Journal of Vascular Surgery
Volume 24, Issue 1 , Pages 1-5, July 1996

Presidential address: Remembrance of things past — New England surgeons and infrainguinal reconstruction☆☆☆★★★♢

Presented at the Twenty-second Annual Meeting of the New England Society for Vascular Surgery, Montreal, Quebec, Canada, Sept. 28-29, 1995.

Boston, Mass.

Received 5 October 1995; accepted 16 October 1995.

Article Outline

 

As I look back on a surgical career spent largely in New England, I am struck by the contributions that have been made by New England surgeons to the development of many aspects of our specialty of vascular surgery. I have chosen to talk about only one of these aspects today—infrainguinal arterial reconstruction—because I believe more New England surgeons have been responsible for substantial advances in this area of vascular surgery than any other. These remarks will reflect a personal perspective only, and I have not attempted to do an exhaustive literature search on this subject. You will undoubtedly find that I have missed important contributors. For the purpose of this discussion and without asking anyone's permission, however, I have claimed as New England surgeons those who received their surgical training in this region as well as those who practice or practiced surgery here.

Although autogenous saphenous vein grafts had been used in a few instances to replace popliteal aneurysms in the early part of the 20th century, it was not until the 1940s, when both angiography and heparin were available, that treatment of occlusive disease in the arteries of the leg was begun, first by Dos Santos with endarterectomy1 and shortly thereafter by Kunlin with reversed saphenous vein grafts.2 Both of these techniques were applied to occlusive lesions of the superficial femoral artery only.

After these initial reports from Europe, both endarterectomy and reversed saphenous vein grafting were attempted by surgeons in the United States. Among those who attempted it were a number of surgeons from New England. For example, endarterectomy of the superficial femoral artery using loop strippers was performed on the West Coast of the United States in the 1950s by Dr. Jack Cannon, who had had his surgical residency at Massachusetts General Hospital, and by Dr. Wiley Barker, who had received some of his surgical training at Peter Bent Brigham Hospital.3 The collaboration of these two transplanted New England surgeons antedated by 40 years the merger of the two Boston hospitals that helped train them.

Because of its apparent simplicity, saphenous vein grafting was greeted with enthusiasm by a number of surgeons in New England as well as in the rest of the country, but the saphenous vein proved difficult to work with in the hands of surgeons who were used to bowel anastomoses, and vein grafting attempts often led to strictures at the proximal and distal anastomoses. The good results reported by Kunlin were not easily duplicated, and many surgeons abandoned vein grafting in favor of arterial homografts taken from cadavers, which were much easier to suture. A technique for the sterilization of frozen arterial homografts by high-voltage cathode ray irradiation had been reported at the beginning of the 1950s by Robert Gross and his associates working at the Children's Hospital in Boston.4 This technique was quickly applied to the storage of homografts of superficial femoral artery by many surgeons, including Dr. Robert Shaw and Dr. Frank Wheelock,5 a past President of this Society, who set up a homograft artery bank at Massachusetts General. Unfortunately, arterial homografts frequently deteriorated after a few years, with aneurysm formation that sometimes led to graft rupture, thrombosis, and distal embolization. This technique for infrainguinal reconstruction was quickly discarded, and synthetic vascular prostheses began to be used in the femoropopliteal position instead.

These grafts became available in the 1950s after the initial discovery by Voorhees, Jaretzski, and Blakemore6 that Vinyon-N tubes would remain patent in the arterial system in dogs. The crimping of these grafts to avoid kinking was the contribution of Sterling Edwards,7 who had his surgical training at Massachusetts General. Dr. Ralph Deterling, a past president of this Society, was on the staff of Columbia Presbyterian Medical Center when Vinyon-N grafts were first implanted and quickly saw the usefulness of fabric arterial prostheses. He did a great deal of pioneering experimental work that led to appropriate selection of fabric porosity to maximize healing and minimize leakage.8 Deterling moved to Boston in the early 1960s to assume the position of Chief of Surgery at the Tufts New England Medical Center, where he continued his laboratory and clinical research. By the late 1950s bypass grafts of knitted or woven Dacron, or in some instances Teflon, were the choice of most surgeons for femoropopliteal reconstruction because they were relatively easy to handle, had proved to be stable, and did not deteriorate in the body.

