1080
lournal of VASCULAR SURGERY
Letters to the Editors
femoral artery in aortofemoral, axillofemoral, femorofemoral, and femoropopliteal bypass. A supralnguinal incision parallel to the inguinal ligament provides adequate exposure of the femoral vessels and is recommended to reduce the likelihood of wound infection in peripheral arterial reconstruction. Kazi A4obin-Uddin, A/AD
Saphenous vein graft
393 E. Town St., Suite 115 Columbus, OH 43215
REFERENCES l. Goldstone J, Moore WS. Infection in vascular prostheses; cliuical manifestations and surgical management. Am I Surg 1974;128:225-33. 2. Hoffert PW, Gensler S, Haimovici H. Infection complicating arterial grafts. Arch Surg 1965;90:427-35. 3. Jamieson GG, DeWeese JA, Rob CG. Infected arterial grafts. Ann Surg 1975;181:850-2. 4. SzilagyiDE, Smith RF, EUiotrJP, Vrandecic MP. Infection in arterial reconstruction with synthetic grafts. Ann Surg 1972; 176:321-33.
billimeter ~ed ET. F. IE. L. Gortex)
I
terior tibial ery
24/41135584
A simple technique to protect subcutaneous vein grafts To the Editors."
Approximately 100,000 lower extremity revascularizations are performed annually. The saphenous vein is unquestionably the conduit of choice for anastomosis involving the small arteries of the lower leg. In bypasses to the anterior tibial artery, the vascular surgeon has two pathways to route the vein graft: through the interosseus membrane in the leg or in the subcutaneous tissue lateral to the knee. A theoretic disadvantage to the technically simpler subcutaneous route is external compression around the knee and subsequent thrombosis of the vein graft. We present an easy method for protecting the vein graft from external trauma or compression. A 51-year-old, white woman was admitted with left lower extremity rest pain after aortofemoral and subsequent femoropopliteal bypass. Angiography revealed occlusion of the popliteal bypass and multilevel occlusive lesions requiring femoral-to-anterior tibial revascularization. A transposition graft of saphenous vein was chosen as the most appropriate conduit. After proximal anastomosis, the valves in the vein were incised by use of an intraluminal circular valvulotome. Two small counterincisions were then made laterally above and below the knee, thereby avoiding the medial scarring from previous surgery. The vein graft was passed subfascially to exit through the superior incision. A segment of 6 mm ringed polytetrafluoroethylene was placed in the scant subcutaneous tissue lateral to the knee, connecting these two incisions. The vein graft was then passed through this protective plastic conduit with the aid of an internal vein stripper to guide the graft. Distal anastomosis was constructed in standard
Fig. 1. Diagram of 6 mm ringed polytetrafluoroethylene segment placed in subcutaneous tissue lateral to knee. fashion, and aH incisions were dosed in layers. After operation the patient's hospital course was unremarkable, and she continues to do quite well. A color-flow duplex scan performed 6 months after operation revealed an average flow rate of 100 cm/second in the vein graft and an ankle-brachial index of 1.19. Kurt Richard Stahlfeld, M D Frank Juver Criado, A4D Luis Anibal Queral, A4D
Maryland Vascular Institute 201 E. University Parkway, Suite 650 Baltimore, MD 21218-2895. 24/41/34657
Intravascular ultrasonography: Redefining vascular imaging with use o f two-dimensional and three-dimensional reconstructions To the Editors:
We are writing to report a promising adaptation of intravascular ultrasound (IVUS) imaging; that is, computerized three-dimensional reconstruction. Standard IVUS imaging produces two-dimensional gray-scale, 360-degree, cross-sectional slices of vessels in a plane perpendicular to the catheter axis, and has developed sufficiently so that unique diagnostic and therapeutic applications are being reported. 1-4 Three-dimensional images are produced by computerized "stacking" ofa set (n = 90) of longitudinally aligned two-dimensional images obtained during a 20second IVUS catheter "pull-back" through a 5 cm vessel
lournal of VASCULAR SURGERY
Letters to the Editors
femoral artery in aortofemoral, axillofemoral, femorofemoral, and femoropopliteal bypass. A supralnguinal incision parallel to the inguinal ligament provides adequate exposure of the femoral vessels and is recommended to reduce the likelihood of wound infection in peripheral arterial reconstruction. Kazi A4obin-Uddin, A/AD
Saphenous vein graft
393 E. Town St., Suite 115 Columbus, OH 43215
REFERENCES l. Goldstone J, Moore WS. Infection in vascular prostheses; cliuical manifestations and surgical management. Am I Surg 1974;128:225-33. 2. Hoffert PW, Gensler S, Haimovici H. Infection complicating arterial grafts. Arch Surg 1965;90:427-35. 3. Jamieson GG, DeWeese JA, Rob CG. Infected arterial grafts. Ann Surg 1975;181:850-2. 4. SzilagyiDE, Smith RF, EUiotrJP, Vrandecic MP. Infection in arterial reconstruction with synthetic grafts. Ann Surg 1972; 176:321-33.
