Carotid interventions (CEA and CAS) in acute stroke patients: which procedure on which patient

Treatment of carotid bifurcation disease in patients presenting with acute stroke has been a controversial issue over the past four decades. Classically, patients were asked to wait four to six weeks before intervention was entertained in order for the brain to stabilize and the risks of intervention to be minimized. Unfortunately, up to 20% of patients will have a secondary event after their index event and the window of opportunity to save, potentially salvageable ischemic tissue will be missed. Early reports had demonstrated poor results with intervention. However, more recently, institutions such as ours have demonstrated excellent result in early intervention in patients who present with stable mild to moderate stroke with an NIH stroke scale less than 15 and preferably less than 10, present with stroke and ipsilateral carotid artery lesion of 50% or greater. Also more recently, we have been aggressively treating patients with larger ulcerative plaques even if the stenosis approaches 50%. In our and others experiences, patients who are treated at institutions that have comprehensive stroke centers (CSCs) where they have a multidisciplinary system that consists of vascular surgeons, neuro interventionalists, stroke neurologists, specifically trained stroke nursing staff and a neuro intensive ICU have had optimal results. Early assessment, diagnosis of stroke with recognition of cause of embolization is mandatory but patient selection is extremely important; finding those patients who will benefit the most from urgent intervention. Most studies have demonstrated the benefit of carotid endarterectomy in these patients. More recent studies have demonstrated acceptable results with carotid stenting, especially in smaller lesions, those less than 1.2 centimeters. Early intervention should be avoided in most patients who are obtunded or with an NIH stroke scale greater than 15 or who do not have any "brain at risk" to salvage. These patients may be better served by being treated medically than those small group of patients that do have some improvement may benefit from interval intervention.

Randomized clinical trial of tranexamic acid-free fibrin sealant during vascular surgical procedures

Background

This study evaluated the safety and haemostatic effectiveness of a fibrin sealant (EVICEL™ Fibrin Sealant (Human)) during vascular surgery.

Methods

This prospective randomized controlled trial compared the haemostatic effectiveness of fibrin sealant (75 patients) or manual compression (72) in polytetrafluoroethylene (PTFE) arterial anastomoses. The primary endpoint was the absence of bleeding at the anastomosis at 4 min after randomization. Secondary endpoints included haemostasis at 7 and 10 min, treatment failures and the incidence of complications potentially related to bleeding. Adverse events were recorded.

Results

A higher percentage of patients who received fibrin sealant versus manual compression achieved haemostasis at 4 min (85 versus 39 per cent respectively; odds ratio 11·34, 95 per cent confidence interval 4·67 to 27·52; P < 0·001). Similarly, a higher percentage of patients who received fibrin sealant achieved haemostasis at 7 and 10 min (both P < 0·001). The incidence of treatment failure was lower in the fibrin sealant group (P < 0·001). The rate of complications potentially related to bleeding was similar (P = 0·426). Some 64 per cent of patients who received fibrin sealant experienced at least one adverse event, compared with 71 per cent who received manual compression.

Conclusion

This fibrin sealant was safe, and significantly shortened the time to haemostasis in vascular procedures using PTFE. Registration number: NCT00154141 (http://www.clinicaltrials.gov).

Long term outcome for extra-anatomic arch reconstruction. An analysis of 143 procedures

PURPOSE

With the FDA approval of thoracic endografts, extra-anatomic reconstruction of the aortic arch has allowed for more suitable proximal landing zones and increased applicability of thoracic endovascular procedures. We evaluated our short term and long term results of extra-anatomic reconstruction of the carotid and subclavian vessels.

METHODS

One hundred and forty three (143) procedures were performed for extra-anatomic carotid and subclavian reconstruction. Of these 143 operations: 85 were carotid subclavian reconstructions, 22 were carotid crossover bypasses, 30 were subclavian carotid reconstructions and 6 were carotid subclavian transpositions. Sixty (42%) were male, 20 (14%) were diabetic, and 63 (44%) were current smokers. Mean age was 63 (SD +/- 12.3). Indication for surgery was primarily for occlusive or embolic disease (97%). In those patients undergoing bypass graft, prosthetic (ePTFE) was used in 93%. Follow-up was performed at 3 and 6 month intervals by ultrasound and pulse volume recordings where indicated. Life table analyses were used to analyze patency.

RESULTS

Of the 143 reconstructions operative mortality was 1 (0.7%). Non-fatal complications included 3 (2.1%) for bleeding, 1 (0.7%) wound infection, 2 (1.4%) TIA, 1 (0.7%) suffered a non-fatal stroke, 2 (1.4%) had postoperative myocardial infarctions, and 6 (4.3%) late (>30-day) occlusions. Follow-up was 1 to 124 months (mean: 39 months). Primary patency at 1 year was 98%, 3 years 96%, and 5 years was 92%.

CONCLUSION

Extra-anatomic arch reconstruction can be performed safely and appears to be durable over long term follow-up. Its use with endovascular grafting should provide a durable reconstruction for patients who require aortic "debranching" prior endovascular thoracic aortic aneurysm repair.

Relationship of proximal fixation to renal dysfunction in patients undergoing endovascular aneurysm repair

