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Biomedical subjects

T C Flynn

Publications and source records attributed to T C Flynn.

At least 19 recordsLinked to original sources
PubMed1997

Intraoperative autologous transfusion during elective infrarenal aortic reconstruction.

Intraoperative autologous transfusion devices have been purported to reduce allogenic transfusions and their associated complications. However, the value of their routine use during elective cardiovascular operations remains undefined. This study was designed to examine the efficacy of the Haemonetics Cell Saver (CS) during elective aortic reconstructions and identify predictors of clinically significant (> or = 500 cc) and cost-efficient (> or = 1250 cc) salvage volumes. The medical records of all patients undergoing elective infrarenal aortic reconstructions between January 1991 and June 1995 were retrospectively reviewed to determine blood loss, CS return, predictors of clinically significant/ cost-efficient CS returns, blood products transfused, and estimated cost per unit CS return. The CS was used for 138 (82.1%) of all reconstructions during the study period. Estimated blood loss (2127 +/- 1467 vs 1415 +/- 1047) and CS return (927 +/- 790 vs 515 +/- 408) were significantly greater in patients with aneurysms (AAA, N = 63) compared to those with aortoiliac occlusive disease (AIOD, N = 75). CS returns > or = 500 cc were common (79.4% AAA, 52.0% AIOD) and predictors of > or = 500 cc CS returns were large aneurysms (6.79 +/- 1.84 vs 5.72 +/- 0.71 cm) and male sex (82.0 vs 46.2%) in AAA patients and lower preoperative platelet counts (262 +/- 93 vs 311 +/- 113 K/mm3), concomitant renal revascularizations (20.5 vs 0%), and prolonged operative time (7.9 +/- 2.4 vs 6.9 +/- 2.1 hr) in AIOD patients. In contrast, CS returns > or = 1250 cc were relatively uncommon (28.6% AAA, 5.3% AIOD), and predictors of these CS returns were found only for AAA patients and included any concomitant vascular procedures (38.8 vs 15.6%) and the need for suprarenal aortic clamping (27.8 vs 6.7%). Despite the use of the CS, 73.8% of all patients required allogenic packed red blood cells with a mean of 3.0 +/- 3.1 units transfused in the perioperative period; no difference was seen between AAA and AIOD patients. The calculated cost for a unit of CS return was +128.77 for the AAA patients and +231.91 for the AIOD patients. Not using the CS and substituting the return with allogenic packed red blood cells would have saved +252.80 and +352.84 for the AAA and AIOD patients, respectively. Routine use of the CS during elective infrarenal aortic reconstructions is not cost efficient and should be abandoned. Use of the device should be reserved only for complex reconstruction.

Aged↗
PubMed1997

Intraoperative autologous transfusion during elective infrarenal aortic reconstruction: a decision analysis model.

PURPOSE: The use of intraoperative autologous transfusion devices expanded during the last decade as a result of the increased awareness of transfusion-associated complications. This study was designed to determine whether routine use of an intraoperative autologous transfusion device (Haemonetics Cell Saver [CS]) during elective infrarenal aortic reconstructions is cost-effective ($50,000/QALYs threshold). METHODS: A decision analysis tree was constructed to model all of the complications that are associated with red blood cell replacement during aortic reconstructions for both abdominal aortic aneurysm (AAA) and aortoiliac occlusive disease (AIOD). It was assumed that a unit of CS return (CSR; 250 ml/unit) equaled a unit of packed red blood cells (PRBCs) and that all CS transfusions were necessary. Transfusion requirements (AAA:PRBC = 2.8 +/- 3.2 units, CSB = 3.7 +/- 3.2 units; AIOD:PRBC = 3.1 +/- 3.0 units, CSR = 2.1 +/- 1.7 units) were determined from retrospective review of all elective aortic reconstructions (AAA, N = 63; AIOD, N = 75) from Jan. 1991 to June 1995 in which the CS was used (82.1% of all reconstructions). Risk of allogenic transfusion-related complications (transfusion reaction, hepatitis B, hepatitis C, human immunodeficiency virus, human T-cell lymphotropic virus types I and II) and their associated treatment costs (expressed in dollars and quality-adjusted life years (QALYs) were obtained from the medical literature, institutional audit, and a consensus of physicians. RESULTS: Routine use of the CS during elective infrarenal aortic reconstructions was not cost-effective in our practice. Use during reconstructions for AAA repairs cost $263.75 but added only 0.00218 QALYs, for a rate of $120,794/QALY. Use during reconstructions for AIOD was even more costly at $356.68 and provided even less benefit at 0.00062 QALYs, for a rate of $578,275/QALY. The sensitivity analyses determined that the routine use of the CS would be cost-effective in our practice only for AAA repairs if the incidence of hepatitis C were tenfold greater than the baseline assumption. The model determined that CS was cost-effective if the CSR exceed 5 units during reconstructions for AAA and 6 units during reconstructions for AIOD. CONCLUSIONS: The routine use of the CS during elective infrarenal aortic reconstructions is not cost-effective. The use of the device should be reserved for a select group of aortic reconstructions, including those in which cost-effective salvage volumes are anticipated. Alternatively, the CS should be used as a reservoir and activated as a salvage device if significant bleeding is encountered.

