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The purpose of this paper is to establish the survival rate of patients submitted to aorto-femoral bypass grafting and compare it with the general mortality rate of the population in the State of São Paulo. The records of 210 patients with aorto-femoral bypass grafts and mean age of 54 years were analysed according the Kaplan and Meyer method. The survival curves of the normal population with the age of 55 and 70 years were used for comparison. Our results are comparable with those reported in the international literature. The aorto-femoral atherosclerotic disease Hás the same features wherever lives the patient. The death is caused mainly by cardiac disease. In our patients, however, the infection of the prosthesis was also an important factor in the fatal outcome of the disease. After ten years about half of the patients submitted to an aorto-femoral bypass grafting are still alive.

The surgical treatment of telangiectasis synchronous to sclerotherapy is presented in this paper. Two female patients with extensive telangiectasis of the lower limbs comprise our report. They were considered typical cases for application of the proposed technique: abolishing venous reflux. The adjacent veins were resected through skin incisions of about 2 mm with crochet hooks, under local anesthesia, immobilized with adhesive tape. Sclerotherapy was performed simultaneously. The cosmetic result was excellent in both cases, with complete removal of the telangiectasis. This procedure should be considered the method of choice in the treatment of telangiectasis resulting from obvious venous reflux.

This article is to evaluate the results of surgical treatment of aorto-femoral graft infections. The records of 20 patients with aorto-femoral graft infections were reviewed. The patients were submitted mostly to a combination of surgical procedures. They were: a) conservative treatment; b) partial removal of the infected graft and c) total removal of the infected graft. The removal of the prosthesis, partial or total, was followed by a new arterial reconstruction in some patients. The final treatment was: total removal of the infected graft in 11 (55%) patients, total removal plus arterial reconstruction in six, partial removal in two and partial removal plus arterial reconstruction in one. The results of treatment were presented as the survival rate and the effective palliation (patient alive, lower limbs preserved and infection cured). The survival rates after one month, 12, 24, 36 and 48 months were respectively: 80%, 60%, 53%, 42% and 27%. The effective palliation rates after one month and after 48 months were respectively 50% and 27%. The highest effective palliation rate was obtained when the infected prosthesis was removed and a new arterial reconstruction performed. We conclude that the treatment of choice of aorto-femoral graft infections seems to be the total removal of the graft followed by new arterial reconstruction.

Thirty patients were operated for arterial reconstruction with synthetic grafts. They presented one of the following complications: 1) prosthesis exposed by a cutaneous fistula; 2) prosthesis in communication with a hollow viscus; 3) prosthesis involved by pus; 4) positive culture of a fragment of the prosthesis or of the surrounding secretion. The clinical manifestations were cutaneous fistula in 21 patients (70%), external bleeding in 14 (47%), exposition of the prosthesis in five (17%), anastomotic aneurysm in five (17%), and enteric fistula in four (13%). The infection became evident during the first postoperative year in half of the patients. The most important agents of infection were staphyilococci and Gram negative bacteria.

A 59 year old female patient was admitted to the hospital complaining of lower back pain and fever for four months, with worsening of symptoms during the last two weeks. A painful pulsatile abdominal mass was the only positive sign at her physical examination. Her CT-Scan showed a periaortic hematoma and a rupture of the aortic wall while the Aortography disclosed a false aneurysm below the renal arteries. All blood cultures were negative. The patient was operated on and had her aneurysm resected and her aorta reconstructed with an in situ bifurcated aorto-femoral Dacron graft. The bacteriological examination of the aortic wall revealed a Salmonella type B, which confirmed the clinical hypothesis of abdominal aortic mycotic aneurysm. It was not possible to maintain a prolonged antibiotic therapy and the patient had to be submitted to a second operation three months later because of an infected graft; when the aorto-femoral graft was removed and an axillobifemoral bypass prosthesis was done. After a three years follow-up period the patient is doing well and has no signs of recurrences. We conclude, based on the literature review and our personal experience, that: 1) the symptomatologic triad presented by the patient is highly suggestive of those diagnosis; 2) blood cultures may not be positive; 3) the CT-Scan and aortography are the best examinations for the diagnosis of abdominal aortic mycotic aneurysm; 4) either the in situ or the extra-anatomical arterial reconstruction may be employed with good results. Higher infection rates are reported with the in situ grafts; 5) life-long antibiotic therapy is recommended whatever reconstruction procedure is selected.

