Local anaesthesia for endovascular repair of infrarenal aortic aneurysms.

OBJECTIVE: The study aimed to analyse and report the results of a 'local anaesthesia first' approach in elective endovascular aneurysm repair (EVAR) patients. MATERIAL AND METHODS: Between January 2007 and August 2010, a total of 217 continuous patients (187 men, median age 76 years, range 52-94 years) underwent elective EVAR using this approach, with predefined exclusion criteria for local anaesthesia (LA). A retrospective analysis regarding technical feasibility, mortality, complication and endoleak rate was performed. The results are reported as an observational study. RESULTS: LA was applied in 183 patients (84%), regional anaesthesia (RA) in nine patients (4%) and general anaesthesia (GA) in 25 patients (12%). Anaesthetic conversion from LA to GA was necessary in 14 patients (7.6%). Airway obstruction (n = 4) and persistent coughing (n = 3) were the most common causes for conversion to GA. Thirty-day mortality in the LA group was 2.7%, with 16/183 patients (8.7%) experiencing postoperative complications. All type I endoleaks (n = 5, 2.7%) occurred in patients with LA and challenging aneurysm morphologies. CONCLUSIONS: A 'local anaesthesia first' strategy can successfully be applied in 75% of patients undergoing EVAR. The use of LA can impact imaging quality and thus precise endograft placement, which should be considered in patients with challenging aneurysm morphologies.

Simultaneous aortic replacement and renal artery revascularization: the influence of preoperative renal function on early risk and late outcome.

PURPOSE: We documented the postoperative complication rate and the late results of simultaneous infrarenal aortic replacement and renal artery (RA) revascularization at the Cleveland Clinic and correlated these findings with the preoperative serum creatinine level (S(Cr)) and other baseline risk factors. METHODS: A retrospective review of hospital charts and outpatient records was supplemented with a telephone canvass and the invitation to return for a complimentary RA duplex scan, when a scan had not been done within the previous year. Data were collected for 73 consecutive patients (mean age, 69 years) who underwent aortic procedures that were combined with the repair of RA stenosis from 1989 to 1997 (mean follow-up, 44 months). The preoperative S(Cr) was 2 mg/dL or lower in 45 patients (group R1; median, 1.5 mg/dL) and was higher than 2 mg/dL in the remaining 28 patients (group R2; median, 2.6 mg/dL). RESULTS: Forty-seven of the patients in this series had aortic aneurysms, 15 patients had aortoiliac occlusive disease, and 11 patients had both types of lesions. Bilateral RA revascularization was necessary for seven patients in group R1 (15%) and for eight patients in group R2 (29%). Group R2 contained more patients with medically resistant hypertension (57%) than group R1 (29%, P = .019). Although there was no statistically significant difference between the 30-day mortality rates (group R1, 2.2%; group R2, 11%), the related in-hospital mortality rate for 15 bilateral RA revascularizations (13%) was nearly twice that of 58 unilateral revascularizations (6.9%). Patients in group R2 were at a higher risk for postoperative dialysis than those in group R1 (36% vs 6.7%, P = .008), and patients in group R2 had longer lengths of stay in the hospital (median, 14 days vs 9 days; P = .004). By means of Kaplan-Meier analysis, the 5-year survival rate was lower for patients in group R2 (53%; 95% CI, 33%-73%) than for patients in group R1 (85%; 95% CI, 74%-96%; log rank P = .005). Despite all other liabilities in group R2 patients, however, their resistant hypertension was cured or improved in 88% of cases and their S(Cr) appeared to decline with time. CONCLUSION: The early postoperative risk of simultaneous aortic/RA procedures appears to be highest in patients who have an elevated S(Cr), bilateral RA stenosis or occlusion, and a comparatively low long-term survival rate. In this particular group, the adjunctive use of endovascular techniques might conceivably reduce the magnitude of the planned surgical procedure and thus enhance the overall outcome.

Angioscopically directed valvulotomy: a new valvulotome and technique.

Despite a large experience with "blind" retrograde valvulotomy in in situ vein bypass grafting, the incidence of residual competent valves remains high, and valvulotome-induced injury is common. In this study we describe a new valvulotome and technique of angioscopically directed valvulotomy and review the video tape recordings of 85 completion angioscopies of in situ femorodistal bypasses. Fifty-three vein grafts were prepared with the blind retrograde valvulotomy technique and 32 vein grafts with the new valvulotome and angioscopy. The use of the new valvulotome and technique is compared with that of the standard blind retrograde valvulotomy technique, and the normal endoluminal anatomy and incidence of primary disease in saphenous vein grafts was noted. The incidence of valvulotome-induced injury was 5/32 (15.6%) and 45/53 (85%) in vein grafts prepared with angioscopically directed valvulotomy and blind retrograde valvulotomy, respectively. Residual competent valves were found in 10/53 (18.9%) in blind retrograde valvulotomy and 0/25 of angioscopically directed valvulotomy vein grafts (p = 0.0114). In 22/53 vein grafts unsuspected primary disease was detected. Angioscopically directed valvulotomy with the new valvulotome and technique is feasible, reliable, and safe. It avoids residual competent valves, minimizes valvulotome-induced injury, and allows the detection and correction of unappreciated primary vein graft abnormalities. The new valvulotome and technique is a first step in the complete endoluminal preparation of the in situ vein graft.

Popliteal-to-distal bypass grafts for limb salvage in diabetics.

Between January 1984 and August 1989, 117 diabetic patients with a palpable popliteal pulse but distal limb threatening ischaemia underwent 124 popliteal artery (or below) to distal bypass grafts. All grafts were intra-operatively monitored. The operative mortality was 0.8% and the 30 day primary patency 93%. Primary patencies at 1 and 3 years were 88.6 and 85.2%, respectively. The results of using the popliteal artery as the proximal graft inflow site in diabetes are comparable to other patient groups and to alternative more proximal inflow sites, but require a shorter length of vein graft with a shorter vein harvesting incision, avoid groin disection and result in a more peripheral operation.