ObjectiveCryopreserved saphenous vein allografts have been offered as an alternative conduit for bypass in ischemic limbs. The ResultsThere was no significant difference in patency related to site of proximal or distal anastomosis, patency of runoff vessels, use of anticoagulation, age, sex, diabetes, hypertension, smoking, indication, source of graft, or use of multiple segments. Revision was required in six grafts for aneurysmal dilatation. Histologic examination of explanted sections of allografts showed no immune response, and immunosuppressive drugs were not used. ConclusionsAlthough limb salvage has been satisfactory, long-term patency rates for cryopreserved vein allografts are poor when compared with autogenous vein. The cost of cryopreserved allografts far exceeds that of prosthetic grafts, for which comparable and superior results have been reported. Use of cryopreserved vein allografts should be reserved for situations in which adequate lengths of autogenous vein do not exist and the risk of infection of prosthetic grafts is high. 664

An amputation rate of 8% to 52% and a mortality rate of 13% to 58% make vascular prosthetic graft infections the most dreaded complication facing a vascular surgeon. In 1978 a randomized prospective double-blind study reported a statistically significant decrease in wound infections in patients treated with prophylactic antibiotics whereas the graft infection difference only approached statistical significance. The present study reviews 2614 arterial prosthetic grafts implanted from January 1975 through June 1986. Twenty-four patients were identified as having a prosthetic graft infection, yielding an overall infection rate of 0.92%. Staphylococcus aureus was the most common organism, occurring in one third of the cases. The most common graft material was polytetrafluoroethylene (PTFE) (33%) followed by Dacron (29%), composite PTFE and Dacron (20%), and umbilical vein grafts (9%). Diabetes was a common factor in one third of the patients. Symptoms of infection were present in 15 patients (63%) within 3 months of operation, with 11 patients showing symptoms within 30 days. The longest interval between operation and onset of symptoms was 48 months. Prophylactic antibiotics were administered to 22 of the 24 patients, but in only 7 of the 22 (29.5%) were they given according to our usual practice. All patients required removal of the infected prosthesis, with limb loss in 17% and death in 17%.

The traditional approach to recurrent carotid stenosis has been repeat endarterectomy or patch angioplasty. Concern with the durability of repeat carotid endarterectomy has resulted in our use of carotid resection with autogenous graft interposition. This study was designed to determine the outcome and efficacy of carotid resection compared with repeat carotid endarterectomy in the management of recurrent carotid stenosis. From 1974 to 1991, 162 operations (repeat carotid endarterectomy 105, carotid resection 57) were performed for recurrent carotid stenosis. Indication for operation was hemispheric symptoms in 63% of patients, nonlateralizing symptoms in 25%, asymptomatic stenosis in 7%, and previous stroke in 5%. Ninety-one percent of patients had stenosis greater than 90% on arteriography. The perioperative stroke rate for carotid resection was 3.5%, with a subsequent rate of 0.0064 strokes per year. For repeat carotid endarterectomy, the perioperative stroke rate was 1.9% with a subsequent rate of 0.011 strokes per year. Graft patency after carotid resection was 93% (mean follow-up, 35 months). Four patients treated with carotid resection had graft thrombosis, and two of the four remained asymptomatic. After repeat carotid endarterectomy, one patient had carotid thrombosis, and recurrent stenosis greater than 50% developed in 23 patients (mean follow-up, 64 months). Twenty patients treated with repeat carotid endarterectomy underwent an additional operation for further symptomatic recurrent carotid stenosis. We conclude carotid resection is a safe and effective alternative to repeat carotid endarterectomy for patients undergoing operation for recurrent carotid stenosis.

