Autologous great saphenous vein tailored graft to replace an infected prosthetic graft in the groin.

The authors propose a technique using the autologous great saphenous vein to replace an infected prosthetic limb graft at the groin. The whole great saphenous vein is incised longitudinally and divided into 2 approximately equal segments, which are sewn side to side. The longitudinal edges of the resulting great saphenous vein are then joined and anastomosed side to side to form a conduit, whose caliber is twice the original vein's diameter. The authors have used this technique to replace 1 limb of a prosthetic aortofemoral bypass infected at the groin. After 5 years, the new venous conduit is patent, with no recurrent infection, dilation, or aneurysmal degeneration. If validated by further experiences, this might be an attractive alternative to restoring flow through clean tissue planes using extra-anatomic bypass or the femoral vein in the infected fields.

Progression of atherosclerosis in asymptomatic carotid arteries after contralateral endarterectomy: a 10-year prospective study.

OBJECTIVE: The best way to manage both symptomatic and asymptomatic severe carotid stenoses has been thoroughly demonstrated by large randomized clinical trials, but less is known about the natural history and management of the contralateral asymptomatic internal carotid artery (ICA). This prospective study was undertaken to determine whether disease progressed in the contralateral ICA of patients who had undergone carotid endarterectomy (CEA) and were followed up clinically and by duplex ultrasound (US) scan. METHODS: The contralateral asymptomatic ICAs of 599 patients who had undergone CEA for severe carotid disease over a 10-year period were followed up clinically and with duplex US scan at 1 month and then every 6 months. ICA stenosis was classified as mild (30%-49%), moderate (50%-69%), severe (70%-99%), or occlusion. Progression was defined as an increase in ICA stenosis of 50% or more for ICAs with a less than 50% baseline lesion or as an increase to a higher category if the baseline stenosis was 50% or more. End points of the study were the incidence of contralateral disease progression and late neurologic events. Kaplan-Meier analysis was used to estimate freedom from disease progression and from neurologic events. The relationship between progression and risk factors was also analyzed. RESULTS: Overall, disease progressed in 25.2% of patients (151/599) after a mean follow-up of 4.1 years. Disease progressed in 34.3% of patients (101/294) with mild stenosis vs 47.9% of patients with moderate stenosis (47/98; P = .016). Three additional patients with mild lesions at baseline progressed to severe lesions. The median time to progression was 29.8 months for mild and 18.5 months for moderate stenoses (P = .033). The rate of late neurologic events referable to the contralateral ICA was 3.2% (19/599) for the entire series and 4.8% (19/392) for patients with a 30% or greater ICA stenosis: these included 4 (0.7%) strokes and 15 (2.5%) transient ischemic attacks. All but 3 events (16.3%; 16/98) occurred in patients with disease progression from moderate to severe stenosis. Overall, 53 late CEAs were performed. CONCLUSIONS: This prospective analysis has shown that disease progression in contralateral asymptomatic ICAs after CEA is relatively common in patients with a diseased ICA at the baseline and strongly supports duplex US surveillance, approximately every 6 months, in patients with more than mild disease. A baseline lesion is significantly predictive of progression to severe stenosis, and progression from moderate to severe stenosis is strongly associated with neurologic clinical events. No demographic or clinical factor proved useful in identifying patients likely to experience disease progression.

High-grade symptomatic and asymptomatic carotid stenosis in the very elderly. A challenge for proponents of carotid angioplasty and stenting.

