Pitfalls in achieving the Dialysis Outcome Quality Initiative (DOQI) guidelines for hemodialysis access?

The Dialysis Outcome Quality Initiative (DOQI) mandates that 50% of permanent hemodialysis (HD) access be native arteriovenous fistulae (AVFs). Recent reports have shown that when these guidelines are followed, the percentage of new AVFs can exceed DOQI guidelines. From July 1998 to July 2001, 330 HD access procedures were performed in an academic tertiary care center. Patients were categorized into two groups. Group I followed DOQI guidelines and underwent history and physical examination; duplex vein mapping; use of basilic vein transposition; and a postoperative protocol to determine maturation and start needle access in a stepwise progression. Group II had history and physical examination and basilic vein transposition was not used. Patient data were retrospectively reviewed. Overall, 100 (31%) HD shunts were AVFs. Group I (42/183, 23%) had significantly less AVFs (p = 0.005) than group II (58/147, 39%). For first-time placement of HD access, there was no significant difference (p = 0.95) in the percentage of AVFs in group I (26/62, 42%) and group II (29/68, 43%). For patients with prior history of HD access, significantly less AVFs (p <0.001) were placed in group I (16/121, 13%) than in group II (29/79, 37%). Group I had significantly less first-time HDS (P = 0.03) than group II, 34% VS. 46%, respectively. AVF maturation for hemodialysis occurred in 79% of group I and 71% of group II (P = 0.52). There were no significant differences (P > 0.05) when comparing age, gender, and incidence of diabetes between the two groups. AVF formation based largely on duplex vein mapping in group I and lack of basilic vein transposition in group II contributed to the inability to achieve DOQI guidelines. Integration of knowledge and practice among vascular surgeons may help to avoid these pitfalls.

Outcome of venous stasis ulceration when complicated by arterial occlusive disease

OBJECTIVE

to report the outcome of patients with venous stasis ulceration (VSU) and severe arterial occlusive disease (AOD).

DESIGN

retrospective study.

METHODS

using the International Classification of Diseases (ICD-9), codes for VSU and AOD were cross-matched to identify patients from 1989 to 1999 at two tertiary hospitals. Entry into the study required the presence of a VSU and an ipsilateral procedure to improve AOD or major amputation during the same hospitalisation.

RESULTS

fourteen patients (15 extremities) with a mean age of 80 years (range: 47-93) were identified as having VSU and AOD. Mean duration of VSU up to the time of revascularisation or amputation was 6.4 years (range: 4 months-21 years). The mean number of VSUs per extremity was 2.1 and mean wound area was 71 cm(2). Mean ankle-brachial index was 0.46 (range: 0.10-0.78). Nine extremities (60%) had a bypass procedure, 3 (20%) had an interventional procedure, 1 (0.6%) had a lumbar sympathectomy, and 2 (13%) had an amputation. Over a mean follow-up of 2.8 years, 3 extremities (23%) healed of which 2 recurred. On last review, 11 patients with 12 afflicted extremities had expired. Nine of the remaining 10 extremities were not healed at the time of death. Eight of nine bypass grafts remained patent in follow-up or at death and subsequent limb salvage was 100%.

CONCLUSIONS

combined VSU and AOD represents a rare condition predominantly found in elderly patients with multiple comorbidities. Few patients had complete healing despite an arterial inflow procedure and mortality was high over the short term.

Mechanism of failure in the treatment of type II endoleak with percutaneous coil embolization

PURPOSE

Type II endoleak after endovascular abdominal aortic aneurysm repair is a failure of aneurysm sac exclusion with unknown long-term consequences. Elevated aneurysm sac pressures documented in these patients have led us to aggressively treat type II endoleaks with percutaneous transluminal coil embolization (PTCE). The purpose of this study was to evaluate the results and the mechanisms of failure of PTCE for type II endoleak.

METHODS

One hundred ninety-one patients underwent endograft repair of infrarenal aortic aneurysms. Twenty-three of 28 patients with persistent primary (>3 months) or secondary (new-onset) endoleak underwent angiography; 14 of these patients had type II endoleaks. We reviewed our endovascular registry data, hospital charts, and radiologic studies of patients with type II endoleaks and analyzed the results in those treated with PTCE of the inflow vessel.

RESULTS

All 14 patients with type II endoleaks were men, with a mean age of 76.7 years and a mean preoperative maximal aneurysm diameter of 5.7 +/- 1.0 cm. The type II endoleak was primary in 12 patients (86%) and secondary in two patients (14%) and iliolumbar in 11 patients (78%) and mesenteric in three patients (21%). Although a dominant affluent collateral channel (inosculation) was apparent in eight patients (57%), six patients (43%) showed a network of collateral vessels (retiform anastomosis). In six patients (43%), angiography revealed a second or "outflow" vessel indicative of a complex endoleak. In four patients with retiform iliolumbar type II endoleaks, PTCE was not attempted because of the retiform nature of the endoleak. The remaining 10 patients underwent PTCE, with coil deployment in all 10 and apparent initial technical success in nine patients. Follow-up computed tomographic scans revealed persistent endoleaks in six patients (60%). Mechanisms of failure included persistent flow through the coils in the treated vessel in two patients, development of a retiform anastomosis around the coiled vessel in three patients, and development of a new mesenteric endoleak after successful occlusion of an iliolumbar endoleak in one patient. Two patients underwent repeat PTCE with successful aneurysm sac exclusion in one. Internal iliac artery injury complicated one of the 12 PTCEs, and the resulting pseudoaneurysm was successfully treated with PTCE. Angiographic visualization of an outflow vessel (complex endoleak) was associated with PTCE failure (P =.008).

