Cost-effective aortic exposure: a retroperitoneal experience.

In this study we investigated whether the surgical approach to infrarenal aortic aneurysm (IAA) repair significantly affects in-hospital morbidity and cost. The study comprised a consecutive series of 96 patients with elective repair of an IAA by two vascular surgeons using an established protocol from March 1995 to March 1999. The outcomes and costs for 50 patients with transperitoneal (TP) exposure were compared with those for 46 patients with retroperitoneal (RP) exposure, all of whom were in a tertiary care center, in a university hospital. Hospital and ICU days, perioperative complications, and cost were measured. All patients followed the same protocol except for intraoperative aortic exposure. There was no significant difference between TP and RP groups with regard to demographic features (all p-values > 0.12), mean IAA size (p = 0.41) or mean operative blood loss (p = 0.89). Incidence of postoperative complications was similar between the groups (11 in TP and 6 in RP; p = 0.29). However, a trend without statistical significance was noted in the incidence of pulmonary complications (7 in TP and 2 in RP; p = 0.11). Mean ICU days (4 vs. 2; p = 0.004) and hospital days (11 vs. 6; p = 0.002) were significantly longer after TP aortic exposure than after the RP approach. Mean total hospital cost was significantly reduced for patients having RP IAA repair compared to TP IAA repair (mean cost difference = $5,527; p = 0.016). Retroperitoneal exposure for IAA repair is associated with decreased pulmonary complications, significantly shorter ICU and hospital days, and significantly decreased hospital cost compared to transperitoneal aortic exposure. In the future, RP exposure for IAA repair should be the benchmark for comparison of any new techniques.

Vascular reconstruction and major resection for malignancy.

HYPOTHESIS: Complications of vascular procedures performed for tumor infiltration of major vessels or for the rescue of complex tumor resections may significantly affect perioperative patient outcome and long-term patient survival rate. DESIGN AND PATIENTS: Retrospective review of 39 patients undergoing major resection for malignancy between April 1980 and April 1998; 35 patients underwent major-vessel reconstruction, 3 patients underwent extra-anatomic bypass, and 1 patient underwent major venous thrombectomy. SETTING: University hospital tertiary referral center. MAIN OUTCOME MEASURES: Vascular complications and patient survival rate. RESULTS: Vascular complications included major stroke (3), carotid artery blowout (2), acute graft thrombosis (1), bowel infarction (1), and anastomotic disruption (1). Factors such as patient demographics, preoperative irradiation, tumor stage, resection for recurrent disease, and vessel or graft type had no bearing on the occurrence of a vascular complication (P>.05 in all cases). Eight patients (21%) died within 30 days of surgery, and 2 (5%) died after 30 days but before hospital discharge. Five of these deaths were directly related to vascular problems (P<.001). Cumulative patient survival rate was 44%, 26%, and 10% at 1, 3, and 5 years, respectively. CONCLUSIONS: The long-term patient survival rate is poor when resections for carcinoma are associated with maj or-vessel infiltration or a complication that necessitates an emergent vascular procedure. In this setting, in-hospital mortality is negatively affected by the incidence of a major vascular complication.

Carotid endarterectomy and abdominal aoritc aneurysm repair: are these reasonable treatments for patients over age 80?

Due to the aging of America, increased numbers of very elderly patients require peripheral vascular surgery. From April 1980 to November 1997, 191 patients age 80 years or older had carotid endarterectomy (CEA) and/or abdominal aortic aneurysm (AAA) repair at Loma Linda University Medical Center. The total perioperative stroke and death rate in the CEA group was 2.9 per cent. Mean postoperative cumulative survival in this group was 8.4 years. The cumulative stroke-free survival rate was 95.5 per cent for all yearly postoperative intervals up to 12 years. The perioperative mortality rate was 10.7 per cent in the nonruptured AAA group and 53.8 per cent in the ruptured AAA group (P < 0.00001). Mean cumulative survival was 8.6 years in the nonruptured AAA group and 1.1 years in the ruptured AAA group (P = 0.0001). These data support the conclusion that CEA and nonemergent AAA repair in octo- and nonagenarians are safe and effective in prolonging stroke-free and rupture-free survival. The utility of ruptured AAA repair in this age-group is less clear.

