Percutaneous revascularization of complex iliac artery stenoses and occlusions with use of Wallstents: three-year experience.

PURPOSE: To assess the outcome of percutaneous placement of Wallstents for treatment of hemodynamically significant diffuse stenoses (> 3 cm in length), chronic occlusions, failed angioplasty procedures, and flow-limiting dissection in the iliac arteries. MATERIALS AND METHODS: Lesions in 94 iliac limbs were treated in 66 patients. Indications for stent placement included claudication in 49 limbs and limb-threatening ischemia in 45. Forty-two limbs were treated for diffuse disease, 39 for chronic occlusion, nine for failed angioplasty, and four for flow-limiting dissection. RESULTS: Technical success was achieved in 86 of 94 limbs (91%), with major complications in 9% of patients. One death occurred within 30 days (not procedure-related). Ankle-brachial indexes improved from 0.51 +/- 0.24 to 0.76 +/- 0.22 (P < .001). Eighty-five percent demonstrated improvement under Rutherford criteria. Follow-up was obtained up to 38 months (mean, 14 months +/- 8). Cumulative primary patency rates were 78% at 1 year and 53% at 2 and 3 years (standard error 10%). Secondary patency rates were 86% at 1 year and 82% up to 32 months (standard error > 10% after 32 months). No significant decrease in mean ankle-brachial index was observed during follow up. No difference in primary patency was observed based on lesion type, symptom severity, lesion location, or runoff status. The limb salvage rate for patients with limb-threatening ischemia was 98% at a mean follow-up of 14 months +/- 7. CONCLUSIONS: Technical success and complication rates for percutaneous iliac artery revascularization with use of Wallstents are favorable, symptoms improved in the majority of patients, and excellent secondary patency can be achieved. With use of Wallstents, most patients with iliac artery insufficiency as a result of long-segment disease or chronic occlusions can be treated percutaneously.

Comparison of basilic vein and polytetrafluoroethylene for brachial arteriovenous fistula.

PURPOSE: The aim of this study was to compare patency and complication rates between basilic vein and polytetrafluoroethylene (PTFE) for brachial arteriovenous fistulas (AVF) for long-term hemodialysis. METHODS: All basilic vein and PTFE brachial AVF constructed between March 1988 and April 1993 were retrospectively reviewed. After construction of life-tables, log-rank testing was used to compare the primary patency rate of basilic vein AVF (n = 59) with the primary and secondary patency rates of PTFE AVF (n = 47). Complication rates were calculated for each type of fistula and compared by use of chi-squared testing. RESULTS: The primary patency rate for basilic vein AVF (90%) was superior to that of PTFE AVF (70%) at 1 year (p < 0.01), and at 2 years (86% vs 49%, p < 0.001). Complications occurred two and a half times more frequently in the PTFE group than in the basilic vein group (p < 0.05). CONCLUSIONS: Basilic vein AVF provided superior patency rates and lower complication rates compared with PTFE AVF. Prospective randomized trials comparing the two fistula types is required to firmly establish the basilic vein AVF as the alternative access procedure of choice after a failed or unconstructable radiocephalic fistula.

Venous stasis complications of the use of the superficial femoral and popliteal veins for lower extremity bypass.

PURPOSE: The widely accepted durability of autogenous vein for infrainguinal arterial bypass has led the authors to use the superficial femoral and popliteal vein in selected cases. The results of this experience are presented. METHODS: From January through December 1991, during which 92 lower extremity bypass procedures were performed, deep vein bypass was attempted in seven patients (three femoral-popliteal grafts, two femoral-peroneal grafts, one femoral-deep femoral bypass, and one popliteal-posterior tibial bypass). In all cases the saphenous vein was absent or inadequate for use as a bypass conduit. The superficial femoral vein was harvested to below the knee in five patients. RESULTS: At last follow-up six of seven patients had patent grafts with relief of their original symptoms. All the procedures were complicated by venous stasis; acute postoperative phlegmasia developed in two cases. In one of these cases the limb was salvaged by below-knee fasciotomy and deep venous bypass (distal popliteal vein to common femoral vein with polytetrafluoroethylene). In the other case an above-knee amputation was required. Of the five remaining patients three had moderate venous stasis edema unresponsive to limb elevation and compression stockings after operation, and two have had resolution of minimal postoperative venous stasis with simple limb elevation. All cases of severe and moderate venous stasis occurred in patients with popliteal vein harvest to below the knee. CONCLUSIONS: The authors conclude that the use of the deep veins of the lower extremity for bypass is effective but is associated with a significant increase incidence of venous stasis edema. Two instances of phlegmasia were associated with popliteal vein harvest below the knee, and the authors caution against harvest of the popliteal vein to this level.