BACKGROUND: Carotid angioplasty and stenting (CAS) is often considered as the preferred treatment for severe carotid occlusive disease in patients labelled as "high risk", including those aged 80 or more. We analyzed 30-day stroke risk and death rates after carotid endarterectomy (CEA) for severe symptomatic or asymptomatic carotid disease in patients aged 80 or more, by comparison with the outcome of CAS reported in the recently- published literature. METHODS: A retrospective review was conducted on a prospectively compiled computerized database of all primary CEAs performed by a single surgeon at our institution from 1990 to 2003. Descriptive demographic data, risk factors, surgical details, perioperative strokes and deaths, and other complications were recorded. RESULTS: In all, 1260 CEAs were performed in 1099 patients; 1145 were performed in 987 patients less than 80 years old, and 115 were performed in 112 patients aged 80 or more. There were 11 perioperative strokes in the 1145 procedures in the younger group, for a stroke rate of 0.8%, and no strokes in the 115 procedures in the older group. The death rates were 0% for the octogenarians and 0.3% for the younger group. CONCLUSION: The conviction that older age means higher risk needs to be revised. Patients aged 80 or more can undergo CEA with no more perioperative risks than younger patients. Proponents of CAS should bear this in mind before recommending CAS as the best therapeutic option for such patients.

Surgical vs medical treatment for isolated internal carotid artery elongation with coiling or kinking in symptomatic patients: a prospective randomized clinical study.

BACKGROUND: Whether surgically correcting symptomatic carotid elongation with coiling or kinking in the absence of an atherosclerotic lesion of the carotid bifurcation (isolated elongation) is effective in preventing stroke remains a controversial issue. The hypothesis behind this study was that surgical correction of symptomatic isolated carotid elongation with coiling or kinking could yield better results, in terms of stroke prevention and freedom from late stroke or carotid occlusion, than medical treatment. METHODS: We conducted a prospective clinical study randomly assigning symptomatic patients with isolated carotid elongation to undergo either elective surgery or medical treatment, with surgery reserved for any new onset or worsening of symptoms. The follow-up ranged from 1 month to 10 years (median, 5.9; mean, 6.2 years) and was obtained for all patients. The study end points were perioperative (30-day) stroke and mortality, late stroke, and stroke-related death and late carotid occlusions. RESULTS: Ninety-two patients were randomly assigned for surgery and 90 for medical treatment. Overall, 139 carotid surgical corrections were performed in 129 patients. All 92 patients in the surgical arm had an elective operation; 10 of these patients later developed symptoms on the opposite side (7 hemispheric and 3 retinal transient ischemic attacks) and had contralateral internal carotid artery surgery. An additional 37 patients (41.1%) randomly assigned to medical treatment crossed over to the surgical group within a mean of 16.8 months after randomization due to new hemispheric symptoms or worsening nonhemispheric complaints. There were no perioperative strokes or deaths. The incidence of late hemispheric and retinal transient ischemic attacks was significantly lower in the surgical than in the medical group, respectively, 7.6% (7 of 92) vs 21.1% (19 of 90) (P = .01) and 3.2% (3 of 92) vs 12.2% (11 of 90) (P = .03). Late strokes, 2 (2.2%) of which were fatal, occurred only in the medical group (6 of 90, 6.6%; P = .01). Late carotid occlusions also developed only in the medical group (5 of 90, 5.5%; P = .02). All surgically treated carotid elongations were analyzed histologically and 78 (56.%) of 139 showed atypical and typical patterns of fibromuscular dysplasia. CONCLUSIONS: The overall results of this trial indicate that surgical correction of symptomatic isolated carotid elongations with coiling or kinking is better for stroke prevention than medical treatment.

Prospective randomized study on asymptomatic severe carotid stenosis and perioperative stroke risk in patients undergoing major vascular surgery: prophylactic or deferred carotid endarterectomy?

We compared the perioperative (30-day) stroke risk in asymptomatic patients with severe carotid stenosis who underwent carotid endarterectomy (CEA) before or after major vascular surgery. Seventy-nine patients with asymptomatic severe carotid lesion were randomly assigned to group I (n = 40) or group II (n = 39) to receive prophylactic CEA (within 1 week before major surgery) or deferred CEA (between 30 days and 6 months after major surgery), respectively. All procedures were eversion CEAs performed under deep general anesthesia and cerebral protection involving continuous electroencephalographic monitoring for selective shunting. There were no perioperative deaths or strokes relating to the major surgical procedure in either group. All group II patients underwent deferred CEA as planned (median 47 days, range 38-94) with no subsequent perioperative deaths or strokes. Two of these patients (5.1%) suffered a minor stroke, however, 65 and 78 days after their major surgical procedure, while awaiting carotid revascularization. Although data emerging from this analysis indicate that severe asymptomatic carotid disease may be safely postponed in patients undergoing major noncarotid vascular surgery, only a multicenter prospective study could determine the most appropriate management of this subset of patients.

