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Intimal angiosarcoma is a most unexpected cause of aortic occlusion. We present the case of a 74-year-old woman with intimal angiosarcoma that manifested with the triad of congestive heart failure, acute renal failure, and abdominal angina. A review of the literature and discussion of postoperative outcomes follows.

Background Obesity and associated comorbidities are associated with a high rate of complications and technical difficulties after a number of surgical procedures. We studied the role of obesity in outcomes in lower extremity arterial revascularization. Methods We reviewed all lower extremity arterial revascularizations performed at our institution in 2000. Body mass index (BMI) greater than or equal to 30 kg/m 2 defined obesity. Perioperative outcomes, long-term survival, and graft patency were evaluated in obese and nonobese patients by using linear regression, the Fisher exact test, and Kaplan-Meier analysis. Results The study population consisted of 74 (26%) obese and 207 (74%) nonobese patients. Patient demographics of the obese and nonobese populations were similar. The mean BMI for obese patients was 35 ± 5 kg/m 2 and in nonobese patients was 25 ± 3 kg/m 2 . The mean age of each group was 67 ± 10 years (BMI ≥30 kg/m 2 ) and 70 ± 13 years (BMI 2 ). There were 45 (61%) obese men and 29 (39%) obese women. There were 128 (62%) nonobese men and 79 (38%) nonobese women. Diabetes was present in 76% of the obese and 70% of the nonobese patients. Perioperative myocardial infarction, 30-day mortality, and rate of reoperation within 30 days were not significantly different. Obese patients had higher increased postoperative wound infection rates (16% vs 7%; P = .04). Survival analysis showed 81% ± 5% and 85% ± 3% 1-year survival and 66% ± 6% and 62% ± 3% 3-year survival in obese and nonobese patients ( P = .58), respectively. Kaplan-Meier estimates showed no effect of obesity on long-term graft patency, with 1-year graft patency rates of 82% ± 6% and 81% ± 4% in obese and nonobese patients, respectively ( P = .79). Conclusions Obese patients have similar limb salvage rates, perioperative cardiac morbidity, long-term survival rates, and long-term graft patency but have increased perioperative wound infections.

Objective This study was undertaken to evaluate our experience with distal arterial bypass to the plantar artery branches and the lateral tarsal artery for ischemic limb salvage. Methods This was a retrospective analysis of data prospectively entered into our vascular surgery database from January 1990 to January 2003 for all consecutive patients undergoing bypass grafting to the plantar artery branches or the lateral tarsal artery. Median follow-up was 9 months (range, 1-112 months). Demographic data, indications for surgery, outcomes, and patency were recorded, and statistical analysis was performed to assess significance. Results Ninety-eight bypass procedures to either the medial plantar artery, lateral plantar artery, or lateral tarsal artery were performed in 90 patients. Eighty-one patients (83%) were men. Mean age was 67.5 ± 11.6 years. Indications for operation were tissue loss in 93 patients (95%), rest pain in 3 patients (3%), and failing graft in 2 patients (2%). Eighteen patients (18%) had previously undergone vascular reconstruction, and 5 patients (5%) had undergone previous bypass to the dorsalis pedis artery. Seventy-one grafts (72%) had inflow from the popliteal artery, 25 grafts had inflow from a femoral artery or graft (26%), and 2 grafts had inflow from a tibial artery (2%). Conduits used were greater saphenous vein in 67 patients (69%), arm vein in 20 patients (20%), composite vein in 10 patients (10%), and polytetrafluoroethylene conduit in 1 patient (1%). There were 77 bypasses (79%) to plantar artery branches, and 21 bypasses (21%) to the lateral tarsal artery. Thirty-day mortality was 1% (1 of 98 procedures). Early graft failure within 30 days occurred in 11 patients (11%). In the subset of patients with a previous arterial reconstruction, there were 2 early graft failures within 30 days (11%). Both occurred in patients who had undergone previous bypass to the dorsalis pedis artery. Primary patency, secondary patency, limb salvage, and patient survival were 67%, 70%, 75%, and 91%, respectively, at 12 months, and 41%, 50%, 69%, and 63%, respectively, at 5 years, as determined from Kaplan-Meier survival curves. Greater saphenous vein grafts performed better than all other conduits, with a secondary patency rate of 82% versus 47% at 1 year ( P = .009). Conclusion Inframalleolar bypass to plantar artery branches and the lateral tarsal artery, even in patients with a previously failed revascularization, can be undertaken with acceptable patency and limb salvage rates. Early graft failure, however, is higher, whereas patency and limb salvage rates are lower, compared with bypass to the dorsalis pedis artery. The use of saphenous vein as a conduit results in the best patency for plantar or lateral tarsal bypass procedures.

Objective Incidence of perioperative complications is increased and outcome is poor in young patients undergoing vascular surgery. We extensively reviewed results of lower-extremity procedures in this group of patients to further define the extent of short-term and long-term morbidity. Methods Results from our vascular registry were retrospectively reviewed for 76 lower-extremity revascularization procedures performed between January 1990 and May 2000 in 51 patients younger than 40 years. This represents 1.88% of 4052 lower-extremity bypass procedures performed during this period. Perioperative cardiac complications, long-term survival, graft patency, and limb salvage were evaluated. Kaplan-Meier curves were generated, and their significance was determined with the Cox-Mantel test. Results Forty-nine percent of patients were male, and 51% were female; mean age at presentation was 35.9 years (range, 27.5-39.8 years). Preoperative morbidity included diabetes mellitus (96.1%), smoking (70.6%), hypertension (78.4%), coronary artery disease (37.3%), hyperlipidemia (33.3%), and renal dysfunction (52.9%). Overall rate for 30-day postoperative mortality was 0.0%, for myocardial infarction was 0.0%, and for congestive heart failure was 1.32%. Thirty-day graft failure was 11.1% (n = 9). At 1 year, primary patency was 71.0%, secondary patency was 82.5%, and limb salvage was 87.1%; and at 5 years these rates were 51.9%, 63.4%, and 77.2%, respectively. After the initial surgery 11.8% (n = 6) of patients required at least one additional ipsilateral revascularization procedure, 31.3% (n = 16) required a bypass graft in the contralateral limb, and 23.5% (n = 12) ultimately required amputation. In patients who required additional ipsilateral procedures, 1-year primary patency rate was 66.7%, secondary patency rate was 62.5%, and limb salvage rate was 77.8%, compared with 5-year rates of 44.4%, 41.7%, and 64.8%, respectively, representing a decrease in patency compared with primary revascularization procedures. Overall survival at 1 year was 88.2%, compared with 73.3% at 5 years. Patients with preexisting renal disease had significantly decreased survival at 5 years compared with those without renal dysfunction (64.5% vs 82.6%; P = .019). Conclusions Our data suggest that age younger than 40 years is not associated with increased perioperative morbidity and mortality. However, these patients have a significant rate of early graft failure and dismal long-term survival, especially in patients with preexisting renal dysfunction. In addition, ipsilateral repeat operations have a marginal success rate.