CONCLUSION

PTCE of type II endoleaks has a high failure rate because of multiple anatomic mechanisms.

The use of color-flow duplex scan for the detection of endoleaks

OBJECTIVE

Computed tomographic (CT) scan represents the criterion standard for surveillance of endoleaks after endoluminal repair of abdominal aortic aneurysms (erAAAs). Given need for surveillance, risks, and expense of CT scan, the accuracy of color-flow duplex (CFD) scan after erAAA was determined.

METHODS

During a 43-month period, patients enrolled in phase II and III of the AneuRx Multicenter Clinical Trial at our institution underwent CFD scan 1 month after erAAA. Patients with CFD scan results that were positive for endoleak underwent CT scanning at 3 months after erAAA, and those with CFD scan results that were negative for endoleak underwent CT scanning at 6 months after erAAA.

RESULTS

Seven of 79 patients (9%) who underwent CFD and CT scanning had the diagnosis of endoleak. All endoleaks that were diagnosed with CT scan were detected with CFD scan. One patient had positive results for endoleak with CFD scan at 1 month and then negative results with CT scan at 3 months. Although this may represent resolution of endoleak, this case was counted as a false-positive result. When compared with CT scan, CFD scan had a sensitivity of 100%, specificity of 99%, positive predictive value of 88%, negative predictive value of 100%, and accuracy of 99%.

CONCLUSION

CFD scan is an accurate test for the detection of endoleak after erAAA. In addition, most endoleaks diagnosed with CFD scan at 1 month continued to be present at 6 months. This important finding increases the emphasis on the use of this noninvasive test and may initiate earlier intervention of endoleak.

Nature and significance of endoleaks and endotension: summary of opinions expressed at an international conference

OBJECTIVE

Endoleaks and endotension are critically important complications of some endovascular aortic aneurysm repairs (EVARs). For the resolution of controversial issues and the determination of areas of uncertainty relating to these complications, a conference of 27 interested leaders was held on November 20, 2000.

METHODS

These 27 participants (21 vascular surgeons, five interventional radiologists, one cardiologist) had previously answered 40 key questions on endoleaks and endotension. At the conference, these 40 questions and participant answers were discussed and in some cases modified to determine points of agreement (consensus), near consensus (prevailing opinion), or disagreement.

RESULTS

Conference discussion added two modified questions for a total of 42 key questions for the participants. Interestingly, consensus was reached on the answers to 24 of 42 or 57% of the questions, and near consensus was reached on 14 of 42 or 33% of the questions. Only with the answers to four of 42 or 10% of the questions was there persistent controversy or disagreement.

CONCLUSION

The current endoleak classification system with some important modifications is adequate. Types I and II endoleak occur after 0 to 10% and 10% to 25% of EVARs, respectively. Many (30% to 100%) type II endoleaks will seal and have no detrimental effect, which never or rarely occurs with type I endoleaks. Not all endoleaks can be visualized with any technique, and increased pressure (endotension) can be transmitted through clot. Aneurysm pulsatility after EVAR correlates poorly with endoleaks and endotension. An enlarging aneurysm after EVAR mandates surgical or interventional treatment. These and other conclusions will help to resolve controversy and aid in the management of these vexing complications and should also point the way to future research in this field.

Endovascular management of iliac limb occlusion of bifurcated aortic endografts

Although aortic endograft iliac limb occlusion is an uncommon event, its treatment is problematic because standard surgical thrombectomy risks graft dislodgment or component separation. Although femorofemoral bypass grafting can restore perfusion to the affected limb, its longevity may be inferior to reestablishing patency of the endograft itself and represents a failure of the endograft procedure. With aortic endografts now commercially available, implanting surgeons must be aware of this important complication and well versed in all of the endovascular treatment options. We report three cases of endoluminal management of unilateral iliac limb occlusion of bifurcated aortic endografts.

Carotid endarterectomy in women: challenging the results from ACAS and NASCET

OBJECTIVE

To evaluate and compare the short- and long-term outcomes in female and male patients after carotid endarterectomy (CEA).

SUMMARY BACKGROUND DATA

Randomized carotid trials have clearly shown the benefits of CEA in specific symptomatic and asymptomatic patients. However, the short- and long-term benefits in women appear to be less clear, and the role of CEA among women with carotid disease remains uncertain.

METHODS

During a 21-year period, 1,204 CEAs were performed, 464 (39%) in women and 739 (61%) in men. Complete follow-up was available in 70% of patients.

RESULTS

Women were less likely to have evidence of coronary artery disease, were more likely to be hypertensive, and had a significantly greater incidence of diabetes. The mean age at CEA was 68.5 +/- 9.5 years for women and 68.0 +/- 8.5 years for men. There were no significant differences in the use of shunts, patching, tacking sutures, or severity of carotid stenoses between men and women. Surgical death rates were nearly identical for asymptomatic and symptomatic patients. Perioperative stroke rates were similar for asymptomatic and symptomatic patients. Life-table stroke-free rates at 1, 5, and 8 years were similar for asymptomatic women and men and symptomatic women and men. Long-term survival rates at 1, 5, and 8 years were higher for asymptomatic women compared with men and for symptomatic women compared with men. As a result, stroke-free survival rates at these follow-up intervals were greater for asymptomatic women compared with men, and for symptomatic women compared to men.

