small intestinal submucosa demonstrates a favorable biologic response as a dural substitute in the canine model. It is a promising biomaterial for dural replacement.

HLA-identity--long-term renal graft survival, acute vascular, chronic vascular, and acute interstitial rejection.

The object is analysis of the impact of acute and chronic rejection on long-term function in HLA-identical renal transplants performed from 1967 to 1995 by the Saskatchewan Renal Transplant Unit. Forty-eight grafts in 46 patients were studied, of which 39 were first and nine second grafts. Forty-two were for primary and six for secondary renal disease. Thirty-five received azathioprine/prednisone prophylaxis, and 13 received cyclosporine/prednisone with/without azathioprine. Ten-year all graft actuarial survival was 84%, 10-year actuarial graft survival in patients with primary renal disease 90%, and with subsequent graft after first HLA graft failed 97.5%, for age-matched population 98.5% (P=NS). Overall death rate was 8.7% (4/46); in secondary renal disease patients 50% (3/6); in primary renal disease patients 2.5% (1/40, P=0.004). All (9/9) HLA-identical second grafts functioned. Acute rejection with azathioprine/prednisone prophylaxis occurred in 55% (9/17) of grafts treated with <6 pre-graft blood transfusions, with the same prophylaxis but >5 units in 12% (2/16, P=0.015), and with cyclosporine prophylaxis in 13% (2/15, P=0.021). Pulse steroids alone reversed all acute rejection. Grafts failed in 6.2% (3/48), all in primary renal disease patients and one from technical one noncompliance, and one chronic rejection. Graft cost/patient/year amortized over 9 years is $3,855 and comparable dialysis cost would be $35,650; cost for all patients on dialysis for 9 years would be $11,293,320 while comparable graft cost was 1,221,418, a savings of 89.2%. Our conclusions are that HLA-identity associates with the following: (1) a 10-year actuarial survival in primary renal disease that equals that of the age-matched population, (2) uniform success in repeat grafts, (3) virtual absence of chronic rejection despite a high incidence of acute rejection in azathioprine/prednisone grafts that (4) always reversed on pulse steroids, and (5) a cost reduction for grafting of 93.2% compared with dialysis therapy.

Results of a policy with arm veins used as the first alternative to an unavailable ipsilateral greater saphenous vein for infrainguinal bypass

Aggressive policies for distal bypass and coronary revascularization increase the need to identify alternatives to autologous saphenous vein grafts. We examined the performance of arm vein as the primary alternative to contralateral saphenous vein when the ipsilateral saphenous vein was not available. A total of 250 arm vein grafts were studied retrospectively in 224 patients (143 men, 81 women, 82.6% with diabetes, mean age 68.3 years) from February 1989 to April 1994. Intraoperative angioscopy was carried out to observe valve lysis, remove abnormalities, and select optimal vein segments. A total of 85 primary, 103 repeat, and 62 graft revision procedures were done for limb salvage in 99.2% of the patients. A total of 41 femoropopliteal, 114 femorotibial-pedal, 33 popliteodistal, and 62 jump or interposition grafts were constructed. A total of 199 grafts were single vein, and 51 were composite vein. The source was cephalic vein alone in 50.4%, cephalic and basilic vein in 35.6%, and basilic vein only in 14%. The contralateral saphenous vein as an alternative conduit was available in 97 (38.8%) instances. Interventions guided by angioscopy to "upgrade" the graft were necessary in 51.6%. Overall early patency (< or = 30 days) was 94.8% (n = 13 occlusions). The cumulative primary patency rate at 1 year was 70.6%, the secondary patency rate was 76.9%, and the limb salvage rate was 88.2%. The 3-year patency rate (limb salvage) was 51.9% (92.4%) for primary grafts, 56.7% (67.1%) in revision grafts, and 42.4% (79.9%) in repeat grafts. In 22.7% (22 of 97) the available contralateral saphenous vein was used for distal revascularization within the follow-up period. Arm veins are an easily accessible autologous conduit of sufficient length to reach the midtibial level. Excellent patency rates allow durable limb salvage in otherwise difficult circumstances. Vein configuration and splicing do not affect patency rates, but vein quality and repeat operations do. Angioscopy is a valuable adjunct to upgrade graft quality. The contralateral saphenous should be saved for subsequent contralateral revascularization or coronary artery bypass grafting.

Repeat Russe bone grafting after failed bone graft surgery for scaphoid non-union

We report the long-term outcome of repeat Russe bone grafting after failure of a previous Russe graft for scaphoid non-union. 15 patients were followed for a mean of 71 months after their last surgical procedure. 11 patients had undergone a single previous Russe graft and four patients had two previous graft attempts. Internal fixation was used in only three patients. Eight out of 15 (53%) patients achieved union after a single repeat graft and one out of four united after a third attempt. When union was achieved, range of motion was unchanged, grip strength was increased 10% and pain was slight to none, allowing return to full employment in seven out of the nine patients. All patients who did not achieve union have either undergone a salvage procedure or are contemplating one. Based on the literature and our relatively low rate of union without internal fixation (53%), we recommmend supplementary internal fixation if repeat Russe bone grafting is undertaken. When union is achieved, satisfactory results can be expected.

