Persistent sciatic artery in a patient with unilateral acute lower extremity ischemia.

We report a rare case of a persistent sciatic artery in a 59-year-old woman who had presented with unilateral acute limb ischemia. A heparin infusion was started. A right lower extremity arterial duplex ultrasound scan showed an occluded superficial femoral artery and underwent catheter-directed thrombolysis of her right popliteal artery, which was fed by a persistent sciatic artery. After recovery, computed tomography angiography was performed, which confirmed a persistent sciatic artery of the right lower extremity. The patient had presented with thrombotic disease secondary to atherosclerosis of popliteal and tibial arteries, in contrast to the more commonly seen aneurysmal disease with thrombosis.

Duplex-guided endovascular treatment for occlusive and stenotic lesions of the femoral-popliteal arterial segment: a comparative study in the first 253 cases.

OBJECTIVE: The standard technique of balloon angioplasty with or without subintimal dissection of infrainguinal arteries requires contrast arteriography and fluoroscopy. We attempted to perform this procedure with duplex guidance to avoid the use of nephrotoxic contrast material and eliminate or minimize radiation exposure. METHODS: From September 2003 to June 2005, 196 patients (57% male) with a mean age of 73 +/- 10 years (range, 42-97 years) had a total of 253 attempted balloon angioplasties of the superficial femoral and/or popliteal artery under duplex guidance in 218 limbs. Critical ischemia was the indication in 38% of cases, and disabling claudication was the indication in 62%. Hypertension, diabetes, chronic renal insufficiency, smoking, and coronary artery disease were present in 78%, 51%, 41%, 39%, and 37% of patients, respectively. The TransAtlantic Inter-Society Consensus (TASC) classification was used for morphologic description of femoral-popliteal lesions. The common femoral artery was cannulated under direct duplex visualization. Still under duplex guidance, a guidewire was directed into the proximal superficial femoral artery, across the diseased segment(s), and parked at the tibioperoneal trunk. The diseased segment(s) were then balloon-dilated. Balloon diameter and length were chosen according to arterial measurements obtained by duplex scan. Hemodynamically significant defects causing diameter reductions greater than 30% and peak systolic velocity ratios greater than 2 were stented with a variety of self-expandable stents under duplex guidance. Completion duplex examinations and ankle-brachial indices were obtained routinely before hospital discharge. RESULTS: There were 11 (4%) TASC class A lesions, 31 (12%) TASC class B lesions, 177 (70%) TASC class C lesions, and 34 (14%) TASC class D lesions in this series. The overall technical success was 93% (236/253 cases). Eight of the 17 failed subintimal dissections belonged to TASC class C and the remaining 9 to TASC class D. End-stage renal disease was the only significant predictor of subintimal dissection failure in patients with femoral-popliteal occlusions (5/17 cases; P < .04). Intraluminal stents were placed in 153 (65%) of 236 successful cases. Overall pre-procedure and post-procedure ankle-brachial indices changed from a mean of 0.69 +/- 0.16 (range, 0.2-1.1) to 0.95 +/- 0.14 (range, 0.55-1.3), respectively (P < .0001). The mean duration of follow-up was 10 +/- 7 months (range, 1-29 months). The overall 30-day survival rate was 100%. Overall limb salvage rates were 94% and 90% at 6 and 12 months, respectively. Six-month patency rates for TASC class A, B, C, and D lesions were 89%, 73%, 72%, and 63%, respectively. Twelve-month patency rates for TASC class A, B, C, and D lesions were 89%, 58%, 51%, and 45%, respectively. CONCLUSIONS: Duplex-guided balloon angioplasty and stent placement seems to be a safe and effective technique for the treatment of infrainguinal arterial occlusive disease. Technical advantages include direct visualization of the puncture site, accurate selection of the proper size balloon and stent, and confirmation of the adequacy of the technique by hemodynamic and imaging parameters. Additional benefits are avoidance of radiation exposure and contrast material.

Morbidity and mortality associated with brachial vein thrombosis.

