Axillobifemoral bypass: elective versus emergent operation.

Axillobifemoral bypass (AxBFB) is considered an inferior operation because of comparatively poor long-term results. One factor that has not been considered in the literature is whether or not the operation is performed electively or for acute ischemia (< 24 hours duration). This may be a more important predictor of poor results than previously recognized. During the last 10 years, we have performed 59 AxBFB. In Group A, 41 patients (mean age 71) underwent elective AxBFB and in Group B, 18 patients (mean age 65) had emergency AxBFB. Indications for surgery in Group A were limb-threatening ischemia (30), infected aortic graft (5), and severe claudication (6); in Group B, indications for surgery were acute limb ischemia (16), and aortoduodenal fistula (2). Primary patency (p < 0.002), limb salvage (p < 0.002), and survival (p < 0.03) were significantly better in Group A versus Group B. We conclude that an AxBFB performed electively provides satisfactory palliation of severe vascular disease in high-risk patients. The indications for operation and timing of the operation may explain the widely disparate clinical results reported in the literature.

Long-term follow-up of bypasses to the brachial artery across the shoulder joint.

BACKGROUND: Most atherosclerotic lesions in the subclavian artery are successfully treated with carotid to subclavian bypass. The need to bypass to the brachial artery (BA) is rare. We reviewed our experience with this bypass. METHODS: Over a 10-year period, we have performed 13 bypasses to the BA originating from an artery proximal to the shoulder joint. In this retrospective study, the demographic and clinical risk factors were evaluated. Long-term results were analyzed. RESULTS: Thirteen operations were performed in 10 patients, aged 47 to 80 years. The operations were carried out for acute severe ischemia in 1 limb, effort discomfort in 9, and rest pain in 3 limbs. Donor arteries were axillary (7), carotid (4), and subclavian (2). All bypasses were to the BA proximal to the elbow joints. Life-table analysis showed 100% patency in the first 3 years and 88% at 7 years. There were 2 deaths in follow-up. Average preoperative brachial to brachial index was 0.59 and postoperative index was 1.1. In patients with bilateral occlusions, mean preoperative brachial artery pressure was 62 mm Hg, which improved to 142 mm Hg postoperatively. There were no neurological complications and no 30-day mortality. CONCLUSIONS: Bypass across the shoulder joint to the BA using expanded polytetrafluoroethylene (ePTFE) or vein is a safe operation with excellent long-term patency. The carotid artery can be used as a donor vessel without complications. Hypertension and female gender appear to be risk factors for extensive disease in proximal upper extremity arteries.

Symptomatic subclavian steal syndrome four decades after operation for dysphagia lusoria.

Congenital abnormalities of the aortic arch may lead to signs and symptoms of tracheal and esophageal obstruction secondary to a restrictive vascular ring. There are many case reports and monographs concerning the surgical management of dysphagia lusoria. This case provides the first example of long-term follow-up of surgical intervention for relief of dysphagia lusoria. A 45-year-old laborer presented with a several year history of episodic bilateral blindness and a more recent onset of "drop attacks." Notably this patient had presented at the age of 18 months with difficulty breathing and eating since birth. The patient also had frequent upper respiratory infections and episodes of pneumonia. Workup revealed a right-sided aortic arch with a left ligamentum arteriosum. When he was first seen in our clinic, history and physical examination revealed claudication and diminished pulses in the left upper extremity. Arteriography and duplex studies confirmed reversal of flow in the patient's left vertebral artery. The arteriogram demonstrated the presence of a right-sided aortic arch and descending aorta along with the proximal stump of the previously ligated left subclavian artery. He underwent left carotid to left axillary artery bypass for the treatment of symptomatic subclavian steal syndrome. His symptoms have resolved with return of antegrade vertebral flow and the presence of normal pulses in the left arm. Congenital aortic abnormalities that lead to tracheal and esophageal compromise are numerous and varied. Surgical management requires a thorough understanding of the person's anatomy and preoperative planning. The life expectancy of patients with dysphagia lusoria necessitates consideration of the long-term consequences of surgical intervention.

Fibromuscular dysplasia of the brachial artery: an endovascular approach.

Fibromuscular dysplasia (FMD) is a nonatherosclerotic segmental disease of unknown etiology primarily affecting muscular arteries of intermediate size. The pathology affects the renal arteries in the majority of cases, followed by the carotid, vertebral, and ilio-femoral arteries. There have been only six reported cases of FMD involving the brachial artery. This case report describes the seventh case and illustrates an endovascular approach to this clinical entity. A 63-year-old female with a history of hypertension presented to vascular surgery clinic with a 4-day history of numbness, pain, and coolness of her left hand. On physical exam, the patient had a normal axillary and brachial pulse, but had only a Doppler signal of the left ulnar artery. There was no Doppler signal of the radial artery. Segmental pressures and PVR waveforms were normal in the upper arm, but there was a significant blunting of the waveform and decrease in pressure at the level of the wrist. An arteriogram revealed significant narrowing and irregularity of the brachial artery with a characteristic "string-of-beads" appearance. There was complete thrombosis of the radial artery and evidence of fresh thrombus in the distal brachial artery. The patient was treated with intra-arterial infusion of urokinase with restoration of the radial pulse and resolution of her symptoms. Subsequently, the patient had a percutaneous transluminal balloon angioplasty of the involved segment of brachial artery, with normal PVR's and segmental pressures upon completion. FMD of the brachial artery and its sequelae are extremely rare, and therefore, there is no consensus on proper management.(ABSTRACT TRUNCATED AT 250 WORDS)

Increased oxygen extraction as adaptation to acute renal ischemia.

Acute renal ischemia is an infrequently encountered clinical entity with occasionally devastating consequences. The renal compensation to acute ischemia is unknown and is the purpose of this report. Eight pigs were anesthetized and ventilated. Left atrial, aortic, CVP, left renal venous, and ureteral catheters were inserted. Renal blood flow (RBF) reduction was accomplished by the graded constriction of the left renal artery using a balloon occluder. Renal oxygen extraction ratio (RER, %), renal oxygen delivery (RO2D, cc/min per 100 gm), renal oxygen consumption (RVO2, cc/min/100 gm), creatinine clearance (CrCl, ml/min), and renal lactate production (delta [L], mg/min per hgm) were measured at baseline and following sequential 90-minute intervals of moderate and then severe left renal flow reduction. Significant increases in renal oxygen extraction were observed when RBF was severely limited (.30 +/- .05 vs .64 +/- .06, p < .01). CrCl decreased precipitously (16.5 +/- 4.6 vs 0.2 +/- 0.07, p < .05). Lactate production by the ischemic organs correlated with blood flow reduction (r = .546, p = .0034). In severe ischemia, healthy kidneys increase oxygen extraction to preserve oxygen consumption.