arterial reconstruction: the first ten years

1
762 and outside Scotland will be grateful to the team of officers of the Home and Health Department for this helpful and practical Note. ARTERIAL RECONSTRUCTION: THE FIRST TEN YEARS FEW developments in surgery can match the growth of restorative arterial surgery in the past decade, and there is no reason to suppose that the phase of achievement is over yet. Now that many thousands of cases of thrombosis and aneurysm of the aorta and its major branches have been successfully operated on in centres the world over, it is the failures and complications of such procedures that make news and influence case-management and research. Irvine et al.l report unfavourably on long by-pass grafts for femoral arterial occlusion: early occlusion was almost the rule where woven teflon was the material used, and late patency of the homograft was marred by aneurys- mal failure at about three years. Against this gloomy pic- ture it has been usual to set the good results of plastic cloth prostheses in aortoiliac replacement: in skilled hands this type of operation now carries no more risk than major gastrointestinal resection; and the expec- tation of life in these atheromatous patients is much better than might have been supposed. In a nine-year review period Cockett and Maurice 2 found that in only 10 of their 90 aortoiliac cases did the patient die of associated arteriosclerotic conditions, and the figure for femoral- artery patients was even better: 8 from all causes among a total of 140 followed up. From the experience of those early at work on this subject come reports of two late failures of cloth grafts,3 4 both in the sixth year. Intensive experimental studies are in progress in the United States, notably those by Wesolowski et awl. in which numerous different types of synthetic vascular grafts have been assessed. The present trend is towards embodying the two opposite requirements of low initial porosity (to prevent leakage at and soon after operation) and later opening up of the inert mesh (to allow the admission of healing tissues). These workers have based their research on 23 different compound materials, in which an early absorb- able constituent is combined with a durable one intended to last as a permanent reinforcement to the new vessel, now largely composed of living tissue: a collagen tube in fact, lined by pavement endothelium, such as Jordan et al. s have shown to be’ present as early as the 30th day after implantation of dacron cloth grafts leak-proofed with gelatin. Clearly it would not be possible for endothelial migration from the host artery at the anastomosis to com- plete such a lining so soon. It now seems fairly certain that most of it comes either from the circulating blood within the graft or by metaplasia from the fibroblastic invasion of its wall; quite possibly both sources contri- bute. Atherosclerosis has been induced in synthetic aortic grafts in rabbits, and has been demonstrated within 25 months of grafting in man. And so the wheel turns full circle: aneurysm and atheromatous narrowing may be tolerable late in the useful life of synthetic arterial grafts. 1. Irvine, W. T., Kenyon, J. R., Stiles, P. J. Brit. med. J. Feb. 9, 1963, p. 360. 2. Cockett, F. B., Maurice, B. A. ibid. p. 353. 3. Eastcott, H. H. G., Robinson, S. H. G. Lancet, 1962, ii, 75. 4. Knox, W. G. Ann. Surg. 1962, 156, 827. 5. Wesolowski, S. A., Fries, C. C., Domingo, R. T., Liebig, W. J., Sawyer, P. N. Surgery, 1963, 53, 19. 6. Jordan, G. L., Stump, M. M., Allen, J., DeBakey, M. E., Halpert, B. ibid. p. 45. 7. Tarizzo, R. A., Alexander, R. W., Beattie, E. J., Economou, S. G. Arch. Surg. 1960, 82, 826. THE DISAPPEARING TUBE THROUGH inadvertence or complacency, simple even- day procedures can suddenly become fraught with tragedy. The story of a bizarre transformation of the mundane into the extraordinary is related by Taylor and Rutherford. I A patient with delirium tremens was admitted to their hospital. As part of the treatment, he was given glucose solution for some days through an indwelling intravenous tube. When the tube was being removed it was cut an inch or so from its point of entry; whereupon it promptly disappeared into the arm vein. A tourniquet was hastily applied to the upper arm, and the brachial vein was exposed under local anxsthesia, but the tube was not found; and injection of intravenous dye failed to show where it had lodged. The patient was discharged, and had remained well up to the time of the report a month later. Looking around for other accounts of this mishap, Taylor and Rutherford found that it had happened once before in their own hospital, and twice in neighbouring hospitals. In all three patients, quick action by nurses and residents had resulted in the recovery of the tube from the brachial vein. The plastic tubes that were used in these hospitals are deservedly popular. They are threaded through a sharp needle which is withdrawn after introduction leaving the tube in the vein. If the tube becomes kinked or the patient moves his arm, the needle can cut through the tube, which can then easily find its way, eel-like, to the Sargasso Sea of the right auricle. Besides the four cases in their immediate neighbourhood, the American workers were able to trace records of eight accidents elsewhere in which tubes were lost in the venous system by the same mechanism, or by fracture of an indwelling catheter in the vein. In two of these, the tube was removed from the right auricle; in one it was left, and the patient was well two years later; but five patients died from infection directly attributable to the retained tubes. In almost all the patients, the tubes had lodged against the annulus of the tricuspid ring and were trailing back into the inferior vena cava, but in one patient the tube had passed into the pulmonary artery through the right heart. There are two conclusions to be drawn. Eternal vigilance is the price not only of liberty but also of safety. With knowledge that this misadventure, can happen and how it happens it should be prevented from happening. If it does happen and the tube is not found in the brachial vein, the right auricle must be explored: leaving the tube and trusting to luck is dangerous. ROYAL MEDICAL BENEVOLENT FUND THE important work of this Fund, in helping doctors and their families in time of misfortune, depends entirely on the financial support of the profession. In 1962 a sum of E59,281 was disbursed in grants and annuities, and this left a revenue deficit of E9626. More money is badly needed; and many doctors in this country will be receiving a letter, signed by Sir Zachary Cope, president of the Fund, and by the presidents of the Royal Colleges in London and the College of General Practitioners, appeal- ing for support by personal contribution and by persuad- ing colleagues to give generously. We hope the response will be immediate and ample. The Fund’s office is at 37, St. George’s Road, Wimbledon. London,S.W.19. 1. Taylor, F. W., Rutherford, C. E. Arch. Surg. 1963, 86, 177.