CONCLUSIONS

The results from this study challenge the conclusions from the Asymptomatic Carotid Endarterectomy Study and the North American Symptomatic Carotid Endarterectomy Trial regarding the benefits of CEA in women. Female gender did not adversely affect early or late survival, stroke-free, or stroke-free death rates after CEA. The authors conclude that CEA can be performed safely in women with asymptomatic and symptomatic carotid artery disease, and physicians should expect comparable benefits and outcomes in women and men undergoing CEA.

A prospective study of discharge disposition after vascular surgery

OBJECTIVE

The purpose of this study was to determine what factors are predictive of a decline in independent living after vascular surgery during recovery.

METHODS

Demographics, risk factors, operations, complications, wound status, and discharge disposition for all patients admitted to a tertiary vascular surgery service for any surgical procedure were prospectively recorded at the time of discharge. The declining order of dispositions at discharge were home (no professional assistance), home (professional assistance), rehabilitation facility, and skilled nursing facility.

RESULTS

Over a 15-month period, 380 patients underwent 442 primary operations. Primary operations included 74 (17%) carotid procedures, 38 (8%) aortic procedures, 186 (42%) extremity revascularizations, 29 (7%) major amputations, 45 (10%) minor amputations, and 70 (16%) other. There were 148 (33%) complications and 85 (20%) subsequent operations (same hospitalization); 159 (36%) open wounds occurred. Forty-six percent of the patients were discharged to home (no professional assistance), 28% to home (professional assistance), 3% to a rehabilitation facility, and 18% to a skilled nursing facility; 5% died. At discharge, 51% of patients required professional assistance, 39% had a decline in disposition, and 12% went from home (+/- professional assistance) to a facility. By multivariate regression analysis, a hospital stay more than 6 days, emergency operation, open operative wound, systemic complications, and minor amputation were significantly associated (P <.001) with a decline in disposition at discharge (odds ratios: 5.5, 3.7, 3.6, 3.6, and 2.8, respectively).

CONCLUSIONS

Prospective study reveals that a large proportion of patients (39%) had a decline in disposition after vascular surgery. A hospital stay more than 6 days, emergency operation, open operative wound, systemic complications, and minor amputation were strong independent predictors of decline. This information suggests modifications in treatment strategies may improve independent living status after vascular surgery and decrease the intense use of extended care resources required for this patient population during recovery.

Management of ectatic, nonaneurysmal iliac arteries during endoluminal aortic aneurysm repair

PURPOSE

Most endografts for an endoluminal AAA repair cannot achieve an adequate hemostatic seal in ectatic common iliac arteries larger than 14 mm. The extension of the endograft into the external iliac artery can alleviate this problem but requires sacrifice of the internal iliac artery. We have used the larger diameter aortic extension cuff to obtain adequate endograft to arterial wall apposition in patients with ectatic, nonaneurysmal common iliac arteries. Because of the resultant flared configuration of the iliac limb, the technique is termed bell-bottom. However, it is unknown whether subsequent enlargement of these ectatic common iliac arteries that will lead to endoleaks or endograft migration will occur.

METHODS

The records of all 96 patients who have undergone endoluminal abdominal aortic aneurysm repair at our institution were reviewed. Fourteen patients were identified in whom aortic extension cuffs were placed into 18 ectatic (>14 mm, but <20 mm) common iliac arteries. The mean follow-up time was 14 months (range, 6-24 months). The maximal diameter of the common iliac artery on computed tomography scan before endograft placement was compared with the maximal diameter at the most recent follow-up. The incidence of endoleaks, ruptures, and endograft migration related to the "bell-bottom" technique were recorded.

RESULTS

The mean preoperative common iliac artery diameter was 18 mm (range, 15-20 mm). Aortic extension cuffs of 20-mm diameter and 24-mm diameter were used in 14 and 4 common iliac arteries, respectively. The diameter did not change in 11 common iliac arteries (61%), increased by 1 mm in 4 common iliac arteries (22%), and decreased by 1 mm in 3 common iliac arteries (17%). No endoleaks, ruptures, or endograft migration related to this technique was identified.

CONCLUSION

The use of aortic extension cuffs for ectatic common iliac arteries expands the number of patients who can be treated endoluminally without sacrifice of the internal iliac artery. Most common iliac arteries do not increase in diameter. When enlargement occurs, the degree of dilation is minimal. Therefore, the "bell-bottom" technique appears to be an acceptable option in the management of large, nonaneurysmal iliac vessels during endoluminal abdominal aortic aneurysm repair.

The AneuRx stent graft: four-year results and worldwide experience 2000

OBJECTIVE

The objective was to review the current results of endovascular abdominal aortic aneurysm repair with the AneuRx stent graft and to determine the effectiveness of the device in achieving the primary objective of preventing aneurysm rupture.

METHODS

The outcome of all patients treated during the past 4 years in the U.S. AneuRx clinical trial was determined, and the worldwide clinical experience was reviewed.

RESULTS

A total of 1192 patients were treated with the AneuRx stent graft during all phases of the U.S. Clinical Trial from June 1996 to November 1999, with follow-up extending to June 2000. Ten (0.8%) patients have had aneurysm rupture, with most ruptures (n = 6) occurring in 174 (3.4%) patients treated with an early stiff bifurcation stent graft design used in phase I and in the initial stages of phase II. Since the current, flexible, segmented bifurcation stent graft design was introduced, four (0.4%) ruptures have occurred among 1018 patients treated. Of these, one was during implantation, two were placed too far below the renal arteries, and one patient refused treatment of a type I endoleak. Kaplan-Meier analysis of all 1192 patients treated with the AneuRx stent graft including both stent graft designs revealed the patient survival rate to be 93% at 1 year, 88% at 2 years, and 86% at 3 years, freedom from conversion to open repair to be 98% at 1 year, 97% at 2 years, and 93% at 3 years, and freedom from secondary procedure to be 94% at 1 year, 92% at 2 years, and 88% at 3 years. Freedom from aneurysm rupture with the commercially available segmented bifurcation stent graft was 99.7% at 1 year, 99.5% at 2 years, and 99.5% at 3 years. The presence or absence of endoleak on contrast computed tomography scanning after stent graft placement was not found to be a significant predictor of long-term outcome measures. Worldwide experience with the AneuRx device now approaches 10,000 patients.

