The Influence of Collagen Impregnation of a Knitted Dacron Patch Used in Carotid Endarterectomy.

BACKGROUND: In selected populations, carotid endarterectomy (CEA) reduces long-term stroke risk. Studies have shown increased risk of restenosis with use of a collagen-impregnated Dacron patch compared to a polytetrafluorethylene patch. There is concern that collagen impregnation may initiate thrombosis or promote restenosis due to platelet activation. We performed a retrospective analysis of our CEA experience with routine patching using knitted Dacron patches with (Hemashield) and without (Sauvage) collagen impregnation. METHODS: Our database was queried for all CEAs between January 2006 and December 2010. Seven surgeons performed 655 CEAs. Patients were excluded if no patch was used (n = 1), a primary CEA was performed before study period or by other surgeons (n = 11), or the patch type was indeterminable (n = 38). Demographics, clinical data, and outcomes were compared between the collagen-impregnated (C, Hemashield) group and non-collagen-impregnated (NC, Sauvage) group. RESULTS: A total of 605 CEAs were analyzed (395 C and 210 NC). Demographics were similar except for coronary artery disease (C 54.3% vs. NC 41.6%, P = 0.003). There was no statistically significant difference in 30-day (C 99.7% vs. NC 99.5%, P > 0.99) or 5-year survival (C 80.0% vs. NC 83.7%, P = 0.26) or 30-day stroke rate (C 0.3% vs. NC 1.0%, P = 0.28). No late ipsilateral strokes occurred during 5-year follow-up. The 5-year freedom from restenosis >30% (C 85.3% vs. NC 86.4%, P = 0.33), restenosis >50% (C 94.5% vs. NC 95.5%, P = 0.44), and restenosis >70% (C 98.6% vs. NC 98.9%, P = 0.73) were similar. Two patients underwent carotid stenting for restenosis >70%. Two patients (both in the C group) developed occlusion of the carotid artery. CONCLUSIONS: The thrombosis and restenosis rates in the 2 groups were similar. This suggests that collagen-impregnated patches do not initiate thrombosis or increase restenosis rates after CEA.

Decreases in diameters of treated abdominal aortic aneurysms and reduction in rupture rate.

OBJECTIVE: To determine whether the diameters of treated abdominal aortic aneurysms (AAAs) have changed during the last 10 years. DESIGN, SETTING, AND PATIENTS: A retrospective record review was completed on all patients undergoing any AAA repair from January 1, 2000, through December 31, 2009, at a single high-volume institution. All cases of repaired AAAs that had computed tomographic scans within 3 months of surgery were included. The mean and median maximal diameters of AAAs were noted. Correlation and regression analyses were used. MAIN OUTCOME MEASURES: The mean and median maximal diameters of AAAs. RESULTS: Of 360 patients with treated AAAs, 339 met the inclusion criteria. The mean (SD) diameter of repaired AAAs decreased from 6.49 (1.46) cm (median, 6.40 cm) in 2000 to 5.83 (1.23) cm (median, 5.60 cm) in 2009. Correlation analysis confirmed a decrease in diameter across years (Pearson R = -0.141; P = .01). A fitted regression line also showed a decreasing trend (slope = -0.059 cm per year; P = .01). CONCLUSIONS: The diameters of repaired AAAs at our hospital have decreased progressively during the last decade. This observation is consistent with a reduction in the expansion rates of AAAs and may account for the progressive decreases in the aneurysm rupture rate in the United States.

Carotid reconstruction in nonagenarians: is surgery a viable option?

Because of limited longevity and perceived increased perioperative risk, the optimal treatment of significant carotid stenosis in nonagenarians is controversial. This study was conducted to evaluate our results in this demographic group. A retrospective review was performed of carotid endarterectomies (CEAs) done in nonagenarians at Cedars-Sinai Medical Center between 1996 and 2006. During this period, a total of 2,038 CEAs were performed on patients of all ages. Data abstracted included demographics, patient risk factors, indications for surgery, perioperative complications, and survival. Fifty-three (2.8%) CEAs were performed as the primary procedure on 49 patients aged 90 or greater during the study period. Of these patients, 11 (22.4%) had diabetes, 38 (77.5%) had hypertension, and 31 (63.3%) had coronary artery disease. Eleven patients (22.4%) had a history of smoking, and there were no current smokers. Renal disease was present in three (6.1%) patients, one of whom was dialysis-dependent. The median length of stay was 2 days with a range of 1 to 24 days. Five patients (10.2%) required the intensive care unit following surgery. There were no postoperative strokes, and none of the patients had suffered ipsilateral stroke during follow-up. One patient (1.8%) had a perioperative myocardial infarction. One patient died in the perioperative period (1.8%). The 1-month stroke and mortality results did not differ significantly from those in patients under the age of 90, 0.3% and 0.4%, respectively (p = nonsignificant by Fisher's exact test). Using Kaplan-Meier life-table analysis, the 1- and 5-year survival rates were 84 +/- 5% and 33 +/- 9%, respectively. Our study demonstrates that in a group of well-selected nonagenarians, CEA is a safe procedure with acceptable perioperative morbidity.

