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Objective: To assess the outcome of surgical (SR) and endovascular (ER) reconstruction for chronic mesenteric ischemia (CMI)., Methods: Retrospective review of consecutive patients who underwent SR or ER for CMI in 3 UK vascular surgery units between 1996 and 2006. Early (<30 days; technical success, morbidity, mortality, length of hospital stay) and late (>30 days) outcomes (symptom recurrence, vessel/graft patency, reintervention, mortality) were assessed., Results: A total of 27 patients underwent 32 reconstructions (SR = 17, ER = 15). A total of 44 of 56 (79%) diseased arteries underwent SR (n = 26; bypass = 24, reimplantation = 2; occlusion = 16, stenosis = 10) or ER (n = 18; stenosis = 16, occlusion = 2). Perioperative mortality for SR and ER was 6% and 0%, respectively (P > or = .99). Hospital stay was shorter following ER (mean, 4.3 vs. 14.2 days, P = .0003). Mean (range) follow-up for SR and ER was 34 (1-94) and 34 (0-135) months, respectively. At 2 years, SR demonstrated superior secondary patency (100% vs. 65%) and clinical patency (100% vs. 73%)., Conclusions: Surgical mesenteric reconstruction is associated with significantly longer hospital stay, but superior long-term outcome compared to endovascular reconstruction.

Aim: Infrainguinal bypass is an effective treatment for critical lower limb ischemia but up to 1/3 of these grafts will occlude within the 1st year. The aim of this audit was to evaluate the efficacy of aspirin in maintaining graft patency and also improving patient survival., Methods: In a single audited year (1997) 125 bypasses were carried out. Seventy-nine were on aspirin, 34 on no treatment and 12 were on other agents and hence excluded from analysis. The indication for surgery was critical ischaemia in 101 and disabling claudication in 12. Autologous vein was used in 104 and prosthetic grafts in 9., Results: The overall 2-year primary graft patency, secondary graft patency and limb salvage were 50%, 71% and 83%, respectively. The 2-year secondary patency in patients with or without aspirin was 73% and 64%, respectively (p<0.12-log rank test). The corresponding patient survival from vascular death in the 2 groups was 73% and 70% (p<0.67-log rank test). Crural/ pedal bypass (51/75 on aspirin) and smoking (51/61 on aspirin) were independent risk factors for graft failure and vascular death respectively whilst those with a previous myocardial infarct (21/28 on aspirin) reached significance in univariate analysis only (p< 0.03)., Conclusion: Aspirin was not a significant factor in preventing graft failure or vascular death in patients undergoing bypass for critical limb ischemia. Dual therapy with other antiplatelet agents needs to be considered in such patients particularly those undergoing crural/pedal bypass, smokers and those with a history of previous myocardial infarction.

Background: microtibial embolectomy is an important technique in cases of limb threatening acute arterial occlusion affecting native crural and pedal vessels. It is particularly useful when thrombolysis is contraindicated or ineffective as in "trash foot"., Methods: in order to evaluate the efficacy of this technique, a retrospective case note review was carried out for patients undergoing microtibial embolectomy from 1990 to 1999. Data collected included the causes and degree of ischaemia, additional procedures required, vessel patency, limb salvage and complications encountered., Results: twenty-two limbs underwent exploration of the crural/pedal vessels with ankle level arteriotomies under local anaesthetic in 12 cases, general anaesthetic in nine and epidural in one. The causes of ischaemia were cardiac emboli (8), "trash foot" (7), emboli from aortic and popliteal aneurysms (3) and thrombotic occlusion of crural vessels (4). The vessel patency rate was 69% and limb salvage rate 62% (13/21) up to 5-years follow-up. Six of the seven cases with "trash foot" were salvaged while one required an amputation at 3-months post-operatively. The 30-day mortality was 22% (5/22)., Conclusions: microtibial embolectomy is effective in acute occlusion of the crural/pedal arteries including cases of "trash foot", offering limb salvage to a worthwhile proportion of cases.

