- Email: [email protected]
Assessment of reconstructive procedures for femoropopliteal artery occlusive disease
Assessment of reconstructive for femoropopliteal artery
The purpose of this study is to review our experience with femoropopliteal artery reconstructive procedures in an attempt to ascertain the method of choice. From June, 1957, to June, 1967, 117 femoropopliteal reconstructions were performed in 105 extremities of 101 patients. Males outnumbered females 9 to 1. Eighty-four per cent of the patients were over 50 years of age and 80 per cent had additional manifestations of arterial disease. Diabetes mellitus was present in 18 per cent. The indications for operation were claudication in 46 extremities; rest pain in 41; and ischemic ulceration or gangrene in 18. Preoperative angiography was performed in all patients to assess the inflow, outflow, and extent of the blockage in the femoral system. The popliteal outflow was considered good or excellent in 76 extremities and fair or poor in 36. Arterial homografts were used prior to 1958. Synthetic grafts were used from 1958 to 1961. Since 1961 reversed autogenous saphenous vein grafts and thromboendarterectomy have been used almost entirely. Thirty-one patients have had concomitant lumbar sympathectomy, usually when rest pain or gangrene were present. There were three postoperative deaths, two due to gram-negative septicemia and one due to liver failure. Leg edema is common following these operations and occurred in 29 patients. Twenty-three patients developed wound complications, the majority of which were superficial skin necroses associated with a long thigh incision for removal of the saphenous vein. Fifteen patients developed pulmonary complications. Two patients developed coronary insufficiency postoperatively. Follow-up examination has been completed by the attending surgeon in most instances. Postoperative arteriograms have been done in 49 patients. Fifteen of the twenty-one deaths in the follow-up period were due to arteriosclerotic cardiovascular disease. All of the homografts have occluded. Synthetic grafts have given relatively poor late results with 40 per cent of the Dacron grafts and 33 per cent of the Teflon grafts remaining patent. Although the early results with thromboendarterectomy were good, the late patency rate of 50 per cent has been disappointing. The reversed autogenous saphenous vein grafts have given the best results with an early success rate of 90 per cent and a late success rate of
procedures occlusive disease
76 per cent. Most of the vein-graft occlusions have occurred within 24 months of operation. Of 41 !rafts at risk over 2 years, none have occluded. It IS apparent that the long-term patency rate is related to the adequacy of the popliteal outflow tract. Of the 13 postoperative occlusions 7 have been reoperated on successfully. The amputation rate for the entire series was 13.3 per cent and for the graft occlusion group 27.4 per cent. Three patients have developed vein-graft stenosis,* and two of these have been successfully repaired. It is apparent that these stenoses are due to valve fibrosis in the graft.8-‘0 In support of the findings of other authors1-7 our own results indicate that reversed autogenous saphenous vein graft is the preferred procedure for femoropopliteal artery reconstruction. Allan
R. Dams,
M.D., F.R.C.S.(C), F.A.C.S. Associate Professor of Surgery University qf Manitoba 700 William Aue. Winnipeg 3, Manitoba
REFERENCES 1. Linton, R. R., and Darling, R. C.: Autogenous saphenous vein bypass grafts in femoropopliteal obliterative arterial disease, Surgerv 51:62, 1962. 2. Kunlin, J.: Rev. Chir. (Paris) 70:206, 1951. 3. Darling, R. C., Linton, R. R.. and Razzuk, M. A.:%aphenous vein bypass grafts for femoropopliteal occlusive disease: A reappraisal, Surgery 61:31, 1967. 4. Gutelius, J. R., Kreindler, S., and Luke, J. C.: Comparative evaluation of autogenous vein bypass graft and endarterectomy in superficial femoral artery reconstruction, Surgery 57:28, 1965. 5. DeWeese, J. A., Terry, R., Barner, H., and Rob, C. G.: Autogenous venous femoropopliteal bypass grafts, Surgery 59:28, 1966. 6. Vollmar, J., Trede, M., Laubach, K., and Forrest, H.: Principles of reconstructive procedures for chronic femoro-popliteal occlusions. Report on 546 operations, Ann. Surg. X8:215, 1968. 7. Litherland, H. K., and Elliott, J. A.: Femoropopliteal arterial occlusive disease: report of 180 autogenous vein by-pass grafts, Canad. J. Surg. 10:186, 1967. -I
Annotations
8.
9.
10.