CONCLUSIONS

Endovascular management of abdominal aortic aneurysms with the AneuRx stent graft has markedly reduced the risk of aneurysm rupture while eliminating the need for open aneurysm surgery in 98% of patients at 1 year and 93% of patients at 3 years. The device was effective in preventing aneurysm rupture in 99.5% of patients over a 3-year period. The overall patient survival rate was 93% at 1 year and 86% at 3 years.

Carotid Endarterectomy in Women: Challenging the results from NASCET and ACAS

P203

Purpose: The randomized trials have clearly demonstrated the benefits of carotid endarterectomy in specific symptomatic and asymptomatic patients. However, the short and long-term benefits in women appear to be less clear, and the role of CEA among women remains uncertain. The purpose of our study was to evaluate and compare the outcomes in women and men after CEA. Methods: Over a recent 21 year period 1204 CEAs were performed, of which 465 (39%) were in women and 739 (61%)in men. Complete follow-up was available in 80% of patients. Results: Women were more likely to be hypertensive, and had a greater incidence of diabetes. The mean age at CEA was 68.5 ± 9.5 years for women and 68.0 ± 8.5 years for men. Operative mortality rates were nearly identical for symptomatic (women, 0.3% vs men, 0.8%) and asymmptomatic (women, 0.0% vs 0.8%)patients. Perioperative stroke rates were similar for symptomatic (women, 2.9% vs 4.5%) (p=0.27) and asymptomatic (women, 0.6% vs. men, 1.2%) (p=0.66) patients. Life-table stroke-free rates at 1, 5, and 8 years were similar for symptomatic women and men, 96% vs. 93%, 89% vs. 89%, and 83% vs. 85% (p>0.10), and asymptomatic women and men, 98% vs. 97%, 97% vs. 92%, and 97% vs. 86% (p>0.11). Long-term survival rates at 1, 5, and 8 years were higher for symptomatic women compared to men, 96% vs. 92%, 88% vs. 76%, and 67% vs. 58% (p=0.06), and for asymptomatic women as compared to men, 97% vs. 96%, 92% vs. 75%, 79% vs. 58% (p=0.01 > 5 years). As a result, stroke-free survival rates at these follow-up intervals were increased for symptomatic women compared to men, 93% vs. 89%, 76% vs. 73%, and 64% vs. 58% (p>0.11), and asymptomatic women as compared to men, 95% vs. 93%, 89% vs. 76%, and 77% vs. 64% (p>0.07). Conclusion: The results from our study challenge the conclusions from the NASCET and ACAS regarding the lack of benefit of CEA in women. Female gender did not adversely affect early or late survival, stroke-free, or stroke-free mortality rates following CEA. We conclude that CEA can be performed safely in women with symptomatic and asymptomatic carotid artery disease, and physicians should expect comparable benefits in women and men undergoing CEA.

Adverse consequences of internal iliac artery occlusion during endovascular repair of abdominal aortic aneurysms

OBJECTIVE

Embolization of the internal iliac artery (IIA) may be performed during endovascular abdominal aortic aneurysm (AAA) repair if aneurysmal disease of the common iliac artery precludes graft placement proximal to the IIA orifice. The IIA may also be unintentionally occluded because of iliac trauma or coverage by the endograft. The purpose of this study was to determine the incidence, etiology, and consequences of IIA occlusion during endoluminal AAA repair.

METHODS

Over 2 years, 96 patients have undergone endoluminal AAA repair. The details of the operative procedure, reasons for IIA occlusion, perioperative complications, and clinical follow-up were recorded.

RESULTS

The IIA was intentionally occluded in 15 patients (16%) to treat 13 common iliac artery aneurysms, one IIA aneurysm, and one external iliac artery aneurysm. The IIA was unintentionally occluded in 9 patients (9%), resulting from traumatic iliac dissection in 5 patients and coverage of the IIA by the endograft in the remaining 4 patients. Three patients had colon ischemia. One patient with a unilateral IIA occlusion had sigmoid infarction necessitating resection. The other two patients underwent intentional occlusion of one IIA followed by unintentional occlusion of the contralateral IIA because of a traumatic iliac dissection. Both had postoperative abdominal pain and distention; rectosigmoid ischemia was revealed through colonoscopy. Conservative treatment with bowel rest and broad-spectrum antibiotics was successful in both cases. Nondisabling hip and buttock claudication occurred in seven patients (32%) at 1 month but resolved by 6 months in three of these patients.

CONCLUSION

Embolization of the IIA for iliac aneurysmal disease and unintentional IIA occlusion due to trauma or graft coverage occurs in a considerable number of patients undergoing endoluminal AAA repair. Most patients with unilateral occlusion do not experience colon ischemia or disabling claudication. Therefore, unilateral embolization of the IIA is well tolerated and allows for the endoluminal treatment of patients with both an AAA and an iliac artery aneurysm, thereby expanding the number of patients who can be managed with an endovascular approach. Although acute, bilateral IIA occlusions should be avoided, significant consequences were not observed in our small series of patients.

