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Purpose: The treatment of ischemic complications that result from aortic dissection is a challenging and controversial problem. The purpose of this study was to evaluate aortic tailoring in the management of acute aortic dissection associated with visceral, renal, or lower extremity ischemia., Methods: We retrospectively reviewed the clinical courses of seven consecutive patients (five men, two women) with a median age of 68 years (range, 48 to 74 years) from January 1994 to January 1997. All patients underwent an abdominal aortic tailoring procedure for relief of ischemic complications associated with acute aortic dissection (type IIIB, n = 6; type I, n = 1) and a normal-sized aorta., Results: All seven patients survived and recovered full mesenteric, renal, and lower extremity function. Two patients required temporary hemodialysis in the immediate postoperative period. There has been no significant dilatation of the tailored aortic segments, with an average follow-up of 19 months (range, 1 to 30 months)., Conclusions: Abdominal aortic tailoring represents a safe and effective method for treating ischemic complications associated with acute aortic dissection and a normal aortic luminal diameter.

Purpose: To determine the efficacy and durability of supraceliac aortorenal bypass grafting for symptomatic atherosclerotic renal artery disease., Methods: Retrospective review of a 10-year, single-institution experience., Results: Seventeen patients underwent 27 bypass procedures (seven unilateral, 10 bilateral) for atherosclerotic renovascular hypertension. The patients' mean age was 62.7 +/- 8.8 years. Diffuse aortoiliac and visceral atherosclerosis was confirmed on arteriogram; most (88%) celiac axis branches and all infrarenal aortas and common iliac arteries were found unsuitable for use as a donor vessel. Twenty-six bypass procedures (96%) were performed with autologous vein grafts. Seventeen bypass procedures (63%) were performed during partial aortic occlusion. There were no operative deaths or early occlusions. Postoperative complications occurred in four patients (24%). The mean duration of follow-up was 28 +/- 19 months (range, 2 to 69 months). By life table analysis, the 5-year primary patency and assisted primary patency rates were 95% and 100%, respectively. The mean systolic blood pressure decreased from 180 +/- 38 mm Hg to 135 +/- 20 mm Hg (p = 0.0003), and the mean diastolic blood pressure decreased from 96 +/- 16 mm Hg to 77 +/- 9 mm Hg (p = 0.0002). The number of antihypertensive medications decreased from 2.8 +/- 1.2 to 1.4 +/- 1.0 (p = 0.002). Significant improvement in serum creatinine level was seen among patients with preoperative renal insufficiency. Hypertension was cured in 29%, improved in 53%, and unchanged in 18%. During late follow-up, only four patients (24%) required subsequent aortic reconstruction., Conclusion: Supraceliac aortorenal bypass grafting is a safe and durable alternative for renal artery revascularization. This technique should be considered in patients who have diffuse infrarenal aortoiliac and visceral artery occlusive disease and require renal revascularization procedures.

Purpose: Results from 34 endovascular repairs of abdominal aortic aneurysms are reviewed to identify technical complications and relate them to anatomic and technical features of the operation., Methods: Twenty-one patients underwent attempted tube graft repair (mean follow-up, 13 months). Thirteen patients underwent placement of a bifurcated graft (mean follow-up, 7.2 months)., Results: Twenty-five patients (74%) underwent repair without technical complication (16 tube graft and nine bifurcated graft). Of five patients who had tube graft complications, two involved small iliac arteries and resulted in arterial injury. One of these patients needed a femorofemoral bypass procedure, and the other required conversion to standard operation. Two patients had distal leaks associated with the attachment system, and one patient had misplacement of the distal attachment system. The two patients who had leaks were followed-up; one required operation after 7 months, whereas the other leak sealed. The patient who had distal attachment system misplacement had a second endograft placed within the first to provide a distal seal. The four patients who had bifurcated graft complications involved two graft limb stenoses, one managed with a Palmaz stent and the other with balloon angioplasty. The patient treated with balloon angioplasty had graft thrombosis 1 week after the operation, which resulted in the need for a femorofemoral bypass procedure. Another bifurcated graft patient had a graft limb twist, which has resulted in chronic claudication. One patient had placement of a limb too proximal in the common iliac artery with chronic leak, and an open operation was performed 18 months later., Conclusions: Technical complications in this series seem to be associated with short distal necks, small iliac arteries, tortuous iliac arteries, and atherosclerosis at the aortic bifurcation. We believe that experience and understanding of these issues will reduce the risk of these complications in the future.

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.

Background: Autogenous bypass to the anterior tibial artery (AT) has been increasingly used for infrageniculate revascularization. The conduit may be routed through the interosseous membrane, a pretibial tunnel, or through a lateral thigh and calf tunnel. This study reviewed results of AT bypass to determine the optimal routing method., Methods: One hundred thirty consecutive vein grafts to the AT were analyzed retrospectively to compare the experience with the interosseous (group I; n = 50), pretibial (group II; n = 51), and lateral (group III; n = 29) routing alternatives., Results: Indications were claudication in 16 (12.3%) and critical ischemia in 114 (87.8%) procedures with no differences among routing subgroups. Ectopic nonreversed and composite conduits were more common in group III. Major operative morbidity occurred after 7 procedures (5.4%) with no differences in early graft failure (7.7% overall) among the three routing subgroups. Wound infections were more common among group I patients, but without predilection to the interosseous tunnel. During a mean follow-up of 24.9 months (0 to 111.2) overall 5-year secondary patency was 70% with no difference among routing technique., Conclusion: Optimal routing choice depends on the location of suitable AT, the length of adequate vein conduit, and the surgeon's preference rather than on factors inherent to the method used.

Purpose: We report the initial French multicenter experience with the Stentor system in the endovascular treatment of AAAs., Methods: Between May 1994 and March 1996, 79 patients with AAAs were consecutively treated with an endovascular technique using the Stentor system. There were 71 bifurcated grafts and eight straight grafts. The patients were followed-up from 1 to 18 months (mean, 5.7 months). Patient data and events were retrospectively analyzed., Results: No patients was lost to follow-up. There were no surgical conversions. Four patients died after operation (4.8%). Two of them had been considered inoperable by the standard technique. Four patients (4.8%) had pulmonary complications, and three had colonic ischemia (3.7%). Forty-five patients (57%) had postoperative fever, and a transitory thrombocytopenia (10%) developed in eight patients. In 66 patients (83%) the aneurysm was immediately excluded. The exclusion was definitive in 62 (78%). In 17 patients, there were 13 initial and six delayed endoleaks. In two of these patients, the initial endoleak sealed temporarily and resumed after 1 year of follow-up, requiring an additional straight, covered stent. Over all, seven of the leaks were treated successfully by an additional endovascular graft, one leak required a lumbar artery embolization, eight leaks sealed spontaneously, and one leak was untreated. During follow-up, there was no aneurysm rupture. Two patients died of unrelated causes., Conclusion: The Stentor system can safely and effectively exclude AAAs in the short term. Careful follow-up is required to detect any delayed endoleak, and long-term results are awaited to confirm the efficacy of the method in preventing AAA rupture.