Downs, A. R., and Morrow, I. M.: Valvular stenoses in vein grafts, Curr. Top. Surg. Res. 1:499, 1969. Breslau, R. C., and DeWeese, J. A.: Successful endophlebectomy of autogenous venous bypass graft, Ann. Surg. 162:251, 1965.
Potentially
dangerous
interaction in an external demand pacemaker
Certain new applications for electronic pacemaking of the heart make it mandatory that such devices perform in accordance with published specifications. Because of our interest in the overdrive technique for control of arrhythmias,r2 we frequently utilize external pacemakers at rates of stimulation over 100 per minute. Recently we have had occasion to test the Medtronics Model 5840 external demand pacemaker at rates of stimulation above 100 per minute. Specifications furnished by the manufacturer (Medtronics, Inc., 30.55 Old Highway Eight, Minneapolis, Minn. 5.5418) indicate pacing rates from 50 to 150 pulses per minute and an output control capable of adjusting the amplitude from 0.5 to 25 Ma. No mention is made of interaction between the controls. Although a recent issue of Medtronic News3 states that this instrument was designed to be used with the Medtronic 5821 endocardial electrode, this pacemaker is commonly used with pacing catheters supplied by other manufacturers. We have found that although this unit is reliable for rapid rates of stimulation at low-amplitude settings, the rate acutely drops and pacing is intermittent when the amplitude is raised above a limit which varies with the individual pacemaker. This characteristic of the Medtronics Model 5840 makes it unsuitable and indeed dangerous for all applications requiring a rapid rate of stimulation in a patient with a high threshold. Our discovery of this phenomenon occurred during treatment of a 54-year-old woman with intermittent sinus bradycardia and episodes of sinoatrial and atrioventricular block punctuated by runs of ventricular tachvcardia. Because of this. a 5 Fr. Goetz transvenous bipolar pacemaker catheter (U. S. Catheter and Instrument Corp., Glens Falhs, N. Y.) was inserted and pacing at a rate of 100 per minute was begun. The ventricular arrhythmia was suppressed and over a period of several weeks her sinus rate speeded up to 70 per minute and sina’atrial and atrioventricular conduction were re-established. The pacemaker was placed in the demand mode at a rate below 70 per minute and she did well. During a routine test of the pacemaker it was discovered that pacing at a rate of 100 per minute could not be accomplished at high milliamperage when the
rate
717
McNamara, J. D., Darling, R. C., and Linton, R. R.: Segmental stenosis of saphenous-vein autografts. Preventable cause of late occlusion in arterial reconstruction, New Eng. J. Med. 277:290, 1967.
and
amplitude
control
battery-powered
pacemaker was set in the demand mode. Fig. 1 demonstrates this phenomenon. In A, three sinus beats at rate 83 are noted. The pacemaker is then turned on at 100 per minute at 0.5 Ma. output. In the following strips, the rate is held constant but the amplitude is gradually increased. When the amplitude reaches 12 Ma. (F) the pacemaker suddenly begins to function intermittently at a rate of 63 per minute. No escape beats are noted. In G the milliamperage is set at 25, which is the maximum output of this unit, and the intermittent pacemaker output continues. Escape sinus beats are now present because of the long pacing interval. In an attempt to determine whether this was a pacemaker malfunction or an intrinsic defect in design, a new battery was inserted into the pacemaker, but pacing was still intermittent at rate of 100 or more with 12 Ma. or higher output. Three other Model 5840 pacemakers were substituted for the original one and all demonstrated the same defect at high output levels. One of these, set at a rate of 80 per minute, intermittently reverted to 60 per minute when the amplitude was raised above 12 Ma. Pacing was maintained, however, when any of the units was shifted to the standard pace (fixedrate) mode. Each of the pacemakers was connected to resistors of varying values from 47 ohms to 15 megohms. In no instance could this phenomenon be demonstrated. However, when a pacemaker was attached to a 5 Fr. Goetz bipolar electrode catheter with the electrodes immersed in a bottle of 0.9 per cent saline, the pacing became intermittent in the demand mode at high outputs with certain configurations of the catheter. The resistance of this system was found to be about 5 K-ohms using a Simpson VOM instrument, but substitution of a 5 K-ohm resistor across the output terminals of the pacemaker for this system did not produce intermittent pacemaker output. Since direct current must be passed through a circuit to determine its resistance, no attempt was made to determine the resistance of the electrode catheter in the patient’s heart. From these tests we conclude that there is an intrinsic design defect in this unit that causes it to stimulate intermittently at high output levels. This
