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Biomedical subjects

L M Taylor

Publications and source records attributed to L M Taylor.

At least 19 recordsLinked to original sources
PubMed1995

Reducing perioperative myocardial infarction following vascular surgery. The potential role of beta-blockade.

OBJECTIVE: To determine which perioperative variables may influence the occurrence of perioperative myocardial infarction (PMI) following vascular surgery. DESIGN: Case-control study. SETTING: Combined Veterans Affairs Medical Center-university hospital vascular service. PATIENTS: During a 4-year period, all major vascular surgical operations (N = 2088) were evaluated with serial postoperative electrocardiography and cardiac enzyme measurements. Patients with PMI following nonemergent vascular surgery (N = 53) were matched with randomly selected control patients without PMI (N = 106) for age, gender, type of operation, hypertension, and symptoms of coronary artery disease. MAIN OUTCOME MEASURES: The two groups were compared for operative blood loss, blood pressure, and heart rate as well as length of operation, type of anesthetic, and use of perioperative beta-blockers, nitroglycerine, calcium channel blockers, vasopressors, and angiotensin-converting enzyme inhibitors. RESULTS: beta-Blockers were used less frequently in patients with PMI than in control patients without PMI (30% vs 50%; P = .01). Overall beta-blockade was associated with a 50% reduction in PMI (P = .03). Perioperative myocardial infarction was not associated with length of operation, type of anesthetic, blood pressure, or use of other medications. CONCLUSIONS: beta-Blockade is associated with a decreased incidence of PMI in patients undergoing vascular surgery. Prophylactic perioperative use of beta-blockers may decrease PMI in patients requiring major vascular surgery. A prospective randomized trial of beta-blockers in these patients appears to be warranted.

Adrenergic beta-Antagonists↗
PubMed1995

Prevalence of asymptomatic carotid stenosis in patients undergoing infrainguinal bypass surgery.

BACKGROUND: The prevalence of asymptomatic carotid stenosis in patients with lower-extremity ischemia is unknown. This report represents the largest carotid screening program to date of patients undergoing leg bypass. DESIGN: Patients undergoing infrainguinal bypass from 1987 through 1993 on the vascular surgery service at Oregon Health Sciences University, Portland, underwent routine carotid duplex examinations to detect the presence of asymptomatic carotid stenosis. PATIENTS: During the study period, 352 patients underwent infrainguinal revascularization for ischemia, of whom 225 (64%) had no prior carotid surgery, carotid arteriography, or cerebrovascular symptoms. There were 117 men and 108 women, with a mean age of 67 years. The indication for surgery was limb salvage in 67% and claudication in 33% of patients. RESULTS: Sixty-four patients (28.4%) who required lower-extremity revascularization had hemodynamically significant asymptomatic carotid artery stenosis or occlusion; 12.4% had stenosis of 60% or greater, the qualifying level for randomization in the Asymptomatic Carotid Atherosclerosis Study. Based on these findings, eight patients with carotid stenosis of 80% or greater underwent elective carotid endarterectomy. There were no postoperative neurologic events in the 225 leg bypass patients. By multivariate logistic regression analysis, the presence of carotid bruit (P < .001) and the presence of rest pain (P = .006) were associated with carotid stenosis of 50% or greater. Limiting screening to patients with carotid bruit, limb salvage indications for surgery, and/or advanced age excluded significant numbers of patients with stenosis; thus, these were not effective screening strategies. CONCLUSION: Screening carotid duplex scanning is indicated in patients who require lower-extremity revascularization.

Aged↗
PubMed1995

Usefulness of fasting and postprandial duplex ultrasound examinations for predicting high-grade superior mesenteric artery stenosis.