Iatrogenic arterial dissection: treatment by percutaneous transluminal angioplasty.

Iatrogenic arterial dissection may require intervention, depending on the severity of resulting stenosis and the degree of symptoms. We present 5 cases of iatrogenic arterial dissection: 1 with dissection of the lower abdominal aorta, common iliac artery, and external iliac artery, and 3 with external iliac artery dissections, all managed with percutaneous transfemoral transluminal angioplasty; and 1 with dissection of the superior mesenteric artery with angioplasty performed by the translumbar approach. Four of the 5 patients had no additional therapy; 1 patient eventually underwent surgery for an asymptomatic residual pseudoaneurysm seen on abdominal computed tomography. Angiographic follow-up in 2 patients demonstrated persistent improvement in stenosis, 1 at 2 weeks after angioplasty, and the other, 6 weeks following angioplasty. None of the 5 patients required further therapy for recurrence of symptoms on clinical follow-up obtained up to 1 year after angioplasty. Though the incidence of recurrent arterial stenosis following angioplasty for dissection may be greater than that incurred after intravascular stent placement or surgery, angioplasty may be effective, and has the advantage of being less expensive than both of these treatment modalities, and more widely available and applicable than intravascular stents.

Selection of the approach to the distal internal carotid artery from the second cervical vertebra to the base of the skull.

Although several approaches for exposure of distal internal carotid artery lesions have been reported, the precise anatomic levels for which each of these maneuvers are most appropriate have not been well described. Since these techniques may require preoperative preparation, it is useful to determine in advance how much exposure will be needed and to select the most suitable and effective technique. We used anatomic dissection in 12 human cadaver specimens (24 carotid bifurcations) to define the limits of distal internal carotid artery exposure by several commonly advocated methods. The standard anterior approach along the sternocleidomastoid muscle allowed exposure of the internal carotid artery to the level of the upper one third of the second cervical vertebra. The upper limit of this exposure was extended to the middle of the first cervical vertebra by division of the posterior belly of the digastric muscle. Anterior subluxation of the mandible increased the distal exposure of the internal carotid artery to the superior border of the first cervical vertebra. Styloidectomy in combination with the preceding maneuvers extended the exposure an additional 0.5 cm cephalad. Lateral mandibulotomy did not significantly extend exposure beyond that obtained with mandibular subluxation and styloidectomy. Exposure of the internal carotid artery in the 1 cm immediately below the base of the skull required a posterior approach with mastoidectomy.

Anatomic and clinical factors associated with complications of transfemoral arteriography.

Complications of transfemoral arteriography requiring surgery are rare but carry significant morbidity. To evaluate clinical factors that might relate to such complications, we retrospectively reviewed our experience from January 1, 1985, to December 31, 1988 (four years). Forty-seven complications requiring surgery occurred among 10,589 cases. The risk was higher after cardiac catheterization than after peripheral arteriography (0.55% versus 0.17%, p less than 0.025). In nearly 40% of these cases, arterial puncture was not in the common femoral artery. Acute bleeding complications were more likely among patients with puncture outside the common femoral artery (p less than 0.001). Older patients and women were at slightly higher risk for complications requiring surgery, but this difference was not statistically significant. The frequency of bleeding complications was not significantly higher among patients who were anticoagulated following the procedure. The distribution of puncture sites was identical in obese and nonobese patients. Three patients died (two from myocardial infarction, one from multisystem organ failure). Two limbs did not improve; one required major amputation. Four limbs had persistent paresthesia and two had persistent weakness. We conclude that complications of transfemoral arteriography requiring surgery occur more frequently among patients who are undergoing cardiac catheterization and who suffer aberrant punctures. Age, sex, body habitus, and anticoagulation have less impact on patient risk.

Vertebral artery pseudoaneurysm. A rare complication of subclavian artery catheterization.