billimeter ~ed ET. F. IE. L. Gortex)
I
terior tibial ery
24/41135584
A simple technique to protect subcutaneous vein grafts To the Editors."
Approximately 100,000 lower extremity revascularizations are performed annually. The saphenous vein is unquestionably the conduit of choice for anastomosis involving the small arteries of the lower leg. In bypasses to the anterior tibial artery, the vascular surgeon has two pathways to route the vein graft: through the interosseus membrane in the leg or in the subcutaneous tissue lateral to the knee. A theoretic disadvantage to the technically simpler subcutaneous route is external compression around the knee and subsequent thrombosis of the vein graft. We present an easy method for protecting the vein graft from external trauma or compression. A 51-year-old, white woman was admitted with left lower extremity rest pain after aortofemoral and subsequent femoropopliteal bypass. Angiography revealed occlusion of the popliteal bypass and multilevel occlusive lesions requiring femoral-to-anterior tibial revascularization. A transposition graft of saphenous vein was chosen as the most appropriate conduit. After proximal anastomosis, the valves in the vein were incised by use of an intraluminal circular valvulotome. Two small counterincisions were then made laterally above and below the knee, thereby avoiding the medial scarring from previous surgery. The vein graft was passed subfascially to exit through the superior incision. A segment of 6 mm ringed polytetrafluoroethylene was placed in the scant subcutaneous tissue lateral to the knee, connecting these two incisions. The vein graft was then passed through this protective plastic conduit with the aid of an internal vein stripper to guide the graft. Distal anastomosis was constructed in standard
Fig. 1. Diagram of 6 mm ringed polytetrafluoroethylene segment placed in subcutaneous tissue lateral to knee. fashion, and aH incisions were dosed in layers. After operation the patient's hospital course was unremarkable, and she continues to do quite well. A color-flow duplex scan performed 6 months after operation revealed an average flow rate of 100 cm/second in the vein graft and an ankle-brachial index of 1.19. Kurt Richard Stahlfeld, M D Frank Juver Criado, A4D Luis Anibal Queral, A4D
Maryland Vascular Institute 201 E. University Parkway, Suite 650 Baltimore, MD 21218-2895. 24/41/34657
Intravascular ultrasonography: Redefining vascular imaging with use o f two-dimensional and three-dimensional reconstructions To the Editors:
We are writing to report a promising adaptation of intravascular ultrasound (IVUS) imaging; that is, computerized three-dimensional reconstruction. Standard IVUS imaging produces two-dimensional gray-scale, 360-degree, cross-sectional slices of vessels in a plane perpendicular to the catheter axis, and has developed sufficiently so that unique diagnostic and therapeutic applications are being reported. 1-4 Three-dimensional images are produced by computerized "stacking" ofa set (n = 90) of longitudinally aligned two-dimensional images obtained during a 20second IVUS catheter "pull-back" through a 5 cm vessel