Aortoiliac stent deployment versus surgical reconstruction: analysis of outcome and cost.

PURPOSE: The purpose of this study is to compare complication rate, primary patency, and cost of stent deployment with direct surgical reconstruction for the treatment of severe aortoiliac occlusive disease. METHODS: From March 1, 1992, to May 31, 1996, 119 patients receiving treatment for aortoiliac occlusive disease were analyzed after exclusions. Sixty-five patients had stent deployment and 54 patients had surgical reconstruction. Data were evaluated within and between the groups by univariate and multivariate logistic regression, life-table, t-test, and cross tabulation with chi2 analysis. RESULTS: There was no significant difference between the groups with regard to demographic features or presenting symptoms (all p values > 0.07). Incidence of procedure-related complications was similar (p = 0.30). However, there were more systemic complications in the surgery group (15 versus 2; RR = 5.5, p < 0.01) and more vascular complications in the stent group (16 versus 3; RR = 12, p < 0.002). Incidence and type of late complications were not appreciably different (all p values > 0.05). Cumulative primary patency rate of bypass grafts was significantly better than stented iliac arteries at 18 months (93% versus 77%), 30 months (93% versus 68%) and 42 months (93% versus 68%); p = 0.002, log rank. Multivariate analysis identified female gender (RR = 4.6, p = 0.03), ipsilateral SFA occlusion (RR = 5.6, p = 0.01), procedure-related vascular complication (RR = 9.7, p = 0.002), and hypercholesterolemia (RR = 5.0, p = 0.02) as independent predictors of bypass graft or stent thrombosis. Mean total hospital cost per limb treated did not differ significantly between surgery and stent deployment groups ($9383 versus $8626, respectively; p = 0.66, t-test). CONCLUSIONS: Treatment of severe aortoiliac occlusive disease by surgical reconstruction or stent deployment has a similar complication rate. Mean hospital cost per limb treated is essentially equal. However, cumulative primary patency rate of bypass grafts is superior to stents. Therefore, considering the elements of cost and patency, surgical revascularization has greater value. The benchmark for cost-effective treatment of severe aortoiliac occlusive disease is direct surgical reconstruction.

Early benefits of subfascial endoscopic perforator surgery (SEPS) in healing venous ulcers.

Efficacy of subfascial endoscopic perforator vein surgery (SEPS) in assisting the healing of venous ulcers was determined. During the period June 1995 to May 1996, 19 limbs in 17 patients were treated by SEPS. Thirteen limbs had open ulcers (class 6), five limbs had healed ulcers (class 5), and one limb had severe lipodermatosclerosis (class 4). There were nine male and eight female patients (average age 58, range 33-86). One male had bilateral open ulcers and one female had one open and one healed ulcer. Open ulcers had been present for an average duration of 4.4 years (range 1-14 years). The average ulcer size was 2.8 x 2.2 cm (range 1 x 1 cm to 12 x 6 cm). All operations were conducted on an outpatient basis. At surgery an attempt was made to correct all superficial venous pathophysiology. In addition to SEPS, 12 limbs (63%) had greater saphenous vein (GSV) stripping and 15 patients (79%) had stab avulsion of painful varicose veins. The average number of perforators ligated during SEPS was 3.68 (range 2-8). All active ulcers healed within 90 days. The mean time to healing was 30.5 days (range 6-90 days). Minor postoperative complications (one groin hematoma, three wound infections) occurred in four limbs (21%). There have been no ulcer recurrences during follow-up (mean 8.6 months, range 3-16 months). Outpatient SEPS is an important adjunct in the treatment of chronic venous insufficiency. Experience in this group of 19 limbs strongly suggests that SEPS appears to accelerate the healing of venous ulcers compared to historical controls.

Cost-effective evaluation and treatment for carotid disease.

