Paty P S, Shah D M, Saifi J, Chang B B, Feustel P J, Kaufman J L, Leather R P, Wengerter K R, Ascer E, Gupta S K
Department of Surgery, Albany Medical College, NY 12208.
J Vasc Surg. 1990 Jan;11(1):171-7; discussion 177-8.
The results of the use of prosthetic materials for femorocrural bypass surgery have been less than optimal. The creation of a distal anastomotic arteriovenous fistula to augment blood flow and velocity through the graft is well known. However, it may create turbulence at the anastomosis and steal blood flow away from the distal artery. A canine model was developed to evaluate the effect of fistula size on graft/arterial hemodynamics. In 16 patients we have constructed a distal arteriovenous fistula, which is remote from the distal anastomosis, and we studied the effect of such fistulas on bypass patency and distal arterial hemodynamics. Patients selected for this procedure had multiple previously failed reconstructions and limb-threatening ischemia and did not have usable autogenous vein. Femorotibial bypass graft reconstructions were performed with polytetrafluoroethylene followed by the creation of a side-to-side arteriovenous fistula 5 to 15 cm below the distal anastomosis in the same artery and accompanying veins. We have achieved a 1-year patency of 67% with a 75% limb salvage rate. We also serially measured blood flow and velocity within the bypass, the arteriovenous fistula, and the distal outflow vessel using duplex scanning after surgery. Mean estimated blood flow through the bypass during the immediate postoperative period was 264 ml/min, the arteriovenous fistula was 157 ml/min, and the distal artery was 19 ml/min. Unlike an arteriovenous fistula created at the distal anastomosis, a remote distal arteriovenous fistula not only increases graft blood flow but also augments native arterial blood flow between the distal anastomosis and fistula and thus may improve distal limb perfusion.
用于股腘动脉搭桥手术的人工血管材料的使用效果并不理想。通过建立远端吻合口动静脉瘘来增加通过移植物的血流和流速是众所周知的。然而，这可能会在吻合口处产生湍流，并从远端动脉分流血液。我们建立了一个犬类模型来评估瘘口大小对移植物/动脉血流动力学的影响。在16例患者中，我们构建了一个远离远端吻合口的远端动静脉瘘，并研究了这种瘘对搭桥通畅率和远端动脉血流动力学的影响。选择进行该手术的患者之前多次重建失败且有肢体威胁性缺血，并且没有可用的自体静脉。采用聚四氟乙烯进行股胫动脉搭桥移植物重建，然后在同一动脉和伴行静脉的远端吻合口下方5至15厘米处建立侧侧动静脉瘘。我们实现了1年通畅率为67%，肢体挽救率为75%。术后我们还使用双功扫描连续测量了搭桥、动静脉瘘和远端流出血管内的血流和流速。术后即刻通过搭桥的平均估计血流量为264毫升/分钟，动静脉瘘为157毫升/分钟，远端动脉为19毫升/分钟。与在远端吻合口处建立的动静脉瘘不同，远端远处动静脉瘘不仅增加了移植物血流量，还增加了远端吻合口和瘘之间的自身动脉血流量，因此可能改善远端肢体灌注。