Aged↗
PubMed1996

Visceral ischemia and organ dysfunction after thoracoabdominal aortic aneurysm repair. A clinical and cost analysis.

OBJECTIVE: Repair of thoracoabdominal aortic aneurysms (TAAAs) is associated with significant postoperative morbidity and mortality. Reperfusion of acutely ischemic abdominal viscera in animals leads to release of multiple factors that cause local and distant organ damage, and similar phenomena occurring in humans after TAAA repair could contribute to the high morbidity/mortality and cost associated with this procedure. METHODS: Twenty-nine patients undergoing elective TAAA repair were studied prospectively. Preoperative organ dysfunction and intraoperative risk factors (cross-clamp time, blood loss, operative time) were assessed and compared with postoperative organ dysfunction (defined as: pulmonary, positive pressure ventilation for > 7 days; renal, increase in serum creatinine > 2.0 mg/dL over baseline; hepatic, lactate dehydrogenase > 500 international units and total bilirubin > 3.0 mg/dL or serum transaminase level > 200 international units; hematopoietic, platelet count > 50 K or leukocyte count > 4.5 K, mortality, and costs. RESULTS: No relationship between preoperative organ dysfunction, blood loss, or operative time and postoperative organ dysfunction or mortality was seen; however, cross-clamp times > 40 minutes were associated with a significantly greater incidence of pulmonary (59%), renal (47%), hepatic (35%), and hematopoietic (47%) dysfunction. In addition, multiple-organ dysfunction (> 2 organ systems) was more common after > 40 minutes of visceral ischemia and led to significantly greater overall hospital ($88,465 + $76,155 vs. $41,782 + $31,244) and intensive care unit ($26,726 + $28,256 vs. $11,234 + $12,146) costs (p < 0.01, Mann-Whitney U test). Mortality associated with leukopenia was 67% compared with 4% without leukopenia (p < 0.01). CONCLUSION: Increasing durations of acute visceral ischemia led to significant multiple organ dysfunction after TAAA repair. Methods of limiting visceral ischemia or the systemic effects of visceral ischemia may decrease both the morbidity and mortality and the overall hospital cost associated with this procedure.

Abdomen↗
PubMed1996

Prediction of cure of hypertension in atherosclerotic renal artery stenosis.

We analysed the outcome of 63 consecutive, adequate interventions for atherosclerotic renal artery stenosis and hypertension: 34 patients had percutaneous transluminal renal angioplasty, and 29 had surgical correction. Hypertension was cured in 21% of patients and improved in 47%, but 32% failed to respond. We analyzed clinical variables predictive of cure. Duration of hypertension, level of diastolic blood pressure, and sex were found to be predictive of cure. The highest probability of cure was found in men with a duration of hypertension of less than 10 years and an initial diastolic blood pressure of greater than 80 mm Hg. Use of these clinical variables in a tree-based model correctly classified 80% of cases, with a sensitivity of 92% and a specificity of 77%. We conclude that a tree-based clinical algorithm based on only three clinical criteria correctly predicted cure of hypertension in most patients with renal artery stenosis and may be useful in decision making. A prospective analysis will be required to evaluate the clinical validity of the algorithm.

Algorithms↗
PubMed1995

Selection of patients for renal artery repair using captopril testing.

