The use of angioplasty, bypass surgery, and amputation in the management of peripheral vascular disease.
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Amputation, Surgical↗
Biomedical subjects
F J Veith
Publications and source records attributed to F J Veith.
Management of juxtarenal aortic occlusions: technique for suprarenal clamp placement.
Atherosclerotic occlusion of the entire infrarenal abdominal aorta can produce gangrene, rest pain or claudication and can progress to involve the renal artery origins. Features of the operative technique for treating these juxtarenal aortic occlusions include self-retaining retraction, mobilization of the left renal vein with division of all non-renal branches, exposure of the suprarenal aorta and renal arteries by division between clamps of the surrounding paraaortic fibroareolar tissue and fat, sharp division of crural attachments to the aorta, control of the two renal arteries with doubled vessel loops and then direct vertical clamping of the suprarenal aorta. Through an arteriotomy below the renal arteries, 2-4 cm of pararenal aorta are cleared of thrombus and atherosclerotic debris under direct vision. After transfer of the suprarenal clamp to an infrarenal position, conventional aortobifemoral bypass is then performed. In a series of 18 patients with juxtarenal aortic occlusion managed by this technique, suprarenal clamp time ranged from 4 to 25 minutes (mean, 13 minutes). There was no morbidity from renal failure or emboli and no mortality. This technique allows for deliberate, careful disobliteration of the pararenal and infrarenal aorta and minimizes the risk of renal embolization.
Aorta, Abdominal↗
Successful conservative management of iatrogenic femoral arterial trauma.
We have developed a protocol for nonoperative management of pseudoaneurysms and arteriovenous fistulas secondary to cardiac catheterization. Hemodynamically stable patients were placed at bed rest and underwent serial physical examination, hematocrit, and duplex ultrasonography for a minimum of three days prior to discharge and subsequently as outpatients. Sixteen initially stable patients out of 56 with femoral artery catheter trauma managed over a four-year period underwent deliberate conservative management. Their lesions included six arteriovenous fistulas, seven pseudoaneurysms, and three patients with both complications. All but one of the pseudoaneurysms resolved spontaneously within four weeks regardless of initial size or associated arteriovenous fistula. One patient receiving anticoagulant therapy required surgery for bleeding after a three-day period of observation of a pseudoaneurysm. Six of the nine arteriovenous fistulas also resolved within the initial period of observation. The remaining three have been followed for four to 20 months and have remained asymptomatic. Nonoperative therapy of catheter-related femoral artery trauma is both safe and effective. Conservative management avoids potential wound complications associated with dissection through surrounding hematoma as well as the additional hospitalization required for postoperative care. We recommend a period of observation for all hemodynamically stable patients with catheter-induced pseudoaneurysms and arteriovenous fistulas of the femoral vessels, with surgery reserved for hemorrhage, expanding masses, or compromised cardiac output.
Aneurysm↗
Superoxide dismutase: enhanced small intestinal preservation.
Injury from oxygen free radicals has been suggested to be of greater significance in the preservation of small intestine than of other organs. To determine if using the free radical scavenger, superoxide dismutase (SOD), with University of Wisconsin (UW) solution would improve preservation of small intestine, acute and chronic studies were conducted. Thirty-centimeter segments of small intestine from Lewis rats were flushed with and stored in Collins, UW, or SOD-modified (8000 U/ml) UW solution at 4 degrees C for 18 hr. For the acute study, small intestine segments were subsequently reperfused using support rats. The support rats in the UW/SOD group also received SOD (1750 U, iv) at the onset of reperfusion of small intestine. After 2 hr of reperfusion, maltose absorption and weight gain of small intestine were determined. For the chronic study, small intestine segments were transplanted as isografts. SOD (1750 U, iv) was also given to recipients prior to reperfusion of grafts in the UW/SOD group. Long-term effects were determined by recipient survival for at least 17 days. Results showed the small intestine in the UW/SOD group had the best recovery of mucosal absorption (256 +/- 39 versus 202 +/- 21 in the Collins group, P less than 0.01), the least percentage weight gain (19 +/- 3% versus 25 +/- 5% in the UW group and 38 +/- 5% in the Collins group, P less than 0.01), and the best 17-day survival rate (9/12 versus 2/9 in the UW group, P less than 0.025, and 0/8 in the Collins group, P less than 0.01) among the three groups.(ABSTRACT TRUNCATED AT 250 WORDS)
Adenosine↗
Open technique for removal of intraarterial sheath after urokinase infusion in patients undergoing heparinization.
