Limb ischemia during intra-aortic balloon pumping: indication for femorofemoral crossover graft.

Catheter insertion for intra-aortic balloon pumping (IABP) was successful in 91% of 332 candidates. Fifty-three patients (16.5%) had significant catheter-associated vascular complications, of which lower extremity ischemia with threatened limb loss was the most prevalent (70%). Thirty-six of these patients required an angioplastic repair or vascular grafting. Of the 36, 19 patients with ischemia who needed continued balloon support received femorofemoral (F-F) grafts to restore and maintain adequate limb perfusion. Wound infection occurred in six of the patients but there was no limb loss. F-F grafting is a simple procedure that requires little time and allows one to maintain IABP for prolonged periods without concern for critical obstruction to limb perfusion.

Endarterectomy of the left anterior descending and mainstem coronary arteries: a technique for reconstruction of inoperable arteries.

The proximal left anterior descending coronary artery (PLAD) is an area of predilection for such severe and diffuse calcific arteriosclerosis that reconstruction of these vessels often is impossible. The branches of this segment include the septal perforators, median artery, the left anterior descending coronary artery, and its first and second diagonal branches. Successful endarterectomy, therefore, would revascularize large areas of the left ventricle and interventricular septum. We have performed 45 such operations during the past 13 months. Following endarterectomy there are several methods of reconstructing the endarterectomized vessel, the preferable technique being the addition of a saphenous vein bypass to the endarterectomized segment. Patients selected for this operation were mostly in the fair (58%) and poor risk (42%) categories; there were no good risk patients. Diffuse arterial disease was the rule. The average ejection fraction was 0.48. The operation was successful with respect to graft patency, bypass flow rates, and symptomatic relief. The operative mortality rate in the entire group was 15%, including the 19 poor risk patients in six of whom elective preoperative use of an antra-aortic balloon pump was required. Most of the surviving patients (92%) were either symptom free or greatly improved. Only two patients were clinically unchanged. There was one late sudden death. This operation is indicated when there is extensive involvement of the life main, the proximal left anterior descending coronary artery and its major branches. It is the only possible way to revascularize otherwise inoperable arteries.

Vascular complications of intra-aortic balloon pumping.

Vascular injury or occlusion from intra-aortic balloon pumping (IABP) that results in actual or potential limb ischemia occurs more frequently than reported. In a series of 79 IABP patients, 36 lived long enough to have the balloon catheter removed; thirteen (36%) of them had vascular complications. The complications were in three patients with an injury at the insertion site, eight patients with arterial thromboses, and two with arterial occlusion by the large balloon catheter. Local artery revision, thrombectomy alone, or thrombectomy with femorofemoral cross-over grafting was required in 11 patients. Femorofemoral crossover graft was utilized when arterial occlusion would have ordinarily required premature balloon removal or when immediate arterial occlusion by the catheter was recognized at the time of balloon insertion. This was preferable to transferring, replacing, or discontinuing IABP, since the same factors that led to thrombosis in the first place would have eventually come into play again. Patients should be observed frequently and have Doppler limb pulse determinations every four hours to avoid ischemic catastrophies. Proper IABP weaning and the use of a Fogarty catheter at the time of balloon removal is mandatory to prevent complications. Femorofemoral crossover graft is indicated for ischemic limbs when IABP must be continued.

Choosing a vessel for aortocoronary bypass.

In practice, the surgeon is left with few choices of the proper ACB graft. His options are limited entirely to autologous tissues, of which the best is the great saphenous vein from the calf (Table 3). Actually, once leg veins and the internal mammary artery are no longer available there are few other choices worth considering. Small calibre allografts, however preserved, and synthetic grafts, are uniformly doomed to failure. The great saphenous vein from the calf is usually a single tube, of suitable diameter and strength for arterial replacement. Most of its tributaries lie in the upper third of the calf; this makes the lower segment preferable for the patient who requires only one or two bypasses. Variations in the normal anatomy have been illustrated.