Saphenous Bypass Research Articles

Un ulcère de jambe par artérite radique et radio-dermite: Revascularisation chirurgicale

A forty-four-year old man was hospitalized for diagnosis and treatment of a left leg ulcer which did not heal despite good compliance with a three-month medical regimen. Twenty years before he had undergone surgical curettage and radiotherapy (81 gy) for an osteosarcoma of the upper third of the left tibia. He was considered completely cured with regular findings. On examination he had a 5 X 7 cm deep ulcer with raised margins and no signs of infection, localized on the radiodermatitis on the medial aspect of his left leg. Arterial examination confirmed the left arteriopathy with absence of distal pulses; the Ankle Brachial Pressure Index was 0.69 and the foot TcPO 227 mmHg. Arteriography confirmed the localized left lesions with three distal popliteal and proximal arterial occlusions, all other arteries being strickly normal. Arterial and dermatological radiation leg ulcer was retained as the etiological diagnosis. As the ulcer was very painful, extensive and limited walking distance, surgical revascularisation was undertaken because endoluminal revascularization was impossible. A femoroperoneal saphenous bypass was performed with surgical incisions beyond the radiodermatitis area. Two months after a split skin graft, the ulcer was considered healed and the patency of the by-pass confirmed on duplex examination. This is the first case report of a successful distal by-pass performed for radiation arteritis and ulcer healing. Long-term follow up should be reported. (J Mal Vasc 2006; 31: 34-37).

Prospective Evaluation of the St. Jude Medical Aortic Connector for Aortic-to-Autologous Vessel Graft Anastomoses

: Evolving technologies of proximal anastomosis devices meet the endeavor of surgeons to minimize manipulation of the ascending aorta during surgical myocardial revascularization. The objective of this study was to compare the patency rate of the saphenous vein coronary bypass grafts in which the proximal anastomoses were performed with automatic connector devices to the suture technique. : From September 2002 through July 2003, 86 patients underwent coronary artery bypass grafting with at least 1 vein graft anastomosed to the ascending aorta with the Symmetry G2 connector. Six-month clinical and angiographic follow-up, including Core-Lab quantitative coronary angiography (QCA) and corrected TIMI frame count (CTFC), was performed. : Eighty patients had at least 1 connector successfully implanted. Freedom from MACE (cardiac mortality myocardial infarction and target vessel reintervention) was 72/80 (90%). Six patients underwent a target vessel reintervention on the connector grafts. Six-month (mean 193 ± 36 days) angiography patency rates for the connector grafts were 72/81 (88.89%), 37/40 (92.5%) in sutured grafts, and 60/62 (96.8%) in arterial grafts. By QCA, 64/65 (98.5%) patent connector-grafts were free from more than 50% stenosis (1 connector-graft with a 51% stenosis). CTFC showed 65/65 (100%) patent connector-grafts with nonrestrictive flow. : Saphenous vein grafts anastomosed to the aorta with the Symmetry G2 connector have early and midterm patency rates comparable to the conventional sutured anastomoses. These results support the efficiency of the second generation of symmetry aortic connectors.

Hepatic Artery Pseudoaneurysm: A Report of Seven Cases and a Review of the Literature

To analyze seven cases of hepatic artery pseudoaneurysm (HAP) encountered at our hospital and review the relevant literature. We searched the computerized medical record database from January 1, 1996, to September 1, 2003, to identify all cases of HAP, which we then reviewed in detail, examining etiology, findings, laboratory data, therapeutic intervention, complications, and outcome. We then compared these findings with those reported in the literature. There were five cases of HAP among 18,015 trauma and surgical admissions to the University of California Irvine Medical Center, representing an incidence of 0.03%. There were an additional two cases of HAP among 200 orthotopic liver transplants (OLT). The five HAPs not associated with OLT were preceded by blunt abdominal trauma, liver biopsy, pancreatic pseudocyst, and polyarteritis nodosa, in one patient each, and there was no apparent cause in one patient. Two patients were treated by ligation, and the patients with post-OLT HAP underwent resection and replacement with saphenous bypass grafts. Successful embolization was performed in the other three patients. Hepatic artery pseudoaneurysm is a rare but dangerous complication of both acute surgical and chronic injury to the hepatic artery. However, early diagnosis and intervention can result in an excellent long-term outcome.

