Dacron or ePTFE graft for above-knee femoropopliteal bypass reconstruction. A bi-centre randomised study.

BACKGROUND: The objective of this study was to compare polyester (Dacron) and expanded polytetrafluorethilene (ePTFE) grafts for above-knee femoropopliteal bypass. PATIENTS AND METHODS: Eighty five patients with disabling claudications or limb threatening ischemia suitable for above-knee femoropopliteal reconstruction were randomized into two groups. In the first group the surgery was performed using 8 mm Dacron graft, whereas the patients in the second group were operated using ePTFE grafts. RESULTS: The primary patency rates for Dacron and ePTFE were 100 %, and 88.37 % (p < 0.05), while secondary patency rates were 83.3 % and 75 % (p > 0.05) respectively. The early limb salvage rates for Dacron and ePTFE were 100 % and 97.7 % (p > 0.05). Early (30-day) complications (bleeding 2.38 % and 2.32 %; wound infection 11.9 % and 11.63 %) occurred in both groups with similar frequency (p > 0.05). The patients were followed up over a period of 6 to 12 months (mean 8.3 +/- 3.6 months). The overall mortality rate in the follow-up period was 2.38 % (one patient) for Dacron and 6.98 % (three patients) for ePTFE group (p > 0.05). Late graft infection was noted in three patients (7.1 %) in Dacron, and two patients (4.65 %) in ePTFE group (p > 0.05). Primary patency rates were not significantly influenced by obesity, diabetes, hypertension, hyperlipidemia, cigarette smoking, (p > 0.05). However, poor run-off (only one crural artery patent on preoperative angiography) significantly decreased patency of both grafts and favored the use of ePTFE graft (p < 0.05). CONCLUSIONS: This study confirms that both materials are suitable for above-knee femoropopliteal reconstructions. Above-knee femoropopliteal bypass does not have a good long-term prognosis in the presence of poor run-off.

Simultaneous surgical treatment of ruptured abdominal aortic aneurysm and acute carotid occlusive disease.

Combined rupture of abdominal aortic aneurysm and acute thrombosis of internal carotid artery is extremely rare but fatal combination resulting in high mortality rate. Presented case, shows successfully performed simultaneous surgery of ruptured abdominal aortic aneurysm and acute cerebrovascular insult caused by thrombosis of carotid artery in 81 year-old male. Post operative course was uneventfull. At 24 months follow up patient was in good condition, with full neurological recovery. Simultaneous surgical treatment of acute occlusive carotid disease and ruptured abdominal aortic aneurysm (RAAA) seems to be the only life saving procedure for this rare, but very complicated condition. To our knowledge, this is the first reported successful simultaneous surgical treatment of RAAA and acute thrombosis of internal carotid artery.

Aorto-caval fistulas: a review of eighteen years experience.

The operative treatment of 26 aorto-caval fistulas during the last 18 years is reviewed (24 male and two female patients; average of 65.3 year). Out of 1698 cases presenting an abdominal aortic aneurysm, 406 presented with rupture, and 26 had aorto caval fistula. In 24 cases (92.3%) it concerned an atherosclerotic aneurysm. One aneurysm with aorto-caval fistula was secondary to abdominal blunt trauma (3.8%), and one due to iatrogenic injury (3.8%). The time interval between first clinical signs of aorto-caval fistula and diagnosis, ranged from 6 hours to 2 years (average 57,3 days). Clinical presentation included congestive heart failure infive patients (11.5%), extreme leg edema in 13 (50.0%), hematuria in 2 (7.0%), renal insufficiency 2 (7.0%), and scrotal edema in six patients. Diagnosis was made by means of color duplex scan in eight patients (30.7%), CT in seven patients (27%), NMR in three patients (11.5%), and angiography in seven patients (27%). Most reliable physical sign was an abdominal bruit,present in 20 patients (77%). In ten patients (38.4%) correct diagnosis was not made prior to surgery. The operative treatment consisted of transaortic suture of the vena cava (25 pts-96.0%), and aneurysm repair. Five operative deaths occurred (19,2%), and for all of them it concerned a misdiagnosis. Cause of death was myocardial infarction (one patient-3.8%), massive bleeding (one patient-3.8%), MOF (two patients-7, 0%), and colon gangrene (one patient-3.8%). Follow-up period varied from six months to 18 years (mean 4 years and two months). Long term results showed a 96% patency rate. No postoperative lower extremity venous insufficiency nor pelvic venous hypertension was observed post-operatively.

Aorto-caval fistulas.