PURPOSE: A fasting duplex ultrasound examination of the superior mesenteric artery (SMA) accurately detects high-grade (> 70%) stenosis. It has been postulated that postprandial mesenteric duplex scanning may further stratify stenosis and improve the ability of a fasting examination to detect a high-grade stenosis. We performed fasting and postprandial duplex scanning of 25 healthy controls and 80 patients with vascular disease undergoing aortography to determine whether postprandial mesenteric duplex scanning provides information beyond a fasting study alone. METHODS: Patients with vascular disease were divided into three groups based on lateral aortography results: group 1, 0% to < 30% SMA stenosis (n = 61); group 2, 30% to < 70% stenosis (n = 10); and group 3, 70% to 99% stenosis (n = 9). Fasting mesenteric duplex scanning was defined as positive for 70% to 99% stenosis if the peak systolic velocity (PSV) was > or = 275 cm/s. The ability of either fasting or postprandial mesenteric duplex scanning, and their combination, to predict high-grade (70% to 99%) SMA stenosis was determined using angiographic control. RESULTS: Mean fasting SMA PSV did not differ among controls and groups 1 and 2. Postprandial PSV increased significantly in all groups, but was not different among controls and groups 1 and 2. Mean fasting PSV was significantly higher, and the postprandial increase in PSV significantly lower, in group 3 compared with controls and with groups 1 and 2. Fasting mesenteric duplex scanning predicted 70% to 99% SMA stenosis, with 89% sensitivity, 97% specificity, 80% positive predictive value, 99% negative predictive value, and 96% accuracy. Corresponding values for postprandial scanning were 67%, 94%, 60%, 96%, 91%, and for the combination of normal fasting and postprandial scanning 67%, 100%, 100%, 96%, 96%, respectively. CONCLUSION: Postprandial increases in SMA PSVs are blunted in patients with high-grade stenosis, but feeding velocities do not stratify between lesser degrees of stenosis. Both fasting and postprandial PSVs identify high-grade (> 70%) stenosis. Their combination marginally improves fasting duplex scan specificity and positive predictive value. Postprandial scanning is not necessary for the diagnosis of high-grade stenosis if a fasting study identifies a PSV > or = 275 cm/s. The combination of normal fasting and postprandial mesenteric duplex ultrasound scanning may effectively rule out high-grade SMA stenosis.

Adolescent↗
PubMed1995

Upper extremity thromboembolism caused by occlusion of axillofemoral grafts.

BACKGROUND: The axillofemoral bypass graft (AxFG) is increasingly accepted as treatment for lower extremity ischemia caused by aortoiliac occlusive disease in high-risk patients. The incidence of upper extremity (UE) thromboembolism caused by occlusion of an AxFG and the results of treatment form the basis for this report. METHODS: From 1984 to the present, all patients undergoing axillofemoral bypass grafting were followed up in a vascular registry. A standardized operative technique, using an externally supported 8-mm polytetrafluoroethylene graft, was used in performing 202 AxFGs in 182 patients. UE thromboembolism caused by occlusion of an AxFG was identified by retrospective patient record review. RESULTS: Occlusion of an AxFG occurred in 20 patients. Fifteen patients (75%) underwent immediate revision of the occluded graft. Two patients (10%) developed UE thromboembolism simultaneous with graft occlusion. One of these patients had immediate revision of the graft, and 1 had brachial embolectomy only. This patient and 4 others (25%) had the occluded AxFG left in place. Four of these 5 patients (80%) developed UE thromboembolism at 26 days, 2 years, 5 years, and 7 years, respectively, after occlusion. Overall, six UE thromboembolic complications occurred in 5 patients. CONCLUSIONS: UE thromboembolism represents a significant and specific complication of occluded AxFGs in our series (2.7% of patients, 25% of occluded grafts). It may be prudent to prophylactically detach the axillary portion of the graft and repair the axillary artery in patients who do not require immediate revision of an occluded AxFG.

Algorithms↗
PubMed1995

Diagnosis and long-term clinical outcome in patients diagnosed with hand ischemia.