Elevated levels of low-density lipoprotein cholesterol, homocysteine, and lipoprotein(a) are associated with the occurrence of symptomatic bypass graft disease 1 year following coronary artery bypass graft surgery.

Severe coronary artery bypass graft disease occurs at a rate of approximately 16%-31% within the first year of surgery. Clinical and laboratory variables, including postoperative lipid profiles closest to the 1-year follow-up, lipoprotein(a) levels, and homocysteine levels, were assessed as predictors of early (< or = 1 year) symptomatic coronary artery bypass graft disease. Of 77 living consecutive patients (from the practice of one cardiologist) who underwent bypass surgery, 60 were asymptomatic at 1 year, and 17 had developed recurrent symptoms and had an angiogram that confirmed >50% lesion in at least one saphenous bypass graft. Using multivariate analysis, the strongest predictors of early symptomatic coronary artery bypass graft disease within 1 year of bypass surgery were elevated levels of low-density lipoprotein cholesterol (>100 mg/dL) (odds ratio [OR], 8:1; p=0.034), homocysteine (>10 micromol/L) (OR, 8:1; p=0.019), and lipoprotein(a) (>30 mg/dL) (OR, 4:1; p=0.011). Male gender was associated with a reduced risk (OR, 1:9; p=0.01) of symptomatic graft disease within 1 year of surgery. The authors conclude that low-density lipoprotein, homocysteine, and lipoprotein(a) levels are associated with symptomatic coronary artery bypass graft disease at 1 year after surgery.

Thromboaspiration dans les syndromes coronaires aigus par le système RESCUE™

Interventional procedures associated with acute coronary syndromes or performed on saphenous bypass grafts frequently lead to embolic complications, resulting in no-reflow phenomenon, side-branch occlusion, or peri-procedural infarction. The RESCUE™ thrombo-aspiration system was used in 19 percutaneous coronary interventions. After initial use of the aspiration device, 81% of procedures were followed by stent deployment. TIMI flow 2 or higher was present in 42% at the beginning of the procedure and in 95% at the end. In-hospital MACE rate was 4.76%. This relatively user-friendly technique appears rapid and efficacious in the case of visible intracoronary thrombus.

Association between coronary artery atherosclerosis and the intima-media thickness of the common carotid artery measured on ultrasonography.

To assess whether the intima-media thickness of the common carotid artery of patients with coronary artery disease is greater than that of individuals without that disease. Case-control prospective study of prevalence assessing the thickness of the intima and media layers of 29 patients with coronary artery disease and 29 individuals without that disease by using ultrasonography of the carotid arteries. Diabetic patients and those with peripheral artery and cerebral vasculopathies were excluded from the study. The mean age was 51 +/- 7.5 years. Fifty-five per cent of the patients were males. Acute myocardial infarction was present in 62%; cardiac catheterization in 72%; saphenous bypass in 5%; and coronary angioplasty in 24%. The intima-media thickness of the common carotid artery in case patients and in control patients was, respectively, 0.81 +/- 0.25 mm and 0.62 +/- 0.18 mm (P=0.001). Intima-media thickness of the common carotid artery was significantly greater in patients with coronary artery disease.

A spontaneous rupture of the external iliac vein revealed as a phlegmasia cerulea dolens with acute lower limb ischemia: Case report and review of the literature

We reported a case in a previously healthy 45-year-old woman of spontaneous rupture of the left external iliac vein, which was revealed as a phlegmasia cerulea dolens with acute lower limb ischemia. A tear on the anterior surface of the vein was discovered during an emergency laparotomy, and the rent was repaired successfully. Twenty-four hours later, the leg swelling increased, and at the reexploration, the common iliac vein was found to be occluded by an organized thrombus as the result of a well-endothelialized membranous band (Cockett or May-Turner syndrome). A Palma-Dale operation (crossover saphenous bypass grafting) was performed secondarily. The swelling in the leg diminished slowly, and the patient was discharged 10 days later with an oral anticoagulant therapy and elastic stockings. (J Vasc Surg 2002;35:999-1002.)

