Tibial and peroneal bypass in severe occlusive disease of the lower extremities

Symptomatic arteriosclerotic occlusive disease involving the femoral and proximal popliteal arteries is currently best treated by reversed autogenous saphenous vein bypass graft. Severe occlusive disease frequently includes the popliteal and/or origin of the trifurcation vessels with reconstitution of one or more of the vessels in the lower leg. We have used distal bypass 97 times in 90 patients during the past decade. There was only one postoperative death in the series in spite of the advanced age and concurrent disease in the majority of the patients. Our indications for operation continue to be relief of pain or salvage of an extremity. We rely on high quality preoperative angiograms for selection of vessels to receive the bypass. The posterior tibial artery was used in 63 of the cases, while the anterior tibial and peroneal were used in 24 and 10 cases, respectively. There were 11 immediate inhospital failures in this series of 97 cases requiring amputation in five. Three additional patients had amputations during the ensuing several months. Of the 85 grafts functioning at the time of discharge from the hospital, 16 or (18.8%) failed during the first years. Grafts that remained patent for one year have a high incidence of long term patency which is in keeping with other reported series.     

Remote endarterectomy in SFA occlusive disease

Mice were exposed to interleukin- (IL-) 3 in vivo by injection of tumor cells transfected with the IL-3 gene. At 10 days post tumor injection, bone marrow cells were recovered, pulsed with particulate antigen in the form of ovalbumin (Ova)-coated magnetic beads, and tested for their ability to present antigen via class I to an Ova/class I-restricted T cell hybridoma. Cells from IL-3-stimulated mice exhibited a marked increase in antigen presentation compared with cells from mice injected with control non-cytokine-secreting tumor cells. These cells were markedly more efficient at presenting particulate Ova antigen than in presenting soluble Ova. Based on adherence, radiation resistance, and surface markers, the cells presenting antigen appear to be in the macrophage cell lineage. These cells are susceptible to lysis by antigen-specific cytotoxic T lymphocytes, which may contribute to limiting the effectiveness of antitumor responses.     

Extra-anatomic bypass from the ascending aorta to the supraceliac abdominal aorta--surgical option applied to reoperation for aortic coarctation or interruption

The optimal approach for reoperation following repair of aortic coarctation (CoA) or interruption (IAA) remains controversial. Four patients underwent extra-anatomic bypass for restenosis after repair of CoA or IAA. The age ranged from 4 to 12 years. The initial repairs for two CoA, one type A-IAA, and one type B-IAA consisted of two grafting, one subclavian arterial turning-down aortoplasty, and one subclavian flap aortoplasty. All of them underwent during infancy. Preoperative right arm systolic pressure ranged from 140 to 190 mmHg ar rest. Through a midline sternotomy and an upper laparotmy incision, an extra-anatomic bypass from the ascending aorta to the supraceliac abdominal aorta was employed using a 12 to 18 mm tube graft. All patients survived surgeries, and their hypertension markedly improved. Our experience confirms safety and effectiveness of this option in selected young patients with re-stenosis of following repair of CoA or IAA.     

Cerebrovascular occlusive disease: hydatidosis

We reviewed six patients with cerebral hydatid embolism from the heart. Although hydatid disease is becoming less common in the world as a whole, it should be considered in the differential diagnosis of embolic stroke in children, especially in the infested areas where hydatidosis is endemic.     