Background: Unlike vein bypasses, the role of duplex surveillance of infrainguinal prosthetic bypass grafts is controversial. The purpose of this study was to evaluate the adequacy of color duplex surveillance in identifying failing infrainguinal polytetrafluoroethylene (PTFE) bypass grafts and to assess its value in predicting continued bypass patency., Method: The surveillance data of primarily patent PTFE bypass grafts were compared with those of revised/occluded PTFE grafts. Ninety-five patients underwent 102 infrainguinal PTFE bypass grafts from January 1991 to December 1996 and were enrolled in a duplex surveillance program at 1 month postoperatively, every 3 months in the first year, every 6 months in the second year, and yearly thereafter., Results: Seventy grafts remained primarily patent, 5 were revised and 27 occluded. There was no significant difference in the mean age, gender, indication for surgery, type of original procedure, or duration of follow-up between both groups. Four hundred and seven duplex surveillance data were available for analysis. Focal increase in peak systolic velocity (PSV) 3 x the adjacent segment or low flow manifested by PSV <45 cm/sec were considered abnormal. In the primarily patent group, 5 bypasses had abnormal duplex surveillance and were found to have no abnormality on angiogram and remained patent during the study period. In the revised/occluded group, duplex surveillance was abnormal in 8 bypasses. Twenty-four bypasses occluded without any predicting abnormalities on their last duplex examination, which was performed within 3 months from the occlusion in the majority of the patients. In the 27 occluded bypasses, no intervention was necessary following the occlusion in 7 grafts because of mild or no symptoms. Two patients were treated with a primary amputation and 2 had new bypasses. In 16 occluded grafts, salvage of the PTFE bypass was attempted. Ten of these grafts were patent at the end of the follow-up. The sensitivity of duplex surveillance was 25% with a positive predictive value of 61.5%., Conclusion: Duplex surveillance of infrainguinal PTFE bypass grafts has a low yield and is inadequate at predicting continued bypass patency.

Objectives: During the endovascular repair of abdominal aortic aneurysms (AAAs), effective anchoring of the stent-graft is difficult in the presence of a short infrarenal aneurysm neck. The aim of this study was to investigate renal artery patency and renal function after deployment of graft anchoring stents across the renal arteries., Design: Retrospective open study., Patients: Twenty-five renal arteries, in 18 patients treated by endovascular exclusion of an AAA, were intentionally covered with the Gianturco Z-stent to ensure stent graft attachment., Methods: Renal artery patency was assessed by repeated spiral computed tomography (CT) scans and angiography. Creatinine levels, blood pressure and antihypertensive medication were recorded. Follow-up was a median 6 months (2-9)., Results: All 25 stent-covered renal arteries remained patent. CT showed a small infarct in one kidney. Creatinine was 108 mumol/l (89-133) before intervention and 98 mumol/l (87-127) at follow-up. Blood pressure was 150/80 mmHg on both occasions. Antihypertensive therapy was intensified in one patient whose creatinine level remained stable and whose separate renin sampling was normal., Conclusions: Covering the renal arteries with the Gianturco Z-stent does not seem to affect renal function within 6 months. Further follow-up is needed before suprarenal stent deployment can be advocated.

Objective: To assess the longterm results of mesocaval interposition shunt in the treatment of bleeding oesophageal varices., Design: Retrospective study., Setting: University hospital, Sweden., Subjects: 60 patients with bleeding oesophageal varices in all Child's classes. 20 of whom were operated on as emergencies, and 40 as elective cases., Interventions: A 14 mm polytetrafluoroethylene graft was used as an interposition shunt between the superior mesenteric vein and the vena cava., Main Outcome Measures: Rebleeding rate, portal blood flow, hepatic encephalopathy, morbidity, mortality, and survival., Results: Rebleeding was rare and occurred mainly during the first 4 months after operation, (n = 5) in 10% of the patients, and at the 24 month follow-up, (n = 4) in 11% of the patients. Portal flow was measured preoperatively in 33 patients and in 22 (67%) it was hepatopetal. During follow-up it was reversed and after 24 months no patient had hepatopetal flow. Hepatic encephalopathy was present in 18 patients (20%) during follow-up. Shunts thrombosed in 9 patients (15%), 8 of which required reoperation. There was no operative mortality, but 4 patients (7%) died within 30 days of surgery. The main late cause of death (18/26) was liver failure. The 1 year survival was 80%, the 3 year survival 70% and the 5 year survival 60%., Conclusions: The mesocaval interposition shunt gives good longterm results and can be recommended both as an emergency and an elective procedure for patients with portal hypertension and bleeding oesophageal varices that are unresponsive to sclerotherapy.

Objective: An ideal valved conduit to repair complex congenital heart defects is yet to be developed. In this study we have evaluated the merits of our newly developed calcification-free biologic valve incorporated in a compatible conduit of biologic origin in an animal model., Methods: Porcine aortic valves and main pulmonary arteries were cross-linked in glutaraldehyde, followed by coupling to partially degraded heparin through an intermediate surface-bound substrate containing amino groups. Because commercially available valves are treated only with glutaraldehyde, control aortic valves and main pulmonary arteries were cross-linked in 0.625% glutaraldehyde. Valved conduits were fabricated from main pulmonary arteries, which were sewn to the aortic and ventricular ends of aortic valves. Valved conduits were examined for calcification and other pathologic changes after being implanted in the descending thoracic aorta in juvenile sheep for 5 months., Results: Severe calcification was noticed in all layers of cusps (calcium, 231.86 +/- 17.90 mg/gm) and aortic wall (calcium, 123.24 +/- 24.72 mg/gm) of aortic valves and main pulmonary arteries (calcium, 135.43 +/- 26.63 mg/gm) of valved conduits treated with 0.625% glutaraldehyde. Cusps (calcium, 1.28 +/- 0.22 mg/gm) of the aortic valve of heparin-bonded conduits did not calcify at all. Only sparse calcific deposits were noticed in the medial layer of the aortic wall (calcium, 25.90 +/- 22.79 mg/gm) of aortic valves and main pulmonary arteries (calcium, 9.64 +/- 10.79 mg/gm) of the valved conduits coupled to heparin., Conclusion: Heparin coupling is effective in preventing calcification of glutaraldehyde cross-linked valved conduits implanted in the systemic circulation of juvenile sheep.

