Use of the superior pedicled rectus abdominis flap to cover infected aortic grafts

Replacement of aortic aneurysms by a prosthetic graft is a common procedure in vascular surgery. Although success is generally achieved, infection or fistula may occur. Prosthetic graft infection has been reported in between one and six percent in most large series and is one of the most dreaded complications of abdominal aorta surgery. Dissatisfaction with extraanatomic procedures has led to the development of techniques of in situ replacement by allogenic material. However, adequate debridement and coverage of the aortic graft is necessary. To our knowledge, this is the first report of the use of a rectus abdominis muscle flap to cover an aortic allograft when other reconstructive options were impossible.

Ten-year experience in autogenous reconstruction with the femoral vein in the treatment of aortofemoral prosthetic infection

OBJECTIVE

to study the short and long term effectiveness of in situ replacement of infected aortic grafts with the lower extremity deep veins.

METHODS

forty-nine patients operated on for infrarenal aortic graft infection since 1990 were studied. Diagnosis of infection was based on clinical signs, bacteriological tests and typical findings on CT scan and leukocyte scan. The surgical treatment consisted in harvesting the femoral vein, total graft excision, thorough debridement and in situ reconstruction with the femoral veins. After discharge, the patients were followed at 6 monthly intervals with clinical examination, duplex and/or CT scan.

RESULTS

there were four in-hospital deaths (8%). One patient required above-knee amputation (2%) and there were two graft limb occlusions (4%). With a mean follow-up 41 months, another 13 patients died, unrelated to the operation (29%). There were no late amputations and only two late graft limb stenoses (4%). We have a 5 year survival rate of 60%, a 5 year limb salvage rate of 98%, and a 5 year primary patency rate of 91%. There were no cases of aneurysmal dilatation of vein grafts and no incidence of reinfection.

CONCLUSION

in situ reconstruction with the lower extremity deep veins is in the long term a safe and attractive alternative in the treatment of infrarenal aortic graft infection.

Thoracic aorta endoprosthesis: the final countdown for open surgery after traumatic aortic rupture?

From December 1998 through May 2001, seven patients with thoracic aortic isthmus rupture underwent endovascular stent graft repair. Diagnosis was made by chest X-ray, transesophageal echography, CT scan, and aortography. The endoprosthesis was ordered and/or custom made on an urgent basis. During the delay period blood pressure was kept low and the tear closely monitored by means of transesophageal echography and CT scan. The mean delay period was 94 days: three patients were treated within 24 hr, two patients had their treatment postponed because of multiple organ failure, and two patients were diagnosed late. Complete exclusion of the pseudoaneurysmal sac was successful in all patients. One patient underwent a preliminary carotidosubclavian bypass because of a short proximal neck, one subclavian artery was unintentionally partially covered, and a second one was deliberately overstented. None of these patients developed arm ischemia or claudication. One patient died 3 weeks after the procedure because of the severity of associated lesions and comorbidity. Our preliminary results prove that endografting for aortic isthmic rupture is technically feasible and that it represents a safe and potentially valuable alternative to the mortality and morbidity of open surgery. Further evaluation is needed to assess the full therapeutic potential and determine the mid and long-term follow-up.

Percutaneous injection of human thrombin to treat iatrogenic femoral pseudoaneurysms: short- and midterm ultrasound follow-up

Our objective was to determine the efficacy of ultrasound-guided direct injection of human thrombin to close postcatheterization pseudoaneurysms and to evaluate the midterm results of this new percutaneous technique by ultrasound follow-up. One hundred one postcatheterization pseudoaneurysms in 100 patients were treated by direct injection of human thrombin (mean dose 200 IU, range 50-750 IU) under ultrasound guidance. Patient demographics, clinical data and ultrasonographic morphology of the pseudoaneurysms were analyzed. Midterm (mean 99 days, range 25-210 days) ultrasonographic follow-up was performed in 57 of 82 called patients (69.5%). Ninety-six of 101 pseudoaneurysms thrombosed completely after the first procedure. Of the remaining 5 pseudoaneurysms, 3 were treated successfully after the second attempt, and 2 patients underwent surgical repair; thus, the primary success rate was 95% (96 of 101), and the overall success rate was 98% (99 of 101). No changes in distal pulses or other adverse events were noted immediately or 1 day after the procedure. Ultrasound follow-up revealed complete disappearance of the pseudoaneurysm in 70% (40 of 57), presence of small, residual groin hematoma in 26% (15 of 57), and partial reperfusion of the pseudoaneurysm in 3.5% (2 of 57). Human thrombin injection under ultrasound guidance is a very effective and safe method of therapy. Failure (immediate and late) of the technique as well as procedure-related complications are very rare. In our institution, sonographically guided human thrombin injection has become the treatment of choice for postcatheterization pseudoaneurysms.

Carotid artery stenting: which stent for which lesion?

Although some early reports describe angiographic as well as clinical success for balloon angioplasty alone in the treatment of carotid occlusive disease, most interventionists prefer stent-assisted balloon angioplasty because of the purported advantages, such as avoiding plaque dislodgement, intimal dissection, elastic vessel recoil and late restenosis. Mainly because of the different characteristics of each carotid artery segment, different types of stents are preferred. A carotid artery lesion located in the intrathoracic brachiocephalic trunc or common carotid artery would need a different stent to a lesion at the carotid bifurcation or a lesion of an intracerebral branch of the internal carotid artery.

Endovascular repair of inflammatory abdominal aortic aneurysms with special reference to concomitant ureteric obstruction

OBJECTIVES

To study the technical feasibility and results of endovascular treatment of inflammatory abdominal aortic aneurysms (AAA).

DESIGN

Prospective study.

MATERIAL AND METHODS

Seven patients underwent endovascular repair of an inflammatory AAA. Five patients (8 ureters) were treated with ureteric stents CT scans were obtained one year.

RESULTS

The early technical success rate was 100%. Four ureters remained entrapped at one year. Partial regression of periaortic fibrosis was documented in three patients, while four patients showed no regression.

