Infrainguinal reconstruction with arm vein, lesser saphenous vein, and remnants of greater saphenous vein: a report of 257 cases.

PURPOSE: The purpose of this study was to evaluate the results of infrainguinal reconstructions with arm vein, lesser saphenous vein, and remnants of greater saphenous vein (ectopic vein grafts). METHODS: The records of 222 patients who underwent 257 bypasses were restrospectively reviewed. Most of the grafts were placed for rest pain or tissue loss (88%) and were secondary reconstructions (70%) to the infrapopliteal level (90%). Single-length vein grafts were constructed in 66% of cases, whereas 34% were composite vein grafts. RESULTS: Secondary graft patency was 70%, 52%, and 43% at 1, 3, and 5 years. Single-length grafts had significantly better patency rates at all intervals: 78% versus 56% at 1 year (p = 0.001), 60% versus 39% at 3 years (p = 0.004), and 52% versus 29% at 5 years (p = 0.002). The limb salvage rate was 69% at 5 years. CONCLUSIONS: Ectopic vein grafts with primarily arm vein are an acceptable alternative for infrainguinal reconstruction in the absence of suitable ipsilateral greater saphenous vein.

Carotid endarterectomy: operative risks, recurrent stenosis, and long-term stroke rates in a modern series.

To determine whether carotid endarterectomy (CEA) safely and effectively maintained a durable reduction in stroke complications over an extended period, we reviewed our data on 478 consecutive patients who underwent 544 CEA's since 1976. Follow-up was complete in 83% of patients (mean 44 months). There were 7 early deaths (1.3%), only 1 stroke related (0.2%). Perioperative stroke rates (overall 2.9%) varied according to operative indications: asymptomatic, 1.4%; transient ischemic attacks (TIA)/amaurosis fugax (AF), 1.3%; nonhemispheric symptoms (NH), 4.9%; and prior stroke (CVA), 7.1%. Five and 10-year stroke-free rates were 96% and 92% in the asymptomatic group, 93% and 87% in the TIA/AF group, 92% and 92% in the NH group, and 80% and 73% in the CVA group. Late ipsilateral strokes occurred infrequently (8 patients, 1.7%). Late deaths were primarily cardiac related (51.3%). Stroke-free rates were significantly (p less than 0.0001) greater than stroke-free survival rates, confirming a non-stroke related cause for late death. Restenoses greater than 50% according to duplex scanning developed in 13%, most (67%) within 2 years after CEA. Most of these (77%) were asymptomatic, and only 0.3% (1 patient) presented with a permanent neurologic deficit. The results of carotid endarterectomy are superior to those of optimal medical management in symptomatic and asymptomatic patients in terms of long-term stroke prevention. When low perioperative stroke mortality/morbidity rates are achieved, carotid endarterectomy is justified for treatment of patients with carotid bifurcation disease.

Color-flow duplex scanning for the surveillance and diagnosis of acute deep venous thrombosis.

Compared with conventional duplex imaging, color-flow scanning facilitates the identification of veins (especially below the knee), decreases the need to assess Doppler flow patterns and venous compressibility, and allows veins to be surveyed longitudinally. These advantages translate into a less demanding and time-consuming examination. This study was designed to determine the accuracy of color-flow scanning for detecting acute deep venous thrombosis in patients in whom the diagnosis is clinically suspected and in asymptomatic patients at high risk for developing postoperative deep venous thrombosis. The diagnostic group included 77 limbs of 75 patients, and the surveillance group included 190 limbs of 99 patients undergoing total hip or knee replacement. All patients were prospectively examined with color-flow scanning and phlebography. In the diagnostic group, the incidence of thrombi in below-knee veins (47%) was approximately equal to that in above-knee veins (43%); but in the surveillance group, the incidence of thrombi in below-knee veins (41%) far exceeded that in veins above the-knee (3%). Nonocclusive clots and clots isolated to a single venous segment were more common in the surveillance group. In symptomatic patients, color-flow scanning was 100% sensitive and 98% specific above the knee and 94% sensitive and 75% specific below the knee. In the surveillance group, color-flow scanning was significantly (p less than 0.001) less sensitive (55%) for detecting thrombi, 93% of which were confined to the tibioperoneal veins. Negative predictive values were 100% and 88% for the diagnostic and surveillance limbs, respectively. Positive predictive values were 80% for the diagnostic limbs and 89% for the surveillance limbs. Color-flow scanning effectively excludes above-knee deep venous thrombosis in symptomatic patients and asymptomatic high-risk patients and predicts the presence of above-knee thrombi in patients in the diagnostic group with reasonable accuracy (97%). We conclude that color-flow scanning is as accurate as conventional duplex imaging and, because of its advantages, is the noninvasive method of choice for evaluating patients with suspected deep venous thrombosis. Its role in the surveillance of patients at high risk remains to be determined and awaits further clinical evaluation.

