Original articles
`
`Transfemoral Intraluminal Graft
`Implantation for Abdominal Aortic
`Aneurysms
`
`J.C. Parodi, MD*, J.C. Palmaz, MD’, H.D. Barone, PhD, Buenos Aires,
`Argentina, and San Antonio, Texas
`
`andinitial clinical trials exploring the
`on animal experimentation
`This study reports
`feasibility of exclusion of an abdominal aortic aneurysm by placement of an
`intraluminal, stent-anchored, Dacron prosthetic graft using retrograde cannulation of
`the commonfemoral artery under local or
`regional anesthesia. Experiments showed
`that when a
`balloon-expandable stent was sutured to the partially overlapping ends
`of a tubular, knitted Dacrongraft, friction seals were created whichfixed the ends of
`the graft to the vessei wall. This excludes the aneurysm from circulation and allows
`normal flow through the graft lumen. Initial treatment in five patients with serious
`co-morbidities is described. Each patient had an
`individually tailored balloon diam-
`eter and diameter and length of their Dacron graft. Standard stents were used and the
`was determined by sonography, computed tomography,
`diameterof the stent-graft
`and arteriography.In three of them a
`cephalic stent was used without a distal stent.
`both ends of the Dacron tubular stent were attached to stents
`In two other patients
`a one-third stent overlap. in these latter two, once the proximal neck of the
`using
`aneurysm was reached, the sheath was withdrawn andthe cephalic ballooninflated
`with a saline/contrast solution. The catheter was
`gently removed caudally towards
`the arterial entry site in the groin to keep tension on the graft, and the second balloon
`inflated so as to deploy the second stent. Four of the five patients had heparin
`reversalat the end of the procedure. We are
`encouraged bythis early experience, but
`believe that further developments and moreclinical trials are needed before this
`technique becomes widely used. (Ann Vase Surg 1991;5:491-499).
`
`KEY WORDS: Graft-stent exclusions; grafts; abdominalaortic aneurysm; transfem-
`oral intraluminalgrafts.
`
`Abdominal aortic aneurysm (AAA) has been rec-
`as a lethal pathologic pro-
`ognized since antiquity
`cess. As a
`the last 50 years of vascular
`result,
`surgery have seen a
`variety of attempts at cure of
`Intraluminal wiring [I], external
`the condition.
`
`From the Department of Vascular Surgery, Instituto
`Cardiovascular de Buenos Aires*, Buenos Aires, Argen-
`tina, and the Department of Radiology, University of
`Texas’, San Antonio, Texas.
`Reprint requests: Dr. J.C. Parodi, Mercedes 4255, Cap.
`Fed. Buenos Aires, Argentina (1419).
`
`wrapping [2], and exclusion of the aneurysm by
`ligation have been tried and discarded in the past
`[3]. Experience with those showedthat they did not
`offer durable protection from aneurysm rupture [4].
`nor thrombosis of the aneurysm
`Neither wrapping
`protected the patient from fatal rupture [5—7].
`dealing with an
`Today, vascular surgeons are
`increasingly aged population. These are persons in
`whom abdominal aortic aneurysms occur.
`Autopsy
`studies have placed the overall incidence of AAA
`disease between 1.8 and 6.6% [8-10]. Actual inci-
`dence of AAAis increasing with the aging of the
`
`491
`
`MEDTRONIC 1018
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`MEDTRONIC 1018
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`

