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We report 3 cases of ureteral obstruction following aortoiliac prosthetic graft surgery owing to secondary retroperitoneal fibrosis around anteriorly positioned ureters. The reversal of symptoms and radiographic demonstration of relief of obstruction after oral steroid therapy are discussed. The necessity of placing such grafts behind the ureters is reiterated and the routine performance of preoperative and postoperative excretory urography is suggested. A trial of steroid therapy following early detection of such obstruction in lieu of early surgical exploration is discussed.

Multiple technological and procedural advances in the technique for hemodialysis have evolved since Kolff in 1944 described his original “dialyzer” [1]. This expansion in methods of angioaccess has an implicit bearing on the proliferation of hemodialysis, so that today virtually no patient in renal failure is denied such therapy. An estimated 70,000 patients in the United States alone are currently enrolled in a hemodialysis program. Progressive knowledge of the management of renal failure and its complications has placed demands on vascular surgeons to create and maintain access to the arteries and veins for the purpose of achieving successful hemodialysis. External shunts, internal shunts, percutaneous venous catheters, primary arteriovenous (AV) fistulas, autogenous bridge fistulas, and prosthetic fistulas have all been used for hemo-access with variable success. The gold standard for hemoaccess remains the primary AV fistula as described by Brescia and Cimino in 1966 [2]. However, conditions for creation of this classic fistula are not always present and some alternative form of hemoaccess is indicated. Expanded polytetraftuoroethylene (c-PTFE) has evolved as a highly successful prosthetic material for use in the creation of secondary forms of hemoaccess.

Prosthetic graft occlusion is most frequent in the early postoperative period when the luminal surface is highly thrombogenic. It is generally believed that graft maturation ultimately results in a non-thrombogenic surface. The accumulation of 111-indium-labelled autologous platelets in Dacron aortofemoral grafts has been measured 1 week following surgery and at intervals of 6 months to 1 year. Platelets from 9 patients were labelled with 111-indium oxine and re-injected. Isotope emissions over the graft and a reference site (aortic arch) were measured daily for 8 days and gamma camera images taken on alternate days. Graft thrombogenicity was calculated as the daily rise in the graft: reference ratio of emissions. All grafts, regardless of age, accumulated platelets and were imaged by gamma camera. Mean thrombogenicity (± s.e.mean) 1 week after surgery was 0·21 ± 0·04 compared with 0·08 ± 0·03 at follow-up (P < 0·01). The platelet survival during the early study was reduced at 6·8 ± 0·6 days but recovered to a value of 8·6 ± 0·8 days (P < 0·01) at follow-up. Further grafts, 2, 5 and 9 years old, were studied and all accumulated platelets, especially near the anastomoses. Platelet accumulation on Dacron grafts does diminish with time but persists beyond the period of altered platelet survival and perhaps indefinitely.

FALSE aneurysms developed at suture lines are serious complications of reconstructive vascular surgery in which prosthetic materials have been used to bypass areas of arterial obstruction. The exact frequency of this problem is unknown, but Stoney et al 1 reported a 23.7% incidence of false aneurysms occurring at the common femoral or popliteal anastomosis. In the cases reported to date, the aneurysms have invariably developed in patients with patent grafts. In fact, Smith and Szilagyi 2 suggest that thrombosis of the graft may effect a spontaneous cure of the problem. The purpose of this report is to present three cases in which false aneurysms developed two to five years after the prosthetic graft occluded and to discuss the possible etiology of the anastomotic dissolution. Report of Cases Case 1. —In April 1959, this 62-year-old man was admitted to the hospital complaining of intermittent claudication in the left calf. On May

