ObjectiveThe authors determined the impact of an intensive surveillance program of autogenous vein bypasses on patency and limb salvage. Summary Background DataSurveillance protocols of vein bypasses can identify graft-threatening lesions to permit elective revisions before thrombosis. The authors compared follow-up based on clinically indicated procedures with intensive surveillance. MethodsFrom 1985 to 1994, 615 autogenous vein bypasses (454 in situ, 161 reversed/composite) to popliteal (n = 169) and tibial (n = 446) arteries were performed for critical limb ischemia (n = 507), claudication (n = 88), and popliteal aneurysm (n = 20). Intensive surveillance of autogenous vein bypasses consisted of ankle brachial index and duplex scan with graft velocities measured at 1 month, 3 months, 6 months, and every 6 months subsequently. After surgery 317 bypasses had intensive surveillance, 222 bypasses were clinically indicated for follow-up, and 76 bypasses were excluded because follow-up or patency was less than 31 days. ResultsPrimary patency at 5 years was similar for bypasses treated by intensive surveillance (56%) and those treated with clinically indicated procedures (67%). Secondary patency and limb salvage at 5 years was significantly improved (p < 0.02) for bypasses followed by intensive surveillance (80% and 94%) compared with clinically indicated procedures (67% and 73%). Revision of patent bypasses was higher (p < 0.000001) for bypasses treated by intensive surveillance (61 of 70, 87%) compared with those treated with clinically indicated procedures (9 of 34, 26%). Secondary patency at 2 years was significantly higher (p < 0.02) for revision of patent bypasses (79%) compared with thrombosed bypasses (55%). ConclusionsLong-term autogenous vein bypass patency and limb salvage is significantly improved by intensive surveillance, permifting identification and correction of graft threatening lesions before thrombosis. 507

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102 patients with penetrating intraperitoneal colon injuries were entered into a prospective study. Colon wound management was undertaken without regard to associated injuries or amount of fecal contamination. Primary repair was performed in 83 patients, segmental resection with anastomosis in 12, and resection with end colostomy in 7. There were no suture line failures in the primary repair group, and one suture line failure in the anastomosis group. The one failure was in a patient who underwent repeated explorations for bleeding before the leak occurred. The septic complication rate was 33% of the entire series and was unrelated to primary repair. Logistic regression analysis to identify risk factors for sepsis included transfusion greater than or equal to 4 units (p less than 0.02), more than two associated injuries (p less than 0.04), significant contamination (p less than 0.05), and increasing colon injury severity scores (p less than 0.02). The method of colon wound management, location and mode of injury, presence of hypotension (BP less than 90), and age did not significantly contribute to sepsis. We conclude that nearly all penetrating colon wounds can be repaired primarily or with resection and anastomosis, regardless of risk factors.

Management of arterial injuries at the thoracic outlet and neck presents a major challenge to the trauma surgeon: hemorrhagic shock, neurologic deficit, and limb loss are the serious sequelae. Over a 13-year period, 118 patients with injuries to the innominate, carotid, subclavian, and axillary arteries were evaluated. Most injuries were penetrating (78%). Half of the patients were diagnosed by physical examination and half by angiography. Patients were treated by either primary repair (35%), interposition graft (31%), ligation (8%), or anticoagulation (26%). Two patients required amputations (1 digit, 1 above elbow). Overall mortality was 14%, with 5% due to consequences of hemorrhagic shock, 7% due to cerebral ischemia, and 2% due to other causes. Claviculectomy, median sternotomy, and trap door incisions were routinely used for proximal vascular control and repair. We conclude that liberal use of angiography is indicated in stable patients for penetrating wounds near major arteries, and for blunt injuries associated with neurologic deficits unexplained by computed tomography. Patients with obvious arterial injury should have immediate exploration. Extensile exposure is mandatory for appropriate management. Blunt carotid dissections are generally best managed non-operatively with anticoagulation.

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