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.     

Adaptive control of arterial blood pressure with a learningcontroller based on multilayer neural networks

The authors discuss a two-model multilayer neural network controller for adaptive control of mean arterial blood pressure (MABP) using sodium nitroprusside. A model with an autoregressive moving average (ARMA), representing the dynamics of the system, and a modified backpropagation training algorithm are used to design the control system to meet specified objectives of design (settling time and undershoot/overshoot) and clinical constraints. The controller is associated with a weighting-determinant unit (WDU) to determine and update the output weighting factor of the parallel two-model neural network for adequate control action and a control-signal modification unit (CMU) to comply with clinical constraints and to suppress the effect of adverse noise and to improve the WDU performance. Extensive computer simulations indicate satisfactory performance and robustness of the proposed controller in the presence of much noise, over the full range of plant parameters, uncertainties, and large variations of parameters     

Erbium-doped fiber amplifier second-order distortion in analog links and electronic compensation

The authors study the second-order distortion when an erbium-doped fiber amplifier (EDFA) is used to amplify the analog optical AM cable TV (CATV) multiple carrier signal from a directly modulated distributed feedback (DFB) semiconductor laser. Experimentally, it was seen that this second order distortion depends critically on the gain of the EDFA fiber amplifier. The authors attribute this distortion to the interaction between the frequency chirping of the DFB laser and the variable gain with wavelength of the amplifier. The authors describe an electronic predistorter that compensates the nonlinearity produced by the DFB-laser-EDFA combination. As a result, the high power advantage of the EDFA can be fully realized in spite of the potential for second-order distortion in the system.<>