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Mechanical stretching of the left laryngeal nerve secondary to an enlarged left atrium was first described by Dr Norbert Ortner in 1987. An extensive literature search revealed only 76 reported cases of Ortner syndrome, with the more recent reports describing other causes of the syndrome such as pulmonary hypertension, aortic dissection, and a thoracic aneurysm. We recently encountered this rare pathologic entity in an elderly man who had presented with severe hoarseness, presumed to be due to one of the aforementioned vascular anomalies. In the present report, we have highlighted the pathology and hybrid repair of this challenging entity.

Background The purpose of this study is to recognize those investigators responsible for initiating progress in limb salvage where runoff beyond the arterial blockage was limited to the crural vasculature and to also describe how crural bypass has evolved into the contemporary setting where endovascular options have become increasingly prominent. Methods An extensive literature review of articles published from 1960 to 1979 was the basis for selecting and recognizing surgeons who pioneered infrageniculate revascularization. Documentation of patency and amputation rates were tabulated for these early series of distal limb bypass. Cases performed in the decade of interest, but not published until the 1980s, are also recognized and recorded separately. Results Subsequent to the first tibial bypass performed in 1961 by McCaughan, a total of 746 crural bypasses were defined in the decades of interest, where possible, with overall 6-, 12-, and 36-month patencies of 76%, 59%, and 48%, respectively. There was an overall amputation rate of 17%. Life table analysis and other statistical methods were also adopted during this time. Conclusions Performance of crural bypass from 1960 to 1979 was analyzed in groups according to the distal anastomosis site. These results confirm the satisfactory early progress leading to further refinement in subsequent decades. It is essential that the current generation of vascular surgeons recognize the value of these early open procedures as a stable force for securing limb salvage in conjunction with evolving endovascular techniques.

The aberrant splenic artery is an uncommon anomaly. It may become a challenging problem when it is associated with an aneurysm diagnosed during pregnancy. Our experience with a patient who underwent two interventions, each performed in the postpartum period without incident, highlights the need to employ techniques that ensure aneurysm closure and thus avoid recurrence and need for repetitive procedures.

Interval gangrene of the thigh is an extremely rare complication in vascular surgery. Most cases have reported interval gangrene of the calf as a consequence of a distal bypass procedure, with little documentation of interval thigh gangrene occurring after endovascular intervention. The present case suggests that in the process of placing multiple-level covered and bare metal stents in the iliac, superficial femoral, and popliteal arteries, interval gangrene of the thigh must be considered as a potential, albeit rare, complication. Preservation of pelvic and profunda femoris flow to the thigh is imperative to prevent the development of interval tissue loss. This case demonstrates the importance of maintaining profunda femoris circulation, especially in patients with significant vascular comorbidities. Patient consent was obtained for details of the case to be used for publication.

The Brescia-Cimino AV fistula is most commonly performed and rarely associated with steal syndrome. A case is presented with details regarding its correction.

Femoral endarterectomy is an established procedure with excellent outcomes. Variations in performing this operation generally reflect the extension of pathology into the superficial and deep femoral arteries. For these instances, we developed a technique not previously described that enables continued flow to the superficial and deep femoral arteries and facilitates patch placement.

Most anterior tibial aneurysm cases described in the literature are pseudoaneurysms resulting from trauma. Since 1967, only 8 cases published on true anterior tibial artery aneurysms were atraumatic. Recent experience with an atraumatic aneurysm of the anterior tibial artery prompted a literature review regarding their incidence, and accordingly, we feel the need exists for greater recognition and understanding of this entity.

Intrathoracic subclavian artery aneurysms are extremely rare

It has long been reported that cryogenic allografts have suboptimal mid- and long-term patencies and consequently are only used in the absence of autologous vein, predominantly in lower extremity limb salvage situations. As such, we felt that our recent experience with an upper extremity bypass for limb salvage using a cryogenic saphenous vein allograft, which aneurysmally degenerated after one month and required multiple endovascular rescues, serves to re-emphasize such concerns and the importance of continuous postoperative surveillance.