Background: To evaluate the efficacy of a modification of the composite sequential femorocrural bypass graft that we adopted in 1985, a retrospective case-note study was undertaken. The grafts combined a prosthetic femoropopliteal section with a popliteal to crural section with autologous vein, linked via a common intermediate anastomosis sited on the above-knee popliteal artery., Patients and Methods: Between 1985 and 2000, 68 grafts of this type were constructed in 65 patients with critical ischemia of the lower limb and insufficient autologous vein for construction of an all venous bypass. Reasons for insufficient long saphenous vein included previous lower limb bypass in 33 cases, phlebitis in 16 cases, venous hypoplasia in eight cases, and previous varicose vein surgery in seven cases. Distal anastomoses were carried out to the peroneal artery in 26 cases, the anterior tibial artery in 17 cases, the posterior tibial artery in 17 cases, and the pedal arteries in eight cases. Sources of vein included the long saphenous vein in 26 cases, the arm vein in 38 cases, and the short saphenous vein in two cases. In 22 limbs (32%), angiography had shown an occluded segment of above-knee popliteal artery, and in these cases, local popliteal disobliteration was performed to receive the composite anastomosis and to provide additional outflow., Results: The 2-year cumulative primary patency, secondary patency, and limb salvage rates were 68%, 73%, and 75%, respectively. Localized popliteal disobliteration did not compromise graft patency (P =.07, with log-rank test)., Conclusion: In the absence of sufficient autologous vein, patients needing bypass to crural arteries can be offered reconstruction with composite sequential grafting with satisfactory results. Furthermore, an occluded above-knee popliteal segment is not a contraindication for composite sequential bypass reconstruction.

Objectives: To establish the incidence of graft stenosis in a large population of patients undergoing femorodistal bypass procedures and to investigate the differences in incidence between individual surgical centres and other subpopulations., Patients and Methods: A total of 277 patients with femorodistal bypasses underwent duplex scanning of vein grafts for 12 months for the detection of graft stenoses. A standard definition of a significant stenosis was used in all twenty participating centres., Results: Overall stenosis rate was 27%. Stenoses were more common in composite vein grafts (43%) than in single segment vein grafts (25%) p=0.05. Stenoses were more common in female patients (38%) than males (22%) p=0.02. Stenosis rates in individual centres entering more than 20 patients varied from 9% to 56%. In a multiple regression analysis only aspirin use, sex and centre were significant factors predicting the likelihood of graft stenosis., Conclusion: Female patients, those taking aspirin and patients with composite vein grafts appear to be more at risk of graft stenosis, but this does not fully explain wide variations in the incidence of stenoses reported by individual centres., (Copyright 2000 Harcourt Publishers Ltd.)

Objective: There is evidence for superior patency in infra-inguinal bypass procedures in men compared to women. A large, prospectively planned series was investigated in order to confirm this finding and to determine the origin of this difference in outcome., Methods: Patients underwent femorodistal bypass surgery and a prospectively planned 12-month follow-up. Outcomes in male and female patients were compared and investigated for associations with characteristics of the patients and the surgical procedures., Results: A total of 517 patients received femorodistal bypass grafts, including 424 vein grafts and 93 prosthetic and vein-prosthetic composite grafts. Patency was confirmed to be higher in male than in female patients (56% vs. 42%, p=0.005). Fewer male patients received prosthetic or composite grafts (21% vs. 33%, p=0.005), but the difference in patency was evident only in patients receiving vein grafts. Female patients were smaller, included fewer smokers (p<0.001) and had worse symptoms (p=0.03), but none of these characteristics explained the difference in outcome. Patency in vein grafts was associated with graft diameter (p=0.004), but graft diameter was not significantly associated with sex (p=0.09) or with body size., Conclusions: It was confirmed that patency of femorodistal bypasses is significantly higher in males than females. None of the factors investigated here explain this difference, but the greater use of prosthetic and composite grafts in female patients suggests that poorer vein quality should be investigated as a possible source of the inferior outcome in female patients., (Copyright 2000 Harcourt Publishers Ltd.)

Objective: To investigate the relationship between bypass patency, limb survival and clinical symptoms after femorodistal bypass procedures., Design: Multicentre, prospectively planned 12-month postoperative follow-up., Patients and Methods: Five hundred and seventeen patients undergoing femorodistal bypass surgery for severe ischaemia. Clinical symptoms, bypass patency were recorded at regular intervals up to 12 months postoperatively., Results: Complete follow-up data was obtained on 498 patients (96%). Fifty-six (17%) of the 341 patients with patent bypasses had either rest pain or ulcers or had undergone major amputation at 12 months. Of the 167 patients with an occluded bypass, 22 patients (13%) had improved clinical symptoms and a total of 59 patients (35%) had avoided major amputation at 12 months. The clinical outcome for patients classified preoperatively as Fontaine stage IV was significantly worse than for those in stage III preoperatively despite similar bypass patency rates., Conclusions: There is a fair correlation between technical and clinical outcome after femorodistal bypass surgery at 12 months, but there are significant numbers of patients with occluded bypasses who have a good clinical outcome and of patients with patent bypasses who have a poor clinical outcome. The reporting of symptoms in addition to bypass patency would aid the interpretation of surgical results.