CONCLUSION

Endovascular reconstruction of inflammatory abdominal aneurysms is technically feasible. Further study is warranted with regard to the evolution of the periaortic fibrosis and the possible benefits for patients with concomitant hydronephrosis.

Significance of endoleaks after endovascular repair of abdominal aortic aneurysms: The EUROSTAR experience

OBJECTIVE

The purpose of this study was to assess the incidence, risk factors, and consequences of endoleaks after endovascular repair of abdominal aortic aneurysm.

METHODS

Data on 2463 patients were collected from 87 European centers and recorded in a central database. Preoperative data were compared for patients with collateral retrograde perfusion (type II) endoleak (group A), patients with device-related (type I and III) endoleaks (group B), and patients in whom no endoleak was detected (group C). Only endoleaks observed after the first postoperative month of follow-up were taken into consideration. Regression analysis was performed to investigate statistical relationships between the occurrence and type of endoleak and preoperative patient and morphologic characteristics, operative details, type of device, and experience of the operating team. In addition, postoperative changes in aneurysmal morphology, the need for secondary interventions, conversions to open repair, aneurysmal rupture, and mortality during follow-up were compared between these study groups.

RESULTS

Patients in group A had a higher prevalence of a patent inferior mesenteric artery compared with patients without endoleak. Patients in group B were treated more frequently than patients in group C by an operating team with experience of less than 30 procedures. The mean follow-up period was 15.4 months. Secondary interventions were needed in 13% of the patients. Rupture of the aneurysm during follow-up occurred in 0.52% (1/191) in group A, 3.37% (10/297) in group B, and 0.25% (5/1975) in group C. Life table analysis comparing the three study groups demonstrated a significantly higher rate of rupture in group B than in group C (P =.002). The incidence of conversion to open repair during follow-up was higher in group B than in the other two study groups (P <.01). Death was related to the aneurysm or to endovascular repair of the aneurysm in 7% of patients. Secondary outcome success, defined as absence of rupture and conversion, was significantly higher in group A and C compared with that in group B (P =.006 and P =.0001, respectively).

CONCLUSIONS

The presence of device-related endoleaks correlated with a higher risk of aneurysmal rupture and conversion compared with patients without type I or III endoleaks. Type II endoleak was not associated more often with these events. Consequently, intervention in type II endoleak should only be performed in case of increase of aneurysm size.

Ruptured renal artery aneurysm during pregnancy: successful ex situ repair and autotransplantation

Rupture of a renal artery aneurysm during pregnancy is a rare event, with a high mortality rate for both mother and fetus. Until now, 25 cases have been reported in the English medical literature. Renal salvage with in situ repair of the renal artery has been documented in only four cases, and successful ex situ repair and autotransplantation in only one case. We report the case of a mother and fetus who both survived acute rupture of a renal artery aneurysm after treatment with ex situ repair and autotransplantation.

Use of cryopreserved arterial homografts for management of infected prosthetic grafts: a multicentric study

The objective of this study was to evaluate the effectiveness of cryopreserved arterial homografts for management of prosthetic graft infection. Between October 1992 and July 1998, 90 patients (84 men) with a mean age of 64 years from six different hospitals were treated for prosthesis infection by in situ replacement using a cryopreserved arterial homograft (CAH). In 43 patients (47%), the primary procedure had been performed at a nonparticipating center. Prosthetic graft infection occurred early (i.e., within 1 month after the primary procedure) in 15 cases and late in 75 cases. In the late group, the mean interval between the primary procedure and CAH replacement was 34 months (range, 3 to 330 months). In 41 patients, infection was located in the aortic region, including 17 presenting with enteroprosthetic fistula (EPF). In 49 patients, infection was confined to the femoral, popliteal, or subclavian region. Bacteriologic cultures were positive for one or more germs in 75 patients and negative in 15. The surgical procedure consisted of complete or partial removal of the infected prosthetic graft, debridement, and in situ reconstruction using one or more CAH. Our results showed that management of prosthetic graft infection, a grave complication, using a CAH is a promising technique, especially for patients in stable condition prior to reconstruction.

The value of dipyridamole thallium scintigraphy and dobutamine stress echocardiography as predictors of cardiac complications following reconstruction of the abdominal aorta

BACKGROUND

The aim of this study was to evaluate the ability of dipyridamole thallium scintigraphy and dobutamine stress echocardiography to predict cardiac complications following elective reconstruction of the abdominal aorta in patients with a stable preoperative cardiac condition and to compare this with information obtained from the medical history, ECG and resting echocardiography alone.

METHODS

This evaluation was performed from January 1993 until December 1995 as part of a prospective, randomised study in 200 patients, with a mean age of 65 (5% women). Dipyridamole thallium scintigraphy was performed on 195 patients and dobutamine stress echocardiography was added to the protocol in the last 83 patients. Cardiac complications were defined before the start of the study.

RESULTS

In the postoperative period 62 cardiac complications occurred (31%). In patients clinically suspected of having coronary artery disease the incidence of complications was 40% (51/126), compared to 15% (11/74) when no coronary pathology was suspected (p<0.001). When reversible defects were present on dipyridamole thallium scintigraphy the incidence of complications was 36% (20/55), compared to 29% (41/140) when no reversible defects had been found (NS). Dobutamine stress echocardiography was impossible or contraindicated in 21 patients. In the remaining patients the incidence of complications was 71% (5/7) when new regional wall motion abnormalities were found, compared to 16% (9/55) when such abnormalities had not been detected (p<0.005).

CONCLUSIONS

These data suggest that cardiac complications following reconstruction of the abdominal aorta in patients with a stable cardiac condition are best predicted by dobutamine stress echocardiography. Dipyridamole thallium scintigraphy, however, does not seem to be useful in this respect.

