Dacron or PTFE for above-knee femoropopliteal bypass. a multicenter randomised study.

OBJECTIVES: To compare polytetrafluorethylene (PTFE) and polyester grafts (Dacron) for above knee femoropopliteal bypass. DESIGN: Multicenter randomised clinical trial. MATERIAL AND METHODS: 427 patients were randomised between 6mm Dacron (Uni-Graft, B. Braun Melsungen AG, 34212 Melsungen, Germany) and PTFE (Goretex, W. L. Gore & Ass. Inc., Newark DE 19711, USA) above-knee femoropopliteal bypass grafts within 13 centres in Denmark (n=261), Norway (n=113) & Finland (n=53) between 1993 and 1998. Fourteen (3%) patients were excluded, leaving 413 patients with 208 Dacron and 205 PTFE grafts for analysis. Age, gender, indication (claudication: 65%), run-off (2 or 3 vessels: 76%), diabetes (17%) and hypertension (31%) as well as cerebrovascular (9%) and cardiac (33%) risks were evenly distributed. Patients were followed postoperatively at 1, 12 and 24 months. Patency assessment was based on ankle-brachial pressures or imaging in case of doubt. RESULTS: The two-year primary patency rates for Dacron and PTFE were 70% and 57% (p=0.02), whereas the secondary patency rates were 76% and 65% (p=0.04), respectively. Primary patency at two years was significantly influenced by the number of patent crural vessels (two or three 67%, one 50%, p=0.01). Amputations at two years, major in 4% and minor in 3%, 30-days mortality and complications (wound infections: 3% and other wound complications: 13%) occurred equally frequent in both groups. At two years, patients treated for critical limb ischemia had a major amputation more often than patients operated on for intermittent claudication, 10 and 3 respectively (p=0.003), and had higher mortality rates, 20% and 8% respectively (p=0.001). CONCLUSION: This trial confirms that Dacron is at least as durable as PTFE for above-knee bypass procedures, and might even be superior.

Long-term outcome following thrombembolectomy in the upper extremity.

OBJECTIVES: To evaluate short- and long-term mortality and morbidity in patients that were treated for acute upper extremity ischemia. DESIGN: Single center retrospective study. PATIENTS: A consecutive series of 148 patients who were admitted with a diagnosis of acute ischemia of the upper extremity during an 11-year period. METHODS: All charts were reviewed retrospectively and 96% of all survivors participated in clinical follow-up. RESULTS: The median age was 78 years and 64% of patients were females. The 30-day mortality was 8% and the overall 5-year survival 37%. The observed mortality during the follow-up period was significantly higher than expected. Survival was not significantly different in patients who received anticoagulant drugs following discharge from the hospital. The duration of ischemia did not significantly influence long-term arm-function. CONCLUSIONS: Acute embolic episodes in the upper extremity primarily occur in elderly and the peri-operative mortality is high. Mortality following discharge from the hospital remains significantly higher than that of the background population.

[Thoracic aortobifemoral bypass in chronic lower limb ischemia]. / Torakal aortobifemoral bypass ved kronisk underekstremitetsiskaemi.

In cases of critical limb ischemia caused by aorto-iliac arteriosclerosis the most common operation is aortobifemoral bypass. This operation has a high patency. We describe two cases in which a thoracic aortobifemoral bypass was chosen as an alternative bypass operation because of a hostile abdomen. Both operations were performed without complications and resulted in normally perfused extremities.

[Vascular prosthesis infected with Salmonella. A rare complication of Salmonella sepsis]. / Karprotese inficeret med Salmonella. En sjaelden komplikation til Salmonella-sepsis.

A case of vascular graft infection secondary to Salmonella septicaemia is described. The patient was a 69 year old man with an aortic bifurcation graft and a femoropopliteal bypass. Despite antibiotics treatment, operation was necessary. An especially long extra-anatomical bypass was used.

[Percutaneous transluminal angioplasty in infrarenal aortic stenosis]. / Perkutan transluminal angioplastik ved infrarenale aortastenoser.

