Preferred strategies for secondary infrainguinal bypass: lessons learned from 300 consecutive reoperations

PURPOSE: To determine the optimal surgical strategies in reoperative infrainguinal bypass, we reviewed our results in 300 consecutive secondary bypasses in 251 patients operated on between Jan. 1, 1975, and Nov. 1, 1993. METHODS: There were 168 men (67%) and 83 women (33%), with a mean age of 64.8 years and a typical distribution of risk factors including smoking (76.4%), diabetes (33.7%), and coronary artery disease (47.1%). The indications for surgery were limb-threatening ischemia in 83.5% and severe claudication in 16.5% of patients. The majority of conduits (n = 213) were autogenous vein and were composed of a single segment of greater saphenous vein in 121 bypasses (57%) and various alternative veins including composite, arm, and lesser saphenous vein in 92 bypasses (43%). Prosthetic conduits included 69 polytetrafluoroethylene, 16 umbilical vein, and two Dacron grafts. RESULTS: There was one perioperative death (0.3%) and a 25% total morbidity rate including a 1.7% myocardial infarction rate. There was a 28.6% early (< 30 days) graft failure and 10.7% early amputation rate for prosthetic bypass grafts compared with 13.6% early graft failure and 5.6% early amputation rates for vein grafts. Autogenous vein bypasses had higher 5-year secondary patency rates than had prosthetic grafts (51.5% +/- 4.6% vs 27.4% +/- 6.1%, p < 0.001). Results with autogenous vein bypass improved significantly from the 1975 to 1984 to the 1985 to 1993 interval with 5-year secondary patency rates increasing from 38.3% +/- 6.9% to 59.1% +/- 5.8% (p = 0.017) and 5-year limb-salvage rates increasing from 40.4% +/- 7.6% to 72.4% +/- 6.6% (p < 0.001). Vein grafts to the popliteal and tibial outflow levels had equivalent long-term results. Vein grafts completed for claudication demonstrated results superior to those for limb salvage, with a 5-year secondary patency rate of 75.8% +/- 8.1% versus 52.3% +/- 7.9% (p = 0.048). Secondary autogenous vein bypass grafting performed after early primary graft failure (< 3 months) did particularly poorly, with only a 27.2% +/- 7.7% 4-year secondary patency rate. Greater saphenous veins tended to perform better than alternative vein bypasses, with a 5-year secondary patency rate of 68.5% +/- 6.0% compared with 48.3% +/- 10.5% (p = 0.09) and a 5-year limb-salvage rate of 77.8% +/- 7.4% versus 54.2% +/- 11.8% (p = 0.046). CONCLUSIONS: When patients suffer a recurrence of limb-threatening ischemia at the time of infrainguinal graft failure, aggressive attempts at secondary revascularization with autogenous vein are warranted based on the low surgical morbidity and mortality rates and the improved patency and limb salvage rates that are currently attainable.     

The inositol-1,4,5-trisphosphate system is involved in rapid effects of aldosterone in human mononuclear leukocytes

There is increasing evidence for rapid steroid action on electrolyte transport in human mononuclear leukocytes (HML). In HML, aldosterone stimulates the Na+/H+ antiporter within a few minutes. Because a variety of hormones and growth factors activate the Na+/H+ antiporter via protein kinase C and inositol phospholipids, a possible involvement of inositol-1,4,5-trisphosphate (IP3) in the rapid effects of aldosterone in HML was investigated. The stimulation of IP3 generation was started by the addition of aldosterone, concanavalin A, or other steroids. A significant increase in IP3 levels by aldosterone (1 nmol/L, P < 0.05) was found after 1 min, similar to that found after concanavalin A (25 micrograms/mL). Aldosterone caused a concentration-dependent elevation of IP3 levels, with an apparent EC50 of approximately 0.1 nmol/L. Fludrocortisone stimulated IP3 generation at similar concentrations, whereas a weaker IP3 stimulation by glucocorticoids (hydrocortisone, dexamethasone) occurred at micromolar concentrations only. Canrenone, a potent inhibitor of classical aldosterone action, was not effective up to a concentration of 100 nmol/L. These findings show kinetic and pharmacological similarities with both the functional data on Na+/H+ antiport stimulation by aldosterone and the studies of 125I-aldosterone binding to plasma membranes of HML. Thus, these data are the first to indicate an involvement of the phosphoinositide pathway in the rapid membrane effects of aldosterone.     

Thermomechanical fatigue—damage mechanisms and mechanism-based life prediction methods

An existing extensive database on the isothermal and thermomechanical fatigue behaviour of high-temperature titanium alloy EVII 834 and dispersoid-strengthened aluminum alloy X8019 in SiC particle-reinforced as well as unreinv conditions was used to evaluate both the adaptability of fracture mechanics approaches to TMF and the resulting predictive capabilities of determining material life by crack propagation consideration. Selection of the correct microstructural concepts was emphasised and these concepts were, then adjusted by using data from independent experiments in order to avoid any sort of fitting. It is shown that the cyclic /-integral (δJ_eff concept) is suitable to predict the cyclic lifetime for conditions where the total crack propagation rate is approximately identical to pure fatigue crack growth velocity. In the case that crack propagation is strongly affected by creep, the creep-fatigue damage parameter δ_CF introduced by Riedel can be successfully applied. If environmental effects are very pronounced, the accelerating influence of corrosion on fatigue crack propagation can no longer implicitly be taken into account in the fatigue crack growth law. Instead, a linear combination of the crack growth rate contributions from plain fatigue (determined in vacuum) and from environmental attack is assumed and found to yield a satisfactory prediction, if the relevant corrosion process is taken into account.