The present case report details a previously unreported complication of subclavian vein catheterization, vertebral artery pseudoaneurysm. Attention to this problem was brought about in the patient by the development of stridor and dysphagia noted 5 days following placement of the subclavian catheter. A computed tomographic scan of the neck revealed a superior mediastinal, contrast-enhancing mass in the region of the right subclavian artery with a "bull's-eye" sign suggestive of a pseudoaneurysm. Arteriography subsequently proved the pseudoaneurysm to be of vertebral origin. The pseudoaneurysm was ligated via a neck incision together with a median sternotomy to obtain vascular control. The evaluation and treatment options of this problem are discussed.

Intraoperative evaluation of PTFE, Dacron and autogenous vein as carotid patch materials.

Between 1983 and 1986 we prospectively randomized 71 consecutive carotid endarterectomy patients to receive patch closure with one of three materials. Autogenous saphenous vein was used in 18 cases, Dacron velour (Sauvage Filamentous) in 30 cases, and PTFE (Gore-Tex CV patch) was used in 23 cases. Blood loss in the excess of 300 ml was seen in 43% (10/23) of the PTFE group in contrast to only 22% (5/23) of the ASV group and 17% (4/23) of the Dacron group. Persistent suture hole bleeding requiring the use of a significantly larger amount of oxidized cellulose (p less than .001) was noted in the PTFE group. Operating time from clamp release to end of procedure was significantly greater in the PTFE group (p less than .05), reflecting the delay associated with suture hole bleeding. In addition, the handling characteristics of PTFE were inferior to those of Dacron or autogenous saphenous vein. Needle penetration was relatively difficult. PTFE was thicker, less flexible, and a less satisfactory match to the endarterectomized carotid than the other materials.

Deep-penile-vein arterialization for arterial and venous impotence.

Eleven impotent men underwent deep-penile-vein arterialization after preoperative assessment by a multidisciplinary team. Penile Doppler pressures, testosterone levels, and nocturnal penile tumescence were used to establish a vasculogenic etiology. Cavernosography, artificial erection by saline infusion, and selective hypogastric arteriography were obtained to delineate whether arterial, venous, or mixed (arterial/venous) factors predominated. Penile revascularization consisted of femoral artery to deep-penile-vein saphenous bypass, with ligation of superficial veins at the base of the penis in patients with venous leakage. Cumulative graft patency was 91% up to 20 months. There were no deaths. The average preoperative flow requirement of values greater than 250 mL/min was reduced to 59 mL/min postoperatively. Follow-up results of nocturnal penile tumescence were excellent in four of four patients with venous (venous leakage), two of three patients with arterial, and one of four patients with mixed factors. Deep-penile-vein arterialization appears to be beneficial for impotence secondary to venous leakage, with inconsistent results for arterial and mixed factors.

Transfemoral placement of intraluminal polyurethane prosthesis for abdominal aortic aneurysm.

Because of the significant mortality associated with the conventional surgical approach to abdominal aortic aneurysms (AAA) in the high risk patients and in those with ruptured aneurysms, we have developed a new approach to this problem, intraluminal aneurysm exclusion. This was achieved by an intraluminal prosthesis which approximated the diameter of the aorta above and below the aneurysm and is inserted through the femoral artery. The prosthesis consisted of biomedical grade elastomeric polyurethane with a NITINOL and/or stainless steel frame and was designed in such a configuration that it could be compressed inside a 15 F catheter and then regain its original shape after being discharged inside the aorta. The polyurethane prosthesis tolerated static pressures in excess of 300 Torr. Aneurysmal aortas were created in three adult sheep using large knitted Dacron pathches (6 X 9 cm) sewn onto a longitudinal aortotomy. After 4-6 weeks, an intraluminal prosthesis was passed transfemorally to the location of the aortic aneurysm. Following satisfactory placement and expansion of the prosthesis, a laceration was produced in the aneurysmal wall. No bleeding developed, which confirmed the integrity of the prosthesis in excluding the aneurysm from the aorta proper. Pulsation in the iliac arteries indicated the presence of aortic blood flow through the prosthesis. Autopsy examination demonstrated directly that the prosthesis was open and that its two ends were fixed in the aorta above and below the aneurysm. The study has demonstrated that intraluminal AAA exclusion could be achieved with an intraluminal polyurethane prosthesis inserted through the femoral artery.