PURPOSE: The long-term clinical outcome of patients diagnosed with digital artery obstruction and symptomatic hand ischemia is largely unknown. Our long-term experience with the diagnosis of symptomatic digital artery obstruction and the long-term natural history of this condition forms the basis for this report. METHODS: From 1971 to 1985, 44 patients with symptomatic hand ischemia and palmar or digital arterial obstruction underwent arteriography and digital photoplethysmography (PPG). Patients were grouped according to severity of hand ischemia symptoms, including ulceration and digital amputation and the presence of a connective tissue disease (CTD). Arteriography was compared with PPG by creating an objective severity scale (digital obstruction index [DOI]). RESULTS: Average follow-up was 15.2 years (range 10 to 22 years). Initially 21 patients (48%) had moderate symptoms, and 23 patients (52%) had severe symptoms of hand ischemia. Follow-up symptoms in 28 patients improved (13 of 26 with CTD, 15 of 18 without CTD), in 15 patients (12 of 26 with CTD, 3 of 18 without CTD) remained unchanged, and in only 1 patient (1 of 26 with CTD) worsened. Seventeen (65%) patients with CTD (n = 26) had development of one or more ulcers, and six (24%) underwent one or more digital amputations. Four (22%) patients without CTD (n = 18) had finger ulceration (p < 0.012 compared with patients with CTD), and one patient (6%) underwent subsequent digital amputation (p = NS). The arteriography-DOI and PPG-DOI were equally accurate in determining severity of finger ischemia as manifested by severity of symptoms or ulcer development. CONCLUSIONS: The favorable long-term prognosis of symptomatic finger artery occlusion described herein mandates the avoidance of premature finger amputation. Patients with CTD fare worse, but even in this group tissue loss is modest. Finger PPG is as accurate as arteriography for determining severity of hand ischemia.

Adolescent↗
PubMed1995

Progression of atherosclerosis in arteries distal to lower extremity revascularizations.

PURPOSE: The characteristics of progression of atherosclerotic occlusive disease (AOD) of the lower extremities after revascularization are unknown. Duplex scanning or angiography were used to determine progression in 150 patients after they underwent revascularization for AOD. METHODS: Follow-up studies were compared with presurgical arteriograms. Superficial femoral (SFA) and popliteal arteries were graded as less than 50% stenosis, 50% to 99% stenosis, or occluded. Tibial arteries were graded with regard to whether they were continuously patent from the popliteal trifurcation to the ankle. Progression was defined as an increase in one stenosis category. RESULTS: At a mean follow-up of 4.8 years, 18% of native arteries, 39% of extremities, and 52% of patients demonstrated progression of AOD. Overall, 21% of arteries in patients undergoing infrainguinal bypass and 14% of arteries in patients undergoing suprainguinal bypass demonstrated progression (p = 0.004). Progression was more frequently detected in examinations performed more than 4 years after baseline arteriography (66%) than in examinations performed 6 months to 2 years (45%, p = 0.032) or 2 to 4 years (44%, p = 0.029) after baseline arteriography. Thirty percent of SFAs demonstrated progression, and 32% with 50% stenosis or greater at baseline became occluded. There was no difference in SFA, popliteal, or tibial artery progression in revascularized versus nonrevascularized extremities after suprainguinal bypass. There was no difference in tibial artery progression in operated and nonoperated limbs after femoropopliteal artery bypass. CONCLUSIONS: AOD progression occurs frequently in patients requiring revascularization and is more prevalent in patients requiring femoropopliteal than in patients requiring suprainguinal bypass. AOD progression in patients undergoing vascular surgery is associated with the pattern of disease producing lower extremity ischemia and does not appear to be worsened by arterial reconstruction.

Adult↗
PubMed1995

Do normal early color-flow duplex surveillance examination results of infrainguinal vein grafts preclude the need for late graft revision?