We have noted a significant incidence of pulmonary embolism (PE) and mortality associated with upper extremity deep venous thrombosis (UEDVT). Since there is an association between site of lower extremity DVT (LEDVT) and PE, we hypothesized that there might also be a correlation between site of UEDVT and PE with associated mortality. To further elucidate this hypotheses, we analyzed the mortality and incidence of PE diagnosed with subclavian/axillary/internal jugular vein thrombosis during an 11-year period at our institution and compared the data to those of patients diagnosed with brachial DVT. We studied 598 patients diagnosed with acute internal jugular, subclavian, axillary, or brachial DVT by duplex scanning. The patients were divided into three groups based on the most proximal location of the thrombus: group I, UEDVT involving the subclavian or axillary veins (n = 467); group II, isolated internal jugular DVT (n = 80); group III, brachial DVT alone (n = 52). Mortality rates at 2 months were 29%, 25%, and 21% for each group, respectively. The number of patients diagnosed with PE by ventilation/perfusion scans in groups I, II, and III, respectively, were 5%, 6.25% and 11.5% (p = 0.13). Furthermore, stratification by risk factors failed to demonstrate factors associated with increased 2-month mortality. Contrary to the initial hypothesis of a relationship between the site of thrombosis and the incidence of PE and mortality, these data demonstrated no statistical differences in mortality or incidence of PE among the groups studied. Additionally, these data suggest that brachial vein thrombosis is a disease process related to comparable associated mortality and morbidity similar to other forms of UEDVT. Based on these data, we suggest that UEDVT may be thought of as a marker for the severity of systemic illness of the patient rather than just as a cause of venous thromboembolism.

Prospective evaluation of combined upper and lower extremity DVT.

The clinical importance of upper extremity deep venous thrombosis (UEDVT) has been increasingly demonstrated in recent literature. Not only has the risk of pulmonary embolism from isolated upper extremity DVT been demonstrated, but a significant associated mortality has been encountered. Examination of this group of patients has demonstrated the existence of combined upper and lower extremity deep venous thrombosis (DVT) in some patients who exhibit an even higher associated mortality. As a result of this information, it has become the standard practice at this institution to search for lower extremity DVTs in patients found to have acute thrombosis of upper extremity veins. Since January 1999, there have been a total of 227 patients diagnosed with acute UEDVT. Within this group, 211 (93%) patients had lower extremity studies; 45 of these 211 (21%) had acute lower extremity DVTs by duplex examination in addition to the upper extremity DVTs. Overall, there were 145 women, 66 men, and the average age was 70 +/-1.2 (SEM); 22 of these patients had bilateral lower extremity thrombosis (LEDVT), and 8 patients were found to have chronic thrombosis of lower extremity veins. Of the patients with bilateral upper extremity DVTs, there were 3 with bilateral LE acute DVTs. Finally, 8 of the remaining 166 patients (5%) with originally negative lower extremity studies were found to develop a thrombosis at a later date. These data serve to confirm previous studies, on a larger scale, that there should be a high index of suspicion in patients with UEDVT of a coexistent LEDVT.

Mini skin incision for carotid endarterectomy (CEA): a new and safe alternative to the standard approach.

PURPOSE: Patients requiring surgery are naturally attracted to shorter incisions because they tend to cause less pain and are esthetically more appeasing. To substantially shorten the length of standard skin incisions (4 to 7 inches) for carotid endarterectomy (CEA), we used preoperative duplex scanning to outline the carotid bifurcation as well as to determine the extent of disease in both the internal and common carotid arteries. METHODS: During the last 21 months, 265 consecutive primary CEAs were performed in 253 patients (mean age 72 +/- 10 years) at a single institution. Of these, 142 were men (56%). Hypertension, coronary artery disease, diabetes mellitus, smoking, and chronic renal failure were present in 81%, 44%, 43%, 28%, and 19% of the patients, respectively. Neurologically asymptomatic patients accounted for 71% of the cases. All patients received general anesthesia. Duplex-assisted skin markings of the diseased carotid artery were performed after proper patient positioning on the operating table. Synthetic patches were routinely used, and intraluminal shunts were deemed necessary by low stump pressures in 64 cases (24%). Completion duplex scanning was performed in all cases. RESULTS: The length of the longitudinal skin incision varied from 0.8 to 3.5 inches (average 1.4 +/- 0.5 inches). It was < or = 1 inch in 56 cases (21%), 1.1 to 1.5 inches in 110 (42%), 1.6 to 2 inches in 85 (32%), and 2.1 to 3.5 inches in the remaining 14 cases (5%). Intraluminal shunts were required in 9 (16%), 18 (16%), 29 (34%), and 8 (57%) of the cases, respectively. Incisions were longer in cases requiring an indwelling shunt (1.6 +/- 0.6 inches vs 1.4 +/- 0.4 inches) (P < .0001). The average patch length was 1.3 +/- 0.3 inches (range, 0.7 to 2.6 inches). The skin incision averaged 1.54 +/- 0.45 inches for the first 133 cases and 1.35 +/- 0.45 inches for the remaining 132 cases (P < .0001). Technical defects occurred in 10 cases (3.8%). The overall incidence of ipsilateral stroke and death was 1.9% and 0%. There were no technical defects or strokes in patients with the shortest incisions (< or = 1 inch). Overall, there were three transitory peripheral nerve injuries (1.1%). A comparative analysis with 265 consecutive CEAs performed immediately before this series without duplex-assisted skin markings revealed no significant differences in age (71 +/- 11 years), incidence of neurologically symptomatic patients (26%), sex (60% men), shunt use (24%), and major technical defects (3%). Also, postoperative transitory peripheral nerve injury (0.8%), stroke (0%), and death (0%) were not significantly different from the duplex-assisted group. It is of interest to note that none of the former cases was performed with a skin incision < or = 2 inches. CONCLUSION: Most CEAs (95%) can safely be performed with < or = 2-inch skin incisions. Pre-CEA duplex-assisted skin marking is a novel approach that confirms the side of the operation, localizes the disease, and minimizes the magnitude of the operation via shorter, more esthetically pleasing incisions.

