Outcome of endovascular intervention for infrainguinal vein graft stenosis.

Assisted graft patency rate following revision of a graft stenosis is far better than that following thrombectomy of an occluded graft. Graft revision by endovascular means has been proposed as a suitable alternative to more invasive surgery. This study reports our experience with endovascular treatment of vein graft stenosis. Between December 1992 and September 2000, percutaneous transluminal balloon angioplasty (PTA) was performed on 90 vein graft stenoses in 87 infrainguinal vein bypass grafts identified by routine graft duplex scan (peak systolic velocity, PSV > 300 cm/sec). All 90 stenoses treated by PTA were retrospectively analysed for stenosis-free patency rate (life-table analysis). Re-stenosis was defined by PSV exceeding 300 cm/sec at the same site of the vein graft where a stenosis was dilated. Ninety vein graft stenoses (72 primary stenoses and 18 recurrent stenoses) in 33 femoropopliteal (above knee), 30 femoropopliteal (below knee) and 24 femorotibial vein bypass grafts were treated by PTA. The timing of PTA ranged from one to 252 months (mean, 23.9 months) from the initial surgery. Cumulative stenosis-free patency rate after PTA was 55.8% at 6 months, 54.0% at one year and 45.0% at three years. Stenosis-free patency rate at six months was significantly lower for revision of recurrent stenosis (25.9%) than for primary stenosis (61.6%) (P = 0.01). The revision of duplex scan detected vein graft stenosis with endovascular intervention was associated with an acceptable stenosis-free patency rate. However, recurrent stenosis treated by PTA had a significantly inferior outcome. Direct surgical revision would be more appropriate for recurrent lesions.

Dextran reduces embolic signals after carotid endarterectomy.

One hundred fifty patients undergoing carotid endarterectomy were randomly assigned to receive intravenous 10% dextran 40 or placebo. Transcranial Doppler monitoring of the ipsilateral middle cerebral artery 0 to 1 hour postoperatively detected embolic signals in 57% of placebo and 42% of dextran patients, with overall embolic signal counts 46% less for dextran (p = 0.052). Two to 3 hours postoperatively, embolic signals were present in 45% of placebo and 27% of dextran patients, with embolic signal counts 64% less for dextran (p = 0.040). We conclude that dextran reduces embolic signals within 3 hours of CEA.

Transcranial Doppler microembolus detection in the identification of patients at high risk of perioperative stroke.

OBJECTIVES: Perioperative ischaemic stroke is the leading cause of morbidity and mortality associated with carotid endarterectomy (CEA). The aim was to test the hypotheses that the detection of microembolic ultrasonic signals (MES) with transcranial Doppler ultrasound (TCD) during and after the operation may be of value in identifying patients at increased perioperative stroke risk. DESIGN: Open prospective case series. PATIENTS AND METHODS: Eighty-one consecutive patients undergoing CEA with TCD monitoring. Preoperative, intraoperative and interval postoperative TCD monitoring of the middle cerebral artery (MCA) ipsilateral to the operated carotid artery. On-line pre- and intraoperative MES counting and blinded off-line analysis of postoperative MES counts. End-points were any focal neurological deficit and death at 30 days postoperatively. RESULTS: MES were detected in 94% of patients intraoperatively and 71% of cases during the first postoperative hour. MES counts ranged from 0 to 25 per operative phase (range of median counts 0-8) and from 0 to 212 per hour postoperatively (range of median counts 0-4). Eight cases (10%) developed postoperative MES counts greater than 50/h. Five of these eight cases evolved ischaemic neurological deficits in the territory of the insonated MCA, indicating a strong association between frequent postoperative microembolism and the development of early cerebral ischaemia (chi 2 = 34.2, p < 0.0001). Intraoperative MES were not associated with clinical outcome measures. CONCLUSIONS: MES counts of greater than 50/h in the early postoperative phase of carotid endarterectomy are predictive of the development of ipsilateral focal cerebral ischaemia.

Transcranial Doppler detected cerebral microembolism following carotid endarterectomy. High microembolic signal loads predict postoperative cerebral ischaemia.

Cerebral ischaemia, the most frequent serious complication of carotid endarterectomy (CEA), usually occurs in the early postoperative period and is often the result of thromboembolism. We hypothesized that the early postoperative detection of microembolic ultrasonic signals (MES) with transcranial Doppler ultrasound (TCD) may be of value in identifying patients at risk of postoperative cerebral ischaemia and that the MES rate may be an important determinant in risk prediction. Sixty-five patients undergoing CEA were studied at intervals up to 24 h postoperatively with TCD insonation of the middle cerebral artery ipsilateral to the operation side. Study design was open and prospective with blinded off-line analysis of MES counts. End-points were any focal ischaemic neurological deficit and/or death up to 30 days postoperatively. MES were detected in 69% of cases during the first hour postoperatively with counts ranging from 0 to 212 MES/h (means 19 MES/h; SEM +2- 4.5; median 4 MES/h). In seven cases (10.8%) counts were > 50 MES/h. Five of these seven cases developed ischaemic neurological deficits in the territory of the insonated middle cerebral artery during the monitoring period. The positive predictive value of counts > 50 MES/h for cerebral ischaemia was 0.71. Frequent signals (> 50 MES/h) occur in approximately 10% of cases in the early postoperative phase of CEA and are predictive for the development of ipsilateral focal cerebral ischaemia.

