European journal of vascular surgery最新文献

There is little information on reconstructive arterial surgery for Takayasu Arteritis, and the approach is generally negative in this regard. Common causes of death are stroke, aneurysm rupture and the complications of renovascular hypertension and renal failure. The present study aims to examine the results of arterial reconstruction in the medium and long term in patients with histologically proven Takayasu's disease. In the last 11 years 134 patients have been referred to the vascular service of whom 81 (60%) were suitable for operation. Forty-nine were women; age range 3–45 years (average 29.5 years). In 28 the disease was confined to the aortic arch (Type 1); 41 had descending aortic involvement (Type II); six had a combination of arch and aortic disease (Type 111) and two associated cardiac lesions (Type IV). Four had isolated peripheral lesions (Type V). Seventy percent of these lesions were aneurysmal. Of the 28 type I patients, two had aortic arch reconstruction, seven segmental replacement. Of the 49 with type II, III and IV disease 26 had thoraco-abdominal aortic replacement using a bypass technique. The remainder had infrarenal aortic replacement and bypass procedures. Type V (four patients) had interposition grafts. Overall operative mortality in the Type I patients was 3.6% (stroke) and in the type II–IV 4%. All of the latter followed operation for aneurysm rupture and there were no elective deaths. Three months to 11 years after operation four patients (5%) developed fatal progression of the disease and seven (8.9) non fatal disease progression of whom three required surgical intervention. Nineteen of 22 with renovascular hypertension were improved or cured. In conclusion 60% of the patients referred were amenable to surgery and had an acceptable perioperative morbidity. It would appear that surgery can significantly influence the natural history of the disease.

The purpose of this study was to investigate the distribution of vein incompetence and the nature of venous haemodynamics accompanying the development of lower extremity primary varicose veins (LEPVV). The entire venous circulation of 77 lower extremities in 55 patients (pts) with LEPVV was evaluated, by using Duplex colour Doppler ultrasonography. The greater and lesser saphenous veins (GSV, LSV) and their branches were thoroughly scanned. The valvular integrity of the deep venous system was determined in the areas of common and superficial femoral vein, saphenofemoral junction, popliteal vein, saphenopopliteal junction, and perforating veins. Demonstration of bidirectional flow signified venous incompetence. Quantitation of venous reflux was estimated after manual calf compression with pts in a standing position. All the symptomatic legs had branch venous disease, 60% had GSV incompetence, 3% had LSV incompetence, 10% showed concurrent GSV and LSV incompetence, while 27% demonstrated no evidence of GSV, and LSV disease. Thirty per cent and 50% of the symptomatic legs demonstrated deep and perforating vein incompetence, respectively. Furthermore, 30% of the asymptomatic lower extremities had insufficiency of saphenofemoral (nine pts) and saphenopopliteal (one pt) junction. The median peak venous reflux in the incompetent GSV and popliteal vein was 0.74 ml/s (range 0.2 to 2.5 ml/s) and 3.5 ml/s (range 2.5 to 8 ml/s), respectively. In conclusion, the observed heterogeneity in anatomic and functional distribution of lower extremity venous insufficiency in pts with LEPVV support the hypothesis that this condition is probably a part of another entity that might be called “lower extremity primary venous insufficiency” whose treatment should be highly individualised. To this end, colour Doppler imaging can help.

The objective was to explore possible time trends in the indications for peripheral vascular surgery in Sweden. Design: Analysis of data from the Swedvasc vascular registry 1987–1991. Setting: Routine vascular surgery in university, county and district hospitals within the Swedish public hospital system. The registry is independent of local administration, run by the surgeons themselves and financed by national authorities. Materials: 4950 procedures registered in the 17 original centres 1987–91 and 1892 procedures registered in 16 new centres 1991. Chief outcome measures: Distribution of indications, mortality within 30 days and clinical outcome at one year. Main results: During the first 5 years of the registry (1987 to 1991) the proportion of procedures performed for acute ischaemia significantly decreased from 20% to 14.3%. Simultaneously procedures for critical leg ischaemia significantly increased from 24.8 to 30.3%. Changes in the proportions treated for aortic aneurysms, carotid artery stenosis, claudication, vascular access or other indications were less striking or nonsignificant. The 30-day mortality decreased in patients operated on for acute ischaemia but did not change in other groups. The proportion of elective/emergency operation for aortic aneurysm changed from 1.2 to 2.0 leading to a minimal decrease in overall aneurysm mortality. The proportion of patients treated for claudication who were alive and improved at one year changed from 77.2% to 72.9% which was not statistically significant, while the proportion of patients treated for critical ischaemia who were alive with an intact leg after one year increased from 65.2% to 80.2% which was a significant improvement. Conclusions: Decision making among vascular surgeons in Sweden appears to have improved as proportionally fewer patients are operated on for acute ischaemia, more for critical ischaemia with possibly an improved outcome.

