Recurrent stenosis by duplex scan following carotid endarterectomy.

Between June 1984 and January 1986, 155 carotid endarterectomies were performed with routine shunting. Serial duplex scanning was performed during an 18-month period on 124 vessels. The results of this duplex scan review revealed the following data: A normal scan was obtained in 87/124 (70.1%). Recurrent stenosis was identified in 35/124 (28.1%), and an occluded vessel was identified in 2/124 (1.6%). Of the total recurrent stenosis group, recurrent stenosis was graded mild in 22/124 (17.7%), moderate in 7/124 (5.6%), and severe in 6/124 (4.8%). Of the 35 vessels with recurrent stenosis by duplex scanning, 22/35 (62.8%) were in female patients, and 13/35 (37.2%) were in male patients. Of the vessels with severe recurrent stenosis, 5/6 (83%) were in female patients. Recurrent stenosis following carotid endarterectomy is more common than appreciated clinically, and female patients in particular may be more prone to recurrent stenosis.

Carotid endarterectomy in a metropolitan community: the early results after 8535 operations.

Several retrospective community surveys have provoked speculation concerning the safety of carotid endarterectomy (CEA) throughout the United States. To address this serious issue, surgical outcome was calculated for 8535 CEAs entered prospectively into a computer registry by 51 trained vascular surgeons in a large metropolitan area from 1973 to 1985. A total of 7480 procedures (88%) were performed for symptomatic lesions and 1055 (12%) were performed for asymptomatic stenosis or ulceration. There were 178 operative strokes (2.1%) and 135 early deaths (1.6%), for a combined morbidity-mortality rate of 3.2%. Fatal events were attributed to cardiac disease in 0.7%, neurologic complications in 0.6%, and other causes in 0.3%. The stroke rate (n = 148; 2.0%) in symptomatic patients was better than that in asymptomatic patients (n = 30; 2.8%) (chi 2 = 5.2; p less than 0.025), but the combined morbidity-mortality rates (2.9% and 3.7%) were not statistically different. The incidence of stroke reported by surgeons who performed more than 5 CEAs annually (1.7%) was statistically superior to the stroke rate (3.4%) among those with less experience (chi 2 = 37.1; p less than 0.0001). Nevertheless, both groups had acceptable results that were consistent with their training and continued interest in vascular surgery.

A metropolitan experience with infrainguinal revascularization. Operative risk and late results in northeastern Ohio.

Despite being of fundamental importance, the late results of major arterial reconstruction rarely have been documented throughout a large metropolitan area. In this study of 932 patients entered into the computer registry of the Cleveland Vascular Society, 19 surgeons representing 13 community hospitals and referral centers in Cleveland and Akron report the intermediate-term outcome during a mean interval of 35 months after infrainguinal lower extremity revascularization performed in northeastern Ohio from 1978 through 1982. Operative risk (5%), the early amputation rate (7%), and actuarial 5-year survival (48% to 55%) for patients with rest pain or tissue necrosis were significantly worse (p less than 0.05) than comparable figures (0.6%, 0%, and 77%, respectively) for others who underwent procedures for disabling claudication. Although both materials had similar success above the knee, the cumulative 3-year patency rate of autogenous vein bypass to the distal popliteal (69% to 88%; p less than 0.05) and tibioperoneal arteries (43%; 0.05 less than p less than 0.1) was superior to the results of polytetrafluoroethylene grafts (32% to 50% and 19%, respectively). Moreover, polytetrafluoroethylene grafts required reoperations at three times the rate of vein grafts to maintain limb salvage.

The early results of vascular surgery in patients 75 years of age and older: an analysis of 3259 cases.