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Catheterization, Peripheral↗
Management of infected lower extremity autologous vein grafts by selective graft preservation.
Between 1975 and 1991, we treated 16 patients with infected lower extremity autologous vein grafts performed for limb salvage by complete graft preservation. Traditional treatment of these infections includes immediate graft excision and complex revascularization procedures to prevent limb loss. The infection involved an intact anastomosis in 12 patients or the body of a patent graft in 4 patients. None of the patients was systemically septic. All patients were treated with appropriate intravenous antibiotics. Six patients were treated by placement of autologous tissue on the exposed graft (4 rotational muscle flaps, 2 skin grafts), and 10 were treated with antibiotic-soaked dressing changes and repeated operative débridements to achieve delayed secondary wound healing. This treatment resulted in a 19% (3 of 16) mortality rate and an 8% (1 of 13) amputation rate in survivors. Of the six patients managed by autologous tissue placement onto the infected graft, five patients had wounds that healed without complications, and one died of a myocardial infarction. Of the 10 patients treated by delayed secondary wound healing, 2 developed anastomotic hemorrhage, which resulted in death in 1 patient and above-knee amputation in the other, 1 died of a myocardial infarction, 1 developed graft thrombosis, and 6 had wounds that healed. Placement of autologous tissue to cover an exposed, infected patent vein graft with intact anastomoses may prevent graft dessication, disruption, and thrombosis, which renders graft preservation an easier, safer method of treatment compared with routine graft excision.
Aged↗
Are gram-negative bacteria a contraindication to selective preservation of infected prosthetic arterial grafts?
Management of infected prosthetic arterial grafts has traditionally included total graft excision especially when gram-negative bacteria were cultured. Between 1973 and 1991 we treated 42 patients with infected prosthetic grafts (33 polytetrafluoroethylene (PTFE), 9 Dacron) by complete graft preservation when the graft was patent, the anastomoses were intact, and the patient did not have sepsis. The infection involved the anastomosis (36 cases) or the body (6 cases) of 33 peripheral grafts and the distal segment of five aortofemoral and four iliac-distal grafts. Cultures of the 42 infected grafts grew gram-positive bacteria in 33 cases and gram-negative bacteria in 22 cases. Treatment adjuncts included repeated, radical operative wound debridement and rarely (7 of 42) rotational muscle flaps. This management resulted in a 10% (4 of 42) hospital mortality rate and an amputation rate in survivors of 3% (1 of 38 threatened limbs). All four deaths were due to sepsis: gram-positive bacteria were cultured in all cases and gram-negative bacteria in two cases. Of the 38 survivors, 29 (76%) wounds healed and remained healed after average follow-up of 3 years (range, 1 to 18 years). Nine other patients required total graft excision for nonhealing wounds (7 cases) or delayed anastomotic hemorrhage (2 cases). Gram-negative bacteria were cultured in four, and gram-positive bacteria were cultured in six of these nine wounds. Four of nine (44%) graft infections that cultured Pseudomonas organisms healed without complications versus 23 of 33 (70%) wounds that cultured gram-positive bacteria, and 12 of 13 (92%) wounds that cultured gram-negative bacteria other than Pseudomonas organisms.(ABSTRACT TRUNCATED AT 250 WORDS)
Blood Vessel Prosthesis↗
Natural history, duplex characteristics, and histopathologic correlation of arterial injuries in a canine model.
The treatment of patients with penetrating extremity trauma in proximity to major arteries as well as the nonoperative treatment of clinically occult arterial injuries remain controversial. Duplex ultrasonography (DUS) has recently been advocated in this setting. We therefore studied experimentally induced arterial injuries in dogs to correlate the natural history, duplex findings, and histopathologic condition of different injuries and to help define criteria for operation. Fifty-two canine femoral and carotid arteries were randomized to have surgically created intimal flaps (n = 15), crush injuries (n = 15), or lacerations (n = 15) or to be controls (n = 7). An experienced sonographer, blinded to the presence or type of injury, evaluated the vessels every 10 days for 1 month. Histopathologic study was performed 1 month after injury when the arteries were retrieved. The sensitivity (96.5%), specificity (86.4%), and accuracy (95.1%) of DUS in evaluating arterial injuries at 1 month correlated well with histopathologic evaluation. All arteries subjected to crush injuries showed abnormal duplex findings. These findings correlated well with the histologic picture of severe injury (arterial wall thickness = 2.72 x +/- 0.23 x control; intramural hemorrhage, 93%; mural thrombus, 60%). DUS and histologic study revealed healing of intimal flaps in 27% of the arteries. Other intimal flaps deteriorated (stenoses, 47%; dilation, 13%; occlusion, 13%). Most lacerations (86%) revealed duplex evidence of healing within 10 days of injury. This was confirmed by histologic study at 1 month in 73% of lacerated arteries. This study confirms the accuracy of DUS in diagnosing various arterial injuries and shows that the natural history of these injuries varies with the mechanism of injury.(ABSTRACT TRUNCATED AT 250 WORDS)
Animals↗
Correction of steal syndrome secondary to hemodialysis access fistulas: a simplified quantitative technique.