Technological advancements have lead to dramatic improvements in stentgraft device design resulting in more trackable delivery systems and transrenal uncovered stents and barbs for better fixation. Transrenal bare-stents may limit stentgraft migration, particularly in patients with short or flared proximal aortic necks. However, potential disadvantages might be in worsening renal function, particularly in patients with preexisting renal insufficiency. We retrospectively analyzed our recent 7 year experience of patients undergoing endovascular aneurysm repair (EVAR) using a variety of stentgrafts with and without transrenal bare-stent fixation. Patients were divided into 2 groups; infrarenal fixation (IRF) vs transrenal fixation (TRF), or patients with preoperative serum Cr values that were normal (= or <1.5 mg/dl) vs slightly elevated (1.6-2 mg/dl), vs markedly elevated (2.1- 3.5 mg/dl). The exclusion criteria included patients with chronic renal insufficiency (CRI) on hemodialysis, and preoperative high-grade renal artery stenoses requiring angioplasty and stenting. Of 705 patients that underwent EVAR, 496 (IRF: 385 [78%], and TRF: 111 [22%]) were available with routine evaluations of serum Cr and CT scans. Preexisting comorbidities, mean procedure contrast volume, and postprocedure follow-up were similar in both groups. In the immediate postoperative period, mean serum Cr did not change significantly in either the IRF group (1.3+/-0.7 mg/dl to 1.2+/-0.9 mg/dl) or the TRF group (1.3+/-0.5 mg/dl to 1.3+/-0.6 mg/dl). Mean serum Cr did, however, significantly increase over longer follow-up in both groups: 1.4+/-0.8 mg/dl for IRF (P<0.03), and 1.5 +/- 0.8 mg/dl for TRF (P<0.01). Cr clearance was similarly unchanged in the immediate postoperative period (58+/-23 to 61+/-25 ml/min/1.73 m2 for IRF group, 53+/-17 to 55+/-17 ml/min/1.73 m2 for TRF group), but was significantly decreased in longer follow-up (53+/-23 ml/min/1.73 m2 for IRF, p<0.02: and 48+/-16 ml/min/1.73 m2 for TRF, P<0.01). There were no significant differences in serum Cr increase (p=0.19) or Cr clearance decrease (p=0.68) between the IRF and TRF groups. Small renal infarcts were noted in 6 patients (1.6%) in the IRF group, and in 8 patients (7%) in the TRF group (p=0.37). Of patients with normal preoperative renal function, renal dysfunction developed in 7.7% of IRF group and 6.1% of TRF group (p=0.76). In patients with preexisting CRI, renal dysfunction developed in 18.2% of IRF group, and 17.1% of TRF group (p=0.95). Eight patients with postoperative renal dysfunction, 5 (1.3%) from IRF group and 3 (2.7%) from TRF group subsequently required hemodialysis, and this difference was not statistically significant (p=0.91). We also analyzed 200 consecutive patients undergoing EVAR with intra-arterial contrast agents with and without preexisting CRI not on dialysis. The groups were identified on the basis of preprocedure serum Cr: group 1 (n=108), Cr less than 1.5 mg/dL (normal range); group 2 (n=65), Cr 1.5 to 2.0 mg/dL; group 3 (n=27), Cr 2.1 to 3.5 mg/dL. Routine precautions in patients with CRI included preoperative intravenous hydration with 2 L of normal saline solution, discontinuation of all nephrotoxic drugs, intraoperative administration of mannitol (0.5 g/kg intravenously), and use of nonionic, low osmolar intra-arterial contrast agent (Omnipaque 350). One-hundred and eight patients had normal renal function (group 1), and 92 patients had preexisting CRI with baseline Cr 1.5 to 2.0 mg/dL (group 2, n=65) or 2.1 to 3.5 mg/dL (group 3, n=27). Comorbid conditions included coronary artery disease (group 1, 51%; group 2, 49%; group 3, 59%), hypertension (group 1, 39%; group 2, 46%; group 3, 52%), and diabetes mellitus (group 1, 25%; group 2, 35%; group 3, 48%). In groups 1, 2, and 3, the mean volume of low osmolar contrast agent used was 210 cc, 160 cc, 130 cc, respectively; hemodynamic instability developed in 3, 1, and 1 patient, respectively. The incidence of postoperative complications between the 3 study groups was not statistically different. In grications between the 3 study groups was not statistically different. In group 1 a transient increase in serum Cr (>30% over baseline and >1.4 mg/dL) was noted in 3 patients (2.7%), 2 of whom (1.9%) required temporary hemodialysis and 1 (0.9%) who died of renal failure. In group 2 a transient increase in serum Cr was noted in 2 patients (3.1%); both patients (3.1%) required temporary hemodialysis, and 1 patient (1.5%) died of renal failure. In group 3 a transient increase in serum Cr was noted in 2 patients (7.4%); 1 patient (3.7%) required temporary hemodialysis, and 1 patient (3.7%) died of renal failure. Perioperative hypotension significantly increased the risk for elevated serum Cr and death (p<0.05), and larger contrast volume was associated with an increase in serum Cr (p<0.05) during the postoperative period. Following EVAR renal function declines slightly with both IRF and TRF. Our data show no overall difference between patients with IRF and TRF with respect to infarcts, decline in renal function, or onset of dialysis. There were a slightly greater number of renal infarcts in the TRF group, but these infarcts were clinically inconsequential. In patients with CRI, EVAR with intra-arterial radiographic contrast agents is believed to impair renal function, and CRI is considered a relative contraindication to the procedure. Results of our investigation indicate that risk for worsening renal insufficiency, dialysis, and death is only slightly and not significantly greater in patients with CRI compared with patients with normal renal function. With appropriate precautions of avoiding perioperative hypotension and limiting the volume of nonionic contrast agents, CRI need not be a contraindication for EVAR with intra-arterial contrast agents.

Is prosthetic renal artery reconstruction a durable procedure? An analysis of 489 bypass grafts

OBJECTIVE

Renal artery stenosis has been classically addressed with saphenous vein bypass graft or transaortic endarterectomy performed either primarily or in combination with an aortic procedure. In this series, we report the outcome of our 12-year experience with renal artery reconstruction using prosthetic conduit.

METHODS

Patients undergoing renal artery bypass grafting from 1987 to 1999 were identified. Demographics, indications, concurrent operations, complications, and patency were analyzed. Patients underwent postoperative duplex scan with subsequent ultrasound scans at 6-month intervals.

RESULTS

There were 489 procedures performed in 414 patients with indications: high-grade renal artery stenosis in combination with abdominal aortic aneurysm repair or symptomatic aortoiliac occlusive disease (309 [63%]), renovascular hypertension (118 [24%]), and renal salvage (20 [4%]). Indications for the remainder included trauma, renal artery aneurysm, or an infected aortic graft. Inflow was aorta or aortic graft in 95% of patients with the remainder taken from the iliac or visceral vessels. The retroperitoneal approach was used in 97.8%. Nonfatal complications occurred in 11.4% with a 1.4% early and 4.8% late occlusion rate. Renal function worsened in 3.1% of all patients. Secondary patency at 1 and 5 years was 98% and 96%, respectively.

CONCLUSION

Renal artery reconstruction with prosthetic conduit has an acceptable and durable result whether used for primary renal artery reconstruction or concomitant reconstruction with aortic procedures.

Brachial artery reconstruction for occlusive disease: a 12-year experience

OBJECTIVE

Symptomatic arterial disease of the upper extremity is an uncommon problem. In this study, we evaluate our results with brachial artery reconstruction in patients who present with symptomatic atherosclerotic occlusive disease and compare this cohort's demographics with a similar group with lower extremity ischemia.

METHODS

From 1986 to 1998, all patients presenting for upper extremity revascularization with chronic ischemia were prospectively entered into a vascular registry. Demographics, indications, outcomes, and patency were recorded. Patients presenting with embolus, pseudoaneurysm, or trauma were excluded. The Fisher exact and Student t tests were used to assess significance.

RESULTS

Fifty-one (83%) bypass grafts were performed with autogenous conduit and the remainder with polytetrafluoroethylene. Indications included 18 (30%) patients with exertional arm pain, 35 (57%) with rest pain, and 8 (13%) with tissue loss. Twenty-five (45%) patients were male, 8 (14%) had diabetes, and 30 (54%) were smokers. The mean age was 58 years (range, 33-93). The operative mortality rate was 1.8%, and follow-up ranged from 1 to 140 months. Eight occlusions were identified, with six occurring early. Five of these were in women with a smoking history. Only one of the 26 reconstructions that did not cross a joint occluded, whereas bypass grafts that did cross a joint occluded more frequently. No other major complications were recognized.

CONCLUSION

Arm revascularization for ischemia can be performed with reasonable mortality and morbidity rates. These patients may represent a different subgroup of atherosclerotic disease than those with lower extremity involvement: they are more commonly women and smokers and less likely to be diabetic.

The multidisciplinary approach to prevention and treatment of cardiovascular disease: creation of a vascular care network

Vascular care, diagnosis, and intervention can be very complex. Multiple specialists commonly are involved in dealing with patients with systemic atherosclerotic disease. Although each specialist may provide state-of-the-art care with good result, it would be advantageous to minimize duplication of effort and thereby improve cost efficiency. Patients still could reap the benefit of all these disciplines if evaluated for their vascular complaint in a coordinated system. In doing so, atherosclerosis prevention with risk factor modification, as well as diagnosis and therapy for the presenting problem all can be simultaneously managed. This is the concept that has motivated groups such as our own to form a comprehensive vascular center. We describe our experience with establishing a vascular center and outline its benefits and limitations.

Coronary artery bypass combined with bilateral carotid endarterectomy

BACKGROUND

Surgical management of patients presenting for coronary artery bypass grafting with significant bilateral carotid artery stenosis has not been well defined. In this study, our preliminary results of coronary artery bypass grafting with concomitant bilateral carotid endarterectomy have been reviewed.

METHODS

A retrospective nonrandomized chart review was performed in 33 patients with unstable angina and bilateral carotid artery stenosis, more than 70%, undergoing simultaneous coronary artery bypass grafting and bilateral carotid endarterectomy using an eversion technique.

