Long-term follow-up of last autogenous option arm vein bypass

BACKGROUND

The superiority of autogenous conduits in infrainguinal bypass surgery is well established. At our institution, arm vein is utilized as the last autogenous option for infrainguinal bypass surgery. The aim of this study was to review the long-term outcomes of last autogenous option arm vein bypass.

METHODS

All infrainguinal arm vein bypasses performed between 1997 and 2005 by The Queen Elizabeth Hospital vascular surgeons were identified. Patency, reintervention, limb salvage and survival were calculated using the Kaplan-Meier survival estimate method.

RESULTS

Thirty-eight arm vein bypasses were performed in 35 patients. Eighty-nine per cent were performed for critical limb ischaemia. Median follow-up was 58 months (range 2-121). Twelve-month primary, assisted primary and secondary patency rates were 52%, 73% and 76%, respectively. Three-year primary, assisted primary and secondary patency rates were 32%, 61% and 63%, respectively. Five-year primary, assisted primary and secondary patency rates were 21%, 47% and 49%, respectively. Patency was superior in single compared with spliced vein grafts (P < 0.05). Limb salvage rates at 1, 3 and 5 years were 94%, 87% and 76%, respectively. Patient survival at 1, 3 and 5 years was 92%, 68% and 49%, respectively.

DISCUSSION

Infrainguinal bypass surgery with arm vein can be performed safely with favourable patency and high rates of limb salvage. Secondary interventions to maintain patency are common and we recommend a vigilant surveillance programme to identify the threatened graft.

Arm Vein as a Last Autogenous Option for Infrainguinal Bypass Surgery: It is Worth the Effort

OBJECTIVES

Considerable evidence exists for the use of arm vein conduit in lower limb bypass surgery. The use of arm vein in preference to synthetic conduit as a last autogenous option was assessed for patency and limb salvage outcomes.

MATERIALS AND METHODS

A prospective database was interrogated and checked against TQEH operating theatre database to detect all infrainguinal arm vein bypasses performed between 1997 and 2005. Patency, limb salvage and survival data for 37 arm vein bypasses was calculated using the Kaplan-Meier survival estimate method.

RESULTS

There were no perioperative deaths. 30 day patency rates were 89% primary, 95% secondary and 95% limb salvage. 12 month patency rates were 56% primary, 79% secondary and 91% limb salvage. 5 year patency rates were 37% primary, 76% secondary and 91% limb salvage. There was no significant patency advantage for primary vs. "redo" grafts (p=0.54), single vessel vs. spliced conduits (p=0.33) or popliteal vs tibial outflow (p=0.80). Patient survival rate was 92% and 65% at 1 and 5 years respectively.

CONCLUSION

Lower limb bypasses using arm vein can be performed with favourable patency and limb salvage compared to synthetic conduits. However, secondary interventions are frequently required to maintain patency. We recommend a vigilant surveillance program for early identification of patency threatening disease.

The detection of early femoro-distal vein graft stenosis by treadmill exercise testing

A prospective study of 125 femoro-distal vein bypass grafts (103 patients) was undertaken to assess the role of treadmill exercise testing in the detection and correction of early vein graft stenosis. Patients were followed at 1,3,6,12 months and then annually with routine clinical assessment, palpation of pulses and resting Doppler ankle/brachial index. In addition, the Doppler index was repeated after 5 minutes exercise on a treadmill set at 5 degrees and 3 km/hr. Follow-up has been carried out for a mean of 24 months (range 3-48 months) and during that time 30 vein grafts (28 patients) were submitted to angiography. This revealed vein graft stenosis in 15, native vessel disease in 11 and no morphologic abnormality in 4. One additional graft was suspected to have a stenosis but occluded before angiography could be carried out. At the time of detection by the treadmill test, 8 of the 15 (53%) confirmed vein graft stenoses, and 4 of 11 (36%) native vessel stenoses would not have been detected by clinical assessment or resting Doppler pressure measurements. The 15 vein graft stenoses which were corrected all remain patent, suggesting that treadmill testing is of value in the detection and prevention of early femoro-distal vein graft occlusion.

Asymptomatic carotid murmur: ultrasonic factors influencing outcome

Sixty consecutive patients with an asymptomatic mid-cervical murmur on auscultation were identified amongst 1000 patients who underwent duplex scanning of the extracranial carotid arteries during 1981-83. They were classified according to the scan results into 12 high risk subjects with greater than 75 per cent stenosis of an internal carotid artery, 37 low risk subjects with a less than 75 per cent stenosis and 6 with no detectable stenosis. The mean duration of follow-up was 3 years (minimum 2 years) or until stroke or death. One was lost to follow-up and four were excluded having undergone carotid endarterectomy during the study. Six of twelve subjects with greater than 75 per cent stenosis suffered a stroke (five fatal and one non-fatal). There were no premonitory signs except in one patient with non-focal cerebral ischaemia for 2 months before an hemispheric stroke. There was one fatal stroke in the less than 75 per cent stenosis group and none in the control group. In all, 17 (28 per cent) patients died (myocardial infarction, 8; stroke, 6; malignant disease, 3). These results confirm that asymptomatic carotid murmurs are associated with increased mortality with most having non-severe carotid disease on duplex scanning and few strokes during follow-up. There is an important minority with tight carotid stenosis who carry a worrying risk of stroke if left untreated.

Haemodynamics of the interposition vein cuff

It has been suggested that the use of an interposition vein cuff for anastomosing PTFE grafts to small calibre arteries confers a haemodynamic advantage. Pulsatile blood flow through a standard anastomosis was compared, in vitro, to that incorporating a vein cuff. 6 mm PTFE was anastomosed end-to-side to 10 pairs of cadaver internal mammary arteries matched for length and internal diameter (median 1.8 mm, range 1.6-2.4). Blood flow was significantly higher through the vein cuff anastomosis than the standard anastomosis (comparison of regression analysis, P less than 0.001) when the arterial diameter was less than 2.0 mm (five pairs). These results suggest that the vein cuff does confer a significant haemodynamic advantage when PTFE is anastomosed to arteries less than 2.0 mm diameter and this may be because the compliant vein cuff allows more distension of the anastomosis thus reducing anastomotic resistance.

Cervical thymic cyst: report of an unusual presentation of a rare lesion

A case of cervical thymic cyst presenting as a thyroid swelling is reported, and the embryology of the thymus gland is discussed in order to explain this unusual presentation.

Squamous carcinoma of thyroglossal duct remnants: a case report and review of the literature

The first reported case in Australia of a squamous carcinoma arising in a thyroglossal duct remnant is presented. This case shows the previously unreported feature of associated hyperthyroidism.