Laparoscopic extraperitoneal lumbar sympathectomy: technique and early results.

A new technique of balloon-assisted laparoscopic lumbar sympathectomy is described and the results of the initial three cases are described. The procedure is technically straightforward and was accomplished without any complications. It should be compared with other techniques of lumbar sympathectomy in comparative trials; however, this early experience is most encouraging.

Duplex ultrasound examination of the acutely painful and swollen leg.

OBJECTIVE: The aim of this study was to assess the value of duplex ultrasound examination in establishing diagnosis in acutely swollen and painful lower limbs, and to examine how often the diagnosis of superficial and/or deep venous thrombosis can be made in the symptomatic legs. METHODS: Venous duplex scan examination was performed on 188 extremities of 180 ambulatory outpatients. The examination included testing patency and competency of the deep and superficial veins. The ultrasound study was also extended to finding soft tissue abnormalities. RESULTS: Of the 188 lower limbs venous thrombosis was found on 82 occasions: 29 legs contained deep venous thrombosis only; 23 legs presented with superficial thrombophlebitis as a sole venous pathology; and in 30 cases superficial and deep venous thrombosis coexisted. In those 106 limbs where venous thrombosis was not present the most frequent positive ultrasound findings were incompetent leg veins or soft tissue masses (Baker's cyst and calf haematoma). CONCLUSION: The variety of pathological processes related to the lower limb veins and the extravascular tissue suggest that routine, "detailed" ultrasound scanning would be indicated in all acutely symptomatic legs with a suspected venous disorder. The important diagnostic information so gained provides guidance to the most appropriate treatment strategy.

Percutaneous transluminal angioplasty: follow-up with treadmill exercise testing.

Between 1986 and 1992, 308 percutaneous transluminal angioplasties in 252 patients were reviewed in the vascular laboratory of the Austin Hospital. The follow-up period ranged from 1 month to 6 years. Treadmill exercise testing was used as an additional mode of assessment to resting ankle/brachial pressure indices in monitoring outcome. Early haemodynamic improvement rate was 86.7%. In 267 successful cases, 199 had increased the mean(s.d.) resting ankle/brachial pressure index from 0.68(0.15) to 0.96(0.14) (P < 0.05) and another 68 with normal or unchanged resting ankle/brachial pressure indices after the procedure increased the mean(s.d.) post-exercise pressure index from 0.45(0.24) to 0.82(0.23) (P < 0.05). The primary haemodynamic improvement rate of initially successful percutaneous transluminal angioplasties was 80.1% at 1 year and was maintained in 46.1% of cases 5 years after. Treadmill exercise testing revealed reduction of the ankle/brachial pressure index in 69 patients during follow-up, indicating restenosis of the dilated lesion or development of a new arterial stenosis. Fifty-two of the 69 patients exhibited a significant drop in the resting pressure index. However, in the 17 remaining patients, only the post-exercise index decrease indicated haemodynamic deterioration. Treadmill exercise testing proved to be valuable adjunct in detecting haemodynamic changes after percutaneous transluminal angioplasty.

Anatomical examination of leg telangiectases with duplex scanning.

BACKGROUND: Earlier studies using Doppler ultrasound suggested that thigh telangiectasia might be associated with reflux in the larger subcutaneous veins. OBJECTIVE: The aim of the study was an accurate description of the anatomy of the venous drainage from thigh telangiectases and evaluation of the extent of venous valvular incompetence using a noninvasive imaging method. METHOD: High-definition color duplex ultrasonography was used to achieve the objective. RESULTS: Thirty-seven legs with lateral and/or medial thigh telangiectasia were examined. Patients studied were those without saphenofemoral, saphenopopliteal, or deep venous abnormalities on Doppler ultrasound examination. Altogether 53 sites were tested. In 89% reticular vein incompetence was found close to telangiectases. Often reticular vein incompetence was associated with reflux in larger epifascial veins. In 15% incompetent perforating veins were detected between reticular veins and the deep venous system. CONCLUSION: An accurate, functional reconstruction of the subcutaneous venous drainage was accomplished. It was found that telangiectasia was rarely an isolated condition, but was usually associated with incompetence in other elements in the venous drainage of the subcutaneous tissue.

Duplex scanning and light reflection rheography in the assessment of the severity of short saphenous vein incompetence.

