Vein Patch Rupture Research Articles

Vein Patch Closure Using Below the Knee Greater Saphenous Vein for Femoral Endarterectomy Procedures is Not Always a Safe Choice.

BackgroundThe complication of vein patch rupture is well described after carotid patch angioplasty; however, there is a paucity of data about the safety of vein patch closure in the setting of femoral endarterectomy.Methods/resultsFrom May 2012 to May 2015, 115 femoral endarterectomies with patch closure were performed. A patch rupture occurred in three cases (2.6%) with a mortality rate of 66% (2/3). In all cases the greater saphenous vein below the knee was used as patch material.Discussion/conclusionVein patches, particularly from small calibre veins, should be excluded in femoral endarterectomy procedures as they pose a substantial risk of rupture.

Spontaneous Vein Graft Rupture after Infrainguinal Vascular Reconstruction: Report of Three Cases

We report three cases of spontaneous vein graft rupture within 2 weeks of infrainguinal vein bypass for limb salvage. Two of the three ruptures were in the distal vein graft and the last just beyond the proximal anastomosis. All were longitudinal slits in the vein with no proximity to branches or valves. Endovascular treatment failed in one patient. Surgical correction with graft salvage was possible in all three cases. This may be an ischemic injury analogous to carotid vein patch rupture, nonapparent trauma to the vein, or simply mechanical stress causing vein rupture with arterial flow.

Prosthetic patch remnants to treat infected arterial grafts

Purpose: Our previous experience with the traditional management of infected prosthetic arterial grafts, which included graft excision and vein patch repair of the involved artery, was complicated by a high incidence of vein patch rupture. This study assessed the treatment of infected prosthetic grafts with subtotal graft excision and oversewing of small graft remnants.Methods: During the last 20 years, we treated 53 wounds involving 45 infected prosthetic grafts in 42 patients by means of subtotal graft excision and oversewing of a residual 2-to 3-mm graft remnant (patch) at an intact arterial anastomosis. This technique was selectively used to maintain patency of small-diameter arteries (41 common femoral, five deep femoral, three axillary, two iliac, and two popliteal), which were critical for limb salvage or amputation healing. This strategy avoided difficult dissection of the underlying artery in scarred wounds and obviated the placement of a new patch in an infected field. Graft remnants were polytetrafluoroethylene in 51 cases and Dacron in two cases. Of the 45 grafts, 31 were occluded and 14 were patent. All infected tissue was widely debrided, wet-to-dry dressing changes were performed three times daily, and appropriate intravenous antibiotics were administered for at least 1 week. Secondary bypass grafting procedures were performed as needed to achieve limb salvage. The follow-up period in surviving patients averaged 32 months (range, 1 to 218 months).Results: No complications were directly attributable to prosthetic patch remnants in 92% of cases (49 of 53 cases). Six of 42 patients (14%) died during hospitalization (three of cardiac complications and three of sepsis with multiple organ failure). Two infected pseudoaneurysms developed 8 and 34 months after surgery, and two wounds failed to heal. Sixteen secondary bypass grafting procedures were necessary to achieve limb salvage. Patch oversewing led to limb salvage without the need for secondary revascularization in 26 other cases and to the successful healing of 10 amputated limbs when secondary revascularization was not possible.Conclusion: Prosthetic patch remnants are a useful adjunct that simplify management of infected prosthetic grafts, are associated with a low incidence of wound complications, and help maintain patency of essential collaterals to achieve limb salvage or heal an amputation.

Carotid endarterectomy saphenous vein patch rupture revisited: selective use on the basis of vein diameter.