Background Although evidence suggests that end-stage renal disease is associated with poor limb salvage and patient survival after arterial revascularization, little is known about the effect of renal transplantation. We analyzed the outcome in patients with renal transplants who underwent infrainguinal bypass procedures. Methods Data prospectively entered into our vascular registry were reviewed for all patients who underwent lower extremity bypass procedures from January 1, 1990, through January 31, 2002. Sixty patients were identified who had a functioning renal allograft at infrainguinal revascularization. Kaplan-Meier survival curves were generated for limb salvage, patency, and patient survival and were compared with the Mantel-Cox log- rank test. Results Sixty patients (40 men, 20 women; mean age, 47.1 years) underwent 76 bypass procedures in 71 limbs. Preoperative demographic data included diabetes (59 of 60 patients, 98.3%), coronary artery disease (26 of 60 patients, 43.3%), and preoperative serum creatinine concentration (SCr) greater than 2.0 mg/dL (9 of 60 patients, 11.7%). Mean follow-up was 25.1 months. Overall major complication rate was 11.8%, and 30-day mortality rate was 1.3%. Survival was 93.3% at 1 year and 66.6% at 5 years. Limb salvage was 87% at 1 year and 78% at 5 years. Primary graft patency was 78% at 1 year and 44% at 5 years. Preoperative SCr less than or equal to 2.0 mg/dL was associated with improved overall patient survival (5-year survival, 73.4% vs 37.5%; P = .01, log-rank test). Limb salvage and patency rates were not significantly affected by preoperative SCr greater than 2.0 mg/dL. Conclusions Lower extremity bypass can be performed safely and effectively in patients who have undergone renal transplantation. However, the importance of a well-functioning renal allograft at surgery is demonstrated by marked improvement in patient survival.

Purpose: Higher complication rates have been reported in patients with renal insufficiency (RI) undergoing peripheral vascular surgery. Little attention has been paid specifically to carotid endarterectomy (CEA) in patients with RI where the risk/benefit considerations are very sensitive to small increases in postoperative complications. Methods: One thousand one consecutive CEAs performed since 1990 were reviewed from our vascular registry, and 73 CEAs on patients with RI were identified. For comparison, two groups were established: group I (n = 928), normal renal function (creatinine level

Purpose: The purpose of this study was to evaluate our results with lower extremity arterial reconstruction (LEAR) in patients 80 years of age or older and to assess its impact on ambulatory function and residential status. Methods: We performed a retrospective review of all patients 80 years of age or older undergoing LEAR at a single institution from January 1990 through December 1995. Preoperative information regarding residential status and ambulatory function was obtained from the hospital record and vascular registry. Telephone interviews with patients or next of kin were undertaken to provide information regarding postoperative residential status and ambulatory function. Residential status and level of ambulatory function were graded by a simple scoring system in which 1 indicates living independently, walking without assistance; 2 indicate living at home with family, walking with an ambulatory assistance device; 3 indicates an extended stay in a rehabilitation facility, using a wheelchair; and 4 indicates permanent nursing home, bedridden. Preoperative and postoperative scores for both residential status and ambulatory function were compared. Kaplan-Meier survival curves were generated for graft patency, limb salvage, and patient survival. Results: Two hundred ninety-nine lower extremity bypass operations were performed in 262 patients 80 years of age or older (45% men, mean age 83.6 years, range 80 to 96 years). Sixty-seven percent of the patients had diabetes mellitus. Limb salvage was the indication for operation in 96%. The preoperative mean residential status and ambulatory function scores were 1.79 ± 0.65 and 1.55 ± 0.66, respectively. The perioperative mortality rate at 30 days was 2.3%. The median length of hospital stay decreased from 16 days in 1990 to 8 days in 1995 (range 4 to 145 days). Eighty-seven percent of grafts were performed with the autologous vein. The 5-year primary, assisted primary, and secondary graft patency rates for all grafts were 72%, 80%, and 87%, respectively. The limb salvage rate at 5 years was 92%. The patient survival rate at 5 years was 44%. The postoperative residential status and ambulatory function scores were 1.95 ± 0.80 and 1.70 ± 0.66, respectively. Overall scores remained the same or improved in 88% and 78% of patients, respectively. Conclusion: LEAR in octogenarians is safe, with graft patency and limb salvage rates comparable to those reported for younger patients. LEAR preserves the ability to ambulate and reside at home for most patients. (J Vasc Surg 1998;28:215-25.)