Cases of cystic adventitial disease of the popliteal artery are presented to highlight the level of alertness necessary to recognise the characteristic clinical history of this uncommon condition before it progresses to critical limb ischaemia when expeditious investigation and surgery are necessary to salvage the limb.

This paper decribes the morphologic appearance during long term follow-up of in vitro endothelialised ePTFE grafts (IVECL) implanted in patients with crural reocclusions. Between June 1989 and December 1990, 13 femorocrural IVECL bypasses were implanted. Follow-up angiograms demonstrated stenoses in the middle of the graft in six patients. Two of these patients developed symptoms, and the grafts were biopsied approximately 1.5 years after implantation during a patchplasty procedure. The remaining four patients with asymptomatic stenoses refused elective reoperation and suffered a graft occlusion 53 to 619 days after implantation, all leading to amputation. Biopsy specimens and explanted grafts were examined with standard and electron microscopy. Both biopsies demonstrated multiple layers of degenerating myofibroblasts (MFB). The four explanted grafts also showed altered MFB in addition to necrosis of the graft surface. No endothelial cells were seen on any of the preparations. Long term follow up of IVECL protheses in the crural position has demonstrated that it is possible to lastingly bind cells on an artificial surface. Whether the MFB found are a substitute of lost endothelial cells, or are an end product of metaplastic and/or degenerative alterations, can only be clarified through further biopsy studies.

The occlusion rate of peripheral vascular grafts depends on technical as well as endogenous factors. Platelets play an integral part in graft failure and it has been suggested that anaesthesia may influence platelet function. In order to evaluate the influence of anaesthesia on stress response and platelet function in peripheral vascular surgery, patients (n=18) were allocated to either general anaesthesia (GA; n=9) followed by alleviation of postoperative pain with intramuscular analgesics or to lumbar epidural anaesthesia (EPI; n=9) which was continued for 24 hours postoperatively. Before, during, as well as after vascular surgery of the lower extremity plasma levels of cortisol, glucose, serotonin (p-5HT), and urinary 5-hydroxyindole-3-acetic acid (5-HIAA) were analysed and platelet aggregability was determined. In the GA group surgery was accompanied by a significant stress response while in the EPI group this stress response was almost completely abolished. Platelet aggregability was reduced intraoperatively in both groups but in the postoperative period there was a marked hyperaggregability only in the GA group. P5HT was increased preoperatively in both groups but was not affected by surgery. It is concluded that epidural anaesthesia, due to its effects on platelet aggregability, may be advantageous for peripheral vascular surgery.

There is currently no established treatment for intermittent claudication with proven long term benefit. Exercise classes have been shown to improve walking distance. Chronic electromyostimulation (CEMS) a method of stimulating skeletal muscle has effects on normal muscle which may also benefit claudicants. We investigated the effects of one month of CEMS on claudicants in a single blind placebo controlled study. Patients were randomised to either CEMS (treatment) or transcutaneous nerve stimulation (TENS) placebo. The effects of the two modalities were assessed using the conventional measures of claudicating distance (CD), maximum walking distance (MWD), ankle—brachial pressure index (ABPI) and pressure recovery time (PRT). Muscle performance was assessed by the fatigue index (FI) a technique determining the decrease in ischaemic muscle response to repeated contraction. After 4 weeks treatment the CEMS group showed significant improvements in their median CD (88 to 111) and MWD (118 to 158); this was not seen in the control group. Muscle performance also increased significantly during the 4 weeks of treatment in the CEMS group but not in the control group. These changes were not maintained after CEMS was stopped. This pilot study suggests that CEMS may well have a role to play in the treatment of intermittent claudication though a number of further studies need to be undertaken.