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762

and outside Scotland will be grateful to the team ofofficers of the Home and Health Department for thishelpful and practical Note.

ARTERIAL RECONSTRUCTION:

THE FIRST TEN YEARS

FEW developments in surgery can match the growth ofrestorative arterial surgery in the past decade, and there isno reason to suppose that the phase of achievement is overyet. Now that many thousands of cases of thrombosis and

aneurysm of the aorta and its major branches have beensuccessfully operated on in centres the world over, it isthe failures and complications of such procedures thatmake news and influence case-management and research.

Irvine et al.l report unfavourably on long by-passgrafts for femoral arterial occlusion: early occlusion wasalmost the rule where woven teflon was the material used,and late patency of the homograft was marred by aneurys-mal failure at about three years. Against this gloomy pic-ture it has been usual to set the good results of plasticcloth prostheses in aortoiliac replacement: in skilledhands this type of operation now carries no more riskthan major gastrointestinal resection; and the expec-tation of life in these atheromatous patients is much betterthan might have been supposed. In a nine-year reviewperiod Cockett and Maurice 2 found that in only 10 oftheir 90 aortoiliac cases did the patient die of associatedarteriosclerotic conditions, and the figure for femoral-artery patients was even better: 8 from all causes among atotal of 140 followed up. From the experience of thoseearly at work on this subject come reports of two latefailures of cloth grafts,3 4 both in the sixth year. Intensive

experimental studies are in progress in the United States,notably those by Wesolowski et awl. in which numerousdifferent types of synthetic vascular grafts have beenassessed. The present trend is towards embodying the twoopposite requirements of low initial porosity (to preventleakage at and soon after operation) and later opening upof the inert mesh (to allow the admission of healingtissues). These workers have based their research on 23different compound materials, in which an early absorb-able constituent is combined with a durable one intendedto last as a permanent reinforcement to the new vessel,now largely composed of living tissue: a collagen tube infact, lined by pavement endothelium, such as Jordan et al. shave shown to be’ present as early as the 30th day afterimplantation of dacron cloth grafts leak-proofed withgelatin. Clearly it would not be possible for endothelialmigration from the host artery at the anastomosis to com-plete such a lining so soon. It now seems fairly certainthat most of it comes either from the circulating bloodwithin the graft or by metaplasia from the fibroblasticinvasion of its wall; quite possibly both sources contri-bute. Atherosclerosis has been induced in synthetic aorticgrafts in rabbits, and has been demonstrated within 25months of grafting in man. And so the wheel turns fullcircle: aneurysm and atheromatous narrowing may betolerable late in the useful life of synthetic arterial grafts.1. Irvine, W. T., Kenyon, J. R., Stiles, P. J. Brit. med. J. Feb. 9, 1963,

