Eversion technique increases the risk for post-carotid endarterectomy hypertension.

OBJECTIVE: The incidence of postoperative hypertension (HTN) after eversion carotid endarterectomy (e-CEA) was compared with that after standard carotid endarterectomy (s-CEA). METHODS: In a retrospective analysis from January 1998 to January 2000, 217 patients underwent 219 CEAs for symptomatic (68) or asymptomatic (151) high-grade (>80%) carotid artery stenosis by either standard (137) or eversion (82) techniques. The eversion technique involves an oblique transection of the internal carotid artery at the carotid bulb and a subsequent endarterectomy by everting the internal carotid artery over the atheromatous plaque. All procedures were done under general anesthesia, and somatosensory-evoked potentials were used for cerebral monitoring. Patients with s-CEA were compared with those with e-CEA for postoperative hemodynamic instability, carotid sinus nerve block, requirement for intravenous vasodilators or vasopressors, stroke, and death. RESULTS: Patients who underwent e-CEA had a significantly (P <.005) increased postoperative blood pressure and required more frequent intravenous antihypertensive medication (24%), compared with patients having an s-CEA (6%). Furthermore, postoperative vasopressors were required after 10% of s-CEAs, but after none of the e-CEAs. No statistically significant difference was noted in the morbidity or mortality of patients after s-CEA and e-CEA. CONCLUSION: e-CEA is a substantial risk factor for HTN in the immediate postoperative period, when compared with the s-CEA. This difference would be even more remarkable in the absence of antihypertensive medications in the e-CEA group and vasopressors in the s-CEA group. Therefore, particular attention should be focused on diagnosing and controlling postoperative HTN in patients after e-CEA.

Fetuin, a negative acute phase protein, attenuates TNF synthesis and the innate inflammatory response to carrageenan.

Activation of the innate immune system, even by relatively innocuous stimuli, stimulates the release of cytokines (e.g. TNF) that can injure or kill the host. To maintain homeostasis, mammals have evolved a counter-regulatory response that suppresses the development of excessively robust inflammation. Fetuin, a 66-kD negative acute phase glycoprotein, was first identified in 1944. We recently discovered an anti-inflammatory role for fetuin, because it suppressed the release of TNF from lipopolysaccharide- (LPS) stimulated macrophages. Here the anti-inflammatory effects of fetuin were studied in vivo in an LPS-independent model of acute inflammation caused by administration of carrageenan. Administration of fetuin (5-500 mg/kg intraperitoneally) dose-dependently attenuated the development of paw edema as compared to either asialofetuin (500 mg/kg) or bovine albumin (500 mg/kg). TNF production in the carrageenan-injected paws was significantly inhibited by administration of fetuin (586+/-98 pg TNF/paw) as compared to either asialofetuin (1018+/-186 pg TNF/paw) or saline (1,005+/-172 pg TNF/paw). When specific anti-fetuin IgG was administered into the paw prior to the application of carrageenan, the development of edema formation was significantly increased as compared to irrelevant IgG, indicating that endogenous fetuin normally attenuates the inflammatory response. These results now reveal a previously unrecognized anti-inflammatory role of fetuin in counter-regulating the innate immune response, and suggest that it may be possible to use fetuin as an experimental anti-inflammatory agent.

Unilateral and bilateral hypogastric artery interruption during aortoiliac aneurysm repair in 154 patients: a relatively innocuous procedure.

OBJECTIVE: Hypogastric artery (HA) occlusion during aortic aneurysm repair has been associated with considerable morbidity. We analyzed the consequences of interrupting one or both HAs in the standard surgical or endovascular treatment of aortoiliac aneurysms (AIAs). METHODS: From 1992 to 2000, 154 patients with abdominal aortic aneurysms (n = 66), iliac aneurysms (n = 28), or AIAs (n = 60) required interruption of one (n = 134) or both (n = 20) HAs as part of their endovascular (n = 107) or open repair (n = 47). Endovascular treatment was performed with a variety of industry- or surgeon-made grafts in combination with coil embolization of the HAs. The standard surgical techniques included oversewing or excluding the origins of the HAs and extending the prosthetic graft to the external iliac or femoral artery. RESULTS: There were no cases of buttock necrosis, ischemic colitis requiring laparotomy, or death when one or both HAs were interrupted. Persistent buttock claudication occurred after 16 (12%) of the unilateral and 2 (11%) of the bilateral HA interruptions. Impotence occurred in 7 (9%) of the unilateral and 2 (13%) of the bilateral HA interruptions. Minor neurologic deficits of the lower extremity were observed in 2 (1.5%) of the patients with unilateral HA interruption. CONCLUSIONS: Although HA flow should be preserved if possible, selective interruption of one or both HAs can usually be accomplished safely during endovascular and open repair of anatomically challenging AIAs. We believe other comorbid factors such as shock, distal embolization, or the failure to preserve collateral branches from the external iliac and femoral arteries may have contributed to the morbidity in other reports of HA interruption.