Endoleak as a predictor of outcome after endovascular aneurysm repair: AneuRx multicenter clinical trial

OBJECTIVE

The purpose of this study was to determine whether evidence of blood flow in the aneurysm sac (endoleak) is a meaningful predictor of clinical outcome after successful endovascular aneurysm repair.

METHODS

We reviewed all patients in Phase II of the AneuRx Multicenter Clinical Trial with successful stent graft implantation and predischarge contrast computed tomographic (CT) imaging. The clinical outcome of patients with evidence of endoleak was compared with the outcome of patients without evidence of endoleak. The CT endoleak status before hospital discharge at 6, 12, and 24 months was determined by each clinical center as well as by an independent core laboratory. Endoleak status at 1 month was assessed with duplex scanning examination or CT at each center without confirmation by the core laboratory.

RESULTS

Centers reported endoleaks in 152 (38%) of 398 patients on predischarge CT, whereas the core laboratory reported endoleaks in 50% of these patients (P <.001). The center-reported endoleak rate decreased to 13% at 1 month. Follow-up extended to 2 years (mean, 10 +/- 4 months). One patient had aneurysm rupture and underwent successful open repair at 14 months. This patient had a Type I endoleak at discharge but no endoleak at 1 month or at subsequent follow-up times. There were no differences between patients with and patients without endoleak at discharge in the following outcome measures: patient survival, aneurysm rupture, surgical conversion, the need for an additional procedure for endoleak or graft patency, aneurysm enlargement more than 5 mm, the appearance of a new endoleak, or stent graft migration. Despite a higher endoleak rate identified by the core laboratory, neither the endoleak rate reported by the core laboratory nor the endoleak rate reported by the center at discharge was significantly related to subsequent outcome measures. Patients with endoleak at 1 month were more likely to undergo an additional procedure for endoleak than patients without endoleaks. Patients with Type I endoleaks at discharge and patients with endoleak at 1 month were more likely to experience aneurysm enlargement at 1 year. However, there was no difference in patient survival, aneurysm rupture rate, or primary or secondary success rate between patients with or without endoleak. Actuarial survival of all patients undergoing endovascular aneurysm repair was 96% at 1 year and was independent of endoleak status. Primary outcome success was 92% at 12 months and 88% at 18 months. Secondary outcome success was 96% at 12 months and 94% at 18 months.

CONCLUSIONS

The presence or absence of endoleak on CT scan before hospital discharge does not appear to predict patient survival or aneurysm rupture rate after endovascular aneurysm repair using the AneuRx stent graft. Although the identification of blood flow in the aneurysm sac after endovascular repair is a meaningful finding and may at times indicate inadequate stent graft fixation, the usefulness of endoleak as a primary indicator of procedural success or failure is unclear. Therefore, all patients who have undergone endovascular aneurysm repair should be carefully followed up regardless of endoleak status.

Factors affecting the diagnosis of peripheral vascular disease before vascular surgery referral

OBJECTIVE

Many new patients evaluated by vascular surgeons are referred by internal medicine physicians (IMPs). Objectives shared by vascular surgeons and IMPs include early identification of peripheral arterial disease (PAD), improved referral relationships, and reduction of health care costs. The approach to PAD by IMPs and identification of deficiencies that might contribute to suboptimal care form the basis for this report.

METHODS

An anonymous survey was mailed to all IMPs (n = 843) in the central and southern parts of Illinois. Questions concerned IMP demographics, approach to diagnostic testing, referral patterns, perception of adequacy of education of PAD, and how often parts of the history and physical examination for PAD would be performed on the initial office visit of a hypothetical 65-year-old male with hypertension (each answer measured as 0%-25%, 25%-50%, 50%-75%, and 75%-100% of the time completed).

RESULTS

There was a response from 360 IMPs: 230 IMPs (27.3%) returned the questionnaire, and 130 IMPs (15.4%) declined to participate. Practice locations for IMPs returning the questionnaire included rural (36%), suburban (22%), and urban (40%). Practice types included academic (7%), solo private (29%), group private (53%), and other (14%). A history of cardiac disease was obtained most of the time by 92% of IMPs (75%-100% answer category). Histories for pulmonary disease, diabetes mellitus, stroke, and smoking were obtained most of the time with similar frequencies (85%, 86%, 73%, and 96%, respectively). In contrast, only 37% obtained a history for claudication, and 26% obtained a history for foot ulceration 75% to 100% of the time (P <.05, all comparisons). Examination of the heart (95%) and lungs (96%) occurred most of the time (75%-100% answer category) compared with each part of the pulse examination (range, 34%-60%; P <.05, all comparisons) and aortic aneurysm palpation (39%; P <.05). If pedal pulses were absent, examination by IMPs with Doppler scan and ankle-arm indices were mostly distributed in the 0% to 25% answer category (79% and 79%, respectively). After suspecting PAD, most IMPs obtained diagnostic tests first compared with specialist referral: carotid disease (91% vs 9%), aortic aneurysm (91% vs 9%), and lower extremity PAD (86% vs 14%). Initial referral patterns were made to vascular surgeons (49%), general surgeons (33%), cardiothoracic surgeons (13%), cardiologists (4%), and radiologists (1%). Most IMPs believed medical school (70%) and residency (73%) provided adequate training for PAD diagnosis.

CONCLUSIONS

Deficiencies may exist in the identification of PAD by IMPs that could adversely affect diagnosis, time to referral, health care costs, and ultimately, patient outcome. Improvements in medical school education and IMP training in the diagnosis of PAD are needed.