PURPOSE: Optimal duration of postoperative duplex surveillance of infrainguinal vein grafts is not known. Previous reports have suggested nearly all vein graft stenoses are present within the first postoperative year, and normal duplex examination results during this time eliminate the need for ongoing graft surveillance. To determine whether surveillance may be safely discontinued in patients with normal early postoperative surveillance studies, we reviewed the color-flow surveillance examinations in our patients who underwent infrainguinal reverse vein graft revisions during a 4 1/2 year period. METHODS: Clinical and vascular laboratory records were reviewed of all patients who underwent infrainguinal reverse vein bypass grafting followed by subsequent graft revision for a duplex scanning-detected abnormality at our institution between January 1990 and July 1994. RESULTS: Of 447 infrainguinal reverse vein bypasses performed, 36 (8.1%) underwent surgical revision as a result of an abnormal finding during routine duplex surveillance. The initial postoperative duplex examination was obtained within 2 weeks of graft implantation in 23 (64%) patients, between 2 weeks and 3 months in 10 (28%) patients, and between 3 and 6 months in three (8%) patients. Duplex abnormalities prompting revision included 11 (31%) grafts with a mid-graft peak systolic velocity (PSV) < or = 45 cm/sec, 23 (64%) grafts with a focal PSV > or = 200 cm/sec, one graft with a PSV > or = 150 cm/sec but < 200 cm/sec, and one thought to be occluded by duplex but found to be patent by angiography. Abnormal duplex findings were initially detected within 2 weeks of graft implantation in five (14%) patients, between 2 weeks and 3 months in eight (22%) patients, from 3 to 6 months in 12 (33%) patients, from 6 to 12 months in six (17%) patients, and > 1 year in five (14%) patients. In only 25% of cases were mid-graft PSVs < or = 45 cm/sec or focal velocities > or = 200 cm/sec identified on the initial examination; 75% were found during subsequent surveillance. CONCLUSIONS: Although most reverse vein graft abnormalities detected by duplex surveillance and prompting graft revision appear within the first postoperative year, many are not detected on the initial examination. In our recent experience 31% of duplex abnormalities leading to vein graft revision were first detected more than 6 months after operation. Discontinuation of graft surveillance based on normal early findings will result in thrombosis of some vein grafts that may otherwise be salvaged.

Adult↗
PubMed1995

Deep vein thrombosis associated with lower extremity amputation.

PURPOSE: Patients undergoing lower extremity amputation are perceived to be at high risk for deep vein thrombosis (DVT). Limited data are available, however, to confirm this impression. The purpose of this study is to prospectively document the incidence of DVT complicating lower extremity amputation. METHODS: During a recent 28-month period, 72 patients (71 men, 1 woman; mean age 68 years) undergoing major lower extremity amputation (31 above-knee and 41 below-knee) were prospectively evaluated with perioperative duplex scanning for DVT. RESULTS: DVT was documented in nine (12.5%) patients (one bilateral, four ipsilateral, and four contralateral to amputation). Patients with a history of venous disease were at significantly higher risk for development of DVT (p = 0.02). Thrombi were located at or proximal to the popliteal vein in eight patients and were isolated to the tibial veins in one patient. DVT was identified before operation in six patients and after operation in three. Patients with DVT were treated with heparin anticoagulation, with no patient experiencing clinical symptoms compatible with pulmonary embolism. CONCLUSIONS: In our recent experience, lower extremity amputation is associated with DVT at or proximal to the popliteal vein in 11% of patients. Documentation of DVT prevalence is essential to assist surgeons in planning a management strategy for prevention, diagnosis, and treatment of DVT associated with lower extremity amputation.

Aged↗
PubMed1995

Screening for asymptomatic internal carotid artery stenosis: duplex criteria for discriminating 60% to 99% stenosis.

PURPOSE: The Asymptomatic Carotid Atherosclerosis Study (ACAS) showed that carotid endarterectomy reduces stroke risk in symptom-free patients with 60% or greater internal carotid artery (ICA) stenosis. This will surely lead to the performance of an increased number of screening duplex examinations. Assuming that positive study results will lead to arteriography or endarterectomy and keeping in mind the modest benefit for prophylactic endarterectomy demonstrated by ACAS (absolute risk reduction for ipsilateral stroke of 5.8% at 5 years), duplex criteria for 60% or greater ICA stenosis must have high positive predictive values (PPV). Determining criteria for 60% or greater stenosis, which emphasized high accuracy and PPV, forms the basis for this study. METHODS: Stenoses detected by angiography in 352 ICAs were blindly compared with those detected by duplex scanning. Duplex criteria were determined for highest overall accuracy in detection of 60% or greater ICA stenosis and for 95% or greater PPV. RESULTS: Maximal accuracy for detection of 60% or greater stenosis was 90%. This was achieved by the combination of a peak systolic velocity of 260 cm/sec or greater and an end diastolic velocity of 70 cm/sec or greater (sensitivity 84%, specificity 94%, PPV 92%). The 95% PPV for 60% or greater stenosis results from combining peak systolic velocity of 290 cm/sec or greater and end diastolic velocity of 80 cm/sec or greater. CONCLUSIONS: With use of these criteria duplex scanning accurately detects with high PPVs the threshold level of ICA stenosis defined in ACAS as receiving stroke reduction benefit from prophylactic carotid endarterectomy. These criteria should be useful for carotid artery screening and minimizing unneeded intervention.