ObjectiveEpigallocatechin-3-gallate (EGCG), a catechin gallate ester, is the major component of green tea and has been demonstrated to inhibit tumor growth as well as inhibit smooth muscle cell migration. We evaluated the effect of the phytochemicals resveratrol, allicin, sulforaphane (SFN), and EGCG on intimal hyperplasia in the carotid artery injury model.MethodsIntimal hyperplasia was induced in carotid arteries of adult Sprague-Dawley rats with a wire injury. Experimental animals received intraperitoneal injections of one of the four phytochemicals daily beginning 1 day prior to surgery and continued for up to 4 weeks. Control animals were administered saline. Carotid specimens were harvested at 2 weeks and subjected to quantitative image analysis. In addition, EGCG specimens were analyzed for cell proliferation, immunohistochemistry, and Western blot analysis.ResultsQuantitative image analysis showed significant phytochemical suppression of intimal hyperplasia at 2 and 4 weeks postoperatively with EGCG (62% decrease in intimal area). Significant decreases were also noted at 2 weeks for SFN (56%) and resveratrol (44%), whereas the decrease with allicin (24%) was not significant. Quantification of intimal hyperplasia by intima:media ratio showed similar results. Cell proliferation assay of specimens demonstrated suppression by EGCG. Immunohistochemical staining of EGCG-treated specimens showed extracellular signal-regulated kinase (ERK) suppression but not of the c-jun N-terminal kinase or p38 pathways. Western blot analysis confirmed reduced ERK activation in arteries treated with EGCG.ConclusionsIntraperitoneal injection of the phytochemicals EGCG, SFN, resveratrol, and allicin have suppressive effects on the development of intimal hyperplasia in the carotid artery injury model, with maximal effect due to EGCG. The mechanism of EGCG action may be due to inhibition of ERK activation. EGCG may affect a common pathway underlying either neoplastic cellular growth or vascular smooth muscle cellular proliferation.Clinical RelevanceIntimal hyperplasia remains an unsolved problem in the treatment of occlusive vascular diseases. Migration of smooth muscle cells and proliferation in the intima are currently thought to be the primary mechanisms leading to intimal hyperplasia. Among the numerous agents investigated to suppress this pathologic entity, green tea has been considered as a potential remedy. We investigated this role for epigallocatechin-3-gallate (EGCG), the major component of green tea, and compared it with other phytochemicals derived from garlic, grapes, and broccoli. EGCG proved to be the most potent of these phytochemicals by inhibition of extracellular signal-regulated kinase activation. These results suggest that EGCG may be useful to suppress or prevent intimal hyperplasia.

Percutaneous transluminal angioplasty and stenting is being employed with increasing frequency for stenosis involving the brachiocephalic circulation. However, the efficacy of these procedures is limited by intimal hyperplasia and subsequent re-stenosis. Long-term results for treating lesions of the subclavian or innominate artery have shown significant re-stenotic rate. Accordingly, carotid–subclavian bypass remains as an important procedure. Alternative methods may still be required, particularly after failure of open re-vascularization and percutaneous techniques. This report describes an underused technique that enables upper extremity revascularization following prior attempts at endovascular and standard open techniques.

Lower extremity ulcers (venous, diabetic) are often unresponsive to standard treatment. Various systemic and local cellular, vascular, and anatomical factors can result in nonhealing wounds that are refractory to normal healing processes and standard care.Several published wound care guidelines strongly suggest that if an ulcer does not respond to standard good wound care within 4 weeks, then advanced wound therapies should be considered. These advanced therapies include wound bed preparation agents (negative wound pressure therapy, hyperbaric oxygen), recombinant growth factors, or bioengineered cell therapies.The CascadeFrom the FDA 510(k) clearance: The Cascade system "is designed to be used for the safe and rapid preparation of autologous platelet-rich plasma from a small sample of blood at the patient point of care." PRFM has been used to successfully treat severe venous leg ulcer (VLU), neuropathic diabetic foot ulcer (DFU), mixed arterial and Charcot-deformity associated foot ulcers.When treating venous or DFUs, the Cascade system should be used together with standard wound care practice (therapeutic compression for VLU and weight off-loading, debridement, and infection control for DFU) in patients with an adequate blood supply to the lower limb.