Purpose: To evaluate and compare the intraaneurysmal pressure (IAP) after exclusion using two different endovascular grafts., Methods: Eight mongrel dogs had a 3 x 3 cm polytetrafluoroethylene (PTFE) aneurysm sewn as an interposition graft of the infrarenal aorta. A pressure transducer implanted into the aneurysm wall permitted continuous electronic IAP monitoring. Four aneurysms were excluded with a transluminally placed endovascular graft made of a PTFE graft and two Palmaz stents (PTFE-EG), three were excluded with a tantalum-Dacron endovascular graft (TD-EG), and one was surgically treated with a standard PTFE graft (PTFE-Surg). The dogs were observed for 18 to 50 days (mean, 37.5 days) and were evaluated after surgery with duplex and spiral computed tomographic scans., Results: All grafts successfully excluded the aneurysms without perigraft channels or leaks as documented by arteriogram and duplex and computed tomographic scans. The mean IAPs after repair with all PTFE-EGs were significantly lower (p < 0.001) than the mean systemic pressures. In addition, the mean IAP reduction was significantly greater (p < 0.005) in the PTFE-EG group than in the TD-EG group., Conclusions: Aneurysm exclusion with PTFE-EG significantly lowered IAP, did so significantly better than the TD-EG, and approached the IAP reduction obtained by standard repair. Such pressure reduction is necessary for effective protection against aneurysm rupture.

Purpose: This report describes our experience with endovascular repair of aortic and iliac anastomotic aneurysms., Methods: Between June 1994 and March 1996, 12 noninfected aortic or iliac anastomotic aneurysms in 10 patients who had serious comorbid medical conditions that precluded or made difficult standard operative repair were treated using endovascular grafts. No patient in this study had a history of fever, leukocytosis, or computed tomographic evidence of a periprosthetic fluid collection that was suggestive of infection of the original graft. Endovascular grafts composed of polytetrafluoroethylene and balloon-expandable stents were introduced through a femoral arteriotomy and were placed using over-the-wire techniques under C-arm fluoroscopic guidance., Results: Endovascular grafts were successfully inserted in all patients with aortic or iliac anastomotic aneurysms. There were no procedure-related deaths, and complications included one postprocedure wound hematoma and one perioperative myocardial infarction. Graft patency has been maintained for a mean of 16.1 months, with no computed tomographic evidence of aneurysmal enlargement or perigraft leakage., Conclusions: Endovascular grafts appear to be a safe and effective technique for excluding some noninfected aortoiliac anastomotic aneurysms in high-risk patients and may become a treatment option in all patients who have clinically significant lesions.

Purpose: To explore a method of combined endovascular/conventional treatment of abdominal aortic aneurysm (AAA), in which the iliac arteries are reconstructed by conventional surgical techniques to provide the anatomic substrate for subsequent endovascular repair of the aortic aneurysm., Method: A 77-year-old patient with severe cardiac disease was found to have a 6.5-cm AAA, bilateral common iliac artery (CIA) aneurysms, and diffusely narrowed, tortuous external iliac arteries. The left internal iliac artery was occluded. At operation, the right CIA was exposed through a transverse retroperitoneal incision under epidural anesthesia. An iliobifemoral bypass was constructed using a preformed bifurcated graft. A stent-graft was delivered through the right limb of the bifurcated iliobifemoral graft. The proximal end of the stent-graft was implanted in the neck of the aneurysm, and the distal end was deployed in the common trunk of the iliobifemoral graft, thereby excluding the AAA and both native iliac arteries from prograde arterial flow., Results: Completion angiography and follow-up contrast computed tomography showed the aneurysm to be excluded from the circulation. The patient was not intubated, was never hemodynamically unstable, and had aortic blood flow interrupted for no more than 20 seconds. In addition, he was able to resume his usual diet on the first postoperative day. He continues to be well and without evidence of endoleak at 6-month follow-up., Conclusions: This case demonstrates that iliac artery stenosis, tortuosity, and aneurysmal dilatation are not impediments to endovascular AAA exclusion. Any necessary surgical modifications of pelvic arterial anatomy can be performed before stent-graft insertion to minimize aortic occlusion time.

Vascular surgeons are increasingly encountering older patients with large aneurysms associated with severe comorbid conditions. This situation can increase operative morbidity and elevate the mortality rate of aortic surgery over 60%. With some frequency many patients will represent a prohibitive risk for conventional graft replacement. The endoluminal treatment of 110 patients has proved to be feasible and may represent an alternative solution. One hundred six of the patients had an abdominal aortic aneurysm and in four patients, the thoracic aorta was involved. All of them underwent endoluminal repair for the aortic pathology using the combination of stents and grafts in aorto-aortic or aorto-iliac position, with straight, tapered, or bifurcated stent-graft devices. The results are as follows: Initial success was 84% in aorto-aortic abdominal devices and 100% in aorto-aortic thoracic devices. In aorto-iliac devices, initial success was 75%. Late success rates were 62% of the initial group and 80% of the initially successful group.

Although Bentall's operation has become a routine procedure for annuloaortic ectasia (AAE), few reports on its effects on operative mortality in elderly patients have been published. The results of Bentall's operation for AAE on 4 elderly patients were reviewed. There were two males and two females in the series. The ages ranged 71 to 77 years with an average of 73. The etiology of aneurysms was syphilitic in three and arteriosclerotic in one patients. All patients had AAE, aortic regurgitation and ascending aortic aneurysms. Of all these patients, 1 had a subacute Type A dissecting aneurysm, 1 had a proximal arch aneurysm and 1 had an aortic arch aneurysm plus a sacciform descending aortic aneurysm. All patients had composite graft replacement with coronary reimplantation. Three patients received the concomitant operative procedures including aortic arch replacement and CABG to right coronary artery with saphenous vein graft. All patients survived operation. Postoperative CTR and NYHA classification showed remarkable improvement and serious complications were not found in spite of old age. In the late postoperative period, all patients were alive and well from 4 to 6 years after operation. Bentall's operation can be performed in elderly patients with AAE.

Purpose: To test a percutaneous concept for creation of a sutureless terminolateral vascular anastomosis in vivo., Material and Method: By creating sideholes into the middle portion of a stent and a stent graft, both implants could be arranged in a Y-shaped configuration. An arteriovenous shunt was created in 3 sheep between the left carotid artery and the left external jugular vein. A stent graft was partially inserted into the venous lumen. Axial venous patency was restored by placing a stent through the sidehole into the graft lumen from an upstream puncture site. Graft patency was maintained by placing the sidehole of the stent at the bridging point between stent graft and stent with no stent struts crossing. Arterial end-to-end anastomosis was performed by retrograde placement of a stent graft into the arterial lumen. Both anastomoses were connected by a silicone tube., Results: In all cases, a venous end-to-side anastomosis was created that was blood-tight and safely secured into the vascular lumen., Conclusion: Y-shaped configuration of stent and stent grafts through sideholes allows creation of sutureless end-to-side anastomoses in vivo.

