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During the evolution of vascular surgery as a specialty, many conduits have been used to revascularize the lower extremities. Superficial veins and prosthetic materials make up the majority of materials used to bypass diseased segments of native artery. The deep veins of the thigh have also been reported as alternatives for arterial bypass. However, the use of the in situ superficial femoral and popliteal vein bypass has not been reported to our knowledge in current literature. We report a 79-year-old white female with lower extremity rest pain who underwent an in situ femoral popliteal bypass graft for limb salvage.

This study was undertaken to evaluate the use of directional atherectomy, balloon angioplasty, and video angioscopy in highly selected patients with superficial and popliteal artery stenoses. Directional atherectomy and balloon angioplasty for superficial femoral and popliteal artery stenosis (> 80%) were performed in 96 limbs (88 patients) between 1990 and 1994. All procedures were performed by the authors with angioscopy and C-arm angiography. Society for Vascular Surgery/International Society for Cardiovascular Surgery (SVS/ISCVS) categorical classification of chronic limb ischemia and run off scoring was utilized pre- and postoperatively to assess outcome. The indicators for atherectomy were moderate claudication (category 2, 15% of limbs), severe claudication (category 3, 65%), ischemic rest pain (category 4, 12%), and tissue loss (category 5, 12%). Morbidity was 6.0% with no perioperative mortality. All technically and (angiographically) successfully treated patients demonstrated postoperative improvement. Clinical assessment, vascular laboratory studies (outcome criteria), and/or angiography were monitored at follow-up visits. Intraoperative failures occurred in 6% of limbs due to inability to pass a guide wire (3%), impacted atherectomy catheter (1%), or vessel perforation (2%). In the remaining 90 limbs, 23% failed due to either progression of disease (7.7%) or restenosis at the original site (15.3%). Seventy-one percent of limbs maintained their postoperative categorical improvement at a mean follow up of 24 months. Combining atherectomy and balloon angioplasty may be more durable than angioplasty or atherectomy alone. A long-term prospective study of the role of directional atherectomy and balloon angioplasty by vascular surgeons appears to be warranted utilizing SVS/ISCVS guidelines for lower extremity chronic ischemia categories, run-off score, and outcome criteria for patency.

Purpose: This retrospective study is to determine the efficacy and durability of renal endarterectomy in patients undergoing simultaneous aortic reconstruction. In addition, the operative risk to patients with symptomatic and asymptomatic renal artery stenosis is evaluated., Methods: The results of a retrospective study of 101 patients who underwent combined procedures are presented. All patients demonstrated at least a 75% stenosis of the renal artery ostium by arteriography and underwent surgical repair of aneurysmal (n = 33) or aortic occlusive (n = 68) disease. The indications for renal revascularization were hypertension necessitating multiple medications (47%), hypertension combined with renal insufficiency (18%), renal insufficiency alone (5%), and asymptomatic stenosis (30%). Blood pressure and antihypertension medications were monitored during the follow-up period (mean 3.3 years)., Results: The perioperative mortality rate was 1%, with a postoperative morbidity rate of 15%. The conditions of 74% of patients with hypertension were improved or cured, 23% were unchanged, and 3% were worse after surgery. Systolic and diastolic blood pressure in all patients remained significantly diminished during follow-up visits at 3 months, 6 months, 1 year, 3 years, and 6 years (p < 0.01). There was no significant improvement in serum creatinine levels in patients with preexisting renal insufficiency. A small but statistically significant decrease in systolic blood pressure and serum creatinine level was noted after operative intervention in the symptom-free patients (p < 0.005). There were no deaths in the asymptomatic subgroup, and significant azotemia did not develop in any of these patients after operation., Conclusions: Renal endarterectomy is an effective and durable method of renal revascularization. Furthermore, it is a technique that can be safely combined with aortic surgery and can be considered in the treatment of high-grade, asymptomatic lesions in patients undergoing aortic reconstruction.

Intraoperative balloon angioplasty was performed on 80 patients undergoing a concomitant vascular reconstructive procedure during the past 30 months. All angioplasties were performed by the operating surgeon with the aid of fluoroscopy and in conjunction with the vascular reconstruction. The primary purpose of balloon angioplasty was to either increase inflow (66%) or outflow (23%) in association with a planned vascular procedure. The remaining patients had a variety of other arterial dilatations. Dilatation obviated the need for additional arterial reconstructions in these elderly patients. One episode of peripheral embolization constituted the only operative complication. Follow-up ranged from 1 to 30 months (mean, 13.4 months). Sixty-four patients remained asymptomatic during the follow-up period. Sixteen patients became symptomatic in the postoperative period and underwent angiography. One iliac and three superficial femoral arteries had restenosed. The remaining 12 patients had additional vascular problems not associated with the dilatation or previous operation. The intraoperative use of the balloon catheter by the vascular surgeon broadens the therapeutic armamentarium available for the correction of multiple, symptomatic, arterial lesions. Balloon angioplasty as a separate procedure was thus avoided, resulting in decreased morbidity and expense. The scope of arterial reconstructions was expanded without expansion of the operation. The balloon catheter should be used intraoperatively as adjunctive therapy in appropriate circumstances.

The successful surgical treatment of three patients with primary aortoduodenal fistulae was achieved in a retrospective analysis. The treatment of this rare disorder included primary duodenal closure, resection of the atherosclerotic aneurysm, and placement of a Dacron graft. A review of the literature demonstrated only 18 survivors with this surgical problem. These three additional cases emphasize that primary duodenal repair and Dacron graft replacement of the aneurysm may be performed instead of an extra-anatomic bypass.