Autogenous vein grafting, however, was kept alive by some surgeons, both in the United States and abroad. Prominent among these was Dr. Robert Linton, first President and founding member of this Society, for whom I had the pleasure of working as a surgical resident in the late 1950s. Linton had traveled to Europe after Kunlin's initial reports in the 1940s and had watched carefully how Kunlin performed his vein grafting operations. Linton brought back to the United States the Kunlin technique of vein graft anastomosis, which consisted of spatulating the end of the vein graft and carefully suturing it end-to-side to the host artery with small-caliber, running silk sutures started at each corner and proceeding toward the middle of the anastomosis to ensure that the anastomosis was widely patent and free of kinks. This meticulous anastomotic technique allowed Linton and a few other surgeons to achieve success with autogenous vein grafting while others were reporting poor results.9

By the early 1960s it was apparent to most surgeons that femoropopliteal bypasses with fabric grafts were yielding poor long-term results, with patency rates at the 5-year interval of considerably less than 50% in most instances. Among those with vast experience with this operation was Dr. E. Stanley Crawford, who had been my first chief resident at Massachusetts General. As Dr. Crawford pointed out to me in 1962, Dacron femoropopliteal grafts would remain patent long-term only if (1) the distal anastomosis was placed above the knee joint, (2) the popliteal artery was widely patent distally from that point, and (3) excellent runoff was present all the way to the foot. Among those physicians who made a critical assessment of the effectiveness of femoropopliteal reconstruction in these early days were Drs. Nathan Couch, Brownell Wheeler, Edward Edwards, and Richard Warren,10 all past Presidents of this Society, who pointed out that if salvage of the extremity was the surgeon's goal, femoropopliteal reconstruction with prosthetic grafts often left much to be desired.

In 1962 the report of Linton and Dr. R. Clement Darling, another past President of this Society, on a large series of autogenous saphenous veins from the femoropopliteal position with a cumulative 5-year patency rate of greater than 70% caused a marked renewal of interest in the vein graft as a conduit for infrainguinal reconstruction.9 By this time, many surgeons with experience in treating vascular disease had become sufficiently practiced in the suturing of blood vessels that adaptation of the Kunlin technique for vein graft anastomosis, or a variant thereof, was no longer daunting.

At about this time, bypass grafting to the infrapop-liteal vessels was attempted. In 1960, I had brought Linton's technique of reversed saphenous vein grafting to the department of Dr. David Hume at the Medical College of Virginia. David Hume, of course, had his surgical training at the Peter Bent Brigham Hospital and had been a prominent member of the staff at that institution. At the time I arrived in Richmond, Hume had become disappointed with the results of endarterectomy of the superficial femoral artery and was delighted to abandon that technique for autogenous vein grafting. Beginning in 1960t he and I embarked on a series of vein grafts for limb salvage in patients with poor runoff. In 1961, we began to use femorotibial reversed saphenous vein grafts to treat some of these patients, and we thought that we were the first to perform this operation. We were therefore surprised at Dr. Andrew Dale's report at the North American Chapter of the International Cardiovascular Society in 1962.11 Included in this paper was a description of several femoral to posterior tibial reversed saphenous vein graft procedures. Other investigators had previously reported homograft and prosthetic bypasses to the tibial arteries with little or no success,12 and I believe Dale deserves credit for the first tibial vein grafts. It does seem likely, however, that Hume and I performed the first anterior tibial vein graft, which we described in a paper read before the Society for Vascular Surgery in 1963.13