BACKGROUND: Duplex ultrasound assessment of veins in the popliteal fossa is an accepted alternative to venography. Light reflection rheography provides additional quantitative information on venous reflux in chronic venous insufficiency. OBJECTIVE: To use duplex ultrasound and light reflection rheography to study the venous reflux patterns in the popliteal fossa in a group of patients. METHODS: Duplex ultrasound examination and light reflection rheography were used in the assessment of the severity of short saphenous vein incompetence. RESULTS: The study revealed that any associated deep venous reflux which was detectable beyond the saphenopopliteal junction represented a more advanced stage of superficial venous insufficiency. CONCLUSIONS: Light reflection rheography, as a semiquantitative test, provided useful additional information to duplex scan findings in assessing venous reflux of the popliteal fossa. Short saphenous vein reflux with functional deep venous incompetence was associated with shorter venous refilling times and clinically represented a more advanced stage of primary varicose vein disease.

AIDS and the vascular surgeon.

The presence of the HIV virus has introduced a new risk to the surgeon and the operating team. Vascular and cardiac surgeons are at a higher risk of percutaneous exposure to blood than many other surgical groups. Re-examination of basic surgical techniques enables the development of strategies for the handling of instruments to minimise the risks of accidental injuries to operating room staff. This includes methods for transfer of sharp instruments and the tying of knots, techniques for operating in deep cavities, retraction of wounds, and the abandonment of some traditional techniques such as the use of hand needles. All cardiac and vascular surgeons must re-examine their surgical techniques. Trainee surgeons in these specialties must be taught safe strategies, which will then reduce the risk of AIDS in the whole surgical team.

Venous reflux patterns in the popliteal fossa.

Incompetent veins in the popliteal fossa were assessed with duplex ultrasound in 123 legs of 104 patients. In 91 cases the venous reflux was the result of a single incompetent vein draining into the deep system. In 32 cases duplex ultrasound demonstrated a combination of incompetent veins. With the exception of 3 patients duplex scanning accurately localised the incompetent veins and their "junctions" with the deep system. In 48 legs the reflux signal, detected in the surface vein, extended back beyond the "junction" into a proximal segment of the popliteal vein or superficial femoral vein; in most cases the distal popliteal vein remained competent. Six distinct venous reflux patterns were identified in the popliteal fossa, which seemed to correlate with the severity of related clinical symptoms.

Repair of veno-occlusive disease of the lower limb using internal iliac vein graft and distal A-V anastomosis.

A patient with longstanding chronic venous obstruction due to occlusion of the femoral vein, was subjected to vein graft repair with adjuvant A-V fistula. The repair failed but the fistula stimulated collateral development to alleviate symptoms.

Blunt abdominal aortic trauma.

Due to its well protected position within the abdomen, blunt injuries to the abdominal aorta are uncommon. A review of previous reports in the literature, together with four new cases, are presented here. Motor car accidents are the most common cause of this injury, especially if seat belts are worn. Associated gastrointestinal injuries did not lead to any increased mortality; however, delay in the diagnosis was a significant factor in the deaths of several patients. Prompt recognition and early surgical management are essential in the treatment of this problem.

The detection of early femoro-distal vein graft stenosis by treadmill exercise testing.

A prospective study of 125 femoro-distal vein bypass grafts (103 patients) was undertaken to assess the role of treadmill exercise testing in the detection and correction of early vein graft stenosis. Patients were followed at 1,3,6,12 months and then annually with routine clinical assessment, palpation of pulses and resting Doppler ankle/brachial index. In addition, the Doppler index was repeated after 5 minutes exercise on a treadmill set at 5 degrees and 3 km/hr. Follow-up has been carried out for a mean of 24 months (range 3-48 months) and during that time 30 vein grafts (28 patients) were submitted to angiography. This revealed vein graft stenosis in 15, native vessel disease in 11 and no morphologic abnormality in 4. One additional graft was suspected to have a stenosis but occluded before angiography could be carried out. At the time of detection by the treadmill test, 8 of the 15 (53%) confirmed vein graft stenoses, and 4 of 11 (36%) native vessel stenoses would not have been detected by clinical assessment or resting Doppler pressure measurements. The 15 vein graft stenoses which were corrected all remain patent, suggesting that treadmill testing is of value in the detection and prevention of early femoro-distal vein graft occlusion.

Spontaneous internal jugular vein thrombosis and venous-stasis retinopathy.

A case is presented in-which the detection of venous-stasis retinopathy in one eye led to investigation of the carotid circulation. There were no neurologic symptoms of carotid insufficiency, and noninvasive tests failed to reveal significant carotid pathology. Digital subtraction angiography and carotid angiography demonstrated a carotid plaque of doubtful significance. At carotid endarterectomy, the venous-stasis retinopathy was found to be associated with venous thrombosis distant from the eye and in the internal jugular vein. This site is beyond the range over which isolated ocular vascular effects would be expected and was thought to be unrelated to the hemodynamically insignificant, nonulcerated carotid artery plaque. The possibility of this association being causal is discussed.