Purpose: The performance of a graft created from the upper arm basilic and cephalic veins in continuity was investigated. Methods: Retrospective analysis of 50 patients, who underwent 54 distal reconstructions with an upper arm vein loop graft between February 1989 and October 1993 (male-to-female ratio of 30/20; mean age of 69.2 years, range 39 to 87; 74% had diabetes) was undertaken. Vein grafts were harvested through a near continuous incision, leaving a skin bridge in the cubita. Intraoperative angioscopy was used to exclude endoluminal disease and to directly observe valvulotomy of the nonreversed part of the graft. Results: Operations were performed for limb salvage in 98.2% of 17 primary and 37 reoperative procedures. Eleven femoropopliteal, 33 femorotibial-pedal, seven popliteal-distal, and two outflow jump grafts were performed. The ipsilateral saphenous vein was unavailable because of previous infrainguinal bypass in 35, coronary artery bypass grafting in 14, and unsuitable quality in 5 cases. Thirty-eight grafts were used in continuity, and 16 grafts required repair or splicing with additional vein segments. Primary 30-day patency rate was 92.6% (n = 4 occlusions). No operative deaths occurred. The cumulative patency rate at 1 year was 74.4%, the limb salvage rate 90.7%. Conclusions: The upper arm vein loop is a durable graft with excellent short-term and midterm patency rates. Sufficient vein length can be obtained to reach the below-knee and midtibial levels. Angioscopic quality assessment is a valuable adjunct to exclude endoluminal disease most commonly occurring in the median cubital vein. Straightening the curve of the median cubital vein and valvulotomy do not influence patency rates. This is a valuable technique for vascular surgeons that enables rescue of ischemic limbs under otherwise difficult circumstances. (J VASC SURG 1995;21:586-94.)

Purpose: Although the technical feasibility of pedal artery bypass for limb salvage is now well established, questions remain about its most appropriate use and its long-term durability. Methods: We reviewed our experience over an 8-year period in 367 consecutive patients undergoing 384 vein bypass grafts to the dorsalis pedis for limb salvage. Results: Ninety-five percent of the patients had diabetes mellitus. Infection complicated ischemia at initial presentation in 55.2% of patients. The preoperative arteriogram demonstrated a patent dorsalis pedis in 362 extremities (92.8%). Four hundred two patients underwent exploration for bypass, including 29 patients without demonstrated arteries on the arteriogram but audible pedal Doppler signals. Successful bypasses were carried out in 357 of 362 cases, where preoperative arteriography demonstrated a patent dorsalis pedis artery (98.6%), 16 of 28 cases explored on the basis of a Doppler signal alone (57%), and 11 of 12 patients where angiographic status was unknown. All procedures were performed with vein: in situ 38.5%, reversed 29%, onreversed 18%, arm vein 7%, and composite vein 8%. Inflow was taken from the common femoral artery in 34%, superficial femoral or popliteal arteries in 60%, a previously placed graft in 5%, and a tibial artery in 1%. There were seven erioperative deaths (1.8%) and 21 myocardial infarctions (5.4%). Twenty-nine grafts failed within 30 days (7.5%), but 19 were successfully revised. Eight of the 10 failed grafts resulted in major amputation (80%). Over the remaining study period, there were 39 additional graft failures, of which 17 were successfully revised, and 17 additional major amputations. Actuarial primary and secondary patency and limb salvage rates were 68%, 82%, and 87%, respectively, at 5 years' followup. The actuarial patient survival rate was 57% at 5 years. Patency rates were similar for in situ and translocated saphenous vein grafts. Conclusions: Dorsalis pedis arterial bypass is an effective limb salvage procedure with long-term durability comparable to distal vein grafts placed into more proximal arteries. (J VASC SURG 1995;21:375-84.)

Purpose: The purpose of this study was to assess functional status, well-being, and symptom relief of patients after infrainguinal revascularization for severe peripheral vascular disease. Methods: Two questionnaires were used to assess symptoms, functional status, and well-being before operation and 6 months after operation. Sociodemographics, comorbidities, indications for surgery, graft location, and morbidity, mortality, patency, and limb salvage rates were obtained via vascular registry. Very good Results: Of 318 patients who underwent revascularization over a 1-year period, 276 patients were asked to complete the questionnaires. Of the 156 patients who completed both questionnaires, mean age was 66 years, 67% were men, 84% had diabetes mellitus, and 83% had various heart-related conditions. Mean length of stay was 15.3 days. Distal graft sites were popliteal (29%), tibial/peroneal (40%), and pedal/plantar (31%). The operative morbidity rate was 21%, the cumulative primary graft patency rate was 93%, the cumulative secondary graft patency rate was 95%, and the limb salvage rate was 97% at 6 months. At follow-up, improved functioning of instrumental activities of daily living, mental well-being, and vitality were reported. Symptoms of calf cramping and toe or foot pain when walking and at rest were also improved. Sores or ulcers improved, but leg swelling did not. The only independent predictor of improved function and well-being was the patients' perception of their status at baseline: those patients who functioned better before operation reported improved function and well-being at 6 months. Only 45% of patients reported feeling "back to normal" at 6 months. Conclusion: Reported health status at baseline was a predictor of improved function, mental well-being, and resolution of symptoms after infrainguinal revascularization. Expected return to "normal" may take longer than 6 months. (J VASC SURG 1995;21:35-45.)