Patch angioplasty is commonly performed after carotid endarterectomy. Randomized prospective trials and meta-analyses have documented improved rates of perioperative and long-term stroke prevention as well as reduced rates of restenosis for patches compared to primary closure of the arteriotomy. Although use of vein patches is considered to be the “gold standard” for patch closure, newer generations of synthetic and biological materials rival outcomes associated with vein patches. Future bioengineered patches are likely to optimize patch performance, both by achieving minimal stroke risk and long-term rates of restenosis, as well as by minimizing the risk of unusual complications of prosthetic patches such as infection and pseudoaneurysm formation; in addition, lessons from bioengineered patches will likely enable construction of bioengineered and tissue-engineered bypass grafts.

Le syndrome du ligament arque du diaphragme (SLAD) est une entite rare et souvent mal comprise caracterisee par la compression de la partie proximale du tronc coeliaque par le ligament arque du diaphragme. L'existence du SLAD, egalement appele syndrome de compression du tronc coeliaque ou syndrome de Dunbar, a ete mise en doute dans la mesure ou la compression du tronc coeliaque est souvent demontree par l'aortographie chez des malades asymptomatiques. De plus, une stenose isolee du tronc coeliaque peut etre compensee par la circulation collaterale a partir de l'artere mesenterique superieure. Malgre ces arguments negatifs, il existe de nombreux cas de malades ayant ce syndrome et dont les symptomes ont ete gueris par la section chirurgicale du ligament arque du diaphragme. Nous rapportons le cas d'une malade ayant des symptomes du meme type, non seulement pour apporter des arguments en faveur de l'existence de ce syndrome mais aussi pour souligner la necessite d'une revascularisation lorsque des modifications pathologiques se sont developpees au niveau du tronc coeliaque.

Median arcuate ligament syndrome (MALS) is a rare and often misunderstood condition characterized by compression of the proximal portion of the celiac artery by the median arcuate ligament. The existence of MALS, also called "celiac artery compression syndrome" or "Dunbar syndrome," has been questioned since compression of the celiac artery is often demonstrated on aortography in asymptomatic patients. Additionally, isolated stenosis of the celiac artery can be compensated for by collateral circulation from the superior mesenteric artery. Despite these dissenting arguments, there are many cases of patients with this syndrome whose symptoms have been relieved by surgical division of the median arcuate ligament. We report on a case involving a patient with similar symptoms not only to provide further support for the validity for this syndrome but also to emphasize the critical need for revascularization once pathological changes develop in the celiac artery.

El sindrome del ligamento arcuato medio (SLAM) es un proceso poco frecuente y a menudo mal interpretado, caracterizado por la compresion de la porcion proximal del tronco celiaco por el ligamento arcuato medio. La existencia del sindrome, tambien llamado “sindrome de compresion del tronco celiaco” o “sindrome de Dunbar”, se ha cuestionado porque, con frecuencia, la compresion se demuestra en la aortografia efectuada en pacientes asintomaticos. Por otra parte, la estenosis aislada del tronco celiaco puede compensarse con la circulacion colateral de la arteria mesenterica superior. Pese a estos razonamientos discrepantes, existen muchos casos de pacientes con este sindrome cuyos sintomas se han resuelto con la seccion quirurgica del ligamento medio. Describimos el caso de una paciente con sintomas similares no solo para proporcionar una confirmacion adicional de la validez de este sindrome sino tambien para destacar la necesidad decisiva de revascularizacion una vez se desarrollan cambios patologicos en el tronco celiaco.

Gastrointestinal bleeding is a morbid complication of pancreaticoduodenectomy. Determining its etiology is often a daunting challenge in that both common and unusual mechanisms may be operative. Visceral artery pseudoaneurysms, although rare, must be considered in that minimally invasive means are available for effective therapy. Our recent experience with two cases highlights the importance for both general and vascular surgeons to be aware of the diagnostic and therapeutic role for early angiography and deployment of endovascular techniques to achieve a successful outcome.