The population in the United States older than 75 years of age will double by the year 2000. The computerized registry of The Cleveland Vascular Society includes 19,990 vascular procedures, which have been divided into two groups. Group A consists of 16,731 operations performed on patients younger than 75 years of age and group B consists of 3259 procedures performed on patients older than 75 years of age. The overall operative mortality rate in group A was 4.4% (736 of 16,731). In subsets of group B the mortality rates were: age 75 to 79 years, 11.3% (210 of 1862), age 80 to 84 years, 13.4% (125 of 932), age 85 to 89 years, 18.0% (68 of 376), and age 90 to 98 years, 28.1% (25 of 89). In carotid endarterectomy there were no significant differences in the stroke and operative mortality rates when groups A and B were compared. Group A stroke rate was 1.8% (94 of 5220), operative mortality rate was 1.5% (77 of 5220); group B stroke rate was 2.2% (17 of 782) and the mortality rate was 2.3% (18 of 782). For aortic reconstructions group A mortality rate was 7.1% (276 of 3905); group B operative mortality rate was 24.1% (148 of 615) (p less than 0.001). In femoropopliteal reconstructions group A operative mortality rate was 2.2% (55 of 2377) and group B mortality rate was 6.7% (38 of 571) (p less than 0.0001). For lower extremity thromboembolectomy group A operative mortality rate was 14.3% (113 of 789) and the mortality rate for group B was 28.4% (196 of 689) (p less than 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Femorofemoral bypass grafts: ten-year experience.

From August 1972 to September 1982, one of us (F.R.P.) performed 119 femorofemoral bypass grafts on 78 men and 35 women with an average age of 62 years. Axillofemorofemoral grafts were excluded. The 30-day operative mortality rate was 1.7% (2 of 119). The cumulative patency rates determined by the life-table method were 97.4% at 30 days, 95.1% at 1 year, 83.3% at 3 years, 72.2% at 5 years, and 55% from 6 through 10 years. There were no graft failures in the 21 patients followed up for more than 6 years. There were 21 grafts at risk at 7 years, 15 at 8 years, 10 at 9 years, and four at 10 years. Donor iliac arteries were judged to be acceptable by a combination of simple analyses including physical examination, noninvasive laboratory testing, angiography, and intraoperative direct blood pressure measurements. There was no evidence of a vascular steal in any of the postoperative patients. One patient required an inflow procedure 2 years following femorofemoral grafting. Two patients required resection of an abdominal aortic aneurysm 2 and 3 years, respectively, following femorofemoral grafting. There was one early graft failure secondary to infection, and five grafts became infected at 20,29,33,46, and 62 months, respectively, following femorofemoral grafting. False aneurysm formation, diabetes, and trauma were significant factors in these infections. Initially only high-risk patients were selected as candidates for femorofemoral grafting. Because we were encouraged by the early success rate and the apparent durability of the method, the indications were broadened to include good-risk patients who met rigid criteria for femorofemoral grafting.

Control of postcarotid endarterectomy hypotension with baroreceptor blockade.

The reported incidence of hypotension after carotid reconstruction ranges from 21 to 50 percent. To evaluate baroreceptor dysfunction, 283 carotid reconstructions were studied. During 181 consecutive reconstructions, a transcutaneous Teflon catheter was positioned intraoperatively at the carotid bifurcation for postoperative injection of lidocaine as necessary. Of 283 reconstructions, 210 (74 percent) were not followed by hypotension. In the remaining 73 (26.5 percent), hypotension (systolic blood pressure less than 100 mm Hg) was seen. In 14 of the 73 cases of hypotension, vasoactive drugs, atropine, or a fluid bolus was administered with variable responses. In 27 of the 73, no treatment was instituted. In the remaining cases of hypotension, treatment consisted of 1 to 2 ml of lidocaine administered through the catheter. A prompt increase in systolic blood pressure from 93 to 139 mm Hg (means) within 30 minutes of treatment occurred in 29 of the 32 cases (91 percent). These data currently support routine catheter placement.

The risk of vascular surgery in a metropolitan community. With observations on surgeon experience and hospital size.

