Technical complications of endovascular abdominal aortic aneurysm repair.

PURPOSE: Results from 34 endovascular repairs of abdominal aortic aneurysms are reviewed to identify technical complications and relate them to anatomic and technical features of the operation. METHODS: Twenty-one patients underwent attempted tube graft repair (mean follow-up, 13 months). Thirteen patients underwent placement of a bifurcated graft (mean follow-up, 7.2 months). RESULTS: Twenty-five patients (74%) underwent repair without technical complication (16 tube graft and nine bifurcated graft). Of five patients who had tube graft complications, two involved small iliac arteries and resulted in arterial injury. One of these patients needed a femorofemoral bypass procedure, and the other required conversion to standard operation. Two patients had distal leaks associated with the attachment system, and one patient had misplacement of the distal attachment system. The two patients who had leaks were followed-up; one required operation after 7 months, whereas the other leak sealed. The patient who had distal attachment system misplacement had a second endograft placed within the first to provide a distal seal. The four patients who had bifurcated graft complications involved two graft limb stenoses, one managed with a Palmaz stent and the other with balloon angioplasty. The patient treated with balloon angioplasty had graft thrombosis 1 week after the operation, which resulted in the need for a femorofemoral bypass procedure. Another bifurcated graft patient had a graft limb twist, which has resulted in chronic claudication. One patient had placement of a limb too proximal in the common iliac artery with chronic leak, and an open operation was performed 18 months later. CONCLUSIONS: Technical complications in this series seem to be associated with short distal necks, small iliac arteries, tortuous iliac arteries, and atherosclerosis at the aortic bifurcation. We believe that experience and understanding of these issues will reduce the risk of these complications in the future.

Limb ischemia: surgical therapy in acute arterial occlusion.

Mortality and amputation rates from acute arterial occlusion are reported from 7 to 37 per cent and 10 to 30 per cent, respectively. Recent data from thrombolysis or peripheral arterial surgery suggest no significant differences between initial management with surgical or thrombolytic therapy. Mortality and amputation rates were in the above ranges. The last 230 procedures (216 patients) over 10 years were reviewed. All graft occlusions, cardiac catheterization injuries, and aortic balloon-related thromboses were excluded. Immediate and delayed amputation rates were 6.5 and 0.9 per cent. Death occurred in 21 patients (9.7%), with only 6 deaths over the last 6 years (3.8%). Except for transesophageal echocardiography, perioperative studies were of limited value. Long-term anticoagulation was also not effective in preventing recurrent episodes. A mortality rate of 9.7 per cent and amputation rate of 7.4 per cent justifies an early aggressive surgical approach. Limited perioperative studies and less prolonged anticoagulation may also improve cost containment.

Resource utilization and pathways: meeting the challenge of cost containment.

The 1990s will bring sweeping changes with managed care and capitation. To address this cost/quality paradox, selective intensive care utilization is coupled with clinical pathways as an innovative change for all patients having cerebral revascularization (CVR) or femoral revascularization (FR). From January 1, 1991 through June 30, 1995, data were accumulated on 2023 procedures in 1524 patients. The study was based on 848 CVRs and 1175 FRs. Intensive care unit (ICU) observation was necessary in 73 patients (3.6%) for cardiac or hypertensive management. Twenty-six patients (1.2%) transported to a vascular surgical floor from the postanesthesia recovery room required return to an ICU for complications during hospitalization. There were nine strokes or transient ischemic attacks (0.4%) in the CVR group, four myocardial infarctions (0.2%), and five perioperative deaths (0.3%). In the FR group, there were 14 deaths (0.9%). Readmission during the perioperative period, 30 days, was necessary in 46 patients (3.1%). Financial cost analysis revealed the mean adjusted cost for CVR in 1990 adjusted to 1995 dollars was $7223. The institution of case management reduced this to $4490 (37.8 per cent reduction in total hospital costs). The cost for FR in 1990 dollars adjusted to 1995 was $14,332 reduced to $5541 (a 59 per cent reduction in total hospital costs). This study suggests the use of clinical pathways does not impair quality of care, leads to no higher morbidity or mortality, and can produce significant cost savings to a hospital.