Prospective randomized study on reversed saphenous vein infrapopliteal bypass to treat limb-threatening ischemia: common femoral artery versus superficial femoral or popliteal and tibial arteries as inflow.

PURPOSE: Use of inflow sources distal to the common femoral artery (CFA) for bypass to infrapopliteal arteries is a compromise measure when the length of the vein is not adequate. The purpose of this study was to compare the clinical outcome of vein infrapopliteal bypass arising from the CFA and from the distal superficial femoral or popliteal and tibial arteries in patients with limb-threatening ischemia. METHODS: Over 13 years, 160 vein infrapopliteal vein bypass procedures (160 patients) were randomized into 2 groups, 80 with inflow arising from the CFA (group 1) and 80 with inflow from below the CFA (group 2). Patency and limb salvage rates were assessed with the Kaplan-Meier method. All patients underwent graft surveillance at discharge and at 30 days and 6 months after surgery, then every 6 months thereafter. Follow-up ranged from 30 days to 127 months (mean, 49 months). RESULTS: Groups were similar with regard to age, sex, and most atherosclerotic risk factors. Gangrene as an indication for surgery was statistically more frequent in group 1 (73.7% vs 48.7%; P = .002), whereas nonhealing ulcer and rest pain were statistically more frequent in group 2 (respectively, 51.2% vs 25%; P = .001 and 46.2% vs 28.7%; P = .03). No patients died during the perioperative (30 days) period. At 1, 3, and 5 years patency and limb salvage rates were comparable between groups, tending toward significance for the 5-year primary patency rate (73% vs 57%; P = .08). CONCLUSIONS: In the absence of significant proximal disease, infrapopliteal revascularization arising distal to the CFA can ensure patency and limb salvage rates statistically similar to those with use of the CFA. Moreover, procedures arising distal to the CFA required fewer graft revisions to maintain patency of failing grafts.

Octogenarians with contralateral carotid artery occlusion: a cohort at higher risk for carotid endarterectomy?

PURPOSE: Carotid angioplasty and stenting has been proposed as a treatment option for carotid occlusive disease in patients at high risk, including those 80 years of age or older or with contralateral carotid occlusion. We analyzed 30-day mortality and stroke risk rates of carotid endarterectomy (CEA) in patients aged 80 years or older with concurrent carotid occlusive disease. METHODS: From a retrospective review of 1000 patients undergoing 1150 CEA procedures to treat symptomatic and asymptomatic carotid lesions over 13 years, we identified 54 patients (5.4%) aged 80 years or older with concurrent contralateral carotid occlusion. These patients were compared with 38 patients (3.8%) aged 80 years or older with normal or diseased patent contralateral carotid artery and 81 patients (8.1%) younger than 80 years with contralateral carotid occlusion. All CEA procedures involved either standard CEA with patching or eversion CEA, and were performed by the same surgeon, with the patients under deep general anesthesia and cerebral protection involving continuous perioperative electroencephalographic monitoring for selective shunting. Shunting criteria were based exclusively on electroencephalographic abnormalities consistent with cerebral ischemia. RESULTS: The 30-day mortality and stroke rate in patients aged 80 years or older with concurrent contralateral carotid occlusion was zero. CONCLUSIONS: The concept of high-risk CEA needs to be revisited. Patients with two of the criteria considered high risk in the medical literature, that is, age 80 years or older and contralateral carotid occlusion, can undergo CEA with no greater risks or complications. Until prospective randomized trials designed to evaluate the role of carotid angioplasty and stenting have been completed, CEA should remain the standard treatment in such patients.