Outcome and one year follow-up of intra-arterial staphylokinase in 191 patients with peripheral arterial occlusion

Wild-type or equipotent variants of recombinant staphylokinase (rSak) were given intra-arterially (as a 2 mg bolus injection followed by an infusion of 1 mg/h or 0.5 mg/h overnight, with concomitant heparin [1000 IU/h]) to 191 patients of less than 80 years (62 +/- 1 years, mean +/- SEM), with a peripheral arterial occlusion (PAO) of less than 120 days (mean 14 +/- 1 days, median 11 days, 5 to 95 percentiles 3 to 30 days). Ninety nine patients presented with acute or subacute ischemia, 57 with severe claudication, 33 with chronic rest pain and 2 with gangrene. Occlusion occurred in 122 native arteries and in 69 grafts. Revascularization was complete in 83 percent (158/191), partial in 13 percent (24/191) and absent in 4 percent (7/191) after administration of 12 +/- 0.5 mg rSak over 14 +/- 0.7 h. Complete revascularization of acute occlusions of popliteal or more distal arteries was less frequent (60 percent, 15/25) than of acute occlusions of more proximal native arteries (95 percent, 37/39, p <0.001) or grafts (89 percent, 50/56, p = 0.005). Additional endovascular procedures were performed in 47 percent and subsequent elective bypass surgery in 23 percent of patients. Major bleeding occurred in 12 percent (23/191), one month mortality was 3.1 percent (6/191) and one year mortality was 6.9 percent (12/174). However, four patients (2.1 percent) had an intracranial bleeding following therapy: a 85 year old woman with severe diabetic arteriopathy, who was included in violation of the protocol, a 79 and a 74-year-old woman and a 74-year-old man, all with severe hypertension and limb threatening ischemia; these four patients died within two months after treatment. Amputations were performed within the first year in 16 of 162 surviving patients (9.8 percent): in 7 percent (7/96) with an occluded native artery and 14 percent (9/66) with an occluded graft (p = 0.19). No significant difference in lysis rate, one month mortality or one year amputation-free survival was observed in occlusions of recent onset (< or =14 days, n = 126) as compared to occlusions of longer duration (>14 days, n = 65). Treatment was interrupted prematurely in 4 patients because of a suspected allergic reaction. Fibrinogen levels remained unaffected during treatment (3.3 +/- 0.1 g/l before vs. 3.3 +/- 0.1 g/l after infusion, n = 167). In conclusion, rSak appears to be a highly effective thrombolytic agent in patients with PAO, resulting in a low one month mortality (3.1 percent) and a high one year amputation free survival (84 percent), with an acceptable incidence of major bleedings, but with occasional fatal intracranial hemorrhages.

Aorto-bi-femoral bypass for aorto-iliac occlusive disease using a videoscopic assisted retroperitoneal approach--a preliminary report

In recent years laparoscopic techniques have been adapted for application in vascular surgery. Since 1993 several authors have published preliminary results of complete or videoscopic-assisted reconstructions of the abdominal aorta. The aim of this retrospective study was to report our initial results with the retroperitoneal videoscopic-assisted technique of aorto-bifemoral grafting (AFG) in ten patients (age 45-71). In one case, conversion into classic reconstruction was necessary because the aorta was to heavily calcified. The duration of the procedures varied between 230 and 390 minutes. The length of the incision ranged between 6 and 9 cm. The hospital stay varied between 5 and 13 days. One patient developed gout, and a left sided, temporary ureteral stent was necessary in another because of hydronephrosis. It is confirmed that video-assisted AFG is feasible. However, whether this technique is truely less invasive, will have to be demonstrated by randomized, prospective studies, once the equipment and instruments have sufficiently been developed and a technique of choice finalized.

Factors influencing patency of infrainguinal bypasses with polytetrafluoroethylene

This retrospective study was undertaken to investigate the patency and limb salvage rates of 308 PTFE infrainguinal bypasses in 272 patients over a 5-year period. In addition a univariate analysis was performed to identify factors that could predict the outcome of these operations. Long-term survival was 83% and 50% at one and five years respectively. For the whole series the primary cumulative patency at one and five years was 70% and 41% respectively. Graft revision for failed or failing grafts resulted in secondary patency rates of 78% and 43% for the same periods. The limb salvage rates were 93% and 84% at one and five years. Patency rates showed no statistical significant difference for gender, age at operation or the use of a venous cuff at the distal anastomosis. Although there was a tendency towards better results for above the knee operations, this difference failed to achieve statistical significance. Only redo operations were associated with a significant worse outcome.

Complications in the endovascular repair of abdominal aortic aneurysms: a risk factor analysis

OBJECTIVES

to identify risk factors for complications following endovascular repair of abdominal aortic aneurysms (AAAs).

MATERIALS AND METHODS

endovascular AAA exclusion was attempted in 64 patients. Patient characteristics, anatomic features of the aneurysm, operative technical aspects, and the experience of the teams were correlated with mortality, occurrence of endoleak, and other complications. Perioperative complications were graded following the recommendations of the Ad Hoc Committee on reporting standards. For the assessment of correlation between risk factors and outcomes a logistic regression analysis was used.

RESULTS

complications were observed in 43% of the procedures and were classified as mild (24%), moderate (55%) or severe (21%). American Society of Anaesthesiology (ASA) risk class 3 or 4, and advanced age were independent risk factors for perioperative death and complications. Adjuvant procedures or overstenting of the renal arteries with the uncovered part of the stent were not associated with increased risk of complications. Nevertheless, in four of 24 overstented renal orifices, a renal infarction or ischaemia of the kidney was observed on a postoperative CT scan. Advanced experience was associated with less complications, less endoleaks, and shorter operating time.

CONCLUSIONS

high age and medical co-morbidity were associated with increased risk for perioperative complications and death. Additional perioperative procedures are usually well tolerated. With greater experience in endovascular AAA grafting the incidence of complications and endoleaks decreased.

Is transcranial Doppler useful in the detection of internal carotid artery cross-clamp intolerance?