p. 360.2. Cockett, F. B., Maurice, B. A. ibid. p. 353.3. Eastcott, H. H. G., Robinson, S. H. G. Lancet, 1962, ii, 75.4. Knox, W. G. Ann. Surg. 1962, 156, 827.5. Wesolowski, S. A., Fries, C. C., Domingo, R. T., Liebig, W. J., Sawyer,

P. N. Surgery, 1963, 53, 19.6. Jordan, G. L., Stump, M. M., Allen, J., DeBakey, M. E., Halpert, B.

ibid. p. 45.7. Tarizzo, R. A., Alexander, R. W., Beattie, E. J., Economou, S. G.

Arch. Surg. 1960, 82, 826.

THE DISAPPEARING TUBE

THROUGH inadvertence or complacency, simple even-day procedures can suddenly become fraught with

tragedy. The story of a bizarre transformation of themundane into the extraordinary is related by Taylor andRutherford. I A patient with delirium tremens was

admitted to their hospital. As part of the treatment, hewas given glucose solution for some days through anindwelling intravenous tube. When the tube was beingremoved it was cut an inch or so from its point of entry;whereupon it promptly disappeared into the arm vein.A tourniquet was hastily applied to the upper arm, andthe brachial vein was exposed under local anxsthesia, butthe tube was not found; and injection of intravenous dyefailed to show where it had lodged. The patient wasdischarged, and had remained well up to the time of thereport a month later.Looking around for other accounts of this mishap,

Taylor and Rutherford found that it had happened oncebefore in their own hospital, and twice in neighbouringhospitals. In all three patients, quick action by nursesand residents had resulted in the recovery of the tubefrom the brachial vein.The plastic tubes that were used in these hospitals

are deservedly popular. They are threaded through asharp needle which is withdrawn after introductionleaving the tube in the vein. If the tube becomes kinkedor the patient moves his arm, the needle can cut throughthe tube, which can then easily find its way, eel-like, tothe Sargasso Sea of the right auricle. Besides the fourcases in their immediate neighbourhood, the Americanworkers were able to trace records of eight accidentselsewhere in which tubes were lost in the venous systemby the same mechanism, or by fracture of an indwellingcatheter in the vein. In two of these, the tube wasremoved from the right auricle; in one it was left, and thepatient was well two years later; but five patients died frominfection directly attributable to the retained tubes. Inalmost all the patients, the tubes had lodged against theannulus of the tricuspid ring and were trailing back intothe inferior vena cava, but in one patient the tube hadpassed into the pulmonary artery through the right heart.There are two conclusions to be drawn. Eternal

vigilance is the price not only of liberty but also of safety.With knowledge that this misadventure, can happen andhow it happens it should be prevented from happening.If it does happen and the tube is not found in the brachialvein, the right auricle must be explored: leaving the tubeand trusting to luck is dangerous.

ROYAL MEDICAL BENEVOLENT FUND

THE important work of this Fund, in helping doctorsand their families in time of misfortune, depends entirelyon the financial support of the profession. In 1962 a sumof E59,281 was disbursed in grants and annuities, and thisleft a revenue deficit of E9626. More money is badlyneeded; and many doctors in this country will be receivinga letter, signed by Sir Zachary Cope, president of theFund, and by the presidents of the Royal Colleges inLondon and the College of General Practitioners, appeal-ing for support by personal contribution and by persuad-ing colleagues to give generously. We hope the responsewill be immediate and ample.The Fund’s office is at 37, St. George’s Road, Wimbledon.

London,S.W.19.1. Taylor, F. W., Rutherford, C. E. Arch. Surg. 1963, 86, 177.