The single major disadvantage of carotid endarterectomy (CEA) patch reconstruction with greater saphenous vein (GSV) is central patch rupture, which has a reported incidence of 0.5% to 4%. This is a prospective evaluation of the selective use of GSV for a CEA patch based on previously established vein diameter criteria. Between 1988 and mid-1995, 534 of 671 CEAs (80%) were reconstructed with GSVs that had a distended diameter > or = 3.5 mm. Thigh veins were used in all 252 women who underwent CEA. Of the 282 men who underwent CEA, 265 GSVs (94%) were harvested from below the knee and 17 from the thigh. During this period four thigh and 13 below-knee veins (3.2%) were rejected because the diameter was < 3.5 mm, and a synthetic patch was used instead. In 408 of the CEAs with GSV (76%) the vein rupture pressures and diameters were measured, the CEA geometry was measured, and the predicted CEA vein patch rupture pressures were calculated. No GSV patches ruptured in this series. This compares favorably with three patch ruptures in 239 previous CEAs when no vein diameter criteria was used (p = 0.03). This also compares favorably with a multicenter series of 13 GSV patch ruptures (0.73%) in 1773 CEAs (p = 0.03) and with a single-center series of eight ruptures (0.47%) in 1699 CEAs (p = 0.05). GSV diameters were 4.9 +/- 0.9 mm (mean +/- 1 SD); vein rupture pressures, 3.9 +/- 1.5 atmospheres; carotid bulb major axis diameters, 12.5 +/- 1.6 mm; carotid bulb maximum diameters of curvature, 14.2 +/- 2.2 mm; and CEA patch rupture pressures, 1.3 +/- 0.6 atmospheres (range, 280 mm Hg to 4 atmospheres). CEA vein patch rupture pressure correlates positively with vein diameter (p < 0.001, slope), but there is wide variability (correlation coefficient = 0.39). The 14 CEAs (3.4%) with predicted rupture pressures < 400 mm Hg were performed with veins 3.5 to 5.5 mm in diameter (mean, 4.2 mm), and all had carotid bulb major axis diameters > 12 mm (mean, 15.3 mm). Eight of these CEAs were reconstructed with thigh veins. Use of GSVs with a distended diameter > or = 3.5 mm for CEA patch reconstruction significantly reduces the probability of central patch rupture; however, a few CEAs reconstructed with veins > 3.5 mm in diameter and large carotid bulbs have predicted patch rupture pressures < 400 mm Hg. Because at times some veins will have rupture pressures lower than desirable, CEA reconstruction should be tailored to keep the carotid bulb major axis diameter < 13 mm.

Carotid endarterectomy saphenous vein patch rupture revisited: Selective use on the basis of vein diameter

Carotid endarterectomy saphenous vein patch rupture revisited: Selective use on the basis of vein diameter

Intraoperative Assessment of Carotid Endarterectomy: A Comparison of Techniques

Routine intraoperative imaging of the carotid artery following carotid endarterectomy can detect defects at the site of endarterectomy that may lead to neurologic morbidity. A number of methods have been used to evaluate the completed endarterectomy. In this prospective study we compared subjective methods of assessment (hand-held, continuous-wave Doppler imaging with audible interpretation of signals) and objective methods of assessment (duplex ultrasonography with color flow and digital subtraction arteriography) with respect to their ability to detect operative abnormalities. Fifty-three carotid endarterectomies were evaluated by means of all methods of assessment. Six patients had significant abnormalities in which the vessel was reopened and the abnormality confirmed. The sensitivity and specificity for detecting abnormalities for each method are, respectively: duplex ultrasonography with color flow, 100% and 100%; digital subtraction arteriography, 66% and 95.7%; and continuous-wave Doppler imaging with audible interpretation of signals, 16% and 97.8%. There was one (1.8%) operative carotid neurologic complication during the postoperative period and follow-up (stroke due to vein patch rupture on postoperative day 2). These data suggest that an objective rather than a subjective method of assessing carotid endarterectomy is more useful in detecting operative abnormalities and that duplex ultrasonography with color flow is as useful as digital subtraction arteriography.

Vein patch rupture after carotid endarterectomy

Controversy continues to surround the use of patch angioplasty after carotid endarterectomy. Vein patch rupture is considered to be an uncommon occurrence with an incidence of 0.4-4% 1-3 related to the use of long saphenous vein harvested from the ankle. A recent publication has suggested this can be avoided by using long saphenous vein from the upper thigh. However this case confirms that there is still a risk of rupture even when vein patches are taken from the upper thigh long saphenous vein.

Carotid Endarterectomy Complicated by Vein Patch Rupture

Carotid Endarterectomy Complicated by Vein Patch Rupture

Carotid Endarterectomy Complicated by Vein Patch Rupture

Carotid Endarterectomy Complicated by Vein Patch Rupture

Carotid Endarterectomy Complicated by Vein Patch Rupture

SAPHENOUS VEIN PATCH angioplasty has been used to improve the results of carotid endarterectomy by decreasing the incidence of postoperative occlusion and recurrent stenosis. A rare but potentially lethal complication of this technique is aseptic necrosis and rupture of the vein patch during the postoperative period. We report three cases of this phenomenon and review an additional 13 cases from the literature. This event generally occurs without warning 2 to 7 days postoperatively and may result in death or stroke. At reoperation, the central portion of the vein patch is necrotic, without evidence of infection. Technical considerations in the harvesting and preparation of these grafts are reviewed, as are the physical parameters predisposing certain vein patches to rupture. Saphenous vein harvested from the ankle has been linked to every reported case. Small diameter veins in particular appear to carry a higher risk of rupture.

