The value of adjunctive vein patches to improve the outcome of femorodistal polytetrafluoroethylene bypass grafts.

PURPOSE: A non-randomised comparative study was carried out to determine whether an interposition vein patch improves the long-term outcome of infrapopliteal and distal PTFE bypass grafts. PATIENTS AND METHODS: A prospective study (1992-1999) was carried out between 2 groups of patients. The first group comprised 86 patients undergoing the same number of femoropopliteal or infrapopliteal bypass procedures between March 1992 and February 1999 at our institution. PTFE with modified interposition vein patch was used as bypass graft. The second group comprised 191 patients who received 216 autogenous vein bypass grafts in the same period. The third group consisted of 94 patients from a retrospective study between 1985-1992, in whom PTFE bypass procedures without interposition vein patches had been performed. The indication for surgery was critical lower limb ischemia in all groups. Primary, secondary and limb salvage rates were calculated using the life-table method. The life tables were compared with the log-rank test. RESULTS: Five-year primary, secondary and limb salvage rates for PTFE with interposition vein patches were 53.4%, 60.7% and 68% for below-knee popliteal, and 29.5%, 35.5% and 41% for infrapopliteal bypass grafts, respectively. Five-year primary, secondary and limb salvage rates for autogenous vein grafts were 78.9%, 82.3% and 84.2% for below-knee popliteal, and 51%, 54.7% and 75% for infrapopliteal bypass grafts, respectively. Five-year primary, secondary and limb salvage rates for PTFE grafts without interposition vein patches were 29.7%, 37.8% and 43.6% for below-knee popliteal, and 6.9%, 9.2% and 14.7% for infrapopliteal bypass grafts, respectively. Statistical analysis showed a significant difference in primary, secondary and limb salvage rates between the groups. CONCLUSION: The results of our study indicate that autogenous vein still remains the graft of choice for below-knee and infrapopliteal bypass reconstruction. Their long-term patency and limb salvage rates were significantly better compared with PTFE grafts, with or without interposition vein patches. When adequate autogenous vein is not available, the interposition of a vein patch considerably improves the long-term outcome of PTFE bypass grafts.

Role of arteriovenous shunting in venous ulcers--therapeutic implications.

Although the presence of arteriovenous communications in patients with chronic venous ulcers has been confirmed in several studies, their role in the pathogenesis of venous ulcers is still uncertain. They possibly do play an important role in the aetiology of chronic venous insufficiency. There is also substantial evidence to suggest that arteriovenous communications develop as a result of chronic venous hypertension. The question raised in this pilot study was whether the importance of arteriovenous shunts in the genesis of venous ulcer disease is such that their obliteration might lead to long-term healing. This clinical study was also designed to determine whether therapeutic microembolization of nutritive arterial branches to arteriovenous fistulas, found in patients with venous ulcers, facilitates healing of venous ulcers resistant to previous conservative and/or classical surgical treatment. From 1997 to 1999, 34 patients (22 women and 14 men, mean age 51.3 years) with chronic venous ulcer resistant to classical treatment were included in the study. Arteriovenous shunting was demonstrated by digital subtraction angiography in 31 patients (31/34 = 91%). The embolization procedure of muscular arterial branches feeding the arteriovenous shunts with microspirals and microparticles led to ulcer healing in 13 patients (13/31). The results suggest that the role of arteriovenous shunting in chronic venous ulceration resistant to classical treatment is more important than previously suggested, and that their microembolization might lead to complete healing.

Carotid body tumour surgery. A report of seven patients.

The purpose of the present paper is to analyse diagnostic and therapeutic aspects of carotid body tumours. Seven patients with carotid body tumour underwent surgery at our department between 1982 and 1998. All of them had an asymptomatic cervical lateral mass. The preoperative evaluation included angiography in 7 patients, duplex scanning in 2 patients and computed tomography in one patient. Tumour excision was performed in 5. Carotid artery resection with the tumour was required in 2 patients and in both, interposition of a 5-mm polytetrafluoroethylene graft was performed. During the resection, temporary carotid shunt was required in one patient. Perioperative transcranial Doppler was used once; the use of a shunt during carotid artery resection was not required in the second case. All tumours were identified as carotid paragangliomas without evidence of malignancy. There was no mortality and no hemiplegia. After surgery, temporary cranial nerve dysfunction was noted in 2 cases. In the follow-up period of 2 to 14 years (mean, 7 years), no recurrent disease occurred. Patency of the grafts was good at 4 and 7 years after carotid artery reconstruction. We conclude that with non-invasive investigation and arteriography it is possible to obtain an early and precise diagnosis. The decision to perform simple tumour excision or additional arterial resection is based on diagnostic preoperative as well as intraoperative evaluation of the individual tumour. As demonstrated in our cases, after resection of the internal carotid artery a polytetrafluoroethylene graft may be used for carotid reconstruction. Early surgery is recommended because it minimises the risk of complications associated with large tumours.

Surgical aspects of fusiform and saccular extracranial carotid artery aneurysms.

The purpose of this paper is to analyse surgical aspects of aneurysms of the distal extracranial internal carotid artery. Nine cases of extracranial carotid artery aneurysm are reported. Five were fusiform, located at the carotid bifurcation, and four were saccular, confined to the internal carotid artery. An end-to-end plication technique and Dacron patch angioplasty were employed for all fusiform aneurysms. In three saccular lesions, resection and 4-mm polytetrafluoroethylene (PTFE) graft interposition were carried out. In one case with a high lesion, ligation of the carotid artery was performed. Ligation resulted in severe postoperative stroke and fatal outcome. One patient with a saccular lesion developed a transient ischaemic attack after the operation. In other patients no central neurological deficit was produced by the surgery itself. Transient cranial nerve damage occurred in four patients (two hypoglossal nerve: two superior laryngeal nerve). As demonstrated by these cases, synthetic material may be used in restoration of the carotid artery. It is concluded that, according to type, location of the aneurysm and adequacy of contralateral cerebral blood flow, selective management is necessary.

Profunda femoris revascularization in limb salvage.

A retrospective study of 282 profunda femoris artery reconstructions between 1971 and 1981 with follow-up at least two years in 212 (75.1%) is presented. Arteriographic evaluation was performed in 92 cases. Stages III and IV were the indication for revascularization in 86% of cases. An inflow correction was necessary in 60.3% of profunda reconstructions. Factors that bear on the success or failure of profundaplasty were evaluated. These were aorto-iliac inflow, the extent of disease in the profunda femoris artery, the run-off in the distal popliteal-tibial system and the extent of the ischemic lesion. Of the failures most were due to established gangrene, obstructions throughout the whole length of the profunda or patients with a poor popliteal-tibial run-off system. The cumulative limb salvage at two years was 86.8% in limbs subjected to inflow correction procedure and profundaplasty but only in 56.5% of repair of the profunda alone. In the majority of the below-knee amputations after profundaplasty, repair of the profunda was used to lower the level of amputation from above knee to below the knee. Profundaplasty is worth considering even in those patients who cannot be offered other revascularization surgery.

[Dumping syndrome after selective vagotomy and pyloroplasty]. / Dumping sindrom po selektivni vagotomiji in piloroplastiki

We have analysed the late complications (3--6 years after the operation) in 48 patients we treated by selective vagotomy and pyloroplasty because of duodenal ulcer. Authors have encountered six patients with so severe postoperative dumping syndrome that revison surgery has been performed. By reoperation there was no evidence of peptic disease but gastroduodenitis. After additional antrectomy dumping symptoms disappeared in all but one patient and radiologically the rate of test meal emptying of the stomach was reduced.