704
Letters
Jouna! of VASCULAR SURGERY
to the Editms
vivo labeling of autologous granulocytcs has been validated as a scintigraphic test for inflammatory lesions. Time consuming vitality testing of the labeled granulocytes is not recommended. A shortcoming of this method is false-positive results in early infection caused by hematomas or physiologic wound healing, which may lead to increased granulocytc accumulations. In our series we did not observe any side effects after administration of this substance even in repcatcd examinations. Michad
&hs,
MI>
Bebbcrg Laboratory of Neuroscience University Hospital, UBC Site 2211 Wesbrook ,Mall Vancouver, British Columbia V6T Canada
1W5
Wo&a?tg Hepp, MD Gewg Banen, ML) R14th Lunpr, MD REFERENCES 1. Brunner IMC, ‘Mitchell KS, Baldwin JC. Prosthetic graft infection: limitations ofwhite blood cell scanning. J VASC SURC 1986;3:42-8. 2. Vorne M, Laitinen TJ, Lehtonen J, et al. 99mTc-leukocyte scintigraphy in prosthetic vascular graft infections. Nucl Med 1989;28:95-9. 3. Lawrence PE, Dries DJ, Alazraki N, Albo D. Indium 11 llabclcd leukocyte scanning for detection of prosthetic vascular graft infection. J VASC SUN 1985;2:165-73. 4. La IMuraglia GM, Fischman AJ, Strauss HW. Utility of the iridium Ill-labeled human immunoglobulin G scan for the detection of focal vascular graft infection. J VASC SURC 1989;10:20-8. 5. Bunt TJ. The management of infected grafts in reconstructive surgery. Thorac Cardiovasc Surg 1986;34:265-8.
Aortobifemoral
prosthesis:
a new design
To the Editurs:
The major problem in the surgery of atherosclerotic lesions of the distal aorta and the iliac arteries is the longevity of the restoration.’ This is mostly due to the progressive degradation of the distal circulation and the quality of the initial intervention. The initial intervention itself can crcatc the following functional anomalies: (1) a protusion of the prosthesis and conflicts with the digestive tract as well as with the superior mcscntcric artcry caused by an end-to-side anastomosis at the anterior face of the subrenal aorta; (2) an increase in aortic diameter caused by the lateral implantation of the prosthesis, thereby increasing the parietal tension of the aorta, which can create an
aneurysm;’ (3) turbulent flow at the end-to-side anastomosis site;” (4) competitive Aow between branches of the prosthesis and the stcnoscd iliac axes4 Although an anatomic restoration done by end-to-end
Fig.
1. The new aortobifcmoral
prosthesis.
anastomosis on the aorta and the femoral arteries associated with the reimplantation of the inferior mcscnteric artery and hypogastric arteries can avoid the above inconveniences, this technique is longer and more difficult to implement and has not been adopted by most surgeons5 Another problem occurs in subrenal aortic aneurysm interventions when they are associated with external iliac artcry stenosis. In these cases the prosthesis is inevitably implanted by end on the subrcnal aorta and by side onto the femoral arteries. The evolution of the lesions along the external
iliac
arteries
threatens
retrograde
hypogastric
perfusion. In view of the technical difficulties and drawbacks listed above, we propose a new, easily implantable prosthesis, where all anastomosis are end to end, and whcrc the perfusion of the hypogastric arteries is preserved in a physiologic direction. This new aortobifemoral prosthesis is made of woven Dacron, and it is constituted by an aortic tube with two lateral anastomosed branches that radiate from the midpoint of the tube. The branches arc anastomosed at a 30-dcgrce angle, and their diameter is half of that of the principal tube (Fig. 1).
Volume 14 Number 5 November 1991
Letters to the Editors 705
following: (1) Treatment of subrenal aortic aneurysm associated with external iliac artery stenosis: In these cases the aneurysms may be flattened, the lower extremities can be revascularized, and perfusion of the hypogastric arteries in a physiologic direction can be achieved. This is attained with a very simple operative technique that may also be used in an emergency situation of a ruptured aneurysm. (2) Treatment of large atheromatous lesions of the aortobiiliac bifurcation associated with long and significant stenosis of the external iliac arteries: In these cases interventions can be made with two anastomoses on the aorta, and the drawbacks of side anastomosis are eliminated. In addition, hypogastric perfusion is maintained in a physiologic direction, and the lower extremities are revascularized by the two branches of the prosthesis, D.ROUX,MD
Fig. 2. Picture shows an operative with
an aneurysm
technique in patients associated with iliac arteries stenosis.