Tumors at the aortoiliac/inferior vena cava bifurcation: preoperative, anesthetic, and intraoperative considerations.

Primary and recurrent retroperitoneal tumors can involve the aortoiliac vasculature. They are often considered inoperable or incurable because of the locally advanced nature of the disease or the technical aspects involved in safely resecting the lesion. Safe resection of these lesions requires experience and extensive preoperative planning for success. A retrospective database review of 76 patients with retroperitoneal tumors identified tumors involving major vascular structures in the abdomen and pelvis undergoing resection of tumor en bloc with the aortoiliac vasculature. Preoperative planning and intraoperative technical maneuvers are reviewed. Patients were followed until time of this report. Four patients with retroperitoneal tumors involving the aortoiliac vessels underwent surgery: two patients with sarcoma (one primary and one recurrent), one with metastatic renal cell carcinoma, and one with a paraganglioma. All patients had resection of the aorta and vena cava or the iliac artery and vein. Arterial reconstruction (anatomic or extra-anatomic) was performed in all cases. The patient with renal cell carcinoma also required venous reconstruction to support a renal autotransplant. Veno-venous bypass was required in one patient. Local control was achieved in 3 of 4 cases. Surgery for retroperitoneal tumors involving major vascular structures is technically feasible with appropriate planning and technique. Multiple disciplines are required, including general surgical oncology, vascular surgery, and possibly, cardiothoracic surgery.

Access strategies for revision or explantation of the Charité lumbar artificial disc replacement.

BACKGROUND: Several lumbar disc prostheses are being developed with the goal of preserving mobility in patients with degenerative disc disease. The disadvantage of lumbar artificial disc replacement (ADR) compared with anterior interbody fusion (ALIF) is the increased potential for displacement or component failure. Revision or removal of the device is complicated by adherence of the aorta, iliac vessels, and the ureter to the operative site. Because of these risks of anterior lumbar procedures, vascular surgeons usually provide access to the spine. We report our experience with secondary exposure of the lumbar spine for revision or explantation of the Charité disc prosthesis. METHODS: Between January 2001 and May 2006, 19 patients with prior implantation of Charité Artificial Discs required 21 operations for repositioning or removal of the device. Two patients had staged removal of prostheses at two levels. One patient had simultaneous explantation at two levels. The mean age was 49 years (range, 31 to 69 years; 56% men, 42% women). The initial ADR was performed at our institution in 14 patients (74%). The mean time from implantation to reoperation was 7 months (range, 9 days to 4 years). The levels of failure were L3-4 in one, L4-5 in nine, and L5-S1 in 12. RESULTS: The ADR was successfully removed or revised in all patients that underwent reoperation. Three of the 12 procedures at L5-S1 were performed through the same retroperitoneal approach as the initial access. One of these three, performed after a 3-week interval, was converted to a transperitoneal approach because of adhesions. The rest of the L5-S1 prostheses were exposed from a contralateral retroperitoneal approach. Four of the L4-5 prostheses were accessed from the original approach and five from a lateral, transpsoas exposure (four left, one right). The only explantation at L3-4 was from a left lateral transpsoas approach. Nineteen of the 22 ADR were converted to ALIF. Two revisions at L5-S1 involved replacement of the entire prosthesis. One revision at L4-5 required only repositioning of an endplate. Access-related complications included, in one patient each, iliac vein injury, temporary retrograde ejaculation, small-bowel obstruction requiring lysis, and symptomatic, large retroperitoneal lymphocele. There were no permanent neurologic deficits, deep vein thromboses, or deaths. CONCLUSIONS: Owing to vascular and ureteral fixation, anterior exposure of the lumbar spine for revision or explantation of the Charité disc replacement should be performed through an alternative approach unless the procedure is performed < or = 2 weeks of the index procedure. The L5-S1 level can be accessed through the contralateral retroperitoneum. Reoperation at L3-4 and L4-5 usually requires explantation and fusion that is best accomplished by way of a lateral transpsoas exposure.

