The Sparks’ Mandril Graft A Seven Year Follow-Up of Mandril Grafts Placed by Charles H. Sparks and His Associates

Roger W. Hallin, MD, Portland, Oregon William R. Sweetman, MD, Portland, Oregon

The Sparks’ mandril method of preparing autogenous Dacron@-supported fibrous tissue tubes for arterial replacement has been in clinical use since 1968. The purpose of this report is to give a detailed follow-up of the patients subjected to revasculari&ion using the Sparks’ mandril graft technic. Since this includes all Doctor Sparks’ patients so treated, plus those of his associates, it is the longest followed series of patients treated by this method. Our results with this technic have not been good. The graft is potentially dangerous when immature and should only be used for revascularization in its present form in highly selected cases. Its use as a hemodialysis conduit Portland on a limited

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Material and Methods Seventy-three mandril grafts were implanted and thirteen were unsuitable for use because of poor maturation or inflammation. Sixty grafts were placed in fifty-four patients. There were eight initial (less than 1 month) failures. Ages ranged from sixteen to eighty-three years (average, 60.5 years) and male:female ratio was 2.3:1. Between May 1968 and December 1969, the die-cluster method of forming the grafts was used in six patients, three successfully [I]. Between 1970 and 1973, forty-eight patients were subjected to revascularixation procedures using the silicone mandril technic [2]. In November 1973, just after Doctor Sparks’ death, the only graft in this series grown over a sponge rubber mandril was used to form a femoropopliteal bypass.

From the Department of Sugery. Goal Samaritan Hospital and Medical Center, Patland. Drecm Reprint requests &uld be addressed to Roger W. Hallin. MD, 2226 NW Pettygove. Portland, Dry 97210. Presented at the Forty-Seventh Annual Meeting of the Pacific Coast Surgical Association, Monterey. Califcmia. February 15-16. 1976.

Vofume 132, AugusllO76

The grafts were placed in the axillofemoral(3), ilioiliac and iliofemoral(8), femorofemoral (suprapubic) (4), femoropopliteal(38), and femorotibial(7) sites. The indications for revascularixation were disabling claudication, peripheral necrosis, and rest pain. Results

Best results have been obtained in the ilioiliac and iliofemoral positions, and all grafts in that position from twenty-four to forty-eight months are patent (average, 38.3 months). Eight grafts were placed in five patients. One of four grafts is open in the suprapubic femorofemoral position at forty-four months. In the femorotibial position all of seven grafts placed are closed. The average duration of patency was 5.3 months; one graft remained patent eleven months. Of thirty-eight grafts placed in thirty-four patients in the femoropopliteal position, ten grafts are now functioning (26 per cent). The average duration of patency of these grafts is 25.6 months; maximal duration of patency has been 72 months. Three grafts were open when replaced because of aneurysm formation (average duration of patency, 20 months). Four patients died with open grafts (average duration of patency, 13 months). All three grafts placed in the axillofemoral position are closed (average duration of patency, 9 months) Complications

Complications due to the use of the mandril-grown graft have been described previously [3]. The complications in this (combined) series are: (1) Difficulties with maturation of the graft (10 patients, 12 grafts) preuenting its use nine times and resulting in fatal hemorrhage in one patient. (2) Initial thrombosis requiring thrombectomy in the first 24 hours after anastomosis (17 per cent).

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(3) Late thrombosis due to thickening of the lining

with stenosis and occlusion of the graft (44 per cent). (4) Bleeding in the postoperative period either from fraying of the graft at an anastomotic site or from the body of the graft (3 grafts, 5 per cent). (5) Aneurysm formation in the body of the graft (12 grafts, 20 per cent). (6) Anastomotic aneurysm (1 graft). (7) Infection occurred in four cases and healing occurred without removal of the graft in one patient. A second patient came to amputation because the distal wound site never healed. A third patient died from hemorrhage associated with infection in a graft incompletely matured. Inflammation along the implanted mandril graft without positive culture occurred in five patients preventing use of the graft in three instances. comlllents Postoperative arteriograms and patency statistics clearly demonstrate the unsuitability of this graft in the femoropopliteal position. In that position, the most severe testing ground for prosthetic arterial grafts, the 26 per cent patency rate for two to six year follow-up does not compare favorably with readymade cloth prostheses. Harmon and Hoar [4] in 1973 reported an accumulated five year patency rate of 59 per cent in twenty-nine diabetic patients subjected to femoropopliteal cloth bypass grafting. Since one objective of the mandril graft is avoiding kinking at the popliteal level, a comparison with composite grafting is in order. Linton and Wirthlin [5] report 54 per cent five year patency using composite Dacron@ saphenous vein bypass grafting. All grafts studied after twenty-four months show marked luminal irregularity, and a significant percentage show aneurysm formation. Most aneurysmal grafts have been replaced. Aneurysms form along the entire length of the graft. This is due to separation of the Dacron fibers, the fibrous tissue between Dacron fibers being inadequate to support arterial pressure. We have not seen breakage of the Dacron fibers. True hypertension has been associated with aneurysm formation in only three of eleven aneurysmal grafts. The incidence of aneurysm formation is considerably higher than that reported in saphenous vein grafting. In the iliofemoral position, one pair of grafts, although patent, is becoming aneurysmal. Four tests of infection had occurred clinically, one graft tolerating infection well: A possible advantage of this technic could be tolerance to infection. Lab-

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oratory investigation of tolerance to infection has not been carried out by us. Mandril placements that were explored for use but not used because of difficulties with maturation were included in this analysis. However, numerous mandrils placed without complications and never explored for use were not included in this series. Summary

