Extended patency of expanded polytetrafluoroethylene grafts for vascular access using optimal configuration and revisions.

During a seven year period, 189 expanded polytetrafluoroethylene (PTFE) grafts for vascular access were implanted in 131 patients with end stage renal disease requiring long term hemodialysis. Over-all cumulative patency rate for all grafts was 76 per cent at 12 months, 50 per cent at 36 months and 40 per cent at 60 months. Forearm grafts of loop configuration yielded greater over-all patency rates and required fewer revisions than forearm grafts of straight configuration. Graft thrombosis was the universal indicator of graft malfunction. In the instance of a malfunction, immediate thrombectomy followed by angiography was considered essential to decisions regarding further therapy. Of 95 grafts that malfunctioned, 49 ultimately required revision, extending the survival to a rate equaling that of continuously functioning grafts. Extensive venous stenosis limiting outflow and multiple intragraft stenosis were the main causes of graft failure. For patients in whom all vessels of the upper extremity had been exhausted, thigh grafts of the loop configuration and axilloaxillary grafts proved to be satisfactory alternatives. Although PTFE grafts are not the final solution for vascular access in hemodialysis, in many instances, they will serve well, provided the surgeon gives proper consideration to their most efficacious use.

Choledochoduodenostomy. A safe and efficacious alternative in the treatment of biliary tract disease.

A review of 75 patients who underwent side-to-side choledochoduodenostomy as primary or secondary treatment for various forms of biliary tract disease was performed. Ages of patients ranged from 23 to 89 years (mean of 61 years), with 40 per cent of patients 70 years or older. All anastomoses were created with a minimal diameter of 2 cm. During a follow-up period ranging from 6 months to 8 years, there was no incidence of ascending cholangitis or anastomotic stricture. Six patients continued to have non-specific complaints of abdominal pain postoperatively that could not be attributed to the "sump syndrome" after necessary diagnostic studies were performed. The overall morbidity and mortality was 6.6 per cent and 1.3 per cent, respectively. This study confirms the notion that choledochoduodenostomy can be performed safely, with good results, particularly in the expanding high-risk elderly patient population.