`492
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`TRANSPFEMORAL INTRALUMINAL GRAFT IMPLANTATION
`
`ANNALS OF
`VASCULAR SURGERY
`
`by fusiform-shaped Dacron conduit.
`
` Fig. 1. Artificial abdominal aortic aneurysm created
`
`population |11]. in the 30-year period of study, the
`incidence of AAA wasseen to rise threefold. Fur-
`thermore, aneurysm screening in select populations
`such asfirst-order relatives of patients with AAA or
`in cardiovascular clinics has shown that in
`patients
`select populations, the incidence of aneurysms may
`vary from 5% to 20% [12-14].
`Durable protection from aneurysm rupture began
`with DuBost
`[15] who demonstrated that aortic
`was an effective method of treatment.
`replacement
`is the treatment of
`Prosthetic graft replacement
`choice for aortic aneurysms today. Elective repair
`is regularly performed with an
`operative mortality
`of under 5% with the expectation that long-term
`survival is markedly extended [16,17].
`Increasingly, vascular surgeons are
`encountering
`older patients with severe co-morbid conditions. These
`can increase operative morbidity and may even elevate
`mortality of aortic surgery to a
`figure in excess of 60%
`[18]. With this in mind, new methods of aortic aneu-
`rysm exclusion deserve exploration. The following
`on animal experimentation and initial
`study reports
`clinical trials which exploredthe feasibility of exclusion
`of AAA by placement of an
`intraluminal, stent-an-
`can-
`chored, Dacron prosthetic graft using retrograde
`nulation of the common femoral artery under local or
`regional anesthesia.
`
`ANIMAL STUDIES
`Initial exploration of a solution to the problem
`was
`involved in intraluminal graft placement
`begun
`in 1976. Simultaneously, experiments progressed
`so thatit
`towards debulking the Dacron prosthesis
`a miniaturized sheath,
`could be implanted through
`and modification of stents so that they could anchor
`the Dacron prosthetic material to aortic wall. Fi-
`nally, artificial AAAs were created in experimental
`
` DA DE PEDeO
`3 Fig. 2. Intraluminal exclusion of artificial aneurysm by
`
`,
`
`implanting Dacron tubular grafts by transfemoralroute.
`Balloon expandable tents anchorgraft to aortic wall.
`
`a
`segment of the infrarenal
`animals by replacing
`aorta with a
`fusiform-shaped, Dacron conduit (Fig.
`1). After creation of the artificial AAA in the
`were
`experimental animal, experiments
`completed
`by successfully excluding the aneurysm by implant-
`ing Dacron tubular grafts through the transfemoral
`route (Fig. 2) [19-21].
`Experimental study had shown that stents could
`suture and could act as friction
`replace surgical
`to vessel wail. These
`seals to fix ends of the graft
`a trans-
`friction seals were
`developed by creating
`a Pal-
`luminal graft-stent combination by suturing
`
`

`

`VOLUME 5
`-
`No 6
`199]
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`TRANSFEMORAL INTRALUMINAL GRAFT IMPLANTATION
`
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`
`Distal Lumen
`
`a B
`
`alloon
`
`1—
`
`Introducer
`
`Ai a)
`
`Endoprosthesis Fig. 3. Graft-stent combination is mounted on
`
`valvuloplasty balloon and placed under fluoroscopy through
`sheath introduced through femoral arteriotomy.
`maz, balloon-expandable stent* to the partially
`overlapping ends of a tubular, knitted Dacron graft.
`This was done so that the stent
`expansion would
`a
`press the graft against the aortic wall, creating
`assem-
`watertight seal. Placement of the stent-graft
`was
`to be done by actually mounting
`bly
`planned
`on a balloon angioplasty catheter.
`the assembly
`This would then be placed under
`fluoroscopy
`a
`a #14 French sheath introduced through
`through
`femoral arteriotomy (Fig. 3).
`Figures 4 and 5 show that the conceptis correct.
`Thegraft-stent combination, when expanded bythe
`can exclude the aneurysm from the circu-
`balloon,
`flow through the graft
`lation and allow normal
`was proven that a Dacron
`lumen. Once the concept
`a catheter and be
`graft could be delivered through
`firmly fixed in place by balloon-expandablestents,
`attention turned to human studies.
`This report details the initial treatment in five
`A sixth patient treated by J.C. Palmaz is
`patients.
`not
`reported here.
`
`contains the balloon catheter consisting of a #9
`French, polyethylene (PE) shaft and one or two PE
`valvuloplasty balloons, 3.5 cm in length, and either
`23 or 25 mm in diameter’. The assembly contains
`either one or two aortic balloon-expandable stents,
`6 mm in diameter and 3.5 cm in length. These are
`stainless steel, modified Palmaz stents. A specially
`thin-walled, crimped, knitted, Dacron
`created,
`one-
`was sutured to the stents, overlapping
`graft’
`third of the length of the stent**.
`stent was used with-
`a
`In three patients,
`cephalic
`out a distal stent (Fig. 2). In the two otherpatients,
`both ends of the Dacron tubular stent were attached
`to stents using one-third stent overlap. In these two
`cases, once the proximal neck of the aneurysm was
`reached, the sheath was withdrawn and the cephalic
`balloon inflated with a solution containing 50%
`saline and 50% nonionic contrast material. The
`balloon was
`inflated under low pressure to
`kept
`expand the folded graft. Finally, in those two cases
`the catheter was
`with a double balloon,
`gently
`moved caudally toward the arterial entry site in the
`keep tension on the graft, and the second
`to
`groin
`balloon was inflated so as to
`deploy the second
`
`GRAFT-STENT COMBINATION
`A Teflon, #22 French sheath, 45 cm in length
`with a hemostatic valve closure in the operator end
`
`*Johnson & Johnson Interventional Systems, Warren,
`N. J.
`
`*Mansfield Corporation, Boston, Massachusetts.
`§Barone Manufacturers, Buenos Aires, Argentina.
`**Barone Manufacturers, Buenos Aires, Argentina.
`
`