Increased serum concentrations of high-mobility-group protein 1 in haemorrhagic shock.

Serum concentrations of high-mobility-group protein 1 (HMG1) were increased during an episode of haemorrhagic shock in a patient who had undergone repair of an abdominal aortic aneurysm. HMG1 may be involved in the pathogenesis of human haemorrhagic shock.

Frey's syndrome after carotid endarterectomy.

Frey's syndrome after carotid endarterectomy (CEA) is due to iatrogenic injury to the auriculotemporal nerve and has not been previously reported. One month after uncomplicated CEA, our patient noted an erythematous flush and copious drainage of clear fluid from the superior portion of his neck wound whenever he ate, or smelled or thought of food. These symptoms lasted for 2 months and eventually resolved without intervention. The cause and treatment of Frey's syndrome is also described.

Subclavian artery pseudoaneurysm in type IV Ehlers-Danlos syndrome.

We report case of a subclavian artery pseudoaneurysm in a patient with type IV Ehlers-Danlos Syndrome. A 16-year-old boy underwent successful repair of a subclavian artery pseudoaneurysm that occurred after a cervical hyperextension injury. Subsequent workup included skin biopsy and fibroblast culture, which were consistent with a diagnosis of type IV Ehlers-Danlos Syndrome. This condition is a dominantly inherited connective tissue disorder, which in this patient was found to be caused by a spontaneous point mutation in the COL3A1 gene that encodes the chains of type III procollagen. The clinical, genetic, and molecular characteristics of type IV Ehlers-Danlos Syndrome are briefly reviewed.

Axillofemoral bypass graft fracture.

Since the introduction of axillofemoral bypass more than 30 years ago, there have been numerous reports demonstrating the value of this procedure in patients with aortoiliac occlusive disease who are too ill to undergo direct reconstruction. Along with the increasing use of axillofemoral bypass have come the usual graft-related complications including thrombosis, hematoma formation, and infection. A more unusual occurrence, however, is disruption of the axillary anastomosis with formation of a false aneurysm. We report herein a case in which the body of an axillofemoral graft fractured just distal to the axillary anastomosis resulting in complete disruption of the graft.

A prospective randomized study of abdominal aortic surgery without postoperative nasogastric decompression.

Nasogastric decompression following abdominal aortic aneurysmectomy or bypass, for 3-4 days, is a routine part of postoperative care in many centers. A prospective randomized study of 80 patients undergoing abdominal aortic surgery was performed in order to determine the necessity of prolonged nasogastric decompression. Patients were divided evenly between removal of the nasogastric tube upon tracheal extubation and retention of the tube until the passage of flatus. Preoperative risk factors, aortic cross-clamp time, estimated blood loss, length of procedure, length of intensive care unit stay, numbers of days with nasogastric tube, number of days until clear liquid and regular diets commenced, and the length of hospital stay were recorded for all patients. There were no significant differences in any of the measured variables between the two groups. The length of hospital stay was similar in both groups and three patients in each group required a nasogastric tube or reinsertion of one. In conclusion, the routine postoperative use of nasogastric tubes for abdominal aortic procedures is unnecessary.

Utilization patterns with inferior vena cava filters: surgical versus percutaneous placement.

PURPOSE: To determine whether more inferior vena cava (IVC) filters were used after interventional radiologic placement methods became available, and if so, whether this increase could be due to expansion of indications. PATIENTS AND METHODS: A retrospective analysis of the number of filters placed, the method of placement used, the indications for placement, and patient survival was performed during the 3 years before and the 3 years after 1989, the first year filters were placed percutaneously at the authors' institution. RESULTS: From 1986 through 1988, 35 filters were all placed by surgeons in the operating room. From 1990 through 1992, 201 filters were all placed by radiologists in the special procedures suite. In the surgery group, 13 of 35 filters (37%) were placed for contraindications to anticoagulation therapy, 12 (34%) were placed for complications of anticoagulation, and nine (26%) were placed for recurrent thromboembolic disease despite anticoagulation. One filter was placed because of a free-floating thrombus in the IVC. In the radiology group, 98 of 161 patients (60%) underwent placement for contraindications to anticoagulation, 25 (16%) experienced complications of anticoagulation, 28 (17%) experienced recurrent thromboembolic disease, and nine (6%) had a free-floating thrombus. The 6-month survival in patients treated before 1989 was 80% versus 43% after 1989. CONCLUSION: At the authors' institution, filters are now placed exclusively by interventional radiologists. The overall indications for placement remain unchanged. The increase in utilization appears primarily related to more frequent placement in severely ill patients who may not experience considerably improved survival but may benefit from a substantial reduction in the risk of hemorrhagic complications.