BACKGROUND: Prediction of improvement following surgical or radiologic intervention in patients thought to have renovascular hypertension (RVH) is often unreliable. Use of the angiotensin-converting enzyme inhibitor captopril in conjunction with measurement of peripheral renin levels or radioisotope renograms is thought to detect patients with functionally significant renal artery stenosis. However, it is unclear whether these tests can identify patients whose hypertension will significantly improve after renal artery repair. PATIENTS AND METHODS: The records of 52 consecutive hypertensive patients undergoing captopril studies followed by renal artery repair were reviewed. All patients had either renal artery stenosis > 75% or renal artery occlusion. Preprocedure evaluation included a captopril challenge test (measurement of peripheral renin levels after captopril ingestion) (n = 12) or a captopril renogram (determination of renal blood flow and glomerular filtration rate before and after captopril administration) (n = 40). Either renal artery bypass/nephrectomy (n = 41) or balloon angioplasty (n = 11) was done in all patients (18 bilateral/34 unilateral). No periprocedural deaths occurred. All surgically placed bypass grafts were shown to be patent by contrast or carbon dioxide arteriography before hospital discharge. RESULTS: Preprocedure captopril tests were positive (suggestive of RVH) in 39 patients (75%) and negative in 13 (25%). All patients with positive captopril tests had improvement in their RVH after intervention (17 cured, 22 improved) while 8 of 13 patients with negative captopril tests had no improvement in blood pressure control. Four of five false-negative tests were associated with a unilateral total renal artery occlusion, making detection of a postcaptopril effect impossible. If these 4 patients are excluded from analysis, preprocedure captopril testing was 98% accurate in predicting postprocedure outcome. CONCLUSIONS: Preprocedure captopril testing permits extremely accurate selection of patients with renal artery stenosis who will benefit from renal artery repair.

Adult↗
PubMed1995

Operative mortality rates after elective infrarenal aortic reconstructions.

PURPOSE: This study was designed to test the hypothesis that cardiac complications (myocardial infarction, congestive heart failure, fatal arrhythmias) are no longer the leading cause of death after elective aortic reconstructions. METHODS: The medical records of all elective infrarenal aortic reconstructions performed between January 1982 and June 1994 were retrospectively reviewed. All perioperative deaths were analyzed to determine the cause of death and were compared with a subset of 266 survivors to identify any associated preoperative or intraoperative factors. RESULTS: Seven hundred twenty-two aortic reconstructions were performed for aneurysmal or occlusive disease, and there were 44 deaths (overall mortality rate of 6.1%). The mortality rate after aortic reconstruction alone was 4.9% and increased with the addition of renal (8.9%, p = 0.16) or lower extremity vascular procedures (15.8%, p = 0.01). Multisystem organ failure (MSOF) was the cause of death in 56.8%, of the patients (3.5% overall mortality rate) followed by cardiac events in 25% (1.5% overall mortality rate). Visceral organ dysfunction was the most common cause of MSOF leading to death in 14 patients (56.0%), and postoperative pneumonia was responsible for the fatal MSOF in nine patients (36.0%). Patient age, history of myocardial infarction/congestive heart failure, ejection fraction less than 50%, duration of operative time, and performance of additional procedures were associated with increased operative mortality rates by multivariate analysis. CONCLUSIONS: MSOF, predominantly from visceral organ dysfunction, was the leading cause of death after elective infrarenal aortic reconstruction. The risk of MSOF and operative death increases with the complexity of the procedure and the number of comorbid conditions.

Aged↗
PubMed1995

Limb-threatening ischemia due to multilevel arterial occlusive disease. Simultaneous or staged inflow/outflow revascularization.