Hyperperfusion syndrome after carotid endarterectomy.

The hyperperfusion syndrome is a rare delayed postoperative complication of carotid endarterectomy (CEA) characterized by headache and seizure, with or without intracranial edema or hemorrhage. Between January 1996 and December 2003, 1,602 CEAs were performed. Six patients (0.4%) developed symptoms of hyperperfusion within 2 weeks of surgery. All patients had critical stenoses, five > or =90% and one 80-90%, with poor backbleeding from the distal internal carotid artery noted at operation in all cases. Five patients were asymptomatic prior to operation; one had a hemispheric transient ischemic attack. Three patients had severe contralateral internal carotid disease (two occlusions and one severe stenosis). Two patients developed severe, self-limiting headache that prolonged hospitalization. Three patients had ipsilateral intracranial bleeding, two occurring after an uneventful postoperative course. After initial discharge from the hospital, severe intracranial hemorrhage caused death in two patients. One patient experienced focal seizures 1 week after discharge. Hypertension did not appear to be related to the symptoms in any case. During the study period, the hyperperfusion syndrome caused three of five perioperative strokes (60%) and two of seven deaths (29%) in the entire endarterectomy population. Although rare, the hyperperfusion syndrome accounts for a significant percentage of the neurological morbidity and mortality following CEA.

Early experience with radiofrequency ablation of the greater saphenous vein.

Radiofrequency ablation of the greater saphenous vein (GSV) has been proposed as an alternative to conventional ligation and stripping in the treatment of varicose veins. We have reviewed our initial experience with this new technology in 28 procedures on 24 patients. Preoperative duplex scans confirmed venous valvular incompetence of the GSV in all patients. Intraoperative ultrasound was used to measure the depth of the GSV, to precisely place the radiofrequency catheter adjacent to the saphenofemoral junction, and to confirm the results of the ablative procedure. Occlusion of the GSV was seen on 96% of completion scans and in all patients within 1 week of the procedure. Duplex scans were available for 21 limbs at 3 months and for 3 at 1 year. Persistent occlusion was documented in all cases. No patient had paresthesias or thermal skin injury. Two patients had transient superficial thrombophlebitis around the knee in a treated segment of the GSV. One patient was found to have extension of an asymptomatic, nonocclusive thrombus into the common femoral vein on a routine scan 3 days after surgery. Postoperative patient questionnaires showed that 96% of respondents were very satisfied with the procedure. Radiofrequency ablation of the GSV appears to be a safe alternative to conventional stripping and ligation. Subjective assessment by the surgeons suggests an earlier return to work and active lifestyle compared to traditional extirpative techniques. Longer follow-up is required to establish the durability of the procedure.

Spontaneous infrarenal abdominal aortic dissection presenting as claudication: case report and review of the literature.

Spontaneous infrarenal abdominal aortic dissection (SIAAD) is rare. Patients with SIAAD may be asymptomatic or may present with abdominal pain or lower extremity ischemia. We describe a case report of a patient with SIAAD who presented with claudication. We reviewed the English literature on this disorder and specifically evaluated the differences between patients on the basis of their presenting symptoms. Patients who had SIAAD and lower extremity ischemia were more likely to have the dissection process extend into the iliac or femoral artery and were less likely to have an associated abdominal aortic aneurysm. Aortic rupture in the presence of SIAAD was associated with increased risk of death.

Cryopreserved saphenous vein allografts in infrainguinal revascularization: analysis of 240 grafts.