Saphenous vein patch rupture after carotid endarterectomy

From January 1983 to September 1990, 2731 carotid endarterectomies were performed at The Cleveland Clinic. Patch angioplasty with autogenous saphenous vein was used for arteriotomy closure during 1691 (62%) of these procedures and was associated with eight postoperative ruptures (0.5%) of the central portion of the patch in seven patients. This complication occurred in three men and in four women (mean age, 69 years), all of whom were hypertensive and all but one were smokers. Two patients (29%) had diabetes. In each case of patch rupture the vein had been harvested from the leg distal to the knee. Although the harvest site could not be determined retrospectively for every patient in this series, no patch ruptures were encountered among 370 procedures for which it could be documented that the saphenous veins had been obtained from the groin. All ruptures occurred within 5 days of the primary operations (including four during the first 24 hours) and were urgently corrected by primary closure of the original arteriotomy in two cases and by replacement of the ruptured patch in the remaining six. Two (29%) of the seven patients either died or sustained a permanent neurologic deficit. Central rupture of a saphenous vein patch is a rare but devastating complication after carotid endarterectomy. Since vein harvested from the lower leg or ankle may be marginally more likely to rupture than proximal vein from the thigh or groin, it should not be used indiscriminately for carotid patch angioplasty.

Saphenous vein patch rupture after carotid endarterectomy.

From January 1983 to September 1990, 2731 carotid endarterectomies were performed at The Cleveland Clinic. Patch angioplasty with autogenous saphenous vein was used for arteriotomy closure during 1691 (62%) of these procedures and was associated with eight postoperative ruptures (0.5%) of the central portion of the patch in seven patients. This complication occurred in three men and in four women (mean age, 69 years), all of whom were hypertensive and all but one were smokers. Two patients (29%) had diabetes. In each case of patch rupture the vein had been harvested from the leg distal to the knee. Although the harvest site could not be determined retrospectively for every patient in this series, no patch ruptures were encountered among 370 procedures for which it could be documented that the saphenous veins had been obtained from the groin. All ruptures occurred within 5 days of the primary operations (including four during the first 24 hours) and were urgently corrected by primary closure of the original arteriotomy in two cases and by replacement of the ruptured patch in the remaining six. Two (29%) of the seven patients either died or sustained a permanent neurologic deficit. Central rupture of a saphenous vein patch is a rare but devastating complication after carotid endarterectomy. Since vein harvested from the lower leg or ankle may be marginally more likely to rupture than proximal vein from the thigh or groin, it should not be used indiscriminately for carotid patch angioplasty.

Vein Patch Rupture After Carotid Endarterectomy: A Survey of the Western Vascular Society Members

To determine the prevalence, demographics and morbidity of vein patch rupture, the authors polled members of the Western Vascular Society. Forty-eight surgeons (53% of the members) reported an experience with 23,873 carotid operations. A vein patch was used in 1,760 operations (7.4%), and rupture of the patch occurred in 13 patients (0.7%), 10 women and three men. Indications for the patch were a small artery in 10 patients and restenosis in three. Saphenous vein was used for all patches and was harvested from the ankle in 12 patients and from the groin in one patient. All ruptures occurred from a split in the vein patch. Hypertension was present in seven of the 13 patients. None of the ruptures were associated with infection. Two ruptures occurred on the first postoperative day, six on the second day, three on the third day, one on the eighth day, and one on the twenty-first day. Four patients died: airway obstruction (1), hemorrhagic cerebral infarction (1), and myocardial infarction (2) were the causes. Three had a stroke and survived, one had a retinal embolus, and five underwent reoperation without complication. Vein patch of the carotid artery is used infrequently by members of the Western Vascular Society. The incidence of rupture of the patch is low (0.7%), but when it occurs, there is significant mortality (30.7%), and morbidity (30.7%). Patients with a vein patch should be observed in the hospital for three days after endarterectomy because rupture demands immediate reoperation.

Material and structural characterization of human saphenous vein

Saphenous vein patch rupture after carotid endarterectomy is an infrequent but devasting complication. This study was undertaken to evaluate the material and structural properties of fresh human saphenous veins to understand the causes of this complication. Segments of saphenous veins were obtained from 22 patients from vein harvested during coronary artery bypass surgery. Ninety-three specimens, oriented in both circumferential (n = 45) and longitudinal (n = 48) directions, were prepared from the available vein segments for testing. Specimens were mounted on specially designed grips and then subjected to uniaxial tension testing. For each specimen the following material and structural parameters were determined: vessel diameter, tensile stiffness, failure and ultimate forces, and tensile modulus, failure stress, and strain. The physical properties of specimens evaluated in circumferential orientations were two to three times lower than when evaluated in longitudinal orientations and thus limit the inherent strength of the vein. The physical properties of circumferentially tested vein specimens were negatively correlated to age, female gender, diabetes, and hypertension. The data obtained in this investigation suggest that age, hypertension, as well as diabetes and gender may adversely influence the circumferential tensile strength of human saphenous veins used as patch grafts.