RESULTS

Concomitant coronary artery bypass grafting with bilateral carotid endarterectomy was performed urgently in 24 (73%) and electively in 9 (27%) patients. The average carotid artery cross-clamp and total perfusion times were 14.7 +/- 4.9 minutes and 123 +/- 29.2 minutes, respectively. The average length of stay in the cardiopulmonary intensive care unit was 4.2 +/- 14.2 days and total hospital stay was 16.2 +/- 20.5 days. Postoperative in-hospital stay was 14.9 +/- 20.3 days. There were no postoperative strokes. Twenty-one (64%) patients were discharged before the tenth postoperative day. Nonfatal postoperative complications occurred in 27% (9 of 33) of patients. The overall 30-day mortality was 6.1% (2 of 33) and that was unrelated to primary cardiac or cerebrovascular events.

CONCLUSIONS

Favorable outcome supports the justification for performing concomitant coronary artery bypass grafting with bilateral carotid endarterectomies in selected patients.

Long-term results in patients treated with thrombolysis, thoracic inlet decompression, and subclavian vein stenting for Paget-Schroetter syndrome

PURPOSE

In an effort to minimize long-term disability related to effort thrombosis of the subclavian vein, selected patients were treated with thrombolysis, thoracic inlet decompression, percutaneous transluminal angioplasty (PTA), and subclavian vein stenting. We evaluated the long-term outcomes of patients treated with this algorithm.

METHODS

Between 1994 and 2000, 23 patients were evaluated with effort thrombosis of the subclavian vein. Thrombolysis was instituted on an average of 9.4 days (range, 1-30 days) after initial onset of symptoms. Average time to clot lysis was 34 hours (range, 12-72 hours). After immediate supraclavicular thoracic inlet decompression, all patients underwent PTA. Fourteen patients with residual vein stenosis (>50%) after PTA underwent stenting of the subclavian vein. Complications in this series included three wound hematomas that required drainage in two patients and one subpleural hematoma that required thoracotomy for decompression.

RESULTS

All patients who underwent PTA are patent, with a mean follow-up of 4 years (range, 2-6 years). In the veins treated with stents, 9 of 14 veins are patent, with a mean follow-up of 3.5 years (range, 1-6 years). Two veins had early occlusions (2 days); two veins occluded at 1 year; and seven veins occluded at 3 years. Three of the patients (including those patients who experienced the early failed procedures) were later identified with factor V Leiden. Early failures also had clot extending into the brachial vein.

CONCLUSION

Patients with short-segment venous strictures after successful lysis and thoracic outlet decompression may safely be treated with subclavian venous stents and can expect long-term patency.

Outcomes with plantar bypass for limb-threatening ischemia

Patients with severely diseased or occluded infrageniculate arteries, limited runoff, and tissue loss may often present for primary amputation. In this study, we review our experience with plantar artery revascularization when no other bypass options are feasible. All patients requiring infrainguinal bypass to the plantar artery level over the last 3 years were prospectively entered into our vascular surgery database. Indications, demographics, length of stay (LOS), outcome, and patency were reviewed. Our results showed that plantar artery bypass is a safe and reasonable alternative to primary amputation. Excellent limb salvage can be achieved if the bypass remains patent through the initial 30 days postoperatively.

Use of shunts with eversion carotid endarterectomy

PURPOSE

The purpose of this study was to examine the utility of carotid shunting in the context of eversion endarterectomy. A comparison of patients who underwent carotid endarterectomy by eversion with and without shunts was performed.

METHODS

Over a 5-year period, 2724 eversion carotid endarterectomies were performed. In most of these operations patients were under cervical block anesthesia. A shunt was used in 112 eversion endarterectomies (4.1%). Cervical block anesthesia was used in 103 patients (92.0%), general anesthesia was used in 5 patients (4.5%), and 4 patients (3.6%) were converted from cervical block to general anesthesia intraoperatively. The indications for shunting were neurologic deterioration in 99 patients (88.4%) who were under cervical block anesthesia, procedures performed in neurologically unstable or otherwise compromised patients who were under general anesthesia, and the operator's discretion in the remaining eight patients.

RESULTS

There was a combined stroke/death rate of 2.7% in the shunt group. These three cases included one death from myocardial infarction and one delayed death due to intracerebral hemorrhage after discharge. Shunt insertion was unrelated to the negative outcome in these two cases. One perioperative major stroke in the shunt group was identified. Follow-up averaged 12.3 months (range, 1-53 months).

CONCLUSION

Carotid shunts can be used effectively in the context of eversion endarterectomy. Shunt insertion is not associated with an increased stroke/death rate in these patients.

Analysis of the effect of asymptomatic carotid atherosclerosis study on the outcome and volume of carotid endarterectomy

Recent studies have demonstrated the benefits of carotid endarterectomy (CEA) and risk factor control in preventing stroke in asymptomatic patients. In this study, the effect of the asymptomatic carotid atherosclerosis study (ACAS) on the frequency of CEAs performed and the outcome of such procedures on symptomatic and asymptomatic patients were analyzed. From 1990 to 1996, all patients undergoing CEA were prospectively entered into a computerized vascular registry. The number of procedures, indications, demographics, and early and late results were analyzed and compared with similar data compiled prior to the ACAS study. The total volume of CEAs performed increased from 66 in 1990 to 719 in 1996 (ratio 1:12.3). The ratio of symptomatic to asymptomatic patients changed from 1.75:1 in 1990 to 1:1.52 in 1996. The combined stroke/mortality rate dropped from 4.75% in 1990 to 2.15% in 1996. The stroke mortality in the asymptomatic group decreased significantly from 4.3 to 1.9% in the pre and post-ACAS groups respectively (P<0.0005). The stroke mortality of symptomatic patients remained constant at 2.1 and 1.4% respectively.Since the completion of ACAS in 1993, the number of CEAs performed on our service has increased tenfold. An increase in volume has translated into an improved stroke/mortality rate and significantly decreased length of stay.

Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs

PURPOSE

The long-term patency for infrapopliteal bypass grafting with prosthetic material is less than optimal. Our experience demonstrates a 40% patency at 2 years for these grafts. Several adjuvant techniques have been developed to improve patency rates, two of which are a remote distal arteriovenous fistula and the creation of a distal vein cuff. This study summarizes our experience with these two techniques.

METHODS

Between 1987 and 1998, 107 bypass graftings were performed to the below-knee popliteal or tibial vessels with the use of polytetrafluoroethylene. One group (48 bypass grafts) had polytetrafluoroethylene with adjuvant distal arteriovenous fistula (DAVF), and a second group (59 bypass grafts) was reconstructed with a distal vein cuff (DVC). The type of bypass grafting that was performed was based on surgeon experience and preference. Indications and demographics were similar in the two groups. All patients underwent the operation for limb-threatening ischemia, including gangrene (DAVF, 23%; DVC, 9%), ulceration (DAVF, 27%; DVC, 51%), and rest pain (DAVF, 50%; DVC, 40%).

RESULTS

The primary patency rate was 48% and 38% at 3 years for DAVF and DVC, respectively. Secondary patency was 48% and 47% at 3 years, with limb salvage rates of 76% and 92% for DAVF and DVC, respectively (P <.05). Attempted thrombectomy without continuation of patency was undertaken in two patients with a failed DAVF. Attempts at restoration after thrombosis were made in eight patients with failed DVCs. Five patients underwent thrombectomy, of which four procedures were successful. Three patients had thrombolytic therapy, and two of these remained patent.

