Use of autologous spiral vein grafts for vascular reconstructions in contaminated fields

Autologous Saphenous Vein Panel Graft for Vascular Reconstruction

BACKGROUND

This study aims to present early and midterm results of vascular reconstruction with saphenous vein panel graft.

METHODS

Between August 2014 and August 2017, 11 saphenous vein panel grafts were used for vascular reconstruction in 10 patients. Patient data including age, gender, etiology of the vascular pathology, concomitant injury, site of injury, surgical procedure, additional surgical procedure, and hemodynamic status were retrospectively collected and analyzed. The Kaplan-Meier method was used to calculate the reintervention and patency rates.

RESULTS

Mean duration of follow-up was 16.5 ± 13.2 months (ranged, 2-39 months). The freedom from reintervention for any reason was 82% at 1 and 2 years. There was no evidence of arterial claudication or venous insufficiency in all patients. The primary patency rates were 82% at 1 and 2 years. There was no mortality, deep venous thrombosis, pulmonary embolism, graft thrombosis, anastomotic stenosis, diameter discrepancy, and aneurysm formation during late follow-up.

CONCLUSIONS

The autologous saphenous panel vein graft enables the surgeon to prepare suitable conduits easily with an appropriate diameter and length for vascular reconstruction. Although long-term results are unknown, this technique provides high patency rates in midterm follow-up, resistance to infection, and low reintervention rates. In conclusion, autologous saphenous vein panel grafts may well be preferred in various vascular disorders that require surgical reconstruction.

Use of Self-Expanding Covered Stents as Bailout Treatment of Spontaneous Rupture of the Femoral Artery Caused by Staphylococcus aureus Infection

Spontaneous rupture of femoropopliteal arteries caused by infection requires treatment in the urgent setting. The present article reports on the performance of self-expanding covered stents in 3 patients who experienced acute rupture of the femoral artery caused by Staphylococcus aureus infection. After a mean follow-up of 16.4 months, the bailout placement of self-expanding covered devices showed sustained patency and sufficient exclusion of the rupture site. A surgical conversion and bypass reconstruction was not necessary. Long-term follow-up and inclusion of more patients are needed to provide more evidence about the utility of this approach.

Vascular grafts

Autogenous vein is the conduit of choice in the surgical creation of bypasses of small-to-medium-caliber vessels in patients with peripheral occlusive arterial disease and will remain so for the near future. The success rate of bypasses using conduits of diameters greater than 6 mm has been excellent, whereas the majority of bypasses using smaller conduits fail within 5 years. In addition, due to a steep increase in rates of diabetes and decreasing cardiovascular mortality rates, increasing challenges are presented by this population. These facts have motivated much of the research in the cardiovascular arena over the past four decades, with improved techniques and new materials. Strategies to improve outcomes include the use of alternative materials including autologous, nonautologous and prosthetic grafts, utilizing different methods for their harvesting and preservation; tissue engineering, using either polymer- or biological-based scaffolds for cell seeding; endovascular methodologies; and gene therapy. This report presents an overview of the several options currently available in the management of patients with peripheral arterial occlusive disease, as well as the ongoing research directed towards the creation of an artificial engineered vessel, discussing experimental work in which endothelial cells have been seeded on different scaffolds and finally the potential application of gene therapy in the field of vascular reconstruction.

Superior vena cava obstruction: bypass using spiral vein graft

BACKGROUND

Previous midterm experience with the composite spiral saphenous vein graft to bypass the obstructed superior vena cava (SVC) has been favorable. This study looks at the long-term results in patients followed for up to 23 years.

METHODS

Sixteen patients aged 17 to 68 years had operation for obstruction of the SVC with SVC syndrome caused by benign disease. Eleven patients had fibrosing mediastinitis with or without caseous necrosis, 4 had thrombosis caused by a catheter or a pacemaker electrode, and 1 had spontaneous thrombosis. All operations were performed using a composite spiral vein graft constructed from the patient's own saphenous vein. Graft diameter ranged from 9.5 to 15.0 mm. Ten grafts were from the left innominate vein, and six grafts were from the right or left internal jugular vein. The grafts were placed to the right atrial appendage in all patients except 1. Follow-up extends from 1 month to 23 years 8 months (mean follow-up, 10.9 years).

RESULTS

Fourteen of 16 grafts remain patent for up to 23 years, and all patients but 1 are free from SVC syndrome. One patient required revision of the graft for thrombosis 4 days after operation. Two grafts closed during the first year after operation: one because of recurrence of spontaneous venous thrombosis and the other because of aggressive fibrosing mediastinitis requiring operation for graft revision three times over a 12-year period prior to death.

CONCLUSIONS

These data demonstrate that a spiral vein bypass graft for treatment of the obstructed SVC relieves SVC syndrome and has excellent long-term patency.

