Chapter 63 - Autogenous grafts

Question 1

First use of autogenous vein for occlusive arterial disease

Answer 1

1944 Dos Santos

Question 2

Difference between vein and arterial wall

Answer 2

Endothelium - cuboidal with poor interendothelial tight junctions Internal elastic lamina - not well developed, large fenestrations Medial - type I collagen dominate; sparse elastin fragments only External elastic lamina - not well developped Adventitia - loose connection matrix with sparse vasa vasorum

Question 3

New name for the saphenofemoral junction

Answer 3

Confluence of superficial inguinal veins

Question 4

Proper names for the saphenous veins

Answer 4

Great saphenous Small saphenous

Question 5

Where does the small saphenous join popliteal in relation to knee crease

Answer 5

5 cm proximal

Question 6

Where does the femoral vein join the deep femoral in relation to inguinal ligament

Answer 6

9 cm below

Question 7

Median cubital vein course

Answer 7

start at apex of antecubital fossa branch of cephalic ascends medially to join basilic vein

Question 8

Origin of the axillary vein

Answer 8

brachial vein + basilic vein

Question 9

Which never runs with basilic vein

Answer 9

Medial cutaneous nerve of the forearm paresthesia along medial portion of forearm

Question 10

Probe frequency to use for vein mapping

Answer 10

> 8 MHz

Question 11

Reference zones of the lower extremity

Answer 11

Zone 2-4 = proximal, middle distal thigh Zone 5-7 = proximal middle distal calf same with upper extremity

Question 12

Minimal usable vein diameter

Answer 12

2-3 mm

Question 13

Improved patency of the pedicle harvest technique

Answer 13

90% vs 76% after 8.5 years due to less touch or actually due to more NO from the surrounding adipose tissue

Question 14

Irrigation for the harvested vein solution type

Answer 14

crystalloid. buffered chrystalloid or blood no clear difference but buffered solution suggested

Question 15

Concentration of papaverine to be used

Answer 15

120 mg/L

Question 16

Other vasodilators to use intraop for vein dilatation

Answer 16

Trinitrate 8.3 mg/L Verapamil 16.7 mg/L

Question 17

Vein dilation maximum pressure

Answer 17

100-150 mmHg

Question 18

Wound complication with skip incisions vs open filet

Answer 18

9.6 vs 28%

Question 19

Factors that dictate saving the contralateral GSV for future revasc

Answer 19

1) Age < 70 2) DM 3) CAD 4) ABI < 0.7 if 3/4 then risk of needing it is 25-43% in 5 years

Question 20

Project of ex-vivo vein graft engineering via transfection PREVENT III database on vein type and size

Answer 20

>3.5 GSV as reference 3.0-3.5 = 1.5x primary failure < 3.0 mm = 2.4x primary failure (63% secondary patency 1 year) composite vein = 1.5x failure arm vein = 1.6x failure

Question 21

Valves in the reversed vein graft

Answer 21

1) lysis decreases 15% hydrodynamic resistance 2) lysis increases flow rate 15-30%

Question 22

Reversed vein valves in long term how often stenosis and critical stenosis

Answer 22

10% > 50% stenosis 2.5% critical stenosis some demodynamic significant valves also regress with time

Question 23

Nonreversed graft after lysis vs reversed grafts in flow rate

Answer 23

nonreversed with lysis 20% better flow rate more pronounced in smaller veins 2-2.5mm where leaflets can take up 45% of lumen

Question 24

Valvulotome types

Answer 24

1) Mills 2) Lemaitre expandable 3) fixed uresil

Question 25

Mills valvulotome steps

Answer 25

1) introduce via side branch or distal end 2) advance through valve leaflet 3) distend graft 4) slowly withdraw

Question 26

Lemaitre valvulotome vein diameteres

Answer 26

1.8 - 6 mm

Question 27

Fixed valvulotome head sizes

Answer 27

2, 3, 4 mm

Question 28

Ability of angiography or duplex to detect retaining valves

Answer 28

20% only

Question 29

Intraoperative venography or duplex on identifying side branches of GSV angioscope

Answer 29

50% only Angioscope 67%

Question 30

GSV fistula natural course

Answer 30

1/3 close spontaneously 1/3 decrease graft velocity 1/3 stable persistent no need to intervene

Question 31

Cephalic vein conduit key points

Answer 31

Upper arm cephalic 4-6 mm reverse implant, too thin to lyse Forearm cephalic has webs and phlebitis due to previous access thick enough for lysis

Question 32

Basilic vein conduit key points

Answer 32

upper arm large diameter hard for valve lysis forearm - too small, posterior position; rarely used

Question 33

Patency of SSV in composite graft 1 and 3 year primary

Answer 33

50% and 35%

Question 34

Patency of SSV primary 1 and 3 year

Answer 34

75% and 60%

Question 35

Patency of FV for conduit

Answer 35

same as GSV

Question 36

Patency of SFA as conduit

Answer 36

75% blow out in infection 1 year patency 60% primary Acute thrombosis in the absent of stenotic lesion

Question 37

Causes of graft failure within 30 days

Answer 37

1) inadequate inflow 2) inadequate outflow 3) extrinsic lesions 4) intrinsic lesions

Question 38

Pathogenesis of intimal hyperplasia

Answer 38

1) injury 2) chemokine and GF release 3) neutrophil and mononuclear cells recruited 4) amplified inflammation 5) SMC differentiate from contractile to synthetic phenotype 6) SMC migrate into intima 7) thickening of intima

Question 39

Rate of restenosis at prox + dis anastomosis

Answer 39

53%

Question 40

Rate that restenosis at retained valves

Answer 40

20%

Question 41

Rate of annual graft patency loss due to atherosclerosis

Answer 41

4%/year during the 2-10 year mark

Question 42

Edifoligide what is it

Answer 42

Double stranded oligodeoxynucleotide Inactivation of E2F transcription factor pathway inhibit bursts of SMC proliferation no difference

Question 43

Papaverine concentration to treat vein graft spasm

Answer 43

30-60 mg in 1-2ml saline

Question 44

Intraoperative duplex monitoring criteria and management

Answer 44

TABLE 63.2

Question 45

Surveillance duplex diagnostic criteria and management

Answer 45

TABLE 63.3

Question 46

Duplex scanning for follow up surveillance evidence

Answer 46

Cohort study suggest cost effective RCT disagree Recommendation for now is clinical follow-up +/- duplex but not strong recommendation