Preferred strategies for secondary infrainguinal bypass: lessons learned from 300 consecutive reoperations

PURPOSE: To determine the optimal surgical strategies in reoperative infrainguinal bypass, we reviewed our results in 300 consecutive secondary bypasses in 251 patients operated on between Jan. 1, 1975, and Nov. 1, 1993. METHODS: There were 168 men (67%) and 83 women (33%), with a mean age of 64.8 years and a typical distribution of risk factors including smoking (76.4%), diabetes (33.7%), and coronary artery disease (47.1%). The indications for surgery were limb-threatening ischemia in 83.5% and severe claudication in 16.5% of patients. The majority of conduits (n = 213) were autogenous vein and were composed of a single segment of greater saphenous vein in 121 bypasses (57%) and various alternative veins including composite, arm, and lesser saphenous vein in 92 bypasses (43%). Prosthetic conduits included 69 polytetrafluoroethylene, 16 umbilical vein, and two Dacron grafts. RESULTS: There was one perioperative death (0.3%) and a 25% total morbidity rate including a 1.7% myocardial infarction rate. There was a 28.6% early (< 30 days) graft failure and 10.7% early amputation rate for prosthetic bypass grafts compared with 13.6% early graft failure and 5.6% early amputation rates for vein grafts. Autogenous vein bypasses had higher 5-year secondary patency rates than had prosthetic grafts (51.5% +/- 4.6% vs 27.4% +/- 6.1%, p < 0.001). Results with autogenous vein bypass improved significantly from the 1975 to 1984 to the 1985 to 1993 interval with 5-year secondary patency rates increasing from 38.3% +/- 6.9% to 59.1% +/- 5.8% (p = 0.017) and 5-year limb-salvage rates increasing from 40.4% +/- 7.6% to 72.4% +/- 6.6% (p < 0.001). Vein grafts to the popliteal and tibial outflow levels had equivalent long-term results. Vein grafts completed for claudication demonstrated results superior to those for limb salvage, with a 5-year secondary patency rate of 75.8% +/- 8.1% versus 52.3% +/- 7.9% (p = 0.048). Secondary autogenous vein bypass grafting performed after early primary graft failure (< 3 months) did particularly poorly, with only a 27.2% +/- 7.7% 4-year secondary patency rate. Greater saphenous veins tended to perform better than alternative vein bypasses, with a 5-year secondary patency rate of 68.5% +/- 6.0% compared with 48.3% +/- 10.5% (p = 0.09) and a 5-year limb-salvage rate of 77.8% +/- 7.4% versus 54.2% +/- 11.8% (p = 0.046). CONCLUSIONS: When patients suffer a recurrence of limb-threatening ischemia at the time of infrainguinal graft failure, aggressive attempts at secondary revascularization with autogenous vein are warranted based on the low surgical morbidity and mortality rates and the improved patency and limb salvage rates that are currently attainable.     

Low-temperature interface reaction in aluminium-silicon carbide particulate composites produced by mechanical alloying

An experimental investigation has been carried out on the reaction that takes place between 3 and 20 μm SiC particles and the aluminium alloy 1050 matrix of composite materials prepared by a mechanical alloying process. The work is different from that undertaken by other researchers in that the SiC-Al interface reaction has been studied in the temperature range 853–933 K, i.e., with the matrix initially in the solid state. Differential thermal analysis, X-ray diffraction and scanning electron microscopy all show that the SiC-Al reaction initiates in the solid state at temperatures as low as 883 K. The reaction produces Al4C3 and Si, the latter entering into solid solution in the aluminium matrix. At temperatures exceeding 903 K, the reaction produces a liquid phase and at this stage the speed of the interface reaction increases significantly. The results are discussed in terms of Al-Si-C metastable equilibrium and the kinetics of the reaction. This revised version was published online in November 2006 with corrections to the Cover Date.     

Young children''s understanding of pretense expressions of independent agency

Data from the Cancer Registry of Slovenia were used in a cohort study to determine whether the incidence of second primary cancers in patients with first primary breast cancer differs from the incidence expected in the general population. Special interest was given to long-term survivors. The expected numbers of second primary cancers were calculated by multiplying the number of appropriate person-years at risk by the corresponding age- and calendar-period-specific cancer incidence rates for women in Slovenia. The risk of a second primary cancer was expressed as the standardized incidence ratio (SIR). Of the 8,917 patients newly diagnosed in the period 1961-85 and followed-up to the end of 1994, 547 (6.2 percent) developed second primary cancers, whereas 410 (4.7 percent) were expected (SIR = 1.3, 95 percent confidence interval [CI] = 1.2-1.4). The risk was higher among younger patients. In long-term survivors, the risk was increased significantly for second primary cancer of the breast (SIR = 1.4, CI = 1.1-1.7), lung cancer (SIR = 1.6, CI = 1.1-2.3), melanoma (SIR = 2.7, CI = 1.5-4.4) and non-melanoma skin cancers(SIR = 2.0, CI = 1.6-2.4), corpus uteri cancer(SIR = 1.6, CI = 1.2-2.1), ovarian cancer(SIR = 2.3, CI = 1.7-3.0), and thyroid cancer (SIR = 2.5, CI = 1.2-4.6). Our results confirm the findings of several cohort studies carried out in Europe, the United States, and Japan, indicating that breast cancer patients should be monitored carefully for the occurrence of second primary cancers.     

Interaction of protein percent with caloric density and protein source for lactating cows

Experiment 1 was to test effect of three ratios of energy to protein in complete mixed diets for 36 lactating cows in three, 28-d periods. Energy was varied with cottonseed hulls, pelleted ground corrugated boxes, and a mixture of the two. Crude protein was varied with soybean meal to give energy:crude protein of 5.7, 5.0, and 4.6 for each energy amount. Cottonseed meal was compared with soybean meal in corrugated box diets. Feed intake was much higher with cottonseed hulls, and appreciable feedlot bloat resulted from pelleted ground corrugated box diets. Data adjusted to equal feed intake showed significant effect of energy to crude protein ratio on milk yield and improved digestion of organic matter with soybean meal vs. cottonseed meal. Experiment 2 tested the hypothesis that lactating cows consuming high-protein alfalfa may benefit from supplemental protein. Diets were 50% forage. Six diets were 14 or 18% crude protein in three ratios of alfalfa hay to corn silage (0:100, 50:50, 100:0). Additional corn silage diets were to compare: 14 versus 18% protein from distiller's dried grains with solubles only and with .5 or .9% urea (four diets); two 14% protein diets compared .6% added potassium chloride with or without .5% urea. Thirty-six Holstein cows in early lactation received one of the 12 diets in each of three 28-d periods. Distiller's grains with solubles markedly depressed milk yield (2.2 kg/d) and milk protein (.22%); heat damage of distiller's grains was evident. Protein interacted with alfalfa so gain in milk from 18 versus 14% increased from .55 to 1.36 to 2.66 kg/d as alfalfa changed from 0 to 50 to 100%. Thus, crude protein of alfalfa was not as effective as that from soybean meal in supporting milk yield.