A clinical follow-up study of the Sparks’ mandril graft used for lower extremity revascularization between 1968 and 1973 is presented. Of seventy-three mandril grafts placed, sixty were used to revascularize lower extremities in fifty-four patients. Results show 100 per cent patency in the ilioiliac and iliofemoral sites, 26 per cent patency in the femoropopliteal sites, and 0 per cent patency in the femorotibial and axillofemoral grafts. Complications include poor maturation of the graft, early thrombosis, postoperative hemorrhage, and aneurysm. References 1. Sparks CH: Autogenous grafts made to order. Ann Thorac Surg 8: 105, 1969. 2. Sparks Cl-f: Silicone rnandrilmethod of femoropoplitealartery bypass. Am JSurg 124: 244, 1972. 3. Hallin RW: Cfxnplicatkms with the mandril grown (sparks) Dacron arterial graft. Am Surg 41: 550, 1975. 4. Harmon JW. Hoar CS: Cloth femoral-popliteal bypass grafts in 29 diabetic patients. Arch Surg 100: 282, 1973. 5. Linton RR. Wirthlln LS: Femcfopopliteal composite Dacron and autogenow vein bypass grafts. Arch Surg 107: 748. 1973.

Discussion Lester R. Sauvage (Seattle, WA): The Sparks’ mandril graft represents an exceedingly interesting concept: a prosthesis that begins as a very porous, wide mesh, smooth walled arterial prosthesis but which, prior to use as arterial substitute, becomes lined by autogenons fibrous tissue. The mandril graft is therefore impervious at implantation. It was hoped that the presence of a “prehealed” wall would provide decreased thrombogenicity immediately upon implantation and thus avoid the waiting period between implantation and the hoped-for complete healing of a prosthesis wall. But the fibrous tissue lining (collagenous tissue) of the Sparks’ mandril graft has proved to be very thrombogenic, as one sixth of all implanted grafts thrombosed within 24 hours. Indeed it would appear that the underlying, relatively unsupported fibrous tissue of the Sparks’ mandril graft is poorly equipped to organize the surface thrombus that forms upon it. The fibrous tissue appears, in fact, to be actually more thrombogenic than a properly preclotted nontissuefied synthetic graft of greater wall density (a~ represented by essentially all types of conventional grafts used in clinical practice).

The Amorloan Joumal of Swguy

Sparks’ Mandril Graft

The aneurysm formation that has developed in many of the mandril grafts suggests that the fibrous tissue (scar tissue) which forms the wall of this prosthesis cannot contain the arterial pressure. More support than the wide mesh is needed. Hence, the Sparks’ mandril graft (a tissuefied wide mesh prosthesis) has been shown by both early and late results to be inferior to conventional (tighter mesh) knitted Dacron arterial prostheses. The aim of the mandril graft was to have a tissuefied prosthetic wall that would be of low thrombogenicity at implantation, but this objective was not achieved. It appears that this aim can be better achieved by a tighter mesh arterial prosthesis that can heal after implantation. However, conventional smooth wall, knitted arterial prostheses appear unable to complete the tissuefication post implantation. More complex designs (which we have termed “filamentous”) are achieved with velouring. We have found that human and animal tissue ingrowth (graft healing) responds differently to varying degrees of filamentousness. The fastest healing has been observed with grafts of differential degrees of filamentousness throughout the prosthetic wall-maximal outside and minimal inside. Continued development of the trellis concept of assisted cellular migration should further improve the results that can be obtained with arterial prostheses in critical small vessels. The ultimate aim is to develop prostheses that can be used satisfactorily in the coronary and tibia1 vessels. It is of interest in this regard that we have one patient with a functioning filamentous velour vascular prosthesis in the right coronary artery now sixteen months postoperatively. Although the Sparks’ mandril graft has lost its place in current clinical practice, its position in surgical history is assured for the studies of this prosthesis have contributed information that enables us to understand more of the basic biology of arterial prosthetic healing.

Volume 132, August 1376

Sherman Day (Seattle, WA): We have employed Sparks’ mandril grafting twenty-four times in eighteen patients. Results show that only two of the twenty-four grafts are still functioning. Four patients were lost to follow-up and seven grafts were never used; two grafts failed to mature, seven were occluded, and two were aneurysmal. Of the eleven documented failures, four resulted in amputation and one in reoperation. John Thomas Mehigan (Palo Alto, CA): In our experience during a thirty month period, sixty-four Sparks’ mandril grafts were placed in fifty-three chronic hemodialysis patients. Ultimately, thirty-one mandril grafts were hooked up to dialysis in twenty-six patients. Average patency time was thirty-six weeks. Two of the thirty-one grafts are still patent at fifty-seven and eighty weeks, but twenty-nine grafts have failed. Multiple complications including serious aneurysmal dilatation, infection, and hematoma formation and poor acceptance by hemodialysis technicians as well as patients were noted. We have reluctantly concluded that the Sparks’ mandril graft, although a feasible blood access technic for chronic hemodialysis, is currently less desirable than other available technics because of low patency and high rates of complication. Roger W. Hallin (closing): I want to thank Doctor Sauvage particularly for making this presentation worthwhile by capping it off with a very learned and scientific inquiry into this whole problem. I would like to thank Doctor Mehigan for his comment on hemodialysis shunts; we intended to include them in this study but believed they complicated the paper unnecessarily. Our experience in Portland has been much the same as theirs with the hemodialysis shunt, although it is still being used as an alternative technic for hemodialysis. I might add that our follow-up was 95 per cent complete.

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The Sparks' mandril graft. A seven year follow-up of mandril grafts placed by Charles H. Sparks and his associates.

The Sparks’ Mandril Graft A Seven Year Follow-Up of Mandril Grafts Placed by Charles H. Sparks and His Associates Roger W. Hallin, MD, Portland, Oreg...
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