For non-invasive detection of obstructive disease in the internal iliac artery, the femoral compression test was devised. This test consists in the compression of the inguinal arcade of the patient with the examiner's thumb, until the disappearance of the arterial beats in this region and peripherically in the correspondent lower limb, while one auscultates the sound in the dorsal penial artery with ultrasonic stethoscope and measures the penial pressure. The test was considered positive when there was abolition of sound in the penial artery, or reduction superior to 15% in the penial pressure. The test was negative when there was no abolition or reduction of sound and pressure, as referred respectively. In 15 normal individuals the 30 tests, one for each inguinal region, were negative. In 23 patients with ischemia of lower limbs registered by the analysis of angiographies to which they were submitted, there were 39 tests, one in each inguinal region, in which there was femoral pulsation. There was abolition of sound in the penial dorsal artery in 20 of 22 tests in which the arteriography showed obstruction of the homolateral internal iliac artery. In 15 tests, in which there was reduction of penial pressure, the arteriography showed presence of unique or multiple stenosis in the internal homolateral iliac artery. In two cases of patency of the internal homolateral iliac artery, the test was negative. The positivity of the test was significantly higher in patients with obstructive lesions of internal iliac artery when compared to normal individuals (p < 0.001, chi-square test).(ABSTRACT TRUNCATED AT 250 WORDS)

From October 1985 to December 1988, 31 iliofemoral eversion endarterectomies were performed in 29 patients with arteriosclerosis. The surgical procedure was carried out for trophic lesions in 74% of the patients and for ischemic rest pain in the remaining 26%. In 11 operations the endarterectomy was associated with profundoplasty, and in eight with saphenous vein femoropopliteal bypass. There were six immediate failures, four of them submitted to successful reoperations, and two to above knee amputations. In cases with good immediate patency no complications occurred during the follow-up periods which ranged from one to 34 months. With one post-operative death the mortality rate was 3.2%. Two patients displayed later severe ischemic manifestations in the opposite limbs and were both submitted to the same type of operation with good result. It may be concluded that iliofemoral eversion endarterectomy is an appropriate alternative procedure to the aortoiliofemoral reconstruction surgery in patients with severe ischemia of the lower limbs.

Twenty patients with peripheral arteritis due to an infectious disease were studied with the purpose to detect the etiological agent in the vessels belonging to ischemic areas; to establish the relationship between the onset and evolution of the ischemic lesions and the infectious disease; and to verify the appropriateness of the treatment with anticoagulants. Ten patients had meningococal disease with positive blood culture for Neisseria meningitidis. The meningococci were found in vessel walls of ischemic areas. The cutaneous lesions had sudden onset and a rapid evolution. Five patients had pneumonia or gastroenteritis. No microorganisms were detected in the vessel walls of the ischemic areas. The cutaneous necrotic lesions appeared from two to six days after the infectious disease was diagnosed. Therefore, heparinization was considered appropriate to block the extension of the disseminated intravascular coagulation secondary to the vasculitis. Three patients had, probably, post-streptococcal sensibilization arteritis and two post-measles arteritis. No etiological agent was identified in the vessel walls. The necrotic lesions of the extremities appeared from five to 21 days after the clinical course of the infection. The lesions had the complete evolution in a period from one to four days. It was considered appropriate to start the heparinization in the evolutive period of the peripheral lesions in an attempt to reduce the ischemia by the interruption of the intravascular coagulation related to the vasculitis. In heparinized patients in whom the necrotic lesions did not extend completely in the extremities, the evolution to irreversible gangrene and limb loss did not occur.(ABSTRACT TRUNCATED AT 250 WORDS)