CONCLUSION

Adjuvant techniques, including DAVF and DVC, produce acceptable long-term patency and limb salvage rates in bypass grafts performed to the below-knee popliteal and tibial vessels. This study suggests that DVCs may offer improved limb salvage rates and a greater opportunity for revision when bypass graft failure occurs.

Carotid endarterectomy using the eversion technique

Carotid endarterectomy by the eversion technique allows for all of the benefits of conventional endarterectomy but obviates the need for a distal suture line on the smaller internal carotid artery, and thus batching. Carotid artery reanastomosis onto the bifurcation can be quickly and simply performed with almost no risk of closure-related restenosis, given the anastomosis is on the larger of 2 arteries. In our experience of over 3,000 eversion carotid artery endarterectomies, the restenosis rate has been less than 1% judged by rigorous duplex follow-up. In this article, the technique and utility of eversion carotid endarterectomy is discussed.

Repair of large abdominal aortic aneurysm should be performed early after coronary artery bypass surgery

PURPOSE

The surgical repair (coronary artery bypass grafting [CABG]) of symptomatic coronary artery disease (CAD) in patients with co-existent large abdominal aortic aneurysm (AAA) may result in an increased rate of AAA rupture after operation. Simultaneous CABG/AAA repair has been recommended by some surgeons, but with a somewhat higher mortality rate than staged repair. We reviewed the outcome of staged AAA repair that was performed early after CABG in patients with symptomatic coronary disease and AAA.

METHODS

The records of all the patients with symptomatic CAD that required CABG with large AAA (greater than 5 cm) were reviewed. In most patients, CABG was performed first, followed by AAA repair within 2 weeks. Patient demographics, severity of coronary disease, AAA size, interprocedure duration, and perioperative morbidity and mortality rates were examined.

RESULTS

Between 1991 and 1998, 1105 AAA repairs were performed. Within this group, 30 patients with AAA underwent CABG for symptomatic CAD. Mean AAA size was 6.6 cm (range, 5.0-10.0 cm). The median interprocedure interval between CABG and AAA repair was 11.5 days. There was no in-hospital AAA rupture during this interval. The patient group was comprised of 24 men and 6 women with a mean age of 71 years. There was no operative death after such staged AAA repair, and nonfatal complications occurred in seven patients (23%). During this period, seven patients had AAA rupture when they were sent home after CABG for recovery and intended AAA repair at a later date.

CONCLUSION

Staged elective AAA repair may be performed safely and effectively after CABG. Performance of these procedures with a short interprocedure interval may be preferable to the higher complication rate observed after combined procedures.

Infrainguinal reconstruction in octogenarians: should age be a contraindication?

With the graying of America comes an increasing demand for medical care of the elderly. Unfortunately, due to a combination of rising costs of health care and driving force from the public to lower spending, health maintenance organizations and insurance companies are less willing to pay for expensive surgical procedures. Recently, infrainguinal arterial reconstructions have been denied at our institution solely on the basis of patient's age, without adequate assessment of data. We evaluated the results of patients aged over 80 years who underwent infrainguinal reconstruction and compared them to results of younger cohorts during the same time period. From 1989 to 1998, 629 octogenarians had infrainguinal reconstructions performed at our institution. In the same time period, 3257 procedures were performed on patients <80 years old. Demographics, indications for operations, and outcomes were compared. Statistical analysis was performed with Fisher's exact test and log rank analysis, assuming significance for p < 0.05. Indications for operation were significantly more often limb salvage and less often claudication in the older group. Nonfatal complication rates were similar. Primary and secondary patency rates as well as limb salvage rates were comparable in both groups. Patients who are >80 years of age should expect comparable outcomes to those of their younger cohorts when undergoing infrainguinal reconstructions. Health care dollars can be well spent on octogenarians and age should not be a contraindication for infrainguinal reconstruction.

The incidence, natural history, and outcome of secondary intervention for persistent collateral flow in the excluded abdominal aortic aneurysm

OBJECTIVE

The goal of abdominal aortic aneurysm (AAA) repair is the prevention of rupture. Exclusion of the infrarenal AAA by means of operation or endovascular graft placement is an alternative therapy to achieve this goal. However, thrombosis of the excluded aneurysm sac does not always occur and further intervention may be needed. This study examines the efficacy of available screening methods to detect the persistence of aneurysm sac flow and the outcome of secondary procedures to treat this problem.

METHODS

During the past 14 years, 1218 patients have undergone operative retroperitoneal exclusion of AAA. To date, 48 patients have been found to have persistent flow in the excluded AAA sac with duplex scanning. Twenty-seven patients underwent surgical intervention, and seven of these procedures were performed for rupture. Six patients have undergone treatment with interventional techniques (four successfully). The patients were evaluated for preoperative angiographic, anatomic, and comorbid factors that may have predisposed them to failed exclusion. Also, perioperative morbidity and mortality, estimated blood loss, and survival were assessed in the patients who required surgical treatment.

RESULTS

There were no perioperative parameters that correlated with postoperative persistent flow in the excluded AAA sac. The mean time to secondary intervention was 51 months (range, 2 to 113 months). Two patients had false-negative computed tomographic angiogram results, eight patients had false-negative angiogram results, and six patients had duplex scan examinations that had initially negative results that were then positive for flow in sac. Reoperation had a 7.4% mortality rate (two deaths) and a median blood loss of 2600 mL, as compared with 500 mL for primary procedures.

CONCLUSION

Secondary operations for patent excluded aortic aneurysm sacs have higher mortality and intraoperative blood loss rates than do primary procedures for AAA repair. The localization of branch leaks with computerized tomographic angiography, angiography, and duplex scanning were imprecise, and better methods are needed to adequately diagnose patent sacs. Expansion of AAA sac may be the only reliable factor.

Outcome of renal artery reconstruction: analysis of 687 procedures

OBJECTIVE

To evaluate the short- and long-term results of surgical reconstruction of the renal arteries, the authors review their experience with more than 600 reconstructions performed over a 12-year period.

SUMMARY BACKGROUND DATA

Reconstruction of the renal arteries, whether for primary renal indications or concomitantly with aortic reconstruction, has evolved over the past 40 years. There is concern that renal artery reconstructions carry significant rates of mortality and morbidity and may fare poorly compared with less-invasive procedures.

METHODS

From 1986 to 1998, 687 renal artery reconstructions were performed in 568 patients. Of these, 105 patients had simultaneous bilateral renal artery reconstructions. Fifty-six percent of the patients were male; 11% had diabetes; 35% admitted to smoking at the time of surgery. Mean age was 67 (range, 1 to 92). One hundred fifty-six (23%) were primary procedures and the remainder were adjunctive procedures with aortic reconstructions; 406 were abdominal aortic aneurysms and 125 were aortoiliac occlusive disease. Five hundred procedures were bypasses, 108 were endarterectomies, 72 were reimplantation, and 7 were patch angioplasties. There were 31 surgical deaths (elective and emergent) in the entire group for a mortality rate of 5.5%. Predictors of increased risk of death were patients with aortoiliac occlusive disease and patients undergoing bilateral simultaneous renal artery revascularization. Cause of death was primarily cardiac. Other nonfatal complications included bleeding (nine patients) and wound infection (three patients). There were 9 immediate occlusions (1.3%) and 10 late occlusions (1.5%). Thirty-three patients (4.8%) had temporary worsening of their renal function after surgery.

CONCLUSION

Renal artery revascularization is a safe and durable procedure. It can be performed in selected patients for primary renovascular pathology. It can also be an adjunct to aortic reconstruction with acceptable mortality and morbidity rates.

Management of failing prosthetic bypass grafts with metallic stent placement

PURPOSE

To evaluate the role of metallic stents in treating stenoses involving prosthetic arterial bypass grafts.

