Vascular prostheses.

The quest for an ideal vascular graft began in the early 1950s and continues at a steady pace. The perfect graft has yet to be designed. As a result, patients with vascular prostheses may suffer complications that range from minor to catastrophic. The emergency physician may be faced with the initial presentation of patients with these vascular graft complications. If he or she is not familiar with these possibilities, then the resulting morbidity and mortality could be devastating. Probably the most unnerving complication involving the failure of vascular prostheses is that of the aortoenteric fistula. Instantaneous decisions and interventions must be made when a patient presents in this state of pre-exsanguination. Massive GI bleeding is at one end of the spectrum with other less-severe GI complications involving aortoenteric erosions and small bowel obstructions due to graft migration at the other end of the spectrum. Infection of a vascular prosthesis is a complication much feared by vascular surgeons. A spectrum of presentation also exists here whereby a patient may present with an obvious draining wound or with subtle complaints of fever, weakness, and a minimally elevated white blood cell count. The function of the emergency physician is critical here but only if he or she is able to suggest the possibility of graft infection to the admitting physician. Fortunately, thrombosis of a vascular graft is an infrequent complication that may occur at any time postoperatively, although the frequency decreases with time. There are many different causes of graft occlusion of which the emergency physician should be aware. If the cause of the thrombosis is known, then the secondary vascular reconstruction can be optimized. The dialysis population has grown rapidly over the past two decades and as a result so have complications of renal dialysis grafts. Because the dialysis population now includes large numbers of older subjects as well as those with systemic diseases such as diabetes and HIV, recognition and prompt aggressive management of clinical complications is of paramount importance.