Blood Flow Velocity↗
PubMed1994

Axillofemoral grafting with externally supported polytetrafluoroethylene.

OBJECTIVE: To evaluate the results of axillofemoral bypass grafting using externally supported polytetrafluoroethylene. DESIGN: Consecutive patients who were operated on by us from 1983 to the present were prospectively followed up in a vascular registry. The results of surgery with respect to morbidity and mortality, patency, limb salvage, and patient survival were determined by life-table methods. PATIENTS: A standardized operative technique was used to perform 184 axillofemoral bypass procedures in 164 consecutive patients (age range, 14 to 90 years; mean age, 67 years; female, 33%). Follow-up ranged from 0 to 95 months (mean, 23 months). RESULTS: Ischemia was the indication for 83% of the procedures, and aortic sepsis was the indication for 16%. There were nine operative deaths (5%) and 17 major complications. Life-table primary patency, limb salvage, and survival rates at 5 years were 71%, 92%, and 52%, respectively. Indication for surgery, patency of the superficial femoral artery, and the performance of multilevel procedures did not significantly influence patency. CONCLUSIONS: The results of axillofemoral grafting using polytetrafluoroethylene are equivalent to those achieved with other accepted methods of treatment for lower extremity ischemia, including balloon angioplasty, aortofemoral bypass, and infrainguinal bypass. Axillofemoral bypass is an appropriate technique that is deserving of more widespread use.

Adolescent↗
PubMed1994

Isolated bypass to the superior mesenteric artery for intestinal ischemia.

OBJECTIVE: A number of reports indicate revascularization for intestinal ischemia should include the superior mesenteric artery (SMA) and the celiac artery. However, no controlled or randomized studies have proven this approach superior to SMA bypass alone. We report our results using bypass to only the SMA for intestinal ischemia. DESIGN: Retrospective review with mean follow-up of 40 months (range, 2 to 110 months). SETTING: University medical center and Veterans Affairs hospital. PATIENTS/METHODS: The records of patients who underwent intestinal revascularization of the SMA alone from 1982 through 1993 were reviewed. Patients were assessed for indication for operation, operative technique, perioperative mortality, and long-term outcome. The SMA grafts were examined for patency within the last 6 months using duplex scanning or arteriography. Patient survival and graft patency rates were calculated using life-table methods. RESULTS: Twenty-nine bypasses to only the SMA were performed in 26 patients (16 female and 10 male; mean age, 59 years; age range, 13 to 81 years). Indication for operation was symptomatic chronic mesenteric ischemia in 23 cases and acute intestinal ischemia in five cases. One bypass was performed for asymptomatic SMA occlusion. There were three perioperative deaths (10% mortality rate), all in patients with acute intestinal ischemia and previous mesenteric arterial surgery. Life-table 4-year primary graft patency and patient survival rates were 89% and 82%, respectively. Symptomatic improvement was maintained in all patients available for follow-up. CONCLUSION: Revascularization of only the SMA for intestinal ischemia provides excellent graft patency with acceptable perioperative mortality and long-term patient survival. The SMA bypass alone for intestinal ischemia appears as successful as bypasses to multiple visceral vessels.

Adolescent↗
PubMed1994

Importance of elevated plasma homocysteine levels as a risk factor for atherosclerosis.

Atherosclerosis is a leading cause of death and disability in the Western world, and an important risk factor for it may be an elevated level of the plasma amino acid homocysteine. The biochemical characteristics of homocysteine, along with historical, laboratory, and clinical evidence for its pathologic role in atherosclerosis, are reviewed. Possible therapies for reducing elevated homocysteine levels and the possible impact of therapy in atherosclerosis are examined.

Animals↗
PubMed1994

Acute disruption of polytetrafluoroethylene grafts adjacent to axillary anastomoses: a complication of axillofemoral grafting.

