Title: Progressive enlargement of a Miller vein cuff
Abstract: Since Miller et al. described their technique for an interposition vein cuff in 1984,1Miller JH Foreman RK Ferguson L Faris J Interposition vein cuff for anastomosis of prosthesis to small artery.Aust N Z J Surg. 1984; 54: 283-285Crossref PubMed Scopus (210) Google Scholar this procedure has been widely practiced, and several large clinical series have been reported. To date, 386 patients have been described.2Tyrrell MR Grigg MJ Wolfe JHN Is arterial reconstruction to the ankle worthwhile in the absence of autologous vein?.Eur J Vasc Endovasc Surg. 1989; 3: 429-434Abstract Full Text PDF Scopus (33) Google Scholar, 3Morris GE Raptis S Miller JH Faris I Femoro-crural grafting and regrafting: does PTFE have a role?.Eur J Vasc Endovasc Surg. 1993; 7: 229-234Google Scholar, 4Brumby SA Petrucco MF Walsh JA Bond MJ A retrospective analysis of infrainguinal arterial reconstruction—three-year patency rates.Aust N Z J Surg. 1992; 62: 256-260Crossref PubMed Scopus (9) Google Scholar We have encountered a late complication of Miller vein cuff construction that to the best of our knowledge has not been previously described. A 74-year-old man sought medical attention for critical ischemia of his right foot and underwent right femorodistal popliteal bypass in November 1990. At surgical exploration the long saphenous vein was found to be varicose at the midthigh level and appeared to have been damaged by thrombophlebitis, leaving inadequate length for use in the intended bypass. An 8-mm externally supported polytetrafluoroethylene graft therefore was used with an interposition vein cuff and a nonvaricose length of long saphenous vein from the proximal thigh. An intraoperative completion angiogram was performed; it indicated a technically satisfactory appearance, with the transverse diameter of the cuff being 18 mm. The patient made a good recovery and was discharged. Because it was not our policy to perform surveillance scans of interposition vein cuffs at that time, the patient was discharged from follow-up after his first clinic review. The patient returned in February 1994 with critical ischemia of his left foot, which was successfully managed by a left axillofemoral bypass. At this time he was noted to have a pulsatile mass in his right popliteal fossa. Ultrasonography showed the transverse diameter of the vein cuff to be 25 mm, expanding to 28 mm on repeat scanning 6 months later. Magnetic resonance angiography was performed to obtain a view comparable with that of the initial completion angiogram; it confirmed the cuff diameter to be 28 mm (Fig. 1).The patient remains asymptomatic with regard to the dilated vein cuff, although his general medical condition is deteriorating. He is receiving warfarin, and a policy of active surveillance is being continued. When Miller et al. first described the interposition vein cuff, they stated that the segment of vein used should be four to five times longer than the arteriotomy and 2 to 3 mm in diameter. Other authors who have reported adopting Miller's technique, however, have not described the maximum diameter of saphenous vein that can be used with safely. In view of the relevance of Laplace's law to blood vessels, however, it does seem likely that there is an optimal size for a Miller cuff that is dictated both by the diameter of the long saphenous vein used and by the length of the arteriotomy, and that above this size, progressive dilatation of the cuff is a possibility. In the patient described above, the mechanical consequences of a large cuff may have been compounded by the use of a vein with a relatively poor media, although this was not apparent at the time of the procedure. We thank Dr. Francis Smith, Consultant in Nuclear Medicine, and Dr. R. Mahaffy, Consultant Radiologist, both of Aberdeen Royal Infirmary, for supplying the radiographic images. 24/41/72594