PURPOSE To evaluate the safety profile, pharmacokinetics, and thrombolytic activity of alfimeprase, a novel direct-acting thrombolytic agent, in patients with chronic peripheral arterial occlusion (PAO). MATERIALS AND METHODS In this multicenter, open-label, single-dose, dose-escalation study, 20 patients with worsening symptoms of lower extremity ischemia within 6 months of enrollment were treated with alfimeprase in five escalating dose cohorts (0.025 mg/kg, 0.05 mg/kg, 0.1 mg/kg, 0.3 mg/kg, and 0.5 mg/kg) by means of intraarterial and sometimes intrathrombic pulsed infusion. The primary endpoint was safety assessed by adverse event rates. Additional safety assessments included vital sign monitoring, serum chemistry testing, hematologic testing, and coagulation testing for 28 days after the procedure, as well asα2-macroglobulin and antialfimeprase antibody testing for as long as 3 months after treatment. Pharmacokinetic parameters were evaluated with use of an assay that measures free and α2-macroglobulin–bound (ie, total) alfimeprase. RESULTS No patient experienced a hemorrhagic adverse event. Mean plasminogen and fibrinogen concentrations were not substantially altered by treatment. Three transient treatment-related adverse events were reported in the same patient: one incidence each of increased blood fibrinogen level, skin rash, and headache. All three adverse events were graded as mild. The pharmacokinetic profile of alfimeprase suggested that the half-life for total alfimeprase ranges from 11 to 54 minutes (median, 25 min) in patients with PAO. The serumα2-macroglobulin concentrations decreased transiently in a dose response–like manner between 12 and 24 hours and returned to within normal limits approximately 14 days after alfimeprase exposure. CONCLUSIONS Alfimeprase in doses as high as 0.5 mg/kg was generally well-tolerated in patients with chronic PAO. No bleeding complications were noted. The stable fibrinogen concentrations suggest that the activity of alfimeprase may be limited to the target thrombus. Alfimeprase holds the potential to achieve dissolution of thrombus with a diminished risk of hemorrhage.

Background and Purpose— In the 1980s, carotid endarterectomy was controversial because proof of efficacy was lacking, complication rates were high, and one third of cases were reported to be inappropriate. Since publication of several randomized controlled trials (RCTs), rates of carotid endarterectomy have doubled nationwide. This study assesses the appropriateness and use of carotid endarterectomy since publication of the RCTs. Methods— Using the literature, we developed a list of 1557 mutually exclusive indications for carotid endarterectomy and asked a panel of national experts to rate the appropriateness of each indication using the RAND methodology. We used these ratings to assess appropriateness in a sample of 2124 patients who underwent the procedure in 1997 to 1998 in 6 hospitals. We also analyzed the reasons for the procedure and rates of death, stroke, and myocardial infarction within 30 days of surgery. Results— Overall, 84.9% of operations were done for appropriate reasons, 4.5% for uncertain reasons, and 10.6% for inappropriate reasons. Among procedures considered inappropriate, the most common reasons were high comorbidity (46.6%) and minimal stenosis (27.1%). Overall, 72.5% were asymptomatic, 17.4% had a carotid transient ischemic attack, and 10.1% had a stroke. The 30-day rate of death or stroke was 5.47% for symptomatic patients and 2.26% for asymptomatic patients. Among patients having combined carotid and coronary artery bypass graft surgery, the rate was 10.32%. The complication rate in asymptomatic patients with high comorbidity was 5.56%. Conclusions— Since the RCTs, rates of overuse appear to have fallen considerably, although they are still significant. A major shift has occurred toward operating on asymptomatic patients. Although overall complication rates were low, rates among asymptomatic patients with high comorbidity exceeded recommended thresholds.

Deposition of von Willebrand factor (vWF) is increased in hyperplastic intima of grafts, vWF levels are elevated in patients with cardiovascular diseases, and there is resistance to progression of atherosclerosis in pigs with von Willebrand disease. We hypothesize that increased expression of endothelial vWF has mitogenic effects on smooth muscle cell (SMC) proliferation.In an in vitro study, mouse aortic smooth muscle cells (SMC) were exposed to vWF in various concentrations (0, 5, 20, 100, 500, and 1000 ng/mL). DNA synthesis of SMC was measured with (3)H-thymidine incorporation. In an in vivo study, 108 mice from inbred strains of C57BL/6J (control) and RIIIS/J (characteristic of low plasma vWF) underwent carotid artery ligation (flow cessation model) and were divided into three groups: C57BL/6J, RIIIS/J, and RIIIS/J treated with desmopressin (DDAVP; intraperitoneal injection at 3 micro g/kg/d). At 2 and 4 weeks, carotid arteries were harvested for analysis with immunohistochemical analysis, morphometric studies, and reverse transcriptase polymerase chain reaction; plasma vWF was measured with an enzyme-linked immunosorbent assay.In vitro SMC proliferation showed a positive dose-response curve with vWF stimulation. Intimal hyperplasia (IH) in carotid arteries was prominent in C57BL/6J mice, absent in RIIIS/J mice, and moderate in RIIIS/J treated with DDAVP (intima-media ratio, 71% +/- 18%, 0, and 32% +/- 12%, respectively; P.01). vWF deposition occurred in all hyperplastic intima subjacent to intact endothelium. Plasma vWF correlated with degree of IH (110% +/- 10%, 21% +/- 7%, and 45% +/- 8%, respectively; P.05). vWF-messenger RNA was 9 times higher in carotid arteries of C57BL/6J mice and 4 times higher in RIIIS/J with DDAVP, compared with RIIIS/J.vWF directly stimulates SMC proliferation in vitro via a direct dose-response effect. In vivo low shear stress accelerates IH proportional to vWF expression. This could occur under intact endothelium without platelet activation and platelet-derived growth factor release. In effect, control of IH may entail modulation of vWF expression.