PURPOSE: Acute disruption at or adjacent to axillary anastomoses of axillofemoral grafts has been sporadically reported. We have recently reported the patency and limb salvage results of a large number of axillofemoral grafts. In this report we describe a series of axillary artery-graft disruptions that occurred in these patients. METHODS: Beginning in 1983, axillofemoral bypass was performed by the authors using standardized operative technique and a single prosthetic graft material (8 mm externally supported polytetrafluoroethylene). Axillary anastomoses were placed on the first portion of the artery and were performed with the arm abducted and with the graft redundant. The records and operative reports of all patients with disruption were reviewed for findings and subsequent hospital course. RESULTS: Two hundred two axillofemoral grafts were performed from 1983 to 1993. Ten patients (5%) had axillary disruption at intervals ranging from 1 to 46 days (mean 21 days) after operation. Ischemia was the indication for operation for seven of the patients and infected aortic prostheses for three. Infection did not occur in any of the axillary wounds and was not the cause of any of the disruptions. Four disruptions occurred with arm abduction/shoulder elevation movements; three awakened patients from sleep, and one occurred while the patient was sitting quietly. For the other two patients, preceding activity was unknown. Brachial plexus deficit was present in one patient. Four of the 10 disrupted grafts were also acutely occluded. Operative findings included sutures pulling out of the artery in four cases, tearing or sutures pulling out of the graft in four cases, and cause unknown in two cases. Treatment included arterial ligation in one patient, and restoration of circulation through revision of the axillofemoral grafts in the other nine patients. There were no operative deaths. One patient had a prolonged hospital course followed by nursing home placement and died 9 months later. The brachial plexus deficit did not resolve. There have been no repeat disruptions. CONCLUSIONS: We conclude that axillofemoral grafting includes the potential for disruption of the proximal anastomosis, which has occurred in 5% of our patients. Although multiple steps have been recommended to avoid this complication, occasional cases continue to occur despite observing all precautions.

Acute Disease↗
PubMed1994

Surgical treatment of threatened reversed infrainguinal vein grafts.

PURPOSE: Current information concerning the results of surgical revision of threatened infrainguinal vein grafts is largely limited to in situ conduits. Infrainguinal grafts may be threatened by intrinsic graft lesions or significant stenosis in the adjacent inflow or outflow arteries. To assess the results of operative revision of infrainguinal reversed vein grafts, we reviewed our experience with surgical revision of threatened infrainguinal reversed vein grafts identified through a program of postoperative clinical and vascular laboratory graft surveillance. METHODS: All patients who underwent surgical revision of a threatened but patent infrainguinal reversed vein graft from January 1987 through April 1993 were identified through review of our vascular registry. Data were analyzed for type of vein used, date of original reversed vein graft, clinical and vascular laboratory findings leading to reversed vein graft revision, results of preoperative angiography, patient risk factors, operative techniques and complications, and long-term assisted primary graft patency and limb salvage. RESULTS: Ninety-six patients with 100 infrainguinal reversed vein grafts (69) femoral-popliteal, 31 femoral-tibial) underwent 117 surgical vein graft revisions or inflow procedures during the study period. Eighty-one percent of the original reversed vein grafts consisted of a single segment of greater saphenous vein. All revised grafts had at least a 50% stenosis in the graft itself or the proximal or distal artery. A single revision was performed in 85 grafts, two revisions in 13 grafts, and three revisions in two grafts. There were nine (8%) isolated inflow procedures, eight (7%) vein patch angioplasties, 62 (53%) interposition vein grafts, and 29 (25%) vein graft extensions to a new distal anastomotic site. The remaining nine (8%) procedures consisted of combinations of the above. Median time to primary graft revision after initial graft implantation was 15 months (range 2 days to 316 months). Mean time to secondary revision after primary revision was 21 months. Operative mortality was 0.9%. Cumulative assisted primary patency of the original grafts revised for stenotic lesions was 99%, 96%, and 92% at 1, 3, and 5 years, respectively. Limb salvage was 99%, 97%, and 97% at 1, 3, and 5 years, respectively. CONCLUSIONS: Although surgical revision of reversed vein graft requires much use of alternative vein sources, these procedures can be performed with minimum mortality and provide excellent assisted primary graft patency and limb salvage.