Aim: The purpose of this study was to analyse the technical problems associated with conversion from endoluminal repair of abdominal aortic aneurysms (AAA) to open repair and document the outcome in patients with this clinical course., Methods: Between May 1992 and May 1996 endoluminal repair of AAA was undertaken in 113 patients. Forty-eight of these had medical co-morbidities which led to them being rejected for open repair at other medical centres. Conversion from endoluminal to open repair was required in 18 patients. Thirteen of these occurred at the original operation (primary conversion) and five occurred at a later operation (secondary conversion). Seven of the 18 patients undergoing conversion had serious medical co-morbidities. Three different methods of open repair were used. The technique selected was determined by the cause of failure leading to conversion. Standard open AAA repair was used in patients requiring conversion for access problems (n = 2) and balloon malfunction, where the device ended up entirely within the aneurysmal sac (n = 1). Modifications to the standard technique were required in patients in which the endograft was correctly positioned immediately below the renal arteries and/or where part of the endograft was within one or both common iliac arteries (n = 11). Supra-coeliac control was required for patients with aortic rupture (n = 1), renal arteries covered by the endograft (n = 2) and situations where the delivery catheter was trapped within the aorta above a twisted bifurcated graft (n = 1). The mean volume of contrast used was 225 ml and the mean operative time was 5.25 h in patients undergoing primary conversion., Results: Conversion to open repair was achieved in all 18 patients. Renal impairment requiring dialysis occurred in three patients. There were three perioperative deaths, all of which were procedure-related (17%), and one late death. All four deaths occurred from among the group of seven patients with preoperative co-morbidities., Conclusions: Converting an endoluminal to an open AAA repair may require modifications to the standard open technique and result in a much higher than generally accepted morbidity and mortality rate. Patients rejected for open repair because of co-morbidities ran the same chance of requiring conversion as those without co-morbidities (15-17%). If conversion was required, however, they stood a 3 in 7 or 43% chance of dying.

Discontinuity of central intrapericardial pulmonary arteries requires reconstruction of a pulmonary artery confluence before cavopulmonary connection, whether this connection be by bidirectional Glenn or Fontan procedure. Reconstruction of the central pulmonary arteries has previously been described using material of poor or no growth potential. A method is described for central pulmonary artery reconstruction that provides growth potential and is based on previous experience with Fontan lateral tunnel construction.

Objectives: To assess the early experience with the transfemorally placed modular endovascular MinTec graft (TPEG) for abdominal aortic aneurysm (AAA)., Design: One single centre prospective evaluation of the endograft procedure as well as early postoperative results., Setting: An academic teaching hospital., Patients: 30 consecutive patients treated during a period of 15 months., Results: Peri- and postoperative morbidity and mortality were evaluated according to the recommendations of the Ad Hoc Committee on Reporting Standards. The endograft procedure was successful in 28 patients (93.4%); two patients (6.6%) needed conversion into open conventional y-graft replacement; one patient died 36 days following intervention from multiple organ failure. Another patient died from pancreatitis unrelated to the implantation. Endoleaks were treated by "overstenting" or distal extension of the endografts, but conversions were unnecessary. Five severe adverse events were noted in four patients., Conclusions: TPEG is a feasible but technically demanding procedure, requiring both surgical techniques and catheter skills. The potential for less operative morbidity and simpler aneurysm management compared to conventional open surgery may be present. Close follow-up of patients is necessary to understand the development and treatment of endoleaks.

Purpose: To detail a methodology for evaluation of endovascular abdominal aortic aneurysm (AAA) repair that has been achieved through consensus of an international multidisciplinary team of investigators., Methods: This schema features an anatomical classification for AAAs, a definition of procedural success, and a procedure for clinical assessment, as well as the necessary data collection forms. Patient data include demographics, procedural and clinical success, complications, and follow-up. Procedural details can be related to anatomic situations, comorbid processes, devices, and effective aneurysmal exclusion., Results: These data would allow assessment of the procedures, physician learning curves, procedural indications, techniques, methodologies, the relationship of indications to success and complications, devices and subsequent graft patency, and aneurysmal exclusion., Conclusions: The use of this standardized data collection system could enable physicians and industry to better understand endovascular AAA repair and ultimately improve patient care.

This article describes the development of a new experimental model using rats for the evaluation of small-caliber vascular grafts. By modifying heterotopic heart transplantation, two 1.5- to 2.0-cm long vascular prostheses were interposed between a syngeneic donor heart and the recipient abdominal vessels in the form of vascular bridges. Once blood flow through the vascular grafts was reestablished, the donor heart resumed normal beating. The status of the vascular grafts could be easily monitored by palpation. Occlusion of the grafts stopped donor heart beating without affecting survival of the animals. Once the surgical method was mastered, the postoperative mortality was approximately 10%, and the total procedure took less than 2 hours. Although microvascular surgical technique and equipment are required, this model has several advantages, including easy detection of thrombotic occlusion of the grafts, the use of small animals of defined genetic background, the absence of effect of graft occlusion on the recipient's life, and possible repeated operation on the same animal.

The inability to obtain or maintain a secure seal between a vessel wall and a transluminally implanted intra-aneurysmal graft is a complication unique to the evolving technique of endovascular aneurysm exclusion. Because the term "leak" has long been associated with aneurysm rupture, the term "endoleak" is proposed as a more definitive description of this phenomenon. Embracing both persistent blood flow into the aneurysmal sac from within or around the graft (graft related) and from patent collateral arteries (nongraft related), endoleak can be classified as primary or secondary depending on the time of occurrence (within 30 days of implantation or following apparent initial seal, respectively). Diagnostic techniques to detect endoleak include arteriography, intraprocedural pressure monitoring, contrast-enhanced computed tomography, abdominal X ray, and duplex scanning. Management strategies for endoleak range from observation with periodic imaging surveillance to correction by additional endoluminal or surgical procedures. Standardization of the terminology describing this important sequela to endovascular aneurysm exclusion should facilitate uniform reporting of clinical trial data vital to the evaluation of this emerging technique.

Objective: Three cases of kidney transplantation that required a vascular prosthesis are described and the literature reviewed., Methods: Of 920 cases of kidney transplantation, 3 required a vascular prosthesis to repair the aortoiliac vessels. One patient with severe atherosclerotic disease had an aorto-bifemoral prosthesis (Gore-Tex) six months before renal transplantation and the other two patients required a vascular prosthesis to repair iliac artery lesions discovered during transplantation., Results: The initial surgical results were satisfactory. No complications arising from the vascular prosthesis were observed. Two patients have a functioning renal graft, but the third patient developed acute tubular necrosis and tubulo-interstitial rejection and died from acute pulmonary edema., Conclusion: The importance of the preoperative cardiovascular evaluation in patients undergoing kidney transplantation is underscored. Some patients may require a vascular prosthesis. We should therefore be familiar with the prosthetic materials and the surgical techniques, which are not particularly difficult, and optimum results can be achieved. In patients with both end-stage renal disease and severe aortoiliac atherosclerotic disease, the controversy remains whether aortoiliac repair and kidney transplantation should be done simultaneously or in two stages.

In this article, the use of prosthetic grafts for above-the-knee femoral-popliteal arterial bypass reconstruction is discussed. The issue as to whether prostheses should be used preferentially, selectively, or not at all, remains both topical and controversial in vascular surgical circles. The debate has been heightened by a recently presented, and soon to be published, randomized prospective trial comparing two different prostheses, knitted polyester and polytetrafluoroethylene. The results showed equivalent patency rates and reasonably satisfactory overall results. The general considerations (pro and con) as whether to proceed with prosthetic repair and, if so, which graft to select in such patients, is elaborated on this issue, and a recommendation appropriate to the perspective of 1997 is presented.