The surgical repair of 16 aorto-caval (A-C) fistulas (15 male and one female patient; average age of 61.3 years) is reviewed. Fourteen fistulas were caused by aneurysm's erosion, one by iatrogenic injury, while one followed abdominal blunt trauma. The interval from presumed occurrence to diagnosis ranged from 6 h to 2 years. The presence of an abdominal bruit (87.5%) was the most reliable physical finding. Congestive heart failure was prominent in three (18.7%) cases, while severe lower extremity edema in five (31.2%). Two patients (12.5%) had hematuria, two (12.5%) renal insufficiency, while four (25%) scrotal edema. The diagnosis was not recognized before the surgery in five (31.2%) cases. In all 16 cases after transaortic suture of the fistula, aortic reconstructions were performed. Four operative deaths (25%) occurred, in patients who were not correctly diagnosed before surgery. In one case the cause of death was massive bleeding, and in three MOFS. All other patients were followed from 1 to 17 years (mean 4 years and 2 months). All grafts are patent, and there is no lower extremity venous insufficiency or pelvic venous hypertension. Surgical repair of A-C fistulas is mandatory to prevent serious complications.

[The upper thoracic outlet vascular syndrome]. / Vaskularni sindrom gornjeg torakalnog otvora.

A 16 patients with 20 vascular TOS have been evaluated at the our Institute. Fourteen of them were female, and 2 male patients, with average age of 33.1 (18-44) years. 19 of them had congenital, and one acquired TOS after trauma at neck-shoulder region. 13 cases had arterial, and 7 venous TOS. In 10 cases a cause of TOS was cervical rib, in one scar tissue after clavicle fracture, while in 9 soft tissue anomalies. Eight cases with arterial TOS had a hand ischemia, one TIA and 5 periodical symptoms only during the arm hyperabduction. Two cases with venous TOS also had symptoms and signs during arm hyperabducrtion only, while five patients had axillary-subclavian deep venous thrombosis (DVT). All patients underwent CW-Doppler, Duplex-ultrasonographic and angiographic examination in normal position of the arm and during the hyperabduction. The four aneurysms of the subclavian artery, two poststenotic dilatation of the subclavian artery were found as well as one thrombosis of the axillary artery and 8 brachial artery embolism. The operative treatment consists from decompression and vascular procedure. A decompression procedure include 10 resections of the cervical rib, three transaxilary and 6 supraclavcular resection of the first rib, as well as one scalenectomy. A vascular procedures included 8 transbrachial thrombembolectomy and 4 resection and replacement of subclavian artery aneurysms. Four early complications were noticed: two partial pneumothorax, and two transiet medianus nerve paresis. The follow-up period was between one and six years (mean 3 years). In this period one (12.5%) late arterial occlusion was found. The vascular TOS is more rare than neurogenic, however in mostly cases requires surgical management.

Femoro-popliteal reconstructions: 'in situ' versus 'reversed' technique.

This study examined 191 patients with 'reversed' and 99 patients with 'in situ' femoro-popliteal bypass technique. There were 85 diabetic patients (44.5%) in the group with 'reversed' bypass, and 43 patients (43.43%) in the 'in situ' group. There were 152 (79.68%) smokers in the 'reversed' bypass group, and 80 (80.8%) in the 'in situ' group. The graft patency was confirmed immediately after operation using CW Doppler and then followed up after 1, 6, l2 months and annually thereafter. The statistical analysis was performed using Pearsons chi-square test, Fischer's test and 'Life table' statistic methods. The patients were followed from 3 to 10 yr after surgery. 'In situ' bypass showed better patency than the 'reversed' bypass technique but only in the second and tenth follow-up year (P < 0.05). Also, 'in situ' bypass proved to be better than 'reversed' only in patients with one patent crural artery (P < 0.01). Diabetes and preoperative smoking did not significantly affect late patency regarding this technique (P > 0.05). However, continuous smoking after the operation significantly decreased late patency rate in both groups of patients (P < 0.01). There was no significant difference in the early thrombectomy rate between groups with 'reversed' and 'in situ' bypasses (P > 0.05). The early thrombectomy, however, significantly reduced late patency rate in both groups (P < 0.01). Therefore we suggest 'in situ' bypass in cases with poor run off, small-calibre vein and 'long' bypass. Also, we consider important more frequent physical and Doppler ultrasonographic control in patients who had early thrombectomy.

[Aneurysms of the subclavian artery]. / Aneurizme potkljucne arterije.

