Endoscopic versus open saphenous vein graft harvest for lower extremity bypass in critical limb ischemia.

OBJECTIVE: Endoscopic vein harvest (EVH) has been demonstrated to improve early morbidity when compared with conventional open vein harvest (OVH) technique for infrainguinal bypass surgery. However, recent literature suggests conflicting results regarding mid- and long-term patency with EVH. The purpose of this study is to compare graft patency between harvest techniques specifically in patients with critical limb ischemia. METHODS: This retrospective study compared two groups of patients (EVH = 39 and OVH = 49) undergoing lower extremity revascularization from January 2009 to December 2011. Outcome measures included patency rates, postoperative complications, and wound infection. Graft patency was assessed using Kaplan-Meier curves. RESULTS: Both groups were matched for demographics and indications for bypass (critical limb ischemia). Median follow-up was 22 months. There was a significant reduction in the incidence of wound infection at the vein harvest site in the EVH group (OVH = 20%; EVH = 0%; P < .001), nevertheless, the difference was not significant when only the anastomotic sites were included (OVH = 12.2%; EVH = 15.4%; P = .43). The hospital length of stay was comparable between the two groups (EVH = 8.73 ± 9.69; OVH = 6.35 ± 3.28; P = .26) with no significant difference in the recovery time. Primary graft patency rate was 43.2% in the EVH group and 69.4% in the OVH group (P = .007) at 3 years. The most common reason for loss of primary patency was graft occlusion (61.5%) in the OVH group and vein graft stenosis (54.5%) in the EVH group. The average number of vascular reinterventions per bypass graft was significantly lower in the OVH group compared with the EVH group (OVH = 0.37; EVH = 1.28; P < .001). CONCLUSIONS: Our findings demonstrate inferior primary patency when using the technique of EVH. Additionally, we identified a significantly higher rate of reintervention in the EVH cohort as well as a higher rate of vein graft body stenosis. However, EVH was associated with a decreased rate of wound complications with similar limb salvage and secondary patency rates when compared to OVH. EVH should therefore be selectively utilized in patients at high risk for wound complications.

Delayed open conversions after endovascular abdominal aortic aneurysm repair.

OBJECTIVE: Secondary interventions after endovascular aneurysm repair (EVAR) remain a concern. Most are simple catheter-based procedures, but in some instances, open conversions (OCs) are required and carry a worse outcome. We reviewed our experience to characterize these OCs. METHODS: A retrospective review was conducted of all patients who underwent an OC after a previous EVAR for an aneurysm-related indication from 2001 to 2010. Clinical outcomes are reported. RESULTS: Data were reviewed for 44 patients (77% men) with a mean age of 74 years (range, 55-90 years). The average time from EVAR to the first OC was 45 months (range, 2-190 months). In six patients (14%), the initial EVAR was at another institution. The endografts used were Ancure in 16, Excluder in 13, AneuRx in eight, Zenith in three, Lifepath in one, Renu in one, and undetermined in two. Twenty-two patients had previously undergone a total of 32 endovascular reinterventions before their index OC. Indications for OC were aneurysm expansion in 28 (64%), rupture in 12 (27%), and infection in four (9%). The endograft was preserved in situ in 10 patients (23%). Explantation was partial in 18 (41%) or complete in 16 (36%). Endograft preservation was used for type II endoleak in all but one patient by selective ligation of the culprit arteries (lumbar in four, inferior mesenteric artery in five, and middle sacral in one). Proximal neck banding was performed in one type Ia endoleak. Overall morbidity was 55%, and mortality was 18%. No deaths occurred in a subgroup of patients who underwent endograft preservation with selective ligation of culprit vessels for type II endoleak. Intraoperative complications included bowel injury in two, bleeding in two, splenectomy in one, and ureteral injury in one. At a mean follow-up of 20 months, two patients underwent additional procedures after the index OC: one after endograft preservation and one after partial explantation. None of the patients who underwent elective OC with endograft preservation required subsequent endograft explantation. CONCLUSIONS: Most OCs after EVAR are associated with significant morbidity and mortality, except when electively treating an isolated type II endoleak with ligation of branches and preservation of the endograft.

Expanding the role of endovenous laser therapy: results in large diameter saphenous, small saphenous, and anterior accessory veins.

BACKGROUND: Endovenous laser therapy (EVLT) is an accepted form of axial vein ablation for symptomatic venous reflux but there is debate regarding its efficacy and complication rates in large veins (≥1 cm). In addition, its role in the treatment of small saphenous veins (SSVs) and anterior accessory veins (AAVs) has not been well characterized either. METHODS: A retrospective review of patients undergoing EVLT on the great saphenous vein (GSV), SSV, or AAV between August 2007 and May 2009 was conducted. A total of 885 limbs were reviewed. In all, 153 patients were excluded because of incomplete information. Gender, age, vein size, operative details, ultrasound, and clinical follow-up results were recorded. Veins that measured <1 cm in diameter were considered small, whereas those that measured ≥1 cm at any point were considered to be large. RESULTS: A total of 732 ablations were reviewed, involving 175 men and 557 women (76.1%). Average follow-up with duplex ultrasound was 3 weeks, and all patients underwent at least one postprocedural ultrasound. In all, 565 (77.3%) GSVs, 113 (15.5%) SSVs, and 53 (7.3%) AAVs were treated. A total of 88 ablations were performed on veins measuring ≥ 1 cm, 12% of all treated veins. In all, 82 GSVs, three SSVs, and three AAVs measured >1 cm, and GSVs comprised 93.2% of treated large veins (p ≤ 0.001 vs. entire cohort). For active ulceration, 4.9% of small vein and 9.1% of large vein treatments were performed (p = 0.11). An average of 2,983 J (range: 250-7,922) was used for each ablation, with veins measuring ≥ 1 cm being treated with significantly more energy (3,733 vs. 2,876 J, p < 0.001). Complications occurred in 7.61% of small vein ablations and 7.95% of large vein ablations (p = 0.91). This included failure in 3.4% of small vein and 4.5% of large vein ablations (p = 0.59). In addition, two deep vein thromboses (0.4%) occurred, both in GSVs. The most common complication was failure of closure, occurring in 1.6% of GSVs, 8.8% SSVs, and 13.2% AAVs (p < 0.001). Overall, the GSV was more likely to have successful closure (p ≤ 0.001) and fewer complications (p = 0.005) than SSV or AAV. CONCLUSIONS: Complication rates and closure rates are not significantly different for veins of diameter ≥ 1 cm and smaller veins. Although more energy is used, this has not translated into higher complication rates, thus making EVLT safe and effective for large vein closure. Significantly higher failure and complication rates were seen in SSV and AAV treatment as compared with GSV treatment.

