Objectives: The purpose was to test the durability of the use of the unobstructed popliteal or tibial arteries as alternative inflow sources.Materials: We examined 106 such bypasses performed during a 12 year period (1981-93). The indication for surgery was limb salvage in 99.1%. Seventy-five percent of the patients were male, 78% were diabetic and the average age was 59.6 years. The inflow source was the above-knee popliteal artery in 15 cases, the below-knee popliteal artery in 70 cases, the anterior tibial artery in 11 cases and the posterior tibial artery in 10 cases. Adequacy of inflow uas determined by angiogram as well as ingtraoperative pressure measurement when indicated. Outflow was to a distal tibial or plantar arteries in 77.4% of the procedures. Forty-six bypasses were performed by an in situ technique. Excised vein was used as conduit in 60 patients (56.6%); greater saphenous vein (38), lesser saphenous vein (10), cephalic/basilic vein (4), and spliced vein (8).Results: Operative mortality was 2.8%. Five year cumulative primary patency tons 75.4% with a secondary patency of 82.6%. Five year cumulative limb salvage was 93.5%. Patency rate was not significantly different for various inflows or outflows. Only four of the 106 bypasses ultimately required a reconstruction from the femoral level for proximal progression of disease. Bypasses performed using an in situ technique showed a significantly better 5 year cumulative secondary patency rate (96.3%) than those done with excised vein (70.5%), p < .05.Conclusion: Results of this study indicate that use of the popliteal or tibial arteries as an inflow source in the absence of significant proximal disease carries acceptable results, especially when using the vein in situ.

Purpose: The use of autogenous vein, whether in situ or excised, for arterial bypass procedures is well accepted. However, this usually requires the presence of a length of good-quality vein of adequate diameter. In patients lacking sufficient length of vein, two or more pieces of vein may be spliced together to complete the reconstruction. The effect of vein splicing on vein bypass patency is not well studied.Methods: Over a 14-year period, 1956 lower extremity revascularizations were performed with a single autogenous vein, 1806 in situ and 150 excised veins. During the same time, 184 bypasses required splicing vein segments together, of which 111 were in situ bypass: procedures, which required splicing of one or more pieces of excised vein to complete the reconstruction (partial in situ bypass). Seventy-three bypasses were completed with multiple pieces of spliced excised vein. The source for the excised, spliced vein segments was the distal ipsilateral greater saphenous vein (GSV) in 40%, accessory ipsilateral GSV in 8%, contralateral GSV in 13%, lesser saphenous vein in 28%, and arm vein in 11%.Results: The 1- and 4-year primary patency rates for the entire spliced vein group were 72% and 45%, with secondary patency rates of 79% and 61%. The 1- and 4-year secondary patency rates of partial in situ bypasses were 80% and 70%, compared with 91% and 83% for in situ bypasses completed without a spliced segment (p < 0.0001). The 1- and 4-year secondary patency rates were 78% and 67% in the spliced excised vein group and 85% and 75% in the single excised vein group (p = not significant). The 4-year limb salvage rates were as follows: in situ (96%), partial in situ (85%), single excised vein (95%), and spliced excised vein (90%).Conclusions: We conclude that the use of excised vein segments to complete partial in situ bypasses may be associated with a decrement of bypass patency. Use of spliced excised vein segments of good quality for arterial bypass can produce acceptable patency rates. Such spliced autogenous conduits are clearly preferable to prosthetic bypasses for infrageniculate arterial reconstructions. Meticulous technique is a prerequisite for the successful performance of vein-to-vein anastomoses.

PURPOSE:The purpose of this study was to determine the safety and efficacy of performing carotid endarterectomy procedures with the patient receiving cervical block anesthetic.METHODS:Over the last 14 years, 654 carotid endarterectomy procedures were performed with patients receiving regional anesthetic. Intraluminal shunts were placed on demand, if neurologic changes with clamping of the carotid artery developed in the patient. During the same period, 419 cases were done with the patients receiving general anesthetic. Choice of anesthetic was based on surgeon and patient preference.RESULTS:In the regional anesthetic group the indications for operation included transient ischemic attack (311), asymptomatic hemodynamically significant stenosis (146), amaurosis fugax (106), stroke (86), restenosis (3), and aneurysm (2). Shunts were used in 46 of 654 cases (7%). Conversion from regional to general anesthetic was required in seven patients (1.1%). The operative mortality rate was 0.76% (5 of 654). Permanent nonfatal neurologic deficits occurred in 0.76% (5 of 654), and temporary neurologic deficits occurred in 1.07% (7 of 654).CONCLUSIONS:On the basis of these results, we believe regional cervical block anesthetic is an acceptable option to the routine use of shunts performed with the patient receiving general anesthetic during carotid endarterectomy. In addition, the ability to continuously assess the awake patient receiving cervical block may contribute to a decrease in perioperative stroke and mortality rates while simplifying functional cerebral monitoring during carotid endarterectomy.

Chang, B B MD; Shah, D M MD; Darling, RC III MD; Robinson, L W MD; Leather, R P MD; Bock, DEM MD.; BB, Chang MD; RC, Wray MD Author Information