Clinical failure after percutaneous transluminal angioplasty of the superficial femoral and popliteal arteries

OBJECTIVE

Anatomic patency after percutaneous transluminal angioplasty (PTA) of the superficial femoral and popliteal arteries does not guarantee clinical success. The aim of this report is to determine the causes of clinical failure after PTA.

METHODS

The records of all patients who have undergone PTA of the femoropopliteal arterial segment by our vascular group were retrospectively reviewed. Only patients with complete records and at least one postprocedure clinical and anatomic assessment within the same 30-day time interval were included. Success was defined according to the Society for Vascular Surgery/International Society for Cardiovascular Surgery Ad Hoc Subcommittee on Reporting Standards for Endovascular Procedures. Anatomic cumulative patency and clinical success were calculated according to life table analysis on an intent-to-treat basis.

RESULTS

We identified 85 patients who met inclusion criteria. We treated 112 lesions with an average stenosis of 80% +/- 16% and lesion length of 2.3 +/- 1.8 cm. Technical failure occurred in six (5.4%) of 112 lesions. Cumulative clinical success was 69% at 1 year, 54% at 2 years, 49% at 3 years, and 40% at 4 years. Anatomic patency was 74% at 1 year, 62% at 2 years, 57% at 3 years, and 52% at 4 years. There were 45 clinical failures; of these, twenty-seven (60%) occurred in conjunction with anatomic failure. Anatomic failure was due to restenosis in 12 patients (44%), occlusion in eight patients (30%), and restenosis with progression of disease in six patients (22%). Anatomic failure at the time of the procedure occurred in one patient (4%). Clinical failure occurred despite anatomic patency in the remaining 18 patients (40%). Etiology for clinical failure in this latter group included progression of disease within the treated vessel in 12 patients (67%), iliac disease in three patients (17%), tibial disease in two patients (11%), and bypass graft failure in one patient (5%). Fifty percent of all 45 clinical failures were successfully treated with supplemental percutaneous procedures.

CONCLUSION

A PTA is an acceptable therapeutic option for the treatment of focal occlusive disease of the femoropopliteal arterial segment. Most clinical failures were due to anatomic failure, but a significant number occurred despite patency at the PTA site. Although primary clinical success rates were inferior to surgical bypass graft, supplemental PTA was possible in 50% of patients. Repeat percutaneous treatment may extend the interval of clinical success and may obviate the need for surgical bypass graft.

Algorithm for the diagnosis and treatment of endoleaks

BACKGROUND

Endoluminal grafting of abdominal aortic aneurysms (AAA) has shown promising early results. However, endoleaks present a new and challenging obstacle to successful aneurysm exclusion. We report our experience with primary, persistent endoleaks and provide an algorithm for their diagnosis and management.

METHODS

Over a 19-month period, 73 patients underwent endoluminal repair of their AAAs using a modular bifurcated endograft as part of a US FDA Investigational Device Exemption trial. Spiral computed tomography (CT) scanning was performed prior to discharge after repair to evaluate for complete aneurysm exclusion. If no endoleak was present on that initial CT scan, color-flow duplex scanning was performed at 1 month, with repeat CT scanning at 6 months and 1 year. If the initial CT scan revealed the presence of an endoleak, repeat CT scanning was performed at 2 weeks, 1 month, and 3 months, or until the endoleak resolved. Any patient with an endoleak that persisted beyond 3 months underwent angiographic evaluation to localize the source of the leak.

RESULTS

At 1 month, 62 patients (85%) had successful aneurysm exclusion. The remaining 11 patients (15%) had primary endoleaks, 8 (11%) of which persisted beyond 3 months, prompting angiographic evaluation. In 2 patients the endoleak was related to a graft-graft or graft-arterial junction. One was from the endograft terminus in the common iliac artery and was successfully embolized, along with its outflow lumbar artery. The other required placement of an additional endograft component across a leaking graft-graft junction to successfully exclude the aneurysm. The remaining six endoleaks were due to collateral flow through the aneurysm sac. In 4 cases this was lumbar to lumbar flow fed by hypogastric artery collaterals to the inflow lumbar artery. In the remaining 2 patients the endoleak was found to be due to flow between a lumbar and inferior mesenteric artery. Resolution of the endoleak by coil embolization of the feeding hypogastric artery branch in 1 patient was unsuccessful due to rapid recruitment of another hypogastric branch. Two of the six collateral flow endoleaks have resolved spontaneously without treatment, while the remaining cases have been followed up without evidence of aneurysm expansion.

CONCLUSION

Systematic postoperative surveillance facilitates proper diagnosis and treatment of endoleaks. This involves serial CT scans to detect the presence of endoleaks, followed by angiography to determine their etiology and guide treatment, if clinically indicated.

Special iliac artery considerations during aneurysm endografting

BACKGROUND

The feasibility of endograft exclusion of abdominal aortic aneurysms (AAA) has been established. However, the technical challenges of graft delivery through tortuous or diseased iliac arteries and the treatment of associated iliac aneurysmal disease have received little attention.

METHODS

Over 19 months, 74 patients underwent endoluminal repair of AAA and/or iliac artery aneurysms. Iliac anatomy that required special consideration during endografting was reviewed.