SUMMARY BACKGROUND DATA: Limb-threatening ischemia due to severe multilevel arterial occlusive disease may require both inflow and outflow bypass to achieve limb salvage. Simultaneous inflow/outflow bypass has been advocated because the cumulative risks of separate staged inflow/outflow procedures can be avoided. However, the magnitude of complete revascularization is substantial; thus, the morbidity and mortality of simultaneous inflow/outflow bypass may be excessive. METHODS: The medical records of 450 patients undergoing lower extremity arterial reconstruction between 1988 and 1994 were retrospectively reviewed, allowing identification of 54 patients who had undergone simultaneous aortoiliac and infrainguinal bypasses. This group consisted of 38 men and 26 women (mean age: 64.7 years), with significant cardiac disease in 24, smoking history in 53, and diabetes mellitus in 15. Indications for surgery were limb-threatening ischemia in 48 (89%) and severe short-distance claudication in 6 (11%). Inflow disease was corrected by direct aortoiliac reconstruction in 28, whereas other extra-anatomic bypasses were constructed in 26. Outflow revascularization required infrainguinal bypass to the infragenicular arteries in 46 (below-knee popliteal: 21; tibial: 25), a concomitant profundaplasty in 26, and a composite bypass conduit in 14. RESULTS: Limb salvage was 97% at 30 days whereas morbidity/mortality were 61% and 19%, respectively. However, the majority of complications and deaths occurred in patients undergoing aortic inflow plus complex outflow procedures (profundaplasty and/or composite bypass conduits), in which the morbidity/mortality rates were 84.2% and 47.4%, respectively, compared with rates of 45.7% and 2.9% (p < 0.01) after all other inflow/outflow procedures. The increased difficulty of these complex procedures is reflected in the significantly greater blood loss and operative times (1853 mL and 10.0 hours) compared with similar values (1125 mL and 7.7 hours)(p < 0.01) for all other inflow/outflow procedures. CONCLUSION: Simultaneous inflow/outflow bypasses are effective and safe in patients with severe, multilevel arterial occlusive disease, except when a complex outflow procedure is needed in conjunction with direct aortoiliac reconstruction. In the latter setting, a staged procedure is recommended because it may be associated with less morbidity and mortality.

Adult↗
PubMed1994

Impact of angioscopy on infrainguinal graft patency.

To investigate the impact of angioscopy on infrainguinal graft patency, 50 consecutive cases with angioscopy as an adjuvant to infrainguinal arterial bypass performed during a 12-month period were reviewed (group I). For comparison, 42 similar cases of infrainguinal arterial reconstruction performed during the 12 months prior to introduction of routine intraoperative angioscopy were also reviewed (group II). Patients were followed up for 12 months and graft patency was determined at 1, 3, 6, and 12 months. An abnormality was identified in 13 (26%) group I patients (10, angioscopy alone; 1, arteriography alone; 2, both). Defects were anastomotic abnormalities (n = 7), vein sclerosis (n = 3), retained valve cusp (n = 2), and proximal artery stenosis (n = 1). A similar percentage, but different types of defects, were seen in group II; 11 patients (26%) had an abnormality (anastomotic abnormality [n = 3], vein sclerosis [n = 4], retained valve cusp [n = 1], and arterial outflow stenoses [n = 3]). All significant defects were surgically explored and corrected. Graft patency rates in group I and II at 1, 3, 6, and 12 months were 100% and 85% (P < 0.005), 94% and 80% (P < 0.05), 87% and 74% (P = non-significant [NS]), and 86.1% and 73.7% (P = NS), respectively. Intraoperative angioscopy detects anastomotic and vein graft defects not always seen on arteriography; the repair of these defects significantly improves early infrainguinal bypass graft patency rates.

Adult↗
PubMed1994

Does routine stress-thallium cardiac scanning reduce postoperative cardiac complications?

OBJECTIVE: Prophylactic cardiac revascularization in patients with ischemic myocardium could reduce postoperative cardiac complications after aortic reconstruction. However, the effectiveness of this approach has not been documented. SUMMARY BACKGROUND DATA: Stress-thallium scanning can identify patients with ischemic myocardium. Morbidity and mortality after aortic reconstruction appears to be largely caused by co-existent coronary artery disease, and patients who have had recent cardiac revascularization have few postoperative cardiac complications. METHODS: Preoperative stress-thallium scanning was evaluated prospectively in 146 patients undergoing aortic reconstruction. Patients with positive studies underwent coronary arteriography and cardiac revascularization, when appropriate. Postoperative cardiac complications and long-term survival in these patients were compared with results from 172 similar patients undergoing aortic reconstruction without stress-thallium scanning. Results also were analyzed to determine predictors of postoperative cardiac events. RESULTS: Forty-one per cent of patients undergoing stress-thallium testing underwent coronary arteriography, and 11.6% had cardiac revascularization. In contrast, 14.7% of patients treated without stress-thallium testing had coronary arteriography, and 4.1% had revascularization (p < 0.01). Despite this, cardiac mortality, serious cardiac complications, and long-term cardiac mortality were similar in both groups. Only advanced age and intraoperative complications (but not a positive stress-thallium test) predicted postoperative cardiac events. CONCLUSIONS: Preoperative stress-thallium testing confirmed a high incidence of significant coronary artery disease in patients undergoing aortic reconstruction, but prophylactic cardiac intervention does not reduce operative or long-term mortality. Thus, the risk and expense of routine stress-thallium testing and subsequent cardiac revascularization cannot be justified.

