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Biomedical subjects

D E Bock

Publications and source records attributed to D E Bock.

7 recordsLinked to original sources
PubMed1995

The use of spliced vein bypasses for infrainguinal arterial reconstruction.

PURPOSE: The use of autogenous vein, whether in situ or excised, for arterial bypass procedures is well accepted. However, this usually requires the presence of a length of good-quality vein of adequate diameter. In patients lacking sufficient length of vein, two or more pieces of vein may be spliced together to complete the reconstruction. The effect of vein splicing on vein bypass patency is not well studied. METHODS: Over a 14-year period, 1956 lower extremity revascularizations were performed with a single autogenous vein, 1806 in situ and 150 excised veins. During the same time, 184 bypasses required splicing vein segments together, of which 111 were in situ bypass procedures, which required splicing of one or more pieces of excised vein to complete the reconstruction (partial in situ bypass). Seventy-three bypasses were completed with multiple pieces of spliced excised vein. The source for the excised, spliced vein segments was the distal ipsilateral greater saphenous vein (GSV) in 40%, accessory ipsilateral GSV in 8%, contralateral GSV in 13%, lesser saphenous vein in 28%, and arm vein in 11%. RESULTS: The 1- and 4-year primary patency rates for the entire spliced vein group were 72% and 45%, with secondary patency rates of 79% and 61%. The 1- and 4-year secondary patency rates of partial in situ bypasses were 80% and 70%, compared with 91% and 83% for in situ bypasses completed without a spliced segment (p < 0.0001). The 1- and 4-year secondary patency rates were 78% and 67% in the spliced excised vein group and 85% and 75% in the single excised vein group (p = not significant). The 4-year limb salvage rates were as follows: in situ (96%), partial in situ (85%), single excised vein (95%), and spliced excised vein (90%). CONCLUSIONS: We conclude that the use of excised vein segments to complete partial in situ bypasses may be associated with a decrement of bypass patency. Use of spliced excised vein segments of good quality for arterial bypass can produce acceptable patency rates. Such spliced autogenous conduits are clearly preferable to prosthetic bypasses for infrageniculate arterial reconstructions. Meticulous technique is a prerequisite for the successful performance of vein-to-vein anastomoses.

Arm↗
PubMed1995

Durability of short bypasses to infragenicular arteries.

OBJECTIVES: The purpose was to test the durability of the use of the unobstructed popliteal or tibial arteries as alternative inflow sources. MATERIALS: We examined 106 such bypasses performed during a 12 year period (1981-93). The indication for surgery was limb salvage in 99.1%. Seventy-five percent of the patients were male, 78% were diabetic and the average age was 59.6 years. The inflow source was the above-knee popliteal artery in 15 cases, the below-knee popliteal artery in 70 cases, the anterior tibial artery in 11 cases and the posterior tibial artery in 10 cases. Adequacy of inflow was determined by angiogram as well as intraoperative pressure measurement when indicated. Outflow was to a distal tibial or plantar arteries in 77.4% of the procedures. Forty-six bypasses were performed by an in situ technique. Excised vein was used as conduit in 60 patients (56.6%); greater saphenous vein (38), lesser saphenous vein (10), cephalic/basilic vein (4), and splice vein (8). RESULTS: Operative mortality was 2.8%. Five year cumulative primary patency was 75.4% with a secondary patency of 82.6%. Five year cumulative limb salvage was 93.5%. Patency rate was not significantly different for various inflows or outflows. Only four of the 106 bypasses ultimately required a reconstruction from the femoral level for proximal progression of disease. Bypasses performed using an in situ technique showed a significantly better 5 year cumulative secondary patency rate (96.3%) than those done with excised vein (70.5%), p < .05 CONCLUSION: Results of this study indicate that use of the popliteal or tibial arteries as an inflow source in the absence of significant proximal disease carries acceptable results, especially when using the vein in situ.

Adolescent↗
PubMed1994

Retroperitoneal approach for bilateral renal and visceral artery revascularization.