`

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`ANNALS OF
`VASCULAR SURGERY
`
`of aorta four weeks after replac-
`Arteriogram
`ing segmentwith artificial aortic aneurysm in dogs.
`
` Fig. 4.
`
`an
`
`was anchored in
`stent. Thus,
`the prosthetic graft
`place both proximally and distally.
`was terminated by performing
`The procedure
`an
`arteriogram after
`introducing
`arteriographic
`catheter over the guidewire. After removal of the
`guidewire and overlying catheter, the arteriotomy
`in the femoral vessels was closed with 6-0 polypro-
`pylene suture. Because 10,000 units of heparin
`solution was
`given intravenously before graft place-
`was reversed with the appropri-
`ment, the heparin
`ate dose of Protamine sulfate at the conclusion of
`procedure. Patients were
`routinely monitored in
`the
`the coronary care unit, postoperatively.
`In the following cases, each patient had an indi-
`vidually tailored device. Both the diameter of the
`balloon and diameter and length of the Dacron graft
`were individualized. The stents themselves were
`standard and the diameter of the stent and graft
`combination was determined by data obtained from
`sonograms, computed tomographic (CT) scans, and
`arteriograms. Stent size determined diameterof the
`balloon used to
`deploy the stent. Cardiopulmonary
`was done under cover of an antibiotic
`monitoring
`umbrella (1 gm Keflin, given intravenously).
`
` Fig. 5. Arteriogram of same
`
`dog after implanting
`graft-stent combination through right femoral artery.
`
`CASE HISTORIES
`
`Patient No. 1
`
`man with severe chronic obstructive
`A 70-year-old
`pulmonary disease complained of severe back pain
`caused by a6cm AAA(Fig. 6). Incidental note was made
`of bilateral lower extremity intermittent claudication. The
`patient refused a
`surgical procedure but did agree to enter
`the clinical trial. After explanation of the alternatives and
`expected complications, informed consent for the exper-
`was obtained.
`imental procedure
`as if for standard surgical
`was
`The patient
`prepared
`AAAresection. Under epidural anesthesia, the common
`femoral artery was
`freely dissected and mobilized. Arte-
`was then performed under fluoroscopy (Fig.7)
`riography
`and an
`Amplatz wire was
`placed in the descending
`on
`was
`thoracic aorta. An intraluminal graft
`implanted
`
`