Aged↗
PubMed1994

Peripheral vascular injury.

Over the past 20 years, the predominant trend in the care of the civilian trauma patient has been toward less invasive therapy. Splenic injuries that are now being identified with computed tomography scan or ultrasound are managed without laparotomy. Similarly, in caring for the patient with potential vascular injury of the extremity, the trend has been toward less invasive means of diagnosis and therapy. Defining which patients need angiography and how to use duplex scanning and pressure indices are still evolving issues.

Aneurysm, False↗
PubMed1993

What do applicants look for when selecting internal medicine residency programs? A comparison of rating scale and open-ended responses.

OBJECTIVE: To develop reliable scale measures of factors most important to applicants when they select internal medicine residencies and to assess their validity by comparing scores from these measures with responses to open-ended questions. DESIGN: All 353 applicants ranked by the University of North Carolina at Chapel Hill (UNC-CH) for the 1988 National Residency Match Program received a questionnaire after submitting their match lists. First, they listed the three most important factors considered in ranking residency programs and starred the single most important factor out of the three. Then, they rated 41 items on a five-point Likert scale ranging from 1 (not important) to 5 (extremely important). SETTING: Categorical internal medicine residency program at an academic medical center. MEASUREMENTS AND MAIN RESULTS: 315 (88%) applicants responded to the survey. Three reliable scales, Interpersonal Issues (7 items, alpha = 0.78), Reputation (5 items, alpha = 0.77), and Work Issues (11 items, alpha = 0.89), were developed using exploratory factor analysis of applicants' responses to the 41 items. Applicants felt interpersonal issues were very important (mean score = 4.2 +/- 0.5), academic reputation was important (3.3 +/- 0.8), and work issues were less important (2.8 +/- 0.7). The differences between these scores were significant (F = 3.76, p < 0.05). The ratings for the top five items not in these scales also indicated that education and location were very important. These results were corroborated by applicants' responses to the open-ended request to list the three most important factors in ranking residencies. CONCLUSION: These findings suggest that work issues are important, but greater emphasis is placed on interpersonal issues, education, location, and a program's reputation when applicants select residency programs. Furthermore, this study provides evidence supporting the reliability and validity of the three scales.

Adult↗
PubMed1993

Multiple organ dysfunction after mesenteric artery revascularization.

PURPOSE: Mesenteric arterial reconstruction in patients with acute or chronic intestinal ischemia is associated with significant morbidity and mortality rates. Reperfusion of ischemic bowel in animals leads to release of multiple factors that cause organ dysfunction. Similar phenomena potentially occur in human beings after repair of symptomatic chronic mesenteric arterial disease. The purpose of this study was to define the incidence of multiple organ dysfunction seen after reperfusion of the chronically ischemic bowel. METHOD: Between January 1990 and January 1993, 18 patients underwent surgical revascularization for symptomatic chronic mesenteric arterial occlusive disease. Four patients required emergency surgery, whereas 14 procedures were done electively. Hepatic, renal, pulmonary, and coagulation function were evaluated in all patients. Bypass graft patency was confirmed by duplex scanning or repeat operation in all patients with deteriorating conditions. RESULTS: Immediately after surgery hepatic function deteriorated. The serum transaminases increased 90- to 100-fold whereas lactate dehydrogenase increased 25-fold. Simultaneously, platelet counts dropped below 40,000 mm3 in 11 patients. On postoperative day 2, 16 patients had acute pulmonary insufficiency demonstrated by an increase in the pulmonary shunt fraction to a mean of 32% +/- 3% (range 21% to 60%). Ten patients required reintubation, and lung failure lasted an average of 8.4 days (range 1 to 35 days). Hepatic and coagulation function changes were usually transient, returning to baseline within 7 to 10 days. Four of the patients who had multiple organ dysfunction died (two after elective surgery), and one patient died of myocardial infarction after emergency surgery. CONCLUSION: Revascularization of chronically ischemic bowel leads to significant multiple organ dysfunction, potentially as a result of intestinal ischemia and reperfusion injury.

