Hemodialysis graft salvage.

Hemodialysis access procedures account for a large percentage of patients undergoing surgical treatment. Salvage procedures are frequently used to extend the life of a thrombosed graft and thereby maximize the limited available access sites. Factors that may influence the success of salvage procedures, as well as the financial risk to benefit comparison, may be of increasing importance in the era of aggressive medical cost containment. The charts of 70 patients who underwent 116 thrombectomies or revisions of polytetrafluoroethylene (PTFE) hemodialysis arteriovenous grafts of the upper extremity for thrombosis were retrospectively analyzed. Patency of salvaged grafts by life-table analysis was 75.0 percent at two days, 45.0 percent at 30 days, 18.0 percent at 120 days and 2.5 percent at one year. Patency was 59 and 25 percent for revised grafts at 30 and 120 days, respectively, versus 30 and 10 percent at the same time intervals for thrombectomized grafts only. Minimum combined operative and hospital costs were $4,350 per salvage attempt. Salvage patency of PTFE dialysis grafts of the upper extremity was dismal, especially when thrombectomy alone was used. No specific patient factors were predictive of patency interval. Based upon these results, we cannot continue to recommend graft thrombectomy alone for thrombosed dialysis grafts. Because the poor results with graft revision as well, placement of a new graft without any attempt at salvage may be the best therapeutic and cost-effective option.

Lower extremity revascularization via the lateral plantar artery.

Lower extremity bypass grafts to the tibial and crural arteries are commonly employed to treat patients with atherosclerotic limb-threatening ischemia. Although occasional series have mentioned bypasses to a plantar artery, few of these specifically examine the results of arterial reconstructions using these vessels. Six patients underwent femoral to lateral plantar artery (LPA) bypass within a 19-month period for gangrene of the forefoot. There was one early graft failure and in the five completely autogenous reconstructions, graft patency and limb salvage had been achieved during a follow-up ranging from three to 22 months. The LPA is an acceptable site for anastomosis of lower extremity bypass grafts and the early results presented herein support its more liberal use when proximal sites are unavailable.

Traumatic juxtarenal aortocaval fistula and pseudoaneurysm.

We discuss the treatment of a fistula located between the aorta and inferior vena cava which was caused by trauma. Fewer than 30 such cases have been reported in the English literature. A juxtarenal pseudoaneurysm and aortocaval fistula resulting from a gunshot wound, unrecognized upon the initial presentation of the patient, is reported herein.

A technique for reducing the size discrepancy between large reversed veins and small arteries.

Autogenous vein remains the conduit of choice for lower extremity revascularization. When a large or dilated vein is used in a reversed manner, there may occasionally be a large size discrepancy between it and a small tibial artery. A technique is presented that reduces this mismatch and facilitates anastomoses between large veins and small arteries.

Primary venous aneurysms.

Venous aneurysms are rare lesions. They may, however, be the source of pulmonary emboli and can result in death. We have recently treated several patients who had venous aneurysms of the upper extremity and jugular system. In these locations, venous aneurysms appear to have a safe natural history, although two patients required surgery after the development of symptoms. These cases are presented, with a review of venous aneurysms occurring at other sites and their cause.

Abdominal aortic aneurysmectomy without preoperative angiography. A prospective study.

In an attempt to analyze whether routine angiography is necessary prior to elective abdominal aortic aneurysmectomy (AAA), a prospective study was designed in which this examination was obtained only for specific indications. These included significant hypertension, renal dysfunction, symptoms of visceral ischemia, suprarenal extension of the aneurysm or a coexisting thoracic aneurysm, and diminished or absent femoral pulses. A consecutive series of 124 abdominal aortic aneurysms is reported, in which 110 procedures were performed electively. Preoperative angiograms were obtained in only ten patients (9.1%) and in nine of these an alteration in the usual operative strategy resulted. In the remaining 100 patients undergoing elective AAA without preoperative aortography, acceptable morbidity and mortality rates were obtained despite the intraoperative discovery of iliac aneurysms in 25 patients (23%) and accessory renal arteries in three patients (2.7%). In the absence of specific indications for angiography, the mainstay of the preoperative evaluation for abdominal aortic aneurysms should be computed tomography (CT). The preoperative workup can be done entirely on an outpatient basis.

Late results of preferential use of tube versus bifurcation grafts for abdominal aortic aneurysmectomy.

The advantages of tube versus bifurcation graft replacement of abdominal aortic aneurysms are well known, yet the risk of future development of iliac occlusive or aneurysmal disease still leads many to use bifurcation grafts routinely. Several studies have reported little risk of this development when patients are followed clinically. They suffer, however, from lack of an objective means of identifying iliac aneurysms. Among 83 patients undergoing abdominal aortic aneurysmectomy during a 53 month period, 36 who had received a tube graft were available for follow-up. After a mean of 54 months from the time of surgery, these patients were evaluated by abdominal and pelvic computed tomography to determine the incidence of subsequent iliac aneurysm formation. No patient had developed symptoms or signs of iliac occlusive disease during this interval. In addition, no residual aortic aneurysms or new iliac aneurysms were noted. In the absence of iliac occlusive or aneurysmal disease, straight graft replacement is the preferred therapy for abdominal aortic aneurysms. The risk of future development of these lesions is minimal.