Unfortunately, it soon became apparent that tibial vein grafts did not succeed as often as femoropopliteal vein grafts. The 5-year cumulative patency rate of reconstructions to the tibial arteries was 50% or less as compared with cumulative patency rate of 70% or so when autogenous vein grafts were placed into the popliteal artery. This led me, Hume, and our asso-ciates to suggest in 196714 and again in 197515 that bypass grafts to an isolated popliteal artery segment with distal outflow only through collateral vessels might be preferable to tibial artery vein grafting in patients with this anatomic option. Papers are still published proposing this idea,16 though with the improved results with tibial vessel vein grafting seen since the 1980s, most surgeons probably no longer would perform an isolated-segment popliteal bypass in preference to a direct tibial artery vein graft. Drs. Dominic DeLaurentis and Paul Friedmann,17 a past President of this Society, described in 1972 another use for an isolated, above-knee popliteal segment as the site of the distal anastomosis of a femoral popliteal prosthesis and as the site of the proximal anastomosis of a popliteal distal vein graft, a type of reconstruction they called a “sequential” bypass, and which they have shown to function better than most composite prosthetic and vein grafts. Dr. Michael Belkin and his associates at Tufts New England Medical Center18 carried the isolated popliteal segment idea one step further and have reported success with vein grafts to isolated tibial artery segments.

The 1960s and early 1970s also saw fading of interest in femoropopliteal endarterectomy as a treatment of infrainguinal occlusive disease. The inferior performance of endarterectomy as compared with reversed saphenous vein grafting was clearly demonstrated in the report of Darling and Linton19 in 1972. However, proponents of short segmental endarterectomy of the superficial femoral artery, which is usually performed under direct vision and with the use of patch-graft angioplasty, have continued to get good results with this technique up to the present.20

Because of widespread disillusionment with Dacron prostheses in the infrainguinal position and because of a lack of suitable autogenous saphenous vein in a substantial minority of individuals who require infrainguinal reconstruction, surgeons began searching for better artificial conduits for use in bypass grafting. As we all know, the prostheses most commonly used for infrainguinal bypass at this time are made from expanded polytetrafluoroethylene (PTFE). Most reports, however, suggest that the patency rate of PTFE grafts, with the distal anastomosis in the infrageniculate popliteal artery or in the tibial vessels, is discouragingly low at the 5-year interval. Whether the addition of autogenous vein cuffs or patches at the distal anastomosis will yield improved long-term patency rates remains to be determined.21, 22 However, PTFE currently has its champions in New England. Dr. Tom O'Donnell,23 immediate past President of this Society, has recommended the preferential use of PTFE grafts in femoropopliteal reconstruction above the knee to preserve the greater saphenous vein for later use as occlusive disease progresses more distally and the PTFE graft fails. This position, although debatable, is clearly defensible. Other New England surgeons have pointed out that at the present time there is no adequate demonstration that PTFE prostheses perform better than Dacron prostheses in the femoral popliteal position. In fact, a recent retrospective study that was published by Dr. William Pevec and his associates from Massachusetts General24 suggests that Dacron bypasses may, in fact, perform somewhat better than PTFE.

Probably the outstanding development in infrainguinal reconstruction in the 1980s was improvement in the long-term success of autogenous venous bypass grafts, particularly those to the tibial vessels. Dr. Andy Whittemore, Recorder of this Society, and his asso-ciates at the Brigham hospital noted in 198125 that the chief cause of autogenous vein graft failure was myointimal hyperplasia of the conduit itself, which was a process limited in time to the first 18 months after surgery. These workers also pointed out that repair of a vein graft stenosis before thrombosis of the graft often resulted in excellent long-term graft patency rates, whereas thrombectomy and repair of a similar lesion in a graft that had already clotted usually led to a poor outcome. These observations obviously mandated careful surveillance of vein grafts in the first 18 months after surgery so that stenotic lesions could be repaired before graft thrombosis.

Because myointimal hyperplasia is very likely related to damage to the intima of the vein graft, a number of surgeons also began to experiment with methods of harvesting autogenous vein without producing intimal damage. Prominent among these surgeons was Dr. Frank LoGerfo, who has headed the Vascular Surgical Services at both the University Hospital and the New England Deaconess Hospital in Boston. LoGerfo,26 in a series of carefully documented studies, showed that with the use of papaverine and physiologic electrolyte solution, vein grafts could be removed and reimplanted without intimal disruption. Another method of attempting to preserve the vein graft intima was the use of the in-situ technique whose revival cannot be credited to a New England surgeon.27 A number of New England vascular services, however, have adopted this technique with considerable success. Notable among them is the group at the New England Deaconess Hospital, whose large series of in-situ and nonreversed vein grafts to the pedal vessels in patients with diabetes is the largest and most successful reported thus far.28 The Deaconess group,29 along with Dr. Jack Cronenwett,30 Secretary of this Society, and his associates at Dartmouth, have also been prominent in pioneering the use of the angioscope in the preparation of vein grafts, both in situ and reversed.