Purpose: Biological material has been used as an alternative to autogenous vein since the first lower extremity revascularization procedures were performed. Our experience with glutaraldehyde-tanned human umbilical cord vein graft (UVg), which spanned a period of 28 years, forms the basis of this report, with an emphasis on comparative results between the two decades from 1975 to 1985 and from 1990 to 2000. Methods: Between 1990 and 2000, 283 lower extremity bypass grafting procedures were performed in 230 patients (264 limbs), with UVg used as the predominant, or sole, graft material. Our experience with 907 reconstructions in the decade from 1975 to 1985 has been previously documented and now serves as a baseline comparison with the past decade of experience with UVg. Each reconstruction was classified on the basis of the distal anastomotic site with or without distal arteriovenous fistulas (dAVFs). The primary and secondary graft patency rates were determined for each category as was cumulative palliation, which combines the end points of graft failure, amputation, and death Results: The results from the second decade (1990 to 2000) showed a continuation of improving patency rates for UVg grafts in lower extremity revascularization. Comparison results of complications showed no changes in the low incidence rates of infection, stenosis, dissection, and pseudoaneurysm. The original series results showed a 2.9% requirement for aneurysm surgery, with an incidence rate of biodegradation of 57% (36% aneurysms, 21% dilation), whereas the current series results have shown no aneurysms to date. The comparative 6-year secondary patency rates for past and current popliteal and crural bypass grafts (with or without dAVF) were: popliteal, 53% versus 67%, P

Vascular graft infections are associated with the potential for devastating sequelae, including hemorrhage, septicemia, amputation, and death. Graft excision and debridement of the infected bed with revascularization via an extra-anatomic site or orthotopic vein bypass has been the traditional treatment of choice. Because the morbidity of these operations is substantial, less radical graft preservation techniques are desirable, such as myoplasty, omental flap transposition, and vacuum-assisted closure therapy. We report a patient with infection involving a prosthetic graft that was treated with vacuum-assisted closure and transposition of an omental tongue to enable coverage of the exposed graft.

Background Critical ischemia of the lower limb continues to challenge the ingenuity of all interventionalists in achieving reliable, predictable, and durable patency. The objective of this study was to investigate the role of the distal arteriovenous fistula (dAVF) to enhance crural revascularization patency rates particularly when prosthetics are used. Methods All patients who underwent crural bypass with dAVF since 1979 were included. Graft patency was assessed periodically by clinical examination and Doppler studies. Results were analyzed by life-table methodology to obtain primary and secondary patency rates and limb salvage rates. Results A total of 502 crural bypass plus dAVF procedures were studied within 4 consecutive periods. Primary patency rates at 1 and 3 years for each of the 4 consecutive periods were (1) 36% and 10%, (2) 52% and 15%, (3) 54% and 31%, and (4) 70% and 46%. Corresponding secondary patency rates were (1) 43% and 17%, (2) 60% and 29%, (3) 60% and 44%, and (4) 72% and 50%. There was a statistically significant improvement for primary and secondary patency rates when comparing the last 2 periods with the first 2. Limb salvage rates also showed significant improvement for the same periods. Conclusions Creation of a dAVF should be considered as a component of crural revascularization when prosthetics are used. The altered hemodynamics associated with dAVF prevents overload and as a consequence, potential bypass closure. The contribution of dAVF for enhancing patency rates when autologous vein is used with compromised runoff requires further study.