Adult↗
PubMed1993

Carbon dioxide gas as an arterial contrast agent.

OBJECTIVE: To investigate the clinical utility of CO2 gas as an arterial contrast agent, the experience with CO2 arteriography at the University of Florida was reviewed. SUMMARY BACKGROUND DATA: Preliminary studies have demonstrated the feasibility of CO2 arteriography and shown that arterial injection of CO2 gas appears non-toxic (which could limit the risks of contrast induced renal injury and allergic reaction). However, numerous technical problems make CO2 arteriography a demanding technique and recent studies have suggested that distal lower extremity vessels are difficult to image using CO2 arteriography, especially when significant arterial occlusive disease is present. METHODS: One hundred twenty-eight CO2 arteriograms done in 115 patients were reviewed. CO2 arteriograms were graded as excellent, good, poor, or inadequate by two blinded observers and results of CO2 studies compared to results of standard contrast studies (done in 98 patients for image comparison). In addition, a therapeutic plan based on the CO2 arteriograms was compared with the therapy each patient received. RESULTS: One hundred-seventeen (91%) of the CO2 arteriograms were of good or excellent quality and agreement between CO2 studies and standard contrast studies was seen in 93 of 98 cases (95%). Accurate therapeutic plans based on CO2 studies were possible in 92% of cases with inadequate visualization of infrapopliteal arteries being the major limitation (7 cases). No allergic reactions occurred and only one patient potentially had contrast-induced nephrotoxicity. CONCLUSIONS: CO2 arteriography provides accurate, clinically useful arterial imaging with minimal risk. Thus, this new technology significantly increases the utility of arteriography in patients with peripheral vascular disease.

Adult↗
PubMed1992

Immunohistochemical examination of lichen nitidus suggests that it is not a localized papular variant of lichen planus.

BACKGROUND: Lichen nitidus is believed, by some, to be a variant of lichen planus, and by others to be a distinct entity. OBJECTIVE: We examined five cases of lichen nitidus with immunohistochemical reagents designed to characterize the dermal inflammatory infiltrate in an attempt to resolve the uncertainty. METHODS: We stained formalin-fixed, paraffin-embedded tissue sections with the following antibodies: L26, A6, KP1, BerH2, OPD4, and HECA-452. RESULTS: The inflammatory infiltrate was 90% A6+, with few L26+ cells. In contrast to lichen planus, KP1+ macrophages were seen and fewer of the lymphocytes demonstrated HECA-452. Fifty percent to 80% of lymphocytes were OPD4 positive, similar to that usually seen in lichen planus. Rare Ki-1+ cells were seen in one case. CONCLUSION: We believe that the pattern of a mixed cellular infiltrate characterized by macrophages and a helper T cell response with few HECA-452+ cells is somewhat different from the pattern seen in lichen planus, wherein almost all of the cells are CD4+/HECA-452+ lymphocytes. This suggests a different immunologic pathogenesis.

Dermatitis↗
PubMed1992

The use of arm vein conduits during infrageniculate arterial bypass.

To further examine the use of arm vein for bypass to the popliteal or infrapopliteal arteries, we retrospectively reviewed 43 patients undergoing infrageniculate arterial bypass by use of an arm vein as a conduit. Nine grafts were done to the below-knee popliteal artery and 34 to the infrapopliteal arteries. Six grafts were done by use of a single segment of an arm vein, whereas 37 grafts were composites of either multiple segments of arm vein (n = 19) or segments of saphenous and arm vein (n = 18). Mean follow-up time was 15 1/2 months. Initial (30-day) graft patency and limb salvage were 95%. Primary graft patency by life-table analysis was 67% at 1 year and 49% at 3 years. Follow-up examination detected graft stenosis before occlusion in six patients (all of whom were given anticoagulant medication) and three failing grafts were salvaged. This increased overall 3-year secondary graft patency to 64% and 3-year secondary patency for infrapopliteal bypasses to 66%. Eleven of 12 graft occlusions resulted in major amputations (eight were above the knee, and three were below the knee) so that limb salvage paralleled secondary graft patency (63% at 3 years). Thus arm veins provide an excellent alternative venous conduit for infrageniculate arterial bypass, even when composite venous grafts must be used.

Aged↗