Along with these technical improvements in sa-phenous vein grafting has come the realization that the lesser saphenous vein and arm veins are appropriate conduits when the greater saphenous veins are diseased or absent from previous use. One of the first series to affirm the success of arm vein bypasses was reported by Dr. David Campbell and his colleagues from the Deaconess Hospital in the late 1970.31 With the use of a duplex scanner to search before surgery for adequate venous conduits, it is now possible to offer autogenous tissue reconstruction with vein grafts, either in situ or reversed, coupled in some instances with short endarterectomies, in 95% of patients who require infrainguinal arterial reconstruction, as has been pointed out by Donaldson and his colleagues from the Brigham hospital.32

These modern improvements in infrainguinal vein grafting, to which New England surgeons have contributed substantially, appear to have had a dramatic impact on limb salvage. For patients who undergo surgery for critical ischemia, the 5-year limb salvage rate is now at least 85% in the hands of a number of surgical groups in our area, whereas 10 to 15 years ago it was probably no greater than 60% on average. Whether new prostheses or endothelial lining of currently available prosthetic grafts will yield results in infrapopliteal reconstruction that are equal to those of vein grafts remains a hope for the future. At present, however, the vast majority of patients in New England can undergo durable autogenous arterial reconstruction in the infrainguinal area with the expectation of long-term limb viability. This is truly a regional as well as national success story.