Successful Angioplasty of Radiation-induced Iliofemoral Artery Stenosis: a Case Report

Introduction saphenous vein graft 6 months later, with a good result. Arterial injury secondary to radiotherapy is uncommon but well documented in the medical literature. It is generally accepted that surgery is the primary mode of treatment and there are very few documented cases of successful balloon angioplasty Discussion of the iliofemoral vessels in the medical literature. We report this case with the longest documented interval The age of patients presenting with radiation induced of 25 years between exposure to radiation and preiliofemoral lesions ranges from 50 to 56 years and sentation. these lesions cannot be histologically or biochemically distinguished from normal atherosclerosis. It is quite probable that the incidence is underestimated because when such patients present symptoms may be attributed to atherosclerotic disease rather than raCase History diation. Our patient was only 26 years old with no family history of early onset atherosclerotic disease A 26-year-old man presented with a 6 month history of left sided calf claudication and no palpable pulses and his lesion was focal. He smokes approximately 10 cigarettes per day, and hypertension, cigarette smoking in that limb. He had previous pelvic radiotherapy at age 16 months for an embryonic bladder sarcoma and and hyperlipidaemia act synergistically with radiation. It was also interesting that the accompanying veins had a subsequent cystectomy. An angiogram revealed marked attenuation of the left external iliac with ocdid not show any damage and veins are known to be more radioresistant than arteries. clusion of the distal end of this vessel that extended down to the level of the origin of the profunda femoris. Radiation delays wound healing and causes perivascular fibrosis which makes surgery more difficult. Collateral vessels reconstituted the superficial femoral artery and on the right side all the vessels appeared In our case our patient responded well to the initial angioplasty but returned with stenosis of the proximal normal. He underwent a successful open balloon angioplasty superficial femoral artery, which was most likely a fibrotic reaction to the patch. This was treated with a of the left external iliac and femoral arteries and the femoral artery was closed with a dacron patch. Eight reverse saphenous vein femoral-popliteal bypass with good result. months after the balloon angioplasty, he presented with left calf claudication. An angiogram confirmed Angioplasty in our case avoided an aorto-bifemoral bypass, which has a significantly higher morbidity. It patency of the previously angioplastied segment but revealed stenosis of the proximal superficial femoral was quite unexpected for the patient to respond so well to angioplasty 25 years after the initial insult. We artery. He had a dacron patch angioplasty and surgical endarterectomy but his symptoms did not improve believe that in cases like this, angioplasty should be considered as the primary mode of treatment. and had a left femoral-popliteal bypass using a reverse

Long term outcome after coronary stent implantation: a 10 year single centre experience of 1000 patients

OBJECTIVETo describe the long term clinical outcome (up to 11 years) after coronary stenting.DESIGNA single centre observational study encompassing 1000 consecutive patients with a first stent implantation (1560 stents) between...

Avaliação imediata da troponina I cardíaca em pacientes submetidos à revascularização do miocárdio

O presente trabalho foi desenvolvido com o objetivo de determinar o comportamento evolutivo imediato e o valor prognóstico em termos de sobrevivência tardia, da dosagem sérica de troponina I em pacientes submetidos a operações cardíacas para revascularização miocárdica. Foram analisados 108 pacientes, não selecionados, sendo 85 (78,7%) do sexo masculino, submetidos à operação de revascularização do miocárdio com ou sem auxílio de circulação extracorpórea, no período de dezembro de 1996 a dezembro de 1997. O método empregado na dosagem da troponina I foi o da Quimioluminiscência, em equipamento Acess da Sanofi-Pasteur. Foram feitas dosagens no pré-operatório, logo na chegada na Unidade de Terapia Intensiva, no primeiro e no segundo dia de pós-operatório, adquirindo-se como normais valores abaixo de 0,1 nanogramas por mililitro (ng/ml). Foram estabelecidos níveis de corte para avaliação prognóstica. Os pacientes foram avaliados pós-operatoriamente, registrando-se a evolução em meses, com vistas à determinação das taxas de sobrevivência. A dosagem de troponina I em pacientes submetidos a operações de revascularização miocárdica mostrou comportamento evolutivo agudo característico, com importante elevação dos níveis séricos no primeiro dia de pós-operatório. Pacientes operados com auxílio de circulação extracorpórea (CEC) mostraram níveis significativamente mais elevados, mas não houve correlação com tempo de isquemia ou tempo de CEC, sugerindo que a elevação da troponina I seja decorrente de sofrimento miocárdico específico (obstrução coronária, oclusão de ponte, etc.) e não decorrente da CEC propriamente dita. Foi ainda possível determinar que os níveis de corte estabelecidos separam pacientes com mau prognóstico, uma vez que valores acima de 2,5 ng/ml no primeiro dia de pós-operatório levaram a taxas de mortalidade de 33% a 50% em tempo máximo de seis meses de seguimento. A troponina I eleva-se em pacientes submetidos a operações de revascularização miocárdica, traduzindo sofrimento celular mesmo nos casos sem emprego de circulação extracorpórea. Valores de troponina I em torno de 2,5 ng/ml no primeiro dia de pós-operatório devem alertar para a necessidade de medidas diagnósticas ou terapêuticas mais agressivas.

