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Objective: To compare end-to-side (ETS) and end-to-end (ETE) distal anastomoses for femoropopliteal bypasses., Design: Prospective, randomized, multicenter trial., Methods: Patients from 14 centers were randomized to either ETS or ETE distal anastomosis, with stratification according to center and four categories: venous and prosthetic above knee bypass, and venous and prosthetic below knee bypass. Follow-up, with history, physical examination, ankle-brachial pressure index and duplex scan was performed at 3 months, 6 months and every 6 months thereafter until 36 months postoperatively., Results: A total of 328 femoropopliteal bypass operations were performed in 274 patients. Due to anatomical considerations at the time of surgery, 15 procedures (4.6%) were excluded from further analysis. Patient characteristics, cardiovascular risk factors, Rutherford classification and number of open run-off vessels were similar for both groups. Primary patency was 75 vs 74%, 65 vs 66% and 63 vs 55% for ETE vs ETS after 1, 2 and 3 years, respectively, (p = 0.26). During follow up major amputations were necessary in 20 ETE bypasses and in nine ETS bypasses (p = 0.028)., Conclusion: ETE distal anastomosis infemoropopliteal bypasses does not improve patency compared to ETS anastomosis. Major amputations, after failure of the bypass, were required more frequently for ETE distal anastomoses.

The primary goal of endovascular treatment of abdominal aortic aneurysms (AAA) is prevention of death from rupture. Even in the absence of an endoleak, the AAA may continue to enlarge. The pathogenesis of this phenomenon remains unclear. Therefore, surveillance after endovascular AAA treatment must include regular evaluation of aneurysm size, or even better, aneurysm volume. Aneurysm sac enlargement without an endoleak is not a benign condition. Recurrent or persistent pressurization of the AAA sac will eventually result in rupture. Besides that, continued expansion of the AAA sac can result in dilatation of the infrarenal neck and/or iliac arteries, which may threaten the integrity of proximal and distal anastomotic seals. Many centers will take a pragmatic approach in case of endotension and a growing AAA, and convert to open surgery with removal of the endograft and placement of a regular vascular graft. Direct puncture and pharmacological intervention in the cause of sac enlargement by local instillation seems logical, but has failed so far. The third option for aneurysm sac enlargement without an endoleak is laparoscopic or open fenestration of the aneurysm. Until permanent solutions for endotension and endoleaks are found, endovascular aneurysm repair will remain an imperfect long-term treatment and continued follow-up will be mandatory.

Background: The optimal method of operative treatment of prosthetic aortic graft infection (PAGI) has been the subject of debate; incidence rates of PAGI are low. Diagnosis of PAGI can be difficult. The aim of this retrospective study is to evaluate our results in treating PAGI in order to try and optimize the treatment of this grave problem., Methods: Thirty-eight patients (median age 68.5 years) were treated for PAGI between 1991 and 2000. Management of PAGI was performed with total graft excision and simultaneous extra-anatomic bypass (n=18), total graft excision and in situ repair with a Rifampicin-soaked gelatin-impregnated prosthetic aortic graft (n=8), or a partial excision with in situ repair (n=11). In 1 patient, only local irrigation was performed. The median follow-up was 45 months., Results: Clinical presentation of PAGI (median interval 3 years) was: discomfort/pain (n=14), gastro-intestinal bleeding (n=11), persisting fever (n=8), or a non-healing wound (n=5). The primary patency rate in patients with extra-anatomic bypass was 67% at 6 months follow-up. In patients with other surgical reconstructions no graft occlusion was encountered. Overall amputation rate was 5%. Recurrent infection of the graft was 15%. The overall early mortality rate in this study was 21%., Conclusions: The diagnosis of PAGI is difficult and should be based on a combination of clinical symptoms, laboratory findings and imaging techniques. There are several treatment options that should be tailored to the extent of infection and the patients' physical condition. In a selected group of patients partial excision of the infected graft only can be justified.

Objectives: to compare end-to-side (ETS) and end-to-end (ETE) distal anastomoses. Design retrospective cohort study., Methods: retrospective cohort study. Between 1988 and 1992, 204 femoropopliteal bypasses (188 patients) were performed for claudication (55%), rest pain (22%) and tissue loss (23%). One hundred and eighteen ETS were compared with 86 ETE in terms of patency or a mean (range) follow-up of 68 (0.5-120) months., Results: overall patency was 86%, 66% and 57% at 1, 5 and 8 years, respectively. Multivariate analysis showed ETE anastomoses (p =0.04), and also knee bypass ( p =0.05) and venous conduit ( p =0.004) to be significantly associated with impaired patency., Conclusions: ETE may improve femoropopliteal bypass patency., (Copyright 2001 Harcourt Publishers Limited.)