Reconstruction of large veins for nonmalignant venous occlusive disease

To evaluate the effectiveness of venous grafting, we reviewed the management and clinical course of 28 patients (21 males and seven females) who underwent 29 reconstructions of large veins for benign disease. There were 12 patients with superior vena cava (SVC) syndrome, two with subclavian vein thrombosis, and 15 with occlusion of the inferior vena cava (IVC) or iliac veins. One of these patients underwent both IVC and SVC reconstructions. Reconstruction of the SVC was performed with spiral saphenous vein graft (SSVG) in nine patients and expanded polytetrafluoroethylene (ePTFE) in three. All seven straight SSVGs had documented patency at a median of 7 months (2 weeks to 5 years) after reconstruction. Six patients had complete relief of symptoms. Two patients with bifurcated SSVG had early occlusion of one graft limb. Two of the three ePTFE grafts needed early thrombectomy. One graft reoccluded at 6 months and two were patent at 2 and 5 years. The two subclavian vein reconstructions with axillary-jugular ePTFE grafts with an arteriovenous fistula had documented early patency. Both patients had rapid resolution of symptoms. The IVC or iliac vein was reconstructed with ePTFE graft in 11 patients, SSVG in three, and Dacron in one. A femorofemoral arteriovenous fistula was added in eight patients with ePTFE grafts. Seven of the 11 ePTFE grafts had documented patency at the last follow-up (median 9 months; range 2 weeks to 5 years). None of the three SSVGs had documented long-term patency. The one Dacron cavoatrial graft occluded at 3 years. A straight SSVG continues to be our first choice for SVC replacement. Short, large-diameter ePTFE grafts perform the best in the abdomen. Femorocaval or long iliocaval grafts need an arteriovenous fistula to maintain patency. Long-term patency after closure of the fistula is still unknown. Femorocaval grafts with poor venous inflow have limited chance of success. Failed or failing grafts may be salvaged by early thrombectomy. Venous reconstruction to treat selected patients with symptoms with large vein occlusion continues to be a viable option.     

Predilection of occlusive disease for the left iliac artery

Eighty-six consecutive patients operated on for atherosclerotic occlusion of the aortoiliac segment were examined regarding the severity of the disease in the left or right iliac arteries. Sixty-nine percent of 78 patients were found to have predominantly more severe lesions on the left side. A study of the geometric anatomy of the aortoiliac region in 14 male and 12 female cadavers revealed that the right common iliac take-off angle was wider than the left and the radius of curvature of the right osculating circle at the aortoiliac bifurcation was smaller than the left, with the asymmetry of the region being much more marked in males than in females. The predilection of occlusive disease for the left iliac artery is explained on the basis of these differences in local geometric anatomy and their effect on the local hemodynamics.     

Endoluminal treatment of vascular occlusive disease

The logical desire to avoid major cutaneous incisions and surgical dissection in the treatment of vascular occlusive disease has, in recent years, led to a surge of new therapeutic options whereby access to the diseased blood vessel is obtained via a distant site and treatment is effected from within the vessel. Such endoluminal treatment modalities include thrombolysis, balloon angioplasty, atherectomy, stenting, and stent grafting. For the purpose of this surgically oriented article, the latter two techniques are discussed.     

Total aortic arch reconstruction for multiple great vessel occlusive disease

The immune system involvement in psoriasis has been documented by the presence of activated T-cells both in peripheral blood and in psoriatic skin lesions and by the intervention of cytokines in the inflammatory process. On this basis, we have undertaken a study in order to examine, in addition to activation markers such as CD25 and CD54 (ICAM-1) on peripheral blood mononuclear cells (PBMNCs) surface, serum levels of soluble interleukin (IL)-2 receptor (sIL-2R), soluble ICAM-1 (sICAM-1), soluble CD4 (sCD4), soluble CD8 (sCD8), beta 2-microglobulin and fibronectin (FN) in psoriatic patients analyzed both in acute and remission phase obtained by topical therapy alone. Our results show that PBMNCs expressing IL-2 receptor (CD25) were increased both in percentage and absolute number in respect to controls, and were not modified after remission. On the contrary, the significantly higher number of CD54+ lymphocytes evaluated in acute psoriasis, showed a reduction during the remission phase, even if the values persisted higher than controls. Serum levels of sIL-2R, sICAM-1, sCD4, sCD8 and beta 2-microglobulin were significantly higher than controls both in acute and remission phase; only FN levels were found to be lower, in patients evaluated both in acute psoriasis and after therapy, in respect to normal donors. On the whole, these results seem to indicate the persistence of both cellular and soluble activation markers even in psoriasis remission phase; in this light, we can suppose that topical therapy alone is not able to efficiently down-regulate activation mechanisms involved in the pathogenesis of the disease.     