Basilic vein transposition: an underused autologous alternative to prosthetic dialysis angioaccess.

PURPOSE: Provision of lifelong angioaccess for hemodialysis generally requires multiple procedures. To extend the availability of each extremity as an access site, we have used the transposed basilic vein for fistula construction since 1988. Our purpose is to present our initial experience, with follow-up of 30 months. METHODS: We have used the transposed proximal basilic vein in 65 procedures to construct an autogenous arteriovenous fistula (AVF) to the brachial artery in 58 patients without suitable superficial venous anatomy. There were 25 males and 33 females, with a mean age of 47 years (range 10 to 77). The basilic vein transposition was the initial angioaccess procedure in only 25% of cases and secondary in 75%. Three additional patients underwent exploration of an inadequate basilic vein with subsequent prosthetic grafting. RESULTS: There were no operative deaths. Two postoperative complications included a wound infection and a transient steal syndrome. The actuarial life-table patency rate for all successfully completed AVFs was 49% at 30 months. Late revisions with continued patency were required in 11 cases, including repair of a focal stenosis in six, pseudoaneurysm resection in two, and thrombectomy in one. Sixty-seven percent of patients who required subsequent prosthetic grafting for a failed basilic vein AVF had an ipsilateral procedure. Patient preference for the opposite arm was the usual indication for contralateral grafting in the remainder. CONCLUSIONS: The transposed basilic vein AVF was technically feasible in 95% of cases, can frequently be performed in patients with multiple previous access procedures, does not compromise the arm for future prosthetic grafting, and has a long-term patency rate that is comparable to more traditional autologous AVFs. This underused procedure should be considered before placement of polytetrafluoroethylene graft for long-term angioaccess.

Correction of steal syndrome secondary to hemodialysis access fistulas: a simplified quantitative technique.

Correction of symptomatic vascular steal distal to an arteriovenous fistula requires either fistula ligation or banding. Ligation carries the obvious disadvantage of destruction of a functioning angioaccess, whereas banding procedures have been plagued by the complexity of many of the reported techniques and by the difficulty of balancing fistula flow with distal perfusion. In this study a simple plication technique is described that avoids the introduction of any additional foreign material and that quantifies distal perfusion by means of intraoperative pulse volume recordings. Five patients have been treated by this method, two with autologous vein fistulas and three with bridge fistulas using polytetrafluorethylene. All five have had resolution of their ischemic symptoms with an increase in intraoperative pulse volume recordings of 5 mm or more. Only three of the patients had restoration of the radial pulse, which was not a specific end point of the banding procedure. Furthermore, all fistulas remained patent for at least 6 months and continued to provide adequate flows for hemodialysis. Banding/plication is clearly preferable to fistula closure for the management of steal syndrome. The method described herein is simple and hemodynamically identifies the minimal constriction that will resolve symptoms and preserve fistula flow.

Epidural versus general anesthesia for infrainguinal arterial reconstruction.

A prospective evaluation of 213 consecutive infrainguinal bypass procedures was performed to determine the effect of anesthesia technique on the postoperative complication rate. Limb salvage was the indication for surgery in 92% of cases. No significant differences were observed in age, sex, indication for surgery, presence of cardiovascular and pulmonary risk factors, American Society of Anesthesiologists classification, or Goldman scores between patients receiving epidural anesthesia and those receiving general endotracheal anesthesia. Epidural anesthesia was used for 96 procedures and general endotracheal anesthesia was used in 117 cases. Cardiac complications for the epidural anesthesia and general endotracheal anesthesia groups, respectively, included a mortality rate of 5% versus 3%, nonfatal infarctions in 6% versus 7%, and reversible cardiac events in 14% versus 16%. A high-risk subgroup of 69 patients (American Surgical Association classes IV and V or Goldman score greater than 10 points) also had no significant difference in outcome between epidural anesthesia and general endotracheal anesthesia. Major noncardiac complications occurred in an additional 8% of each group. Regional and general anesthesia therefore produce equivalent cardiovascular risk for infrainguinal arterial reconstruction. These results suggest that indicated operations should not be postponed or avoided for patients either requiring or requesting general anesthesia. Furthermore, other investigations of cardiac risk in vascular surgery do not require a uniform anesthetic technique for valid interpretation of results.

