Autologous great saphenous vein tailored graft to replace an infected prosthetic graft in the groin.

The authors propose a technique using the autologous great saphenous vein to replace an infected prosthetic limb graft at the groin. The whole great saphenous vein is incised longitudinally and divided into 2 approximately equal segments, which are sewn side to side. The longitudinal edges of the resulting great saphenous vein are then joined and anastomosed side to side to form a conduit, whose caliber is twice the original vein's diameter. The authors have used this technique to replace 1 limb of a prosthetic aortofemoral bypass infected at the groin. After 5 years, the new venous conduit is patent, with no recurrent infection, dilation, or aneurysmal degeneration. If validated by further experiences, this might be an attractive alternative to restoring flow through clean tissue planes using extra-anatomic bypass or the femoral vein in the infected fields.

High-grade symptomatic and asymptomatic carotid stenosis in the very elderly. A challenge for proponents of carotid angioplasty and stenting.

BACKGROUND: Carotid angioplasty and stenting (CAS) is often considered as the preferred treatment for severe carotid occlusive disease in patients labelled as "high risk", including those aged 80 or more. We analyzed 30-day stroke risk and death rates after carotid endarterectomy (CEA) for severe symptomatic or asymptomatic carotid disease in patients aged 80 or more, by comparison with the outcome of CAS reported in the recently- published literature. METHODS: A retrospective review was conducted on a prospectively compiled computerized database of all primary CEAs performed by a single surgeon at our institution from 1990 to 2003. Descriptive demographic data, risk factors, surgical details, perioperative strokes and deaths, and other complications were recorded. RESULTS: In all, 1260 CEAs were performed in 1099 patients; 1145 were performed in 987 patients less than 80 years old, and 115 were performed in 112 patients aged 80 or more. There were 11 perioperative strokes in the 1145 procedures in the younger group, for a stroke rate of 0.8%, and no strokes in the 115 procedures in the older group. The death rates were 0% for the octogenarians and 0.3% for the younger group. CONCLUSION: The conviction that older age means higher risk needs to be revised. Patients aged 80 or more can undergo CEA with no more perioperative risks than younger patients. Proponents of CAS should bear this in mind before recommending CAS as the best therapeutic option for such patients.

Prospective randomized study on asymptomatic severe carotid stenosis and perioperative stroke risk in patients undergoing major vascular surgery: prophylactic or deferred carotid endarterectomy?

We compared the perioperative (30-day) stroke risk in asymptomatic patients with severe carotid stenosis who underwent carotid endarterectomy (CEA) before or after major vascular surgery. Seventy-nine patients with asymptomatic severe carotid lesion were randomly assigned to group I (n = 40) or group II (n = 39) to receive prophylactic CEA (within 1 week before major surgery) or deferred CEA (between 30 days and 6 months after major surgery), respectively. All procedures were eversion CEAs performed under deep general anesthesia and cerebral protection involving continuous electroencephalographic monitoring for selective shunting. There were no perioperative deaths or strokes relating to the major surgical procedure in either group. All group II patients underwent deferred CEA as planned (median 47 days, range 38-94) with no subsequent perioperative deaths or strokes. Two of these patients (5.1%) suffered a minor stroke, however, 65 and 78 days after their major surgical procedure, while awaiting carotid revascularization. Although data emerging from this analysis indicate that severe asymptomatic carotid disease may be safely postponed in patients undergoing major noncarotid vascular surgery, only a multicenter prospective study could determine the most appropriate management of this subset of patients.

Prospective randomized study on reversed saphenous vein infrapopliteal bypass to treat limb-threatening ischemia: common femoral artery versus superficial femoral or popliteal and tibial arteries as inflow.

PURPOSE: Use of inflow sources distal to the common femoral artery (CFA) for bypass to infrapopliteal arteries is a compromise measure when the length of the vein is not adequate. The purpose of this study was to compare the clinical outcome of vein infrapopliteal bypass arising from the CFA and from the distal superficial femoral or popliteal and tibial arteries in patients with limb-threatening ischemia. METHODS: Over 13 years, 160 vein infrapopliteal vein bypass procedures (160 patients) were randomized into 2 groups, 80 with inflow arising from the CFA (group 1) and 80 with inflow from below the CFA (group 2). Patency and limb salvage rates were assessed with the Kaplan-Meier method. All patients underwent graft surveillance at discharge and at 30 days and 6 months after surgery, then every 6 months thereafter. Follow-up ranged from 30 days to 127 months (mean, 49 months). RESULTS: Groups were similar with regard to age, sex, and most atherosclerotic risk factors. Gangrene as an indication for surgery was statistically more frequent in group 1 (73.7% vs 48.7%; P = .002), whereas nonhealing ulcer and rest pain were statistically more frequent in group 2 (respectively, 51.2% vs 25%; P = .001 and 46.2% vs 28.7%; P = .03). No patients died during the perioperative (30 days) period. At 1, 3, and 5 years patency and limb salvage rates were comparable between groups, tending toward significance for the 5-year primary patency rate (73% vs 57%; P = .08). CONCLUSIONS: In the absence of significant proximal disease, infrapopliteal revascularization arising distal to the CFA can ensure patency and limb salvage rates statistically similar to those with use of the CFA. Moreover, procedures arising distal to the CFA required fewer graft revisions to maintain patency of failing grafts.