Long-term results with the above-knee popliteal expanded polytetrafluoroethylene graft.

Since approximately 30% to 40% of autogenous vein bypass grafts to the femoropopliteal level may occlude within 5 years of implantation, additional vein will be required for subsequent revisions. We undertook a study to determine whether the preferential use of an above-knee expanded polytetrafluoroethylene bypass graft to save vein is an appropriate option. We reviewed our experience with 114 above-knee expanded polytetrafluoroethylene bypass reconstructions.

Massive splenomegaly.

A 16 year review of 391 splenectomies performed at New England Medical Center was done to evaluate the morbidity and mortality of patients with drained splenic weights greater than 1,000 grams. Thirty-six met the criteria for study. Twenty men and 16 women with an average age of 55.

Subclavian artery insufficiency. Treatment with axilloaxillary bypass.

Twenty patients underwent axilloaxillary bypass at Tufts-New England Medical Center, Boston, between 1973 and 1983, all for tight stenosis or occlusion of the subclavian artery. Review of records was possible for 19 cases. Symptoms included intermittent claudication and numbness of the upper extremity, as well as dizziness, vertigo, and ataxia due to episodes of vertebrobasilar insufficiency.

The costs of surgery for limb-threatening ischemia.

The clinical courses of 106 patients with limb-threatening ischemia were traced for as long as 5 years to determine the cost of their care. Seventy-eight patients initially treated with vascular reconstruction accrued an average of $40,769 +/- $3726 in costs over a mean follow-up period of 805 +/- 57 days, during which they had an average of 2.4 +/- 0.

Improvements in the diagnosis and management of aortoenteric fistula.

To assess the impact of an aggressive approach (early operation, graft removal, and extraanatomic bypass) adopted by us 5 years ago in patients with aortic synthetic grafts and gastrointestinal bleeding, we reviewed our 15 year experience with aortoenteric fistula in 13 patients. The courses of six patients from the recent series (1979 through 1984) were contrasted with those of seven patients from our earlier series (1968 through 1978). Twelve of 13 patients presented with gastrointestinal bleeding (usually low volume), and no patient presented in shock.

The clinical implications of acute thrombosis of the inferior vena cava.

A review of the clinical records of 25 patients with IVC thrombus, proved by cavography during a ten year period, showed that this form of venous thrombosis accounted for less than 5 per cent of all phlebographically documented DVT at this institution. Before phlebography was performed, only eight patients (32 per cent) were suspected clinically of having IVC thrombus because of the absence of classic signs of bilateral lower extremity edema and pain in the majority of patients. Five patients presented with an acute PE, one being fatal.

Correlation of operative findings with angiographic and noninvasive hemodynamic factors associated with failure of polytetrafluoroethylene grafts.

The causes of autogenous saphenous vein (ASV) graft failure have been well described and are predominantly due to stenosis of the ASV graft during the first year after implantation. Distal atherosclerotic disease is a late cause of ASV graft failure. Furthermore, with failure of the ASV graft the clinical and hemodynamic status of the limb usually reverts to the preoperative state.

Infrarenal aortic occlusion: a reassessment of surgical indications.

Citing a high incidence of proximal propagation of aortic thrombosis, several authors have advocated aortic reconstruction for all patients with infrarenal aortic occlusion irrespective of their preoperative symptoms and potential operative risks. To test this thesis, the records and follow-up data of 38 patients seen at our institution between 1965 and 1982 with infrarenal aortic occlusion were analyzed. Twenty-four of the 38 patients were treated surgically (Group I); 16 (42 percent) had an aortobifemoral graft and 8 (21 percent) had an axillofemoral bypass graft.

Above-knee polytetrafluoroethylene femoropopliteal bypass graft: Is it a reasonable alternative to the below-knee reversed autogenous vein graft?

To determine whether an above-knee polytetrafluoroethylene (AK-PTFE) femoropopliteal bypass graft might be an acceptable alternative to a below-knee reversed autogenous saphenous vein (BK-ASV) bypass graft, we compared 51 AK-PTFE grafts to 39 concurrently performed BK-ASV grafts. All patients were staged by preoperative noninvasive vascular laboratory criteria into limiting claudication or limb salvage groups and by intraoperative arteriography according to degree of runoff. There was no significant difference in the primary graft patency at 36 months between the AK-PTFE group (63%) and the BK-ASV group (72%).

Intraabdominal variceal bleeding.

A patient with known liver cirrhosis, but no previous variceal bleeding, presented with sudden abdominal pain and distention, hypotension, and bloody ascitic fluid. At exploration, he was found to be bleeding from varices in the gastrohepatic omentum and perisplenic area. Pathology of the liver showed cirrhosis and metastatic undifferentiated carcinoma.

Staging laparotomy for Hodgkin's disease.

