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This investigation was to determine whether intraoperative monitoring of the transcutaneous partial pressure of oxygen (tcPo2) can be used to assess the success or failure of vascular reconstruction. A total of 347 limbs in 224 patients were studied, including 136 limbs without ischemic symptoms or signs, 173 limbs with intermittent claudication, and 38 limbs with ischemic rest pain, ulceration, or gangrene. The tcPo2 values were determined just before surgery, just before vascular declamping, at 5-minute intervals for 30 minutes after declamping, and just after surgery. A stable tcPo2 value of ≥ 45 mm Hg within 30 minutes after declamping indicated a good outcome, while graft failure or poor distal vascular runoff was suggested by a tcPo2 level of ≤ 45 mm Hg. Extremely poor results were indicated by persistent tcPo2 levels of < 10 mm Hg. Continuous tcPo2 measurement can be used to sensitively reflect distal tissue perfusion and determine the success or failure of vascular reconstruction.

The goal of clinical pathways is to reduce the cost of the hospitalization while maintaining acceptable results (patency, morbidity, and mortality). Patients who present with lower extremity revascularization pose a difficult problem, for they have significant comorbid medical disease. In this study the authors analyze their results and the treatment cost for patients undergoing lower extremity revascularization before and after the institution of clinical pathways. Data were collected independently by the hospital financial office, and surgical outcomes were derived from the prospectively collected computerized vascular registry. Data were analyzed for 12 months before and after institution of pathways. Cost, length of stay (LOS), and use of ancillary service as well as mortality, morbidity, and patency rates were evaluated. During each period, patients were selectively admitted to the intensive care unit based on perioperative risk factors independent of the pathway. Three hundred ninety-nine patients with distal reconstructions were placed on the path during this time period. These were compared to a group of 286 patients who were not on the path in the year prior. The LOS decreased from 14.3 days to 9.2 days. Electrolyte laboratory panels decreased from 12 draws per patient per admission to two draws per patient per admission. This trend was also seen in complete blood count (11.8 to 6.8), glucose (12.6 to 2.1), and electrolytes (12.2 to 1.8). Perioperative mortality rates were similar (2.5% vs 1.9%) with no change in morbidity rates. Total cost for hospitalization decreased by 27% after institution of the clinical pathway. From these data, the authors can demonstrate that the institution of clinical pathways not only decreased total cost, use of ancillary laboratory tests, and LOS but also did not negatively impact on outcome.

Fifty six patients underwent fifty nine complex extra-anatomic revascular ization procedures using Gore Tex®. Nine grafts (15%) occluded. We opted not to revise 2 grafts and other two grafts thrombectomized ultimately failed. Five grafts were declotted and have remained patent. The other patients have patent grafts or died of their primary illness with patent grafts (overall patency 93%). The surviving patients have been followed for an average period of 27.7 months (0.5-56 mo.). Based on this experience we conclude that Gore Tex®, is a suitable conduit for complex extra-anatomic bypass in patients whose condition contraindicates direct vascular reconstruction.

A case of pseudoaneurysm of the cervical internal carotid artery in a sixteen- year-old girl is reported. The enormous neck mass was initially misdiagnosed as a lymphomatous tumor; neck biopsy was compounded by a massive hemor rhage. The neck wound became secondarily infected, rendering the pseu doaneurysm mycotic. In the presence of infection any attempt of vascular reconstruction was pointless, so the internal carotid artery was doubly ligated. Recovery was uneventful, without neurologic deficit.

A sixty-eight-year-old man developed a groin lymphocele following an aorto- femoral bypass graft. Despite four weeks of conservative therapy, lymphorrhea persisted. A lymphangiogram, performed to accurately identify the site of leak age, resulted in cessation of the lymphatic leak. To our knowledge, this is the first report of lymphangiography as a therapeutic tool in the management of lymphorrhea following vascular reconstruction.

Infection of the abdominal aorta by Salmonella organisms is a rare but com monly fatal condition. Successful man agement depends on rapid diagnosis, ag gressive surgical intervention, extra- anatomic vascular reconstruction and antibiotic therapy. A review of the surgical literature re veals 25 cases of Salmonella aortitis with only five survivors. Pre-operative death from aortic rupture is common and post operative death due to graft infection is to be anticipated if a prosthesis is placed in the normal retroperitoneal location. A successfully managed case is pre sented with a three year follow-up. Therapy consisted of aneurysm resection, axillobifemoral bypass and a six week course of antibiotics. The status of the oversewn aortic stump has been followed at yearly intervals by means of the in travenous digital subtraction angiogram. No aneurysmal dilatation of the aortic stump has occurred during the three year follow-up and the extra-anatomic recon struction has remained patent without the need for thrombectomy. Important con siderations in the operative and post operative management are discussed.