Correction of symptomatic vascular steal distal to an arteriovenous fistula requires either fistula ligation or banding. Ligation carries the obvious disadvantage of destruction of a functioning angioaccess, whereas banding procedures have been plagued by the complexity of many of the reported techniques and by the difficulty of balancing fistula flow with distal perfusion. In this study a simple plication technique is described that avoids the introduction of any additional foreign material and that quantifies distal perfusion by means of intraoperative pulse volume recordings. Five patients have been treated by this method, two with autologous vein fistulas and three with bridge fistulas using polytetrafluorethylene. All five have had resolution of their ischemic symptoms with an increase in intraoperative pulse volume recordings of 5 mm or more. Only three of the patients had restoration of the radial pulse, which was not a specific end point of the banding procedure. Furthermore, all fistulas remained patent for at least 6 months and continued to provide adequate flows for hemodialysis. Banding/plication is clearly preferable to fistula closure for the management of steal syndrome. The method described herein is simple and hemodynamically identifies the minimal constriction that will resolve symptoms and preserve fistula flow.
Adult↗
Emergency abdominal aortic aneurysm surgery.
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Aorta, Abdominal↗
Improved small intestinal preservation with additional use of superoxide dismutase to University of Wisconsin solution.
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Adenosine↗
Unsuspected preexisting saphenous vein disease: an unrecognized cause of vein bypass failure.
Our prior anecdotal experience with unsuspected preexisting saphenous vein disease prompted us to study its incidence, its relation to graft failure, and to identify techniques for its detection. Thick-walled, postphlebitic sclerotic occluded, postphlebitic sclerotic recanalized, calcified, and varicose vein lesions were detected in 63 (12%) of 513 infrainguinal vein bypasses. In 13 (2% to 5%) cases, severe saphenous vein disease precluded use of the vein. In the remaining 50 cases, the entire vein or a portion thereof, with minimal or unsuspected disease, was used for bypass. Early graft failures occurred in 10 (20%) of the 50 cases. The cumulative primary patency rate at 30 months for bypasses performed with diseased veins was 32%. This was significantly less than the 73% cumulative primary patency rate for bypasses with veins without detectable disease (p less than or equal to 0.001). Retrospective evaluation of preoperative duplex ultrasonography (n = 21) originally used to evaluate saphenous vein length and diameter correctly identified thick-walled, occluded, calcified, and varicose veins in 62% of cases. Intraoperative methods of vein evaluation included inspection, palpation, irrigation, catheter or valvulotome insertion to identify obstruction, and intraoperative arteriography. Histologic examination of diseased veins demonstrated a spectrum of disease with thickening of the intima and media, vein wall calcification, and luminal recanalization. We conclude that (1) unsuspected preexisting saphenous vein disease occurs in approximately 12% of cases and results in both early and late graft failures; (2) detection, in some cases, is possible with duplex ultrasonography and intraoperative techniques; and (3) diseased veins that are recanalized, calcified, or thick-walled should not be used if an alternative vein is available.
Chi-Square Distribution↗
A twelve-year experience with the popliteal-to-distal artery bypass: the significance and management of proximal disease.