Purpose: The purpose of this study was to evaluate the effects of a distal arteriovenous fistula (dAVF) on the morphologic changes occurring in arterial bypass grafts by the use of a novel experimental model. Methods: Aortofemoral bypass grafts with or without dAVFs were constructed in 36 Sprague-Dawley rats with a microsurgical technique. The bypass graft material consisted of deendothelialized autogenous tail artery (length, 25 mm; inside diameter, 0.5 mm). In 18 rats, dAVFs were constructed at the distal anastomosis. After 6 weeks, flow rates and shear stress were determined, and grafts were then harvested. Luminal, intimal, and medial cross-sectional areas were measured with computer imaging. Desmin, α–smooth muscle actin, and von Willebrand factor (vWF) were identified with immunohistochemistry. Endothelialization was evaluated with SEM. Results: All bypass grafts remained patent at the time of graft harvest. Grafts with dAVFs showed increased flow rates (11.5 ± 0.6 mL/min) compared with grafts without dAVFs (2.1 ± 0.3 mL/min; P

Variations in the arterial anatomy of the upper extremities, although uncommon, occur in up to one in five patients. Most of these variants occur in either the radial or ulnar artery; brachial artery variations are less common. The case we report is a rare anomaly consisting of brachial artery agenesis or regression. The brachial artery was absent from its origin but reconstituted as a normal-appearing vessel 3 cm above the antecubital fossa. The profunda brachii artery and the superior and inferior ulnar collateral arteries were also absent in this patient. The axillary artery served as the main collateral to the forearm. This constellation of anomalies has not been previously described or explained by developmental models in humans and other primates. We speculate that failure of development or arrest of specific vascular anlage in the upper extremity occurs at particular embryological stages because of unknown factors. (J Vasc Surg 2001;33:191-4.)

Reconstruction of the mesenteric venous system, particularly during pancreaticoduodenectomy, is a formidable procedure. The trend of increasing the extent of resections to encompass the portal– superior mesenteric venous system with tumor adherence or ingrowth is being performed with increasing frequency worldwide. 1,2 This article was prompted by our use of a modified shunting technique to perform mesenteric venous reconstruction, preventing visceral congestion and permitting hepatic perfusion during most of the time period required for this component of a pancreaticoduodenectomy. Recent large series of pancreatic resections have reported no instances of using shunts.

DESPITE the strong association between gas-troesophageal reflux disease (GERD) and asthma has been undisputedly established and widely recognized by experts in advanced countries.……

A thoracic-aorta-left renal artery bypass with polytetrafluoroethylene (PTFE) and three gastroduodenal right renal artery bypasses were constructed in four patients in whom loss of renal function and the potential for dialysis were imminent. These extraanatomic bypasses showed durable patency with preservation of renal function. Gastroduodenal- renal bypass requires an appreciation of the anatomic relationship of the right renal artery to the right renal vein. Anatomic studies were performed in 80 human cadavers to assess the anatomic relationships of the right renal artery with respect to the right renal vein. In 50% of the cadavers studied, the right renal artery was superior to the right renal vein. It was located inferior to the right renal vein in 17.5% and directly posterior in 32.5%. Extraanatomic bypasses may be required for treatment of renal hypertension or parenchymal salvage. Gastroduodenal-renal and thoracorenal reconstructions are unusual variants of extraanatomic bypasses, and though uncommonly required, may be extremely useful methods to employ for renal revascularization.

A self-centering, expandable valvulotome was employed to establish femoral distal in situ vein reconstructions in 41 patients. The focus of the early follow-up was to assess graft patency and the incidence of incomplete valve closure. Residual arteriovenous fistulas, clearly unrelated to the methodology of valvulotomy, were also noted. Early patency was achieved in all 41. Missed valves occurred in two instances, requiring open direct valve excision in one case and use of a Mills valvulotome in the other. One vein was injured but successfully repaired. The authors conclude that excellent patency results with complete valve cutting can be achieved in the majority of cases for in situ reconstruction in the lower extremity with a new self-centering, expandable valvulotome. The role of angioscopy is uncertain and requires further study.