The coronary physiology of a prosthetic Perma-Flow coronary bypass graft conduit is demonstrated in the first patient at 1-yr follow-up. Coronary blood flow velocity was measured in the body of the graft and into the side-to-side anastomosis to the first diagonal branch. This case report demonstrates the first information on the coronary and prosthetic graft flow in a patient with atherosclerotic coronary disease.

The radial artery has been used as a free bypass graft with excellent results. An autologous vein graft-coated stent, a novel type of stent developed at our institution, has been applied successfully under both experimental and clinical conditions. To extend the spectrum of biological linings for coated stents, we used an arterial graft. We describe the first application of the radial artery as an autologous coating for a conventional stent to be used in treatment of coronary artery disease.

Background: Aortic aneurysm anatomy is crucial when considering patients for endovascular repair. The aim of this study was to determine the proportion of patients with aortic aneurysm suitable for endovascular repair with three different graft-stent systems., Methods: Spiral computed tomographic angiography was used to assess the anatomy of 154 abdominal aortic aneurysms. Measurements were made of aneurysm neck length and diameter, renal artery to aortic bifurcation length, common iliac artery diameter and length, and external iliac artery diameter. Aneurysms were assessed for anatomical suitability for currently available aortoaortic, aortobi-iliac and aortouni-iliac devices., Results: Six patients (4 per cent) had a distal aortic neck suitable for implantation of a straight aortic graft. Fifteen patients (10 per cent) had arterial anatomy suitable for implantation of a bifurcated graft and 85 (55 per cent) patients were suitable for endovascular repair with an aortouni-iliac graft. The primary reasons for unsuitability were: proximal neck length less than 1.5 cm (44 patients), proximal neck diameter greater than 3.0 cm (12), and angulation of the proximal neck (three). A further ten patients were considered unsuitable for an aortouni-iliac graft because of bilateral common iliac artery aneurysms (four), tortuous iliac arteries (four) and narrow external iliac arteries (two)., Conclusion: The aortouni-iliac device has the widest applicability of the currently available endovascular systems but open repair remains the only option for a large proportion of patients.

Background: The past decade has seen an increase in the use of distal arterial bypass grafts for treating critical lower limb ischaemia. However, this surgical policy is associated with variable results. The aims of this study were to identify factors that affect outcome and to calculate the cost of such surgical interventions., Methods: A prospective analysis of femorocrural and femoropedal bypass grafts and primary amputations was performed between June 1991 and January 1995. A consecutive series of 109 limbs with critical lower limb ischaemia underwent a bypass graft to a single crural or pedal vessel shown on either preoperative intra-arterial digital subtraction angiography or at surgical exploration. Complete data were available for all patients during follow-up which ranged from 0 to 42 (median 12) months. The factors assessed were age, sex, diabetes, pedal arch, graft material, outflow vessel, number of calf vessels, number of vessels crossing the ankle, inflow state, previous revascularization procedures and foot gangrene and tissue necrosis. Chief outcome measures were survival, knee and limb salvage, patency rates and hospital cost. The Kaplan-Meier method was used to construct life tables and the log rank test for comparison of factors. Cost was measured according to National Health Service criteria, and comparisons were made by the Mann-Whitney U test., Results: At 36 months primary patency was 27 per cent, primary assisted patency 31 per cent and secondary patency 45 per cent; limb salvage was 54 per cent, knee salvage 73 per cent and survival 58 per cent. Significant factors in predicting outcome were graft material (P = 0.004), inflow state (P = 0.0001), number of calf vessels (P = 0.039), number of vessels crossing the ankle (P < 0.0001) and the condition of pedal vessels (P < 0.0001). Cost analysis showed that the median price for a successful bypass was 4320 pounds, that of a failed bypass leading to amputation 17,066 pounds and that of primary amputation in patients with non-reconstructable distal disease 12,730 pounds., Conclusion: The patency rate of femorotibial and peroneal bypass depends on the inflow state, the availability of a venous conduit, the number of calf vessels, the presence of straight flow to the foot and the presence of patent pedal vessels. These factors can help in the selection of patients for femorodistal reconstruction and may explain the wide variation in published results. The low cost of revascularization compared with amputation justifies attempted reconstruction. However, repeated attempts to reconstruct patients with severe distal disease who may benefit more from primary amputation will significantly increase the cost.

Background: The treatment of aortic aneurysms with endovascular stents or stent-graft prostheses is receiving increasing attention as an alternative to major abdominal surgery. To define the clinical value of this technique, we prospectively studied the use of stent-graft endoprostheses made of nitinol and covered with polyester fabric for the treatment of infrarenal abdominal aortic aneurysms., Methods: We treated a total of 154 patients at three academic hospitals. Twenty-one patients with aortic aneurysms not involving the aortic bifurcation received straight stent-grafts, and 133 patients with aortic aneurysms involving the bifurcation and the common iliac arteries received bifurcated stent-grafts. After a unilateral surgical arteriotomy, the endoprostheses were advanced through the femoral arteries and placed under fluoroscopic guidance. Computed tomography and intraarterial angiography were performed during an average follow-up of 12.5 months., Results: The primary success rate, defined as complete exclusion of the abdominal aortic aneurysm from the circulation, was 86 percent in the group receiving straight grafts and 87 percent in the group receiving bifurcated grafts. In three patients the procedure had to be converted to an open surgical operation. Minor (n=13) or major (n=3) complications associated with the procedure (including 1 death) occurred in 10 percent of the patients. All patients had a postimplantation syndrome, with leukocytosis and elevated C-reactive protein levels., Conclusions: Our results suggest that endovascular treatment of infrarenal abdominal aortic aneurysms is technically feasible and can effectively exclude abdominal aortic aneurysms from the circulation. With further refinement, endoluminal repair may emerge as an interventional strategy to treat infrarenal aortic aneurysms, especially in patients at high surgical risk.

The authors present a new technique for the treatment of atherosclerotic occlusive disease of the superficial femoral artery in highly symptomatic cases. The endovascular technique consists of recanalization, dilation and intraluminal positioning of a distally stented and dilated polytetrafluoroethylene (P.T.F.E.) graft. Until submission of this manuscript, 41 patients with total occlusion of the superficial femoral artery and collateral refill at the level of the proximal popliteal artery were treated with this technique with a very low morbidity. At 1 year follow-up, the life-table analysis shows a primary patency rate of 75.1% and an assisted primary patency of 79.1%. Amputation rate at 1 year was nil. The endovascular technique is depicted in detail and some important features are discussed.

