Multicenter randomized prospective trial comparing a pre-cuffed polytetrafluoroethylene graft to a vein cuffed polytetrafluoroethylene graft for infragenicular arterial bypass.

Poor patency of synthetic grafts for infragenicular revascularization has led to use of distal vein patches or cuffs. The aim of this study was to compare the distally widened Distaflo PTFE graft, which mimics a vein cuff, with a PTFE graft with distal vein modification. In this prospective, randomized, multicenter trial we compared use of a precuffed PTFE graft wit that of PTFE grafts with distal vein modification for infragenicular revascularization in patients with critical limb ischemia without saphenous vein. Study end points were primary and secondary patency and limb salvage rates at 2 years. From January 28,1999 to November 1, 2000, 104 patients were enrolled in 10 North American centers. Thirteen were excluded for protocol violation. Ninety-one bypasses were performed in 89 patients with a mean age of 73 years (range 47-90). By randomization, 47 bypasses were done with the precuffed graft and 44 with PTFE graft with vein cuff. Both groups were comparable for comorbidities and operative variables, except for a higher incidence of acute ischemia in the precuffed group (19% vs. 4.5%, p = 0.03). Bypass was a redo procedure in 53% and was performed at the infrapopliteal vessels in 79%. Operative mortality was 2.2% (2/91). Mean follow-up was 14 months (range 1-30). At 1 and 2 years, primary patency was 52% and 49% for the precuffed group and 62% and 44% for the vein cuffed group, respectively (p = 0.53). At 1 year and 2 years, the limb salvage rate was 72% and 65% for the precuffed group and 75% and 62% in the vein cuffed group (p = 0.88). Although numbers are small and follow-up short, this midterm analysis shows similar results for the Distaflo precuffed grafts and PTFE grafts with vein cuff. A precuffed graft is a reasonable alternative conduit for infragenicular reconstruction in the absence of saphenous vein and provides favorable limb salvage.

Relief of iliofemoral vein occlusion with the Palma bypass in a patient with Klippel Trenaunay syndrome.

Klippel Trenaunay syndrome is usually managed conservatively with surgery reserved for patients with symptomatic but mild cosmetic deformity or persistent venous hypertension despite nonoperative measures. Deep venous reconstruction is necessary in a small group of patients who present with significant chronic venous insufficiency due to hypoplastic, absent, or occluded deep venous outflow. Most often, venous outflow occlusion results from inadequate or surgically removed superficial collateral veins or from complications of endovascular procedures. In this article, we review the English-language literature and the Mayo Clinic experience, and report on a patient with Klippel Trenaunay syndrome who developed symptomatic iliofemoral venous occlusion following iliac vein stenting, which was successfully treated with a crossover saphenofemoral vein (Palma) bypass.

Aneurysm and stenosis of the celiomesenteric trunk: a rare anomaly.

A celiomesenteric trunk (CMT) anomaly is extremely rare, occurring in less than 0.5% of people. We describe two cases of CMT anomaly treated surgically for median arcuate ligament compression with stenosis causing intestinal angina and an asymptomatic aneurysm. Disease involving a CMT is extremely uncommon. This comprises the first report of symptomatic median arcuate ligament compression of a CMT. Only four cases of aneurysmal disease are reported so far. Indications and technique of surgical repair of CMT aneurysms are similar to those used for splanchnic artery aneurysms.

Intraoperative use of a new angle-independent Doppler system to measure arterial velocities after carotid endarterectomy.

OBJECTIVE: The purpose of this study was to assess the intraoperative use of a new angle-independent ultrasound scan device (EchoFlow [EF]) in measurement of carotid artery velocities after endarterectomy. Specifically, the purpose was to determine the reproducibility of velocity measurements obtained with EF and to compare these measurements with the velocity measurements obtained with duplex ultrasound scan. METHODS: Velocity measurements of the common, internal, and external carotid arteries were performed by the operative surgeon with EF in 65 consecutive patients after carotid endarterectomy (36 female, 29 male; mean age, 71 years). Three velocity measurements were obtained from each of the arteries with EF and compared with the velocity measurements obtained with duplex ultrasound scan performed by a radiologist. RESULTS: Velocity measurements obtained with the EF device were reproducible in the common, internal, and external carotid arteries (intrapatient correlation coefficients, 0.95, 0.96, and 0.95, respectively). Seventy-five percent of common, 88% of internal, and 78% of external carotid velocity measurements obtained with the angle-independent ultrasound scan device were within 25 cm/s of the velocities measured with duplex ultrasound scan. The mean differences in velocity measurements between EF and duplex scan were -12 cm/s in the common, -8 cm/s in the internal, and -11 cm/s in the external carotid arteries. Differences between the EF device and duplex scan velocity measurements correlated with increasing arterial velocities in each of the three arteries measured (P <.05). CONCLUSION: Reproducible measurements of carotid artery velocity may be obtained with a new angle-independent Doppler system after endarterectomy. Most measurements obtained with the EF system are clinically comparable with those obtained with standard duplex ultrasound scan. This novel low-cost device may be useful in the intraoperative assessment of hemodynamic adequacy of carotid endarterectomy.

Carotid artery reconstruction combined with myocutaneous flap coverage: a complex and durable rescue operation.

Carotid reconstruction combined with myocutaneous flap coverage is a rare and challenging operation. We reviewed our experience to define the indications and outcome of this complex procedure. Clinical data and neurologic, wound, and vascular complications of all patients who underwent carotid artery reconstruction combined with myocutaneous flap coverage over a 17-year period were retrospectively reviewed. Results from this procedure indicate that pectoralis major myocutaneous flap is a safe and durable option for wound coverage in patients who undergo carotid endarterectomy, resection, and/or reconstruction for neck malignancy, previous irradiation or graft infection. Late outcome is favorable with low neurologic, vascular, and wound complication rates.