Extended iliac exposure from the groin.

Knowledge of iliac artery and inguinal anatomy enables extraperitoneal exposure of the iliac arteries for surgical treatment of unilateral inflow disease. A method is presented for exposing the distal common iliac artery, the iliac bifurcation, and the full length of the external iliac artery by detachment and retraction of the inguinal ligament though a single extended groin incision. The indications for unilateral iliac artery exposure, revascularization, surgical anatomy, and technique of iliofemoral exposure through a single, extended groin incision are presented. Extended iliac exposure through a single, extraperitoneal exposure facilitates all methods of unilateral iliac revascularization and provides access for delivery of endovascular devices.

Gross hematuria secondary to renal vein hypertension from unilateral retroperitoneal fibrosis.

We report the first case of localized, unilateral, idiopathic retroperitoneal fibrosis encasing the left renal vein, which resulted in secondary renal vein hypertension. The patient presented with sudden and dramatic gross hematuria. Surgical release and excision of the surrounding localized retroperitoneal fibrosis resulted in prompt resolution of the hematuria.

Pararenal aortic aneurysms: the future of open aortic aneurysm repair.

PURPOSE: As endovascular stent graft repair of infrarenal abdominal aortic aneurysms (AAAs) becomes more common, an increasing proportion of patients who undergo open operation will have juxtarenal aneurysms (JR-AAAs), which necessitate suprarenal crossclamping, suprarenal aneurysms (SR-AAAs), which necessitate renal artery reconstruction, or aneurysms with associated renal artery occlusive disease (RAOD), which necessitate repair. To determine the current results of the standard operative treatment of these patterns of pararenal aortic aneurysms, we reviewed the outcome of 257 consecutive patients who underwent operation for JR-AAAs (n = 122), SR-AAAs (n = 58), or RAOD (n = 77). METHODS: The patients with SR-AAAs and RAOD were younger (67.5 +/- 8.8 years) than were the patients with JR-AAAs (70.5 +/- 8.3 years), and more patients with RAOD were women (43% vs 21% for JR-AAAs and SR-AAAs). The patient groups were similar in the frequency of coronary artery and pulmonary disease and in most risk factors for atherosclerosis, except hypertension, which was more common in the RAOD group. Significantly more patients with RAOD had reduced renal function before surgery (51% vs 23%). Supravisceral aortic crossclamping (above the superior mesenteric artery or the celiac artery) was needed more often in patients with SR-AAAs (52% vs 39% for RAOD and 17% for JR-AAAs). Seventeen patients (7%) had undergone a prior aortic reconstruction. The most common renal reconstruction for SR-AAA was reimplantation (n = 37; 64%) or bypass grafting (n = 12; 21%) and for RAOD was transaortic renal endarterectomy (n = 71; 92%). Mean AAA diameter was 6.7 +/- 2.1 cm and was larger in the JR-AAA (7.1 +/- 2.1 cm) and SR-AAA (6.9 +/- 2.1 cm) groups as compared with the RAOD group (5.9 +/- 1.7 cm). RESULTS: The overall mortality rate was 5.8% (n = 15) and was the same for all the groups. The mortality rate correlated (P <.05) with hematologic complications (bleeding) and postoperative visceral ischemia or infarction but not with aneurysm group or cardiac, pulmonary, or renal complications. Renal ischemia duration averaged 31.6 +/- 21.6 minutes and was longer in the SR-AAA group (43.6 +/- 38.9 minutes). Some postoperative renal function loss occurred in 104 patients (40.5%), of whom 18 (7.0%) required dialysis. At discharge or death, 24 patients (9.3%) still had no improvement in renal function and 11 of those patients (4.3%) remained on dialysis. Postoperative loss of renal function correlated (P <.05) with preoperative abnormal renal function and duration of renal ischemia but not with aneurysm type, crossclamp level, or type of renal reconstruction. CONCLUSION: These results showed that pararenal AAA repair can be performed safely and effectively. The outcomes for all three aneurysm types were similar, but there was an increased risk of loss of renal function when preoperative renal function was abnormal. These data provide a benchmark for expected treatment outcomes in patients with these patterns of pararenal aortic aneurysmal disease that currently can only be managed with open repair.