Case management in cerebral revascularization.

PURPOSE: We examined the clinical and financial outcomes of case management coupled with the initiation of selective use of the intensive care unit (ICU) in all cerebral revascularization procedures. METHODS: Three hundred eighty-four procedures in 331 patients were retrospectively reviewed. Morbidity and mortality rates, hospital length of stay, cost, and ICU or hospital readmissions were examined. Hypertension was examined as an independent variable for its effect on patient outcome. RESULTS: Cerebral revascularization, including carotid endarterectomy, vertebral-carotid artery transposition, and subclavian-carotid artery transposition, yielded a 0.78% stroke rate and 0.26% perioperative death rate in this series. ICU admission was necessary in nine patients (2.3%) for cardiac or respiratory instability. Three patients (0.78%) required transfer to the ICU for management of hypertension or hypotension. The mean hospital length of stay after institution of case management was reduced by 2.1 days, and the mean cost was decreased by $1987, a savings of 28.9% of total hospital cost. CONCLUSION: The dual approach of case management and selective use of the ICU promotes quality patient care, conserves financial resources without adversely affecting morbidity or mortality rates, enhances physician/nurse collaboration, and improves patient satisfaction.

Cryopreserved saphenous vein allografts for below-knee lower extremity revascularization.

OBJECTIVE: Cryopreserved saphenous vein allografts have been offered as an alternative conduit for bypass in ischemic limbs. The authors examined the efficacy of this conduit for arterial bypass to the distal popliteal and tibial arteries in patients in whom autogenous vein was not available. SUMMARY BACKGROUND DATA: Previous experience with arterial and venous allografts has been unsatisfactory because of aneurysmal degeneration and poor patency. Endothelial loss and host rejection have been suggested as mechanisms of graft failure. Cryopreservation by modern techniques with rate controlled freezing, dimethyl sulfoxide (DMSO), and other cryopreservants, has addressed these issues and rekindled interest in vein allografts. METHODS: Over a period of more than 5 years, 115 cryopreserved vein allografts were implanted in 87 limbs to the distal popliteal (14) or tibial (101) arteries. The indication for surgery was rest pain in 56 procedures (49%), gangrene in 36 (31%), claudication in 21 (18%), and replacement of aneurysmal allografts in 2. Follow-up was 1 to 61 months (mean 25 months). RESULTS: There was no significant difference in patency related to site of proximal or distal anastomosis, patency of runoff vessels, use of anticoagulation, age, sex, diabetes, hypertension, smoking, indication, source of graft, or use of multiple segments. Revision was required in six grafts for aneurysmal dilatation. Histologic examination of explanted sections of allografts showed no immune response, and immunosuppressive drugs were not used. CONCLUSIONS: Although limb salvage has been satisfactory, long-term patency rates for cryopreserved vein allografts are poor when compared with autogenous vein. The cost of cryopreserved allografts far exceeds that of prosthetic grafts, for which comparable and superior results have been reported. Use of cryopreserved vein allografts should be reserved for situations in which adequate lengths of autogenous vein do not exist and the risk of infection of prosthetic grafts is high.

Subclavian revascularization. A quarter century experience.

OBJECTIVE: Twenty-five years of experience with subclavian revascularizations were reviewed to determine the long-term patency rates of different extrathoracic approaches. SUMMARY BACKGROUND DATA: Although it is generally agreed that proximal subclavian stenosis should be treated by an extrathoracic route whenever possible, the optimum procedure is debated. Alternatives include subclavian carotid bypass, subclavian-to-subclavian or axillo-axillary bypasses, and the authors' preferred technique of subclavian carotid transposition (SCT). METHODS: Records were researched for the past 25 years in a single specialty surgical clinic for extrathoracic subclavian revascularizations. One hundred ninety such procedures were identified, and hospital charts and office medical records were reviewed for procedure, preoperative symptoms, blood pressure differentials, and postoperative complications. Patency was determined by physical examination, differential blood pressures, Doppler spectral analysis, duplex examinations, and arteriography. RESULTS: Bypass procedures were used infrequently, and although the results are reported, they are excluded from any analysis. Subclavian carotid transposition was used in 178 procedures. All anastomoses were found to be patient at follow-up, except for one, which failed at 26 months. Mean follow-up was 46 months, with five patients lost to follow-up. Overall mortality rate was 2.2%, with the mortality falling to 1.1% if only subclavian carotid transposition patients are included. CONCLUSIONS: Subclavian carotid transposition should be the treatment of choice for routine subclavian carotid occlusive disease because of its exceptional long-term patency and low morbidity.