INTRODUCTION: The Subclavian artery aneurysms are not a commonly seen peripheral aneurysm [1-5]-. We present the experience of the Institute of Cardiovascular Diseases of the Serbian Clinical Centre, Belgrade. PATIENTS AND METHODS: Eight cases of subclavian artery aneurysms are presented. There were 3 male and 5 female patients, average age 51 (32-65) years. Of them 3 aneurysms were of atherosclerotic origin, 4 developed due to thoracic outlet syndrome (TOS), and one developed after intra-arterial drug injection. More details about our cases are presented in Table 1. One of our patients had intra-thoracal aneurysm (Case 3), and 7 had extra-thoracal aneurysm (Figure 1). Two aneurysms appeared as an asymptomatic pulsatile mass in supraclavicular space, and two with compression in the brachial plexus (Figure 2). Our patient 3 manifested skin necrosis and haemorrhage in supraclavicular region (Figure 3). The other 3 patients manifested acute hand ischaemia due to partial aneurysmal thrombosis and distal embolization. In these patients all distal arterial pulses were absent (Figures 4 and 5). In patient 8, besides hand ischaemia, transitory ischaemic attack (TIA) with contralateral hemiparesis also occurred. The reason was microembolization of ipsilateral carotid artery due to retrograde thrombo propagation. The diagnosis was established by selective angiography of the subclavian artery, and in 4 patients Duplex ultrasonography was also used. All patients were treated surgically. In 7 patients supraclavicular approach to subclavian artery was used, and in case 3 we used a combined trans-sternal and supraclavicular approach. In 7 patients a complete aneurysmal resection was performed, and in patient 5 due to infection aneurysm was excluded by proximal and distal arterial ligations. In this case arterial flow was reestablished by extra-atomic carotid axillary bypass with saphenous vein graft. In three patients with TOS, after aneurysmal resections, end-to-end anastomosis was performed. In patient 2 in whom aneurysm was also caused by TOS, saphenous vein graft was used for reconstruction. In all 4 patients with TOS, some kind of decompressive procedure at the thoracic outlet was also performed (two cervical and two first-rib resections using supraclavicular approach). In 3 patients with atherosclerotic subclavian artery aneurysms, PTFE graft was used for reconstruction (Figures 6 and 7). RESULTS: One early postoperative complication occurred. It was embolism of the brachial artery which has been successfully treated by transbrachial embolectomy. The early patency rate was 88%. The patients were controlled using physical and Doppler ultrasonographic examinations 1, 3, 6, 12 months, and then every year postoperatively. The mean follow-up period was 3.6 (1-8) years. In that period one (13%) late complication was observed. It was thrombosis of the saphenous vein graft true aneurysm in our patient 2. This aneurysm was resected and replaced with PTFE graft. Postoperative histological examination showed connective tissue disorder of the vein wall. The long-term patency rate was 88%. DISCUSSION: In most cases the true subclavian artery aneurysms are of atherosclerotic origin [1-4, 6, 7, 12]. We had 3 such cases. TOS is also often caused by subclavian artery true aneurysms [5, 13-17]. We had 4 such cases. Fibromuscular dysplasia [1, 18], cystic idiopathic medionecrosis [1, 19, 20], infection [1, 21, 22] and congenital disorders [23, 24], are rare causes of subclavian artery true aneurysms. Subclavian artery pseudoaneurysms can develop after different reconstructive vascular procedures [5, 28-41]. Subclavian artery aneurysms can rupture, thrombosis, embolize, or cause symptoms by local compression [6, 12, 41]. We had two cases with compression on brachial plexus. The compression on the trachea, oesophagus, laryngeal nerve, ganglion stellatum were also described [6, 12, 25, 42, 43]. Most subclavian artery aneurysms present ischaemic symptoms of

[Pseudo-occlusion of the femoro-popliteal bypass]. / Pseudookluzije femoro-poplitealnog bajpasa.

INTRODUCTION: Pseudo-occlusion of femoro-popliteal/crural (F-P/Cr) bypass occurs when a patent graft is clinically indistinguishable from a thrombosed graft because of reduced flow [1]. The aim of this paper is the presentation of 24 new cases which, as far as we know, have not been published in Yugoslav medical literature. CASE REPORT: The group consisted of 20 men and 3 women (aged 28 to 71 years, mean 61.95) with 24 cases of "pseudo-occlusion" of the F-P/Cr bypass. More details are presented in Tables 1 and 2. Saphenous vein graft was used for the reconstruction in 19 patients, and Dacron in 5 subjects. "Pseudo-occlusion" was symptomatic in all 24 patients. Fifteen patients had pain at rest, seven presented disabling claudication, and 2 foot gangrene. The mean time interval between primary operation and occurrence of new symptoms was 25.41 (4-84) months (Table 2). In 15 patients control angiography showed hemodynamically significant lesions in inflow tract, and in 9 subjects in outflow tract. Of the total number of inflow tract lesions, there were 3 late occlusions of previously implanted aorto-femoral graft (1, 3 and 17, Table 1), and in other 21 patients lesions of the native aorto-iliac segment. In 8 patients with changes in outflow tract, a distal progression of atherosclerotic disease was found, while one patient (number 8) had intraoperative lesion of the popliteal artery with vascular clamp. All 24 patients were treated operatively. The early postoperative result was favourable in all 24 (100%) patients. Patients were followed-up from 3 months to 5 years (mean 29.625 months). In this period one (4.1%) late graft occlusion was followed by major limb amputation. Four (16.6%) patients died with patent graft. CONCLUSION: 1. Pseudo-occlusion of the F-P/Cr bypass occurs when a patent graft is clinically indistinguishable from a thrombosed graft because of reduced flow. 2. Pseudo-occlusion may be provoked by changes in inflow and outflow tract. 3. Pseudo-occlusion is not associated only with saphenous vein graft. 5. Recurrence of symptoms, loss of previously palpable distal pulses and reduction of Doppler indices in a previously patent F-P/Cr bypass graft, can indicate pseudo-occlusion. Early diagnosis provides a simple and safe treatment.