The purpose of this study is to review our experience with femoropopliteal artery reconstructive procedures in an attempt to ascertain the method of choice. From June, 1957, to June, 1967, 117 femoropopliteal reconstructions were performed in 105 extremities of 101 patients. Males outnumbered females 9 to 1. Eighty-four per cent of the patients were over 50 years of age and 80 per cent had additional manifestations of arterial disease. Diabetes mellitus was present in 18 per cent. The indications for operation were claudication in 46 extremities; rest pain in 41; and ischemic ulceration or gangrene in 18. Preoperative angiography was performed in all patients to assess the inflow, outflow, and extent of the blockage in the femoral system. The popliteal outflow was considered good or excellent in 76 extremities and fair or poor in 36. Arterial homografts were used prior to 1958. Synthetic grafts were used from 1958 to 1961. Since 1961 reversed autogenous saphenous vein grafts and thromboendarterectomy have been used almost entirely. Thirty-one patients have had concomitant lumbar sympathectomy, usually when rest pain or gangrene were present. There were three postoperative deaths, two due to gram-negative septicemia and one due to liver failure. Leg edema is common following these operations and occurred in 29 patients. Twenty-three patients developed wound complications, the majority of which were superficial skin necroses associated with a long thigh incision for removal of the saphenous vein. Fifteen patients developed pulmonary complications. Two patients developed coronary insufficiency postoperatively. Follow-up examination has been completed by the attending surgeon in most instances. Postoperative arteriograms have been done in 49 patients. Fifteen of the twenty-one deaths in the follow-up period were due to arteriosclerotic cardiovascular disease. All of the homografts have occluded. Synthetic grafts have given relatively poor late results with 40 per cent of the Dacron grafts and 33 per cent of the Teflon grafts remaining patent. Although the early results with thromboendarterectomy were good, the late patency rate of 50 per cent has been disappointing. The reversed autogenous saphenous vein grafts have given the best results with an early success rate of 90 per cent and a late success rate of
procedures occlusive disease
76 per cent. Most of the vein-graft occlusions have occurred within 24 months of operation. Of 41 !rafts at risk over 2 years, none have occluded. It IS apparent that the long-term patency rate is related to the adequacy of the popliteal outflow tract. Of the 13 postoperative occlusions 7 have been reoperated on successfully. The amputation rate for the entire series was 13.3 per cent and for the graft occlusion group 27.4 per cent. Three patients have developed vein-graft stenosis,* and two of these have been successfully repaired. It is apparent that these stenoses are due to valve fibrosis in the graft.8-‘0 In support of the findings of other authors1-7 our own results indicate that reversed autogenous saphenous vein graft is the preferred procedure for femoropopliteal artery reconstruction. Allan
R. Dams,
M.D., F.R.C.S.(C), F.A.C.S. Associate Professor of Surgery University qf Manitoba 700 William Aue. Winnipeg 3, Manitoba
REFERENCES 1. Linton, R. R., and Darling, R. C.: Autogenous saphenous vein bypass grafts in femoropopliteal obliterative arterial disease, Surgerv 51:62, 1962. 2. Kunlin, J.: Rev. Chir. (Paris) 70:206, 1951. 3. Darling, R. C., Linton, R. R.. and Razzuk, M. A.:%aphenous vein bypass grafts for femoropopliteal occlusive disease: A reappraisal, Surgery 61:31, 1967. 4. Gutelius, J. R., Kreindler, S., and Luke, J. C.: Comparative evaluation of autogenous vein bypass graft and endarterectomy in superficial femoral artery reconstruction, Surgery 57:28, 1965. 5. DeWeese, J. A., Terry, R., Barner, H., and Rob, C. G.: Autogenous venous femoropopliteal bypass grafts, Surgery 59:28, 1966. 6. Vollmar, J., Trede, M., Laubach, K., and Forrest, H.: Principles of reconstructive procedures for chronic femoro-popliteal occlusions. Report on 546 operations, Ann. Surg. X8:215, 1968. 7. Litherland, H. K., and Elliott, J. A.: Femoropopliteal arterial occlusive disease: report of 180 autogenous vein by-pass grafts, Canad. J. Surg. 10:186, 1967. -I
Annotations
8.
9.
10.