METHODS

Patients undergoing stent placement within a failing prosthetic bypass graft, during a 41-month period, were reviewed for treatment outcome and complications. The indications for stent placement in 15 patients included severe claudication (n = 3), rest pain (n = 9), and minor or major tissue loss (n = 3). Lesions were at the proximal anastomosis (n = 6), the distal anastomosis (n = 3), or within the graft (n = 6).

RESULTS

Treatment with metallic stents was successful in all patients. There was one acute stent thrombosis, successfully treated with thrombolytic therapy. Follow-up data are available for a mean duration of 12.3 months. The mean duration of primary patency was 9.4 months with 6- and 12-month primary patency rates of 51.9% and 37.0%, respectively. The mean duration of secondary patency was 12.1 months with 6- and 12-month secondary patency rates of 80.0% and 72.7%, respectively. Two patients with discontinuous runoff and preexisting gangrene required a below-knee amputation. Six patients were revised surgically after stent placement (at a mean of 10.8 months). Three late deaths occurred during follow-up.

CONCLUSION

Given the mortality risks of surgical revision and the reduced life expectancy of this patient population, metallic stent placement represents a viable, short-term treatment option for stenoses within or at the anastomoses of prosthetic grafts. Further evaluation is warranted to compare intragraft stent placement with surgical graft revision.

Outcome after distal vascular reconstruction in women

Although women are less likely to develop symptomatic atherosclerosis, little data exists on the long-term outcome of women undergoing infrainguinal arterial reconstructions. This study analyzes the operative mortality rate, complications, and the short-term and long-term results after these procedures in both men and women who had symptomatic vascular disease. From 1984 to 1997, 3956 infrainguinal arterial reconstructions were performed at Albany Medical Center. A total of 2474 (62.54%) reconstructions were performed in men and 1482 (37.46%) in women. The mean ages were 67 years for men and 71 years for women. Forty-three percent of the men were smokers compared with 26% of the women. Diabetes was present in 51% of the men and 55% of the women. Claudication was the indication for bypass in 298 (12.05%) men and 110 (7.42%) women. Limb salvage occurred in 2176 (87.95%) men and 1372 (92.58%) women. Perioperative 30-day patency rates were 96.66% in men and 96.50% in women. Primary patency rates at 1, 3, 5, and 10 years were compared; no significant difference existed between men and women. Secondary patency also was similar in both men and women. These results indicate that women requiring arterial reconstruction for infrainguinal occlusive disease had short-term and long-term graft patency results that were comparable with the results of men.

Vascular surgical society of great britain and ireland: review of 94 tibial bypasses for intermittent claudication

BACKGROUND: The management of intermittent claudication is usually non-operative. Most surgeons accept, however, that intervention may be warranted for those with debilitating symptoms. Such interventions are limited to above-knee bypass or balloon angioplasty. However, the authors have performed almost 4500 bypasses for limb salvage, with careful audit of results, and suggest that, in very carefully selected cases, tibial bypass can also be performed for intermittent claudication. The present study aimed to review the results of infrainguinal bypass in this unit; to compare the results for above-knee, below-knee popliteal and tibial bypass in claudicants using either in situ or excised vein as the conduit; and to examine the indications and long-term follow-up for those undergoing tibial bypass for claudication. METHODS: A database has been maintained prospectively in this unit since 1986. Details of all patients undergoing infrainguinal bypass for claudication were retrieved. In-hospital charts were also reviewed and cross-referenced with the computer database. In addition to demographic details, data were extracted on operative indication and procedure, postoperative complications, return to desired level of activity and long-term graft patency. RESULTS: From 1987 to 1997, 409 infrainguinal reconstructions were performed for intermittent claudication (9 per cent of all infrainguinal reconstructions). Of these 73 per cent were in men and 27 per cent in women with a mean age of 64 (range 24-91) years. The operative procedures comprised 165 above-knee popliteal grafts, 150 bypasses to the below-knee popliteal artery and 94 to tibial arteries. There were no operative deaths. However, one of 165 patients who had an above-knee popliteal graft underwent an amputation. Primary and secondary patency rates at 4 years were 62 and 64 per cent for above-knee popliteal bypass, 77 and 81 per cent for below-knee popliteal bypass, and 86 and 90 per cent for tibial bypass. Cumulative survival was 93 per cent at 4 years. CONCLUSION: Tibial bypass for severely disabling claudication can be performed with minimal morbidity and mortality rates, and is at least as durable as more commonly performed bypasses. These data indicate that concern over limb loss, death and limited life span may be exaggerated.

Infrainguinal arterial reconstruction for claudication: is it worth the risk? An analysis of 409 procedures

PURPOSE

Infrainguinal reconstruction traditionally has been reserved for patients with limb-threatening ischemia. Surgery for debilitating claudication, however, has been discouraged as a result of the perceived fear of bypass graft failure, limb loss, and significant perioperative complications that may be worse than the natural history of the disease. In this study, the results of infrainguinal reconstructions for claudication performed during the past 10 years were evaluated for bypass graft patency, limb loss, and long-term survival rates.

METHODS

Data were collected and reviewed from the vascular registry, the office charts, and the hospital records for patients who underwent infrainguinal bypass grafting for claudication.

RESULTS

From 1987 to 1997, 409 infrainguinal reconstructions were performed for claudication (9% of all infrainguinal reconstructions in our unit). The patient population had the following demographics: 73% men, 28% with diabetes, 54% smokers, and an average age of 64 years (range, 24 to 91 years). Inflow was from the following arteries: iliac artery/graft, 10%; common femoral artery, 52%; superficial femoral artery, 19%; profunda femoris artery, 16%; and popliteal artery, 2%. The outflow vessels were the following arteries: 165 above-knee popliteal arteries (40%), 150 below-knee popliteal arteries (37%), and 94 tibial vessels (23%). The operative mortality rate was 0%, and one limb was lost in the series from distal embolization. The primary patency rates were 62%, 77%, and 86% for above-knee popliteal artery, below-knee popliteal artery, and tibial vessel reconstructions at 4 years, and the secondary patency rates were 64%, 81%, and 90%, respectively. Cumulative patient survival rates were 93% and 80% at 4 and 6 years as compared with 65% and 52%, respectively, for infrainguinal reconstructions performed for limb salvage.

CONCLUSION

Infrainguinal arterial reconstruction for disabling claudication is a safe and durable procedure in selected patients. These data indicate that concern for limb loss, death, and limited life span of the patients with this disease may not be warranted.

Combined use of iliac artery angioplasty and infrainguinal revascularization for treatment of multilevel atherosclerotic disease

The purpose of this report is to review our recent experience with the combined use of iliac artery angioplasty and infrainguinal surgical revascularization for the treatment of multilevel atherosclerotic disease. A retrospective review of all patients with multilevel atherosclerotic disease who were treated with both iliac artery angioplasty and infrainguinal bypass surgery during a 4-year period was performed. The medical records and preoperative arteriograms of all patients were reviewed for demographic information, radiologic findings, and postoperative follow-up data. Ninety-three limbs in 87 patients were studied. There were 57 male and 30 female patients with an average age of 67.2 years (range: 38-90). We concluded that the combined use of iliac artery angioplasty and infrainguinal surgical revascularization is an effective and durable means of treating multilevel atherosclerotic disease.