`

`VOLUME 5
`-
`No 6
`199]
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`TRANSFEMORAL INTRALUMINAL GRAFT IMPLANTATION
`
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`
`scan of Patient Number1.
`
` Fig. 6. Computed tomographic
`
`September 6, 1990. This patient had a hematoma in the
`right groin containing approximately 100 cc of blood. This
`was evacuated on the day of operation. In this instance,
`the initial heparin dose wasnot reversed following place-
`mentof the stent-graft combination.
`was reversed in the
`Note: Heparin anticoagulation
`following four cases and care was
`given not to admin-
`or Dextran to these patients.
`ister antiplatelet agents
`
`Patient No. 2
`man was admitted because of a 6 cm,
`A 68-year-old
`pulsatile abdominal mass, confirmed to be an AAA. He
`volunteered to enter the clinical trial, and after informa-
`tion was
`given regarding alternative treatments and de-
`scription of complications, he gave written consent for
`the procedure. A single stent-graft combination was im-
`on
`September 6, 1990. During the procedure,
`planted
`there was an accidental displacement of the marking
`therefore, failed to identify the
`ruler, This reference,
`exact target area in which the stent would be placed. As
`a consequence, the stent was
`deployed 3 cm distal to the
`was
`selected site. Therefore, the Dacron graft
`overly long
`and the caudal end of the prosthesis lay within the right
`common iliac artery. This effectively excluded the con-
`tralateral iliac artery from the circulation, This was a
`was
`patently unsatisfactory situation and the patient
`room where a standard AAA
`taken to the operating
`resection was
`performed. Fortunately, he recovered from
`this procedure uneventfully. In surgery, it was found that
`the stent was
`firmly attached to the wall of the aorta
`which required resection.
`
`Patient No. 3
`man wasreferred from the French Hos-
`A 63-year-old
`pital in Buenos Aires where he had been admitted be-
`
`scans
`cause of an acute stroke. Computed tomographic
`had shown a
`massive, right hemispheric, hemorrhagic
`infarction. Two weeks following admission for treatment
`was
`of this event while the patient
`recovering satisfacto-
`rily, he experienced acute abdominal discomfort and
`mass in his abdomen
`increasing pain. A large, pulsatile
`enlarged rapidly, and he was transferred with the diagno-
`sis of AAA dissection. Because of his severe
`neurologic
`a decision was made to use the transfemoral
`injury,
`prosthetic graft implantation technique, and the proce-
`dure was done on November 11, 1990 after informed
`consent.
`a
`proximal stent was used in this case,
`Because only
`reflux was noted at the distal end of the prosthetic graft.
`The stent effectively closed the proximal intimal disrup-
`tion, the patient’s pain subsided, and the diameter of the
`seven
`aorta dramatically diminished. Follow-up at
`months has been completed, and refluxat the distal end of
`the graft is still noted. The reflux does notfill the false
`the intimal rent
`lumen of the dissection. Presumably,
`whichinitiated the dissection has been sealed (Figs. 6, 7).
`
`Patient No. 4
`
`asymptomatic but wasafflicted
`man was
`A 61-year-old
`with a 6.5 cm AAA. He was a severe asthmatic with
`profound chronic obstructive pulmonary disease. He
`volunteered for the graft trial and the stent-graft combi-
`nation was
`on January 3, 1991. Following
`implanted
`placement of the prosthetic graft and proximal stent,
`reflux was notedat the distal end of the graft and a second
`stent was
`placed. Six months of follow-up have been
`completed. The aneurysm has not increasedin size andis
`effectively excluded from the circulation with arterial
`continuity being established through the prosthetic graft
`and its double stent fixation.
`
`

`

`496
`
`TRANSFEMORAL INTRALUMINAL GRAFT IMPLANTATION
`
`ANNALS OF
`VASCULAR SURGERY
`
` Fig.
`
`Fig. 8. Graft-stent combination with cephalic
`
`stent.
`
`patients have been studied by duplex Doppler color
`ultrasound and CT scans. Late arteriograms have been
`performed in two patients (Cases |! and 3) (Fig. 9). As
`noted above in Case 3, persistent distal reflux has been
`noted at the distal end of the prosthetic graft. However,
`the dissection itself has been controlled and no attempt
`has been madeto attach the distal end of the prosthesis.
`The size of the excluded AAA is considered to have
`decreased in three patients.
`
`7. Aortography of Patient Number1 depicting an
`infrarenal aneurysm.
`Patient No. 5
`
`man was referred from the Argentinian
`A 62-year-old
`province of Santa Fe. He had experienced multiple,
`recurrent episodes of atheromatous embolization to the
`lower extremities. In addition, he had severe and non-
`correctable coronary artery occlusive disease with a
`cardiac ejection fraction of less than 20%. Recent pulmo-
`nary edema had been treated successfully. A small, 3.8
`cm AAA was discovered and this was found to have an
`irregular luminal surface, suggesting mural thrombosis.
`Cardiac echocardiography demonstrated an
`enlarged left
`ventricle without thrombus formation. No arrhythmias
`were found on Holter monitoring.
`The distal atheromatous embolization was treated with
`intraartenial
`infusion of prostaglandin E,
`(Prostin)*. After
`a marked improvementin the
`ofarterial infusion,
`four days
`was achieved. There-
`perfusion of the distal lower extremity
`fore, on
`the graft-stent combination was
`May 26, 1991,
`implanted. In this case, a double stent was
`placedinitially,
`thus sealing the proximal and distal ends of the prosthetic
`graft to aortic wall. There has been no recurrence ofdistal
`embolization since implantation of the device (Fig. 10).
`are
`At
`this time, all five patients
`doing well. The
`follow-up time has been 12 months in two patients, and
`nine, eight, and three months in the other three. All
`
`“Upjohn Company, Kalamazoo, Michigan.
`
`The study in experimental animals and in the five
`human subjects cited above suggests that transfem-
`
`DISCUSSION
`
`