Downs, A. R., and Morrow, I. M.: Valvular stenoses in vein grafts, Curr. Top. Surg. Res. 1:499, 1969. Breslau, R. C., and DeWeese, J. A.: Successful endophlebectomy of autogenous venous bypass graft, Ann. Surg. 162:251, 1965.
Potentially
dangerous
interaction in an external demand pacemaker
Certain new applications for electronic pacemaking of the heart make it mandatory that such devices perform in accordance with published specifications. Because of our interest in the overdrive technique for control of arrhythmias,r2 we frequently utilize external pacemakers at rates of stimulation over 100 per minute. Recently we have had occasion to test the Medtronics Model 5840 external demand pacemaker at rates of stimulation above 100 per minute. Specifications furnished by the manufacturer (Medtronics, Inc., 30.55 Old Highway Eight, Minneapolis, Minn. 5.5418) indicate pacing rates from 50 to 150 pulses per minute and an output control capable of adjusting the amplitude from 0.5 to 25 Ma. No mention is made of interaction between the controls. Although a recent issue of Medtronic News3 states that this instrument was designed to be used with the Medtronic 5821 endocardial electrode, this pacemaker is commonly used with pacing catheters supplied by other manufacturers. We have found that although this unit is reliable for rapid rates of stimulation at low-amplitude settings, the rate acutely drops and pacing is intermittent when the amplitude is raised above a limit which varies with the individual pacemaker. This characteristic of the Medtronics Model 5840 makes it unsuitable and indeed dangerous for all applications requiring a rapid rate of stimulation in a patient with a high threshold. Our discovery of this phenomenon occurred during treatment of a 54-year-old woman with intermittent sinus bradycardia and episodes of sinoatrial and atrioventricular block punctuated by runs of ventricular tachvcardia. Because of this. a 5 Fr. Goetz transvenous bipolar pacemaker catheter (U. S. Catheter and Instrument Corp., Glens Falhs, N. Y.) was inserted and pacing at a rate of 100 per minute was begun. The ventricular arrhythmia was suppressed and over a period of several weeks her sinus rate speeded up to 70 per minute and sina’atrial and atrioventricular conduction were re-established. The pacemaker was placed in the demand mode at a rate below 70 per minute and she did well. During a routine test of the pacemaker it was discovered that pacing at a rate of 100 per minute could not be accomplished at high milliamperage when the
rate
717
McNamara, J. D., Darling, R. C., and Linton, R. R.: Segmental stenosis of saphenous-vein autografts. Preventable cause of late occlusion in arterial reconstruction, New Eng. J. Med. 277:290, 1967.
and
amplitude
control
battery-powered
pacemaker was set in the demand mode. Fig. 1 demonstrates this phenomenon. In A, three sinus beats at rate 83 are noted. The pacemaker is then turned on at 100 per minute at 0.5 Ma. output. In the following strips, the rate is held constant but the amplitude is gradually increased. When the amplitude reaches 12 Ma. (F) the pacemaker suddenly begins to function intermittently at a rate of 63 per minute. No escape beats are noted. In G the milliamperage is set at 25, which is the maximum output of this unit, and the intermittent pacemaker output continues. Escape sinus beats are now present because of the long pacing interval. In an attempt to determine whether this was a pacemaker malfunction or an intrinsic defect in design, a new battery was inserted into the pacemaker, but pacing was still intermittent at rate of 100 or more with 12 Ma. or higher output. Three other Model 5840 pacemakers were substituted for the original one and all demonstrated the same defect at high output levels. One of these, set at a rate of 80 per minute, intermittently reverted to 60 per minute when the amplitude was raised above 12 Ma. Pacing was maintained, however, when any of the units was shifted to the standard pace (fixedrate) mode. Each of the pacemakers was connected to resistors of varying values from 47 ohms to 15 megohms. In no instance could this phenomenon be demonstrated. However, when a pacemaker was attached to a 5 Fr. Goetz bipolar electrode catheter with the electrodes immersed in a bottle of 0.9 per cent saline, the pacing became intermittent in the demand mode at high outputs with certain configurations of the catheter. The resistance of this system was found to be about 5 K-ohms using a Simpson VOM instrument, but substitution of a 5 K-ohm resistor across the output terminals of the pacemaker for this system did not produce intermittent pacemaker output. Since direct current must be passed through a circuit to determine its resistance, no attempt was made to determine the resistance of the electrode catheter in the patient’s heart. From these tests we conclude that there is an intrinsic design defect in this unit that causes it to stimulate intermittently at high output levels. This