Videoscopic perforator ligation (VPL) is emerging as a safe and viable alternative to open techniques. Complete ligation of all perforators is crucial to reversal of venous stasis consequences. A review of the authors' experience with 19 VPLs revealed six missed perforators when completeness was evaluated by intraoperative duplex scanning. Two were paratibial, three were in the distal part of the compartment, and one was outside the compartment. Three were ligated videoscopically and three by direct subfascial ligation. Nonhealed ulcers proved to have retained perforators requiring direct ulcer excision and perforator ligation. The authors conclude that intraoperative duplex scanning allows more thorough perforator ligation and eliminates retained perforator problems.

The purpose of this study was to examine biophysical and biochemical approaches that would reduce circulatory collapse produced in a splanchnic artery occlusion (SAO) shock rat model. Sprague-Dawley rats were divided into six groups: (1) control (Ctl) rats-no infusions, n=5; (2) control rats receiving 10 mg/kg superoxide dismutase (SOD), n=7; (3) SAO shock rats-no infusion, n=7; (4) SAO shock rats receiving 1.75 mL of normal saline (Sal), n=7; (5) SAO shock rats receiving 1.75 mL of hydroxyethyl starch (HES), n=7; (6) SAO shock rats receiving SOD, n=7. All animals, except controls, underwent clamping of the celiac and superior mesenteric arteries for fifty minutes. Intravenous heparin (500 units/kg) was administered twenty minutes prior to clamping. Following release of the clamps mean arterial blood pressure (MABP) was monitored for an additional one hundred minutes. Animals whose MABP could not be maintained above 50 mmHg at one hundred minutes after reperfusion was initiated were considered nonsurvivors. Blood chemistries and serum osmolarity were measured at the end of each experiment. HES was conjugated to 10 nm gold particles prior to infusion to allow HES location in electron micrographic (EM) studies. The following results were obtained: Tab Group 1 (Ctl) Group 2 (SAO) Group 3 (Sal) Group 4 (HES) Group 5 (SOD) Final MABP (mmHg) 120±6.14 43.5±3.5 53.3±4.8 79±8.9 51.2±5.0 Osmolarity (mOsm/kg) 304±6.3 309±10.1 306±7.1 311±9.3 306±8.0. The group 4 (HES) MABP was significantly higher than that in groups 2, 3, and 5 (P

Aortic surgery in renal transplant patients introduces a complex problem. Various means to protect the transplant kidney under these circumstances have been described including ex vivo renal perfusion, in situ renal perfusion with aortoiliac shunt, in situ renal perfusion with a pump oxygenator, and axillofemoral bypass. The authors' experience with a temporary axillofemoral bypass to maintain perfusion of a renal transplant during aortothromboendarterectomy with patch angioplasty is described. They believe that the risks for injury to the transplant kidney are substantially reduced with maintenance of renal perfusion during aortic occlusion.

Purpose: The aim of this study was to evaluate the clinical efficacy of everted cervical veins used as patches after carotid endarterectomy. Methods: A prospective nonrandomized comparative analysis was performed on patients with either everted cervical veins or saphenous veins as patches after carotid endarterectomy. Two hundred ninety-six patients underwent 329 carotid endarterectomies during an 8 ½-year period (1987 to 1995). Saphenous vein patches were used in 125 (38%) cases and everted cervical veins in 167 (51%). These two groups were compared clinically and by sonographic surveillance. The mean follow-up of patients in this study was 27 ± 11 months. Results: No significant differences were noted regarding postoperative morbid events between the everted cervical and saphenous vein patch groups. Even at 5 years the percentage of patients without stroke for both groups exceeded 95%. Duplex surveillance studies also showed comparable percentages of recurrent moderate (50% to 69%) and severe (70% to 99%) stenosis, 5.6% and 6.9%, respectively, for everted cervical vein and 5.4% and 6.5%, respectively, for saphenous vein. Cumulative recurrent stenosis-free rates at 5 and 6 years exceeded 82% for each of the patch study groups. Conclusions: Based on the results of this study everted cervical veins are useful adjuncts to carotid endarterectomy, when patch angioplasty is necessary or desirable. Their performance is comparable to that of saphenous veins. Cervical veins are usually available, even when the saphenous vein is absent or inadequate. In addition, good saphenous veins can be spared and lower extremity excisions avoided. (J Vasc Surg 1997;25:545-53.)