Our purpose was to determine the incidence and segmental distribution of intraluminal disease in the arm veins of patients in whom saphenous vein was unavailable or inadequate for bypass, determine whether angioscopic evaluation and directed interventions can upgrade the quality of arm vein conduit and improve early graft patency, and describe the angioscopic technique of in situ retrograde arm vein inspection.Retrospective review of 109 infrainguinal arm vein bypass grafts in 104 patients performed with intraoperative angioscopic vein preparation and monitoring between August 1989 and March 1992 was undertaken. Four additional arm veins harvested were discarded because of diffuse disease.Intraluminal disease was noted in 71 (62.8%) of 113 arm veins, "webs" in 61 (54%), vein sclerosis in 25 (22.1%), localized stenosis in 11 (9.7%), and thrombus in 7 (6.2%). Intraluminal disease was most common in the cephalic (forearm 49.2%; arm 35.1%) and median cubital (33.3%) veins and least common in the basilic vein (11.7%). Eighty-three angioscopically directed interventions in 68 of 71 abnormal arm veins resulted in upgraded vein conduit quality in 47 (66.1%) of 71. Primary patency (30 days) was 99 (90.8%) of the 109 grafts, 85 (95.5%) of 89 grafts with normal or upgraded quality conduits, and 14 (70%) of 20 inferior-quality grafts (p = 0.0024). These differences persisted through 1 year by life-table analysis, (p0.001).Not only is the routine use of the angioscope in arm vein bypass grafting a sensitive technique to detect the intraluminal diseases so prevalent in arm veins but it can also direct endoluminal and surgical interventions that upgrade the quality of the vein conduit and improve early graft patency.

This study was designed to determine whether, in primary infrainguinal bypass grafts in which only saphenous vein is used as the graft conduit, routine monitoring with intraoperative angioscopy can improve early graft patency as compared with standard monitoring with intraoperative completion angiography; and to delineate the advantages and disadvantages of these two modalities and their respective roles for the routine monitoring of the infrainguinal bypass graft.A total of 293 patients undergoing primary saphenous vein infrainguinal bypass grafting were prospectively randomized and monitored with either completion angioscopy or completion angiography. Clinical parameters, indications for operation, graft anatomy, and configuration were evenly matched in both groups. Forty-three bypasses were excluded from the study after randomization, including 12 veins randomized to angiogram, deemed inferior, and prepared with angioscopy.In the 250 bypass grafts (angioscopy 128, angiography 122) there were 39 interventions (conduit, 29; anastomosis, 8; distal artery, 2), 32 with angioscopy and 7 with angiography (p0.0001). Twelve (4.8%) of the 250 grafts failed in less than 30 days, four (3.1%) of 128 in the angioscopy group and eight (6.6%) of 122 in the angiography group (p = 0.11 by one-sided hypothesis test).Although no statistical improvement in the proportions of failures in primary saphenous vein bypass grafts routinely monitored with completion angioscopy rather than the standard completion angiogram was demonstrated, the study delineates a trend that favors completion angioscopy for routine vein graft monitoring and demonstrates the advantages of angioscopy in preparing the optimal vein conduit.

The results of 56 vein bypasses to the dorsal pedal artery performed in 53 diabetic patients who were admitted with ischemic foot lesions complicated by infection were reviewed. All patients had one or more of the following: infected ulcers (73%), cellulitis (45%), osteomyelitis (29%), gangrene (20%), or abscess (2%). Organisms were cultured from 84% of patients (average 2.6, range 1 to 9 organisms per infection). Elevated temperature (greater than 37.7 degrees C) or leukocytosis (greater than 9.0 x 10(3)/ml) were seen in 13% and 50% of patients, respectively. All patients were treated with broad-spectrum antibiotics, local debridement, wound care, and bed rest. Operative debridement or open partial forefoot amputation were required to control sepsis in 11 patients (20%). Treatment of infection delayed revascularization by an average of 10.7 days. All patients underwent autogenous vein bypasses to the dorsal pedal artery. Two grafts failed within 30 days (3.6%), and one patient died (1.8%). Wound infections developed in seven patients (12.5). One wound infection resulted in graft disruption and patient death at 2 months. Average length of stay of the initial hospitalization was 29.8 days. Fifty-two patients were discharged with patent grafts and salvaged limbs; however, 31 subsequent foot procedures and 35 rehospitalizations were required to ultimately achieve foot healing. Actuarial graft patency and limb salvage were 92% and 98%, respectively at 36 months. Pedal bypass to the ischemic infected foot is efficacious and safe as long as infection is adequately controlled first. The complexity of these situations often requires multiple surgical procedures and extensive wound care, resulting in prolonged or multiple hospitalizations.

This study was performed to evaluate the results of peripheral vascular reconstruction for arterial occlusive disease in patients with juvenile-onset diabetes mellitus. The results of 67 bypass procedures performed on 60 patients with juvenile-onset diabetes mellitus between Jan. 1, 1984 and Dec. 31, 1989, were reviewed. These patients had a mean age of 44.4 years (range, 29 to 59 years), with an average age of onset of diabetes mellitus of 9.8 years (range, 1 to 19 years). These procedures comprised 5.5% (67 to 1214) of the bypasses performed on diabetic patients during the same time period at a single institution. Fifty-four of 67 (91%) procedures were performed for limb salvage. Fifty-four (81%) procedures were primary infrainguinal bypasses with saphenous vein (femoropopliteal 19, femorodistal or popliteal-distal 35). Six procedures (9%) were revision procedures, four (6%) were in-flow procedures, and three (4%) were infrainguinal procedures with polytetrafluoroethylene. Thirty-day morbidity and mortality rates were 31% and 0%, respectively. Actuarial patency and limb salvage rates of the primary vein graft group were 66.0% (+/- 10.7) and 83.4% (+/- 8.0%), respectively, at 24 months. Cumulative survival of the entire group at 2 years was 84.1%. Although follow-up in this study is relatively short (24 months), the results suggest that the outcome of vascular reconstruction in patients with juvenile-onset diabetes mellitus is acceptable when compared with procedures performed in adult-onset diabetic and nondiabetic populations. The presence of juvenile-onset diabetes mellitus should not diminish the vascular surgeon's expectations of a successful outcome when considering lower extremity revascularization in these patients.