Back to Article Outline

References 

  1. Dos Santos JC. Sur la desobstruction des thromboses arterielle anciennes. Memorandes Acadamie Chirurgie. 1944;73:409–411
  2. Kunlin JL. Le traitement de l'arterite obliterante par le greffe veineuse. Arch Mal Coeur Vaiss. 1949;42:371–374
  3. Cannon JA, Barker WF, Kawakami IG. Femoral popliteal endarterectomy in the treatment of obliterative atherosclerotic disease. Surgery. 1958;43:76–93
  4. Meeker IA, Gross RE. Sterilization of frozen arterial grafts by high voltage cathode-ray irradiation. Surgery. 1951;29:19–28
  5. Shaw RS, Wheelock F. Blood vessel grafts in the treatment of chronic occlusive disease in the femoral artery. Surgery. 1955;37:94–104
  6. Voorhees AB, Jaretzski A, Blakemore AH. The use of tubes constructed from vinyon “N” cloth in bridging arterial defects: a preliminary report. Am Surg. 1952;135:332–336
  7. Edwards WS, Tapp JS. Peripheral artery replacement with chemically treated nylon tubes. Surg Gynecol Obstet. 1956;102:443–447
  8. Deterling RA, Bhonslay S. An appraisal of woven synthetic prostheses in the vascular system. AMA Arch Surg. 1956;72:21–23
  9. Linton RR, Darling RC. Autogenous saphenous vein bypass grafts in femoropopliteal obliterative arterial disease. Surgery. 1962;51:62–65
  10. Couch NP, Wheeler HB, Hyatt DF, Crane C, Edwards EA, Warren R. Factors influencing limb survival after femoral popliteal reconstruction. Arch Surg. 1967;95:163–169
  11. Dale WA. Grafting small arteries. Arch Surg. 1963;86:36–40
  12. McCaughan JJ. Successful arterial grafts to the anterior tibial, posterior tibial (below the peroneal) and peroneal arteries. Angiology. 1961;12:91–94
  13. Mannick JA, Hume DM. Salvage of extremities by vein grafts in far-advanced peripheral vascular disease. Surgery. 1964;55:154–164
  14. Mannick JA, Jackson BT, Coffman JD, Hume DM. Success of bypass vein grafts in patients with isolated popliteal artery segments. Surgery. 1967;61:17–25
  15. Davis RC, Davies WT, Mannick JA. Bypass vein grafts in patients with distal popliteal artery occlusion. Am J Surg. 1975;129:421–425
  16. Drake S, Lamont P, Chant A, et al.  Femoropopliteal versus femorodistal bypass grafting for limb salvage in patients with an “isolated” popliteal segment. Eur J Vasc Surg. 1989;3:203–207
  17. DeLaurentis DA, Friedmann P. Sequential femoropopliteal bypasses: another approach to the inadequate saphenous vein problem. Surgery. 1972;71:400–404
  18. Belkin M, Welch HJ, Mackey W, O'Donnell TF. Clinicaland hemodynamic results of bypass to isolated tibial segments for ischemic ulceration of the foot. Am J Surg. 1992;164:281–286
  19. Darling RC, Linton RR. Durability of femoropopliteal reconstructions. Am J Surg. 1972;123:472–479
  20. Inahara R, Scott CM. Endarterectomy for segmental occlusive disease of the superficial femoral artery. Arch Surg. 1981;116:1547–1553
  21. Miller JH, Foreman RK, Ferguson L, Faris I. Interposition vein cuff for anastomosis of prosthesis to small artery. Aust N Z J Surg. 1984;54:283–285
  22. Tyrrell MR, Chester JF, Vipond MN, Clarke GH, Taylor RS, Wolfe JHN. Experimental evidence to support the use of interposition vein collars/patches in distal PTFE anastomoses. Eur J Vasc Surg. 1990;4:95–101
  23. O'Donnell TF, Farber SP, Richmand DM, Deterling RA, Callow AD. Above-knee polytetrafluoroethylene femoro-popliteal bypass graft: is it a reasonable alternative to the below-knee reversed autogenous vein graft?. Surgery. 1983;94:26–31
  24. Pevec WC, Darling RC, L'Italien GJ, Abbott WM. Femoropopliteal reconstruction with knitted, nonvelour Dacron versus expanded polytetrafluoroethylene. J VASC SURG. 1992;16:60–65
  25. Whittemore AD, Clowes AW, Couch NP, Mannick JA. Secondary femoropopliteal reconstruction. Ann Surg. 1981;193:35–42
  26. LoGerfo FW, Haudenschild CC, Quist WC. A clinical technique for prevention of spasm and preservation of endothelium in saphenous vein grafts. Arch Surg. 1984;119:1212–1214
  27. Leather RP, Powers SR, Karmody AM. A reappraisal of the in situ saphenous vein arterial bypass: its use in limb salvage. Surgery. 1979;86:453–460
  28. Pomposelli FB. Jepsen SJ, Gibbons GW, et al. Efficacy of the dorsal pedal bypass for limb salvage in diabetic patients: short-term observations. J VASC SURG. 1990;11:745–752
  29. Miller A, Marcaccio EJ, Tannenbaum GA, et al.  Comparison of angioscopy and angiography for monitoring infrainguinal bypass vein grafts: results of a prospective randomized trial. J VASC SURG. 1993;17:382–398
  30. Gilbertson JJ, Walsh DB, Zwolak RM, et al.  A blinded comparison of angiography, angioscopy, and duplex scanning in the intraoperative evaluation of in situ saphenous vein bypass grafts. J VASC SURG. 1992;15:121–129
  31. Campbell DR, Hoar CS, Gibbons GW. The use of arm veins in femoral-popliteal bypass grafts. Ann Surg. 1979;190:740–742
  32. Donaldson MC, Whittemore AD, Mannick JA. Further experience with an all-autogenous tissue policy for infrainguinal reconstruction. J VASC SURG. 1993;18:41–48

☆ From the Departments of Surgery, Harvard Medical School and Brigham and Women's Hospital, Boston.

☆☆ Reprint requests: John A. Mannick, MD, Department of Surgery, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115.

★ J Vasc Surg 1996;24:1-5.

★★ 0741-5214/96/$5.00 + 0

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Journal of Vascular Surgery
Volume 24, Issue 1 , Pages 1-5, July 1996

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