The use of low-dose heparin is safe in carotid endarterectomy and avoids the use of protamine sulfate

Controversy exists concerning the appropriate dose of heparin needed during carotid endarterectomy. Use of high-dose heparin (100 U/kg) during carotid endarterectomy may require the use of protamine to minimize perioperative bleeding complications. At the authors' institution the use of 30 U/kg heparin for arterial reconstruction has obviated the need for protamine. A retrospective study of carotid endarterectomies performed was undertaken. Patients undergoing combined procedures with carotid endarterectomy were excluded. A total of 420 carotid endarterectomies were performed in 330 patients. All received 3000 U of heparin or less during carotid endarterectomy. Non-fatal stroke and transient neurological deficits occurred in 0.48% and 1.9%, respectively. Mortality was 0.9%. Wounds were dry in 97%, swollen in 2.5% and bloody in 0.5%. No patient received protamine. Two patients were returned to the operating room for re-exploration because of hematoma. In conclusion, the use of protamine may be safely avoided with 30 U/kg heparin, and give acceptable stroke- and minimal complication rates.

Carotid endarterectomy by eversion technique: its safety and durability

SUMMARY BACKGROUND DATA

The outcome of standard longitudinal carotid endarterectomy (CEA) can be measured by preservation of neurologic function with a low incidence of restenosis. Closure of the internal carotid arteriotomy with or without a patch may predispose to restenosis. Alternatively, transection of the internal carotid artery at the bulb with eversion endarterectomy allows expeditious removal of the plaque and direct visualization of the endpoint. Because the proximal internal carotid artery is anastomosed to the common carotid artery, this obviates the need for patch closure. The authors report their results with this technique in more than 2200 procedures.

METHODS

From May 1993 to March 1998, 1855 patients underwent 2249 CEAs using the eversion technique. During the same period, 410 patients had 474 CEAs by standard technique. Three hundred fifteen procedures in the eversion group and 65 procedures in the standard group were combined CEA and coronary artery bypass grafts. Most solo CEAs (97%) were performed in awake patients using regional anesthesia. Shunts were used on demand in 6% of CEAs.

RESULTS

The operative mortality rate was 1.02% (16/1575) in the solo eversion group and 2.2% (9/410) in the standard group. There were 18 permanent neurologic deficits (0.8%) in the eversion group and 11 (2.3%) in the standard group. Transient neurologic deficits occurred in 20 patients (0.9%) in the eversion group and 13 patients (2.7%) in the standard group. Of the 1855 patients, 1786 (96%) presented for duplex ultrasound follow-up. There were seven (0.3%) stenoses greater than 60% in the eversion group versus five (1.1%) in the standard group.

CONCLUSIONS

Eversion CEA can be performed safely with a low rate of stroke and death and a minimal restenosis rate in short- and long-term follow-up.

Combined carotid endarterectomy and coronary artery bypass grafting does not increase the risk of perioperative stroke

Patients who present for coronary artery bypass grafting with hemodynamically significant carotid artery lesions pose a difficult problem for both the cardiac and vascular surgeons. There is no consensus as to the proper management of these patients despite numerous studies. Prospective collection of data was performed in patients undergoing combined carotid endarterectomy and coronary artery bypass grafting's from April 1980 to November 1996. A total of 470 simultaneous carotid endarterectomy's and coronary artery bypass grafting's were performed in 420 patients. The average age of the patient was 69 years, with 62% being male, 15% being diabetic and 38% being smokers. Sixty (13%) presented with Transient ischemic attacks, 22 (5%) presented with amaurosis fugax, 16 (3.4%) presented with a prior history of stroke and 372 (70%) were asymptomatic. Operative mortality was 2.4% or 10 patients; 90% of those patients died from cardiac complications postoperatively and one patient died of a stroke. Permanent neurological deficits occurred in five (1%) of the patients, and six (1.7%) of the patients had a transient neurological deficit that improved prior to discharge. In conclusion, in our experience simultaneous carotid endarterectomy with coronary artery bypass grafting can be performed with an acceptable mortality and morbidity and does not appear to put the patient at a higher risk than when either procedure is performed alone.

Timing of carotid endarterectomy in patients with recent stroke

BACKGROUND

There is little objective data to support the conventional wisdom of waiting 4 to 6 weeks after stroke to improve surgical outcome of subsequent carotid endarterectomy (CEA). We have aggressively pursued CEA in patients after recent stroke; in this study we report our results.

METHODS

We performed 215 CEA procedures in 200 patients who presented with an indication of stroke within 6 months of CEA. Cervical block anesthesia was used 193 cases. The rest were performed with the patient under general anesthesia.

RESULTS

Perioperative stroke rate was 1.4% (3/215), and operative mortality was 2% (4/200) (stroke mortality = 3.4%). There were four early occlusions. Shunts were used in 13.9%, patch closure in 8.4%, and eversion endarterectomy in 48% of cases. There was no correlation between timing of surgery, extent of infarct on computed tomography/magnetic resonance imaging, and postoperative neurologic complications with the occurrence of postoperative stroke (p = NS). During the same period, 1,922 patients underwent CEA for indications other than stroke, with a perioperative stroke rate and mortality rate of 1.1%.

CONCLUSIONS

Selected patients presenting with a history of stroke and significant carotid artery disease can safely undergo early CEA with a mortality and morbidity comparable to patients undergoing CEA for other indications.

A critical approach for longitudinal clinical trial of stretch PTFE aortic grafts

Adaptation of new clinical products should be based upon thorough scientific evaluation of properties and performance in vitro and in vivo. Developmental animal research experimentation is classically carried out by the manufacturer with eventual government approval. However, objective data needs to be recorded during clinical trials including handling characteristics, bleeding, tensile strength, kinking, seamline break, dilatation, anastomotic deterioration, patency, and incorporation. Since April 1991, 1010 stretch polytetrafluoroethylene (PTFE) aortic grafts have been implanted at our institution and data were recorded prospectively. Six hundred and seven were for elective abdominal aortic aneurysms, 46 for symptomatic abdominal aortic aneurysms, 58 for ruptured abdominal aortic aneurysms, 17 for elective thoracoabdominal aneurysms, 3 for ruptured thoracoabdominal aneurysms and the remainder were for various aortoiliac pathology. Average age of the patients was 69 (range: 10-95), 66% were males, 25% were diabetics. Overall operative mortality was 5.8% (2.9% in elective cases and 26.6% in emergent cases). There were 23 occlusions; 21 were revised and 2 were replaced with axillofemoral bypasses. Estimated blood loss was 784 cc in elective cases and 1918 cc in emergent cases. Grafts were followed by duplex ultrasound or CT scan every 3 months during the first year and every 6 months thereafter. There were no graft dilatations or false aneurysms in this series. There was one graft infection and no perigraft seromas or anastomotic deteriorations during this follow up. Follow up was complete in 94% of these patients. In conclusion, stretch PTFE graft has acceptable handling characteristics, no excessive bleeding at the suture line and had no anastomotic or graft dilatation. This graft material was suitable for thoracic, visceral, renal and abdominal aortic reconstructions.

The performance of femoropopliteal bypasses using polytetrafluoroethylene above the knee versus autogenous vein below the knee

BACKGROUND

Controversy exists as to the choice of conduit for the treatment of superficial femoral artery occlusive disease, particularly when a patent above-knee popliteal artery exists. Some surgeons advocate the preferential use of polytetrafluoroethylene (PTFE), whereas others favor the use of autogenous vein. This report compares our experience with above-knee femoropopliteal bypass with PTFE versus below-knee femoropopliteal bypass with autogenous vein.

METHODS

This study covers a 15-year period extending from 1982 to 1996 during which 1,313 arterial reconstructions were performed for superficial femoral and/or proximal popliteal arterial disease. Four hundred and thirty-eight procedures were performed to the above-knee popliteal artery using PTFE, and 875 procedures were performed to the below-knee popliteal artery using autogenous vein. The indication for surgery was limb salvage in 77% of patients in the PTFE group and 88% of patients in the vein group.