In situ femoropopliteal and infrapopliteal bypass. Two-year experience.

We describe 83 in situ femoropopliteal and infrapopliteal artery bypass grafts. The in situ technique involved the valve incision method using scissors, the valvulotome (Leather), and a modified valve cutter (Hall). Arteriovenous fistulae were detected intraoperatively by angiography and/or the Doppler method and ligated. The operative indications were rest pain, ulcer, and gangrene in 88% of cases, and claudication in 7.2%. The mean preoperative ankle pressure was 61.3 mm Hg and the ankle-brachial index was 0.43. The mean postoperative ankle pressure was 125.3 mm Hg and the ankle-brachial index was 0.97. The vein utilization rate was 96%. One-year patency for popliteal anastomoses was 85.7%, for peroneal anastomoses it was 100%, and for infrapopliteal anastomoses it was 89.6%. The data suggest that the practicing vascular surgeon can adopt the in situ technique and can expect high graft patency rates even in limb salvage situations with poor distal outflow.

Tumor embolism as the first manifestation of cancer.

Major tumor emboli (obstructing segmental or larger branches of the pulmonary artery) are a rare mechanism of spread of cancer to the lungs. Less frequently are tumor emboli the cause of respiratory failure and death. The present case of major tumor embolism as the initial manifestation of cancer is unusual for the chronicity, documentation of recurrence, and tissue pathology encountered. In retrospect, we can describe clues which may arouse suspicion of tumor embolism in future cases.

One hundred consecutive carotid reconstructions: local versus general anesthesia.

One hundred consecutive patients who underwent carotid reconstructions were divided into two groups by anesthesia type (general 46, local 54) and retrospectively reviewed. Particular interest was paid to length of hospital stay and billing data. There were no differences in presenting symptoms, risk factors, incidence of stroke, cranial nerve injury, or wound hematoma. Significant reductions in length of operating time, intensive care unit time, and postoperative stay and intraluminal shunt usage were demonstrated. Calculated billings and actual billings were reviewed and found to be markedly diminished in the local anesthesia group.

Carotid bruit as a risk factor in aortoiliac reconstruction.

Records of 248 patients undergoing aortoiliac reconstruction for occlusive disease between 1957 and 1975 were reviewed. Carotid bruits were ausculted in 35 patients (14%). Five of the patients with bruits also were thought to have symptoms of transient ischemia. Strokes occurred after operation in four of the 248 patients (1.6%). No patient with a previously noted bruit developed postoperative stroke. Two patients with transient cerebral ischemia and no confirmed bruit before operation did develop postoperative strokes. Cerebral angiography was performed in 18 of the patients with carotid bruits. Two of these patients underwent carotid endarterectomy prior to aortoiliac reconstruction. None of these 18 patients developed strokes following their carotid surgery of aortoiliac reconstruction. A third patient with no bruit but with retinal cholesterol emboli also underwent arteriography and endarterectomy without complication. The results suggest that the asymptomatic carotid bruit alone does not indicate an increased risk of stroke during aortoiliac reconstruction. The authors conclude that their experience does not support prophylactic carotid endarterectomy in the asymptomatic patient prior to aortoiliac reconstruction.

Control of acute aortic dissection.

An experimental model of acute aortic dissection has been designed in an effort to examine myocardial contractility and systolic arterial pressure as factors influencing the progression of dissection. Thirty mongrel dogs divided into three experimental groups underwent left thoracotomy and construction of a standard intimal tear in the proximal descending aorta. Nine of ten animals in the control group showed progression of the aortic dissection a mean of 81.5 percent of the distance from the aortotomy to the celiac axis. Group II consisted of ten dogs pretreated with propranolol. The myocardial contractility (dp/dt) was significantly depressed in this group without change in systolic pressure. However, progression of dissection occurred in nine of ten animals as in the control group. In Group III, ten dogs were pretreated with trimethaphan lowering the systolic blood pressure to 90 mm. Hg and depressing the dp/dt to levels equal to those of Group II. There was no progression of aortic dissection in any of the animals in this group. The results indicate that, under these experimental conditions, depression of myocardial contractility alone has no inhibitory effect on the progression of dissection. When controlled hypotension is added to myocardial depression, aortic dissection is inhibited completely.