Background: A few patients with critical limb ischaemia are believed to be too unfit for an attempt at revascularization using conventional anaesthesia., Methods: A retrospective analysis was undertaken of 46 revascularization procedures performed in high-risk patients for critical limb ischaemia between 1989 and 1995, in which local anaesthetic techniques were utilized in preference to general or spinal anaesthesia., Results: Cumulative survival rates at 6, 12 and 24 months were 67, 57 and 51 per cent. Primary patency rates were 77 per cent at 6 months, 67 per cent at 12 months and 53 per cent at 24 months, with associated limb salvage rates of 87, 87 and 79 per cent., Conclusion: Selective use of local anaesthetic techniques extends the benefits of limb salvage to patients considered unfit for conventional anaesthesia.

Ankle-branchial pressure indices (ABPIs), measured by sphygmomanometer and Doppler probe, are an accepted index of chronic leg ischaemia. However, tibial artery sclerosis or calcification decreases compliance, producing falsely elevated cuff occlusion pressures. Arterial cannulation is invasive and impractical, but by elevating the foot and measuring the height at which the Doppler signal disappears, ankle systolic pressure in mmHg can be derived. Using an 8MHz Doppler apparatus and calibrated pole, ankle systolic pressures measured by sphygmomanometer and elevation were compared in 49 severely ischaemic legs (40 patients). ABPIs were derived by dividing ankle systolic pressure by brachial pressure. Median (interquartile range) ABPI assessed by sphygmomanometry was 0.46 (0.35-0.56). Median ABPI measured by leg elevation was significantly lower at 0.21 (0.14-0.30), p < 0.0001, Wilcoxon. In 20 patients undergoing in situ vein bypass grafting, direct transducer-derived pressure measurements were obtained. Median ABPI for this method was 0.15 (0.11-0.27). No significant difference was found when compared with ABPIs derived by elevation, median 0.2 (0.13-0.31), p = 0.324, however median ABPI measured by sphygmomanometry was significantly higher at 0.37 (0.27-0.6), p = 0.0008. Correlation of elevation with transducer-assessed pressure measurements (r = 0.88) was closer than with cuff-derived measurements (r = 0.69). Pressures derived by leg elevation provide a more accurate index of severe leg ischaemia than sphygmomanometry, although the technique is limited to assessing pressures of less than approximately 60 mmHg. Falsely elevated ABPIs may underestimate the extent of disease in patients assessed for vascular reconstruction.

A prospective randomized placebo-controlled trial was conducted to determine the effects of the stable prostacyclin analogue iloprost on early graft patency and hemodynamic parameters during femorodistal reconstruction for critical leg ischemia. Peripheral resistance and graft blood flow were measured using an operative Doppler flowmeter and graft pressure transducer. Postoperative graft surveillance was continued at 1-month and then at 3-month intervals by duplex Doppler ultrasonography, measurement of ankle-brachial pressure indices, and intravenous digital subtraction angiography when indicated. In patients receiving 3000 ng of iloprost (n = 45) infused into the graft on completion there was an immediate mean decrease in peripheral resistance of 44% that persisted to skin closure in comparison with controls (n = 38) in whom no such decrease in resistance occurred (p < 0.001, Wilcoxon test). During the same period, mean graft blood flow increased in iloprost-treated patients by 74.5% compared with controls in whom there was a 6% increase in flow (p < 0.001). Primary cumulative patencies at 1 month were significantly higher in iloprost-treated grafts, 98% compared to 83% for controls (p < 0.05, log-rank test). Cumulative primary patencies at 1 year and secondary patencies at 1 month and 1 year were also greater in the iloprost-treated group (67%, 98%, and 87.6%, respectively) compared to controls (65%, 86%, and 79.3%, respectively), but these did not achieve statistical significance. A single bolus infusion of iloprost has prolonged beneficial effects on graft blood flow and peripheral resistance during femorodistal reconstruction. This is reflected by improved early primary graft patencies.(ABSTRACT TRUNCATED AT 250 WORDS)

A consecutive series of 315 patients underwent arterial reconstruction for 329 critically ischaemic lower limbs over a 5-year period. Patients were not excluded from limb salvage surgery on the basis of poor run-off on preoperative angiography. Femorocrural bypass to a single calf vessel was required in 239 limbs (73 per cent); the 30-day cumulative mortality rate was 7 per cent, rising to 41 per cent at 5 years. Cumulative graft patency at 30 days, 1 year, 2 years and 5 years was 96, 85, 84 and 82 per cent respectively and was independent of the level of reconstruction. In situ long saphenous vein was the conduit of choice for distal bypass but, when this was absent, satisfactory results were obtained with arm vein or composite vein grafts. Acceptable results can be obtained for reconstructive surgery without preoperative angiographic selection of patients. An aggressive approach to limb salvage is therefore justified.