RESULTS

The 1-, 3-, and 5-year cumulative life table primary patency rates for the PTFE group were 74%, 56%, and 50%, respectively. The primary patency rates for the vein bypass group were 83%, 75%, and 67%, respectively (P < 0.01). The 5-year cumulative limb salvage rates were 91% and 95% for the PTFE and vein groups, respectively (P = NS).

CONCLUSIONS

In this series, below-knee femoropopliteal venous reconstructions have superior patency rates compared with above-knee femoropopliteal PTFE reconstructions. Venous reconstruction for femoropopliteal occlusive disease gives the optimal long-term result. Prosthetic reconstruction should be considered for patients with limited venous conduit or decreased life expectancy.

Choice of peroneal or dorsalis pedis artery bypass for limb salvage

BACKGROUND

Arterial reconstructions performed for limb salvage have increasingly used peroneal and dorsalis pedis arteries as outflow vessels. However, there have been few published reports comparing the patency and limb salvage of these alternative outflow tracts. In this report, we have examined our experience with the peroneal and dorsalis pedis artery bypasses for limb salvage.

METHODS AND MATERIALS

During a 19-year period, more than 3,500 infrageniculate reconstructions were performed for limb salvage at our institution. Eight hundred and eighty were performed to the peroneal artery and 291 were performed to the dorsalis pedis. Patients' demographics were similar in both groups. Sixty-three percent of patients were male and 52% were diabetic. All surgeries were performed for patients with critical ischemia. In situ technique was used in 68% of peroneal reconstructions and 66% of dorsalis pedis bypasses, respectively. Translocated veins were used in 28% of bypasses and spliced veins were used in 32%.

RESULTS

Secondary patency rates to the peroneal reconstructions were 89% and 76% at 1 and 5 years, and 88% and 68% for the dorsalis pedis bypasses, respectively. No statistical difference was found. Sixteen (1.8%) of peroneal artery reconstructions were hemodynamic failures and four (1.4%) were hemodynamic failures in the dorsalis pedis group. Wound complications were observed in 19 (2.2%) of the peroneal group and 7 (2.4%) of the dorsalis pedis group. Limb salvage rates for the peroneal artery are 96% and 93% at 1 and 5 years, respectively, and 95% and 87% for the dorsalis pedis reconstructions, respectively.

CONCLUSION

This experience indicates that both peroneal and dorsalis pedis artery reconstructions have acceptable patency and limb salvage rates. Selection of one of these two outflow tracts, when a choice exists, may depend on the conduit limitation and the adjacent tissue infection. However, both outflow tracts are durable and hemodynamically effective for limb salvage.

A prospective randomized study comparing exclusion technique and endoaneurysmorrhaphy for treatment of infrarenal aortic aneurysm

PURPOSE

The retroperitoneal approach used in aortic replacement for infrarenal aortic aneurysm has become an important part of the vascular surgeon's armamentarium. Use of the exclusion and bypass technique, however, remains controversial. Although benefits may include reduced blood loss, less operative dissection, and a smoother intraoperative and postoperative course, critics of this technique have alluded to potential drawbacks. In this study the results of the exclusion technique and open endoaneurysmorrhaphy for surgical treatment of abdominal aortic aneurysm were compared.

METHODS

One hundred patients were randomized to either exclusion (EXC) or open endoaneurysmorrhaphy (OP) procedures. A posterolateral left retroperitoneal approach was used in all patients. During surgery, autotransfusion devices were used when needed. Doppler flow and pressures in the excluded aneurysm sac were determined during surgery in EXC to evaluate the completeness of the exclusion.

RESULTS

Patient demographics were similar between the two groups. The mean age was 70 years (range, 53 to 89 years). The operative mortality rates were 0% and 1.9% (1 of 51) in the EXC and OP groups, respectively. Nonfatal postoperative complications occurred in 10.2% (5 of 49) of the EXC group and in 23.5% (12 of 51) of the OP group (p < 0.05). Aneurysm sacs were opened in two EXC procedures. Blood loss (mean +/- SD) was 703 +/- 570 ml in the EXC group and 1031 +/- 703 ml in the OP group (p < or = 0.01). The intensive care unit stay (mean +/- SD) was 1.9 +/- 1.2 days in the EXC group and 3.2 +/- 6.9 days in the OP group (p = NS). The hospital stay (mean +/- SD) was 9.8 +/- 5.8 days and 12.1 +/- 17 days in the EXC and OP groups, respectively (p = NS). There has been persistent flow in the excluded sac in two patients, with sac enlargement in one of these patients on postoperative follow-up by duplex scan or clinical examination.

CONCLUSION

The exclusion and bypass technique for repair of infrarenal aortic aneurysm appeared to be an acceptable technique and was associated with less operative blood loss and fewer postoperative complications than those of open aortic endoaneurysmorrhaphy. Exclusion bypass may contribute to a smoother perioperative course and postoperative treatment of these patients.

Alternative approach for management of infected aortic grafts

PURPOSE

Prosthetic infection after aortic reconstructive surgery historically has been treated with extraanatomical bypass, graft excision, and aortic stump closure, but at the cost of substantial mortality and amputation rates. Alternatives to this strategy include in situ prosthetic replacement in the infected area, as well as autogenous reconstructions. Inherent to all of these procedures, however, is either the creation of an aortic stump, which carries a significant risk of subsequent blowout, or the placement of a bypass conduit in the infected field, thereby maintaining the potential for subsequent infectious complications. To avoid such problems, we have used retroperitoneal in-line aortic bypass with polytetrafluoroethylene through dean tissue planes.

METHODS

Since 1987 we have treated 16 graft infections in this manner. The surgical approach consisted of obtaining retroperitoneal proximal aortic control outside of the infected field (above or below the renal arteries), followed by infrarenal division and oversewing of the distal aorta. A polytetrafluoroethylene bifurcated graft was then sewn to the proximal aorta and tunnelled through the psoas sheath laterally to the profunda femoris artery on the ipsilateral side and via the space of Retzius to the contralateral appropriate femoral vessel, so as to avoid any contact with the infected areas. After the closure of the wounds, a plastic barrier was placed over all incisions and the patient was placed supine. The old infected graft was removed transperitoneally. Extensive cultures were taken at various sites to demonstrate no cross-contamination.

RESULTS

All patients were followed-up clinically and with tagged white cell scans at 6-month intervals. There were no immediate postoperative deaths and no amputations. One patient had a myocardial infarction and died at 5 months, and a second patient died at 2 months. Of the remaining 14 patients, none had recurrent sepsis and all have had negative Indium-labeled white cell scans in follow-up. Eleven (78%) are still alive, with a mean follow-up of 32 months (range, 20 to 106 months).

CONCLUSIONS

In-line aortic bypass for treatment of aortic graft infections yields excellent results and has become our treatment of choice in dealing with this difficult problem.