`

`VOLUME 5
`~
`1991
`No 6
`
`TRANSFEMORAL INTRALUMINAL GRAFT IMPLANTATION
`
`497
`
`Phe ya
`‘eeke:
`ORR
`iets
`AORTOGRAMA
`FS]
`1f]
`te Fie.
`
`ate CS tee te)
`WUE MI RSL,
`
`ae:
`a. Le i.
`
`Fig. 9. Aortography of Patient Number 1, 53 days after
`
` implantation of graft-stent combination.
`
`can be
`oral, intraluminal prosthetic graft placement
`stentfixation of
`achieved using balloon-expandable
`the prosthetic graft. The transfemoral approach
`allows placementof the prosthesis and exclusion of
`the AAA from the circulation underlocal or limited
`epidural anesthesia without the morbidity of a
`high,
`or
`inhalation anesthetic.
`regional block,
`general
`Lack of aortic cross-clamping and brief total aortic
`occlusion time allows graft exclusion of the aneu-
`rysm without cardiac compromise.
`Justification for the procedure is found in the fact
`that AAAs must be excluded from the circulation in
`order to prevent aneurysm rupture. In Szilagyi’s
`classic study [22], small, surgically untreated aneu-
`rysms were the cause of death in 29.5% of
`patients.
`Treatment of small AAAs has been shownto im-
`prove late survival [22]. Furthermore, in Darling’s
`much quoted study [23], 18.1% of 182 ruptured
`aneurysms wereless than 5 cm in diameter. A more
`[24] suggests that
`modern report by Cronenwett
`AAAsas small as 4 cm in diameter can be associ-
`as 20% peryear if
`ated with a rate of rupture as
`high
`
`hypertension is present. These facts have suggested to
`some that the presence, and not the size, of an AAA
`should be the indication for exclusion from the circula-
`tion. It is the smaller aortic aneurysm thatlendsitself to
`correction by this technique.
`The larger the aneurysm, the greater the risk of
`so resection and graft replacement have
`rupture,
`as the treatment of choice for these le-
`emerged
`sions. This is true even in high-risk patients with
`associated co-morbidity. Even non-correctable
`myocardial ischemia, cardiomyopathy, and pulmo-
`con-
`nary and renal insufficiency do not
`entirely
`traindicate graft replacement of the aortic aneu-
`increase operative
`rysms. They do, however,
`mortality. Other factors, when present, may in-
`crease the difficulty and therefore the morbidity and
`mortality of the procedure. These include the hos-
`tile abdomen with impenetrable peritoneal adhe-
`sions, multiple prior arterial reconstructive proce-
`or abdominal wall stomas. Patients with such
`dures,
`medical co-morbidities or with technical factors
`
`