In a small subgroup of heavily-smoking young women the atherosclerotic lesion is confined to the infrarenal abdominal aorta. So far the management of these patients has been laparotomy with thrombendarterectomy of the aorta. Ten consecutive patients have been treated with percutaneous transluminal angioplasty PTA and in four patients stent implantation was performed. In two patients local haemorrhagic complications occurred, but no microembolization or thrombosis was noticed. All patients were controlled clinically and with blood pressure measurement. There was a rise in ankle systolic blood pressure from 63% to 96% compared to the systemic blood pressure and all patients were asymptomatic. It could be concluded that PTA of symptomatic stenosis of the infrarenal abdominal aorta is a minimal invasive treatment with a good long term result and should be the primary treatment in these patients.

[Vena saphena magna in situ bypass to the ankel and foot. A prospective assessment of results of 101 procedures in 94 patients with threatening amputation]. / Vena saphena magna in situ-bypass til ankel og fod. En prospektiv opg|relse af resultaterne af 101 procedurer hos 94 amputationstruede patienter]

The results of 101 in situ by-pass operations to the ankle and foot are given. Seventy-five percent of the patients had other arteriosclerotic manifestations and 55% were diabetics. Ninety-nine percent of the operations were limb salvage surgery. The accumulative secondary patency rate was 87% after one month and 65% after three years. The results did not differ from by-pass surgery to the crural arteries. The wound complication rate was 16% with an infection rate of 7% and the major amputation rate was 8% after one month and 10% after three years. The survival of this selected group of patients was lower than a group of sex- and age-matched controls. The long term results of this type of advanced by-pass surgery in limb threatening ischaemia are very satisfactory and should be a must in every vascular surgeon's armamentarium.

[Internal carotid artery stent]. / Arteria carotis interna-stent.

Stent implantation is a well established treatment of vascular stenoses if the result after percutaneous transluminal angioplasty (PTA) is suboptimal, or as a primary treatment to reduce the number of restenoses. Carotid artery stents have only been used in a relatively limited number of cases up till now. The first Scandinavian case of a successful internal carotid artery stent implantation after suboptimal PTA with five months follow-up is presented.

[Bilateral iliac artery aneurysms in a Behçet-like disease]. / Bilaterale iliacaaneurismer ved Behçet-lignende sygdom.

A case of bilateral iliac artery aneurysms in a 24 year old patient with a Behçet-like disease is presented. Behçet's disease is characterized by multiple organ involvement. Primary manifestations are genital and oral mucosal ulcerations and eye and skin affections. Among secondary manifestations are non-specific arteritis causing thrombosis as well as aneurysmal disease of the medium-sized and large arteries. Behçet's disease should be considered in young patients with arterial aneurysms.

[Surgery of ruptured abdominal aortic aneurysm. Are the results compatible with the effort?]. / Operation for rumperet abdominalt aorta-aneurisme. Stoar resultaterne mål med indsatsen?

During 1979-1988 218 patients were operated on for ruptured abdominal aortic aneurysm. On admission 110 patients (50%) were in shock. Patients with a systolic blood pressure less than 100 mmHg, anuria on admission, peroperative bleeding of more than five litres and aged more than 70 years had an increased mortality. The intraoperative mortality was 15% and the postoperative mortality 21%. The perioperative mortality decreased from 45% in 1979 to 32% in 1988. The most frequent complications were renal failure and respiratory insufficiency, both were associated with a mortality of more than 50%. The five year survival was 48%. This study has revealed that patients with ruptured abdominal aortic aneurysm have an acceptable prognosis. The investigation emphasizes the importance of early diagnosis and elective operation to avoid rupture.

[Mortality and survival after surgery for abdominal aortic aneurysm. A 10-year follow-up]. / Letalitet og overlevelse efter operation for abdominalt aorta-aneurisme. En ti års opgørelse.

From 1979-1988, 656 patients were operated for abdominal aortic aneurysm. The perioperative mortality was 18%. The mortalities for elective, symptomatic and ruptured aneurysms were 5%, 17% and 38% respectively. The overall five year survival rate was 58%. In 87% of the patients one or more risk factor was found. Survival was unaffected in patients with a single risk factor, whereas patients with two or more risk factors had lower five year survival. Postoperative organ failure increased the perioperative mortality and the five year survival in patients with multiorgan failure was 20%. In view of the fact that 56% of the patients are operated on as emergencies, this study stresses the importance of early diagnosis and elective treatment.

Renal failure after operation for abdominal aortic aneurysm.

