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Background: Controversy exists as to the choice of conduit for the treatment of superficial femoral artery occlusive disease, particularly when a patent above-knee popliteal artery exists. Some surgeons advocate the preferential use of polytetrafluoroethylene (PTFE), whereas others favor the use of autogenous vein. This report compares our experience with above-knee femoropopliteal bypass with PTFE versus below-knee femoropopliteal bypass with autogenous vein., Methods: This study covers a 15-year period extending from 1982 to 1996 during which 1,313 arterial reconstructions were performed for superficial femoral and/or proximal popliteal arterial disease. Four hundred and thirty-eight procedures were performed to the above-knee popliteal artery using PTFE, and 875 procedures were performed to the below-knee popliteal artery using autogenous vein. The indication for surgery was limb salvage in 77% of patients in the PTFE group and 88% of patients in the vein group., Results: The 1-, 3-, and 5-year cumulative life table primary patency rates for the PTFE group were 74%, 56%, and 50%, respectively. The primary patency rates for the vein bypass group were 83%, 75%, and 67%, respectively (P < 0.01). The 5-year cumulative limb salvage rates were 91% and 95% for the PTFE and vein groups, respectively (P = NS)., Conclusions: In this series, below-knee femoropopliteal venous reconstructions have superior patency rates compared with above-knee femoropopliteal PTFE reconstructions. Venous reconstruction for femoropopliteal occlusive disease gives the optimal long-term result. Prosthetic reconstruction should be considered for patients with limited venous conduit or decreased life expectancy.

Background: Carotid endarterectomy has demonstrated excellent results over the past 2 decades with combined stroke mortality of < 4% in most active centers. However, the optimal technique for surgical reconstruction for patients with acute postoperative deficits is more controversial., Patients and Methods: In the last 10 years (1985 to 1995), we performed 1,267 carotid endarterectomies, with 17 strokes (1.3%) and 16 deaths (1.2%). Twenty-four patients developed acute (within 72 hours) postoperative neurologic deficits. In 10 patients, the carotid artery was confirmed patent by duplex scan or angiography, and the neurologic deficit resolved without further therapy. Early reexploration was performed in 14 cases for suspected thrombosis associated with a new neurologic deficit. In each case, resection of the endarterectomy site and an interposition bypass was performed with greater saphenous vein (11), jugular vein (2), or polytetrafluoroethylene (2) grafts. (One patient required a new bypass for acute occlusion of the initial vein bypass.) Postoperatively, 8 patients had complete resolution of their deficit, 3 had minimal residual deficits, and 3 suffered permanent stroke. However, 2 of these patients died., Results: Carotid artery bypass with exclusion of the endarterectomy site resulted in improvement in symptoms in 79% (11 of 14) of the patients and complete resolution in 57% (8 of 14). In long-term follow up (1 to 41 months), there have been no occlusions and one restenosis requiring revision at 11 months., Conclusions: Carotid artery bypass can be performed safely with acceptable results. The use of autogenous venous conduits allows reconstruction with an endothelial lined conduit that may improve results in patients with acute postoperative neurologic deficit secondary to thrombosis of the endarterectomized carotid artery.

Background: Arterial bypasses performed for limb salvage have increasingly used peroneal and pedal arteries as outflow. However, few reports have been published that compare the patency of limb salvage of these alternative outflow tracts. In this report, we have examined our experience with peroneal and dorsalis pedis (DP) artery bypasses for limb salvage., Methods and Materials: Of more than 3,000 infrainguinal reconstructions performed for limb salvage, 732 were completed to the peroneal artery. During the same period, 238 bypasses were performed to the DP artery. Patient demographics were similar in both groups. The in situ technique was used in 68% of the peroneal bypasses and in 66% of the DP bypasses, respectively. Translocated veins were used in 28% of bypasses, and spliced veins were used in 32%., Results: Secondary patency rates for the DP bypass at 1 and 5 years were 89% and 67%, respectively, as compared with 89% and 78% for the peroneal artery bypass. Limb salvage rates for the DP bypass were 94% at 1 year and 86% at 5 years, as compared with 96% and 93% at 1 and 5 years, respectively, for the peroneal artery bypass. No statistical difference was found. Four (1.7%) hemodynamic failures occurred in the DP group and 10 (1.4%) in the peroneal group. Wound complications were seen in 9 (3%) patients in the DP group and in 11 (1.5%) in the peroneal group., Conclusion: This experience indicates that both peroneal and DP bypasses have acceptable patency and limb salvage rates. Selection of one of these two outflow tracts, where a choice exists, may depend on the conduit limitation and adjacent tissue infection; however, both outflow tracts are durable and hemodynamically effective for limb salvage.