During the period between Feb. 19,1989, and Oct. 15, 1990, 19 male patients ages 55 + 11 years were operated on. Eleven patients had a subrenal aortic aneurysm associated with bilateral external iliac artery stenosis (Fig. 2). Eight patients had atheromatous lesions of the aortoiliac bifurcation associated with long and narrow stenosis of the external iliac arteries. The quality of the common iliac arteries assured sufiicient perfusion of the hypogastric arteries in all 19 cases. In all cases the immediate postoperative results were satisfactory. An angiographic control showed a satisfactory results in 18 cases and one stenosis of approximately 20% on the proximal aortic anastomosis. This stenosis has been analyzed every 6 months by digitalized angiography and is now stable. One patient came back at 3 months after operation with claudication of the right lower extremity. Angiographic study showed a stenosis of the femoral anastomosis. Reintervention revealed intimal hyperplasia corrected by a prosthetic patch. In summary, this new prosthesis may be used for the
Service de Chiurgie Cardio-Vasculaire Hbpital de Rangeuil 1 Avenue Jean-Poulhts 31054 Toulouse-France I? Toumigand, MD G. Foumial, MD Y. Glock, MD H. Boccalon, MD A. Barret, MD A. Guidicelli, MD J. Mouss, PbD I? Puel, MD REFERENCES 1. Crawford ES, Bomberger RA, Glaeser DH, Saleh SA, Russel WL. Aorto iliac occlusive disease: factors influencing survival and function following reconstructive operations over a twenty-five period. Surgery 1981;90:1055-67. 2. Szilagyi DE, Smith RF, Elliott JP, Hageman TH, D’all Olmo CA. Anastomotic aneurysm after vascular reconsuuctionproblem of incidence, etiology and treatment. Surgery 1975; 78:326-31. 3. Filinger M, Kerns B, Bruch D, Reinin RE, Schartz AR. Does the end-to-end venous anastomosis offer a functional advantage over the end-to-side venous anastomosis in high out-put arteriovenous graft? J VASC SURG 1990;19:676-90. 4. Ferguson GB, Roach MR. Flow condition at bifurcation as determined in with reference to the focal distribution on vascular lesion: cardiovascular fluid dynamics. ~012. Bergel, ed. Londres: Academic Press, 1972;141-56. P, Djurakdjan D, Paulin M. Plaidoyer for the final 5. Tournigand anastomosis of prosthesis on the aorta. J Chir 1984;3:215-20.
Letters
Jouna! of VASCULAR SURGERY
to the Editms
vivo labeling of autologous granulocytcs has been validated as a scintigraphic test for inflammatory lesions. Time consuming vitality testing of the labeled granulocytes is not recommended. A shortcoming of this method is false-positive results in early infection caused by hematomas or physiologic wound healing, which may lead to increased granulocytc accumulations. In our series we did not observe any side effects after administration of this substance even in repcatcd examinations. Michad
&hs,
MI>
Bebbcrg Laboratory of Neuroscience University Hospital, UBC Site 2211 Wesbrook ,Mall Vancouver, British Columbia V6T Canada
1W5
Wo&a?tg Hepp, MD Gewg Banen, ML) R14th Lunpr, MD REFERENCES 1. Brunner IMC, ‘Mitchell KS, Baldwin JC. Prosthetic graft infection: limitations ofwhite blood cell scanning. J VASC SURC 1986;3:42-8. 2. Vorne M, Laitinen TJ, Lehtonen J, et al. 99mTc-leukocyte scintigraphy in prosthetic vascular graft infections. Nucl Med 1989;28:95-9. 3. Lawrence PE, Dries DJ, Alazraki N, Albo D. Indium 11 llabclcd leukocyte scanning for detection of prosthetic vascular graft infection. J VASC SUN 1985;2:165-73. 4. La IMuraglia GM, Fischman AJ, Strauss HW. Utility of the iridium Ill-labeled human immunoglobulin G scan for the detection of focal vascular graft infection. J VASC SURC 1989;10:20-8. 5. Bunt TJ. The management of infected grafts in reconstructive surgery. Thorac Cardiovasc Surg 1986;34:265-8.
Aortobifemoral
prosthesis:
a new design
To the Editurs:
The major problem in the surgery of atherosclerotic lesions of the distal aorta and the iliac arteries is the longevity of the restoration.’ This is mostly due to the progressive degradation of the distal circulation and the quality of the initial intervention. The initial intervention itself can crcatc the following functional anomalies: (1) a protusion of the prosthesis and conflicts with the digestive tract as well as with the superior mcscntcric artcry caused by an end-to-side anastomosis at the anterior face of the subrenal aorta; (2) an increase in aortic diameter caused by the lateral implantation of the prosthesis, thereby increasing the parietal tension of the aorta, which can create an
aneurysm;’ (3) turbulent flow at the end-to-side anastomosis site;” (4) competitive Aow between branches of the prosthesis and the stcnoscd iliac axes4 Although an anatomic restoration done by end-to-end
Fig.