Portal vein thrombosis and stenosis in pediatric liver transplantation

The aim of this study was to determine the outcome of venous conduits used in living donor liver transplantation (LDLT). We analyzed the portal vein complications in 66 LDLT recipients and 48 cadaveric reduced-size liver transplant (RLT) recipients performed from November 1989 through January 1995. Three different venous conduits were utilized in the LDLT recipients: Group 1, reconstructed vein from the living donor, n=18; Group 2, cadaveric cryopreserved iliac vein, n=37; and Group 3, cadaveric cryopreserved femoral vein, n=11. Overall, 47 percent of the patients were less than one year of age; the age distribution was not significantly different among the groups. The incidence of early thrombosis was significantly greater in LDLT Group 1, (33%) than any of the other groups (LDLT Group 2, 8%; LDLT Group 3, 9%; and RLT, 4%:P<0.0005 vs. reduced graft and < 0.03 vs. other LDLT groups). The incidence of late portal vein stenosis or thrombosis was significantly higher in the LDLT Group 2, (51%) than any of the other groups (LDLT 1, 16%; LDLT Group 3, 9%; RLT 4%;P<0.005 vs. cadaveric and < 0.02 vs. LDLT Group 1 and LDLT Group 3). Five year arterial graft and patient survival for patients who have experienced portal vein thrombosis or stenosis is 61% and 67%, respectively, versus 67% and 71% for those patients who have not experienced portal vein pathology, P=ns. Based on this experience, we recommend avoiding the use of cryopreserved iliac vein for portal vein reconstruction in liver transplantation. Every effort should be taken to eliminate the need for venous conduits in liver transplantation. If venous conduits must be utilized, cryopreserved femoral veins seem to provide superior patency rates. Careful clinical and ultrasonopraphic monitoring of patients at high risk for late venous thrombosis permits therapy with excellent graft and patient survival.

Advances in treatment of vascular injuries from blunt and penetrating limb trauma

Military and civilian experience has contributed to the current state of the art in management of extremity vascular injuries. Thorough physical examination and judicious use of emergency center arteriography and formal arteriography provide means for prompt diagnosis and treatment which is critical is limb loss and disability are to be avoided. Prosthetic graft material has provided an alternative to vein grafting in many circumstances for arterial and venous injuries. Compartment syndrome should be anticipated when an ischemic extremity is revascularized and fasciotomy should be used liberally. Vascular repairs are the first priority in extremity wounds, but associated injuries to bones, joints, soft tissues, and nerves are often critical determinants of rehabilitation once blood supply has been re-established. The best results are obtained when a multidisciplinary approach is used combining expertise in orthopedic surgery, neurosurgery, and plastic surgery.

The use of internal jugular vein as interposition graft for femoral vein reconstruction following traumatic venous injury: a useful approach in selected cases

Complex venous injuries remain a controversial and interesting challenge to the vascular and trauma surgeon. Data from the Vietnam Vascular Registry, combined with experience from recent civilian series, seem to indicate that the best results are obtained when venous repair is undertaken. This is especially true of combined arterial and venous injury where compromised venous outflow may lead to limb loss in spite of patent arterial reconstruction. The larger size of veins, however, has required the construction of complex and time-consuming panel and spiral-vein grafts. This makes them far from ideal in the trauma treatment setting, where minimization of blood loss and operating room time are high priorities. We present a case of combined injury to both femoral artery and vein, where the femoral vein injury was repaired using autologous internal jugular vein as interposition graft while the arterial injury was repaired with autologous saphenous vein from the opposite limb. The avoidance of prosthetics, ease of harvest, size match, and little associated morbidity all make a strong case for use of the internal jugular vein where speedy reconstruction of large venous conduits is indicated.

Fate of the exposed saphenous vein graft

Patients with functioning vein grafts may present with wound problems resulting in exposure of the graft. We reviewed the courses of 16 patients presenting with this problem to determine the causative factors and the most appropriate management of this therapeutic dilemma. Diabetes mellitus (11 of 16, 68.7%) and wound infection (12 of 16, 75%) were frequent pre-existing conditions associated with exposed venous grafts. All patients with exposed vein grafts were initially treated conservatively with regular application of moist sterile dressings, followed by split-thickness skin graft coverage of the wounds when clean. The wounds healed in 7 patients, whereas 9 patients developed complications of hemorrhage (7 patients) and graft thrombosis (2 patients). The outcome of therapy was highly dependent on the type of organism originally cultured from the wounds. The incidence of vein graft disruption was lowest when the wounds were sterile (25%) or when gram-positive bacteria grew (25%). Gram-negative infection uniformly resulted in disruption of the exposed venous graft. When a new graft was placed, the secondary graft became reinfected in all patients with gram-negative primary graft infection. There were no instances of secondary graft reinfection when gram-negative bacteria were not present. These data suggest that the outcome of patients presenting with exposed vein grafts is highly dependent on the bacterial flora of the process. Vein graft disruption is frequent in patients with gram-negative infection, suggesting that these patients should be treated with distant graft ligation and extra-anatomic bypass. By contrast, patients without gram-negative infection may be successfully managed with local wound care.