OBJECTIVE: To compare carotid endarterectomy (CEA) based solely on Duplex ultrasonography (DU) with CEA based on DU and arteriography. DESIGN AND SETTING: Retrospective case series analysis in a regional tertiary care center. PATIENTS: Consecutive sample of 194 patients undergoing 218 CEAs from January 1, 1993, through June 30, 1995, with either preoperative DU plus arteriography (165 CEAs) or DU only (53 CEAs). MAIN OUTCOME MEASURES: Concordance of the 2 diagnostic imaging techniques and influence of these on the conduct of surgery, surgical outcome, and resource cost. RESULTS: There was agreement (kappa = 0.85) between DU and arteriography in the detection of a carotid occlusion or a stenosis greater than 45%. Arteriography demonstrated 26 aortic arch branch lesions (15.8%), 22 intracranial abnormalities (13.3%), and 6 type C ulcers (3.6%), in addition to 1 nonoccluded internal carotid artery (ICA) (0.61%) and 1 contralateral severe ICA stenosis (0.61%) inaccurately estimated by Duplex. These findings prompted 3 changes (1.8%) in surgical therapy, including 2 decisions in favor of CEA and 1 subclavian-carotid bypass added to CEA. There was no difference in the stroke and death rate for CEA based solely on DU compared with CEA based on DU and arteriography (P = .43). The mean total hospital cost was $5,534 for DU only CEA vs $7,608 for DU plus arteriogram CEA (mean difference = $2,074, P < .01). CONCLUSIONS: The addition of carotid arteriography to a diagnostic Duplex ultrasound study that already suggested the need for CEA did not change the operative plan in 98% (162/165) of the cases. Carotid endarterectomy based solely on DU is appropriate and cost-effective.

Complications of iliac artery stent deployment.

PURPOSE: This study was performed to determine the primary patency, foot salvage, and complication rates associated with iliac artery stent deployment. METHODS: From March 1992 to May 1995, 147 iliac artery stents were deployed in 98 limbs of 72 patients for disabling claudication or limb-threatening ischemia. Procedure-related and late (> 30 days) complications, as well as adjunctive maneuvers required to correct a complication, were tabulated. Stented iliac artery cumulative primary patency and foot salvage rates were calculated with life-table analysis. Factors that impacted early complications, late complications, foot salvage rates, and stented iliac artery primary patency rates were identified with stepwise logistic regression analysis. RESULTS: A procedure-related complication occurred in 19 (19.4%) limbs. Initial technical success, however, was achieved in all but three of 98 limbs (96.9%). Stented iliac artery cumulative primary patency rates were 87.6%, 61.9%, 55.3%, and foot salvage rates were 97.7%, 85.1%, 76.1%, at 12, 18, and 24 months, respectively. External iliac artery stent deployment, superficial femoral artery occlusion before treatment, and single-vessel tibial runoff before treatment negatively affected stented iliac artery cumulative primary patency rates. Stented iliac artery primary patency rates were not significantly affected by age, smoking, coronary artery disease, diabetes, hypercholesterolemia, hypertension, presenting symptom, early complication, number of stents deployed, type of stent deployed, or stent deployment for stenosis versus occlusion. CONCLUSIONS: Limb-threatening and life-threatening complications can be associated with iliac artery stent deployment. Stented iliac artery primary patency rates are affected by distal atherosclerotic occlusive disease and the position of the deployed stent within the iliac system. Stent reconstruction of severe iliac artery occlusive disease is feasible but should be thoughtfully selected.

Combined renal artery stenosis and aortic aneurysm: treatment options.

The purpose of this study was to analyze outcomes of two different treatment strategies in patients treated for renal artery (RA) stenosis and a coincidental abdominal aortic aneurysm (AAA). A total of 50 patients were encountered who required treatment for concomitant RA stenosis and an AAA from 1980 to 1994. Simultaneous operative aortic and RA reconstruction was done in 32 patients, whereas 18 patients where treated with preoperative percutaneous transluminal renal artery angioplasty (PTRA). The two groups were well matched with respect to age, AAA size, incidence of hypertension, preoperative creatinine level, and creatinine clearance (all p values > 0.07). Aortorenal bypass (18 RAs), reimplantation (18 RAs), or endarterectomy (2 RAs) was performed to correct a mean RA stenosis of 88%, whereas 23 RAs (91% mean stenosis) were treated with preoperative PTRA. PTRA failed in four patients with RA stenosis, and they were successfully treated with surgery (3 bypasses and 1 reimplantation). Statistical analysis did not demonstrate a significant difference between these four failed PTRA patients, the 14 successful PTRA patients, and the 32 RA reconstruction patients in terms of operating time (p = 0.15), operative blood loss (p = 0.20), intensive care unit days (p = 0.71), or total hospital days (p = 0.94). Among the 40 patients available for follow-up, hypertension was cured in seven, improved in 10, unchanged in 15, and worse in eight with no difference demonstrated between the groups (p = 0.73). These data suggest that preoperative PTRA has no specific advantage over surgical RA reconstruction in patients with concomitant RA stenosis and AAA. Failed PTRA did not preclude or complicate subsequent operative RA revascularization.

