Nathan P. Couch

Retrospective analysis of the authors' experience with 109 primary femoropopliteal bypass vein grafts that failed allows description of three distinct modes of failure. Within 30 days of surgery, failure resulted primarily from technical or judgmental errors. The development of stenotic lesions within the vein graft caused a second group of failures during the first year after bypass. The third group most commonly failed due to progression of peripheral atherosclerosis a year or more following original bypass. No correlation was found, however, between the mode of failure and results of secondary femoropopliteal-tibial reconstruction, which yielded an overall 50% five-year cumulative limb salvage rate. The results indicate that this salvage rate can be anticipated regardless of the number of secondary operations required. The highest long-term patency rate was achieved when frequent postoperative follow-up examinations allowed recognition of graft failure prior to total occlusion. Under such circumstances a simple vein patch of stenotic lesions yielded an 85% five-year graft patency. Following actual thrombosis, however, the highest five-year patency rate was achieved when reconstruction was performed using a new vein graft; saphenous vein and arm vein were equally effective. When prosthetic material was used, no secondary graft remained patent beyond three years. Finally, when a proximal or distal portion of the original vein graft proved adequate in caliber following thrombectomy, it could be successfully incorporated in a secondary reconstruction with the expectation of a 50% five-year limb salvage rate. No statistically significant difference was found in salvage rates among each of the patient groups representing the three common modes of graft failure. This finding, coupled with an acceptable 2.5% operative mortality rate, provides justification for an aggressive approach toward secondary femoropopliteal reconstruction.

We conducted a one-year prospective survey to identify adverse outcomes due to error during care in the field of general surgery. We identified 36 such cases among 5612 surgical admissions to the Peter Bent Brigham Hospital, but in 23 cases the initiating mishap had occurred in another hospital before transfer. In two thirds of the cases the mishap was due to an error of commission: an unnecessary, defective or inappropriate operative procedure. Twenty of these patients died in the hospital, and in 11 death was directly attributable to the error. Five of the 16 survivors left the hospital with serious physical impairment. A satisfactory outcome was achieved in only 11 cases (31%). The average hospital stay was 42 days, with the duration ranging from one to 325 days; the total cost for the 36 patients was $1,732,432. We suggest that all hospitals develop comprehensive methods to identify and prevent these costly and unnecessary events.

This book covers every facet of hemodynamics, ranging from basic principles through physical and mechanical properties of blood vessels to practical matters such as objective assessment of arterial and venous disease and vascular grafting. The final chapters cover certain special areas including extracranial arterial disease, portal hypertension, renovascular hypertension, Raynaud disease and phenomenon, and cold injury. It is a long, expensive, encyclopedic—and perhaps verbose—book, and an enormous amount of scholarship was poured into it. It is an invaluable reference volume for those interested in minute details of arterial and venous hemodynamics, but the average practitioner, whether vascular surgeon or otherwise, should inspect it carefully at the nearest medical library before buying it. He may find that large portions of the book (for example, the first 205 pages) contain far more theoretical material than he wants or needs, and he may be annoyed by the textual cluttering by parenthetical references. But