Five-step protocol for carotid endarterectomy in the managed health care era.

BACKGROUND: We developed a protocol combining 5 cost-effective strategies to determine whether elective carotid endarterectomy (CEA) could be performed safely without adversely affecting well-established low morbidity and mortality rates and with significant hospital cost savings. METHODS: Between April 1, 1995, and December 31, 1996, 109 of 141 patients were prospectively enrolled as candidates into a 5-step CEA protocol: (1) duplex ultrasonography (DU) performed at an accredited vascular laboratory as the sole diagnostic carotid preoperative study, (2) admission the day of operation, (3) cervical block anesthesia to eliminate intraoperative electroencephalogram monitoring, (4) transfer from the recovery room after a 4-hour observation period to the vascular ward, and (5) discharge the first postoperative morning. The other 32 patients were excluded from analysis; 16 patients were treated by vascular surgeons not participating in the protocol, 9 were treated concomitantly for other medical problems, and 7 were admitted emergently. RESULTS: One patient died of carotid hemorrhage the first postoperative morning, and one had an intraoperative embolic stroke for a combined mortality-stroke rate of 1.8% (2 of 109). Of the 109 patients, 70% (76) underwent operation using DU as the sole diagnostic study, 95% (104) were admitted the day of operation, 76% (83) had cervical block anesthesia, 59% (64) were transferred to the floor the day of operation, and 83% (90) were discharged the morning after operation. None of the 109 patients were adversely affected by these 5 cost-saving strategies except potentially the patient who bled the first postoperative morning. The predicted charges of a patient treated with a perioperative protocol that many vascular surgeons currently use (preoperative arteriography, general anesthesia with intraoperative electroencephalogram monitoring, overnight intensive care unit stay, discharge on postoperative day 2) was $16,073 compared with $10,437 for a patient who completed all 5 steps of the protocol detailed above. CONCLUSIONS: On the basis of these results documenting significant cost savings and acceptably low morbidity and mortality rates, this 5-step protocol may be considered the standard for performing CEA in this era of cost containment. These results may be compared with endovascular intervention, which has recently been proposed as a less expensive technique to treat carotid disease.

Selective use of duplex ultrasound to replace preoperative arteriography for failing arterial vein grafts.

PURPOSE: In an effort to minimize costs and patient discomfort, we determined whether duplex ultrasound (DU) could selectively replace preoperative arteriography performed in the radiology suite to diagnose failing arterial bypass grafts (FABs) constructed of autogenous vein. METHODS: Between January 1, 1994, and December 31, 1996, we treated 106 FABs. Graft revision solely on the basis of DU was performed only if a focal stenosis was clearly identified in the graft (peak systolic velocity [PSV] > 300 cm/sec, ratio of adjacent PSVs > 3.0) or in inflow or outflow arteries (resulting in uniform graft PSVs < 45 cm/sec). Intraoperative arteriograms were frequently obtained to confirm DU findings. Preoperative arteriograms were obtained if DU revealed multiple or ill-defined stenoses, diffuse inflow or outflow arterial disease, uniformly low PSVs without an identifiable lesion, or equivocal stenosis despite clinical evidence of an FAB. RESULTS: Seventy-three (69%) FABs with 81 lesions were revised on the basis of DU only. Of 76 stenotic lesions, an intraoperative arteriogram or surgical findings confirmed a diameter stenosis of 75% to 99% in 69 grafts (91%) and stenosis of 50% to 74% in three grafts (4%). DU incorrectly identified the site of stenosis or underdiagnosed the extent of disease in four grafts (5%). DU correctly identified the site of missed arteriovenous fistulas in five grafts. The 73 FABs were treated with intraoperative balloon angioplasty (30 grafts), patch angioplasty (20), interposition or jump grafts (12), ligation of arteriovenous fistula (3), a new bypass graft (1), or a combination of these interventions (7). A significant change in intraoperative strategy potentially could have been avoided if a preoperative arteriogram had been obtained in three of the 73 FABs (4.1%). CONCLUSIONS: DU can reliably be used to revise FABs and avoid the morbidity, discomfort, and cost of confirmatory arteriography in two thirds of cases.