From 1978 through 1981 complete perioperative information concerning a total of 10,189 peripheral vascular procedures performed in northeastern Ohio was recorded in the computer registry of The Cleveland Vascular Society. This report is an analysis of mortality and morbidity rates for all 5686 operations involving carotid endarterectomy (N = 2646), lower extremity revascularization (N = 1987), and abdominal aortic aneurysm resection (N = 1053). The operative mortality rate was 1.2% for carotid reconstruction, 2.8% for femoropopliteal or distal bypass, 3.5% for aortofemoral revascularization, and 11.9% for aortic aneurysm resection (elective operations 6.5%; emergency operations 32.9%). Postoperative strokes occurred after endarterectomy in 2.7% of patients having preoperative neurologic symptoms and in 2.0% of those with asymptomatic carotid stenosis. Lower extremity amputation was unavoidable in 1.5% of patients after aortofemoral reconstruction and in 6.0% after femoropopliteal or distal bypass. Statistical testing indicated that the operative mortality rate was not related to the respective size of the 27 hospitals involved in the survey. The relative annual experience of the 29 participating surgeons significantly influenced only the mortality rate of elective aneurysm resection and the amputation rate after femoropopliteal or distal revascularization. This study suggests that the results of major arterial reconstruction in metropolitan areas may be expected to be comparable to those of published series if the responsible surgeons are specifically trained and maintain an active interest in the field of vascular surgery.

Operation for ruptured abdominal aortic aneurysms: a community-wide experience.

From 1975 through 1979, 29 members of The Cleveland Vascular Society operated on 1049 patients with abdominal aortic aneurysms; of these, 152 ruptured aneurysms. The postoperative mortality rate was 38% (58 of 152). In 27% (41 of 152) of the patients, a diagnosis was made prior to rupture, and the average interval from diagnosis rupture was 16 months. A history of diabetes, hypertension, or a single myocardial infarction (MI) prior to rupture was not associated with an increased mortality rate. Patients with a history of more than one MI prior to rupture had a 75% (six of eight) mortality rate. The average time from onset of symptoms to examination was 2 days 10 hours. When the initial diagnosis was correct, or an intra-abdominal disease was at least suspected, the mortality rate was 35% (47 of 135). When the initial diagnosis was incorrect and a cardiopulmonary or cerebral cause was suspected, the mortality rate was 75% (13 of 17). When the diagnosis was incorrect, the interval from diagnosis to surgery was 2 1/2 days. With only intramural bleeding or a small hematoma in the area of rupture, the mortality rate was 17% (4 of 24); when the hematoma was more extensive, the mortality rate was 43% (55 of 128). This study encompassed a large number of operations performed in a metropolitan area during a relatively short period of time, during which there had been few changes in operative technique or supportive measures. It demonstrated that the most critical factors influencing survival were correct initial diagnosis, the extent of the hematoma, and the history of more than one preoperative MI.

Effectiveness of reoperation after late failure of femoropopliteal reconstruction.

Eighty-two femoropopliteal reconstructions were performed on sixty-six consecutive patients. Of seventeen late failures, thirteen were secondarily reconstructed. Clinical and angiographic studies demonstrated the reasons for failure in all patients except one. Seven patients were improved and six unimproved by reoperation. The best results were obtained when an inflow problem was found and there had been a long duration of initial patency.

Extra-anatomic bypasses for aortoiliac disease in high-risk patients.

A series of 75 patients, with an average age of 65 years, underwent the following extra-anatomic bypasses involving the crossover femorofemoral principle: femorofemoral (F-F), 54 patients; aortofemorofemoral (A-F-F), 12 patients; common iliac-femorofemoral (CI-F-F), six patients; and axillofemorofemoral (Ax-F-F), three patients. Fifty eight of the 75 patients (77 percent) initially presented with rest pain or gangrene. The operative mortality rate in this high-risk group of patients was 4 percent. Analysis by the life-table method showed the graft patency rate to be 91.1 percent at one year and 87.4 percent at 18 months. There have been no graft failures or deaths in the series of 20 patients followed longer than 18 months. Two amputations followed graft failures and nine of the remaining 11 amputations were done in patients with patent grafts during the same period of hospitalization, reflecting the severity of their gangrene upon admission. High-risk patients who are not suitable for crossover F-F grafts without an inflow procedure may be suitable for a CI-F-F or A-F-F bypass before being considered for an Ax-F-F bypass.