Oral management of a patient with a plasminogen activator inhibitor (PAI-1) deficiency: case report.

Plasminogen activator inhibitor-1 (PAI-1) deficiency causes a rare bleeding disorder by allowing excessive fibrinolysis to occur. Knowledge of the specific type and severity of the bleeding disorder is crucial in planning a safe and appropriate treatment sequence in conjunction with a hemophilia team. This article reports the oral management of a 9-year-old female with PAI-1 inhibitor deficiency using tranexamic acid (Cyclokapron).

Recurrent aortic occlusion.

In a review of 134 aortic occlusions in 123 patients, there were 10 patients that suffered recurrent aortic occlusions (RAO). These patients developed RAO after revascularization for primary aortic occlusion and presented with signs and symptoms of acute lower extremity ischemia. The recurrent occlusions occurred in one native aorta and in 10 aortobifemoral grafts. The etiology of the primary aortic occlusion included chronic aortic occlusion in eight patients and acute aortic occlusion and aortic graft occlusion in one patient each. Original primary operations performed included aortoiliac thromboendarterectomy with Dacron patch aortoplasty (1 patient), AF bypass (8 patients), and aortofemoral graft thrombectomy (1 patient). All of the grafts had end-to-end proximal anastomoses, the diameter of which ranged from 12 to 16 mm. Secondary operations performed for RAO included six axillofemoral bypasses, four redo aortobifemoral bypasses, and one graft thrombectomy. All patients were managed with immediate anticoagulation, expeditious arteriography, and revascularization. There were no perioperative deaths, and no limbs were lost. No patient was lost to follow-up (mean 10 years). Extra-anatomic bypass has proved durable. Redo aortobifemoral bypass is useful in selected patients with surgically correctable lesions.

Suprarenal aortic occlusion.

PURPOSE: This report was designed to elucidate the clinical manifestations of suprarenal aortic occlusion (SRAO) and determine the efficacy of surgical treatment. METHODS: A retrospective review of 135 patients with aortic occlusion was undertaken from which the 16 patients (12%) with SRAO were found. RESULTS: Analysis yielded two subsets of patients based on the time-frame over which SRAO developed. Group I (n = 13) had chronic aortic occlusion with proximal propagation of thrombus to involve the suprarenal aorta. They had uncontrolled hypertension and claudication. Surgical treatment included 16 renal reconstructions (nine patients), two nephrectomies, 10 aortobifemoral bypasses, and three extra-anatomic procedures. The operative mortality rate was 23%. In contrast, group II (n = 3) had acute SRAO, manifest by profound lower extremity ischemia and acute renal failure after cardiac dysrhythmias. Two patients were moribund and died shortly after extraanatomic "salvage" procedures. One patient survived aortobifemoral and bilateral renal artery bypass. CONCLUSION: Chronic SRAO should be suspected in patients with absent femoral pulses and refractory hypertension. Aortic and renal reconstruction offers long-term improvement in hypertension control and relief of claudication. Acute SRAO is a multisystem disorder that is ineffectively managed with extraanatomic "salvage" procedures.

Cefamandole versus cefazolin in vascular surgical wound infection prophylaxis: cost-effectiveness and risk factors.