Despite a large experience with "blind" retrograde valvulotomy in in situ vein bypass grafting, the incidence of residual competent valves remains high, and valvulotome-induced injury is common. In this study we describe a new valvulotome and technique of angioscopically directed valvulotomy and review the video tape recordings of 85 completion angioscopies of in situ femorodistal bypasses. Fifty-three vein grafts were prepared with the blind retrograde valvulotomy technique and 32 vein grafts with the new valvulotome and angioscopy. The use of the new valvulotome and technique is compared with that of the standard blind retrograde valvulotomy technique, and the normal endoluminal anatomy and incidence of primary disease in saphenous vein grafts was noted. The incidence of valvulotome-induced injury was 5/32 (15.6%) and 45/53 (85%) in vein grafts prepared with angioscopically directed valvulotomy and blind retrograde valvulotomy, respectively. Residual competent valves were found in 10/53 (18.9%) in blind retrograde valvulotomy and 0/25 of angioscopically directed valvulotomy vein grafts (p = 0.0114). In 22/53 vein grafts unsuspected primary disease was detected. Angioscopically directed valvulotomy with the new valvulotome and technique is feasible, reliable, and safe. It avoids residual competent valves, minimizes valvulotome-induced injury, and allows the detection and correction of unappreciated primary vein graft abnormalities. The new valvulotome and technique is a first step in the complete endoluminal preparation of the in situ vein graft.

Limbs of diabetic patients with distal tibial disease are frequently considered unreconstructible; however, when studied with intraarterial digital subtraction angiography, the dorsal pedal artery is frequently found to be patent. We have reviewed our recent experience with 96 patients, 94% of whom had diabetes and had 97 bypasses placed to the dorsal pedal artery. All procedures were for limb salvage. Superimposed infection was present in 42.3%. In 92 instances where intraarterial digital subtraction angiography successfully visualized the dorsal pedal artery, 91 bypasses were placed. In 12 other cases where the dorsal pedal artery was not visualized by intraarterial digital subtraction angiography but audible with the continuous-wave Doppler, bypasses were completed successfully in six. All procedures were performed with vein. Inflow was taken from the femoral artery in 48, popliteal artery in 45, tibial artery in 2, and from a femoral tibial graft in 2. Perioperative mortality was 1.92%. Actuarial graft patency, limb salvage, and patient survival were 82%, 87%, and 80%, respectively at 18 months. We conclude that bypass grafting to the dorsal pedal artery can be reliably performed with acceptable short-term results. An attempt should always be made to visualize the foot vessels angiographically, especially in diabetic patients, so that this valuable option in arterial reconstruction will not be overlooked.

IntroductionDespite the frequent performance of minor foot amputations in patients with lower extremity vascular disease, little is known regarding the rate of conversion to major amputations and the role of bypass graft timing in relation to amputation.MethodsBetween January 1990 and December 2001, 670 patients underwent 920 minor amputations (interphalangeal, ray, or transmetatarsal) on 747 limbs.ResultsOf 670 patients, 468 were men (69.9%), 616 had diabetes mellitus (91.9%), and 137 (19.7%) had a serum creatinine level >2.0 mg/dL, of whom 92 were on dialysis (end-stage renal disease) (11.5%). Ipsilateral revascularization was performed ≤30 days before the initial amputation in 64.9% (485 of 747), whereas 9.8% (73 of 747) had a bypass ≤30 days postamputation. The initial amputation levels were 466 interphalangeal (62.4%), 159 transmetatarsal (21.3%), and 122 ray (16.3%). Operative 30-day mortality was 0.7% (6 of 920). Limb salvage was 89.8% at 1 year and 82.3% at 5 years. Diabetes mellitus had no impact on limb salvage (P = .61). Limb loss predictors included end-stage renal disease (odds ratio [OR], 1.72, 95% confidence interval [CI], 1.12 to 2.83, P < .01) and the need for transmetatarsal amputation as the initial procedure (OR, 1.62; 95% CI, 1.15 to 1.93; P < .01). Patients with revascularizations subsequent to an initial amputation had a significant increase in limb loss (OR, 2.11; 95% CI, 1.39 to 4.21, P < .005). Patient survival was 83.9% at 1 year and 43.5% at 5 years. Neither gender nor diabetes mellitus impacted survival; however, serum creatinine levels >2.0 mg/dL (5 years, 48.8% ± 2.3% vs 23.9% ± 4.2%, P < .0001) and the need for a major amputation ≤30 days (3 years, 60.8% ± 2.1% vs 40.1% ± 7.8%, P < .01) adversely affected survival.ConclusionsAlthough minor amputations can lead to limb preservation in most patients, the performance of a revascularization subsequent to amputation, transmetatarsal as the initial amputation, and end-stage renal disease are poor prognostic indicators. Inferior long-term patient survival is most closely associated with renal insufficiency and conversion to major amputation early after the initial procedure.

In the absence of an adequate ipsilateral greater saphenous vein, various alternative conduits have been used for the performance of lower extremity revascularization. In this study we compared the effectiveness of all-autogenous arm vein bypass grafts with that of prosthetic grafts.Seven hundred forty lower extremity revascularization procedures (506 arm vein, 234 prosthetic) performed between 1990 and 1999 were followed prospectively by means of a computerized vascular registry.Bypass graft configurations were femoro-above-knee-popliteal (26 arm vein, 100 prosthetic); femoro-below-knee-popliteal (38 arm vein, 29 prosthetic); femorotibial (174 arm vein, 55 prosthetic); femoropedal (23 arm vein, 2 prosthetic); popliteotibial/pedal (101 arm vein, 1 prosthetic); and extension "jump" grafts (144 arm vein, 47 prosthetic). The indications for surgery were limb salvage (98.0% arm vein, 89.7% prosthetic) and disabling claudication (2.0% arm vein, 10.3% prosthetic). The mean follow-up was 23.4 months (range, 1 month-7.4 years). Overall patient survival at 4 years was 54% (arm vein) and 69% (prosthetic). Cumulative patency varied with graft configuration. The 1-year primary patency rates for femorotibial grafts were 81.6% +/- 3.6% (arm vein) and 58.0% +/- 8.4% (prosthetic); the 3-year rates were 68.3% +/- 6.1% (arm vein) and 41.1% +/- 9.8% (prosthetic) (P.01). The 1-year limb salvage rates for femorotibial grafts were 91.1% +/- 2.8% (arm vein) and 69.1% +/- 8. 8% (prosthetic); the 3-year rates were 81.4% +/- 5.6% (arm vein) and 63.2% +/- 10.3% (prosthetic) (P =.02). The 1-year primary patency rates for femoro-below-knee-popliteal grafts were 92.9% +/- 5.1% (arm vein) and 83.4% +/- 8.0% (prosthetic); the 3-year rates were 72.8% +/- 10.1% (arm vein) and 55.5% +/- 12.1% (prosthetic) (P=.05). The 1-year limb salvage rates for femoro-below-knee-popliteal grafts were 100% (arm vein) and 91.3% +/- 7.0% (prosthetic); the 3-year rates were 94.7% +/- 7.3% (arm vein) and 75.3% +/- 14.6% (prosthetic) (P = NS).In this study autogenous arm vein grafts demonstrated increased patency and limb salvage, compared with prosthetic grafts. These increases achieved statistical significance in the femoro-below-knee-popliteal and femorotibial configurations. An effort to use an all-autogenous vein conduit is justified on the basis of these results; however, if no autogenous vein is available, prosthetic grafts provide a reasonable alternative to primary amputation.

