Venous morbidity after superficial femoral-popliteal vein harvest

PURPOSE

The superficial femoral-popliteal vein (SFPV) is a reliable conduit for aortoiliac, infrainguinal, and venous reconstructions. In this prospective study, we characterized the anatomic and physiologic changes in SFPV harvest limbs and their relationship to the development of late venous complications.

METHODS

Since 1990, we have studied 61 patients after harvest of 86 SFPVs at 6-month intervals with clinical examinations, lower-extremity venous duplex, and venous function tests. The CEAP system was used as a means of categorizing clinical changes.

RESULTS

Mean (+/- SEM) follow-up was 37 +/- 3 months. Less than one third of harvest limbs had edema without skin changes (C3). No patient had major chronic venous changes (C4 to C6) or venous claudication. There were no significant differences in limb measurements between harvest and non-harvest limbs, except in a subgroup of patients with unilateral harvest in which there was a small but significant (P =.046) increase in harvest limb thigh and calf circumference, compared with the opposite non-harvest limb. These clinical results were not affected by the presence or absence of an intact greater saphenous vein (GSV). Large, direct collaterals (4 to 6 mm in diameter) between the popliteal vein stump and profunda femoris vein (PFV) were seen by means of duplex ultrasonography in 29 harvest limbs (34%). The remainder appeared to have smaller, less direct collaterals to the PFV. Mild venous reflux with rapid cuff deflation was present at the popliteal or posterior tibial vein in nine of 79 harvest limbs (11%). Six of these nine limbs (67%) with reflux were clinical class C3, compared with only 19 of the 70 limbs without reflux (27%; P =.02). Ambulatory venous pressure (AVP) with exercise was significantly increased in harvest limbs (60 +/- 4.7 mm Hg), compared with non-harvest limbs (47.8 +/- 5.2 mm Hg; P =.049). The AVP recovery time of harvest limbs (14.0 +/- 1.0 seconds) was reduced, compared with non-harvest limbs (23.5 +/- 4.5 seconds; P =.02). AVPs (exercise) remained stable or decreased in six of 10 harvest limbs measured serially. Venous refill time in harvest limbs (15.1 +/- 1.1 seconds) was shortened, compared with non-harvest limbs (22.3 +/- 2. 1 seconds)(P =.002). Venous outflow obstruction measured by means of plethysmography was present in 93% of harvest limbs, compared with 36% of non-harvest limbs (P =.001).

CONCLUSION

SFPV harvest results in minimal mid-term to late-term lower-extremity venous morbidity despite outflow obstruction. The most likely mechanisms preserving clinical status include the low incidence of mild reflux, the presence of collateral venous channels, and the lack of progression in abnormal harvest limb physiology. The absence of the ipsilateral GSV does not adversely affect clinical outcome.

A randomized trial of intraoperative autotransfusion during aortic surgery

PURPOSE

The net benefit of routine intraoperative autotransfusion (IAT) in patients undergoing elective infrarenal aortic surgery was studied.

METHODS

One hundred patients undergoing abdominal aortic aneurysm (AAA) repair (n = 50) or aortofemoral bypass (AFB) for occlusive disease (n = 50) were randomized to IAT and control groups. This experience accounted for 58% of patients undergoing aortic surgery during the 16-month study period.

RESULTS

IAT and control groups were balanced for preoperative demographics, disease (50:50 split of AFB:AAA in each group), and risk factors. There were no significant differences between patients randomized to IAT and control patients in estimated blood loss (EBL), allogeneic blood transfusion (units administered intraoperatively, postoperatively, and total), proportion of patients not receiving allogeneic blood (34% of patients randomized to IAT and 28% of control patients), postoperative hemoglobin/hematocrit levels, and complications. IAT did not reduce allogeneic blood transfusion among all patients undergoing aortic surgery nor in any subgroups that might be more likely to benefit, such as those undergoing AAA repair, those with 1000 mL or more EBL, and those receiving larger volumes of IAT-processed blood.

CONCLUSION

We could find no net benefit of IAT in patients undergoing elective, infrarenal aortic surgery.

Gastrointestinal complications after aortic surgery

BACKGROUND AND PURPOSE

A major gastrointestinal complication (GIC) after aortic surgery may be disastrous, but these complications have received scant attention. This study was performed to determine the risk factors, associated events, and outcomes for patients with GIC.

METHODS

We performed a secondary analysis of a prospective study that examined 120 consecutive patients who underwent transperitoneal aortic revascularization for aneurysmal or occlusive disease.

RESULTS

The following 29 GICs developed in 25 patients (21%) within 30 days of aortic surgery: paralytic ileus that required replacement of nasogastric tubes (n = 12), upper gastrointestinal bleeding (n = 5), Clostridium difficile enterocolitis (n = 5), acute cholecystitis (n = 2), mechanical obstruction (n = 2), ascites (n = 2), and colon ischemia (n = 1). Seven patients required operations for GICs after aortic revascularization. A comparison of patients with and without GICs showed no differences in the prevalence of risk factors, presence of mesenteric artery stenoses, coexisting medical illnesses, antecedent gastrointestinal history, operative indication, preoperative fluid administration, or duration of operation. However, patients with GICs had more intraoperative complications (P = .004), greater intraoperative blood loss (P = .02), and more fluids during the postoperative period (P = .008). The mean duration of mechanical ventilation was 71 +/- 23 hours for patients with GICs versus 7 +/- 2 hours for patients without GICs (P = .006). A higher prevalence of pulmonary (P = .004) and renal (P = .001) complications was seen in the patients with GICs. The mean stay in the intensive care unit was 16 +/- 2 days for patients with GICs as compared with 5 +/- 0.4 days for patients without GICs (P < .001). Four deaths occurred, all caused by multisystem organ failure: 3 patients had GICs, and 1 did not have a GIC (P = .007).