Background: Patients undergoing the placement of coronary artery bypass grafts (CABG) with hemodynamically significant carotid artery lesions pose a difficult problem for both cardiac and vascular surgeons. Despite numerous studies, there has been no consensus of opinion as to the proper management of these patients. In numerous series, the combined mortality and perioperative stroke rates in concomitant carotid endarterectomy and CABG procedures have ranged from 8% to 40%. This has made many surgeons consider staging these procedures., Methods: Retrospective analysis of patients undergoing combined carotid endarterectomies and CABG from 1980 to 1993 were reviewed. Two hundred six procedures were performed in 189 patients. Seventeen patients had bilateral carotid endarterectomy performed with CABG. The average age of our patient population was 66 years, with 123 being male and 66 being female. Seventy-five percent of the patients were asymptomatic with the remainder having transient ischemic attacks, amaurosis fugax, or prior stroke., Results: Operative mortality was 2%, with three of four patients dying of cardiac failure and one of a stroke. A temporary neurologic deficit was seen in 2% of patients, and a permanent neurologic deficit was seen in 2 of 206, or 1%. Thirty shunts were used in this series, mostly in patients with contralateral carotid occlusion. All procedures were performed under general anesthesia with full invasive monitoring. One patient was re-explored for bleeding, and one patient had a temporary hypoglossal palsy. A total of 203 cases had the arteriotomies closed primarily, and 3 required patches., Conclusion: In our experience, simultaneous carotid endarterectomy and CABG can be performed with an acceptable mortality and morbidity and does not appear to put the patient at an increased risk. Staging of these procedures may not be necessary in most cases.

Improvements in the operative mortality and morbidity rates in elective aortic replacement, which are largely a result of refinements in surgical technique and perioperative management, have allowed a more aggressive approach in the treatment of abdominal aortic aneurysm (AAA) in elderly patients. To evaluate this approach, we reviewed the records of 116 patients 80 years of age and older (range: 80 to 93 years) who consecutively underwent aortic replacement for AAA. Seventy-seven patients underwent elective aortic replacement with 8 complications and a 3% operative mortality rate (2 of 77). Emergent aortic replacement was performed in 39 patients (14 with symptomatic nonruptured AAA and 25 with ruptured AAA) with 12 complications. In this nonselective subset, there were eight deaths, for an operative mortality rate of 20% (symptomatic 14%, ruptured 24%). In comparison, 780 patients less than 80 years of age underwent aortic replacement during the same time period. Within this group, 622 patients who were treated on an elective basis had a similar operative mortality (2%) as did patients 80 years of age and older. On the basis of these results, we believe that elective aortic replacement in elderly patients is justified and can be achieved with low operative mortality and morbidity rates. We suggest that the chronologic age of the patient should not deter aortic replacement.

Retroperitoneal exposure of the abdominal aorta is usually performed through a left flank incision. An alternative approach to the abdominal aorta is described utilizing a right flank incision. Indications for the use of the right retroperitoneal approach during surgery for aortic aneurysms include right renal artery stenosis, right iliac artery aneurysm, need for simultaneous cholecystectomy, multiple or recent intraabdominal procedures, and sigmoid colostomy. A series of 17 patients is presented to illustrate the utility of this approach. There was one operative death in an emergent patient; the cause of death was not related to the method of aortic exposure. The remaining patients recovered quickly. The anatomic advantages and limitations of this exposure are discussed. We believe that retroperitoneal aortic exposure is superior to midline transperitoneal exposure. Aortic exposure utilizing a right retroperitoneal approach is a useful option in the surgical armamentarium.