Purpose: Various alternative conduits have been used for lower extremity revascularization when an adequate ipsilateral greater saphenous vein is absent. This study compared the effectiveness of all-autogenous multisegment arm vein bypass grafts with that of composite grafts composed of combined prosthetic and autogenous conduits. Methods: One hundred fifty-three lower extremity revascularization procedures performed between 1990 and 1998 were followed up prospectively using a computerized vascular registry. The grafts were composed of spliced arm vein segments with venovenostomy in 122 and of composite prosthetic-autogenous conduit in 31. Arm vein conduit was prepared by means of intraoperative angioscopy for valve lysis and identification of luminal abnormalities in 47.7% of cases. Results: Bypass graft configurations were as follows: femoropopliteal (12 arm vein, 2 composite); femorotibial (75 arm vein, 23 composite); femoropedal (14 arm vein, 6 composite), and popliteo-tibial/pedal (21 arm vein, 0 composite). The indication for surgery was limb salvage in 98% and disabling claudication in 2% of cases. The mean follow-up was 25.1 months (range, 1 month to 7.9 years). Overall survival at 4 years was 51%. Overall patency and limb salvage rates were as follows: primary patency, at 1 year—arm vein, 76.9% ± 4.8%; composite, 59.5% ± 9.6% (P =.02); at 3 years—arm vein, 70.0% ± 8.0%; composite, 43.7% ± 12.4% (P

Purpose: The effect of anesthesia type on 30-day graft patency and limb salvage rates was evaluated in patients who underwent femoral to distal artery bypass. Methods: Of 423 patients randomly assigned to receive general, spinal, or epidural anesthetic, 76 did not meet protocol standards and 32 had inadequate anesthesia. A chart review of the remaining 315 patients was undertaken to obtain surgical information not recorded in the original study. All patients were monitored with radial and pulmonary artery catheters. After surgery, patients were in a monitored setting for 48 to 72 hours and had graft function assessments hourly during the first 24 hours and then every 8 hours until discharge. Results: Fifty-one patients were lost to follow-up (15 general, 22 spinal, 14 epidural). Baseline clinical characteristics were similar for the three groups except prior carotid artery surgery, which was more common in the spinal group. Indications for surgery were also similar except for a higher incidence of nonhealing ulcer in the epidural group. There were no differences among groups for 30-day graft patency with or without reoperation, 30-day graft occlusion, death, amputation, or length of hospital stay. Conclusion: These results suggest that the type of anesthetic given for femoral to distal artery bypass does not significantly affect 30-day occlusion rate, limb salvage rate, or hospital length of stay. (J Vasc Surg 1997;25:226-33.)

Although severe, circumferential calcification of distal outflow vessels is frequently encountered, its effect on bypass graft patency rates has not been well established.Using a computerized vascular registry database, we conducted a retrospective review of 1957 bypass grafts with distal anastomoses to infrapopliteal vessels performed at a single institution between 1990 and 1995. Of these cases, 101 procedures involved outflow arteries classified by the operating surgeon as severely calcified and unclampable (requiring intraluminal occluders for vascular control), whereas in 105 cases the outflow arteries had no calcification present at the distal anastomotic site. The remaining cases had varying intermediate degrees of calcification and were not analyzed. Indication for bypass procedure was limb-threatening ischemia in 90% of severe calcification cases and in 84% of cases without calcification. Atherosclerotic risk factors were similar except for the presence of diabetes (92% vs 74%, p0.001), creatinine level2.0 mg/dl (21% vs 8%, p0.01), and dialysis dependency (17% vs 3%, p0.001), all of which were more prevalent in the severe calcification group. Infrapopliteal distal anastomotic location and type of conduit (90% autogenous vein) were comparable between groups.Primary patency, secondary patency, and foot salvage rates at 24 months were 60%, 65%, and 77% for the severe calcification group and 74%, 82%, and 93% for the no calcification group, respectively. With secondary procedures comprising 26% of cases in each group, data from the 150 primary procedures were reanalyzed separately. In this primary procedure group, 24-month primary patency, secondary patency, and foot salvage rates were 66%, 69%, and 77% for the severe calcification group and 84%, 90%, and 96% for the no calcification group, respectively. Although patency and salvage rates were consistently lower for the severe calcification group in all analyses, these differences did not achieve significance by log-rank life-table analysis at 2-year follow-up. Perioperative 30-day mortality (0.99% severe calcification vs 0.95% no calcification) and 24-month survival rates (84% severe calcification vs 83% no calcification) were also similar between groups.These data suggest that effective techniques exist to perform infrapopliteal bypasses to severely calcified, unclampable outflow arteries with results comparable with those obtained with clampable, uncalcified vessels. The finding of severe, circumferential calcification of outflow target arteries should not dissuade vascular surgeons from distal bypass for limb salvage indications.