Circadian variation of skin perfusion in arterial occlusive disease

OBJECTIVE: To evaluate standing, percutaneous, ultrasound-guided, transthoracic liver biopsy in mares, and transabdominal laparoscopically-guided, liver biopsy under general anaesthesia in foals, as techniques for obtaining tissue for assessment of copper status. The techniques were evaluated with respect to ease of use and effect on the animal. PROCEDURE: Twenty of 24 Thoroughbred mares and 21 of their foals were biopsied. The animals were part of a larger study of the effect of copper supplementation on copper status and the prevalence of developmental orthopaedic disease. Livers were also collected from unrelated horses and sampled to investigate the variability in the distribution of copper in liver tissue. RESULT: The biopsy technique caused no lasting effect on the mares, but there was an increased risk of viscus penetration associated with taking multiple biopsy cores. The use of ultrasonography to scan the target area for the liver identified four cases that were not appropriate candidates for liver biopsy, because of large intestine being located in the biopsy area. In the foals there were no serious postoperative adverse effects, nor was there any evidence of problems caused by the procedure when the abdomen was examined post-mortem at 5 months of age. In livers collected to investigate the variability of copper concentration, copper appeared to be relatively evenly distributed through the liver. CONCLUSION: Standing, percutaneous, ultrasound-guided, transthoracic liver biopsy in mares, and transabdominal, laparoscopically-guided, liver biopsy under general anaesthesia in foals are convenient procedures for obtaining liver tissue for assessing copper status in horses. The use of ultrasound to identify liver tissue is recommended, especially in older mares.     

Long-term results after open and semiclosed thrombendarterectomy for aortoiliac occlusive disease

OBJECTIVES: This study reviews the long-term results of 514 aortoiliac thrombendarterectomies (TEA's). DESIGN: A prospective study in a major university hospital in Switzerland. SUBJECTS: 353 male and 62 female patients with aortoiliac occlusive disease. Operative indications: disabling claudication (n=334), rest pain (n=44), and gangrene (n=37). METHODS: Open and semiclosed TEA's were performed on 167 and 347 limbs, respectively. Follow-up was continuous and complete in 97.1 % of patients over a period of more than 15 years. RESULTS: The overall life-table patency rate at 5, 10, and 15 years postoperatively were 93.4 %, 90.4 %, and 84.2 %, respectively. Fifteen years postoperatively, the patency rate of 92.3 % after open TEA was significantly higher (p<0.04) than after semiclosed TEA (79.5 %). However, similar patency rates of 69.5 % and 69.8 % were observed 20 years postoperatively. Further significant prognostic factors on patency were: anatomic localization (p<0.004), preoperative stage of arterial occlusive disease (p<0.008), and gender (p<0.007). Patient's age did not influence the outcome in terms of patency. Hospital mortality rate was 1.2 %. Early obstruction occurred in 2.2 %, leading to subsequent early amputation of 1.4 % and reoperations in 1.2 %. The long-term actuarial survival rates of the patients were 55 %, 36 %, and 18 % after 10, 15, and 20 years postoperatively. CONCLUSION: Both open and semiclosed TEA give highly satisfactory long term results in aortoiliac occlusive disease with a low morbidity and low mortality.     

Coronary angioplasty in octogenarians

Coronary balloon angioplasty was performed on 33 lesions during 28 procedures in 23 octogenarians (median age 83, range 80 to 87 years) between January 1989 and December 1991. 96% of the patients had grade III-IV angina pectoris. The median left ventricular ejection fraction was 64% (range: 38-85%). Single vessel coronary artery disease was present in 43% and multivessel coronary artery disease in 57%. Angioplasty was performed on 1 vessel in 85% of the procedures and on 2 vessels in 15%. Primary angiographic success was 97% for 33 attempted lesions with one failure to recanalize an old occlusion. One patient underwent emergency intracoronary stent implantation after failed angioplasty. None underwent emergency coronary bypass surgery. One patient (4%) had a myocardial infarction and 2 patients (7%) died during hospitalization, the first because of abrupt vessel closure during angioplasty, the second due to acute retroperitoneal bleeding on the 8th day post-angioplasty while fully anticoagulated for an intracoronary stent. Follow-up (median 17, range 8 to 39 months) was obtained for all patients. Out of the 21 patients with primary angioplastic success, 3 (14%) had died (1 cardiac and 2 non-cardiac). At 1 year actuarial survival was 86%, and survival free from myocardial infarction or coronary bypass surgery was 81%. Further angioplasty for either restenosis or another lesion was performed in 5 patients (24%). These results confirm that coronary angioplasty is an effective means of controlling anginal symptoms in a selected group of severely symptomatic octogenarians. However, when complications do occur they are linked to a significant mortality rate.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effects of garlic coated tablets in peripheral arterial occlusive disease

