A paper for debate: Vein versus PTFE for critical limb ischaemia - an unfair comparison?

Introduction:There is a widely held view that vein grafts for infrainguinal arterial reconstruction perform much better than prosthetic conduits, the best of which seems to be PTFE. Many randomised studies have been conducted which confirm this opinion, but is the difference as large as it is thought to be? One interesting feature of published trials is that the results for obligatory PTFE (when no vein is available) were much worse than the results for randomised PTFE grafts. The only way to explain this is that these groups of patients were not similar, and there are probably other factors which contribute to the difference in results when vein and PTFE grafts are compared.Materials and Method:A consecutive series of 109 femoro-infrapopliteal grafts undertaken for critical limb ischaemia was analysed to see the difference between vein and PTFE with vein cuff grafts.Results:Vein grafts were superior to PTFE grafts when the whole cohort was included (p=0.0038); however, there was no significant difference when the patients were stratified for inflow and runoff status.Conclusions:The difference between vein and PTFE has probably been exaggerated in the past, due to differences in risk factors and in the extent of arterial disease between the two groups of patients. The advantage of vein becomes more significant with time

A scoring system to predict the outcome of long femorodistal arterial bypass grafts to single calf or pedal vessels

Objectives:The aim of this study was to develop a scoring system to predict the outcome of long femorocrural and femoropedal bypass grafts performed for critical limb ischaemia.Setting:Teaching hospital.Methods:An analysis of 109 consecutive femorodistal bypass grafts performed for critical lower limb ischaemia between June 1991 to December 1994. Factors shown to affect the outcome were: inflow, number of patent calf vessels, graft material, straight flow to the foot and patent pedal vessels. These variables were weighted according to their relative significance (multivariate Cox regression) and a scoring system (ranging from 0 to 10) was developed.Results:Patients with a preoperative score of 0–4 (n = 35) showed a secondary patency of 36% at 1 month, 12% at 3 months and 0% at 10 months (Cum SE = 6.90/0.0). Secondary patency rates for the 46 patients with score 5–7 were 88.7% at 3 months, 56.3% at 12, and 45.1% at 2 and 3 years (Cum SE = 9.82), while the respective values for the 28 patients with score 8–10 were 92.7%, 88.5% and 81.7% (Cum SE = 8.08). The difference was highly significant (p = 0.000) in all tests of equality. In addition, the median total hospital cost was £12 600 for the group 0–4 compared with £8100 (group 5–7) and £4400 (group 8–10) (p = 0.0085).Conclusions:This preoperative scoring system appears to correlate well with the outcome of distal revascularisation to single calf or pedal vessels. If applied to patient selection, it could significantly reduce the total hospital cost per leg saved. A prospective testing of its predictive ability is needed and is in progress

Acute abdominal aorta embolism caused by primary cardiac echinococcus cyst

Embolism of the abdominal aorta by an echinococcus cyst is extremely rare and is due to rupture of an intracardiac hydatid cyst. We report a case of abdominal aortic embolism by a primary intracardiac echinococcus cyst which was treated successfully with bilateral femoral embolectomy followed by direct aortotomy. We found only 16 previous cases reported and only one caused by a primary cyst. © 1993 Grune & Stratton Ltd