Purpose: Aggressive policies for distal bypass and coronary revascularization increase the need to identify alternatives to autologous saphenous vein grafts. We examined the performance of arm vein as the primary alternative to contralateral saphenous vein when the ipsilateral saphenous vein was not available. Methods: A total of 250 arm vein grafts were studied retrospectively in 224 patients (143 men, 81 women, 82.6% with diabetes, mean age 68.3 years) from February 1989 to April 1994. Intraoperative angioscopy was carried out to observe valve lysis, remove abnormalities, and select optimal vein segments. Results: A total of 85 primary, 103 repeat, and 62 graft revision procedures were done for limb salvage in 99.2% of the patients. A total of 41 femoropopliteal, 114 femorotibialpedal, 33 popliteodistal, and 62 jump or interposition grafts were constructed. A total of 199 grafts were single vein, and 51 were composite vein. The source was cephalic vein alone in 50.4%, cephalic and basilic vein in 35.6%, and basilic vein only in 14%. The contralateral saphenous vein as an alternative conduit was available in 97 (38.8%) instances. Interventions guided by angioscopy to "upgrade" the graft were necessary in 51.6%. Overall early patency (≤30 days) was 94.8% (n=13 occlusions). The cumulative primary patency rate at 1 year was 70.6%, the secondary patency rate was 76.9%, and the limb salvage rate was 88.2%. The 3-year patency rate (limb salvage) was 51.9% (92.4%) for primary grafts, 56.7% (67.1%) in revision grafts, and 42.4% (79.9%) in repeat grafts. In 22.7% (22 of 97) the available contralateral saphenous vein was used for distal revascularization within the follow-up period. Conclusions: Arm veins are an easily accessible autologous conduit of sufficient length to reach the midtibial level. Excellent patency rates allow durable limb salvage in otherwise difficult circumstances. Vein configuration and splicing do not affect patency rates, but vein quality and repeat operations do. Angioscopy is a valuable adjunct to upgrade graft quality. The contralateral saphenous should be saved for subsequent contralateral revascularization or coronary artery bypass grafting.

Objective: The purpose of this study was to review our experience over the last decade with the dorsalis pedis bypass for ischemic limb salvage in patients with diabetes mellitus. Methods: The study was a retrospective analysis of a computerized vascular registry and chart review. From January 10, 1990 to January 11, 2000, 1032 bypasses to the dorsalis pedis artery were performed in 865 patients (27.6% of the 3731 lower extremity arterial bypass procedures performed in that time period). Five hundred ninety-seven patients (69%) were male, with a mean age of 66.8 years. Ninety-two percent had diabetes mellitus. All procedures were done for limb salvage. Conduits included 317 nonreversed saphenous vein (30.7%), 273 in situ (26.4%), 235 reversed vein (22.8%), 170 arm vein (16.5%), 35 other vein (3.4%), and two polytetrafluoroethylene (0.2%) grafts. The inflow arteries were as follows: 294 common femoral (28.5%), 550 popliteal (53.2%), 114 superficial femoral (11%), and 74 other (7.2%). Results: The mortality rate within 1 month of surgery was 0.9%, and 42 grafts (4.2%) failed in the same interval, although 13 were successfully revised. In a follow-up period that ranged from 1 to 120 months (mean, 23.6 months), primary patency, secondary patency, limb salvage, and patient survival rates were 56.8%, 62.7%, 78.2%, and 48.6%, respectively at 5 years and 37.7%, 41.7%, 57.7%, and 23.8% at 10 years. Both polytetrafluoroethylene grafts failed in less than 1 year. Primary graft patency was worse in female patients (46.5% female versus 61.6% male at 5 years; P < .009) but better in patients with diabetes (65.9% diabetes mellitus versus 56.3% non-diabetes mellitus at 4 years; P < .04). Saphenous vein grafts performed better than all other conduits with a secondary patency rate of 67.6% versus 46.3% at 5 years (P < .0001). Multivariate analysis showed that length of stay greater than 10 days and dorsalis pedis bypass for the surgical indication of previous graft occlusion were independently predictive of worse graft patency at 1 year and use of saphenous vein as conduit was predictive of better patency. Conclusion: Dorsalis pedis bypass is durable with a high likelihood of ischemic foot salvage over many years. Saphenous vein is the preferred conduit when available. Short vein grafts from distal inflow sites are possible in more than 50% of cases. These results justify the routine use of pedal arterial reconstruction for patients with diabetes with ischemic foot complications. (J Vasc Surg 2003;37:307-15.)

Objective: Although previous series have reported outcomes of lower extremity (LE) revascularization in patients with end-stage renal disease, the issue of LE bypass for limb salvage in this group has not been resolved. We herein present the largest series to date of a 10-year single-institution experience with LE bypass in patients with dialysis dependence. Methods: With prospectively entered data from a university teaching hospital's vascular registry, we reviewed the records of all patients with dialysis dependence who underwent LE arterial bypass between January 1, 1990, and May 31, 1999. Results: A total of 146 consecutive patients (177 limbs) underwent infrainguinal revascularization, of whom nearly all (92%) had diabetes and tissue loss (91%). The in-hospital mortality rate was 3% (five patients). The rates for perioperative congestive heart failure, myocardial infarction, arrhythmia, and wound infection were 2%, 3%, 5%, and 10%, respectively. The actuarial graft primary and secondary patency rates at 1 and 3 years were 84% and 85%, and 64% and 68%, respectively. The limb salvage rates were 80% and 80% at 1 and 3 years. The 1-year and 3-year cumulative survival rates were 60% and 18%, respectively. At 5 years, survival was poor with only 5% of the entire cohort of 146 patients still alive. Multivariate logistic regression analysis at 6 months identified age (odds ratio, 0.96, 0.91) and number of years on dialysis (odds ratio, 0.79, 0.74) as significant (P < .05) negative predictors of both limb salvage and survival, respectively. Conclusion: Infrainguinal arterial reconstruction can be performed on patients with dialysis dependence with acceptable rates of limb salvage given the high incidence rate of perioperative complications and poor longevity of this patient group. Advanced age and number of years on dialysis seem to correlate with poorer outcome. (J Vasc Surg 2002;36:969-74.)