Common brachiocephalic trunk: strategies for revascularization.

BACKGROUND: A common brachiocephalic trunk, in which both common carotid arteries and the right subclavian artery arise from a single trunk off the arch, is a normal variant of aortic arch branching that occurs in approximately 10% of the population. Because three of the four primary sources of cerebral blood flow arise from a single aortic branch, stenosis or occlusion of a common trunk can cause severe ischemic consequences. Common trunk revascularization has been described, but there have been no reports focusing on the management options for occlusive disease of this vascular anatomy. METHODS: A retrospective review of our experience with innominate artery revascularization identified 6 patients who underwent revascularization of a common brachiocephalic trunk between 1977 and 1997. All patients were symptomatic, with either total occlusion (n = 3) or critical stenosis (n = 3) caused by atherosclerosis (n = 5) or Takayasu's arteritis (n = 1). Revascularization was achieved by a prosthetic bypass graft from the ascending aorta to the innominate or left common carotid arteries or both (n = 5); or transarterial endarterectomy (n = 1). Concomitant endarterectomy of branch vessels was performed in 3 patients. RESULTS: There was one perioperative death from myocardial infarction, and one perioperative stroke, with death occurring 1 month after hospital discharge. One patient developed cerebral hyperperfusion syndrome 1 week after endarterectomy that resolved without sequelae with antihypertensive medications. During a follow-up period ranging from 1 to 20 years, there was one late death from congestive heart failure 5 years after operation. All surviving patients are alive and free from symptomatic recurrence. CONCLUSIONS: Revascularization for occlusive disease of a common brachiocephalic trunk can be achieved with effective and durable relief of symptoms using either a prosthetic bypass graft or endarterectomy. However, neurologic complications in 2 patients, which were fatal in 1, attest to the potential cerebral ischemic threat posed by occlusive disease of a common brachiocephalic trunk.

Surgical management of subclavian-vein effort thrombosis as a result of thoracic outlet compression.

BACKGROUND: There is considerable variability and controversy in the current management of subclavian-vein effort thrombosis. The purpose of this study was to determine the long-term effectiveness and the functional outcome of our preferred treatment strategy of early thrombolysis/recanalization and prompt extensive supraclavicular decompression. PATIENTS AND METHODS: Thirty-three patients who ranged in age from 15 to 60 years underwent operative decompression of 34 primary subclavian-vein thromboses, one of which was bilateral. There were 21 patients with acute thrombosis 7 of whom had had prior unsuccessful balloon venoplasty, 1 with stent placement and 8 patients with chronic/recurrent thrombosis 5 of whom had had 9 unsuccessful prior operations for attempted decompression. Four patients had high-grade symptomatic stenosis and positional occlusion. A supraclavicular approach was used in 32 cases and, in 23 cases, was complemented by an infraclavicular (n = 21) or transaxillary (n = 2) incision. Complete subclavian-vein decompression was achieved by first-rib resection (n = 31), scalenectomy (n = 33), and circumferential venolysis (n = 34). RESULTS: Follow-up was obtained in 30 patients at a mean of 31 months. Twenty of the 21 patients with acute thrombosis had a complete resolution of symptoms with a return to full activity; the other patient was lost to follow-up. Four of the 8 patients with chronic thrombosis reported a mild relief of symptoms but still had limitations of activities of daily living. All of the patients with high-grade symptomatic stenosis with positional occlusion had a complete relief of symptoms and a return to full activity. CONCLUSION: The optimal management of acute effort thrombosis of the subclavian vein includes anticoagulation therapy, thrombolysis/recanalization, confirmatory positional venography, and early supraclavicular decompression of the subclavian vein. In the patients with chronic subclavian-vein thrombosis and positional venographic evidence of compression of first-rib bypass graft collaterals, the initial anticoagulation therapy should be followed by the surgical decompression of the collaterals. The supraclavicular approach alone or with an infraclavicular incision provides optimal exposure for scalenectomy, total first-rib resection, and circumferential venolysis.