The postoperative thrombosis of prosthetic grafts may be due to many factors: technical errors, poor run-off, prosthetic material, graft length, trauma by subcutaneous tunnellization or repeated microtrauma across the joint areas, evolution of atherosclerotic lesions, emorheological changes. In 50 patients submitted to surgical arterial repair of the lower limbs, we have employed 8,000 I.U. AXa/daily of LMW-Heparin, injected subcutaneously for 6 months after the operations to prevent immediate and late thrombosis. During the follow-up, one patient died, four stopped any treatment and in two the medication was changed. Hence our results are based on 43 cases: 10 patients operated upon by aorto-femoral bypass, 19 femoro-popliteal and 14 extra-anatomical procedures. During the follow-up all the patients were investigated by ultrasounds (pressure measurement, waveform analysis and duplex scanning echotomography); moreover 13/43 (30%) were studied by angioscintigraphy and 11/43 (25.5%) by a conventional or digital subtraction angiography. Thrombosis of the grafts at one year term occurred in none aorto-femoral, in one femoro-popliteal (5.2%) and in one extra-anatomical bypass (7.1%). This figure compares favourably with the results obtained in our experience in the patients treated by a variety of drugs. In such group the incidence of occlusion is 3.9% in aorto-femoral, 9.3% in femoro-popliteal and 11% in extra-anatomical grafts. Those results emphasize the possibility to improve the patency of the grafts in the arterial repair of the lower limbs by LMW-Heparin overall in femoro-popliteal and extra-anatomical areas.

Background Pseudoaneurysm of graft–graft anastomosis is an extremely rare but potentially fatal complication after thoracic aorta replacement with a prosthetic graft. We report a case of pseudoaneurysm at the graft–graft anastomosis of a hand-sewn branched graft. Case Presentation A 65-year-old man underwent total arch replacement with a hand-sewn branched graft for Stanford type A acute aortic dissection 22 years ago. During follow-up, serial CT scans showed a pseudoaneurysm on the branched graft which warranted reintervention. Surgical repair involved direct suture of multiple bleeding points which were found at the sites of the hand-sewn branches anastomosis. The postoperative course was uneventful, and no signs of bleeding were observed by CT after the reoperation. Conclusions Long-term follow-up is essential to detect late complications at the site of hand-sewn anastomosis.

Cephalothin sodium was given prophylactically through a central venous catheter to patients having prosthetic graft insertions. Venous pH, Pco2, arterial pH, Pco2, P02, lead 2 electrocardiogram strip, and central venous pressures were recorded before and after the administration of the drug. The tests were run in an attempt to determine if there was any alteration in these parameters due to drug administration. No changes were noted in any of the blood gas, pH, ECG, or central venous pressure values. Arterial P02 changes could not be adequately analyzed due to the wide variation in P02. It was concluded that cephalothin sodium can be given safely through a central venous catheter, every six hours, in 2-gm doses diluted in 100 ml of 5 percent glucose in distilled water.

Since the introduction of porous prosthetic graft material in 1 952 [1 ], graft failure has not been a problem; however, the ideal vascular prosthesis is still being sought. Dacron has the best record to date and is used most often. Despite the infrequency of graft failure, radiologists may be required to perform and interpret examinations in this regard. The features of graft failure have not been recorded in the radiology literature and radiologists may be unfamiliar with angiographic findings of graft deterioration. Our report offers an instructive clinical experience and brief review of the surgical literature.

A new method of anastomosis was devised, intended for the reinforcement of the anastomosed area between the fragile vessel of the patient and the prosthetic graft in cardiovascular surgery. This method, which may be called a headband method, consists of suturing a small prosthetic graft wrapping the anastomosed area together with the arterial vessel in the manner of a headband. Fourteen cases have been evaluated at follow-up periods ranging from 24 to 40 months. All cases proved successful without noteworthy complications.

We describe a case of seroma formation with skin necrosis overlying an axillobifemoral dacron graft, which was treated by excision of the affected skin and closure using a latissimus dorsi myocutaneous flap.

Mycotic aneurysms are uncommon but not rare lesions with potential for catastrophic hemorrhage or sepsis. They have been ascribed to bacterial endocarditis and, when present in the aorta, were termed "inevitably fatal" as recently as 1967. A 15-year review of the English-language literature on mycotic aneurysms showed that arterial trauma, concurrent sepsis, and depressed host immunity have become the cardinal "risk factors" in the development of these lesions. Conventional treatment of mycotic aortic aneurysms usually includes aortic ligation, aneurysmal excision, and extra-anatomic bypass grafting. Nevertheless, four of our patients with well-localized mycotic aortic aneurysms survived three to 54 months (mean, 40 months) after aortic excision and in situ prosthetic graft restoration of aortic continuity. This experience suggests that mycotic aortic aneurysms can be successfully treated, frequently by in situ grafting, if diagnosis and treatment are timely and aggressive.

