Search

Aim: We have developed a new closed technique using a co-axial catheter embolisation system for intraoperative coil embolisation of the side branches of in situ vein bypass grafts in order to avoid long skin incisions., Technique: After completion of the proximal anastomosis, disruption of the valves and completion of the distal anastomosis, the catheter is introduced via a proximal side branch of the greater saphenous vein. Under fluoroscopic control the side branches are identified, selectively catheterised and an embolisation coil is positioned in each side branch., Patients: In 14 patients (eight men, six women), 16 in situ bypasses were performed (12 below knee femoro-popliteal, four femoro-crural)., Results: Once mastered the embolisation procedure took less than 1 hour. In four cases persistent arteriovenous fistulae had to be treated in the postoperative period. Two major wound complications occurred and there were three early failures. One late failure occurred due to a rupture of the venous bypass 6 weeks postoperatively. The remaining 12 bypasses are patent, with a median follow-up of 16 (3-26) months., Conclusion: These preliminary results suggest that the "closed" technique is feasible and that long term occlusion of AV-fistulae can be achieved without ligation via incisions.

In vitro and in vivo studies revealed significantly better haemodynamic properties for a newly designed axillo-bifemoral bypass graft, with a flowsplitter at the bifurcation. In order to analyse the clinical relevance of these improved haemodynamic properties a prospective randomised clinical trial was performed. The patency rates of two different axillo-bifemoral bypass grafts, differing only in the configuration of the bifurcation: one with a contralateral branch at an angle of 90 degrees and one with a flowsplitter, were analysed. In 19 centres, 117 patients were randomised, 59 receiving a prosthesis with a flowsplitter, and 58 a prosthesis with a 90 degrees bifurcation. Indications and risk factors were equally distributed in both groups. Final analysis after 3 years with a mean follow-up of 12 months (range 3-36 months) showed that the prosthesis with a flowsplitter had a significantly better patency rate after 2 years of 84% compared to the patency rate of the prosthesis with a 90 degrees-angled bifurcation of 38% (log-rank test, p less than 0.0001). These data were not significantly influenced by the indication for the operation, associated risk factors (e.g. diabetes mellitus, hypertension or myocardial infarction), outflow tract or anti-coagulant therapy. Other endpoints such as death and graft infection did not differ significantly.

The imaging quality of angiodynography (Quantum; Philips) in the ilio-femoral tract was compared with uniplanar angiography. One hundred ilio-femoral tracts were investigated with both translumbar conventional angiography and angiodynography. The ilio-femoral tract was divided into five parts; proximal and distal common iliac, proximal and distal external iliac and common femoral. Stenosis was scored from 0-24, 25-49, 50-74, 75-99 and 100% and the lengths of those of 25% or more were measured in centimeters. Because the thickness of the subcutaneous fat layer decreases the depth range (normally 11.5 cm) of the 5.0 MHz transducer it was also measured in centimetres. The results showed that a significantly larger number of vessels were not seen (especially the common iliac) with an increasing thickness of the subcutaneous fat. The results based on the real-time imaging quality alone of angiodynography showed a reasonable accuracy of 83.9% when detecting stenoses graded from 0-24, 25-49, 50-74, 75-99 up to 100%. The clinically more important discrimination between a haemodynamically important stenosis of more than 50% showed a sensitivity of 88% and specificity of 98% on visual information alone. By integrating the peak velocity measurements to the results, this sensitivity rose to 95% and the specificity became 99%. The correlation in length was within a range of 1 cm in 94% and within 1-2 cm in 6% of the stenoses. In conclusion, angiodynography is a reliable technique for investigating the ilio-femoral tract.