Infrapopliteal bypass for severe ischemia: comparison of autogenous vein, composite, and prosthetic grafts.

Results of 253 consecutive bypass grafts to infrapopliteal arteries were reviewed. Most (92%) were placed for rest pain (103) or tissue loss (130). Autogenous veins were used in 175 (69%) cases, composite vein-prosthetic grafts were used in 45 (18%), and prosthetic grafts alone were used in 33 (13%). Follow-up ranged from 0 to 101 months (mean, 19 months); 37 grafts (15%) were lost to follow-up. The operative mortality rate was 4%, and 5-year patient survival rate was 44%. Limb salvage was 82% at 5 years. The 5-year patency of vein grafts (63%) exceeded that of both composite (28%) and prosthetic (7%) grafts (p = 0.005 and p = 0.00007, respectively); but the patency of composite and prosthetic grafts did not differ significantly (p = 0.29). The patency of reversed vein (59%) and in situ vein grafts (74%) was not significantly different at 5 years (p = 0.34). Patency was also not affected by the site of the proximal or distal anastomoses or diabetes. The major determinant of long-term patency in infrapopliteal reconstructions continues to be graft material. Composite grafts offered no clear advantage over prosthetic grafts, and both should be used only when there is no other alternative to amputation.

Does color-flow imaging improve the accuracy of duplex carotid evaluation?

To determine whether color-flow imaging enhances the accuracy of noninvasive carotid evaluation, the results of carotid duplex examinations from two laboratories, one with color-flow and the other with standard duplex imaging were compared. The techniques used by both laboratories were identical. All studies were interpreted by one of the authors, using the same criteria. From October 1988 through December 1989, 307 internal carotid arteries were evaluated with both color-flow imaging and standard angiography; and 206 underwent routine duplex scanning and angiography. Perfect agreement between test and angiographic results was significantly better with color-flow (86.6%) than with conventional duplex scanning (79.6%), p = 0.034 (t test for independent samples). Significantly fewer vessels were over classified by one category with color-flow (8.5%) than with routine duplex scanning (16.5%), p = 0.006. However, no difference was found in the number under-classified by one category (4.5% vs 3.4%), p = 0.5. Although these data support the accuracy of both modalities, there appears to be a trend toward improved results with the newer method. We attribute this to more precise placement of the pulsed Doppler sample volume afforded by the color-flow image.

Initial experience with color-flow duplex scanning of infrainguinal bypass grafts.

Seventy-eight infrainguinal grafts were evaluated by means of color-flow duplex imaging to demonstrate its utility in the routine surveillance of leg grafts as well as in the evaluation of grafts in which a problem is already suspected. Stenoses were identified in 15 (20%) of 76 grafts evaluated for screening purposes. Seven of these had confirmatory arteriograms, and five were revised. The remaining eight grafts with suspected stenoses were followed without angiography, and four (50%) subsequently failed. Only two (3.3%) of 61 grafts with normal scan outcomes have thrombosed. Fistulas were identified in 12 (37%) of 32 in situ grafts evaluated. Nine grafts with previously suspected problems based on decreased ankle-brachial indexes were scanned, and an explanation was found, confirmed by angiogram, and corrected in six. Detection of unsuspected stenoses in five grafts requiring revision and four grafts that later thrombosed without revision, as well as identification of fistulas in 37% of in situ grafts, confirms the importance of color-flow imaging as a screening tool.

Weight loss with vertical banded gastroplasty and Roux-Y gastric bypass for morbid obesity with selective versus random assignment.

In a previous study, Roux-Y gastric bypass was found to be significantly more effective than vertical banded gastroplasty for weight loss in morbid obesity, especially for patients addicted to sweets, probably as a result of dumping syndrome symptoms. This study evaluated the ability to selectively assign nonsweet eaters to vertical banded gastroplasty and sweet eaters to gastric bypass. Compared with random assignment, the percentage excess weight lost at 2 years improved significantly with both groups combined. In the vertical banded gastroplasty group, the percentage increased from 41 +/- 19 to 55 +/- 19 percent. With selective assignment, the percentage excess weight lost with gastric bypass was still better than that with vertical banded gastroplasty. Weight loss with gastric bypass was still superior to that of vertical banded gastroplasty but at the expense of more complications. Gastric bypass was ineffective in 19 percent of the super obese patients. A combined restrictive, malabsorptive procedure may be necessary in such persons.