Thirty-nine patients with renal artery aneurysm (RAA) were seen over a period of 15 years. Among 20 women and 19 men, 31 were found to have solitary aneurysms, and eight had multiple RAA. Thirty-three patients had diastolic hypertension; nine of them proved to be of renovascular origin. Of the 18 patients who underwent RAA resection, 13 had reconstruction for treatment of hypertension, three had a solitary functional kidney, one had recurrent flank pain, and one had resection for prevention of rupture in a woman of childbearing age. Six of the 18 patients had aneurysmorrhaphy with primary repair or patching, seven had a resection with an aortorenal bypass, and five patients had six ex vivo renal reconstructions with multiple anastomoses. Nephrectomy was performed in two patients with RAA rupture at the time of childbirth and in one patient with hypertension and RAA in a poorly functioning kidney. Reconstructive procedures for documented renovascular hypertension in seven patients resulted in improvement in all cases. Blood pressure improved in only six of 10 patients operated on with hypertension and no lateralization of renovascular studies. Eighteen patients were observed for one to 16 years without surgery, and none experienced rupture. Resection of RAA is indicated to treat patients with renovascular hypertension, patients with hypertension and a solitary functional kidney, and selected patients with severe hypertension and to prevent rupture in women who may become pregnant. Other patients with asymptomatic RAA can be safely observed clinically without serial arteriograms and without fear of rupture.(ABSTRACT TRUNCATED AT 250 WORDS)

Thirty-nine patients with renal artery aneurysm (RAA) were seen over a period of 15 years. Among 20 women and 19 men, 31 were found to have solitary aneurysms, and eight had multiple RAA. Thirty-three patients had diastolic hypertension; nine of them proved to be of renovascular origin. Of the 18 patients who underwent RAA resection, 13 had reconstruction for treatment of hypertension, three had a solitary functional kidney, one had recurrent flank pain, and one had resection for prevention of rupture in a woman of childbearing age. Six of the 18 patients had aneurysmorrhaphy with primary repair or patching, seven had a resection with an aortorenal bypass, and five patients had six ex vivo renal reconstructions with multiple anastomoses. Nephrectomy was performed in two patients with RAA rupture at the time of childbirth and in one patient with hypertension and RAA in a poorly functioning kidney. Reconstructive procedures for documented renovascular hypertension in seven patients resulted in improvement in all cases. Blood pressure improved in only six of 10 patients operated on with hypertension and no lateralization of renovascular studies. Eighteen patients were observed for one to 16 years without surgery, and none experienced rupture. Resection of RAA is indicated to treat patients with renovascular hypertension, patients with hypertension and a solitary functional kidney, and selected patients with severe hypertension and to prevent rupture in women who may become pregnant. Other patients with asymptomatic RAA can be safely observed clinically without serial arteriograms and without fear of rupture.(ABSTRACT TRUNCATED AT 250 WORDS)

ObjectiveTwenty-five years of experience with subclavian revascularizations were reviewed to determine the long-term patency rates of different extrathoracic approaches. Summary Background DataAlthough it is generally agreed that proximal subclavian stenosis should be treated by an extrathoracic route whenever possible, the optimum procedure is debated. Alternatives include subclavian carotid bypass, subclavian-to-subclavian or axilloaxillary bypasses, and the authors' preferred technique of subclavian carotid transposition (SCT). MethodsRecords were researched for the past 25 years in a single specialty surgical clinic for extrathoracic subclavian revascularizations. One hundred ninety such procedures were identified, and hospital charts and office medical records were reviewed for procedure, preoperative symptoms, blood pressure differentials, and postoperative complications. Patency was determined by physical examination, differential blood pressures, Doppler spectral analysis, duplex examinations, and arteriography.

Technical complications in this series seem to be associated with short distal necks, small iliac arteries, tortuous iliac arteries, and atherosclerosis at the aortic bifurcation. We believe that experience and understanding of these issues will reduce the risk of these complications in the future.

The authors' experience with 113 aortic occlusions in 103 patients during a 26-year period (1965 to 1991) is reviewed. The authors found three distinct patterns of presentation: group I (n = 26) presented with acute aortic occlusion, group II (n = 66) presented with chronic aortic occlusion, and group III (n = 21) presented with complete occlusion of an aortic graft. Perioperative mortality rates were 31%, 9%, and 4.7% for each respective group and achieved statistical significance when comparing group I with group II (p = 0.009) and group I with group III (p = 0.015). Group I presented with profound metabolic insults due to acute ischemia and fared poorly. Group II presented with chronic claudication and did well long-term. Group III presented with acute ischemia but did well because of established collateral circulation. The treatment and expected outcome of aortic occlusion depends on the cause.