Revascularization of the limbs with urokinase and TEC catheter endarterectomy for occluded bypass grafts

Occlusion of a femoral-popliteal or a femoral-tibial bypass graft on a prior occluded superficial femoral artery or the popliteal artery (in cases of ischemia of the legs) creates a complicated problem that may result in limb loss. The revascularization of such limbs with a repeat femoral-tibial or peroneal bypass is difficult and results in a high rate of limb loss from failure of the repeat grafts. Therefore, attempts were made to re-open the grafts through urokinase administration and thrombolysis for the grafts. To address the distal critical stenosis, or occlusion, the urokinase administration and thrombolysis were followed by endovascular endarterectomy using a thromboembolytic catheter (TEC). From 1990 to 1992, the above protocol was followed with 15 patients. In all patients, the protocol included 24 to 48 hours of urokinase administration with 60,000 to 120,000 U of urokinase per hour. A distal pathology was detected in all 15 patients, of whom 8 had complete occlusion at the site of distal anastomosis, 7 had critical stenosis ranging from 90% to 99%, and 1 was found to have a proximal critical stenosis at the femoral-graft junction. TEC catheter endarterectomy was performed to address the problem of occlusion and critically stenosed distal anastomotic lesions; a 100% success rate was immediately achieved, with flow being re-established to the distal limb. Fourteen of 15 patients remained well revascularized for more than 1 year. One patient experienced re-occlusion after 8 months; the occlusion was re-opened using the same technique of urokinase administration and the use of the TEC catheter, in which case the graft subsequently remained open. The longest follow-up of one patient is more than 2 years, during which time the graft has stayed open. With the aforementioned results, after revascularization of the ischemic limbs from occluded bypass grafts, it is strongly recommended that urokinase administration, along with TEC endovascular endarterectomy, be used to establish the circulation when occluded grafts threaten limb loss.

Risk Factors of Corneal Graft Failure

To measure the association between potential risk factors and corneal graft failure. Two failure outcomes are compared: those with and those without a prior immune allograft reaction. Based on a single-center observational study design, 539 adult recipients of a corneal graft were followed for a median time of 30 months. Survival analysis was carried out. Eighty-two graft failures were recorded. Of 82 failures, 53 (65%) were not preceded by an immune allograft reaction. Presence of blood vessels in the recipient cornea was associated with a twofold increase in risk for both failure outcomes. Three factors increased the risk of failure without an immune reaction: prior glaucoma or uveitis (adjusted relative risk estimate = 3.1), vitreous surgery with the graft (adjusted relative risk estimate = 2.0), and a repeat graft in the study eye (adjusted relative risk estimate = 2.0). Conversely, large graft wound size (adjusted relative risk estimate = 2.0). Conversely, large graft wound size (adjusted relative risk estimate = 2.9) and human leukocyte antigen (HLA)-A, -B incompatibility (adjusted relative risk estimate = 2.2) were associated with failures that followed an immune reaction. In this study, the authors support the clinical impression that corneal graft failures with and without a prior immune reaction are distinct phenomena. Enhanced surveillance in recipients with glaucoma and early intensive treatment of allograft reactions are recommended to improve the outcome of corneal grafts.

Corneal Transplantation in a Patient with Congenital Sensory Neuropathy

We describe penetrating keratoplasty for corneal scarring in a patient with congenital sensory neuropathy and repeated self-mutilation. This patient underwent a successful penetrating keratoplasty but suffered a series of postoperative complications necessitating three repeat grafts. Some of these complications were attributable to decreased corneal sensation while others were caused by self-mutilation. Since his last penetrating keratoplasty 4 years ago, this patient has had functional visual acuity.

Corneal Transplantation in a Patient with Congenital Sensory Neuropathy

We describe penetrating keratoplasty for corneal scarring in a patient with congenital sensory neuropathy and repeated self-mutilation. This patient underwent a successful penetrating keratoplasty but suffered a series of postoperative complications necessitating three repeat grafts. Some of these complications were attributable to decreased corneal sensation while others were caused by self-mutilation. Since his last penetrating keratoplasty 4 years ago, this patient has had functional visual acuity.

Twenty-Year follow-up of saphenous vein aortocoronary artery bypass grafting

The clinical records of our first 100 patients to undergo saphenous vein aortocoronary bypass grafting were reviewed. The procedures were performed between March 19, 1970, and March 30, 1972. The patient population included 84 men, and the mean age was 51.4 years. There were 12 patients with single-vessel disease, 36 with double-vessel disease, and 52 with triple-vessel disease, for an average of 2.4 involved vessels per patient. Fortyeight patients were judged to have diffuse atherosclerotic disease. Twelve patients had left main coronary artery stenoses. Each patient received an average of 1.8 saphenous vein grafts. Thirty-six patients underwent repeat coronary artery bypass grafting after an average of 132.8 months and received an average of 3.5 grafts. This resulted in cumulative reoperative rates of 5%, 14%, 27%, and 36% at 5, 10, 15, and 20 years, respectively. The 5-, 10-, 15-, and 20-year survival rates were 89.8%, 68.4%, 53.1%, and 40.8%, respectively. Survival was not significantly related to the cause of death, cardiac-related causes being predominant. There were no significant relationships between the length of survival and sex, the number of grafts received, or the presence of left main stenosis. Survival was inversely related to age at initial operation ( p = 0.046) as well as initial left ventricular end-diastolic pressure ( p = 0.033). Survival positively correlated with the occurrence of triple-vessel disease ( p = 0.031) and the presence of diffuse disease ( p = 0.0077). Survival correlated with the occurrence of repeat grafting ( p = 0.0079), the interval to repeat grafting ( p = 0.0001), and survival after repeat grafting ( p = 0.030), but again did not correlate with the operation received. The 5- and 10-year survival rates for repeat operation were 77.4% and 71.0%, respectively. Saphenous vein coronary artery bypass grafting in this era yielded a 41% 20-year survival. Cardiac-related events continued to account for the majority of all late deaths. Thirty-six percent of all patients and 53% of all long-term survivors underwent repeat operation. Repeat operation significantly influenced long-term survival.