Purpose: To use intravascular ultrasound (IVUS) to document changes in vascular dimensions after placement of a balloon-expandable endograft., Methods: Thirteen patients (9 men; mean age 62 years, range 47-75) treated with an investigational polytetrafluoroethylene endograft for obstructive disease of the femoropopliteal segment were studied with IVUS immediately after endograft implantation and at follow-up. Corresponding IVUS cross sections were analyzed for changes in lumen, vessel, and plaque areas seen inside the endograft, in the anastomotic segment, and in the remote arterial segment., Results: A mean 6-month (range 1.5-9) follow-up was completed in 12 patients. Matched IVUS cross sections derived from within the endograft (n = 12) and at the endograft edges (n = 23) showed no change in lumen area (LA) in 17, reduction in 11, and dilatation in 7. Median changes within the endograft (+3%) were not significant (p = 0.28) and no neointima was found. Cross sections obtained at the anastomotic segment revealed a significant increase in LA (85%, p < 0.001), which was associated with a significant increase in both vessel area (VA) (42%, p < 0.001) and plaque area (PLA) (15%, p = 0.003) area. In the remote arterial segment, the change in LA was minimal (6%, p = 0.07), as were changes in the VA (9%, p = 0.04) and PLA (10%, p = 0.07)., Conclusions: Following endograft placement, luminal changes within the endograft, at the endograft edges, and at the remote arterial segments were minimal. Intimal hyperplasia was not observed in the endograft. The distinct LA increase at the anastomotic segments was determined by the extent of VA and PLA change.

Our objective was to investigate the preliminary use of endovascular stent-grafts for the treatment of femoropopliteal artery aneurysm. Ten patients with an aneurysm of the femoropopliteal artery referred for endovascular treatment were investigated. The series consisted of patients with a true aneurysm of the superficial femoral artery (n = 2); a true aneurysm of the popliteal artery (n = 4); an aneurysmal dilatation of a Biograft bypass (n = 2); a false aneurysm of the superficial femoral aneurysm (n = 1); and a false aneurysm of a composite bypass (n = 1). In 8 of the 10 patients the stent-graft was composed of one or more Palmaz stents sutured to an ePTFE tube graft; in the other 2 patients a venous covering was used in combination with Palmaz stents. The procedure was guided by angiography and intravascular ultrasound. The results of our investigation showed that endovascular stent-grafting of aneurysms of the femoropopliteal artery is a feasible but experimental technique that should be restricted to a selected group of patients.

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.

During a 7-year period 20 patients underwent operation for a graft-enteric fistula after implantation of an intra-abdominal vascular prosthesis months or years before. Eighteen patients had gastrointestinal blood loss as their first symptom; 12 were in shock on admission. Fourteen patients had a fistula between the proximal anastomosis and the duodenum. Graft excision followed by axillobifemoral bypass was performed in 10 patients and four patients underwent local repair. A fistula between the distal anastomosis and the bowel was found in the remaining six patients and a local repair was carried out. Proximal graft-enteric fistula carries a particularly high postoperative mortality rate of more than 50 per cent.

To evaluate the patency of PTFE (Gore-tex) as a femoropopliteal bypass, a prospective randomized trial was performed between PTFE and saphenous vein. Forty-nine consecutive patients with intermittent claudication, rest pain, or tissue loss due to an occlusion of the superficial femoral artery entered the study. Randomization between PTFE and saphenous vein was performed at the time of operation after assessment of the quality of the latter. The two groups did not differ significantly regarding stage of peripheral ischemia, outflow tract, or localization of the distal anastomosis. The patency rate 6 weeks after operation was 92% for each group. After a mean follow-up of 54 months, the patency rate for the PTFE group was 37% and 70% for the saphenous vein group (p less than 0.001). In the PTFE group, there were eight major amputations. No amputations were performed in the saphenous vein group. It is concluded from this study that the saphenous vein is by far superior to PTFE as a femoropopliteal bypass.

A retrospective study was carried out on 386 consecutive patients admitted during the period 1975 to 1981 with an abdominal aortic aneurysm; 110 patients (39%) were treated by means of a straight tube graft instead of the more commonly employed bifurcation prosthesis. Its use reduced the operation time by 26 to 31% (p less than 0.001) in both non-ruptured and ruptured aneurysms. Operative blood loss was significantly reduced in ruptured aneurysms only (29%, p less than 0.05). Secondary operations for iliac aneurysm repair were not required in any patient with a straight tube graft during the follow-up period (6 to 60 months). Our experience suggests that, in the absence of significant iliac artery disease, the use of a straight tube graft is the procedure of choice in the treatment of an abdominal aortic aneurysm.

Fifty PTFE (Goretex) femoropopliteal bypasses were performed for intermittent claudication (23 pts), rest pain (12 pts) or loss of tissue (15 pts). Thirty-one grafts occluded during the follow-up period up to 39 months, 19 grafts were patent. The two groups are compared regarding severity of ischaemia, outflow tract, distal anastomosis and ankle brachial ratio. Except for the severity of ischaemia, these factors showed a statistically significant difference between the two groups. A total of 51 reoperations were performed on 31 thrombosed grafts. Only one of the 24 thrombectomies was successful. A new PTFE or composed grafts never remained patent during the follow-up. Only four of the eight new venous bypasses had a long-term patency. Thrombosis of 31 PTFE femoropopliteal bypass led to amputation in 14 cases.