A 10-year experience with complementary distal arteriovenous fistula and deep vein interposition for infrapopliteal prosthetic bypasses.

Since up to 20% of patients undergoing lower extremity revascularization do not have an adequate venous conduit, some authors have explored the use of prosthetic grafts with adjunctive techniques for lower extremity revascularization. However, the long-term graft patency of those procedures has not been well documented. The purpose of this study was to examine the long-term patency of polytetrafluoroethylene (PTFE) bypass with adjunctive arteriovenous fistula and venous interposition (AVF/VI) for infrapopliteal revascularization. Over a 10-year period, 246 lower extremity reconstructions were performed in 176 (71.5% men) patients with critical ischemia in whom a totally autogenous vein bypass was not feasible. Seventy-six limbs had undergone 1 or more failed ipsilateral infrainguinal bypasses. Indications for surgery were chronic critical limb-threatening ischemia (86%) (rest pain, ischemic ulcer, or gangrene) or acute ischemia (14%). Ages ranged from 46 to 91 years (mean 74 +/-0.6 [SD] years). Risk factors such as diabetes, hypertension, coronary artery disease, end-stage renal disease, and use of tobacco were present in 49%, 49%, 52%, 8%, and 67% of the patients, respectively. During the follow-up, 112 cases (45%) required reinterventions. Twenty-seven patients (15%) required bypass revision twice. During the follow up, 56 limbs (23%) were amputated (above-the-knee amputation 25 (10%); below-the-knee amputation 31 (13%). To date, 150 (85%) patients of a total of 176 are deceased. The primary graft patency rates were as follows: at 1 year, 51%; at 2 years, 41%; 3 years, 35%; and 5 years, 24%. Limb salvage rates were as follows: 1 year, 79%; 2 years, 76%; 3 years 76%; and 5 years, 74%. Patient survival rates were as follows: 1 year, 69%; 2 years, 60%; 3 years, 54%; and 5 years, 40%. Amputation-free patient survival rates were as follows: 1 year, 66%; 2 years, 57%, 3 years, 51%, and 5 years, 30%. This technique appears to offer reasonable patency and limb salvage rates in patients in whom autogenous bypass grafts are not feasible.

Risk factors for mortality in patients with upper extremity and internal jugular deep venous thrombosis.

OBJECTIVE: To elucidate the natural history of upper extremity deep venous thrombosis (UEDVT), we examined factors that may contribute to the high mortality associated with UEDVT. METHODS: Five hundred forty-six patients were diagnosed with acute internal jugular/subclavian/axillary deep venous thrombosis from January 1992 to June 2003 by duplex scanning at our institution. There were 329 women (60%). The mean age +/- SD was 68 +/- 17 years (range, 1-101 years). Risk factors for UEDVT were the presence of a central venous catheter or pacemaker in 327 patients (60%) and a history of malignancy in 119 patients (22%). Risk factors for mortality within 2 months of the diagnosis of UEDVT that were analyzed included age, sex, presence of a central venous catheter or pacemaker, history of malignancy, location of UEDVT, concomitant lower extremity deep venous thrombosis, systemic anticoagulation, placement of a superior vena caval filter, and pulmonary embolism. RESULTS: The overall mortality rate at 2 months was 29.6%. The number of patients diagnosed with pulmonary embolism by positive ventilation/perfusion scan or computed tomographic scan was 26 (5%). The presence of a central venous catheter or pacemaker ( P < .001), concomitant lower extremity deep venous thrombosis ( P = .04), not undergoing systemic anticoagulation ( P = .002), and the placement of a superior vena caval filter ( P = .02) were associated with mortality within 2 months of the diagnosis of UEDVT by univariate analysis. Pulmonary embolism ( P = .42), sex ( P = .65), and a history of malignancy ( P = .96) were not. CONCLUSIONS: These data suggest that the high associated mortality of UEDVT may be due to the underlying characteristics of the patients' disease process and may not be a direct consequence of the UEDVT itself.