Pathology of restenosis in saphenous bypass grafts after long-term stent implantation.

The implantation of saphenous vein grafts on the coronary arterial tree eventually leads to graft narrowing, which can be treated by the implantation of intravascular stents. However, long-term restenosis after stent implantation occurs in at least 30% of cases. Ten saphenous bypass grafts, in which a total of 12 stents had been implanted for an average of 32 months, were retrieved at least 10 months after implantation for angiographic diagnosis of reocclusion or severe restenosis. The metal struts were removed after macroscopic inspection of the vein, and the grafts were examined by light microscopy. Angiography revealed total occlusion in 9 stents and severe narrowing in 3. Pathologic examination revealed graft occlusion due to cellular hyperplasia in 4 cases and to recent thrombus formation in 5. Progression of atherosclerotic plaque was the cause of restenosis in the 3 severely narrowed grafts. In 2 of 5 grafts implanted with Palmaz-Schatz stents, the metallic struts had induced a local inflammatory reaction. Therefore, the long-term reocclusion of saphenous bypass grafts after stent implantation may be due to atherosclerotic plaque or fibromuscular hyperplasia. However, thrombus formation may still occur several years after implantation. In specific cases, stent implantation also induces inflammation around the stent struts.

Long-term angiographic follow-up of occluded saphenous bypass grafts treated with prolonged urokinase infusion.

We report on 10 occluded saphenous vein bypass grafts in nine patients treated with prolonged urokinase infusion. Our purpose was to evaluate the patency of these grafts during long-term follow-up. We retrospectively analyzed consecutive patients treated at a single center. All patients had angiography 0.25 to 54 months after treatment. Results indicated that clot lysis was achieved in all grafts with urokinase infusions of 1,790,000 to 25,920,000 units given over 17 to 108 hours. In two grafts there was no filling of the distal native vessel and in one, a 50% stenosis with ulceration remained. There was a progressive loss of graft patency over the first 18 months, but 50% of the grafts that were opened with prolonged urokinase infusion remain patent. Long-term patency depends upon successful opening without residual obstruction and with good flow into the distal native vessel.

Long‐term angiographic follow‐up of occluded saphenous bypass grafts treated with prolonged urokinase infusion

Long‐term angiographic follow‐up of occluded saphenous bypass grafts treated with prolonged urokinase infusion

Some Popliteal Aneurysms are Congenital

Although the majority of popliteal aneurysms are of atherosclerotic origin and are discovered in patients aged more than 50, the aetiology of a small minority may be attributed to arterial trauma, septic disruption, Behçet's disease, a medial fibromuscular dysplasia, or popliteal entrapment. The aim of this study was to propose a possible congenital origin for popliteal aneurysms without evidence of any other aetiology. A retrospective review of five younger patients (aged 20–45 years) with seven non-atherosclerotic popliteal aneurysms was performed. In patient nos 1 and 2, histological examination showed that the arterial wall had been replaced by an abundant collagenic tissue. After replacement by a saphenous bypass graft, these patients did well with a follow-up ranging from 1 to 15 years. Patient no. 3 was not operated on because of a symptomless occlusion of the tibial and peroneal arteries, and remains well 10 years later. Patients nos 4 and 5 were treated with a saphenous bypass graft. The last patient also had associated bilateral congenital anomalies of the division of the popliteal arteries. In the absence of any evidence of any classical aetiology, particularly fibromuscular dysplasia and popliteal entrapment, a congenital aetiology is proposed in aneurysms diagnosed in younger patients. The complex composition of the popliteal artery, being composed by an association of three original segments, may induce a fragility of the arterial wall that may be responsible for aneurysmal deterioration as well as abnormal branching or popliteal artery entrapment. These aneurysms are associated with the same risk of thrombosis as atherosclerotic aneurysms and therefore, they should be subjected to the same therapeutic considerations.