PURPOSE: Recent studies of perioperative antimicrobial prophylaxis have indicated an improved efficacy of beta-lactamase-stable cephalosporins compared with cefazolin, the most commonly used prophylactic agent. Previous studies in our institution have revealed a superiority of cefamandole to cefazolin in patients undergoing heart surgery, although there was no difference between cefazolin and cefuroxime in patients undergoing peripheral vascular surgery. This study was therefore designed to compare cefamandole with cefazolin in wound infection prophylaxis in clean vascular surgery. METHODS: The study was conducted from August 1990 through May 1992 and consisted of 893 patients with aortic or infrainguinal arterial procedures randomized to receive either cefamandole or cefazolin. RESULTS: The difference in infection rates associated with cefamandole versus cefazolin prophylaxis (3.2% vs 1.9%, respectively) was not significant (p = 0.42). A cost savings of approximately $95,000 per year at our institution favors the continued use of cefazolin over cefamandole. Risk factor analysis was carried out for preoperative and postoperative events that might have predisposed to infection. Only preoperative use of aspirin and the postoperative finding of a lymphocele correlated with a higher infection rate. CONCLUSIONS: Cefazolin continues to be the most cost-effective antibiotic for prophylaxis in clean vascular surgical procedures.

Surgical treatment of common carotid artery occlusion.

Eight patients with common carotid artery (CCA) occlusion underwent bypass with saphenous vein to either the carotid bifurcation (five), the internal carotid artery (two), or the external carotid artery (one). Indications included ipsilateral transient ischemic attack (two), recent nondisabling hemispheric stroke (two), and transient nonhemispheric cerebral symptoms (two). Two asymptomatic patients with CCA occlusion and contralateral internal carotid stenosis underwent prophylactic revascularization prior to planned aortic surgery. There were no perioperative strokes, occlusions, or deaths. Late ipsilateral stroke occurred in two patients, and one patient had a single transient ischemic attack after 2 years. The four patients with preoperative transient cerebral ischemia experienced relief of their symptoms. Duplex ultrasound is an accurate screening modality for distal patency. Collateral filling of the internal or external carotid artery can usually be demonstrated after aortic arch or retrograde brachial contrast injection. End-to-end distal anastomosis after endarterectomy eliminates the original occlusive plaque as a potential source of emboli. The subclavian artery is preferred for inflow on the left. The CCA origin is easily accessible for inflow on the right. Bypass of the occluded CCA is safe and may be effective in relieving transient cerebral ischemic symptoms, although long-term ipsilateral neurologic sequelae may still occur.

The evolving surgical management of recurrent carotid stenosis.

The traditional approach to recurrent carotid stenosis has been repeat endarterectomy or patch angioplasty. Concern with the durability of repeat carotid endarterectomy has resulted in our use of carotid resection with autogenous graft interposition. This study was designed to determine the outcome and efficacy of carotid resection compared with repeat carotid endarterectomy in the management of recurrent carotid stenosis. From 1974 to 1991, 162 operations (repeat carotid endarterectomy 105, carotid resection 57) were performed for recurrent carotid stenosis. Indication for operation was hemispheric symptoms in 63% of patients, nonlateralizing symptoms in 25%, asymptomatic stenosis in 7%, and previous stroke in 5%. Ninety-one percent of patients had stenosis greater than 90% on arteriography. The perioperative stroke rate for carotid resection was 3.5%, with a subsequent rate of 0.0064 strokes per year. For repeat carotid endarterectomy, the perioperative stroke rate was 1.9% with a subsequent rate of 0.011 strokes per year. Graft patency after carotid resection was 93% (mean follow-up, 35 months). Four patients treated with carotid resection had graft thrombosis, and two of the four remained asymptomatic. After repeat carotid endarterectomy, one patient had carotid thrombosis, and recurrent stenosis greater than 50% developed in 23 patients (mean follow-up, 64 months). Twenty patients treated with repeat carotid endarterectomy underwent an additional operation for further symptomatic recurrent carotid stenosis. We conclude carotid resection is a safe and effective alternative to repeat carotid endarterectomy for patients undergoing operation for recurrent carotid stenosis.

Juxtarenal aortic occlusion.