The value of the popliteal-to-distal artery bypass in limb salvage is well documented. However, the influence of progression of disease in the superficial femoral artery or proximal popliteal artery, and the role of percutaneous transluminal angioplasty of these vessels before bypass have not been adequately assessed. To evaluate these and other factors, we reviewed our experience with 153 nonsequential popliteal-to-distal artery bypasses performed over a 12-year period. Limb salvage was the indication for all procedures, and 87% of the patients were diabetic. The 5-year primary and secondary graft patency rates were 55% and 60%, respectively, and the limb salvage rate was 73%. Preoperative arteriograms were evaluated for stenosis in the superficial femoral artery or popliteal artery proximal to the graft. Fifty-six grafts with a proximal stenosis 20% or less were identified and had primary graft patency of 77% at 2 years, similar to the 70% patency for the 20 grafts placed distal to a 21% to 35% stenosis. The 18 grafts placed distal to a stenosis greater than 35% had 53% 2-year primary graft patency (p = 0.25). Percutaneous transluminal angioplasty of a superficial femoral artery or popliteal artery stenosis (24% to 85% luminal narrowing) in 19 limbs resulted in 68% 2-year graft patency, not significantly lower than grafts with 35% or less proximal stenosis (75%, p = 0.25). Other factors associated with significant decreases in graft patency included a vein graft diameter less than 3.0 mm, a dorsalis pedis outflow site, and poor quality outflow. Thus the popliteal-to-distal bypass is a durable procedure.(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
Early experience with the smart laser in the treatment of atherosclerotic occlusions.
A dual-laser system (helium-cadmium and pulsed dye) capable of continuous computer analysis of spectroscopic characteristics of tissue fluorescence, which can distinguish atherosclerotic plaque from components of normal arterial wall, was used to deliver laser energy to ablate plaque. During a 1-year period this system was used to facilitate balloon angioplasty of short (3 to 17 cm) total occlusions of the superficial femoral or popliteal arteries only when standard angioplasty techniques were ineffective. During the year of the study, in one institution 415 patients were subjected to arteriography of the lower extremities for leg ischemia (397 for limb salvage indications). Standard angioplasty techniques were used in 94 of these patients; 218 patients were unsuitable for standard angioplasty, did not fulfill criteria for "smart" laser treatment, and underwent standard bypass operations. Only 11 patients (plus six others in the second institution) requiring treatment fulfilled the criteria for use of the "smart" laser. In 10 patients the occluding lesion was traversed by the laser wire (diameter 0.021 inch), and luminal patency was effectively restored by balloon angioplasty to greater than or equal to 70% of the most normal-appearing segment of that artery. Satisfactory luminal patency has persisted for 2 to 12 months (mean 6 months) in nine patients; the lesion in the tenth patient restenosed at 3 months. The laser procedure was unsuccessful in all three patients with occlusions greater than 10 cm and in four others. Although there were three microperforations with the laser wire, there were no clinically significant complications.(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
Unilateral aortofemoral bypass: a safe and effective option for the treatment of unilateral limb-threatening ischemia.
To determine whether unilateral aortofemoral (AUF) bypass is a safe and effective option for the treatment of unilateral limb-threatening ischemia in patients with aortic or bilateral iliac occlusive disease, we reviewed the results of 42 AUF bypasses performed using polytetrafluoroethylene grafts in patients operated on for limb salvage; 11 (26%) of the patients also underwent femoropopliteal or femorodistal (FP/D) bypasses. The indications for surgery were tissue necrosis or ulceration in 18 (43%) patients and rest pain in 17 (40%) patients. The 5-year primary graft patency and limb salvage rates for AUF bypass were 74% and 84%, respectively. The perioperative mortality rate was 5%. There were no significant differences in the primary graft patency or limb salvage rates in patients who underwent AUF bypass with or without FP/D bypass. Only 3 of 41 (7%) AUF bypass patients required subsequent femorofemoral bypass. We conclude that: (1) AUF bypass is a safe and effective surgical option in patients with unilateral limb-threatening ischemia and aortic or bilateral iliac occlusive disease; (2) the routine performance of an aortobifemoral or axillobifemoral bypass in patients with unilateral limb-threatening ischemia may be unnecessary; and (3) AUF bypass facilitates the combined inflow and infrainguinal operations that are frequently required for limb salvage in these patients.
Adult↗
Value and limitations of secondary femoropopliteal bypasses with polytetrafluoroethylene.