INTRODUCTION: Cryopreserved saphenous vein allografts (Cryograft; CryoLife, Kennesaw, Ga) have been used as conduit in infrainguinal revascularization when autogenous vein is inadequate or unavailable. Although some studies of Cryografts report poor long-term patency, an anticoagulation protocol may improve outcome. We evaluated our experience with Cryografts to further define their role in lower extremity revascularization. Patients and methods Between March 1992 and March 2002, 240 infrainguinal revascularization procedures with Cryografts were performed in 199 limbs of 177 patients. Eighty-nine percent of procedures were performed because of ischemic rest pain or tissue loss, and 75% of vein grafts were implanted into infrapopliteal targets. Most patients received anticoagulation therapy with warfarin sodium or aspirin, or both, postoperatively. Mean age of the cohort was 78 years; 61% were women; 75% had hypertension, 58% had diabetes, and 38% had renal dysfunction; and 47% were current or past smokers. RESULTS: Mean follow-up was 7 months (range, 0-48 months). Primary patency rate was 83% at 1 month, 50% at 6 months, 30% at 12 months, and 18% at 24 months. Diabetes adversely affected graft patency. Warfarin sodium or antiplatelet therapy did not significantly improve graft patency. Limb salvage was 80% at 1 year and 71% at 2 years. CONCLUSIONS: Cryografts have low primary patency rates that are not affected by anticoagulation with warfarin sodium. Short-term patency of these grafts may be sufficient to heal ischemic wounds and thereby prevent limb loss. However, other less expensive alternatives, eg, prosthetic grafts with vein cuffs, are available and appear to have better patency. Accordingly, use of Cryografts should be limited to revascularization through infected fields in patients without autogenous conduit.

Septic embolization to the carotid bifurcation presenting as carotidynia.

Carotidynia is a term that is best defined by neck pain associated with tenderness over the carotid artery. The differential diagnosis of this entity is broad and includes vascular disorders such as carotid dissection, aneurysm, occlusion, and arteritis. We describe the first reported case of carotidynia caused by septic embolization to the carotid bulb and offer a logical plan for its management.

Isolated dissection of the abdominal aorta: clinical presentation and therapeutic options.

INTRODUCTION: Arterial dissection commonly affects the thoracic aorta and is associated with high morbidity and mortality rates. Although dissection of the abdominal aorta is considered rare, liberal use of diagnostic computed tomographic scan imaging for evaluation of abdominal pain has identified this process with increasing frequency. Because the clinical features and therapeutic options of isolated abdominal aortic dissection are not well characterized, we reviewed our recent experience and provide an algorithm for treatment. PATIENTS AND RESULTS: Since 1996, we have treated 10 patients with abdominal aortic dissection. The mean age was 62 +/- 17 years, and 40% were female. Presentation included abdominal pain in seven patients and lower extremity ischemia in one patient. Dissection was asymptomatic in two of the patients. Hypertension, smoking history, remote trauma, and claudication were noted in four, three, two, and two of the patients, respectively. Three patients had abdominal tenderness, three had a pulsatile mass, and five had a benign abdominal examination. The diagnosis of dissection was made on abdominal computed tomographic scan in eight cases, on arteriogram in one case, and at operation in one case. No patient had an associated thoracic aortic dissection. The dissection flap originated below or at the renal arteries in nine of the cases and at the superior mesenteric artery in one case. Length of the dissection ranged between 21 and 110 mm, and in three patients, the dissection flap extended beyond the aortic bifurcation into the common iliac arteries. In three patients who had an aortogram, evidence of flow limitation was found on the basis of the presence of aortic stenosis or occlusion. Treatment consisted of aortic stent graft deployment in one patient, direct aortic reconstruction in three patients, and observation in the remaining six patients. CONCLUSION: Although the natural history of isolated abdominal aortic dissection has not been well defined, our experience adds to the understanding of this rare process. Because aneurysmal degeneration can occur, close surveillance is indicated if definitive treatment is not used initially. Patients with ischemic symptoms and those with intractable pain need intervention, the nature of which should be based on risk profile and aortoiliac anatomy.

Delayed retroperitoneal arterial hemorrhage after inferior vena cava (IVC) filter insertion: case report and literature review of caval perforations by IVC filters.

Transvenous placement of inferior vena cava (IVC) filters has become commonplace in selected patients with deep venous thrombosis (DVT) and pulmonary embolism (PE). IVC filters have been shown to have excellent therapeutic efficacy and low complication rates. Penetration of the IVC by filter hooks or struts has been reported and commonly noted to be inconsequential. We report a laceration of a lumbar artery by a stainless steel Greenfield (SSG) filter strut that resulted in a near fatal hemorrhage, and review the world literature on caval perforation by IVC filters.