Endovascular repair of multiple infrageniculate aneurysms in a patient with vascular type Ehlers-Danlos syndrome.

Patients with vascular type Ehler-Danlos syndrome can develop aneurysms in unusual locations. We describe the case of a 33-year-old woman with vascular type Ehlers-Danlos syndrome who developed metachronous tibial artery aneurysms that were sequentially treated with endovascular means.

Cerebral reserve is decreased in elderly patients with carotid stenosis.

OBJECTIVES: Octogenarians and even patients over 70 years old have unexplained poor outcomes with carotid angioplasty and stenting (CAS). We sought to evaluate whether older patients may have compromised intracranial collaterals and cerebral reserve and be intolerant to otherwise clinically silent emboli generated during CAS. METHODS: One thousand twenty-four cerebral blood flow (CBF) studies performed between 1991 and 2001 with stable xenon computed tomography scans (Xe/CT) were reviewed. CBF was measured before and after 1 gm intravenous acetazolamide (ACZ), a cerebral vasodilator. The normal response to ACZ is an increase in CBF. In areas of significant compromise of cerebral reserve (CR), CBF drops, representing a "steal" phenomenon. CBF changes were categorized as normal or abnormal and correlated with age, gender, cerebral symptoms, and with intracranial, carotid, or vertebral artery disease. Logistic regression was used to determine the effect of age on CR in the entire group and a subgroup of 179 patients with significant carotid stenosis of >50%. RESULTS: Nine hundred sixteen studies were suitable for analysis. Carotid occlusion was predictive of decreased reserve (OR, 3.9; P = .03) regardless of age. There was also a trend toward lower reserve with severe carotid stenosis >70% (OR, 3) and in women (OR, 1.8; P = .08). Age >or=70 had no effect on reserve in the overall heterogeneous population with and without carotid disease and neither did a history of stroke, carotid, or intracranial stenosis. However, in 179 patients with significant carotid stenosis, age >or=70 was predictive of poor reserve (OR, 2.7; P = .03) and so was the presence of peripheral vascular disease (OR, 3.7; P = .03). A trend toward decreased reserve was also seen in women (OR, 2.3; P = .08). CONCLUSIONS: Age >or=70 is associated with poor cerebral reserve in patients with significant carotid stenosis as measured by CBF response to an ACZ challenge. Thus, patients >or=70 may be more sensitive to minor cerebral emboli, which may be one factor explaining their higher risk of stroke during CAS.

Bilateral asymmetric popliteal entrapment syndrome treated with successful surgical decompression and adjunctive thrombolysis.

Popliteal artery entrapment syndrome (PAES) is the most common cause of lower leg claudication in patients younger than 50 years. The different types of PAES can result in different rates of arterial damage, leading to aneurysmal degeneration or occlusion. We report a rare case of a young patient presenting with asymmetrical bilateral popliteal artery entrapment. Type III PAES on the right resulted in severe limb ischemia and was treated by division of the accessory tendon and replacement of damaged artery with vein graft. On the left, the medial head of gastrocnemius was resected to release a type I PAES.

Contemporary results of open repair of ruptured descending thoracic and thoracoabdominal aortic aneurysms.

OBJECTIVE: The purpose of this study was to evaluate the results of open repair for ruptured descending thoracic and thoracoabdominal aortic aneurysm (RDTAA). METHODS: A retrospective review identified 41 consecutive cases of open surgical repair in 40 patients presenting with nontraumatic, atherosclerotic RDTAA from 1996 to 2006. Patients with traumatic injuries or complicated dissections were excluded. Patient characteristics and preoperative, intraoperative, and postoperative variables were collected from the medical record. Univariate and logistic regression were used to identify factors contributing to mortality and morbidity in these patients. RESULTS: The operative mortality rate was 26.8% (11/41). All but two deaths occurred within 24 hours of operation; seven were intraoperative. Overall actuarial survival rates at 1 and 2 years were 53.7% and 47.1%, respectively. For those who survived to hospital discharge, the respective numbers were 73.3% and 64.4%. Intraoperative hypotension and blood transfusion requirements were independent predictors of perioperative death. Octogenarians had a mortality rate equivalent to that of the younger population (25% vs 27.6%; not significant). There was a strong trend toward an improved outcome in the latter part (2003-2006) compared with the first part (1995-2002; 13.6% vs 42.1%, respectively; P = .075). CONCLUSIONS: Direct open repair for RDTAA can be achieved with acceptable mortality and morbidity rates even in elderly patients. Improved outcome can be expected with increased volume and experience. This series should help establish a reference against which the results of endovascular endeavors and hybrid procedures could be compared.