Purpose: The aim of this study was to evaluate the feasibility of endovascular aortic aneurysm repair with use of an aortouniiliac graft secured with self-expanding (Gianturco) stents., Methods: Thirty patients with a median age of 72 years (age range, 52 to 86 years) and aneurysm diameter of 6.0 cm (range, 4.0 to 9.0 cm) were treated with an aortouniiliac endovascular graft. Of these 30 procedures, 28 were carried out electively and two as emergencies for leaking aneurysm. Of the 30 patients, 21 (70%) were considered to be at high risk for open surgery. A modified Gianturco stent, Dacron graft, and Wallstent were used for these procedures., Results: Endovascular repair was successfully carried out in 25 of 30 (83.3%) patients. All these patients were mobile and had resumed a normal diet within 48 hours of the procedure. The overall 30-day mortality rate was two in 30 (6.6%), but it was one in 28 (3.5%) for the elective cases; all deaths occurred in the group at high risk for surgery. Other complications encountered within 30 days of procedure included myocardial infarction in one patient, pneumonia in two patients, homonymous quadrantanopia in one patient, and colonic ischemia in one patient, giving an overall morbidity rate of four in 30 (13.3%). At a median follow-up of 4 months (range, 1 to 13 months), 27 of 30 (90%) patients remain alive and well., Conclusion: Endovascular aortouniiliac repair of abdominal aortic aneurysm with Gianturco stent is feasible in both elective and emergency situations. It appears to be minimally traumatic, and the majority of patients deemed to be at high risk for open surgery can safely undergo endovascular repair. However, data on more patients with longer follow-up is required to determine its role in the management of abdominal aortic aneurysm.

Endoluminal transfemoral repair of an abdominal aortic aneurysm by a stent graft placement requires a segment of the nondilated infrarenal aorta of at least 15 mm long for safe stent graft attachment. The possibility of endoluminal treatment of a juxtarenal abdominal aortic aneurysm with partially covered spiral Z stent was assessed in experiment and in three clinical cases. In the experiment, the noncovered spiral Z stent was placed into the abdominal aorta, across the origins of renal arteries and mesenteric arteries, in six dogs. In the clinical cases, a partially covered stent graft was attached in 3 patients with the juxtarenal abdominal aortic aneurysm (of the group of 12 patients with abdominal aortic aneurysm). The stent grafts were attached with proximal uncovered parts across the origins of the renal arteries. In experiment, the renal artery occlusions or stenoses were not observed 36 months after stent placement, and in clinic, 3 patients with the juxtarenal aortic aneurysm were successfully treated by stent graft placement. There were no signs of flow impairment into the renal arteries 14 months after stent graft implantation. This approach can possibly expand the indications for endoluminal grafting in the treatment of juxtarenal aortic aneurysms in patients who are at high risk for surgery.

The study aim was to develop a reliable endoluminal graft system that would enable the deployment of a bifurcated graft for infrarenal abdominal aortic aneurysms. A life-size plastic model was made of an abdominal aorta and iliac arteries, with a 50-mm infrarenal abdominal aortic aneurysm. This model was used to develop and test self-expanding graft systems, based on a barbed Gianturco stent and series of stainless-steel 'Z' stents within a woven Dacron graft. The bifurcated system developed involves a trouser graft with one long leg and one short. This graft-system is delivered through one femoral artery with deployment of the proximal aortic end infrarenally and the longer trouser leg within the ipsilateral common iliac artery. The short trouser leg is left hanging free within the distal end of the aneurysm cavity, just above the bifurcation. It is held open by a self-expanding stent and is cannulated from the contralateral femoral artery with a guide wire. A simple straight self-expanding stented graft is then deployed to extend this short trouser leg down into the common iliac artery, effectively creating an extension to the short leg. The graft system has been deployed in 21 patients with satisfactory exclusion of the aneurysm in 17 (81%). There has been one mortality and no conversion to open repair. All 17 aneurysms remain excluded at median follow-up of 30 (range 4-60) weeks. None of the four graft stents that leaked (two proximal and two distal) sealed spontaneously. Deployment of the uncovered Gianturco stent across the renal artery origins in 18 cases (85%) has not been associated with renal artery occlusion or deterioration in renal function at a median follow-up of 30 (range 4-60) weeks. The ability to deploy a bifurcated system increases the potential for endoluminal treatment of abdominal aortic aneurysm.

One of the perceived limitations of the left retroperitoneal approach to the aorta is inadequate access to the right renal artery. Many consider the need for a concomitant right renal artery revascularization a contraindication to performing an aortic reconstruction through the left retroperitoneum. Exposure of the right renal artery can be difficult due to the posterior course of the artery behind the vena cava. However, when the aorta is transected, the right renal artery can be easily approached with anterior and cephalad displacement of the aortic root. Over the past 3 years, 52 patients have had right or bilateral renal artery revascularization via the left retroperitoneal approach; of these procedures, 37 were performed with concomitant aortic procedures. In total, 34 patients had bilateral and 18 had unilateral revascularizations. Five patients had a transaortic endarterectomy performed, and 36 were bypassed with 6-mm expanded polytetrafluoroethylene side limbs from the aortic graft. Indications for revascularization were: 39 for suprarenal aortic bypass, seven for renal salvage and six for primary renovascular hypertension. All reconstructions have remained patent and all have been followed by serial duplex and renal flow scans (follow-up for 1-42 months). The operative mortality rate was 5.8% (3/52). There were no major cardiorespiratory complications in this group. Adequate exposure to the proximal right renal artery can be obtained through the left retroperitoneal approach to the aorta, and successful revascularization of one of both renal arteries can be technically performed with acceptable mortality and morbidity.

Purpose: This study was undertaken to examine the effectiveness and the possible advantages of infrainguinal arterial reconstruction with nonreversed greater saphenous vein (NRGSV) grafts. We reviewed the results achieved with 189 consecutive NRGSV bypass procedures from July 1, 1985, to August 31, 1995, and compared them with 568 consecutive in situ greater saphenous vein (INGSV) bypass procedures completed over the same interval., Methods: NRGSV bypass procedures were performed by selecting the optimum inflow and outflow vessels and then excising the best available appropriate-length segment of greater saphenous vein. The valves were lysed with a Mills valvulotome using gentle antegrade distention with an isotonic electrolyte solution containing heparin (1000 U/500 ml) and papaverine (60 mg/500 ml). The graft was then translocated to the inflow site, where the proximal and distal anastomoses were sequentially completed, followed by a completion arteriography., Results: Demographic and risk factor characteristics did not differ between patients who underwent NRGSV and those who underwent INGSV bypass. Compared with INGSV bypasses, NRGSV bypasses were more commonly secondary procedures (26% vs 8%; p < 0.001) and were more often performed for limb salvage indications (89% vs 68%; p < 0.001). NRGSV bypasses also had more distal inflow vessels (23% superficial femoral artery [SFA] and 28% popliteal artery [POP] vs 10% SFA and 1% POP; p < 0.001) and more distal outflow vessels (52% tibial and 22% pedal artery vs 47% tibial and 3% pedal artery; p < 0.001) than did INGSV bypasses. Despite the higher incidence of secondary bypass procedures and more distal outflow vessels in the NRGSV group, the overall results achieved at 5 years did not differ between the two groups. The 5-year primary patency rates were 65% +/- 5% for NRGSV and 72% +/- 3% for INGSV (p < 0.12), and the 5-year secondary patency rates were 74% +/- 5% and 82% +/- 2% (p < 0.08), respectively. Similarly, the 5-year limb salvage rate among bypass procedures performed for limb salvage indications did not differ for NRGSV (82% +/- 5%) and INGSV (90% +/- 2%; p < 0.06)., Conclusions: The application of the NRGSV bypass graft preserves the INGSV's main advantage of optimal size match between artery and vein at each anastomosis, but facilitaties the tailoring of the procedure to the patients anatomy and the completion of the bypass with the shortest, best-quality conduit available. Our application of the NRGSV in a more challenging series of bypass procedures produced equivalent results to those achieved in a concurrent series of INGSV bypass procedures.