RESULTS

Of the 74 patients, 35 (47%) had iliac anatomy that required special attention. Thirteen patients (18%) had aneurysmal involvement of a common iliac artery. Eleven of these patients required endograft extension into the external iliac artery (EIA) and hypogastric coil embolization due to the proximity of the aneurysm to the hypogastric origin. Eleven patients with ectatic, nonaneurysmal iliac arteries required aortic cuffs to achieve a distal seal in these oversized vessels. Iliac artery tortuosity or stenosis were complicating factors in 27 of the 74 patients (36%), requiring the use of brachial guidewire tension in 2 patients to facilitate tracking of the delivery device. Five patients with severely splayed aortic bifurcations required crossed placement of the iliac limbs to prevent kinking of the endograft. Occlusive atherosclerotic disease of the EIA mandated preprocedural dilatation and stenting in 3 patients and postprocedural surgical EIA reconstruction in another 5 patients. Three patients who underwent successful endograft placement required subsequent endovascular repair of traumatized EIAs.

CONCLUSIONS

Iliac artery anatomy plays a significant role in the endoluminal treatment of infrarenal abdominal aortic aneurysms, complicating the procedure in up to 47% of patients with otherwise suitable anatomy. A variety of supplemental procedures, both surgical and endovascular, may be required to facilitate endograft placement. A special understanding of these constraints and proper planning is required for optimal therapy.

Percutaneous transluminal angioplasty and stenting for iliac artery occlusive disease

Atherosclerotic iliac artery stenoses respond well to simple balloon angioplasty and have the best results of all of the peripheral vessels. Nonetheless, initial technical failures occur in as many as 20% of patients, most of which can be salvaged with intravascular stenting, as can many of the potential complications; however, even though the initial technical success rates for stenting approach 100%, stenotic recurrences within stents are not infrequent. Whether promising new concepts, such as brachytherapy, gene therapy, and endoluminal grafting, will have a durable impact on the results of iliac angioplasty is yet to be seen. Meanwhile, the excellent results of endoluminal treatment of patients with iliac artery occlusive disease, combined with the relatively low risk for complications compared with surgical revascularization, ensure an enduring role for this modality of treatment and a diminution in the fraction of patients requiring surgery to correct their iliac artery occlusive disease.

Feasibility of endovascular repair of abdominal aortic aneurysms with local anesthesia with intravenous sedation

PURPOSE

Local anesthesia has been shown to reduce cardiopulmonary mortality and morbidity rates in patients who undergo selected peripheral vascular procedures. The efforts to treat abdominal aortic aneurysms (AAAs) with endovascular techniques have largely been driven by the desire to reduce the mortality and morbidity rates as compared with those associated with open aneurysm repair. Early results have indicated a modest degree of success in this goal. The purpose of this study was to investigate the feasibility of endovascular repair of AAAs with local anesthesia.

METHODS

During a 14-month period, 47 patients underwent endovascular repair of infrarenal AAAs with local anesthesia that was supplemented with intravenous sedation. Anesthetic monitoring was selective on the basis of comorbidities. The patient ages ranged from 48 to 93 years (average age, 74.4 +/- 9.8 years). Of the 47 patients, 55% had significant coronary artery disease, 30% had significant chronic obstructive pulmonary disease, and 13% had diabetes. The average anesthesia grade was 3.1, with 30% of the patients having an average anesthesia grade of 4. The mean aortic aneurysm diameter was 5.77 cm (range, 4.5 to 12.0 cm). All the implanted grafts were bifurcated in design.

RESULTS

Endovascular repair of the infrarenal AAA was successful for all 47 patients. One patient required the conversion to general anesthesia to facilitate the repair of an injured external iliac artery via a retroperitoneal approach. The operative mortality rate was 0. No patient had a myocardial infarction or had other cardiopulmonary complications develop in the perioperative period. The average operative time was 170 minutes, and the average blood loss was 623 mL (range, 100 to 2500 mL). The fluid requirements averaged 2491 mL. Of the 47 patients, 46 (98%) tolerated oral intake and were ambulatory within 24 hours of graft implantation. The patients were discharged from the hospital an average of 2.13 days after the procedure, with 87% of the patients discharged less than 48 hours after the graft implantation. Furthermore, at least 30% of the patients could have been discharged on the first postoperative day except for study protocol requirements for computed tomographic scanning at 48 hours.

CONCLUSION

This is the first reported series that describes the use of local anesthesia for the endovascular repair of infrarenal AAAs. Our preliminary results indicate that the endovascular treatment of AAAs with local anesthesia is feasible and can be performed safely in a patient population with significant comorbidities. The significant potential advantages include decreased cardiopulmonary morbidity rates, shorter hospital stays, and lower hospital costs. A definitive evaluation of the benefits of local anesthesia will necessitate a direct comparison with other anesthetic techniques.

AneuRx stent graft versus open surgical repair of abdominal aortic aneurysms: multicenter prospective clinical trial

The results of a prospective, nonrandomized, multicenter clinical trial that compared endovascular stent graft exclusion of abdominal aortic aneurysms with open surgical repair are presented. During an 18-month period, 250 patients with infrarenal aneurysms underwent treatment at 12 study sites-190 patients underwent endovascular repair using the Medtronic AneuRx stent graft (Sunnyvale, Calif), and 60 underwent open surgical repair. There was no significant difference in operative mortality rates between the groups. The patients who underwent stent grafting had significant reductions in blood loss, time to extubation, and days in the intensive care unit and in the hospital, with an earlier return to function. The major morbidity rate was reduced from 23% in the surgery group to 12% (P <. 05) in the stent graft group. There was no difference in the combined morbidity/mortality rates between the two groups. Primary technical success at the time of discharge for the patients with stent grafts was 77%, largely as a result of a 21% endoleak rate. At 1 month, the endoleak rate had decreased to 9%. There was no difference in the primary or secondary procedure success rates at 30 days between the surgery and stent graft groups. The primary graft patency rate at 6 months was 98% in the surgery group and 97% in the stent graft group. The aneurysm exclusion rate at 1 month and 6 months was 100% in patients who underwent surgery and 91% in patients who underwent stent grafting. Stent graft migration occurred in three patients and resulted in late endoleaks; each endoleak was corrected by means of endovascular placement of a stent graft extender cuff. There have been no aneurysm ruptures and no surgical conversions to open repair in the stent graft group. Stent graft repair compares favorably with open surgical repair, with a reduced morbidity rate, shortened hospital stays, and satisfactory short term outcomes.