Femoral artery exposure for endovascular aneurysm repair through oblique incisions.

PURPOSE: To offer an alternative technique for accessing the femoral artery prior to endovascular grafting. TECHNIQUE: An oblique incision is made over the medial half of the inguinal ligament and continues to the femoral sheath, which is opened longitudinally. The distal external iliac artery and proximal common femoral artery are isolated. A tiny stab wound is made distal to the primary wound for femoral artery puncture and catheter access. CONCLUSIONS: Using an oblique incision at the level of the inguinal ligament optimizes exposure for endograft insertion and may minimize the frequency of serious wound complications.

Innominate artery reconstruction: over 3 decades of experience.

SUMMARY BACKGROUND DATA: Symptomatic atherosclerotic occlusive disease of the innominate artery is a threatening disease pattern that offers a major challenge in achieving definitive surgical repair. To assess the evolution of treatment strategies and their outcomes for this disease, the authors undertook a review of the cumulative experience for more than 3 decades at one institution. METHODS: Between 1960 and 1997, 94 patients (mean age, 62 years) underwent direct innominate artery revascularization for occlusive atherosclerotic disease to relieve neurologic (n = 85) and/or right upper extremity (n = 26) symptoms or asymptomatic critical stenosis (n = 3). The pattern of atherosclerotic involvement revealed by angiography included critical stenosis (n = 77), complete occlusion (n = 10), and moderate stenosis with plaque ulceration (n = 7). A common brachiocephalic trunk was present in five patients. Transsternal (n = 68) or transcervical (n = 4) innominate endarterectomy was performed in 72 patients and bypass grafting in 22. Forty-one patients underwent concomitant endarterectomy or bypass of innominate branches or adjacent arch vessels, and 3 had coronary bypass grafting. RESULTS: There were three perioperative deaths (3%), all due to cardiac causes. Postoperative morbidity included four strokes (three resolved), two myocardial infarctions, two transient ischemic attacks, and one sternal dehiscence. Follow-up ranged from 8 months to 20 years. Postoperative actuarial survival rate was 96% at 1 year, 85% at 5 years, and 67% at 10 years. Freedom from recurrence requiring reoperation was 100% at 1 year, 99% at 5 years, and 97% at 10 years. CONCLUSIONS: Innominate artery reconstruction is safe and durable when either endarterectomy or prosthetic bypass is used. The anatomic variation and disease distribution permit endarterectomy for most patients. The technique of innominate endarterectomy can be extended safely to outflow and adjacent vessels.

In vitro versus in vivo assessment of vein wall properties.

Venous compliance reflects the mechanical properties of the vein wall. Clinical methods of measurement have not been validated by comparison with the accepted in vitro measurement. Despite this, clinical assessment of vein compliance may have a series of useful applications: (1) to assess the progression of chronic venous insufficiency and the related hemodynamic forces acting on the saphenous vein wall; (2) to determine the suitability of the saphenous vein for replacement of an arterial conduit by testing its mechanical properties; and (3) to select the saphenous vein with preferable mechanical performance for coronary artery bypass. The aim of this study is to assess the relationship between in vitro and two in vivo methods of compliance measurement. Compliance of the saphenous vein was determined in 20 patients, using both an invasive and a noninvasive (A and B, respectively) method. Duplex scanning was used for diameter measurement. Venous pressure was derived either intravenously with a needle transducer, or noninvasively with limb length measurement. Patients underwent saphenous excision with further in vitro compliance measurement of the same vein segment (method C). The compliance values obtained with the three methods showed different degrees of correlation (r= 0.516, p = 0.0001 for method A versus method C; r = 0.658, p = 0.0001 for method B versus method C; r = 0.993, p = 0.0001 for method A versus method B). The relationships with the in vitro measurements that were determined validate both in vivo methods for assessment of saphenous vein compliance. Due to its completely noninvasive design, method B appears to have potential use for clinical assessment of saphenous vein wall properties.