Among 656 patients undergoing surgery for abdominal aortic aneurysm, 81 patients (12%) developed postoperative renal failure. Before operation hypotension and shock occurred in 88% of the patients with ruptured aneurysm, whereas none of the patients operated electively were hypotensive. Dialysis was performed in 32 patients, while the remaining 49 patients were managed without dialysis. Within 30 days after the operation 47 patients (58%) had died. There was no difference in mortality between patients in dialysis and patients managed without dialysis. Thirteen patients died during follow-up. In six cases the death was caused by renal failure only or in combination with failure of other organs. Analysis of the cumulative survival shows that, if the patients survive the postoperative period, their life expectancy is comparable to that of patients without renal complications.

[Early and late results after surgery of abdominal aortic aneurysm]. / Tidlige og sene resultater efter operation for abdominalt aorta-aneurisme.

From 1983-1987, 388 patients were operated upon for abdominal aortic aneurysm. Elective operation was performed on 171 patients (44%) with a mortality of 2.9%. Emergency operation was done in 277 patients of whom 132 (34%) had ruptured aneurysms. The mortality for ruptured aneurysms was 36% and 21% for patients operated on as emergencies without signs of rupture of the aneurysm. The five year survival rate was 75% after elective operation, 60% after emergency operation and 40% after operation for ruptured aneurysm. The high mortality after emergency operation for abdominal aortic aneurysm confirms the importance of early diagnosis and elective operation before rupture occurs.

Bronchoplastic procedures for bronchial carcinoma.

In a 22-year period from 1962 to 1984, 51 patients with malignant lung disease had a sleeve resection performed. In 33% of the patients, pneumonectomy was contraindicated because of limited lung function. The operative mortality was 8%. Six per cent of the patients developed complications after the operation. The 5-year survival of the total group of patients was 30%. Patients with lesions classified as stage 1 and stage 2 had the best prognosis, with a 5- and 10-year survival of 43.5% and 27%, respectively. In patients classified as stage 3 and stage 4, the 5- and 10-year survival was 20%. A postoperative measurement of regional ventilation and perfusion indicated that the function of the remaining lung was presumably undisturbed by the operation. Also, the vital capacity and FEV 1 were only minimally reduced as a result of the operation. The amount of functional lung tissue spared by the operation compared to pneumonectomy was estimated to 39%. Because of these functional results and the promising 5-year survival figures, we suggest that sleeve lobectomy should be the operation of choice for tumors localized to the upper lobe orifice involving the main bronchus.

Vascular graft infection: an analysis of sixty-two graft infections in 2411 consecutively implanted synthetic vascular grafts.

Among 2411 consecutive arterial reconstructions performed with synthetic prosthetic material in Denmark during a 4-year period, 62 patients (2.6%) developed graft infection. Graft infection occurred only when the groin had been incised. The incidence of infection and the spread of infection along the graft did not relate to the graft material used (Dacron velour, Dacron woven, polytetrafluoroethylene, and umbilical vein). Retrospective analysis disclosed predisposing or precipitating factors in 50 of the 62 cases; the most important seemed to be unsatisfactory surgical technique. Fifty-three percent of the graft infections occurred within 30 days. Gram-positive cocci were the most common pathogen. The 62 patients had been in the hospital for a mean of 90 days and had undergone an average of 1.4 operations for graft infections. Of the patients, 25.8% died and 30.6% underwent amputations. Vascular graft infection is still one of the major problems in vascular surgery; greater care should be taken to improve antiseptics, improve surgical technique, and establish a rational prophylactic antibiotic regimen. A prophylactic antibiotic regimen of a combination of cephalosporin and ampicillin is recommended.

Thromboendarterectomy vs. aortic bifurcation graft for unilateral iliac artery atherosclerosis.

Retrospective comparison was made of the results from 57 unilateral ilio-femoral thromboendarterectomies in 55 patients and 42 bifurcation grafts in 42 patients. There were three hospital deaths, one after thromboendarterectomy and two after insertion of bifurcation graft. No early or late graft infection occurred. The five-year cumulative patency rate was significantly higher in the bifurcation graft group than after thromboendarterectomy (85% vs. 61%). This higher patency rate supports the concept that local thromboendarterectomy has only limited indications.