Over the past two decades, the mortality rate for elective repair of infrarenal abdominal aortic aneurysms has improved to an acceptable level (< 5%). However, surgical results of ruptured abdominal aortic aneurysms have remained fairly constant with about 50% in hospital mortality rates. Growing experience with the use of the left retroperitoneal exposure for elective aortic surgery allowed the authors to extend the use of this technique to the repair of ruptured abdominal aortic aneurysm. The extended left retroperitoneal approach using a posterolateral exposure through the 10th intercostal space allowed the surgeon expeditiously and reliably to obtain supraceliac aortic control by dividing the left crus of the diaphragm in all patients. In total, 104 aortic replacements were performed for ruptured abdominal aortic aneurysm during the past 7 years. Of these patients, 87 were men and 17 women; mean(range) age was 72(52-95) years. Hemodynamic instability (as defined by a systolic blood pressure of < 90 mmHg) was present before surgery in 41% (43/104) of patients. The operative mortality rate was 27.9% (29/104). Preoperative hemodynamic instability, time of operative delay and aortic cross-clamp time did not correlate with operative mortality. The median duration of intensive care unit stay was 4 (range 1-60) days and hospital stay 11 (range 6-175) days. The results of this series identified that a change in the operative technique for the repair of ruptured abdominal aortic aneurysm beneficially affected patient survival. The authors suggest that expeditious supraceliac control without thoracotomy is an excellent alternative and offers an advantage in the surgical management of ruptured abdominal aortic aneurysm.

The purpose of this study was to determine whether elective abdominal aortic aneurysmectomy in octogenarians is justified or may even be advisable. Between January 1986 and August 1993, 30 octogenarians of mean age 83.1 (range 80-93) years underwent abdominal aortic aneurysmectomy. Patients were divided into two groups: group 1 (n = 9) underwent elective surgical repair; group 2 (n = 21) underwent emergency procedure. In 28 patients location of the abdominal aortic aneurysm was infrarenal; two patients presented with a juxtarenal aneurysm. The average aneurysm diameter was similar in both groups (group 1, 68.8 mm; group 2, 83.5 mm, P = n.s.). In group 2, two patients had free peritoneal rupture, one presented with rupture into the duodenum and one with penetration into the vena cava. Rupture was confined to the retroperitoneum in another 15 patients. Two patients had an expanding aneurysm. Hospital mortality rate was zero in group 1 and 42.8% in group 2 (P = 0.011). Most early deaths were related to cardiac disease. The overall complication rate was 22% in group 1 and 62% in group 2. Mean intensive care unit time was 1.8 (range 1-3) days in group 1 and 3.6 (range 1-8) days in group 2 (P = 0.47). The 5-year survival rate was 67% in the electively managed group and 34% in the emergency group.

Polytetrafluoroethylene grafts are well established for bypassing occlusive disease in the lower limb but there are few reports which deal with the long-term results of such grafts in the neck. The present study was undertaken to evaluate the immediate and long-term results of polytetrafluoroethylene grafts for carotid repair. Between 1982 and 1991, 591 carotid operations (mostly endarterectomies) were performed by the authors. In 32 cases a polytetrafluoroethylene graft was used to replace (n = 12) or to bypass (n = 20) a stenotic lesion of the internal carotid artery. Postoperative angiography was obtained in all patients and the follow-up extended from 1 month to 9 years (mean 30 months) with clinical and duplex scan surveillance. There were no deaths within the first postoperative month. There was one acute postoperative stroke (3%) caused by plaque dislodgement and one symptomless occlusion demonstrated by routine angiography. During follow-up, seven patients died from other causes. No patient developed new neurological symptoms but routine duplex assessment showed one symptomless graft occlusion. The cumulative survival rate was 96% at 1 year and 91% at 4 years. The cumulative primary patency rate was 93% at 1 month, 89% at 1 year and 89% at 4 years. In specific situations polytetrafluoroethylene grafting is an adequate alternative to carotid endarterectomy but is not recommended by the authors as a routine procedure because of its occlusion rate (> 6.2%).

Seven patients with infected arterial conduits (six with prosthetic bypass grafts and one autogenous vein anastomosis) with ten limbs at risk (three patients with bilateral groin infection) are reported. The most common site for infection was the groin and the most frequent organism cultured was Staphylococcus aureus. These patients were selected for arterial homograft implantation through infected fields as they were unsuitable for extra-anatomical prosthetic bypass or had inadequate autogenous tissue available for use as a bypass conduit, i.e. the alternative to homograft insertion was arterial ligation and potential limb sacrifice. The arterial homografts were obtained form brain-dead organ donors (human immunodeficiency virus, hepatitis B- and hepatitis C-negative) and stored at -80 degrees C until ready for use. All seven patients had initial success with their homograft procedures in terms of graft patency, limb salvage and control of infection, although two required early reoperation for haemorrhage. During the follow-up period (mean 24.5, range 6-52 months) three homografts have occluded at 6, 13 and 29 months resulting in limb loss. Two patients have died at 48 and 52 months from causes unrelated to their homograft procedures with functioning homografts and limb salvage. Two further patients remain alive with patent homografts at 7 and 20 months. The authors' experience suggests that arterial homografts have a role in overcoming arterial bypass infection, achieving wound healing and maintaining limb viability rather than resorting to arterial ligation and accepting major limb amputation.