In situ autogenous reconstruction of the thoracoabdominal aorta and branches for treatment of an infected thoracoabdominal aortobifemoral bypass graft.

Graft infection is an uncommon but potentially lethal complication of prosthetic aortic repair. We describe a novel technique for upper abdominal aortic and visceral revascularization after percutaneous drainage and antibiotics failed to cure a thoracofemoral prosthetic graft infection. One week after axillofemoral and femorofemoral bypass grafting, the infected thoracoabdominal graft was removed and a bifurcated iliac artery autograft was used to replace the upper abdominal aorta and revascularize the abdominal viscera. The infected graft was removed from the thorax and retroperitoneum, the infection resolved, and the patient remained well until his death of lung cancer 9 years later.

Percutaneous stenting for symptomatic stenosis of aberrant right subclavian artery.

Aberrant origin of the right subclavian artery is the most common abnormality of the aortic arch vessels and occurs in approximately 0.5% to 1% of the population. Symptoms can result from compression of the esophagus by the aberrant vessel, aneurysm formation, or atherosclerotic occlusion. Occlusive symptoms are typically relieved by surgical revascularization (i.e., transposition or carotid-subclavian bypass) through a cervical approach. An alternative approach to the management of stenosis of normal subclavian arteries is percutaneous angioplasty and stenting, an approach not previously used for occlusive disease of an aberrant right subclavian artery. We describe a case of focal stenosis of an aberrant right subclavian artery causing dizziness and arm claudication in a patient who underwent successful percutaneous angioplasty and stenting.

Combined aortorenal reconstruction: is there an optimum method of exposure?

OBJECTIVE: To determine the advantages and disadvantages of two different transabdominal approaches to expose the pararenal aorta; infacolic (IC) and medical visceral rotation (MVR). DESIGN: Retrospective study. METHODS: We reviewed a consecutive series of concurrently treated patients undergoing combined aortorenal reconstruction using one of these two approaches (IC n = 45; MVR n = 30). RESULTS: The two groups were identical with respect to demographics, risk factors and associated illnesses. Aortic aneurysmal disease predominated among MVR patients, and occlusive disease among IC patients (p = 0.001). The most common aortic reconstruction was aortofemoral bypass grafting. Renal revascularisation was most often performed for symptoms; only in the MVR group it was the result of involvement by aortic aneurysmal disease (p = 0.000). Thromboendarterectomy was the most common renal reconstruction, though performed only 10 times in the MVR group (p = 0.01). Except for supraceliac aortic cross-clamping, which was required more often in the MVR group (p = 0.004), operative details did not differ between the groups. Although the overall perioperative mortality and complication rate were equal, intraoperative splenic injury occurred solely in the MVR group (p = 0.001), and these patients experienced more pulmonary complications (p = 0.004) and they were hospitalised longer than the IC group (29.7 +/- 35.8 vs. 17.2 +/- 15.4 days; p = 0.04). CONCLUSIONS: MVR has increased morbidity, but its unrestricted continuous exposure is optimum for combined aortorenal reconstruction involving pararenal aneurysmal disease. Pararenal occlusive disease is adequately exposed in most cases by the IC approach.

Reoperation for recurrent chronic visceral ischemia.