CONCLUSIONS

These results show that GICs are prevalent in transperitoneal aortic surgery and are associated with severe morbidity rates, increased hospital costs because of prolonged stay, and increased mortality rates. Some GICs appear to be associated with intraoperative events that lead to visceral hypoperfusion, and others can be attributed to mechanical causes. However, none of the variables examined in this study were predictive of GICs. In all, GICs should be considered serious adverse sequela after aortic revascularization. Because no risk factors for GICs have been identified, these complications currently cannot be prevented.

Effectiveness of pulmonary artery catheters in aortic surgery: a randomized trial

PURPOSE

To evaluate the routine use of pulmonary artery catheters (PAC) in patients who undergo aortic surgery.

METHODS

One hundred twenty patients were randomized to placement of PACs for perioperative monitoring and hemodynamic optimization (tune up) in the intensive care unit on the night before aortic operation, or to intravenous hydration in the ward and perioperative monitoring without PACs. Before randomization, all patients underwent routine adenosine thallium-201 scintigraphy.

RESULTS

To meet predetermined endpoints, 30 PAC patients (50%) received nitrates, inotropic agents, or both. PAC patients received more fluid in the preoperative period (p < 0.001) and in the first 24 hours after operation (p = 0.002) than control subjects. Eleven PAC patients (18%) and three control subjects (5%) had adverse intraoperative events (p = 0.02). There were 20 adverse postoperative events in 15 PAC patients (25%; nine cardiac, seven pulmonary, four acute tubular necrosis), which was not different compared with 11 postoperative events in 10 control subjects (17%; five cardiac, five pulmonary, one acute tubular necrosis). There were also no differences in duration of mechanical ventilation, intensive care unit stay, or hospital stay between groups. Postoperative cardiac complications were more common among patients who had a history of congestive heart failure (p = 0.02; odds ratio, 3.75; confidence interval, 1.3 to 11) or reperfusion defects on adenosine thallium scintigraphy (p = 0.01; odds ratio, 3.4; confidence interval, 1.2 to 9.4), regardless of group.

CONCLUSIONS

Routine use of PACs for perioperative monitoring with the above protocol during aortic surgery is not beneficial and may be associated with a higher rate of intraoperative complications. Preoperative tune up does not prevent postoperative cardiac, renal, and other complications. Variables such as cardiac risk factors and adenosine thallium scintigraphy may be more important predictors of cardiac events in patients who undergo aortic operations.

Steal syndrome complicating hemodialysis access

The purposes of this study were to examine potential causes for arterial steal syndrome in patients with hemodialysis shunts and to evaluate the results of treatment. A retrospective analysis was performed on all hemodialysis patients who presented with arterial steal syndrome over a 3-year period. Medical records were reviewed to determine demographic data, time to development of symptoms, operative details, and treatment outcome. Results of upper-extremity arteriography in the last five patients were also documented. Eighteen patients presented with steal syndrome at a mean of 7(4) months after shunt placement. Four patients had prior ipsilateral grafts. Fifteen (83%) patients had forearm shunts in loop configuration between the main brachial artery and a superficial vein, and three had straight upper-arm shunts. Graft sizes were 6 mm in five patients and 4- to 7 step grafts in 13. Graft banding was used to treat steal in 11 shunts, one of which remained patent. All five patients who underwent upper-extremity arteriography had arterial stenoses demonstrated in the inflow circulation. In conclusion, arterial steal is an uncommon complication of hemodialysis shunts. Shunt location and choice of graft do not appear to be major factors: steal can develop regardless of access site, configuration, or use of straight versus step graft. Banding is an ineffective method of treatment. Arteriography may be important to detect unsuspected inflow stenoses in patients with steal syndrome.

Utility of carotid duplex in young adults with lower extremity atherosclerosis: how aggressive should we be in screening young patients?

The purpose of this study was to determine the prevalence and degree of carotid disease in patients with premature lower-extremity atherosclerosis. Seventy-six young men (mean age at onset of symptoms 42+/-0.5 years with premature lower extremity atherosclerosis who underwent complete carotid duplex scans were studied. The mean lowest ankle: brachial index was 0.49+/-0.02. Forty-seven patients (62%) required interventions to treat advanced leg symptoms, and 18 (24%) experienced disease progression during the study period. Carotid duplex scans showed internal carotid occlusions in eight (11%); advanced or critical plaque disease (60-99% diameter loss) in 14 (18%); moderate plaque disease (40-59% diameter loss) in 16 (21%); mild plaque disease (intimal thickening or 1-39% diameter loss) in 18 (24%); and normal carotid arteries in 20 (26%). Comparing the 20 subjects with normal carotid arteries to the S6 with any evidence of disease, there were no differences in age of onset, risk factors, coronary artery disease, mean ankle: brachial index, number of interventions, disease progression, amputation, or death. Fifteen (27%) of the patients with carotid atherosclerosis ultimately developed transient ischemic attack or stroke; 13 of these had advanced carotid stenoses or carotid occlusions. In conclusion, carotid plaque disease is prevalent among patients with premature atherosclerosis of the lower extremity. The presence of carotid atherosclerosis is not related to the degree of lower extremity atherosclerosis, nor to the rate of disease progression. Carotid duplex scans are indicated to screen these young patients for compelling lesions that might warrant prophylactic carotid endarterectomy.