A prospective evaluation of transcutaneous oxygen measurements in the management of diabetic foot problems.

PURPOSE: To test the hypothesis that lower extremity transcutaneous oxygen (TcPO2) measurements can accurately predict severity of foot ischemia and can be used to select appropriate treatment (conservative versus operative) for patients with diabetes and tissue necrosis or ischemic rest pain. METHODS: Fifty-five patients with 66 limbs were prospectively treated from June 1993 to July 1994. Noninvasive hemodynamic arterial assessment and TcPO2 mapping of the involved limb were obtained before treatment was selected. If the transmetatarsal TcPO2 level was 30 mm Hg or greater, the patient's foot problem was managed conservatively with local wound care, debridement, or a minor foot amputation. If the transmetatarsal TcPO2 level was less than 30 mm Hg, arteriography was performed with the anticipated need for vascular reconstruction. The endpoints for determining treatment success or failure were complete wound healing or relief of ischemic rest pain. RESULTS: Thirty-one of 36 (86%) limbs with an initial transmetatarsal TcPO2 level of 30 mm Hg or greater were treated successfully with conservative care, including 73% (11 of 15 feet) of limbs without a palpable pedal pulse. After either bypass or angioplasty, 20 of 24 (83%) limbs achieved a transmetatarsal TcPO2 level greater than 30 mm Hg and had complete resolution of their presenting foot problem. An initial or postintervention transmetatarsal TcPO2 level of 30 mm Hg or greater was more accurate (90%, p = 0.001) than a palpable pedal pulse (65%, p = 0.009), in predicting ultimate wound healing or resolution of rest pain. CONCLUSIONS: TcPO2 mapping is a useful noninvasive modality that can prospectively determine severity of foot ischemia, aid in selecting appropriate treatment for patients with diabetes and foot salvage problems, and decrease the total cost of such care.

Stenting without thrombolysis for aortoiliac occlusive disease: experience in 14 high-risk patients.

Stenting without thrombolysis of 16 occluded iliac artery segments and one occluded infrarenal abdominal aorta was attempted in 14 patients. All patients were either considered to be prohibitive operative risks or had contraindications to thrombolytic therapy. Indications for limb reperfusion included rest pain, disabling claudication, or dry gangrene. Successful recanalization was achieved primarily in 13 patients with self-expandable Wallstents, balloon-expandable Palmaz stents, or a combination of the two stents. Follow-up was carried out in all patients in whom recanalization was successful. All stented patients showed symptomatic improvement, and the mean preprocedure ankle/brachial index, which was 0.31, improved to 0.78 after the procedure (p = 0). Complications included a vertebrobasilar stroke during the procedure in one patient, perforation during angioplasty of a stenotic but nonoccluded external iliac artery in one, and dissection of the distal external iliac artery in one. Distal embolization did not occur. Percutaneous recanalization of aortoiliac occlusions without initial thrombolysis is possible and has a high potential for technical success. Additional data and longer follow-up are still needed, but this procedure may provide a reasonable, less invasive option in some patients at high surgical risk or in patients who have contraindications to thrombolytic therapy.

Autologous saphenous vein popliteal-tibial artery bypass for limb-threatening ischemia: a reassessment.

