Results of prosthetic-vein composite graft with remote popliteal arteriovenous fistula in infragenicular bypass.

OBJECTIVE: The purpose of this study is to report the results of a novel procedure for femoral-distal bypass grafting using a composite graft with an adjunctive remote popliteal fistula distal to the prosthetic portion of the graft. This reconstruction was developed for use in limb salvage in the absence of satisfactory autogenous vein. METHOD: Data were collected prospectively on all patients undergoing this procedure from January 1, 1993 to December 31, 1999. Graft patency was determined from follow-up duplex scanning. Patient survival was determined by clinic follow-up. RESULTS: A total of 43 procedures were performed in 38 patients. In 34 patients, 72 previous arterial operations had been previously performed on the ipsilateral limbs. There were 20 men and 18 women with a mean age of 72 years. The indication for surgery was limb salvage in all, with rest pain in 30, and tissue loss in 13. The outflow artery was the below-knee popliteal artery in 10 and a tibial artery in the remainder. Operative mortality was 6.8%. Mean follow up was 26.9 months. The primary patency was 54% at 12 months. Six reconstructions were revised for a primary assisted patency of 60% at 16 months. Secondary patency was 69% at 16 months. Patient survival was 62% at 2 years and 26% at 5 years. CONCLUSIONS: The technique of composite grafting with remote popliteal arteriovenous fistula may be a useful alternative in infragenicular bypass when a satisfactory autogenous vein is not available.

Axillary vein thrombosis secondary to congenital stricture in a left-sided superior vena cava.

We describe a case of axillary vein thrombosis secondary to unusual venous anatomy. A patient with a strictured left-sided superior vena cava and axillary vein thrombosis was successfully treated with thrombolysis. The underlying stricture was treated with angioplasty and stenting.

Is Canadian cardiac surgeons' management of asymptomatic carotid artery stenosis at coronary artery bypass supported by the literature? A survey and a critical appraisal of the literature.

OBJECTIVE: To document and compare the management of asymptomatic carotid stenosis (ACS) by Canadian cardiac surgeons at coronary artery bypass grafting (CABG) against a critical literature analysis. DESIGN: A multiple choice survey and a structured literature review. DATA SOURCES: Seventy-seven surgeons and 272 publications selected from the English literature between 1980 and 1997. Search terms used were "carotid," "coronary bypass," and "cardiac surgery." STUDY SELECTION: Five natural history studies were identified, and 58 studies were found that had objective documentation of ACS of 50% or more before cardiac surgery, and both operative stroke and mortality data reported for CABG with and without carotid endarterectomy (CEA). DATA EXTRACTION: Natural history and outcome studies were independently rated against published guidelines. Outcome data were independently pooled and compared. Data discrepancy was resolved by consensus. Survey results were tabulated for simple descriptive statistics. DATA SYNTHESIS: No methodologically sound natural history studies were found to document an increased risk of stroke from ACS after CABG. There were no randomized controlled studies to guide treatment recommendations. Pooled data for stroke or death did not support CEA for risk reduction from ACS at CABG (relative risk 0.9, p = 0.5). Ninety-four percent of surgeons believed that the literature is insufficient to support the routine use of CEA to reduce the risk of stroke from ACS after CABG. Despite this, 20% of surgeons advocated CEA for this purpose. CONCLUSION: The management of ACS at CABG by the majority of Canadian cardiac surgeons is consistent with the results of the literature review; however, significant management variation exists.

Intraoperative duplex study of internal thoracic artery spasm during coronary bypass.

In this article, we document flow disturbance due to internal thoracic artery spasm (ITA) in a patient undergoing minimally invasive coronary artery grafting. We used intraoperative duplex scanning. Application of systemic vasodilators resulted in rapid improvement of ITA flow, as demonstrated by serial duplex examinations.