Objective: Multiple large series have retrospectively identified female gender as a risk factor for perioperative stroke and death after carotid endarterectomy (CEA). Methods: Data for all patients who underwent CEA at a single institution from January 1990 to December 1998 were entered into a computerized vascular registry and form the basis of this report. Results: A total of 1298 CEA procedures were performed, of which 520 (40%) were in women and 778 (60%) in men. The mean age was 69.8 ± 8.7 years for men and 71.2 ± 8.5 years for women (P

Objective Patients undergoing infrainguinal arterial reconstruction frequently have increased cardiac risk factors. Diabetic patients are often asymptomatic despite advanced cardiac disease. This study investigates whether preoperative cardiac testing improves the outcome in diabetic patients at risk for cardiac disease. Methods We retrospectively reviewed all patients undergoing lower-extremity arterial reconstructions in a 32-month period from July 1999 to February 2002. Of the 433 patients identified undergoing 539 procedures, 295 had diabetes mellitus and considered in this study. The patients were stratified into two groups according to the present American College of Cardiology, American Heart Association (ACC/AHA) algorithm. We identified 140 patients with two or more of ACC (Eagle) criteria who met the inclusion criteria for a preoperative cardiac evaluation. These patients were separated into two groups: those undergoing a cardiac work-up (WU) according to the ACC/AHA algorithm and those not undergoing the recommended work-up (NWU). Outcomes included perioperative mortality, postoperative myocardial infarction, congestive heart failure, arrhythmia, and length of hospitalization. Significance of association was assessed by the Fisher exact test. Length of hospitalization was compared using the Kruskal-Wallis rank sum test. Survival data was analyzed with the Kaplan-Meier method. Results One hundred forty patients met the criteria for moderate risk. There were 61 patients in the NWU group and 79 in the WU group. Ten patients in the WU group underwent preoperative coronary revascularization (6 had percutaneous transluminal coronary angioplasty, 4 underwent coronary artery bypass grafting). There was no difference between perioperative mortality (WU, 1%; NWU, 2%; P = 1.00) or in postoperative cardiac morbidity, including myocardial infarction, congestive heart failure, and arrhythmia requiring treatment (WU, 5%; NWU, 6%; P = .71). There were no perioperative deaths and one episode of congestive heart failure in the group that had preoperative coronary revascularization. Median length of hospitalization was 10 days in the WU group and 8 days in the NWU group ( P = .11). Patient survival at 12 months for the NWU, WU, and revascularized groups was 85.3%, 78.5%, and 80.0%, respectively; 36-month survival was 73.6%, 62.9%, and 80.0%, respectively. The three survival curves did not differ significantly ( P = .209). Conclusions Preoperative cardiac evaluation, as defined by the ACC/AHA algorithm, does not predict or improve postoperative morbidity, mortality, or 36-month survival in asymptomatic, diabetic patients undergoing elective lower-extremity arterial reconstruction. These data do not support the current ACC/AHA recommendations as a standard of care for diabetic patients with an intermediate clinical predictor who undergo peripheral arterial reconstruction, a high-risk surgical procedure.

Purpose: Although pedal artery bypass has been established as an effective and durable limb salvage procedure, the utility of these bypass grafts in limb salvage, specifically for the difficult problem of heel ulceration, remains undefined. Methods: We retrospectively reviewed 432 pedal bypass grafts placed for indications of ischemic gangrene or ulceration isolated to either the forefoot (n = 336) or heel (n = 96). Lesion-healing rates and life-table analysis of survival, patency, and limb salvage were compared for forefoot versus heel lesions. Preoperative angiograms were reviewed to evaluate the influence of an intact pedal arch on heel lesion healing. Results: Complete healing rates for forefoot and heel lesions were similar (90.5% vs 86.5%, P = .26), with comparable rates of major lower extremity amputation (9.8% vs 9.3%, P = .87). Time to complete healing in the heel lesion group ranged from 13 to 716 days, with a mean of 139 days. Preoperative angiography demonstrated an intact pedal arch in 48.8% of the patients with heel lesions. Healing and graft patency rates in these patients with heel lesions were independent of the presence of an intact arch, with healing rates of 90.2% and 83.7% ( P = .38) and 2-year patency rates of 73.4% and 67.0% in complete and incomplete pedal arches, respectively. Comparison of 5-year primary and secondary patency rates between the forefoot and heel lesion groups were essentially identical, with primary rates of 56.9% versus 62.1% ( P = .57) and secondary rates of 67.2% versus 60.3% ( P = .50), respectively. Conclusion: Bypass grafts to the dorsalis pedis artery provide substantial perfusion to the posterior foot such that the resulting limb salvage and healing rates for revascularized heel lesions is excellent and comparable with those observed for ischemic forefoot pathology. (J Vasc Surg 1999;30:499-508.)

The infection of autogenous vascular grafts from blood-borne contaminants is distinctly unusual. Two cases are reported in which a urinary tract infection caused by Pseudomonas aeruginosa occurred after autogenous saphenous vein bypass grafting. Despite appropriate intravenous antibiotic therapy for 10 days with clearing of both blood and urine, the patients subsequently had significant complications from graft infections. The factors thought to have contributed to this are discussed and the literature reviewed. Recommendations are made concerning the modification of the standard therapy in this situation. (J VASC SURG 1987;5:492-4.)