BACKGROUND: The purpose of this review was to ascertain the cumulative primary and secondary graft patency rates, the cumulative limb salvage rate, and the frequency of atherosclerotic disease progression proximal to the graft origin, in patients with autologous saphenous vein popliteal-tibial artery bypass grafts whose operative indication was limb-threatening ischemia. PATIENTS AND METHODS: Forty-three short autologous saphenous vein grafts originating from the popliteal artery were retrospectively reviewed. The life-table method was used to determine primary and secondary graft patency and limb salvage rates. Atherosclerotic disease progression proximal to the graft origin was assessed via follow-up arteriography, segmental limb pressures, or pulse-volume recordings. All other data were compared by chi-square analysis. RESULTS: The cumulative primary graft patency rate at 1, 3, and 5 years (86%, 66%, 58%) was similar to the cumulative secondary patency rate (90%, 70%, 62%) and the cumulative limb salvage rate (80%, 55%, 55%). No patient developed hemo-dynamically significant atherosclerotic disease proximal to the graft origin during the follow-up period. CONCLUSIONS: The similarity of the life-table data suggests graft-dependent, poorly collateralized limbs; it is therefore not uncommon for these patients to require major amputations shortly after bypass failure. There was no evidence of critical proximal disease progression that might warrant a more proximal graft origin. Poplitealtibial artery bypass grafts are durable, with acceptable graft patency and limb salvage rates.

Open operative balloon angioplasty of the internal carotid artery: a technique in evolution.

Open operative balloon angioplasty is a treatment alternative for certain nonatherosclerotic lesions of the internal carotid artery (ICA) including fibromuscular dysplasia (FMD). Standard operative exposure of the carotid bifurcation is performed with atraumatic passage of a guidewire and balloon through a carotid bulb arteriotomy. Under direct fluoroscopic guidance, precise dilatation of the involved area is possible with minimal risk of intimal tear/flap or distal embolization as compared with graduated intraluminal dilatation or percutaneous balloon angioplasty. Vascular control of the common and external carotid arteries lessens the risk of embolization resulting from the constant backflow of blood through the ICA before, during, and after balloon angioplasty, adding to the overall safety and efficacy of the procedure. We report a case of asymptomatic critical carotid artery stenosis associated with FMD successfully treated with open operative balloon angioplasty and review the current literature regarding treatment options for FMD of the ICA.

The diagnostic accuracy of duplex ultrasonography for evaluating carotid bifurcation.

BACKGROUND: In many medical centers the standard preoperative study for patients undergoing carotid endarterectomy is four-vessel carotid arteriography, but duplex scanning of the carotid bifurcation is also reported to be highly accurate for detecting stenotic or occluded carotid arteries. METHODS: The diagnostic accuracy of duplex ultrasonography was evaluated in a study of 774 carotid bifurcations, in 400 patients comparing the degree of predicted internal carotid artery (ICA) stenosis found using that technique, with that found by contrast arteriography. Agreement between the predicted degree of ICA stenosis and the arteriographic measurement was evaluated using the Spearman rank order correlation. Accuracy statistics for duplex scanning as a diagnostic modality were assessed using 2 x 2 tables. RESULTS: The Spearman rank order correlation coefficient was 0.74 (P = 0) for the symptomatic group, 0.65 (P = 0) for the asymptomatic group, and 0.68 (P = 0) for the total group. The accuracy of duplex ultrasonography for detecting all grades of ICA stenosis ranged from 80% to 97%. CONCLUSIONS: Duplex ultrasonography of the carotid bifurcation is a reliable diagnostic tool and can be used as the sole preoperative study for selected patients with extracranial cerebrovascular disease. Our current algorithm is discussed in conjunction with a critical analysis of this large database.

Popliteal-tibial bypass grafts in the management of limb-threatening ischemia.