Advances in the surgical repair of ruptured abdominal aortic aneurysms

Over the past two decades, the mortality rate for elective repair of infrarenal abdominal aortic aneurysms has improved to an acceptable level (< 5%). However, surgical results of ruptured abdominal aortic aneurysms have remained fairly constant with about 50% in hospital mortality rates. Growing experience with the use of the left retroperitoneal exposure for elective aortic surgery allowed the authors to extend the use of this technique to the repair of ruptured abdominal aortic aneurysm. The extended left retroperitoneal approach using a posterolateral exposure through the 10th intercostal space allowed the surgeon expeditiously and reliably to obtain supraceliac aortic control by dividing the left crus of the diaphragm in all patients. In total, 104 aortic replacements were performed for ruptured abdominal aortic aneurysm during the past 7 years. Of these patients, 87 were men and 17 women; mean(range) age was 72(52-95) years. Hemodynamic instability (as defined by a systolic blood pressure of < 90 mmHg) was present before surgery in 41% (43/104) of patients. The operative mortality rate was 27.9% (29/104). Preoperative hemodynamic instability, time of operative delay and aortic cross-clamp time did not correlate with operative mortality. The median duration of intensive care unit stay was 4 (range 1-60) days and hospital stay 11 (range 6-175) days. The results of this series identified that a change in the operative technique for the repair of ruptured abdominal aortic aneurysm beneficially affected patient survival. The authors suggest that expeditious supraceliac control without thoracotomy is an excellent alternative and offers an advantage in the surgical management of ruptured abdominal aortic aneurysm.

Results of 1000 consecutive elective abdominal aortic aneurysm repairs

In order to identify major risks for death and complications from elective repair of abdominal aortic aneurysm, the authors analyzed their experience with the last 1000 such repairs over a 15-year period. Of the patients, 772 were men and 228 were women; average age was 70 (range 37-92) years. Some 20% of the patients had severe chronic obstructive pulmonary disease and 33% had baseline creatinine level > 115 mumol/l. Fifteen patients were dialysis-dependent and 24% (242/1000) had significant cardiac disease. Operation used a retroperitoneal approach in 834 patients and a transperitoneal approach in 166. The perioperative mortality rate was 2.4%, but this did not change either chronologically or with technique: some 50% of the deaths were due to cardiac causes. Renal and pulmonary impairment did not affect mortality or complication; 64% of non-fatal complications were distributed in the renal (17%), pulmonary (19%) and cardiac groups (28%). The authors' experience showed that patients with cardiac disease remain at significant risk for post-abdominal aortic aneurysm repair complications in spite of selective preoperative cardiac evaluation. Renal and pulmonary risk factors did not cause additional mortality or morbidity. They suggest that elective abdominal aortic aneurysm repair can be performed with low mortality and morbidity, even in increasing numbers of high-risk patients.

Bilateral carotid endarterectomy during the same hospital admission

The efficacy of carotid endarterectomy for the prevention of strokes has been well demonstrated in recent multicenter randomized trials. However, patients presenting with bilateral significant disease pose a difficult problem to the vascular surgeon. Currently, bilateral carotid endarterectomies are staged at varying intervals between operations, with surgeon and patient weighing the risks of waiting for surgery versus the risks of having both procedures done within a shortened interval. There are few data and no consensus on the optimal time interval between these operations. In order to evaluate the timing of carotid endarterectomies in patients with severe bilateral disease, the authors reviewed their experience with patients who had bilateral procedures performed during one hospitalization. Over the past 5 years, they have performed 204 such carotid endarterectomies in 102 patients. Cervical block anesthesia was used in 99% (201/204) of these procedures. All patients either had symptomatic disease, > 60% stenosis or severe ulcerative plaque as defined by duplex scan and/or preoperative angiography. Symptomatic stenoses were the operative indications in 39% (80/204) of the patients; the remaining 61% (124/204) were symptom-free. The majority of patients (80%; 164/204) had their second procedure performed within 2 days of their first operation. There was no operative mortality and only one permanent neurologic defect in this group for a combined stroke mortality rate of 1%. Three patients (1.5%) had transient neurologic deficits postoperatively which completely resolved by discharge. These data show that bilateral carotid endarterectomies can be performed safely and effectively during one hospital admission with a short interprocedural interval and without an increase in mortality or morbidity.

Access to the right renal artery from the left retroperitoneal approach

One of the perceived limitations of the left retroperitoneal approach to the aorta is inadequate access to the right renal artery. Many consider the need for a concomitant right renal artery revascularization a contraindication to performing an aortic reconstruction through the left retroperitoneum. Exposure of the right renal artery can be difficult due to the posterior course of the artery behind the vena cava. However, when the aorta is transected, the right renal artery can be easily approached with anterior and cephalad displacement of the aortic root. Over the past 3 years, 52 patients have had right or bilateral renal artery revascularization via the left retroperitoneal approach; of these procedures, 37 were performed with concomitant aortic procedures. In total, 34 patients had bilateral and 18 had unilateral revascularizations. Five patients had a transaortic endarterectomy performed, and 36 were bypassed with 6-mm expanded polytetrafluoroethylene side limbs from the aortic graft. Indications for revascularization were: 39 for suprarenal aortic bypass, seven for renal salvage and six for primary renovascular hypertension. All reconstructions have remained patent and all have been followed by serial duplex and renal flow scans (follow-up for 1-42 months). The operative mortality rate was 5.8% (3/52). There were no major cardiorespiratory complications in this group. Adequate exposure to the proximal right renal artery can be obtained through the left retroperitoneal approach to the aorta, and successful revascularization of one of both renal arteries can be technically performed with acceptable mortality and morbidity.

Expeditious management of ischemic invasive foot infections

Management of infected ischemic diabetic limbs requires antibiotic therapy, abscess drainage, and revascularization. However, revascularization is often delayed for several days or weeks as the infection is controlled. In an effort to decrease hospital stay and costs and to increase limb salvage, a series of 974 extremities with distal occlusive disease were managed with autogenous distal bypass. Some 136 of these limbs (125 diabetic) had severe invasive infections. These patients received intravenous antibiotics in all cases and abscess drainage if necessary. Vascular reconstruction was carried out as soon as possible, within 48 h of admission. An in situ bypass was used preferentially (107 cases). Patients were maintained on intravenous antibiotics in the perioperative period. Partial foot amputations, when necessary, were performed in 111 cases, usually 3-5 days after vascular reconstruction. There were no graft infections or major wound infections. There were two cases of skin edge necrosis requiring reoperation due to flap mobilization and consequent ischemia. Urgent revascularization with an autogenous conduit may be carried out in patients with invasive foot infections expeditiously, with high rates of limb salvage. Graft and wound infections are not common in this setting. Costly prolonged pre-bypass hospitalization in these cases is unnecessary.

Fate of the excluded abdominal aortic aneurysm sac: long-term follow-up of 831 patients

PURPOSE

Nonresective treatment of the infrarenal abdominal aortic aneurysm by proximal and distal ligation of the aneurysm sac (exclusion) combined with aortic bypass has been previously reported. A 10-year experience with 831 patients undergoing this procedure was reviewed.

METHODS

From 1984 to 1994, 831 (761 elective, 70 urgent) of 1103 patients being treated for abdominal aortic aneurysm underwent repair with the retroperitoneal exclusion technique. Perioperative morbidity and mortality, estimated blood loss, transfusion requirements, natural history of the excluded aneurysm sac, and long-term survival were all assessed.

RESULTS

The operative mortality rate for patients undergoing exclusion and bypass was 3.4%. The incidence of nonfatal perioperative complications was 5.2%. Colon ischemia requiring resection occurred in 2 (0.2%) of the 831 patients. Estimated blood loss was 638 +/- 557 cc (50 to 330 cc). On follow-up 17 (2%) patients were found to have patent aneurysm sacs as detected by duplex examination. Fourteen patients required surgical intervention. No cases of graft infection or aortoenteric fistula have been noted.

CONCLUSION

Retroperitoneal exclusion and bypass is a viable alternative to traditional open endoaneurysmorraphy in surgery for abdominal aortic aneurysm. Most excluded aneurysm sacs have thrombosis without any long- or short-term complications; however, in a small number of patients delayed rupture of patent aneurysm occurs, thus emphasizing the need for diligent follow-up and appropriate intervention.