The aim of this study was to test the hypothesis that a drop in the systolic blood flow velocity in the middle cerebral artery of 70% or more, measured by transcranial Doppler, is a better criteria in the detection of cross-clamp intolerance than electroencephalogram (EEG) and somatosensory evoked potential (SSEP) monitoring. After exclusion of patients with a recent stroke, urgent procedures and combined procedures, a transcranial Doppler with compression test was scheduled in 85 patients. In 13 patients the drop was 70% or more and in these patients a transcranial Doppler was also performed during the reconstruction of the internal carotid artery (the study group) under general anaesthesia. A shunt was used because of EEG and SSEP abnormality in one patient. No changes were observed in the remaining patients and no intraoperative strokes were seen. The transcranial Doppler monitoring was unreliable in three patients. During cross-clamp, the systolic blood flow velocity in the middle cerebral artery dropped less than 70% in four and 70% or more in six patients. It is concluded that using a drop of 70% or more of the systolic blood flow velocity in the middle cerebral artery during internal carotid artery cross-clamp, as an indicator of cross-clamp intolerance, will lead to unnecessary shunting.

Endovascular stent-grafts for superficial femoral artery disease: results of 1-year follow-up

PURPOSE

To document a preliminary study to assess the deployment and outcomes of endoluminal stent grafting in the superficial femoral artery (SFA) with use of a prototype device.

MATERIALS AND METHODS

Twenty patients with lifestyle-limiting intermittent claudication were selected for treatment with a balloon-mounted expansive polytetrafluoroethylene graft. All patients had angiographically proven SFA disease (median length, 17 cm) with normal arterial inflow and at least two calf vessels patent to the ankle. Follow-up was by means of ankle brachial pressure index (ABPI), duplex ultrasound, and angiography.

RESULTS

Fourteen patients were successfully treated. Six patients were excluded: five by the study protocol and one because the procedure was a technical failure. ABPI rose from 0.6 before treatment to 1.0. The treated limbs became asymptomatic. Twelve-month primary, primary assisted, and secondary patency rates of treated patients were 29%, 50%, and 64%.

CONCLUSION

Endovascular stent grafting of SFA lesions is technically feasible, but the patency rates obtained with this design are inferior to those obtained with conventional surgical bypass.

Inflammatory abdominal aortic aneurysm and bilateral complete ureteral obstruction: treatment by endovascular graft and bilateral ureteric stenting

Inflammatory abdominal aortic aneurysms may present a challenge to the surgeon, especially because of associated retroperitoneal fibrosis and possible ureteral complications. We present a case of inflammatory abdominal aortic aneurysm with bilateral ureteral entrapment and complete anuria, successfully treated by endovascular grafting and temporary ureteral stenting.

Invaginating versus classic stripping of the long saphenous vein. A randomized prospective study

Although sound evidence is lacking, many surgeons claim that stripping of the long saphenous vein (LSV) is best performed by invagination. The aim of this prospective, randomized study was to test the hypothesis that invaginating stripping of the LSV is associated with less pain, smaller haematomas and less frequent injury to the saphenous nerve. Thirty patients with bilateral varicose veins and incompetent LSV, but normal short saphenous veins and deep venous systems, were treated by high ligation and stripping of the LSV and multiple stab avulsions. At one side the stripping was performed by invagination (group I), while a classic stripping was done on the other side (group C), so that one leg served as the control of the other. The results were analysed on an intention to treat basis. The median surface of the thigh haematoma between post-operative day seven and ten was 115 cm2 in group I and 135 cm2 in group C (NS). The median pain score was 0.25 and 1.75 respectively (NS). The incidence of saphenous nerve injury was 13% in group I and 17% in group C (NS). At one month 23% of patients stated that the leg with the invaginating stripping had been the more painful, while 33% of patients claimed that the side of the classic stripping had been more painful. The results show that the benefit of invaginating stripping is not as obvious as is generally suggested.

Aneurysm of the iliofemoral vein

In this clinical case we report the use of the superficial femoral vein as an autologous venous interposition graft for the reconstruction of the iliofemoral vein in a 21-year-old female who presented with an asymptomatic primary aneurysm of the left iliofemoral vein. The choice of surgical technique used is discussed.

Experience with cryopreserved arterial allografts in the treatment of prosthetic graft infections

The authors present a retrospective study on 30 patients with prosthetic graft infection. Included are 25 patients with aortic graft infection, three with infection of a femorodistal bypass and two with infected axillofemoral grafts. There were 23 isolated primary prosthetic graft infections and seven aorto-enteric fistulas. Treatment consisted of graft excision and replacement with cryopreserved arterial homografts, harvested from brain-death multi-organ donors. The in situ technique was used in 27 cases. Eight patients died postoperatively and two deaths were from allograft related complications. The operative mortality rate was 11% for isolated aortic graft sepsis and the early limb salvage rate was 100%. Persistent or recurrent infection was noted in two cases. The mean follow-up of the series was 24.5 months and occlusive complications occurred in five patients (23%), which resulted in two major amputations. Serial CT scans showed abnormalities in six of the 22 survivors, all of them related to the aortic segment of the allograft. It is concluded that in situ reconstruction with cryopreserved arterial allografts represents an acceptable alternative, especially in the treatment of isolated aortic graft sepsis. Continued follow-up towards late deterioration and/or occlusive complications remains mandatory.

Classic versus endoscopic perforating vein surgery: a retrospective study

PURPOSE AND METHODS

In this retrospective non-randomized study the results of the FELDER technique (n = 29) were compared to two endoscopic techniques for ligation of incompetent perforating veins: using a mediastinoscope (n = 19) and laparoscopic instruments (n = 57). The indication was a venous ulcer in nine, five and thirteen patients respectively, lipodermatosclerosis in thirteen, five and twenty-four, and simple varicose veins in the remaining patients (NS).

RESULTS

The mean number of interrupted perforating veins was 4.2, 2.4 and 3.8 (p < 0.05). The mean hospital stay was 3.5, 1.9 and 1.6 days (p < 0.0001). The mean period of convalescence was 8.7, 4.1 and 3.7 weeks (NS). The number of complications was 9 (suralis lesion 4, pain/swelling 4, wound problem 1), 6 (saphenous lesion 3, pain/swelling 3) and 15 (pain/swelling 14, deep venous thrombosis 1) (NS). Ten patients were lost to follow-up (five, two and three). Respectively 19, 12 and 45 patients were satisfied with the end-result. The condition had worsened in one, two and three patients (NS). During the short follow-up period all ulcers healed and there was no recurrence.