OBJECTIVES: To ascertain the cumulative rates of primary graft patency and limb salvage and the frequency of proximal arterial disease progression in patients with autologous saphenous vein bypass grafts that originate from the popliteal artery and whose operative indication was limb-threatening ischemia. DESIGN: Five-year retrospective study with follow-up that ranged from less than 1 month to 60 months. SETTING: Tertiary care center. PATIENTS: Twenty-four threatened limbs in 23 patients were reviewed. Surgical indications included gangrene in 15 limbs (63%), rest pain in seven limbs (29%), and a nonhealing ulcer in two limbs (8%). Patients with previous ipsilateral infrainguinal arterial reconstructive procedures were excluded. Mean patient age was 66 years, and 18 patients 78% had insulin-dependent diabetes mellitus. MAIN OUTCOME MEASURES: Percentages of primary graft patency and limb salvage were determined by the life-table method. Proximal arterial disease progression was assessed via follow-up arteriography or segmental limb pressures. RESULTS: The cumulative rates of primary graft patency and limb salvage at 1, 3, and 5 years were 73%, 59% and 59%, and 87%, 57%, and 57%, respectively. No patient developed proximal arterial disease progression that required intervention during the study period. CONCLUSIONS: The cumulative rates of primary graft patency and limb salvage were essentially the same, which indicated poorly collateralized limbs that are solely dependent on the graft. There did not appear to be a critical progression of proximal arterial disease that would warrant a more proximal graft origin. A short autologous saphenous vein graft that originates from the above-knee or below-knee popliteal artery is a durable bypass.

Percutaneous transluminal angioplasty of tibial arteries for limb salvage.

Percutaneous transluminal balloon angioplasty (PTA) was performed in 17 tibial arteries with an average cross-sectional area stenosis of 92% (range 75-99%) in 13 patients (14 limbs) for limb salvage. In 4 of 14 lower extremities, PTA of femoropopliteal arteries was also performed. Technical success with 50% or less residual stenosis was achieved in all 17 tibial vessels. At approximately 2 months after PTA, clinical improvement had occurred in 10 of 14 limbs; no patient was made worse. Most recent follow-up (mean 19 months, range 8-34 months) revealed continued satisfactory clinical success with no further vascular intervention in 9 of these 10 limbs (one patient died). Short segmental stenoses, residual stenoses less than 40% following PTA, and absence of diabetes or gangrene appear to be predictors of favorable clinical outcomes. Our results suggest that PTA of focal tibial stenosis is an effective and safe treatment modality in properly selected patients and that wider use of PTA may be justified.

Primary repair of traumatic aortic rupture: a preferred approach.

Eighty patients with traumatic rupture of the thoracic aorta were treated. Seven patients died during the initial resuscitation. Forty-three patients underwent surgical repair using the clamp-and-sew technique; 14 patients had a heparin-bonded shunt placed, and 16 patients were repaired using cardiopulmonary bypass. An interposition Dacron graft was used in only 19 patients (26%). The last 32 consecutive patients underwent primary repair of the ruptured aorta. Overall mortality was 19.2% (14 of 80); 9 of 14 patients (64%) had laparotomies along with the aortic repair, and 13 of 14 patients (92%) had three or more associated major injuries. Paraplegia occurred in four cases (5.6%). Traumatic aortic rupture remains a difficult surgical problem. Primary repair, without graft interposition, is the preferred technique and can be accomplished even when the two aortic ends have retracted several centimeters.

Transcatheter embolization facilitating surgical management of a giant inferior gluteal artery pseudoaneurysm.

This article is a report on a case of a giant pseudoaneurysm of the inferior gluteal artery where important features of the diagnosis, with special mention of magnetic resonance imaging and arteriography, are discussed. Surgical therapy is the treatment of choice for these lesions. Historically, proximal arterial control has been the main dilemma in the management of gluteal artery pseudoaneurysm. We found transcatheter embolization to provide optimal control and eliminate the need for preperitoneal or intraabdominal dissection. Surgical repair can then be carried out without risk of intraoperative hemorrhage.

Operative balloon angioplasty in the treatment of internal carotid artery fibromuscular dysplasia.

Seven patients with symptomatic fibromuscular dysplasia have had eight internal carotid arteries treated by operative balloon dilatation. This technique is described in detail and provides three distinct advantages over conventional graduated intraluminal dilatation--atraumatic passage of the catheter through the affected vessel with fluoroscopic guidance; precise dilatation of the involved segment of the internal carotid artery; and the application of a radial force against the arterial wall rather than a longitudinal shear force, thereby making intimal damage less likely. There were no treatment complications in this group of patients. This technique of balloon angioplasty is compared with the results of treatment in eight patients with fibromuscular dysplasia of the internal carotid artery, who had percutaneous transfemoral angioplasty. Long-term follow-up revealed the resolution of symptoms in all patients.