The advantages of staging laparotomy in Hodgkin's disease include accurate staging and elimination of the need for prophylactic radiation therapy to the upper part of the abdomen and spleen in those patients who did not undergo exploration, thereby decreasing the chance of a complication of therapy. The disadvantages of laparotomy include the morbidity of the procedure as well as its attendant inconvenience and cost.

Intraoperative prereconstruction arteriography.

Intraoperative arteriography was performed in 57 patients undergoing arterial reconstructive surgery of the lower extremity prior to selection of the site for the distal anastomosis. In 42 patients (74%), this procedure proved to be of significant benefit. Prereconstructive intraoperative arteriography influenced surgery for seven patients in the following ways: (1) two patients had visualization of vessels not demonstrated on the preoperative arteriogram; and (2) five patients had demonstration of occlusive disease that favored selection of a more distal site of anastomosis.

Management of combined segment disease.

Eighty-five of 148 inflow procedures were performed for combined segment disease. Our study shows that aortofemoral bypass is clinically and functionally superior to axillofemoral bypass in limbs with combined segment disease and hemodynamic criteria for limb salvage. The results of these two procedures are comparable for claudicant limbs.

The economic impact of acute variceal bleeding: cost-effectiveness implications for medical and surgical therapy.

The hospital costs and its respective components for 32 patients with acute variceal bleeding were determined. The average total cost for treating the 32 patients was $35,000. The cost for those patients who underwent elective surgery ($53,000) was approximately twofold that of the elective medical group.

Below-knee amputation: is the effort to preserve the knee joint justified?

The records of 50 patients (31 men and 19 women, ranging in age from 49 to 89 years) undergoing definitive below-knee amputation for ischemia from May 1971 to May 1979 were reviewed. Forty-three (86%) had ulceration or necrosis involving the foot or toes. Seven had rest pain without tissue loss.

Management of variceal hemorrhage: results of a standardized protocol using vasopressin and transhepatic embolization.

We reviewed the courses of 40 patients with variceal bleeding treated with a standardized protocol, including intravenous (IV) vasopressin (Pitressin) and transhepatic embolization. Twelve of the 32 patients with acute episodes of massive variceal bleeding responded to the administration of IV vasopressin alone. Of the 20 patients who did not respond to vasopressin therapy, emergency transhepatic portography with embolization produced cessation of bleeding in ten (50%).

Positive blood culture as an aid in the diagnosis of secondary aortoenteric fistula.

The successful management of aortoenteric fistula (AEF) requires early diagnosis. To evaluate the accuracy of our diagnostic approach, the hospital course of seven patients with AEF was reviewed. In six patients, the initial bleeding episodes were of the low volume type characterized by hematemesis and melena or by melena alone.

Prophylactic interruption of the inferior vena cava: immediate and long-term hemodynamic effects.

Two hundred patients were evaluated retrospectively to determine the clinical effects of prophylactic inferior vena cava (IVC) interruption in association with aortic reconstruction. No pulmonary embolism occurred in the group with IVC interruption, but embolisms did occur in seven of 68 patients who had aortic reconstruction performed without IVC interruption. In two patients, the pulmonary embolism was fatal.

Interposition grafting with expanded polytetrafluoroethylene for portal hypertension.

If an interposition graft for the decompression of esophageal varices is necessary, Gore-Tex may be the graft material of choice. It is intert, nonthrombogenic and, possibly, thrombo-resistant. These characteristics of Gore-Tex explain the ease with which a graft thrombectomy was performed in one patient when necessary.

Chronic mesenteric ischemia masquerading as cancer.

Mesenteric vascular insufficiency should be suspected in patients with a history of abdominal pain, marked weight loss and significant atherosclerosis. Selective mesenteric angiography is essential and should be used early in the work-up studies of such patients. To ensure clinical correlation, there should be significant occlusion demonstrated in two of the three major mesenteric arteries.

Transcatheter thromboembolectomy of acute renal artery occlusion.

Direct surgery of the renal artery has been performed for the relief of acute thrombotic or embolic occlusion of the renal artery to restore adequate renal perfusion and prevent irreversible renal failure. Occasionally, severe medical disease may increase surgical risk to a prohibitive level. An angiographic technique has been devised to provide an alternative approach and has been successfully used on five occluded renal arteries in four patients, with measurable benefit.

Warfarin induced necrosis of the skin.

Necrosis of the skin is a rare complication of oral anticoagulation therapy by coumarin congeners. Three males receiving prophylactic warfarin anticoagulation therapy following cardiac valve replacement and one female similarly receiving anticoagulation drugs because of bilateral deep thrombophlebitis associated with carcinoma of the pancreas had typical skin necrosis develop. The lesions passed rapidly through stages beginning with pain, edema, erythema and petechiae.