Endovascular interventions training and credentialing for vascular surgeons

This article reviews issues concerning the training and credentialing of vascular surgeons in the use of endovascular techniques in the peripheral vascular system. These guidelines update a prior document that was published in 1993. They have been rewritten to accommodate the rapid evolution that has occurred in the field and to provide the appropriate requirements that a vascular surgeon should fulfill to be competent in the basic skills needed to safely and effectively perform all presently accepted diagnostic and therapeutic endovascular procedures.

Long-term patency rates, complications and cost-effectiveness of polytetrafluoroethylene (PTFE) grafts for hemodialysis access: a prospective study that compares Impra versus Gore-tex grafts

Manufacturers of polytetraflouroethylene (PTFE) grafts used for chronic hemodialysis access describe specific advantages for their respective grafts, which presumably result in greater graft patency rates, reduced complications and decreased overall costs. There are few data available in the literature to support or contradict these alleged benefits. Therefore, this prospective study was undertaken to evaluate and compare patency rates, complications and costs between two of the leading brands of PTFE that are currently being marketed for use as hemodialysis access grafts. Totals of 190 primary PTFE grafts (100 Gore-tex (W. L. Gore and Associates, Flagstaff, AZ) and 90 Impra (C. R. Bard Inc., Tempe, AZ)) were implanted in 168 consecutive patients with end-stage renal disease. A policy of non-interventions was employed for patent grafts, as no attempt was made to assist primary patency. Grafts that occluded during follow-up underwent secondary revision to maintain patency. There was no difference in primary and secondary patency by life-table analysis between Gore-tex and Impra grafts at 2 years (P > 0.53 and P > 0.13, respectively). There was also no significant difference between Gore-tex and Impra in the number of days before the first thrombectomy or in the number of thrombectomies or revisions per graft (P > O.50). Likewise, the incidence of complications was similar between the two grafts. The cost of graft implantation and maintenance of patency was not significantly different between Gore-tex and Impra grafts. It is concluded that either graft can be used for hemodialysis access with similar expected outcomes for at least 2 years following implantation.

Access to the vascular system for endovascular procedures: techniques and indications for percutaneous and open arteriotomy approaches

The ability to reliably gain access to the vascular system is fundamental to the performance of all endovascular diagnostic and therapeutic procedures. Competence with a variety of different access sites and techniques is essential if one is to be able to address the full spectrum of vascular disease and diversity of clinical circumstances. Although open surgical access is sometimes indicated, most endovascular procedures can and should be performed percutaneously, because this is the least invasive technique. Understanding the advantages, risks, and potential pitfalls of the various approaches influences the site of access chosen and whether a percutaneous or open arteriotomy technique is used. Furthermore, this knowledge permits efforts to minimize attendant risks and facilitates recognition of problems when they do occur. The net result is a procedure unspoiled by failure to gain access or avoidable access site complications.

Local anesthesia for infrainguinal arterial reconstruction

PURPOSE

Perioperative cardiac complications occur in 4% to 6% of patients undergoing infrainguinal revascularization under general, spinal, or epidural anesthesia. The risk may be even greater in patients whose cardiac disease cannot be fully evaluated or treated before urgent limb salvage operations. Prompted by these considerations, we investigated the feasibility and results of using local anesthesia in these high-risk patients.

METHODS

From January 1, 1994, through August 30, 1996, 86 infrainguinal reconstructions were performed under local infiltration anesthesia (0.5% or 1.0% lidocaine). Supplementary intravenous sedation with propofol or other agents was given as needed for patients comfort. Most patients had arterial lines but Swan Ganz catheters were used infrequently. Postoperatively, continuous electrocardiographic monitoring was continued in the intermediate or intensive care units. Patients ranged in age from 37 to 86 years (mean 68 +/- 12); 47% were diabetic, 69% had severe coronary artery disease, and 14% had end-stage renal disease.

RESULTS

Operations included 7 femoral-femoral, 21 femoral-popliteal, 16 femoral-tibial and 13 popliteal-tibial bypass grafts, 9 pseudoaneurysms, and 20 distal graft revisions (+/- thrombectomy). Autogenous vein was used in eight of the femoral-popliteal and all of the femoral-tibial and popliteal-tibial bypass grafts. There were two postoperative deaths. One patient died of a stroke (1.2%) on postoperative day (POD) 2 and one died on POD 27 of unknown cause. Two other (2%) patients had nonfatal subendocardial myocardial infarctions. Conversion to general anesthesia was required in four (5%) operations, three because patients became agitated and one because a long segment of vein had to be harvested from the opposite leg. Otherwise, patients tolerated the procedures well and postanesthetic recovery problems were minimized.

CONCLUSIONS

Limb salvage operations can be done under local anesthesia with acceptable complication rates. In selected patients with high-risk coronary artery disease, local anesthesia has theoretic and practical advantages and should be considered an alternative to general or regional anesthesia.