Chronic perigraft seromas in PTFE grafts.

Well known complications of polytetrafluoroethylene (PTFE) grafts include thrombosis, infection, and pseudoaneurysms. Chronic perigraft seromas (CPS) associated with knitted dacron grafts are well described but only sporadic cases have been described in conjunction with PTFE grafts. In order to document the clinical history of PTFE associated CPS, 1674 PTFE grafts placed during the period from December 1982 through December 1984 were evaluated for the presence of CPS. Eight CPS were documented. All CPS developed in the subcutaneous location of the PTFE graft. Biochemical analysis of the seroma fluid and pathological findings implicate the source of the contents as being due to a local defect in the PTFE graft. CPS can make angioaccess difficult, cause discomfort by mass effect, and as in two patients, occlude a graft. Non-operative therapy was ineffective. Removal of the contents and as much of the pseudocapsule as possible was effective with only a single small recurrence.

Fungal graft infections: case report and review of the literature.

Fungal intravascular graft infections are rare. In addition to our case, which forms the basis of this article, only 13 documented instances could be found in the literature in the 20-year period from 1966 to 1986. Three of these cases (21%) had both fungus and bacteria grown in culture. Candida and Aspergillus species constituted most of the infecting organisms (79%). There was no obvious difference in the clinical presentations between fungal and bacterial infections. In two cases (14%), there was a strong predisposition toward fungal infection: one in a patient with pulmonary histoplasmosis and one in a patient with leukemia. Appropriate intervention appears to be graft excision and extra-anatomic bypass with concomitant therapy with amphotericin B. Survival with this approach was 84%, whereas other methods yielded a survival rate of 20%.

Control of needle hole bleeding with ethyl-cyanoacrylate glue (Krazy Glue).

Needle hole bleeding from polytetrafluoroethylene (PTFE) grafts causes blood loss and prolongs vascular procedures. Past studies have shown the cyanoacrylate glues to polymerize rapidly and cause minimal tissue toxicity. This study was undertaken to evaluate the efficacy of ethyl-2-cyanoacrylate glue (Krazy Glue, KG) in obtaining prompt hemostasis in vascular anastomoses in a heparinized canine model. KG effected complete hemostasis in a significantly shorter time than oxidized cellulose and digital pressure in 18-gauge needle holes in PTFE grafts, graft to graft end-to-end anastomoses, and end of graft to side of artery anastomoses. The only limitation of KG was the development of a glue-adventitia plaque on the arterial side of some of the PTFE-artery anastomoses, causing the need for regluing. KG is an ideal agent for sealing defects in PTFE grafts.

Physiologic anatomy of the palmar circulation in 200 normal hands.

The functional capacity of the Superficial Palmar Arch (SPA) was evaluated in 200 normal hands by a non-invasive narrow beam ultrasonic technique. Peak systolic velocity of flow with radial artery occlusion increased in all SPAs except for 22 (11%) which were considered incomplete. Ulnar artery occlusion resulted in a more variable response including 89 (45%) SPAs with bidirectional flow. SPA blood flow is complex but understandable in terms of hand blood flow and vascular bed resistance. The use of tobacco does not increase the incidence of incomplete SPAs.

Hemodynamic assessment of the circulation in 200 normal hands.

The frequent use of arterial puncture, cannulation, and A-V shunting has demonstrated a greater degree of safety than could be predicted from previous anatomic and angiographic studies. Using a noninvasive technique, the status of the superficial palmar arch (SPA) and relative contributions of radial and ulnar arteries were determined in 100 volunteers with no history of vascular disease. Although there was no significant difference in the diameter of the vessels at the wrist, the flows showed statistically significant ulnar dominance, suggesting that the difference is a factor of a lower distal resistance on the ulnar side. The lower resistance across the ulnar bed probably is responsible for the clinically observed ease of sacrifice of the radial artery contribution to palmar flow. The SPA was found to be incomplete in 11.0% of the hands.

Low-dose streptokinase in the treatment of celiac and superior mesenteric artery occlusion.

Selective delivery of low-dose streptokinase was effective in the treatment of embolic occlusion of the celiac and superior mesenteric arteries. The two-catheter technique resulted in complete lysis of clot in the celiac artery and improvement in patency of the superior mesenteric artery. The procedure restored effective mesenteric blood flow and provided an alternative to surgery in a very ill patient.

Simultaneous bilateral carotid endarterectomies.

Twelve patients with bilateral symptomatic lesions of internal carotid arteries have had bilateral carotid endarterectomy at single operations without complications. These were patients up to age 80 who had prior mycardial infarction, stroke with recovery, and hemispheric and nonhemispheric episodes. Neurologist's clearance and three- or four-vessel intracranial-extracranial angiography preceded all operations, which were performed with the patient under general anesthesia. Stump pressure measurements were the principal guideline of adequacy of collateral flow and predictor of safe outcome. The safety of this concept of bilateral operations during one anesthesia can eliminate uncertainties of sequence and timing, obviate delay and indecision, and avoid the hazards of a second anesthetic-operative experience.