The authors' experience with 113 aortic occlusions in 103 patients during a 26-year period (1965 to 1991) is reviewed. The authors found three distinct patterns of presentation: group I (n = 26) presented with acute aortic occlusion, group II (n = 66) presented with chronic aortic occlusion, and group III (n = 21) presented with complete occlusion of an aortic graft. Perioperative mortality rates were 31%, 9%, and 4.7% for each respective group and achieved statistical significance when comparing group I with group II (p = 0.009) and group I with group III (p = 0.015). Group I presented with profound metabolic insults due to acute ischemia and fared poorly. Group II presented with chronic claudication and did well long-term. Group III presented with acute ischemia but did well because of established collateral circulation. The treatment and expected outcome of aortic occlusion depends on the cause.

Surviving gastrointestinal infarction due to polyarteritis nodosa: a rare event.

Poly arteritis nodosa (PAN) is a systemic vasculitis with a male: female ratio of 2:1 and a peak incidence in the fifth decade. Small to medium-sized arteries are involved by focal transmural inflammatory necrosis. Aneurysms with inflammatory destruction of the media also occur. The most frequently involved organs are the kidney, heart, lung, liver, and gastrointestinal tract. There are few reported cases of ischemic necrosis of the intestine and even fewer survivors. A 22-year-old woman was transferred to St. Thomas Hospital (Nashville, TN) after resection of 80 per cent of the small bowel for ischemic necrosis. She had a history of juvenile onset diabetes mellitus, recurrent abdominal pain, and splinter hemorrhages. Emergency aortogram and selective mesenteric arteriogram were performed. The celiac artery was not visualized and small aneurysms were present in the mesenteric and renal arteries. The patient was successfully resuscitated from a cardiac arrest in x ray from a cardiac tamponade. Laparotomy was performed to determine the viability of the bowel. The celiac, hepatic, and splenic arteries were found to be chronically occluded. Pathology of these arteries revealed a nonspecific arteritis. At a third operation, several more inches of small bowel were removed. Characteristic changes of PAN were present on all small bowel specimens. She was treated with high-dose cyclophosphamide and steroids for 6 months and has continued on low-dose cyclophosphamide. She is now 36 months from her original operation and is doing well on oral nutrition. Intestinal hemorrhage from aneurysm rupture or gangrene with perforation are gastrointestinal complications of PAN that the surgeon may be called upon to treat.(ABSTRACT TRUNCATED AT 250 WORDS)

Cefuroxime versus cefazolin as prophylaxis in vascular surgery.

Although cefazolin prophylaxis has proven efficacy in vascular surgery, Staphylococcus aureus wound infections are still an important postoperative complication. In cardiac surgery, cefazolin's susceptibility to hydrolysis by staphylococcal beta-lactamase has been proposed to account for some prophylaxis failures. To determine whether the incidence of vascular wound infections can be reduced by administering a more beta-lactamase-stable cephalosporin, we undertook a prospective, randomized trial of cefuroxime versus cefazolin. Cefuroxime was administered as a 1.5 gm dose before operation and 750 mg every 3 hours during operation. Cefazolin was given as 1 gm before operation and 500 mg every 4 hours during operation. Both agents were continued every 6 hours after operation for 24 hours. Deep wound infections developed in seven of 272 (2.6%) cefuroxime and three of 287 (1.0%) cefazolin recipients (p = 0.2). Staphylococcus aureus wound infections occurred in five cefuroxime versus two cefazolin recipients. In vitro evaluation of six of the study isolates plus an additional eight S. aureus strains from vascular wound infections showed greater susceptibility of the strains to cefazolin than cefuroxime (median minimal inhibitory concentrations of 0.5 and 2.0 micrograms/ml, respectively, p less than 0.05). Furthermore, despite its more frequent intraoperative redosing, cefuroxime exhibited lower trough serum concentrations than cefazolin. Among cefuroxime recipients, infection-associated procedures were significantly longer than infection-free procedures (p less than 0.05), suggesting that low tissue antibiotic concentrations may have contributed to the pathogenesis of these infections. In contrast, the length of the procedure was not a risk factor for infection among cefazolin recipients.(ABSTRACT TRUNCATED AT 250 WORDS)

Extended profundoplasty to minimize pelvic and distal tissue loss.

