Recurrent femoral anastomotic aneurysms. A 30-year experience.

Of the 1771 patients who underwent aortofemoral bypass grafting (AFB) during the 30-year period of 1957-1986, 43 noninfected recurrent femoral anastomotic aneurysms (RFAA) developed in 28 patients. Thirty-six RFAAs were treated surgically, with one death and no amputations occurring. Seven small RFAAs (less than 2.0 cm) were treated expectantly without complications. Using univariate and multivariate analyses, clinical characteristics and other factors influencing results in patients with RFAAs were compared to two control groups: patients who had undergone AFB without the development of femoral anastomotic aneurysms (FAAs) and patients who had undergone FAA repairs but without recurrence of FAA. Comparative analyses suggested: 1) local wound complications after initial AFB or FAA repair increased risk of a RFAA (p less than 0.03); 2) development of an FAA within 4.5 years after AFB increased risk of a RFAA (p less than 0.0002); 3) following an FAA repair, risk of a RFAA was almost three times greater for women than for men (p less than 0.05); and 4) patients with arteriosclerotic heart disease (ASHD) were less likely to develop RFAA than those without ASHD (p less than 0.05). Among the 20 additional variables analyzed--including hypertension, smoking, diabetes mellitus, and etiology of primary vascular disease--no statistically significant influence on the development of RFAAs could be detected.

A thirty-year survey of the reconstructive surgical treatment of aortoiliac occlusive disease.

With the view of assessing functional durability and the factors that influence or determine it, we reviewed the clinical course of 1748 reconstructive operations performed between Jan. 1, 1954, and Dec. 31, 1983 in the treatment of 1647 patients with aortoiliac occlusive disease (AIOD). Disabling intermittent claudication (in 65.6%), ischemic rest pain and/ or pregangrene (in 20.7%), and ischemic gangrene (in 13.7%) were the operative indications. Patency proven by angiography was the criterion of success. Follow-up was continuous and endless and 94% successful over a period of 30 years. Twenty-five percent of the patients were followed up for 11 to 30 years. The incidence of severe degree of occlusive involvement increased significantly from the first (9.3%) to the third (17.1%) decade of observation, whereas the perioperative mortality rate improved markedly from the first (7.4%) to the third (2.5%) decade. The aortobifemoral bypass (AF2B) procedure remained the most popular type of repair (with a perioperative patency rate of 91.4%) throughout, but both it and unilateral reconstructions lost some ground to remote (extra-anatomic) bypasses in the third decade. Atherosclerotic heart disease remained the most common cause of perioperative (50%) and late (60.2%) death. Among the early postoperative local complications graft thrombosis improved markedly from the first (8.3%) to the third (3.2%) decade. Graft infection remained rare (1.6% to 0.8%). The incidence of the most common late wound complication, anastomotic aneurysm at the common femoral level, remained relatively constant (5.7% per anastomosis), but it responded very well to surgical correction. The partial or complete secondary repair of all late complications (26.0%) improved the cumulative late patency rate in the AF2B procedures by 2% to 12% during 20 years of observation. The perioperative (97.3%), 5-year (76.6%), 10-year (76.6%), 15-year (72.5%), and 20-year (67.5%) cumulative patency rates of AF2B operations were highly satisfactory. The postoperative late survival rate of patients with AIOD declined rapidly (59% at 5, 33% at 10, 14% at 15 years). The cause of late death in 60.2% of the cases was atherosclerotic heart disease.

Popliteal arterial aneurysms. Their natural history and management.

Eighty-seven popliteal aneurysms in 62 patients, of which 50 were treated surgically, were reviewed and their clinical characteristics summarized. The need for alertness in the clinical detection of these lesions was stressed. Because complications, namely thrombosis and embolization, were frequent (23% in the total group, 36% in the surgical group), we recommend surgical treatment not only in all symptomatic but also in asymptomatic aneurysms larger than 2 cm in diameter; nonsurgically treated cases must be followed up carefully. With this aggressive approach, no lives and only two limbs were lost (one in a case of irreversible gangrene of the foot). Of the two surgical techniques described, the bypass procedure with autogenous vein graft is, because of its simplicity, given preference over resection with graft.

Spinal cord damage in surgery of the abdominal aorta.

The incidence, etiology, and clinical manifestations of spinal cord damage after abdominal aortic operations and abdominal aortography are defined on grounds of the authors' experience and of a survey of the pertinent literature. In the authors' experience the incidence of cord damage was 0.25% (three of 3,164) after abdominal aortic operations and 0.01% (two of 17,494) after abdominal aortography. As regards postoperative cord complications in the authors' series, they occurred only in cases of aneurysm, were 10 times more common in ruptured than in unruptured aneurysms, and the neurological loss usually was complete flaccid paraplegia (five of eight or 62%) with high mortality (three of eight or 38%), and rare partial (two of eight or 25%) or complete (one of eight or 13%) recovery. Recovery was more likely the lesser than neurological loss. The cause of postoperative spinal cord damage was ischemia resulting from the interruption of a critical radicular artery at the lower thoracic or high lumbar vertebral levels in the presence of anomalously located greater radicular or infrarenal radicular arteries. High aortic clamping and hypotension increased the probability of this occurrence, which essentially was unpredictable and, therefore, unavoidable. In postartographic cases the cord damage is more variable in its extent, and its cause is a chemical insult brought about by flooding the anterior spinal artery with contrast medium to which the patient probably is hypersensitive. In both groups treatment of the established clinical picture (paraplegia) is confined to support and rehabilitation.

Translumbar aortography: a study of its safety and usefulness.

We reviewed that clinical courses of 14,550 patients in whom translumbar aortography was performed. The principal aim of the survey was to determine the incidence of major and fatal complications attributable to this diagnostic study, as an index of its safety. We found that in this group, seven major (0.05%) and two fatal (0.014%) complications occurred. The corresponding incidences for transfemoral catheter aortography reported in the literature were found to be 1.34% and 0.06%, respectively. Translumbar aortography, when performed under the proper indications and appropriate conditions, has a degree of safety equal to or greater than that of transfemoral catheter aortography, and its diagnostic reliability within its technical scope is high.

Congenital arteriovenous anomalies of the limbs.

Observations in 33 patients with congenital arteriovenous fistulas described ten years ago have been extended with the addition of 49 other cases; the clinical, pathologic, and roentgenographic characteristics of these lesions in the entire group of 82 patients have been summarized. The findings in the entire group over the additional observation period have confirmed the conclusions previously reached, namely, that (1) these clinically extremely varied lesions have a unitary (developmental) cause; (2) for rational management, angiographic investigation is indispensable to establish their extent and complexity; (3) with few exceptions, their radical cure by surgical means is impossible; and (4) the large majority of patients do well on a carefully supervised conservative regimen, with surgical intervention reserved for individually defined instances.