Some popliteal aneurysms are congenital

Although the majority of popliteal aneurysms are of atherosclerotic origin and are discovered in patients aged more than 50, the aetiology of a small minority may be attributed to arterial trauma, septic disruption, Behçet's disease, a medial fibromuscular dysplasia, or popliteal entrapment. The aim of this study was to propose a possible congenital origin for popliteal aneurysms without evidence of any other aetiology. A retrospective review of five younger patients (aged 20-45 years) with seven non-atherosclerotic popliteal aneurysms was performed. In patient nos 1 and 2, histological examination showed that the arterial wall had been replaced by an abundant collagenic tissue. After replacement by a saphenous bypass graft, these patients did well with a follow-up ranging from 1 to 15 years. Patient no. 3 was not operated on because of a symptomless occlusion of the tibial and peroneal arteries, and remains well 10 years later. Patients nos 4 and 5 were treated with a saphenous bypass graft. The last patient also had associated bilateral congenital anomalies of the division of the popliteal arteries. In the absence of any evidence of any classical aetiology, particularly fibromuscular dysplasia and popliteal entrapment, a congenital aetiology is proposed in aneurysms diagnosed in younger patients. The complex composition of the popliteal artery, being composed by an association of three original segments, may induce a fragility of the arterial wall that may be responsible for aneurysmal deterioration as well as abnormal branching or popliteal artery entrapment. These aneurysms are associated with the same risk of thrombosis as atherosclerotic aneurysms and therefore, they should be subjected to the same therapeutic considerations.

Use of the In-Situ Lesser Saphenous Vein Bypass from Popliteal to Peroneal Artery

Lesser saphenous vein grafts have become an important element in limb salvage surgery. Their location frequently dictates that the graft be translocated for use. This incurs the disadvantages of ischemia and increased manipulation of the graft and loses the advantages of an in-situ bypass. The use of the lesser saphenous vein as an in-situ graft for tibial artery reconstruction offers the advantages of reduced vein graft injury and improved patency. Technical requirements for an in-situ lesser saphenous bypass include that graft inflow be based on the popliteal artery, the vein length suffice to reach the target artery, and the runoff vessel have adequate size, length, and collateral connections to allow reasonable likelihood of success. The surgical approach requires the patient be in a prone position allowing a posterior longitudinal incision in the leg. Exposure of the distal portion of the peroneal artery is accomplished by separating the peroneus brevis and flexor hallucis longus. The peroneal artery is then visualized when the fibular attachments of the flexor hallucis longus are divided. Our experience indicates that the lesser saphenous vein may be successfully used as an in-situ conduit for bypass to the distal peroneal artery. Technical innovations such as flexible valvulotomes with detachable heads, and tourniquet control of bleeding facilitate the operation. A posterior approach to the popliteal and crural arteries affords the ability to use the lesser saphenous vein as an in-situ bypass.

Removal of Thrombus from Aortocoronary Bypass Grafts and Coronary Arteries Using the 6Fr Hydrolyser