For the first time, a weak clinical efficacy of a 12-week therapy with garlic powder (daily dose, 800 mg) is demonstrated in patients with peripheral arterial occlusive disease stage II. The increase in walking distance in the verum group by 46 m (from 161.0 +/- 65.1 to 207.1 +/- 85.0 m) was significantly higher (P < 0.05) than in the placebo group (by 31 m, from 172.0 +/- 60.9 to 203.1 +/- 72.8). Both groups received physical therapy twice a week. The diastolic blood pressure, spontaneous thrombocyte aggregation, plasma viscosity, and cholesterol concentration also decreased significantly. Body weight was maintained. It is quite interesting that the garlic-specific increase in walking distance did not appear to occur until the 5th week of treatment, connected with a simultaneous decrease in spontaneous thrombocyte aggregation. Therefore, garlic may be an appropriate agent especially for the long-term treatment of an incipient intermittent claudication.     

Improved walking economy in patients with peripheral arterial occlusive disease

The effect of exercise rehabilitation on the oxygen cost of ambulation in patients with peripheral arterial occlusive disease (PAOD) was evaluated with specific emphasis on the effects of exercise rehabilitation on the slow component of VO2. Because the slow component of VO2 represents an increase in VO2 despite constant-intensity exercise, it can profoundly affect the relative energy cost of exercise in individuals with a low functional capacity. Twenty-six patients with intermittent claudication performed treadmill walking at 2.0 mph/0% grade for 20 min or until maximal claudication pain before and after 4 months of rehabilitation. The slow component of VO2 during the treadmill test was defined as the difference between the end-exercise VO2 and the VO2 observed at minute 3. Ankle/brachial systolic pressure index (ABI) was measured before and immediately following the exercise test. Rehabilitation consisted of 3 d x wk(-1) of treadmill walking for 15-30 min at 60-70% of VO2peak. The slow component of VO2 and end-exercise VO2 at pretraining (0.75 +/- 0.90 and 11.12 +/- 2.10 mL x kg[-1] x min[-1]) were significantly reduced after 4 months of exercise rehabilitation (-0.07 +/- 1.11 and 10.07 +/- 1.80 mL x kg[-1] x min[-1]; P < 0.05). Exercise rehabilitation also significantly (P < 0.05) increased the post-exercise ABI (pre-rehabilitation = 0.36 +/- 0.26, post-rehabilitation = 0.43 +/- 0.25). These data suggest that 4 months of exercise rehabilitation: 1) improves walking economy in PAOD patients because of a decreased slow component of VO2, and 2) increases post-exercise ABI.     

Extracranial to intracranial vascular anastomosis for occlusive cerebrovascular disease: experience in 110 patients

In an attempt to ascertain the value of extra- to intracranial arterial bypass for cerebrovascular disease, the general topic of bypass surgery is reviewed and the results of this procedure in 110 patients are analyzed. The feasibility of high patency rates of the anastomosis with acceptably low permanent morbidity and operative mortality rates is demonstrated. Lesions producing transient ischemic attacks which previously were considered to be inoperable or inaccessible can be bypassed by this procedure, and there appears to be a dramatic improvement in the symptomotology of virtually all patients. Patients with a mild stroke or "progressive stroke" also appear to benefit from bypass, but the erratic natural history of these entities precludes irrefutable substantiation of this conclusion. Patients with moderate-to-serve neurological deficits do not appear to be improved by this procedure. In our group of 20 patients presenting with transient ischemic attacks who have had more than 3 years of follow-up, only one patient has suffered a stroke and that was located in the opposite hemisphere.     

Epidemiology of atherosclerotic peripheral arterial occlusive disease in Hong Kong

Incubation of bovine liver mitochondrial rhodanese in dilute, reducing solutions at temperatures ranging between 30 and 45 degreesC conduced to a rapid loss of enzymatic activity. This inactivation was substantially reduced in the presence of millimolar concentrations of alkali metal ions, divalent cations (including Mg2+, Ca2+, and Ba2+) were ineffective. The extent of protection afforded by monovalent cations was highly dependent on their ionic radii, with K+ and Na+ ions being the most effective protective agents. The protection afforded by a number of anions, including thiosulfate, could be totally ascribed to the presence of the accompanying monovalent cation. The overall results indicate that K+ and Na+, at concentrations and temperatures within the physiological range, substantially contribute to the stabilization of the functional structure of rhodanese.