Adult↗
PubMed1994

Late survival after perioperative myocardial infarction complicating vascular surgery.

PURPOSE: Although early death from perioperative myocardial infarction (PMI) after vascular surgery is well established, long-term outcome in patients surviving PMI is unknown. This prospective study was designed to determine cardiac outcome and survival rates in patients with symptomatic and asymptomatic nonfatal PMI associated with peripheral vascular surgery. METHODS: During a 36-month period for 1989 to 1992, all patients undergoing vascular surgery at our institution were monitored for PMI with serial creatine kinase and myocardial band isoenzymes and electrocardiography. PMIs were classified as symptomatic (associated with chest pain, arrhythmia, congestive heart failure, or hypotension) or asymptomatic (electrocardiographic changes and/or elevated creatine kinase and myocardial band isoenzymes). Patients with PMI were then prospectively monitored and compared for late survival, with control patients undergoing vascular surgery without PMI during the same interval. RESULTS: During the study period 1561 major peripheral vascular procedures were performed. There were 47 PMIs (3.0%). Eleven (0.7%) PMIs were fatal, 31 were nonfatal, and five other patients with PMI died during operation of non-heart-related causes. Eight of 31 patients with nonfatal PMI had a "chemical PMI" with creatine kinase and myocardial band isoenzyme elevation as the sole indicator of PMI. During follow-up (mean 27.7 months), there was a higher incidence of both subsequent myocardial infarction and coronary artery revascularization among the patients with nonfatal PMI compared with control subjects (p < 0.05); however, survival for patients with nonfatal PMI at 1 and 4 years (80% and 51%) did not differ from that of control patients (90% and 60%) (p > 0.05). Patients with "chemical PMI" had similar patterns of subsequent myocardial infarction and coronary intervention as control patients. CONCLUSIONS: Patients surviving nonfatal PMI after peripheral vascular surgery have a higher incidence of subsequent adverse cardiac events and coronary artery revascularization than patients undergoing vascular surgery without PMI, but they have similar survival rates at 1 and 4 years. Patients in the enzyme-only PMI group have a similar outcome compared with control subjects suggesting that a perioperative "chemical MI" may not be a significant clinical event.

Aged↗
PubMed1994

Repeat leg bypass after multiple prior bypass failures.

PURPOSE: The optimal treatment of patients with severe lower extremity ischemia after multiple failed prior bypasses is unclear. It is presently unknown whether failure of attempted revascularization in these patients is so likely that such operation should not be elected. We have maintained an aggressive surgical policy of repeated revascularization regardless of prior failures. A review of our clinical experience with this difficult patient group was performed to determine the results of this policy. METHODS: From 1980 to 1992, 85 revascularization procedures were performed in 81 patients with lower extremity ischemia after failure of two or more prior infrainguinal bypasses in the same leg. All patients were prospectively entered and monitored in our vascular registry. Seventy-two operations were the third procedure, six operations were the fourth procedure, and seven operations were the fifth procedure on the same extremity. Twenty-six of the 85 procedures (30%) were revisions of failing grafts discovered by routine surveillance methods, whereas 59 were replacements of thrombosed grafts. Autogenous reconstruction was used in 67 procedures (79%), and prosthetic reconstruction was used in 18 procedures (21%). The distal anastomosis was to the popliteal artery in 19 patients and infrapopliteal artery in 66. RESULTS: Mean time to failure of the first leg bypass was 24 months and 4.9 months for the second bypass. Detailed hematologic screening revealed identifiable hypercoagulable disorders in nine (15%) of 59 patients screened after 1987. All nine had anticardiolipin antibodies. The operative mortality rate was 4%. Mean follow-up after the most recent operation was 17 months. The primary patency rate at 4 years was 79.8%. The limb salvage rate was 69.6% at 4 years. CONCLUSIONS: These results indicate that limb revascularization after two or more failed leg bypasses results in low operative mortality rates and surprisingly good primary patency and limb salvage rates at 4 years. The patient survival rate through 4 years is unexpectedly high. In our opinion these results justify an aggressive policy of limb vascularization after multiple failed prior bypasses.

Adult↗