Revascularization for renal and visceral arterial occlusive disease has traditionally been performed via a transperitoneal approach. Exposing these arteries transperitoneally is often difficult, however, and may require extensive medial visceral rotation. An alternative is a left retroperitoneal approach for renal and visceral arterial revascularization, including procedures involving the right renal artery. Over the past 7 years, a total of 186 such procedures have been performed using this approach. Of 30 that involved primarily the celiac and mesenteric arteries, 20 were completed with a bypass graft and 10 with transaortic endarterectomy. Of 156 procedures performed for renal arterial occlusive disease or aneurysmal disease extending above the renal arteries, 32 were treated with transluminal endarterectomy, 21 were treated with bilateral bypasses, and 72 were treated with unilateral bypass. Concomitant aortic endarterectomy or graft replacement was performed in 110 of this group. Operative mortality was 3.3%. Reconstructions were followed-up (for 1 to 76 months) with serial duplex and renal flow ultrasonography scans. One thrombosis developed in a renal artery bypass. We conclude that the left retroperitoneal approach may conveniently be used to reconstruct the celiac artery, superior mesenteric artery, and both renal arteries. These reconstructions may be performed with either an endarterectomy or bypass technique. In particular, the need to revascularize the right renal artery should not be regarded as a contraindication to using a left retroperitoneal approach.

Adolescent↗
PubMed1994

Increased limb salvage by the use of unconventional foot amputations.

PURPOSE: Limb salvage in the presence of ischemic foot necrosis requires revascularization followed by debridement or partial foot amputation. Necrosis extending beyond the toes and metatarsal heads may require the use of unconventional types of amputations. METHODS: Over a 15-year period 2105 ischemic limbs were treated with infrainguinal revascularization. In 98 cases, extensive foot necrosis was than managed with amputations, including 59 modified Chopart, 14 Lisfranc, 17 Pirogoff and 8 Syme amputations. Patients were not allowed to bear weight for several days to weeks. RESULTS: Skin flap necrosis in 14 cases was managed successfully by debridement and skin grafting. Ambulation required the use of a "clamshell" prosthesis and foot spacer. The overall limb salvage rate in this group was 84% (82 of 98). In general, the modified Chopart amputation most frequently produced ambulatory limb salvage and is technically easier to perform than a Syme amputation. Patient satisfaction and long-term ambulatory function was highest with the modified Chopart. CONCLUSION: Ischemic foot necrosis extending beyond the limits of conventional transmetatarsal amputation need not be treated with major amputation. This requires the surgeon to be well versed in the use of less common types of partial foot amputations. Acceptable limb salvage and good functional results may be attained by the motivated patient and surgeon with the use of these procedures in the revascularized limb.

Activities of Daily Living↗
PubMed1994

Carotid endarterectomy in awake patients: its safety, acceptability, and outcome.

PURPOSE: The purpose of this study was to determine the safety and efficacy of performing carotid endarterectomy procedures with the patient receiving cervical block anesthetic. METHODS: Over the last 14 years, 654 carotid endarterectomy procedures were performed with patients receiving regional anesthetic. Intraluminal shunts were placed on demand, if neurologic changes with clamping of the carotid artery developed in the patient. During the same period, 419 cases were done with the patients receiving general anesthetic. Choice of anesthetic was based on surgeon and patient preference. RESULTS: In the regional anesthetic group the indications for operation included transient ischemic attack (311), asymptomatic hemodynamically significant stenosis (146), amaurosis fugax (106), stroke (86), restenosis (3), and aneurysm (2). Shunts were used in 46 of 654 cases (7%). Conversion from regional to general anesthetic was required in seven patients (1.1%). The operative mortality rate was 0.76% (5 of 654). Permanent nonfatal neurologic deficits occurred in 0.76% (5 of 654), and temporary neurologic deficits occurred in 1.07% (7 of 654). CONCLUSIONS: On the basis of these results, we believe regional cervical block anesthetic is an acceptable option to the routine use of shunts performed with the patient receiving general anesthetic during carotid endarterectomy. In addition, the ability to continuously assess the awake patient receiving cervical block may contribute to a decrease in perioperative stroke and mortality rates while simplifying functional cerebral monitoring during carotid endarterectomy.

Adult↗