[Factors which affect long-term patency in femoro-popliteal bypass]. / Faktori koji uticu na udaljenu (kasnu) protocnost femoro-poplitealnog bajpasa.

INTRODUCTION: The aim of this study was to investigate how "run off", diabetes, cigarette smoking and early reinterventions influence long-term patency of the "reversed" and "in situ" femoro-popliteal (F-P) bypass grafts. PATIENTS AND METHODS: The study included 1991 patients with "reversed" F-P and 99 patients with "in situ" F-P bypass grafts operated on between 1988 and 1994. There were 153 (80.10%) male and 38 (19.90%) female patients in the group with "reversed" bypass and in the group with "in situ" bypass there were 78 (78.8%) male and 21 (21.2%) female patients. The average age of all patients was 59.04 (27-80) years. Eighty five (44.5%) patients in the group with "reversed" F-P bypass had diabetes mellitus and 43 (43.4%) in the group with "in situ" bypass. One hundred and fifty two (79.68%) patients in the group with "reversed" bypass were cigarette smokers and 80 (80.8%) in the group with "in situ" bypass. In Table 1 patients according to Fontain's classification of occlusive arterial disease are presented. On the basis of angiographic examination all patients were divided into four groups (with patent all 3 crural arteries, with patent 2 crural arteries, with patent one crural artery and without patent crural arteries) (Table 2). All patients were controlled using physical and Doppler ultrasonographic examinations immediately after the operation; after 1, 3, 6 months and then every year postoperativelly. In cases with suspected graft occlusion or any other complication, control angiography has also been carried out. Statistical analysis of the results was performed using chi 2 and Fisher's test. RESULTS: The patients were followed-up from 3 to 10 years. In cases with patent all 3 crural arteries there was no significant difference in long-term patency between "reversed" and "in situ" bypasses (Fisher's test, P = 0.66; p > 0.05) (Graph 1). In cases with patent two crural arteries, there was no significant difference between groups with "reversed" and "in situ" bypasses chi 2 = 0.25, p > 0.05) (Graph 2). The long-term patency was significantly better in the group with "in situ" bypass if only one crural artery was patent (chi 2 = 4.96, p < 0.05) (Graph 3). In cases with occluded all three crural arteries there was no significant difference in long-term patency between the two examined groups (Fisher's test, P = 0.29; p > 0.05) (Graph 4). There was no significant difference between groups with "reversed" and "in situ" bypasses in patients with diabetes mellitus (chi 2 = 0.01; p > 0.05) (Graph 5). There was also no statistically significant difference between the two examined groups regarding the preoperative cigarette smoking (chi 2 = 0.94; p > 0.05) (Graph 6). However, in both groups postoperative cigarette smoking showed a statistically significant decrease in long-term patency (chi 2 = 66.71; p < 0.01) (Graph 7). The early REDO operations statistically significantly decreased long-term patency in both groups (chi 2 = 34.89; p < 0.01) (Graph 8). The late graft occlusions were found in 60 patients with "reversed" and 23 patients with "in situ" F-P bypasses. Table 3 shows causes of late graft occlusions. CONCLUSION: In some cases with pure "run off" "in situ" bypass technique showed better long-term patency. We preferred this technique when "run off" was pure, when diameter of the saphenous vein was small, and when bypass was "long". Diabetes mellitus had no significant influence on long-term graft patency in both groups, as well as regarding preoperative cigarette smoking. However, postoperative cigarette smoking and early REDO operations, statistically significant by decreased long-term graft patency in both groups. The reason was that cigarette smoking was not permitted postoperatively, while in cases with early reinterventions physical screening and ultrasonographic examinations were necessary.