Secondary femoropopliteal bypasses with polytetrafluoroethylene (PTFE) grafts are widely regarded to be of questionable value. This has prompted some to abandon all attempts at secondary revascularization with PTFE and others to recommend that primary femoropopliteal bypasses be performed preferentially with PTFE grafts so that vein may be used for secondary procedures. Because we questioned both of these views, we reviewed all femoropopliteal bypasses done at our institution in the past 12 years and identified 73 secondary PTFE femoropopliteal procedures performed after a failed ipsilateral infrainguinal bypass (69 failed femoropopliteal; 4 failed femorodistal). Seventy (96%) secondary bypasses were performed for limb salvage and 3 (4%) for severe disabling claudication. Insertion of grafts to the popliteal artery was above the knee in 26 (36%) and below the knee in 47 (64%). Primary life-table graft patency at 4 years was only 38%. Forty-eight reinterventions in 34 limbs were required to restore or maintain graft patency in thrombosed or failing grafts. For thrombosed grafts, 20 interventions consisted of 9 simple thrombectomies and 11 thrombectomies with additional revision procedures (5 distal or proximal extensions, 6 patch angioplasties). Twenty-eight lesions threatening graft patency were treated by percutaneous transluminal angioplasty in 3, proximal or distal extensions in 20, and patch angioplasty in 5. As a result of these reinterventions, the overall secondary patency rate was 55% at 4 years, and the limb salvage rate was 74% at 4 years. Although aggressive follow-up and reintervention may be required, the use of secondary PTFE conduits in the femoropopliteal position is a viable option in patients undergoing limb salvage procedures who are at high risk.(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
Epidural versus general anesthesia for infrainguinal arterial reconstruction.
A prospective evaluation of 213 consecutive infrainguinal bypass procedures was performed to determine the effect of anesthesia technique on the postoperative complication rate. Limb salvage was the indication for surgery in 92% of cases. No significant differences were observed in age, sex, indication for surgery, presence of cardiovascular and pulmonary risk factors, American Society of Anesthesiologists classification, or Goldman scores between patients receiving epidural anesthesia and those receiving general endotracheal anesthesia. Epidural anesthesia was used for 96 procedures and general endotracheal anesthesia was used in 117 cases. Cardiac complications for the epidural anesthesia and general endotracheal anesthesia groups, respectively, included a mortality rate of 5% versus 3%, nonfatal infarctions in 6% versus 7%, and reversible cardiac events in 14% versus 16%. A high-risk subgroup of 69 patients (American Surgical Association classes IV and V or Goldman score greater than 10 points) also had no significant difference in outcome between epidural anesthesia and general endotracheal anesthesia. Major noncardiac complications occurred in an additional 8% of each group. Regional and general anesthesia therefore produce equivalent cardiovascular risk for infrainguinal arterial reconstruction. These results suggest that indicated operations should not be postponed or avoided for patients either requiring or requesting general anesthesia. Furthermore, other investigations of cardiac risk in vascular surgery do not require a uniform anesthetic technique for valid interpretation of results.
Aged↗
A ten-year experience with one hundred fifty failing or threatened vein and polytetrafluoroethylene arterial bypass grafts.
Between Jan. 1, 1980, and Dec. 31, 1989, 2187 infrainguinal revascularization procedures were performed. In 130 of these cases with patent bypasses, hemodynamic deterioration was suspected, and urgent arteriography was performed. Twenty additional patients with aortofemoral, femorofemoral, or axillofemoral bypasses demonstrated hemodynamic deterioration. In 93% of failing grafts the condition was suspected because of recurrent symptoms or changes in the pulse examination. Two hundred eighty-five high-grade stenotic or occlusive lesions were identified in inflow arteries, outflow arteries, within the graft, or at proximal or distal anastomoses associated with these 150 grafts. One hundred sixty-one (57%) of these lesions were in patients with failing vein grafts; 115 (40%) were in patients with failing polytetrafluoroethylene (PTFE) grafts; and 9 (3%) were associated with failing composite vein/PTFE grafts. Stenotic lesions less than 5 cm in length were initially treated with percutaneous transluminal balloon angioplasty (PTA). Occlusive lesions, stenoses greater than 5 cm in length, and PTA failures were treated surgically. The overall 6-year cumulative secondary patency rate for failing grafts was 65%, and the limb salvage rate was 75%. The extended patency rate after the first intervention in the failing state was 56% at 5 years. The 5-year secondary patency rate for grafts initially treated with PTA (58%) was not significantly different (p = 0.25) from that for grafts treated initially with surgery (71%). Percutaneous transluminal angioplasty was effective for inflow stenoses of the iliac, femoral, and popliteal arteries and for some outflow lesions.(ABSTRACT TRUNCATED AT 250 WORDS)
Angioplasty, Balloon↗