`

`498
`
`TRANSFEMORAL INTRALUMINAL GRAFT IMPLANTATION
`
`ANNALS OF
`VASCULAR SURGERY
`
`remains to be shown. More importantis the fact that
`postoperative finding than a
`graft dilation is more a
`clinical problem. In two patients in this study, fol-
`low-up has suggested that the excluded aneurysm and
`intraluminal thrombus exterior to the prosthetic graft
`appearto fibrose and diminish in diameter. Such re-
`no
`traction is noted, and to date,
`dilation has been
`graft
`seen.
`The question of patent lumbararteries contribut-
`to
`has not been
`continuing aneurysm expansion
`ing
`solved by the present study. Admittedly, many
`lumbar arterics may have been occluded by the
`atherosclerotic aortic aneurysm wallor intraluminal
`thrombus. However, in some
`patients it is predict-
`able that lumbararteries will remain patent and, in
`fact, the inferior mesenteric artery may also remain
`patent. Whether or not these patent vessels will
`contribute to continuing aneurysm expansion is
`unknown. Theoretically, occlusion of the lumbar
`to
`arteries and mesenteric artery could be expected
`follow intraluminal graft placement.
`frequently contain imtraluminal
`Because AAAs
`thrombus, the possibility of distal embolization of such
`thrombus by intraluminal manipulation remains a
`threat. The fact that no
`apparent intraluminal thrombus
`embolized distally in the initial five cases does not
`as a
`As the Am-
`exclude this complication
`possibility.
`platz guidewire is relatively stiff, the graft-stent sheath
`is maintained in an access
`to the aortic wall,
`parallel
`and this may minimize dislodgement of thrombus from
`the wall of the aneurysm.
`The Palmaz stent has been shown to become
`covered with endothelium relatively rapidly. Thus,
`it becomes included in the wall of the artery in
`which it is placed. The natural history of the aortic
`wall proximal and distal to the aneurysm remains to
`be seen. Whether or not it will be the site of intimal
`hyperplasia is unknown [25,26].
`Certain anatomic characteristics of the aortic
`aneurysm must be present for the graft-stent device
`to be utilized. The aortic aneurysm should be asso-
`ciated with normal aortic wall proximally and dis-
`tally. Such normal aorta should be at least 3 cm in
`length proximally and at least 2 cm in length distally
`near the bifurcation. The iliac arteries should be
`or be suitable for balloon angioplasty. The
`patent
`#22 French sheath is large and the iliac arteries
`or
`nearly straight and not elon-
`should be straight
`or tortuous. Should such anatomic features be
`gated
`the potential advantages of transfemoral
`present,
`are obvious. A lower
`intraluminal graft placement
`respiratory, and renal morbidity
`cardiovascular,
`should decrease mortality. Furthermore, blood
`transfusions can be obviated and trauma to the
`periaortic and periiliac autonomic plexes will be
`avoided by the procedure.
`Weare
`encouraged by the early experience but
`are to be
`acknowledge that further developments
`expected and more
`must be acquired
`experience
`
`i.
`
`and caudal stent.
`
` Ms
` Fig. 10. Graft-stent combination with both cephalic
`
`increasing Operative risk have, over the years,
`stimulated continuation of this study.
`As in all studies, experience with this small group
`as well as answers.
`turns up questions
`of patients
`an extensive follow-up of Palmaz stent
`Fortunately,
`ofthe stent
`placementhas proven that no
`migration
`occurs
`[25,26].
`Transfemoral graft placement requires that the pros-
`thetic material be a
`compliant, knitted graft which is
`thin-walled. The tendency of such graft materials to
`dilate in the arterial stream is well known. However, in
`transfemoral graft placement, this material is placed
`within an
`intact, though dilated, aorta. Whetheror not
`this graft inclusion techniquewill allow graft expansion
`
`

`

`VoLUME 5
`No 6— 1991
`
`TRANSFEMORAL INTRALUMINAL GRAFT IMPLANTATION
`
`499
`
`can be safely included in the
`before the procedure
`armamentarium of vascular surgeons. Once the
`procedure reaches a
`greater degree of perfection,
`there is no doubt
`a
`that patients who present
`can be treated and their
`prohibitive risk of operation
`life expectancy extended.
`
`REFERENCES
`
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`Induced
`3. BERGUER R, SCHNEIDER J, WILNER HI.
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`5. KARMODY AM, LEATHER RP, GOLDMANMp, et al.
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`7. SCHANZER H, PAPA MC, MILLER CM. Rupture of
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`8. MC FARLAND MJ. The epidemiologic necroscopy for
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`9. TURK K. Postmortem incidence of abdominal aortic aneu-
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`
`Commentary
`
`It has been said that the essence
`of great art is
`trans-
`simplification. In working out the details of
`femoral exclusion of abdominal aneurysms from
`the aortic stream, Dr. Juan Parodi and his col-
`leagues have simplified aortic surgery. Thus, their
`work is truly artistic as well as
`scientific.
`There is no doubt that the procedure achievesits
`to
`at
`it will be offered
`purpose. Predictably,
`first
`patients who are at
`prohibitive risk for conventional
`aortic surgery. As experience grows,
`it will be
`patients who are
`to
`good surgical risks,
`offered
`even those with aneurysms smaller than the ones
`conventionally requiring surgical repair. During
`this time, complications will occur, some
`of which
`are cited in this initial clinical experience. As every
`interventional procedure has its own
`complications,
`new
`to the proce-
`problems will arise. Opposition
`In vascular surgery no
`dure will be mounted.
`change for the better has occurred that wise and
`men have not
`opposed. Now that this initial
`good
`harrier is broached, new
`applications,
`including
`are
`transluminal distal bypass
`predictable. Such
`changeis inevitable. It is, as Thoreau said, “‘...a
`miracle to contemplate; but it is a miracle which is
`taking place every minute.”’
`
`John J. Bergan, M.D.
`LaJolla, California
`
`