This study evaluates the feasibility and safety of a 6Fr hydrodynamic thrombectomy catheter, the Hydrolyser, in native coronary arteries and aortocoronary bypass grafts. With use of a conventional contrast injector, saline solution is injected into the narrow lumen of the catheter which makes a 180° bend at the tip. The resultant high-velocity jet (150 km/hour) is directed over a sidehole near the tip into a wide exhaust lumen. As a consequence of the Venturi effect, thrombus is sucked into that sidehole, fragmented, and removed through the wide exhaust lumen into a collection bag. Thirty-one thrombotic lesions were treated in 31 patients. The culprit vessel was a venous graft in 21 patients (15 with Thrombolysis in Myocardial Infarction Trial [TIMI] grade 0 or 1 flow) and a coronary artery in 11 patients (9 with grade 0 or 1 flow). Twenty-six patients had angina New York Heart Association functional class III or IV heart failure and 5 an acute myocardial infarction. In 26 patients, Hydrolyser therapy was the primary treatment, whereas in 5 patients coronary angioplasty preceded Hydrolyser therapy. In 1 patient the Hydrolyser could not reach the lesion. Thrombus was removed in 29 of the 31 patients. Successful reperfusion (TIMI grade 2 or 3 flow) by Hydrolyser therapy alone was achieved in 14 of the 24 patients with TIMI grade 0 or 1 flow before the procedure. Adjunctive therapy (coronary angioplasty, stent, or thrombolysis) was performed in 28 of the 31 patients. At the end of the total procedure 24 patients had TIMI grade 3 flow. Distal embolization during thrombectomy occurred in 2 patients, which led to a non-Q-wave infarction in 1. No patient died or needed emergency coronary bypass due to the Hydrolyser procedure. Thus, thrombectomy using the 6Fr Hydrolyser is feasible and was performed safely in 31 patients.Feasibility and safety of a new hydrodynamic thrombectomy device, the Hydrolyser, was evaluated in thrombus-containing coronary arteries or saphenous bypass grafts in 31 patients. Thrombus could be removed in 29 of the 31 vessels. There were no major adverse events related to the Hydrolyser.

Long-term patency of metallic stents in a 20-year-old saphenous vein coronary bypass graft

Long-term patency of metallic stents in a 20-year-old saphenous vein coronary bypass graft

Internal Carotid Artery Sacrifice for Radical Resection of Skull Base Tumors

When dealing with skull base tumors that encase the internal carotid artery (ICA), the surgeon must decide between ICA preservation and incomplete tumor resection, or radical resection with ICA sacrifice. In our experience with more than 300 anterior skull base tumors, the ICA was sacrificed in only 10 patients. These tumors were malignant, except for one meningioma that occluded the ICA and produced translent ischemic symptoms. All patients had the ICA resected with the tumor, and all patients underwent revascularization (cervical ICA-MCA saphenous bypass, n = 4; cervical-to-supraclinoid bypass, n = 1; petrous-to-supraclinoid bypass, n = 3; bonnet bypass, n = 2). This small patient series reflects our practice of preserving the ICA whenever possible. We recommend preserving the ICA with benign tumors because they do not invade the artery, or do so only to a limited extent. In addition, similar rates of tumor recurrence are seen after aggressive resection with or without ICA sacrifice. In contrast, we recommend radical tumor resection and sacrifice of the ICA with malignant tumors because they directly threaten the integrity of the ICA and the patient's survival. The ICA should not be considered a limitation to radical tumor resection because the ICA can be reconstructed safely with an appropriate bypass procedure.

Revascularization and aneurysm surgery: current techniques, indications, and outcome.

Revascularization is an important component of treatment for complex aneurysms that cannot be directly clipped and instead require parent vessel occlusion. A consecutive series of 61 patients with 63 aneurysms requiring cerebral revascularization is presented. Aneurysms were located along the petrous internal carotid artery (ICA) (n = 5), the cavernous ICA (n = 16), the supraclinoid ICA (n = 12), the middle cerebral artery (n = 17), the anterior cerebral artery (n = 4), the vertebral artery/posterior inferior cerebellar artery (n = 5), and the midbasilar artery (n = 4). Aneurysms were treated by direct clipping (n = 8), trapping (n = 28), proximal vessel occlusion (n = 9), distal vessel occlusion (n = 1), excision (n = 15), and thrombotic occlusion (n = 2). Revascularization was performed with petrous to supraclinoid ICA bypass (n = 12), superficial temporal artery to middle cerebral artery bypass (n = 15), superficial temporal artery to middle cerebral artery bypass with saphenous graft (n = 5), superficial temporal artery to superior cerebellar artery bypass (n = 4) long saphenous bypass (n = 11), in situ bypass (n = 3), and primary reanastomosis (n = 13). Fifty-seven patients (93%) had good outcomes, and one patient died (surgical mortality, 2%). This experience demonstrates that revascularization can be performed with low morbidity and mortality. We think that the cumulative risks of not performing revascularization in patients who tolerate ICA balloon occlusion exceed the surgical risk of revascularization. We therefore favor revascularization in patients with complex aneurysms treated by surgical arterial occlusion.