CONCLUSIONS

The endoscopic techniques produce results comparable to the FELDER procedure, with smaller scars and a tendency towards a faster recovery.

The venous thrombectomy: obsolete or forgotten?

This report describes the surgical management of three patients with an extended ilio-femoral deep venous thrombosis. In the first patient a residual occlusion of the common iliac vein was treated conservatively and this patient developed severe chronic venous insufficiency. In the second patient a residual (sub)occlusion of the common iliac vein was treated with a stent and this patient remained asymptomatic with two years follow-up. In the third patient no residual or underlying anatomical abnormality was found with a good result at one year. Venous thrombectomy still has a place in the treatment of deep venous thrombosis and the long term results may be improved by application of endovascular techniques.

Inflammatory abdominal aortic aneurysms. A retrospective study of 110 cases

OBJECTIVE

The purpose of this study is to review our experience with the surgical treatment of 110 patients with an inflammatory abdominal aortic aneurysm (IAAA). Furthermore, we focus especially on 37 ureteral obstructions.

PATIENTS AND METHODS

Between 1978 and 1996 we treated 110 patients for an IAAA. It concerned 101 men and nine women with mean age of 66.8 years. Emergency surgery was performed in 32 patients (13 ruptures) and elective surgery in 78 patients (only 23 asymptomatic). The IAAA diagnosis was made by CT scan preoperatively in 40% of the patients. Compression of 37 ureters in 23 patients (14 bilateral, 9 unilateral) was noticed and ureteral stenting was performed preoperatively in nine patients (12 ureters). The surgical approach was median laparotomy (88 patients) or retroperitoneal approach (21 patients). One patient was treated with an endovascular Min-Tec Stentor aortic graft by femoral approach. Suprarenal clamping was necessary in 44 patients. Ureterolysis of 23 ureters was performed. Three peroperative iatrogenic lesions were successfully treated intraoperatively.

RESULTS

Fatal complications occurred in nine patients (8%), five patients after urgent surgery and four patients after elective surgery, all of them related to technical problems. Non fatal complications occurred in 22 patients, renal insufficiency was most important in ten patients (two permanent dialysis). The mean follow-up was 4.5 years (range, 0.5 to 15 years). Late survival was 68% at 5 years and 42% after 10 years. Seven patients presented late graft related complications, one fatal. In 14 surviving patients with 21 ureterolysed ureters, one needed a nefrectomy and one a bilateral Boari-plasty. In eight surviving patients with 11 stented ureters, one patient needed a small bowel interposition for ureteral stricture. After CT evaluation, all ureteral stents were removed 3 to 6 months after surgery.

CONCLUSIONS

1. Surgery for IAAA is quite complex. Mortality and morbidity are often associated with emergency or combined vascular and non vascular procedures. 2. When carefull operative repair is performed with minimal dissection of structures from the aneurysmal wall, excellent results can be expected. 3. Ureteral compression should be treated by ureteral stenting, preoperatively, to facilitate ureterolysis or even to avoid it. Regular follow-up CT control is recommended.

The clinical value of duplex surveillance following internal carotid artery reconstruction

BACKGROUND

The purpose of this retrospective analysis was to evaluate the benefit of a yearly duplex ultrasonography of both the reconstructed and the contralateral internal carotid artery (ICA).

METHODS

From 1985 to 1994, 1210 unilateral, primary ICA reconstructions were performed. Although these patients received yearly invitations, duplex follow-up was not available in 114 patients (9%).

RESULTS

At 5 years a stenosis of 50% or more was found in 9% and at 10 years in 14% of patients. During the follow-up period 20 patients developed a stenosis of 80-99%. Ten patients had a redo-procedure. The others remained asymptomatic, even though one patient developed an occlusion. A stroke occurred in 96 patients. 58 of these had no significant stenoses. 57% of all patients had no significant contralateral lesion at the time of the first procedure. In only 4% of these a contralateral CAE was performed during the follow-up.

CONCLUSIONS

In view of the above data, we would conclude that the clinical benefit of duplex surveillance is doubtful.

Transfemoral treatment for iliac occlusive disease with endoluminal stent-grafts

OBJECTIVES

Percutaneous treatment of iliac artery occlusive disease has replaced open vascular reconstruction for several indications. A balloon angioplasty with or without stent is not an option in the presence of infrainguinal extension of the disease. The authors describe a technique that allows the construction of an aorto- or iliofemoral graft through a single groin incision, using a 4 mm PTFE graft, anchoring it proximally with a Palmaz stent and dilating both to the desired diameter.

DESIGN

Retrospective non-randomised study.

MATERIALS AND METHODS

Nineteen procedures were performed in 16 patients mainly because of ischaemic rest pain, often with trophic skin changes or minor gangrene. Three patients had a bilateral procedure. Twelve patients had one or more associated procedures: 10 distal bypasses, one thrombectomy, one reimplantation of a distal bypass on the iliofemoral graft, one contralateral profundaplasty and two stents of the contralateral common iliac artery.

RESULTS

Two patients died, one of small bowel ischaemia and the other of a myocardial infarction. During the mean follow-up of 8.8 months, two graft thromboses occurred. In another patient bilateral stenting of a residual stenosis was necessary.

CONCLUSIONS

Our experience shows that the reported technique is feasible. Whether the procedure is truly "less invasive" and the long-term results acceptable remains to be shown.