PURPOSE: Recurrent visceral ischemia after a failed visceral revascularization occurs in up to one third of patients, yet no comprehensive report has described the management of this problem. The purpose of this study was to examine the presentation, surgical management, and outcome of patients with recurrent visceral ischemia. METHODS: Between 1959 and 1997, 109 patients underwent primary visceral revascularization at the University of California, San Francisco. Nineteen patients (17.4%) had recurrent visceral ischemia (12 chronic visceral ischemia, seven acute visceral ischemia). Fourteen additional patients with recurrent chronic visceral ischemia were referred after failed primary revascularization (two patients underwent multiple operations before referral). Thirty visceral reoperations were performed for recurrent visceral ischemia in 24 patients (10 patients with recurrence at University of California, San Francisco, 14 referred patients). Symptom-free and overall survival rates were determined by life table analysis. RESULTS: Of seven patients (6.4%) who had recurrent acute visceral ischemia, six (85.7%) died of bowel infarction. Twelve patients (11%) had recurrent chronic visceral ischemia. Patients with recurrent chronic visceral ischemia received their diagnoses earlier and lost less weight than at their initial presentation (p = 0.004 and 0.001, respectively). Recurrent ischemia was associated with younger age, greater weight loss, and modification of surgical technique at the time of initial operation (p = 0.5, 0.009, and 0.02, respectively). For 20 (90.9%) of the 22 first reoperations, antegrade aortovisceral bypass (n = 10) or transaortic visceral endarterectomy (n = 10) was used. Multiple techniques (four antegrade bypass, two retrograde bypass, one endarterectomy, one anastomotic revision) were used in the eight second or third reoperations. Postoperative mortality and complication rates were 6.7% and 33.3%, respectively. Symptoms recurred in six of 22 patients (27.3%) after the first reoperation, three of whom were cured or improved after additional reoperations. The life table symptom-free survival rate after reoperation was 77.3% and 62.8% at 1 and 5 years, respectively. The life table overall survival rate after reoperation was 74.6% at 5 years. CONCLUSIONS: Recurrent visceral ischemia is not uncommon after primary visceral revascularization. These results show that reoperation for recurrent chronic visceral ischemia can be accomplished safely and effectively with established revascularization techniques. Furthermore, after repeat visceral revascularization patients achieve durable relief of symptoms and have life expectancy rates comparable with those of patients who undergo primary visceral revascularization.

Redo aortic grafting after treatment of aortic graft infection.

PURPOSE: This study was performed to determine the indications, operative strategy, and hemodynamic benefit of redo aortic grafting procedures after earlier excision of an infected aortic graft. METHODS: Among 164 patients treated for aortic graft infection, 15 later underwent redo aortic grafting procedures an average of 18 months (range, 1 to 59 months) after removal of an infected aortic graft. Redo grafting procedures were performed for leg ischemia (n = 11) or infection (proven, n = 3; suspected, n = 1). The new aortic graft originated either from the distal thoracic aorta (n = 5) or from the juxtarenal aortic stump (n = 10). Follow-up averaged 56 months (range, 7 to 110 months). RESULTS: All patients survived the redo grafting procedure. In the eleven patients who had ischemic symptoms, redo grafting procedures uniformly resulted in symptomatic improvement with an increase in ankle-brachial indexes (0.78 +/- 0.34 vs 0.50 +/- 0.29; p = 0.02). A graft limb occlusion developed in two of these patients (3 and 6 months), but no limbs were amputated. In the four patients who had proven or suspected extraanatomic bypass graft infection, there was one graft limb occlusion (29 months) and one amputation (17 months). Overall, recurrent graft infection occurred in three of 15 patients and may be more frequent in patients who have a proven extraanatomic bypass graft infection (2 of 3 vs 1 of 12; p = 0.08). Infection accounted for two of the three graft limb occlusions and two of the three late deaths. Recurrent infection was not associated with early (< 1 year) regrafting procedures, and culture results did not correlate with the microbiologic features of the primary infection. CONCLUSIONS: Redo aortic grafting procedures can be performed safely and at relatively early intervals (6 to 12 months) after removal of the infected aortic graft. The procedure reliably relieves ischemic symptoms of the hemodynamically inadequate extraanatomic bypass graft. Reinfection remains a risk after redo aortic grafting procedures, particularly when treating established extraanatomic bypass graft infection.