1. The new aortobifcmoral
prosthesis.
anastomosis on the aorta and the femoral arteries associated with the reimplantation of the inferior mcscnteric artery and hypogastric arteries can avoid the above inconveniences, this technique is longer and more difficult to implement and has not been adopted by most surgeons5 Another problem occurs in subrenal aortic aneurysm interventions when they are associated with external iliac artcry stenosis. In these cases the prosthesis is inevitably implanted by end on the subrcnal aorta and by side onto the femoral arteries. The evolution of the lesions along the external
iliac
arteries
threatens
retrograde
hypogastric
perfusion. In view of the technical difficulties and drawbacks listed above, we propose a new, easily implantable prosthesis, where all anastomosis are end to end, and whcrc the perfusion of the hypogastric arteries is preserved in a physiologic direction. This new aortobifemoral prosthesis is made of woven Dacron, and it is constituted by an aortic tube with two lateral anastomosed branches that radiate from the midpoint of the tube. The branches arc anastomosed at a 30-dcgrce angle, and their diameter is half of that of the principal tube (Fig. 1).
Volume 14 Number 5 November 1991
Letters to the Editors 705
following: (1) Treatment of subrenal aortic aneurysm associated with external iliac artery stenosis: In these cases the aneurysms may be flattened, the lower extremities can be revascularized, and perfusion of the hypogastric arteries in a physiologic direction can be achieved. This is attained with a very simple operative technique that may also be used in an emergency situation of a ruptured aneurysm. (2) Treatment of large atheromatous lesions of the aortobiiliac bifurcation associated with long and significant stenosis of the external iliac arteries: In these cases interventions can be made with two anastomoses on the aorta, and the drawbacks of side anastomosis are eliminated. In addition, hypogastric perfusion is maintained in a physiologic direction, and the lower extremities are revascularized by the two branches of the prosthesis, D.ROUX,MD
Fig. 2. Picture shows an operative with
an aneurysm
technique in patients associated with iliac arteries stenosis.
During the period between Feb. 19,1989, and Oct. 15, 1990, 19 male patients ages 55 + 11 years were operated on. Eleven patients had a subrenal aortic aneurysm associated with bilateral external iliac artery stenosis (Fig. 2). Eight patients had atheromatous lesions of the aortoiliac bifurcation associated with long and narrow stenosis of the external iliac arteries. The quality of the common iliac arteries assured sufiicient perfusion of the hypogastric arteries in all 19 cases. In all cases the immediate postoperative results were satisfactory. An angiographic control showed a satisfactory results in 18 cases and one stenosis of approximately 20% on the proximal aortic anastomosis. This stenosis has been analyzed every 6 months by digitalized angiography and is now stable. One patient came back at 3 months after operation with claudication of the right lower extremity. Angiographic study showed a stenosis of the femoral anastomosis. Reintervention revealed intimal hyperplasia corrected by a prosthetic patch. In summary, this new prosthesis may be used for the
Service de Chiurgie Cardio-Vasculaire Hbpital de Rangeuil 1 Avenue Jean-Poulhts 31054 Toulouse-France I? Toumigand, MD G. Foumial, MD Y. Glock, MD H. Boccalon, MD A. Barret, MD A. Guidicelli, MD J. Mouss, PbD I? Puel, MD REFERENCES 1. Crawford ES, Bomberger RA, Glaeser DH, Saleh SA, Russel WL. Aorto iliac occlusive disease: factors influencing survival and function following reconstructive operations over a twenty-five period. Surgery 1981;90:1055-67. 2. Szilagyi DE, Smith RF, Elliott JP, Hageman TH, D’all Olmo CA. Anastomotic aneurysm after vascular reconsuuctionproblem of incidence, etiology and treatment. Surgery 1975; 78:326-31. 3. Filinger M, Kerns B, Bruch D, Reinin RE, Schartz AR. Does the end-to-end venous anastomosis offer a functional advantage over the end-to-side venous anastomosis in high out-put arteriovenous graft? J VASC SURG 1990;19:676-90. 4. Ferguson GB, Roach MR. Flow condition at bifurcation as determined in with reference to the focal distribution on vascular lesion: cardiovascular fluid dynamics. ~012. Bergel, ed. Londres: Academic Press, 1972;141-56. P, Djurakdjan D, Paulin M. Plaidoyer for the final 5. Tournigand anastomosis of prosthesis on the aorta. J Chir 1984;3:215-20.
