Axillopopliteal bypass for limb salvage.

Forty-one axillopopliteal bypass grafts have been placed in 30 patients for limb salvage in the past 12 years. The mean patient age was 65.6 years; 8 were women; 19 smoked; and six had diabetes. Sixteen grafts were straight axillopopliteal bypass grafts, and 25 were sequential axillopopliteal bypass grafts. Cumulative life-table primary patency rates at 1, 2, and 3 years were 70%, 56%, and 43%, respectively; secondary patency rates were 73%, 57%, and 50%, respectively. Corresponding limb salvage rates were 86%, 69%, and 69%, respectively. Ringed polytetrafluoroethylene (PTFE) graft patency at 3 years was 61% versus 40% for unsupported PTFE grafts (p = 0.35). Ringed PTFE axillofemoral grafts with sequential femoropopliteal saphenous vein grafts had a 3-year patency of 67%. Graft patency was restored in 25% of occluded grafts by thrombectomy and in 80% of occluded grafts by thrombectomy with graft revision (p = 0.21). Cumulative 3-year patient survival was 48%. The 30-day operative mortality rate was 20%; patients operated on for graft infection had a 30-day operative mortality rate of 36%. The data support the use of axillopopliteal bypass for limb salvage when standard revascularization techniques are contraindicated. Long-term patency is enhanced by use of externally supported PTFE and sequential femoropopliteal saphenous vein.

Total parathyroidectomy and autotransplantation in hyperplasia of the parathyroid gland.

Hyperparathyroidism caused by multiple-gland hyperplasia has traditionally been treated by subtotal parathyroidectomy. Excellent results have been reported by some, particularly in primary hyperparathyroidism, but other have reported a significant incidence of recurrent hyperparathyroidism. Since 1979, we have chosen to avoid the possibility of remedial exploration of the neck and its attendant risks by treating all patients with primary and secondary hyperplasia with total parathyroidectomy and heterotopic autotransplantation. A total of 20 patients were studied. There were no failures of grafts and no operative complications. We conclude that this procedure is a reliable and safe alternative in the treatment of primary or secondary hyperplasia of the parathyroid gland.

Late occurrence of aortoenteric fistula. After removal of a prosthetic graft.

Aortoenteric fistula is an uncommon but devastating complication of aortic surgery. The authors present a case of aortoenteric fistula occurring several years after resection of an aortic prosthesis that had not previously been involved in fistula formation. The pathophysiology and clinical evaluation of aortoenteric graft fistula are discussed.

In vitro simulations of peritoneal dialysis: a systematic approach to demonstrating isonatric contraction with sodium dextran sulfate.

Two sodium dextran sulfates (DS) were investigated as possible osmotic agents for use in peritoneal dialysis using an in vitro model. Initial studies with a medium molecular weight DS (Mn = 4.000) showed that sodium clearances were higher than water clearances and that both are linear functions of the concentration of polymer. In another series of studies using a low molecular weight DS (Mn = 5,000), it was found that sodium clearances decrease linearly as sodium chloride (NaCL) is added to the initial dialysate solution with only a slight increase in ultrafiltration. By plotting sodium clearances and water clearances as functions of added NaCl at constant polymer concentration, the point at which sodium clearance and water clearances are equal can be determined and, at that point, isonatric contraction can be demonstrated in the vitro model.