• Dilation of prosthetic graft has been noted by authors in association with junctional aneurysm between the synthetic graft and host arteries. Dilation of graft materials was suspected as one of the etiologic factors of the junctional aneurysm. Increase in transverse diameter was observed as early as a few minutes to five years postimplantation in clinical cases. The phenomenon of dilation was studied experimentally. Nine different types of graft materials were tested using intraluminal pulse pressure of 100/60 mm Hg, and the transverse diameters were measured at various time intervals. Knitted grafts showed the more pronounced changes compared with the woven. Degree of dilation differed considerably among the different types of knitted grafts. (Arch Surg114:1296-1303, 1979)

MANY ADVANCES have been made in surgery for abdominal aortic aneurysm since Dubost reported the first resection with homograft replacement in 1952. 1 Presently resection with prosthetic graft replacement is considered the treatment of choice and has been employed with a mortality as low as 5% and late survival approaching that for other people of similar age. 2 Ruptured abdominal aortic aneurysm, however, constitutes a surgical challenge. Operative mortality as high as 85% has been reported. 3 An average hospital mortality of 56% in a recent collective review (Table 1) indicates the need for continued improvement of operative and postoperative management of these critically ill patients, if a higher salvage rate is to be achieved. This study, therefore, was undertaken to obtain a more up to date analysis of surgical experience with this fatal condition and, if possible, determine the factors influencing the results of operative management. Materials and Methods

PLASTIC fabrics have been used in vascular surgery since the early 1950's. In the following case a sarcoma occurred in association with a prosthetic vascular graft. Case Report A 31-year-old man was admitted to the Washington Veterans Administration Hospital on June 2, 1969, because of a rapidly growing mass on the anteromedial aspect of the left thigh of 3 weeks' duration. Ten and a half years previously a laceration of the left superficial femoral artery had been repaired with a short section of a woven Teflon-Dacron prosthetic graft. Physical examination revealed a firm, non-tender, nonpulsatile mass, 8 by 10 cm, . . .

Bilateral aneurysms of the internal carotid artery were treated by permanent bypass grafts. Excision of the aneurysms led to a satisfactory three-year follow-up. The rarity of this condition is noted. The treatment of choice at present for cervical carotid aneurysms is resection with prosthetic graft replacement to bridge the arterial defect.

Revascularization of the visceral arteries during thoracoabdominal aneurysm repair is usually performed sequentially by an anastomosis between a prosthetic graft and an aortic patch. There are immediate operative risks such as bleeding and distortion. In the longer term, aneurysm, pseudo-aneurysm and rupture may occur. These require reoperation and are associated with significant morbidity and mortality. We present our experience with Crawford IV thoracoabdominal aneurysm repair in four patients, using a prefabricated four-branched graft (Coselli graft). At two years there were no deaths, no complications and no vessel abnormalities on computed tomography. We recommend its use as the graft of choice in young patients with an aortic tissue disorder requiring total resection of the aortic wall at the level of the visceral vessels.

Background The traditional surgical intervention of open aneurysmectomy and prosthetic graft is still now the gold standard for the treatment of abdominal aortic aneurysm. Today, the new mini-invasive endovascular approach is a valid therapeutic option to customize the treatment based on clinical characteristics of patient and morphological features of the aneurysmal lesion. The purpose of this study is to establish which technique is more suitable for the treatment of the AAA in the elderly patients. Materials and methods 100 patients aged between 65 and 75 (M:F 85:15) were enrolled in 3 years. After a preoperative cardiac screening, patients were divided into two groups of 50 patients. In group I were included high risk patients (acute renal insufficiency, chronic obstructive pulmonary disease, hypertension and valvular defects), while in group II were included low risk patients with not relevant pathologies. All patients of group I underwent endovascular and surgical treatment, patients in group II were submitted to "open" surgical intervention because of moderate risk.