Purpose: The study evaluated the deployment and healing of a novel self-expanding modular bifurcation endovascular prosthesis in a canine abdominal aortic aneurysm model. The endoluminal prosthesis consists of self-expanding nitinol stents lined by a synthetic prosthesis. One component of the device is a bifurcated body with a 12- to 14-mm diameter aortic segment and an integral 7- to 8-mm diameter iliac limb. The bifurcated body also has a stent-reinforced opening (pant-leg) for subsequent insertion of a contralateral 7- to 8-mm diameter iliac limb component., Methods: Seventeen bifurcated prosthesis were placed; 7 were inserted through the left common carotid artery and 10 from the femoral arteries. With either route of access the 16F or 17F aortoiliac limb and the 13F iliac limb delivery catheters enabled easy passage and secure positioning of the bifurcated prostheses. Predeployment and postdeployment inspection of the dimensions and continuity of the aortoiliac prosthetic components were evaluated by cinefluoroscopy and intravascular ultrasonography (IVUS)., Results: After deployment was done, interval patency was assessed with angiography, IVUS, and contrast-enhanced computed tomography with the prostheses removed for analysis at 1 week (n = 4), 1 month (n = 3), 3 months (n = 4), and 6 months (n = 6). Five of the first seven implanted prostheses had occlusion of segments of the device. In two dogs the bifurcated body and both legs were occluded. In the other three the nonoccluded leg and bifurcation body were fully patent. In the first seven animals IVUS at implantation showed compression of an iliac leg by the orifice of the contralateral iliac component. After concentric fixation of the flow divider was performed, only one additional iliac limb occlusion occurred in the next 10 animals. Cinefluoroscopy, computed tomography, IVUS imaging, and histologic analysis of retrieved specimens demonstrated healing of the aortoiliac prostheses without evidence of perigraft leaks., Conclusions: This feasibility study demonstrates the ability to deploy and maintain acceptable patency of a self-expanding endoluminal, modular bifurcation prosthesis in a canine aortic model. Clinical evaluation of the device is planned for the near future.

A series of 42 consecutive patients undergoing infrainguinal vascular reconstruction for limb salvage using vein harvested from the arm were followed prospectively to determine the long-term graft patency and stenosis rates. Vein harvested from the arm ('arm vein') was used for secondary or tertiary reconstruction in 22 patients (52.4%). The outflow was to a single calf vessel in 37 grafts (88.1%). The cumulative primary, primary assisted and secondary graft patency rates were 35.6%, 49.6% and 59.5% at 2 years, respectively, and the limb salvage rate was 69.0% at 2 years. Eight grafts developed stenoses detected by a graft surveillance programme. Six stenoses were dilated successfully with percutaneous transluminal angioplasty (PTA) and one was treated with an interposition vein graft. Bypass using arm vein is time-consuming and technically demanding as multiple anastomoses are often required. Arm vein grafts, however, have no greater incidence of stenosis than long saphenous vein grafts and these stenoses may be dilated with PTA with good results. The long-term outcome suggests that an arm vein graft is an important treatment option in the absence of the long saphenous vein.

We have examined whether or not endovascular insertion of a bifurcated aorto-iliac graft resulted in greater intraoperative haemodynamic and metabolic stability than that achieved during conventional open graft placement. We studied 20 patients prospectively during surgery for asymptomatic infra-renal aortic aneurysm. All patients received the same anaesthetic technique. Haemodynamic data were collected continuously using indwelling radial artery and pulmonary artery catheters, allowing calculation of mean arterial pressure (MAP), cardiac output (CO) and systemic vascular resistance (SVR). Blood samples were obtained for measurement of serum lactate concentrations. Variables were compared within each group before and after specific critical events, namely occlusion of femoral or aortic blood flow, or both, and sequential reperfusion of each lower limb. Patients undergoing open repair showed significant changes in CO, MAP and SVR related to aortic cross-clamping and lower limb reperfusion, and a significant increase in blood lactate concentration after distal tissue reperfusion. The only significant changes during endovascular repair were a transient increase in SVR secondary to application of the femoral artery clamps, and sequential decreases when each limb was reperfused. Endovascular aneurysm repair imposed significantly less intraoperative haemodynamic and metabolic stress on the patient compared with conventional open surgery.

The first prominent report on the surgical treatment for acute aortic dissection was published by DeBakey in 1975. Since then, many various techniques have been applied for the surgery on dissection at ascending aorta and aortic arch. The basic understanding for the surgical treatment are focused to the climination of intimal tear as well as resection and closure of dissecting lumen and restore the blood flow only to the true lumen. The associated complications such as acute dissection AR should also be repaired simultaneously. At the present, the graft replacement of ascending aorta has become first choice of procedure. No matter where the intimal tear is located, the simultaneous replacement of assending aorta and aortic arch has been proposed recently as the most radical approach toward Type A dissection, although this extended approach has to be carefully evaluated in the future.

Evolution and recent trends in patient selection and reconstruction method for chronic aortic dissection are reported. Although patient selection and reconstruction method for chronic type A aortic dissection are essentially identical with those for acute type A aortic dissection, chronic dissection frequently necessitates extended reconstruction of the aortic arch. Aortic valve-sparing operation is increasingly applied for associated aortic regurgitation. In chronic type B aortic dissection, operation is indicated when the diameter exceeds 5 cm, if it is symptomatic (i.e. those accompanied with pain or malperfusion of the vital organ), or when it is enlarging rapidly. Operative treatment includes resection of the intimal tear and replacement of the dilated segment. With the advance in diagnosis, methods of organ protection and operative techniques, operative results for chronic aortic dissection had been improving, despite the fact that these complex lesion frequently requires extensive aortic reconstruction with reimplantation of the major aortic branches. Spinal cord protection in extensive thoracoabdominal reconstruction for type B aortic dissection remains an unsolved problem.

Since 1982, fourteen patients with aortic aneurysms received thromboexclusion operation. This method was performed in 7 patients with dissecting aortic aneurysms, 6 patients with true thoracic aneurysms, and 1 patient with true thoracoabdominal aneurysm. Among them, 12 patients received the operation of ascending aorta-supraceliac abdominal aorta bypass, one patient received descending aorta-descending aorta bypass, and another one received bilateral axillo-iliac artery bypass. Graft sizes in diameter were from 16 mm to 22 mm. 9 patients received permanent paired-clamps at both the proximal and the distal parts of the thoracic aneurysm, and 5 patients received permanent single-clamp only at the proximal part of the thoracic aneurysm. 5 patients (35.7%) died perioperatively because of low output syndrome, cerebral infarction, hepato-renal insufficiency, and aneurysmal rupture, respectively. 4 late deaths (28.6%) occurred after 4 months, 5 months, 26 months, and 5 years of operation, respectively. Among them, three deaths were due to aneurysmal rupture and one due to heart failure. Although paired-clamps at both the proximal and the distal parts of the thoracic aneurysm were performed in 1 to 3 ruptured-cases, thrombo-occlusion of the thoracic aorta did not occur in any of the cases. Long-term survival was 35.7% in 5 patients after 14 years and 4 months of mean follow-up. Although a single-clamp only at the proximal part of the thoracic aneurysm was performed in 2 of these 5 cases, thrombo-occlusion of the thoracic aorta occurred in all cases. For the four survivors of them, we ran a follow-up survey and found left ventricular hypertrophic pattern in ECG, concentric left ventricular hypertrophy in UCG, and hypertension, but those were absent before operation. We conclude that thromboexclusion method for thoracic aneurysm should be limited only to high-risk patients particularly in bad conditions or to cases with severe adhesion to lung which seem to be inaccessible through direct approach.