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Objective: This study evaluated the morbidity, mortality, and intermediate term follow-up of patients undergoing replacement of their aortoiliac-femoral systems with lower extremity deep and superficial veins., Summary Background Data: The most commonly used treatment for aortic prosthetic infection is ectopic bypass and removal of the prosthesis. The overall mortality rate with this approach is approximately 20%, with an amputation rate of 10% to 14%. Other limitations include thrombosis of the ectopic bypass leading to limb loss, reinfection of the ectopic bypass, and aortic stump blowout. Dissatisfaction with this approach has led the authors to develop the following., Methods: A neo-aortoiliac system (NAIS) was fashioned from lower extremity deep veins (DV), greater saphenous veins (GSV), or both in patients with infected aortobifemoral prosthesis (n = 17) and other complex aortic problems (n = 3). Removal of infected prosthetic material, harvest of vein, and creation of NAIS was performed as a single-staged procedure., Results: The in-hospital mortality and amputation rates were 10% each. The mean (+/- standard deviation [SD]) operative time was 6.5 +/- 1.8 hours and the blood transfusion requirement was 4 +/- 3 units. Four patients experienced postoperative gastrointestinal complications with peritonitis and sepsis; NAIS vein graft resisted infection and remained intact. The mean follow-up time was 22.5 +/- 16 months. NAISs constructed from GSVs were prone to the development of focal stenoses requiring intervention or diffuse neointimal hyperplasia leading to occlusion. In contrast, all NAISs from larger caliber DVs have remained widely patent. The failure rate of GSV NAISs was 64%, compared to 0% for DV NAISs (p = 0.006). Despite the high failure rate in patients with GSV NAISs, none has required amputation. In patients who had DVs harvested for NAIS reconstruction, limb edema and other signs of venous hypertension have been minimal., Conclusion: NAIS reconstruction from lower extremity veins is a successful option in patients with extensive aortic prosthetic infection and other complex aortic problems.

Eighty-three femoral anastomotic false aneurysms occurring in 51 patients were diagnosed from 1972 through 1982. Twenty-two (27%) presented with acute events. Seventy (84%) were confirmed by sonography and/or arteriography. Bilaterality (29%), recurrence (18%), and associated aortic false aneurysms (8%) were significant problems. Eight-one were repaired with a six per cent complication rate, including one death related to preoperative rupture. The 51 patients were evaluated for associated illnesses, risk factors, and etiologies of their false aneurysms. The most common single cause (61%) was host vessel degeneration with an intact suture line remaining attached to a disrupted Dacron limb. Twenty-three patients with host vessel degeneration were matched with case controls not developing false aneurysms. These two groups were matched for gender, age, and year of AFB and compared for associated illnesses and risk factors. Incidences of cigarette smoking, hypertension, cerebrovascular disease, coronary artery disease, diabetes mellitus, previous femoral endarterectomy, outflow disease, other aneurysmal disease, multiple groin operations, wound complications, and training levels of surgeons performing initial AFBs were similar for both groups. Factors observed significantly more often in patients who developed false aneurysms included serum lipid abnormalities (p less than 0.05), braided synthetic suture material as opposed to monofilament polypropylene (p less than 0.05), and continued abuse of tobacco following AFB (p less than 0.005).

Fibromuscular dysplasia of the internal carotid arteries is a rare condition that may cause transient ischemic attacks, stroke and death. The preferred method of treatment of symptomatic lesions is graduated dilatation. Over a six year period, we have dilated 18 lesions. During a follow-up period ranging from 13 to 70 months (mean: 48.3 months), none of the patients operated on has developed a stroke or "hard" ocular/neurologic symptoms in the territory of the artery/arteries operated upon. Additionally, no patient has developed a stroke related to the contralateral asymptomatic, and consequently unoperated, carotid artery. Five patients with global symptoms have not had either carotid artery dilated and none has developed transient ischemic attacks or stroke during a follow-up period ranging from 22 to 100 months (mean: 42 months). These data demonstrate that a rational plan of management is dilatation of lesions associated with hard ocular/neurologic symptoms and nonoperative management of asymptomatic patients and patients with global symptoms.

The results of randomized clinical trials evaluating commonly used methods of deep vein thrombosis (DVT) prophylaxis in moderate- and high-risk general surgery patients were pooled to obtain an unbiased estimate of efficacy and risks. Low-dose heparin (LDH), dextran, heparin-dihydroergotamine (HDHE), intermittent pneumatic compression (IPC), and graded elastic stockings significantly reduced the incidence of DVT; aspirin was ineffective. In contrast to other methods, elastic stockings have not been adequately studied to determine their value in reducing DVT in high-risk patients, such as those with malignancy. Only LDH and dextran were studied in numbers of patients sufficient for demonstrating a clear reduction in pulmonary embolism (PE). In comparison studies, LDH was superior to dextran in preventing DVT, but the two agents were equivalent in protecting against PE. Although HDHE was marginally better than LDH in preventing DVT, it appeared to have no advantage in preventing PE--at least in moderate-risk patients. The incidence of major hemorrhage was not increased with any of the prophylactic agents. However, wound hematomas occurred significantly more frequently with LDH, an effect noted in the pooled data from double-blind and open trials. In comparison trials with LDH, both dextran and HDHE had significantly fewer wound hematomas. LDH administered every 8 hours appeared more effective in reducing DVT than LDH administered every 12 hours; the incidence of wound hematomas was equivalent with both regimens.

Experience with 11 cases of thromboembolectomy of leg arteries explored at the ankle is presented. Patency was established in 19 of 23 arteries (83%), resulting in salvage of 11 of 14 limbs (79%). This experience documents success of this technique with follow-up ranging from 2 to 70 months (mean followup, 24.7 months). Current indications for the procedure include 1) incomplete extraction of thrombus via the popliteal trifurcation, 2) incomplete transfemoral extraction of thrombus with restoration of a popliteal pulse, and 3) thromboembolus initially confined to the infrapopliteal arteries.

Coagulopathy, or non-mechanical hemorrhage, complicated the operative course of 17 of 33 (51.5%) patients suffering severe liver trauma. The highest incidence of non-mechanical hemorrhage (66.7%) occurred in patients undergoing anatomic lobectomy. Serial hemostatic parameters were assessed and thrombocytopenia was the most striking abnormality in patients with non-mechanical hemorrhage. The degree of thrombocytopenia was directly correlated with the number of blood transfusions administered. The mean operative blood transfusion requirement was significantly greater in patients with non-mechanical hemorrhage, 25.1 +/- 2.87 (S.E.M.) units, than in those without, 12.2 +/- 1.83 units (p < 0.001). The bulk of this transfusion was given before the onset of clinically overt coagulopathy. Massive transfusion of stored blood was felt to be the most important factor in causing non-mechanical hemorrhage. Convincing evidence for disseminated intravascular coagulation was lacking, and abnormal fibrinolysis was infrequent and mild when observed. Although uneventful in most, in six patients non-mechanical hemorrhage resulted in excessive blood transfusion, unnecessary operation or death. Infusions of platelet concentrate, fresh frozen plasma, and fresh blood were used to successfully treat most cases of non-mechanical hemorrhage. In all cases, these components were not started until non-mechanical hemorrhage was clinically apparent. The value of prophylactic use of blood components is stressed. Because of troublesome side effects associated with the use of prothrombin complex concentrates, these agents are contraindicated in patients with severe liver injury. After receiving concentrates, one patient developed severe hypotension leading to ventricular fibrillation, two developed transient thrombocytopenia and two others demonstrated multiple pulmonary microthrombi at autopsy, a finding not observed in autopsied patients not receiving the concentrates.