Safety of peripheral vascular surgery after recent acute myocardial infarction.

We have treated 30 patients requiring urgent or emergent vascular procedures in the first 6 weeks after a myocardial infarction (median 11 days) from 1977 through 1989. Forty operations were performed, including 28 lower extremity revascularizations, 10 major amputations and revisions, and two carotid endarterectomies. There were four postoperative deaths (three cardiac related) and two nonfatal reinfarctions. Cardiac complications did not correlate with age, interval from myocardial infarction to surgery within the initial 6 weeks, type of anesthesia, or complexity of operation. Twenty of 24 patients survived attempts at leg revascularization, with ultimate limb salvage in 16. Our cardiac complication rate of 17% (5/30 patients) was reasonably close to that predicted by the Goldman risk scale for classes II and III and significantly better than class IV and also better than that predicted by the Cooperman risk scale for vascular surgery, despite the more recent preoperative myocardial infarctions in our patients. We attribute our low morbidity and mortality to the extracavitary nature of the procedures and possibly to improvements in anesthetic and perioperative management. Patients requiring urgent revascularization for limb salvage should not be denied surgery on the basis of a recent myocardial infarction.

A modified classification and approach to the management of infections involving peripheral arterial prosthetic grafts.

During the past 15 years, we have employed a modified classification and management plan to treat infections involving nonaortic peripheral arterial prosthetic grafts (PAPGs) without graft removal whenever possible. Sixty-eight infected wounds potentially involving PAPGs were initially treated by excision of necrotic and infected wound tissue in the operating room (wound excision). This was sufficient for all 34 minor infections that did not directly involve the graft. In the 34 remaining infected wounds with graft involvement (major infections), partial removal of a PAPG in 13 cases allowed preservation for up to 15 years of a functioning arterial segment and its collaterals. Ten other grafts were entirely saved. Only 11 of 34 major graft infections ultimately required total graft removal. This approach to infection complicating PAPGs resulted in only two deaths (6%) and directly led to limb loss or amputation at a higher level in eight patients (24%). Total removal of an infected PAPG is often unnecessary and may increase mortality and morbidity.

Peripheral vascular injuries associated with falls from heights.

Peripheral vascular injuries associated with falls from heights are uncommon. We report our 15-year experience with ten such injuries in 230 patients who jumped or fell from heights of at least 3 stories. These injuries occurred in seven patients and included four popliteal artery thromboses or disruptions, two popliteal vein disruptions, one traumatic tibial arteriovenous fistula, one subclavian artery pseudoaneurysm, one radial artery transection, and one lacerated medial circumflex artery. Although the mechanism of injury is multifactorial, all were associated with significant orthopedic trauma. Early recognition of vascular injuries, minimization of ischemic time, completion arteriography, venous repair, and liberal use of fasciotomy are emphasized to maximize limb salvage.

Prevention and management of ischemic complications of vein harvest incisions in cardiac surgery--case reports.

Leg wound complications following saphenous vein harvest for coronary revascularization are uncommon. We have encountered five patients in whom unrecognized arterial occlusive disease contributed to wound necrosis. All required vascular reconstruction in addition to local wound care to achieve healing. Careful preoperative attention to symptoms of arterial insufficiency is recommended and appropriate modification of lower extremity incisions may reduce the frequency of this complication. Prompt recognition and appropriate arterial revascularization should avoid prolonged morbidity if ischemic necrosis of leg wounds does occur. If arterial reconstruction is required, PTFE is an acceptable graft material if the remaining saphenous vein is inadequate for use.

Limb salvage in octogenarians and nonagenarians.