Purpose: Successful use of the distal adjunctive arteriovenous fistula (dAVF) for the enhancement of prosthetic graft patency rates in the crural position is critically dependent on the qualitative and quantitative aspects of the arterial and venous runoff. Precise technical performance of the fistula is equally vital to secure optimal results. The purpose of this study was to determine current prosthetic graft patency and limb salvage rates using a modified version of the common ostium dAVF. Methods: The standard method to create the common ostium variant of dAVF has been modified to improve apposition of the "otomy" sites of the artery and vein, avoid twisting and stenosis by terminating the fistula suture line at the artery-vein junctures, reshaping the ovoid ostium to a rectangular shape, and finally, use of multiple interrupted heel-toe sutures. Results: Since 1979 we have created 290 fistulas in 281 patients who required leg revascularization procedures. In different time periods we have documented improving graft patency and limb salvage rates. Fistula patency, reflected by annual attrition rates of 13% to 26% per year, continues as a challenge for long-term results. Current 3-year secondary cumulative graft patency and limb salvage rates by life table analysis are 61% and 74%, respectively. The conduit material may play a role with regard to steal phenomena and the need for banding techniques. Conclusion: Configuration of the adjunctive dAVF may impact on prosthetic graft patency in the crural position. In addition, the type of graft material used for bypass may be instrumental in preventing or precipitating the steal phenomenon. These issues require further study to better understand flow dynamics, patterns of intimal hyperplasia, and blood distribution as a function of conduit material and impedance of the arterial and venous runoff. (J Vasc Surg 1996;24:240-8.)

To compare, using Duplex ultrasonography, different intermittent pneumatic compression (IPC) systems to augment venous blood flow for deep venous thrombosis (DVT) prevention during and after surgery and during periods of immobility.This cross-over study randomly assigned 26 young, healthy, adult subjects, without history of DVT, hypertension, diabetes, stroke. vascular or cardiac pathologies, to an order of knee-high, foam, single-pulse IPC device and thigh-high, vinyl, sequential-pulse pneumatic compression systems. Prior to making the flow measurement, the girth of the calf and thigh and length of the leg of each subject were determined. The right leg was used in this evaluation.The average flow augmentation, which is a direct measure of the amount of femoral vein blood flow velocity increase over the base, was 107%+/-49% with the knee-high system, and 77%+/-35% with the thigh-high IPC system (P0.002). Augmentation was higher for 62% of the subjects with knee-high IPC, and for 23% of the subjects with the thigh-high system. Overall, the blood was actively moving through the vein during the decompression phase. On occasion, the velocity during the decompression phase would fall to zero for short intervals with both systems, indicating complete emptying of the vessel. Variation in limb anatomy did not significantly affect blood-flow augmentation with the knee-high IPC, but augmentation decreased with increase in girth with the thigh-high IPC.The study indicates that the knee-high, foam, single-pulse IPC device produces a significantly higher venous blood-flow augmentation than the thigh-high, vinyl, sequential-pulse system.

A 47-year-old man was referred for evaluation and treatment of gastrointestinal variceal bleeding and possible transjugular intrahepatic portal-systemic shunting. Intrahepatic manometry disclosed a normal portal pressure, but selective mesenteric arteriography revealed occlusion of the superior mesenteric, splenic, and inferior mesenteric veins. Duodenal and gastric varices were noted, but no esophageal varices were seen. The portal vein was clearly patent. At surgery, a 2 cm mass was found at the superior mesenteric vein-splenic vein juncture, and subsequent pathologic examination confirmed the presence of suture material within dense fibrous tissue as the probable cause for this rare condition. The surgical procedure performed was a superior mesenteric vein-to-portal vein bypass, employing ringed expanded polytetrafluoroethylene. Graft patency and function have been confirmed postoperatively by means of both venous-phase mesenteric arteriography and duplex imaging. The surgical procedure was novel, in that it was possible to decompress the hypertensive mesenteric circulation from the distal superior mesenteric vein directly into the portal vein with a prosthetic bypass. The physiologic benefit of this operation is clear: the avoidance of the encephalopathic syndrome and the facilitation of hepatopetal blood flow.