Duplex ultrasonography to diagnose failing arterial prosthetic grafts.

BACKGROUND: Although several reports have documented the usefulness of a surveillance program with duplex ultrasonography (DU) to diagnose failing autologous vein bypasses, the effectiveness of DU to detect failing arterial prosthetic grafts has not been confirmed. We attempted to determine whether our program, which included DU and other noninvasive techniques (NonDU), was useful for this purpose. METHODS: Between July 1, 1991, and September 30, 1994, 85 prosthetic bypasses in 59 patients performed for lower extremity ischemia were entered into a graft surveillance protocol. There were 35 femoropopliteal, 16 femorotibial, 15 iliofemoral, 13 axillofemoral, and 6 femorofemoral bypasses. Both DU and NonDU were performed 1 week and every 3 months after the initial bypass or after graft revision. NonDU criteria of a failing graft included changes in symptoms or pulses, decreased ankle/brachial index greater than 0.15, or diminution of ankle pulse volume recordings greater than 50%. Normal grafts were bypasses that had less than 50% stenosis documented by arteriography or remained patent. Problem grafts were those that required revision or thrombosed before intervention. Follow-up of patient grafts ranged between 3 and 36 months (mean, 11 months). RESULTS: DU predicted 17 (81%) of 21 problem grafts versus only 5 (24%) diagnosed by NonDU (p = 0.001). Lesions associated with these 21 grafts were perianastomotic in 10 cases, in adjacent inflow or outflow arteries in 8 cases, and intrinsic to the graft in 3 cases. The likelihood of a graft thrombosing in the presence of a normal test was 7% (4 of 58) for DU compared with 21% (16 of 76) for NonDU (p = 0.04). CONCLUSIONS: DU is more sensitive than NonDU in predicting failure of prosthetic grafts. This study suggests that DU should routinely be performed as part of a surveillance program for peripheral arterial prosthetic bypasses.

Venous aneurysms: surgical indications and review of the literature.

BACKGROUND: During the last 20 years we diagnosed five cases of venous aneurysm of the jugular (n = 4) and basilic (n = 1) veins. The purpose of this report was to determine the natural history and indications for surgery of venous aneurysms. METHODS: Our five cases were included in an English-language literature review performed through August 1993. RESULTS: In our series two aneurysms (one external jugular vein, one basilic vein) were excised for cosmetic reasons. Three internal jugular vein aneurysms were followed up for up to 4 years without complications with serial color duplex ultrasonography. Of 32 patients with abdominal venous aneurysms (18 portal, seven inferior vena cava, four superior mesenteric, two splenic, one internal iliac), 13 (41%) had major complications including five deaths. Of 31 patients with deep venous aneurysms of the extremity (29 popliteal, two common femoral), 22 (71%) had deep vein thrombosis or pulmonary embolism and in 17 recurrent deep vein thrombosis or pulmonary embolism developed when patients were treated with anticoagulation alone. CONCLUSIONS: Prophylactic surgery is cautiously recommended for low-risk patients with venous aneurysms of the abdomen and strongly recommended for most patients with lower extremity deep venous aneurysms. Other venous aneurysms should be excised only if they are symptomatic, enlarging, or disfiguring.

Successful preservation of an infected common femoral vein to common femoral vein crossover prosthetic graft.

We used selective graft preservation to treat an infected anastomosis of a functioning common femoral vein to common femoral vein crossover PTFE bypass performed for iliac vein occlusion. The graft was successfully salvaged by operative debridement and placement of a rectus abdominis muscle flap. With the growing interest in venous reconstructive surgery, bypass infections may be seen more frequently. This case illustrates that selective preservation of infected prosthetic grafts anastomosed to a peripheral vein may be a simple and improved method to treat these complications.

Deep femoral artery pseudoaneurysm caused by acute trunk and hip torsion.

Spontaneous pseudoaneurysm is extremely uncommon. Apparently the first case of a deep femoral artery pseudoaneurysm, caused by acute trunk and hip torsion during a golf swing, is reported. The lesion was documented by computed tomography, arteriography and surgical investigation. The present report is aimed at making known the possibility of such a complication following this and similar types of physical activity in order to enable prompt assessment and treatment of the lesion.