Neurogenic thoracic outlet decompression: rationale for sparing the first rib.

A total of 168 primary supraclavicular decompressions were performed on 146 patients with neurogenic thoracic outlet syndrome. This report compares the results of rib resection (supraclavicular anterior and middle scalenectomy and first rib resection) with rib-sparing (supraclavicular anterior and middle scalenectomy alone) operations. All patients with cervical ribs were excluded. In total, 125 rib resections and 43 rib-sparing procedures were performed between 1983 and 1992 by a single surgeon. The patients were otherwise comparable in symptoms and physical signs. During surgery there was a significantly higher proportion of pleural injury associated with rib resection (59%) than with rib-sparing (40%) procedures. The mean hospital stay was also prolonged by 1 day in patients undergoing rib resection (p = 0.005). There was no significant difference in early success between the two groups (83% for rib resection, 91% for rib sparing) and no difference in those resuming employment (52% and 63% respectively). Life-table analysis showed that the two groups have similar long-term results (69% and 76% at 2 years). The only important factor determining clinical outcome in primary supraclavicular thoracic outlet syndrome decompression was the duration of symptoms before operation. Some 83% of patients with symptoms less that 2 years had a successful result compared with only 68% in those with symptoms longer than 2 years (p < 0.05). Spontaneous or post-traumatic neurogenic symptoms responded to operation identically. The theoretical benefit of first rib resection to relieve mechanical compression of the brachial plexus is not evident from this review. Thorough removal of the scalene musculature and other myofascial anomalies, preferably through the supraclavicular approach, leads to less patient morbidity, shortens hospitalization, and is recommended for patients with neurogenic thoracic outlet syndrome requiring operative intervention.

Durability of cross-femoral grafts after aortic graft infection: the fate of autogenous conduits.

PURPOSE: Revascularization for the treatment of aortic graft infection is usually accomplished by remote prosthetic axillofemoral bypass combined with cross-femoral bypass. When infection at the femoral level precludes placement of a prosthetic cross-femoral graft, we have used a variety of autogenous tissue conduits to restore circulation to the contralateral leg. To determine which of these conduits offers the most durable reconstruction, we have reviewed 78 patients treated for aortic graft infection. METHODS: Between 1980 and 1991 we used either autogenous saphenous vein (ASV, n = 34), endarterectomized superficial femoral artery (SFA, n = 14), or direct ilioiliac anastomosis (iliac, n = 10) to provide cross-femoral flow. We compared the performance of these tissue conduits with a concurrent patient group with aortic graft infection in whom a prosthetic cross-femoral graft was used (prosthetic, n = 20). RESULTS: Follow-up was available for 98.7% of patients, average 3.8 +/- 2.9 years, and was not different between the four groups. Bleeding complications occurred exclusively in the ASV group (n = 3, 8.8%) and were all in the perioperative period. In addition one ASV and one iliac conduit developed multiple false aneurysms. Hemodynamic conduit failure (thrombosis or stenosis) occurred in nine (26.5%) ASV conduits, six (42.8%) SFA conduits, and one iliac conduit, but not in the prosthetic group. When all of these adverse events were combined for each conduit group, both ASV and SFA conduits had a higher rate of conduit failure when compared with the prosthetic conduits (p < 0.05, log-rank test). Limb loss resulting from cross-femoral conduit failure occurred in six (17.6%) patients in the ASV group, four (28.6%) patients in the SFA group, and one patient each in the iliac and prosthetic groups. These differences were not significant. CONCLUSIONS: We conclude that ASV and SFA conduits do not provide stable long-term cross-femoral revascularization and should be regarded as bridge grains until femoral infection is eradicated. When femoral infection mandates their use, frequent postoperative conduit surveillance is required. If ASV or SFA caliber is marginal, consideration should be given to the use of a larger autogenous conduit, such as superficial femoral vein.