Although advanced age has often been a relative contraindication to attempts at limb salvage, we have not regarded it as an important deterrent to arterial reconstruction. Our 6-year experience with 168 consecutive patients over 80 years of age who underwent arterial reconstruction or percutaneous transluminal angioplasty represented 18% of all patients treated with limb-threatening ischemia during this period. The average age was 84 years, with 14 patients over 90 years of age. Sixty-eight patients were men (41%) and 100 were women (59%). Indications for treatment in 189 limbs were restricted to limb salvage. One hundred eighty-two operative procedures were performed consisting of 84 femoropopliteal, 72 femorotibial, 12 axillofemoral, 11 femorofemoral, two axillopopliteal and one iliofemoral bypass. Percutaneous transluminal angioplasty was performed in 12 iliac and 14 femoral or popliteal arteries as an alternative (seven) or adjunct (19) to vascular reconstruction. The 30-day procedural mortality rate was 6%. The cumulative life table survival rate of all patients who underwent an attempt at limb salvage was 78% at 1 year, 65% at 2 years, and 54% at 3 years. Cumulative life table limb salvage rates were 84% at 1 year, 74% at 2 years, and 71% at 3 years. Overall graft patency for 182 arterial reconstructive operations was 80% at 1 year and 62% at 3 years. Of patients in whom limb salvage was attempted, 65% lived more than 1 year and 51% more than 2 years with a functional limb. Of patients who died within 5 years of treatment, 76% did so with their previously threatened limb intact. These data support an aggressive approach to arterial reconstruction in elderly patients and indicate that advanced age alone should not be considered a contraindication to attempts at limb salvage.

Six-year prospective multicenter randomized comparison of autologous saphenous vein and expanded polytetrafluoroethylene grafts in infrainguinal arterial reconstructions.

Autologous saphenous vein (ASV) and polytetrafluoroethylene (PTFE) grafts were compared in 845 infrainguinal bypass operations, 485 to the popliteal artery and 360 to infrapopliteal arteries. Life-table primary patency rates for randomized PTFE grafts to the popliteal artery paralleled those for randomized ASV grafts to the same level for 2 years and then became significantly different (4-year patency rate of 68% +/- 8% [SE] for ASV vs. 47% +/- 9% for PTFE, p less than 0.025). Four-year patency differences for randomized above-knee grafts were not statistically significant (61% +/- 12% for ASV vs. 38% +/- 13% for PTFE, p greater than 0.25) but were for randomized below-knee grafts (76% +/- 9% for ASV vs. 54% +/- 11% for PTFE, p less than 0.05). Four-year limb salvage rates after bypasses to the popliteal artery to control critical ischemia did not differ for the two types of randomized grafts (75% +/- 10% for ASV vs. 70% +/- 10% for PTFE, p greater than 0.25). Although primary patency rates for randomized and obligatory PTFE grafts to the popliteal artery were significantly different (p less than 0.025), 4-year limb salvage rates were not (70% +/- 10% vs. 68% +/- 20%, p greater than 0.25). Primary patency rates at 4 years for infrapopliteal bypasses with randomized ASV were significantly better than those with randomized PTFE (49% +/- 10% vs. 12% +/- 7%, p less than 0.001). Limb salvage rates at 3 1/2 years for infrapopliteal bypasses with both randomized grafts (57% +/- 10% for ASV and 61% +/- 10% for PTFE) were better than those for obligatory infrapopliteal PTFE grafts (38% +/- 11%, p less than 0.01). These results fail to support the routine preferential use of PTFE grafts for either femoropopliteal or more distal bypasses. However, this graft may be used preferentially in selected poor-risk patients for femoropopliteal bypasses, particularly those that do not cross the knee. Although every effort should be made to use ASV for infrapopliteal bypasses, a PTFE distal bypass is a better option than a primary major amputation.

Six year experience with expanded polytetrafluoroethylene arterial grafts for limb salvage.

We have used 822 polytetrafluoroethylene (PTFE) grafts in arterial reconstructions for limb salvage over the last 6 years at Montefiore Medical Center-Albert Einstein College of Medicine, Four hundred and twenty-seven femoropopliteal reconstructions with PTFE had a 6 year cumulative life table patency rate of 55% with follow-up of 76 grafts for more than 3 years and 28 grafts for more than 4 years. Seventy-nine bypasses to the isolated popliteal segment had a 6 year cumulative patency rate of 72%. There were 207 bypasses performed to the tibial, peroneal or dorsalis pedis arteries. Life table patency rates were 55% at 1 year, 40% at 2 years and 37% at 4 years. Ninety-two PTFE femorofemoral and 62 axillofemoral bypasses had 5 1/2 year cumulative life table patency rates of 83% and 75%, respectively. Axillopopliteal PTFE bypasses can salvage otherwise doomed limbs. Thirty-four such grafts had 74% 1 year and 45% 5 year patency rates. The overall infection rate in all 822 PTFE grafts was only 0.5%. Thus, PTFE is a promising vascular prosthetic material which facilitates otherwise difficult or impossible limb salvage procedures.