Stent grafts for iliofemoral occlusive disease

This report summarizes the technical feasibility and early results of endovascular iliofemoral stented grafts in the treatment of iliofemoral occlusive disease. Twenty-four patients (mean age 71 years) underwent 29 lower-extremity inflow procedures for claudication (n = 7) or limb threatening ischaemia (n = 17). The technical success rate for endovascular grafts was 93% (n = 27). Some 85% of the grafts originated from the aortoiliacjunction or the common iliac arteries. Outflow procedures were performed in all cases and consisted of profundaplasty (n = 17) and/or femorodistal grafting (n = 13). The operative mortality rate was 9% and one occlusion was noted in the early postoperative period. The mean (s.d.) primary and secondary cumulative patency rates after 1 year were 85(10)% and 95(5)% respectively. The corresponding limb salvage rate was 95(4)%. The authors conclude that endovascular iliofemoral stented grafts through a single groin incision are technically feasible and that early patency rates are acceptable. More experience is needed however before widespread application of these new techniques can be justified.

Ehlers-Danlos syndrome type IV: a heterogeneous disease

The Ehlers-Danlos syndrome is an inherited disorder of connective tissue, consisting of at least 10 different clinical subtypes. Type IV Ehlers-Danlos syndrome is an autosomal dominant condition characterized by the joint and dermal manifestations as in other forms of the syndrome but also by the proneness to spontaneous rupture of bowel and large arteries. The authors describe their experience with three patients presenting type IV Ehlers-Danlos syndrome: the first presented with several subsequent arterial ruptures, the second with multiple aneurysms, and the third with a dissection of the internal carotid artery. Clinical features, incidence, diagnosis, and treatment of the syndrome are discussed.

The value of carotid stump pressure and EEG monitoring in predicting carotid cross-clamping intolerance

The authors analyse their experience with carotid stump pressure (CSP) and electro-encephalogram (EEG) monitoring in relation to the incidence of peroperative stroke during internal carotid artery reconstruction. A series of 215 patients is presented, among whom six (2.8%) developed a peroperative stroke. The stroke rate in patients with a CSP below 50 mm Hg (n = 92) was 7% (2/27) without a shunt and 3% (2/62) with the use of a shunt. The respective numbers for patients with a CSP equal to or above 50 mmHg were 1.7% (2/123) and 0% (0/10). The EEG remained normal after cross clamping in 180 cases (84%): the incidence of stroke was 1.5% (2/138) without and 5% (2/42) with a shunt. A shunt was used in 33 of the 35 patients with EEG changes after cross clamping. None of them sustained a stroke in contrast to both patients where despite EEG changes no shunt was used (respective stroke rates 0% and 100%). It is concluded that regarding cerebral function, EEG monitoring provides more accurate information than CSP.

Microbiological monitoring of aortic aneurysm sac contents during abdominal aneurysmectomy: results in 176 patients and review of the literature

To investigate the clinical significance of intraoperative cultures, aneurysmal thrombus was cultured in 176 patients with clinically non suspected infected abdominal aortic aneurysm. The incidence of positive cultures was 14.2% and 88% of the microorganisms were Gram-positive. Differences between elective and urgent reconstruction were not significant. During follow-up, there were no cases of graft infection in either group. Review of the literature shows a positive culture rate of 19% in a series of 1867 patients. 93% Of the microorganisms are Gram-positive and 78% are considered as contaminants. The incidence of graft infection is 1.99% in the group with positive culture and 0.7% in the series with negative culture (P = 0.06). It is concluded that the clinical significance of routine cultures in clinically non suspected infected aortic aneurysms is negligible.

Carotid surgery in octogenarians: is it worthwhile?

Controversy surrounds the role of carotid endarterectomy in octogenarians. Although the prognosis of severe degree carotid stenosis is more ominous in the elderly, operative risk seems more important in the aged. To evaluate the presumed detrimental effect of advanced age on the mortality-morbidity of carotid endarterectomy, the authors reviewed their common experience with carotid surgery in patients aged 80 years or more. From 1980 to 1994, 129 octogenarians were operated on for occlusive carotid artery disease in two university hospitals. The data for these patients, 80 years of age and older (group 1) are compared to these for a large middle age group (less than 80 years) (group 2) operated by the same surgeons during that period. The baseline characteristics of both groups were similar, except for smoking, diabetes and previous myocardial revascularization, more prevalent in the younger age group. In the elderly group prophylactic surgery for asymptomatic stenosis was done in 36%, versus 40% of the middle aged patients, and for stroke in evolution in 8% versus 4% (p < 0.05). The perioperative stroke rate was 0.8% in the group older than 80 years, compared to 1.2% for non octogenarians (NS). The operative mortality was similar for both age groups (2.3 and 1.5 respectively). The long-term results gave a similar outlook for both age groups. The 5-year stroke-free rate reached 89% for group 1 versus 91% for group 2. The 5-year survival rate, however, was less for the elderly patients (47% versus 77%, mean follow-up periods of 30 and 49 months). These results suggest that carotid endarterectomy can be safely done in elderly patients, with a similar risk/benefit ratio as for the younger patients. Advanced age, by itself, is not to be considered as contraindication to carotid surgery.

Technique and early results of videoscopic lumbar sympathectomy

The authors describe their technique of videoscopic (VS) lumbar sympathectomy (LSE), compared to the open LSE. From 1992 to 1994, 21 open and 19 VS LSE were performed. The indication was reflex sympathetic dystrophy in 17 and arterial insufficiency in 23 patients. In the open LSE the mean duration of anaesthesia was 80 min (55-115) and of surgery 37 min (25-65). The length of the chain removed varied from 1 to 3 ganglia (6-7 cm). Complications were noted in 5 patients: 1 pneumonia, 2 superficial wound problems and 2 cases of postsympathectomy neuralgia. Hospital stay of patients with RSD varied from 2 to 5 days. Of the 19 attempts to perform a VS LSE 4 had to be converted to the open technique. The duration of anesthesia was 150 min (90-280) and of surgery 92 min (45-240). Lengths of chain removed varied from 1 to several ganglia (6-7 cm). A pneumoperitoneum was present in 10 procedures, but a Veress needle was placed in only 4 of these. Complications were present in 9 patients: 1 important subcutaneous emphysema, 1 severe costal pain, 2 neuralgia, 1 temporary psoas dysfunction, 1 haemorrhage from a lumbar vein with conversion to the open technique and 3 minor superficial wound problems. The hospital stay ranged from 2 to 5 days. This study suggests that the VS LSE has no benefit over the open technique as far as the operative and early results are concerned. Whether this technique avoids some of the late disadvantages of a lumbotomy remains to be seen.