Multiple levels of aortoileofemoral occlusive disease may necessitate profundoplasty or extension of the outflow anastomosis to insure pelvic and distal arterial perfusion. During the period 1978 through 1988, 1637 patients underwent elective aortic reconstruction for aneurysmal or occlusive disease. One hundred forty-five had profundoplasty performed to ensure adequate outflow. Associated disease was common with 88 (60%) patients having arteriosclerotic heart disease and chronic obstructive pulmonary disease (COPD) present in 89 (61%) patients. Hypertension and extracranial occlusive disease was found in 68 (46%) and 56 (38%) patients, respectively. The superficial femoral artery was occluded in 108 (74%) patients, while in 17 (12%) the profunda femoris was the only patent artery in the groin. Death occurred in nine patients (6.2%). Three were due to arrhythmias or myocardial infarction and ischemic colitis was the cause of death in two. Renal failure, sepsis, aspiration and cerebral anoxia, and disseminated intravascular coagulopathy accounted for one each. Five graft limbs failed. Amputation was required in one patient, while thrombectomy or distal bypass restored flow in four patients. Seventeen graft limbs in 136 patients occluded during the follow-up period. Distal bypass was successful in four and amputation was required in the fifth patient. Extension of the profundoplasty restored flow in nine limbs, while thrombectomy alone was successful in one. Bilateral amputation was required in one patient with poor run off and insufficient autogenus venous tissue. One hundred fourteen (78.6%) of the 145 patients survived 10 years with patency in 268 of the original 290 limbs at risk (92.4%). Profundoplasty in these patients with multilevel disease seems to extend the long-term patency of aortofemoral grafts and allows return to a normal life-style.

Recurrent carotid artery stenosis. Resection with autogenous vein replacement.

Recurrent carotid artery stenosis (RCAS) occurs in 10% to 15% of patients following carotid endarterectomy (CEA). A recurrent stenosis may occur as early as 6 months and will become symptomatic in 3% to 5% of patients. Early stenosis is myointimal hyperplasia, but with the passage of time may progress to the characteristic atherosclerotic lesion. Improvements in noninvasive testing allows for evaluation and early detection of restenosis. Since 1974 we have performed 3711 CEAs in 2909 patients. One hundred and six second or third CEAs were performed in 98 patients (3.5%). In 20 of these reoperations, the common carotid (CCA) and internal carotid artery (ICA) were resected and replaced by autogenous vein, usually saphenous. One of these patients had 3 previous CEAs while 7 patients had 2 and 12 patients had 1 previous operation. There were no deaths; thrombosis of one vein interposition requiring replacement occurred. Hoarseness and hypoglossal nerve palsy occurred in one patient. Follow-up ranged to 5 years with a mean of 2.8 years. Although a second CEA is possible, there are inherent technical difficulties that may be encountered and vein interposition will solve these as well as offer the potential to prevent a further recurrence.

Analysis of a decade of carotid reconstructive operations.

Carotid artery reconstruction surgery for atherosclerotic lesions of the extracranial cerebral circulation has become the most common peripheral vascular operation. A better understanding of the indications for operative intervention, enhanced monitoring during surgery, and more precise management of intraoperative anesthesia have all decreased the risks associated with internal carotid endarterectomy (ICA). In an effort to evaluate the safety and efficacy of extracranial carotid reconstructive surgery, we reviewed 3028 operations performed in 2198 patients during the past decade (1977-1986). Operation was recommended because of hemispheric symptoms in 59% of cases. Fourteen percent were advised to have endarterectomy because of an asymptomatic, significant ICA stenosis. Postoperative hemiparesis occurred in 24 patients (1.1%) and was associated with thrombosis at the operative site in 18 patients. Antiplatelet drugs utilized during the last four years were effective in preventing thrombosis at the operative site. Operative mortality during the decade was 1.2%. Follow-up has ranged from one to. 104 months with 86% of the patients alive and 87% symptom free.