From January 1985 to December 1989, 500 consecutive patients presented to a single vascular unit with limb-threatening acute or critical ischaemia. Vascular reconstruction was attempted unless the patient had insufficient viable tissue to permit weight bearing or complete absence of run-off vessels in the calf. Fifty patients underwent a primary amputation and 450 patients underwent vascular reconstruction, of whom 265 had a femorocrural bypass. Sixty secondary amputations were performed following femorocrural bypass failure. The below-knee amputation to above-knee amputation ratio (BKA:AKA) was 2.0 in the primary amputation group and 1.1 in the secondary amputation group. Direct comparison between the two groups is not valid as they are clinically different. The combined BKA:AKA ratio was 1.4. This compares favourably with the BKA:AKA ratio of recent published series and figures from the National Amputation and Limb Fitting Services. It suggests that an unselective policy of vascular reconstruction for critical ischaemia does not lead to a higher proportion of above-knee amputations.

An adjuvant distal arteriovenous fistula (ADAVF) has been claimed to increase arterial bypass graft flow and patency when run-off is poor but others have suggested that a patent fistula does not improve in distal limb perfusion. In 10 dogs, hind limbs were rendered ischaemic by proximal arterial ligations and then revascularised with vein grafts. In each dog an ADAVF was constructed on the left graft while the right was used as a control. Flow and pressure were measured in each graft and distal artery and the effect of temporary occlusion and release of the fistula noted. These measurements were repeated at re-operation 3 months later. Mean flow through control grafts was 83 +/- 8.57 (S.E.M.) ml/min, increasing to 146 +/- 22.89 (S.E.M.) ml/min with papaverine (P less than 0.001, Student's t test), and was unchanged at 3 months. Mean flow in grafts with a distal A-V fistula was 250 +/- 41.68 (S.E.M.) ml/min with no change after papaverine, and an increase to 730 +/- 110.5 (S.E.M.) ml/min at 3 months (P less than 0.001, Student's t test). However, arterial flow distal to the fistula was invariably retrograde at initial operation (20 +/- 3.0 S.E.M. ml/min), and this retrograde flow increased to 180 +/- 33.2 (S.E.M.) ml/min at 3 months (P less than 0.001, Student's t test). Distal arterial pressure at initial operation fell from 88.8 +/- 3.35 (S.E.M.) mmHg to 10.8 +/- 1.01 (S.E.M.) mmHg with the fistula open. We conclude that in this animal model an adjuvant distal arteriovenous fistula may improve bypass graft flow, but is unlikely to benefit distal limb perfusion.

A method of non-invasive preoperative assessment of chronically ischaemic legs was developed that used clinical data and data derived from Doppler ultrasonography to produce a numerical score that could be compared with an angiographic score for stenosis of the popliteal artery trifurcation. The two scoring systems were applied retrospectively to 144 legs after femorodistal bypass. A close correlation was observed (r = 0.89, p less than 0.001), and both systems tended to predict the level of grafting undertaken. A prospective comparison was then made in 81 ischaemic legs that were examined by arteriography; the correlation between the two scoring systems remained close (r = 0.89, p less than 0.001), and the level of bypass was correctly predicted by the non-invasive assessment in 44 of 50 legs that were operated on. Use of the non-invasive assessment subsequently greatly reduced the indications for preoperative arteriography in patients requiring femorodistal vascular reconstruction.

Transcutaneous oxygen tension (TsPO2) was measured in the foot and chest of 39 patients with severe peripheral vascular disease and the Regional Perfusion Index (RPI) calculated (RPI = Foot TcPO2 divided by Chest TcPO2). TcPO2 was equivalent to RPI as a measure of ischaemia and furthermore RPI did not alter significantly when re-assessed under anaesthesia. Successful vascular reconstruction brought about an ontable rise in RPI which rose further but not significantly post-operatively. Continuous monitoring of RPI allowed intra-operative identification of 20 of 22 successful reconstructions and there were no false positive results.