Autogenous reconstruction with the lower extremity deep veins: an alternative treatment of prosthetic infection after reconstructive surgery for aortoiliac disease

PURPOSE

This report evaluates the efficiency of use of the lower extremity deep vein as arterial conduits in the autogenous repair of prosthetic infection after reconstructive aortoiliac surgery.

METHODS

We reviewed our records for the period 1990 to 1994 of all patients with prosthetic infection after reconstruction for aortoiliac disease, and we selected for this study all those patients who underwent autograft repair with the lower extremity deep veins.

RESULTS

Included were 15 patients: 12 had previously undergone direct aorto(ilio)femoral reconstruction, and three had an extraanatomic prosthetic graft. Thirteen patients were admitted with primary graft infection, and two were admitted with secondary graft-enteric erosion. Treatment consisted of prosthetic excision and aorto(ilio)femoral reconstruction with the superficial femoral vein. In situ reconstruction was performed in 12 cases. The operative mortality rate was 7%. There were no early graft occlusions. One patient underwent an above-knee amputation because of concomitant femoropopliteal occlusion in the presence of a patent deep venous aortofemoral graft. Early postoperative limb swelling was common and was controlled with bed rest, elastic stockings, or intermittent pneumatic compression. The mean follow-up of this series was 17 months (range 4 to 33 months). Two patients died of unrelated causes. One graft occluded after 16 months. There were no reinfections, and all but one patient resumed normal daily activities. Disability from removal of the deep veins was minimal: only one patient continues to wear elastic stockings for limb swelling and shows signs of venous hypertension more than 2 years after surgery.

CONCLUSION

Harvesting of the lower extremity deep veins is well tolerated. Autogenous reconstruction with these veins provides good potential for salvage of life and limbs in case of prosthetic infection. A longer period of follow-up is required to study the long-term behavior of these grafts and to allow definite comparison with more conventional approaches.

Recurrent aortic infection: treatment by arterial homograft replacement

Deep infection remains the most problematic complication following prosthetic aortoiliofemoral reconstruction. Prosthetic excision and extra-anatomic revascularization is associated with significant morbidity and mortality. The possibilities of autogenous reconstruction are frequently limited. The authors present a patient with recurrent aortic infection who was successfully treated by prosthetic excision and revascularization in situ with a cryopreserved arterial homograft.

Early inflammatory response to gelatin- and collagen-sealed Dacron prostheses

The immediate inflammatory response following aortic reconstruction with two types of sealed Dacron grafts was studied in a prospective, randomized manner. C-reactive protein (CRP) levels were measured before surgery and on days 2 and 8 postoperatively. In the collagen-sealed group (n = 10) CRP levels were 10 +/- 9.6, 180.2 +/- 48.3, and 54.3 +/- 34.3 mg/L, respectively. In the gelatin-impregnated group (n = 10) the values were 10.5 +/- 8.7, 200.7 +/- 27.3, and 80.3 +/- 30.2 mg/L, respectively. The slight differences were not significant according to the analysis of variance test for repeated measurements. These findings suggest that implantation of a knitted Dacron graft sealed with collagen does not lead to a higher inflammatory reaction compared with a gelatin-sealed graft.

Diagnostic value of 99Tcm-d,l-HMPAO-labelled leukocyte scintigraphy in the detection of vascular graft infections

Prosthetic vascular graft infection is a relatively uncommon complication of peripheral vascular surgery. We retrospectively analysed technetium-99m-d,l-hexamethylpropylene amine oxime (99Tcm-d,l-HMPAO) labelled leukocyte scans of 21 patients with a suspected vascular graft infection. Operative findings, bacteriological cultures, radiological findings or clinical follow-up were used to confirm the diagnosis. We found eight true-positive and six true-negative cases. There were no false-positive scintigraphic diagnoses. The false-negative rate was 33% (n = 7). Our results show a sensitivity of 53%, a specificity of 100% and an accuracy of 66%. The conclusion is that a negative 99Tcm-d,l-HMPAO-labelled leukocyte scan is of limited value in ruling out a vascular graft infection. A combination of computed tomography (CT-scan) and a 99Tcm-d,l-HMPAO-labelled leukocyte scan is probably the most efficient way of diagnosing a vascular graft infection.

Atheromatous embolization precipitated by oral anticoagulants

Five patients with a "blue or purple" toe syndrome due to atheromatous embolization probably precipitated by oral anticoagulant therapy are reported. In four, the symptoms started a few weeks after initiation of oral anticoagulants and in the fifth they were clearly aggravated by coumarinic drugs. Prior to anticoagulation, one patient had received a course of thrombolytic therapy and two had undergone an arterial catherization without embolic events. A diagnostic arteriography performed in four patients caused no new symptoms. All patients had advanced atherosclerosis. A shaggy aorta and/or pelvic arteries were found in four and in the fifth a highly stenotic femoral lesion appeared the source of peripheral embolization. Oral anticoagulants were interrupted in all five and four underwent reconstructive vascular surgery to eradicate the nidus of atheromatous emboli. One died postoperatively from multiple organ failure. The poor condition of the fifth patient precluded aorto-iliac surgery. No new episodes of embolization occurred and the symptoms disappeared, although one patient needed a toe amputation for a skin lesion that had proceeded to gangrene. The possible role of anticoagulant drugs in precipitating atheromatous embolization is discussed and the importance of recognizing the syndrome is emphasized.

Local thrombolysis for occluded arterial grafts: is the yield worth the effort?

This study reports the results and complications of local thrombolytic therapy of 50 recently occluded grafts. These occurred in 41 patients with acute severe but still reversible ischemia. The majority were infra-inguinal synthetic grafts. Thrombolysis was induced with urokinase (n = 1), streptokinase (n = 11) or alteplase (n = 38) via an intra-arterial catheter. Complete angiographical lysis was obtained in 36 grafts (72%) and partial lysis in 6 (12%). The highest lysis rate was obtained with alteplase (32/36; 89%). Complementary endovascular and/or surgical intervention was needed in 17 patients to correct an underlying stenosis and/or to save the limb. Fifteen complications occurred (30%) of which distal embolization (n = 4) and bleeding (n = 8 of which 3 fatal) were the most frequent. Six of the bleeding episodes occurred in patients on chronic aspirin intake. The late results were poor. At six months, the primary patency of successfully lysed grafts dropped to 19% and the limb salvage rate to 64%. Thrombolytic therapy is far from the ideal management of thrombosed grafts: maintenance of restored patency is the challenge.

Carotid artery surgery in the presence of an occlusion of the contralateral carotid artery: perioperative risk analysis and follow-up

A retrospective study of 129 carotid artery reconstructions with an occlusion of the contralateral internal carotid artery (group CO) is presented. A control group comprised 489 patients with a stenosis of < 50% at the contralateral side (group CN). Both groups had the same mean age. There were fewer women in group CO (14% versus 31%, P < 0.0001), and more patients had a history of coronary heart disease (57% versus 44%, P < 0.05). In addition more patients of group CO had suffered a stroke (36% versus 27%, P < 0.05). A temporary shunt was used selectively and more frequently in group CO (87% versus 31%, P < 0.001). Major postoperative complications occurred with equal frequency in both groups: all strokes plus non-cerebral mortality (total combined morbidity and mortality): 4.65% versus 5.5%. The late incidence of stroke was the same in both groups: 8% in CO and 7% in CN at 5 years. The authors conclude that, under the described circumstances and with the appropriate surgical technique, the presence of an occlusion of the contralateral internal carotid artery does not imply an increase in major postoperative complications nor a higher stroke rate during follow-up.

Transperitoneal versus extraperitoneal approach for routine vascular reconstruction of the abdominal aorta

In this non-randomised retrospective study we have compared 79 cases with transperitoneal approach and 90 cases with extended postero-lateral extraperitoneal approach for elective reconstruction of the infrarenal aorta. In the extraperitoneal group more patients were diabetic (7.8% vs 1.3%, p < 0.05) or had a serum creatinine of more than 1.5 mg % (10.1% vs 2.5%, p < 0.05). The study shows that in spite of a higher proportion of risk factors, a longer preparation (61' vs 44', p < 0.001), dissection (55' vs 46', p < 0.05) and total procedure time (193' vs 173', p < 0.05), the need for more blood transfusion (2.8 U vs 2.3 U, p < 0.05) and colloid perfusion (2.1 L vs 1.8 L, p < 0.05) in the extraperitoneal group, the incidence of complications is not higher compared to the transperitoneal group (29% vs 24%, NS). On the contrary, problems of intestinal transit were found exclusively in the transperitoneal group (7.6%, p < 0.01). Therefore it seems that, as far as the peri- and postoperative period is concerned the extraperitoneal approach might be the technique of choice for the simple elective infrarenal aorta reconstructions.

Paraprosthetic fistula after aortobifemoral prosthetic reconstruction: treatment by autogenous saphenous venous replacement. A case report

Paraprosthetic fistula is a rare but dramatic complication of aortofemoral prosthetic reconstruction. Conventional treatment consisting of removal of the prosthesis and extra-anatomical revascularization results in a high morbidity and mortality rate. The authors present a patient with a paraprosthetic fistula, who was successfully treated by excision of the graft and "in situ" replacement by autogenous saphenous vein.

The superficial femoral vein as autogenous conduit in the treatment of prosthetic arterial infection

Autogenous reconstruction is a well-accepted alternative treatment for prosthetic infection after reconstructive arterial surgery. Because of its technical complexity and the lack of suitable substitutes, the procedure remains limited to a few selected centers. We describe four patients with prosthetic infection after reconstructive surgery for lower limb ischemia. Treatment consisted of prosthetic excision and aortofemoral grafting with the use of the superficial femoral vein. All patients survived the operation and infection was eradicated in all cases. We conclude that the superficial femoral vein represents an acceptable arterial conduit in the treatment of these difficult cases.

Blood pressure management during aortic surgery: urapidil compared to isosorbide dinitrate

The efficacy and hemodynamic effects of urapidil, an arteriolar vasodilator, and isosorbide dinitrate, a venodilator, were compared, when used for blood pressure control during abdominal aortic surgery. Urapidil is an alpha-adrenergic receptor antagonist with serotonin-1A receptor-agonist activity in the central nervous system. Hemodynamic profiles were recorded before and after the administration of the study drug (+/- 10 minutes before aortic clamping), 3 and 10 minutes following aortic clamping, and before and 3 and 10 minutes following the removal of the aortic clamp. Arterial and mixed venous oxygen contents were compared. Both groups of 18 patients were similar with respect to demographic profiles, anesthetic technique, and perioperative fluid therapy. Identical heart rate and blood pressure profiles were obtained. In contrast to isosorbide dinitrate, urapidil produced a 17% (P < 0.05) increase in cardiac index as a result of a 30% (P < 0.001) decrease in systemic vascular resistance before placement of the aortic clamp. In patients treated with urapidil, cardiac index was higher (P < 0.05) 10 minutes after aortic clamping, before removal of the clamp, and 10 minutes later. The arterio-venous oxygen content difference decreased from 3.2 +/- 0.8 mL O2/dL to 2.4 +/- 1.0 mL O2/dL (P < 0.01) following urapidil, but did not change during the administration of isosorbide dinitrate. It is concluded that urapidil is an effective and safe drug for the prevention of the hemodynamic consequences of aortic clamping. Compared to a venodilator (isosorbide dinitrate), urapidil offers the advantage of improving cardiac output and oxygen delivery.