Sequential helical CT angiography of aortoiliac disease.

OBJECTIVE: The purpose of this work was to study aortoiliac disease with sequential helical CT angiography. SUBJECTS AND METHODS: Sequential helical CT angiography combines two successive helical sets for data acquisition obtained during two successive bolus injections of IV contrast material and two breath-holds. Twenty-eight patients with aneurysm and 11 with occlusive disease had CT angiography. Of those 39 patients, 18 also had conventional catheter angiography. For each of the 39 patients, a CT angiogram of three segments of the aorta and 13 arteries was assessed, including the suprarenal, juxtarenal, and infrarenal aorta; celiac axis; superior and inferior mesenteric arteries; and pairs of renal, common iliac, hypogastric, external iliac, and common femoral arteries. In 18 patients undergoing both CT and conventional angiography, the appearance of these vessels was graded as occlusive (grade 0), severely stenotic (grade 1), moderately stenotic (grade 2), mildly stenotic (grade 3), normal (grade 4), ectatic (grade 5), and aneurysmal (grade 6). RESULTS: Of the 624 arteries expected to be opacified in 39 patients, 585 (94%) were actually imaged with CT angiography. In the 18 patients who had both CT angiography and catheter angiography, the two studies were in complete agreement in 243 (90%) of 269 arteries. In 13 vessels (5%), CT angiography produced an image that was one grade higher-and in 11 vessels (4%), one grade lower-than conventional angiography. In two vessels, a two-grade difference was noted. The independent readings matched on the 0-6 scale in 95% of the evaluations. An additional 5% of the readings differed by one unit. Compared with conventional angiography, CT angiography of clinically significant (> or = 85%) narrowing (grades 0 and 1) and aneurysm (grade 6) yielded sensitivity of 93%, specificity of 96%, and accuracy of 95%. CONCLUSION: Sequential helical CT angiography of the abdomen can provide sufficient vascular detail to allow evaluation of expanded vascular territories. The technique can allow accurate assessment of both stenotic and aneurysmal disease of the aorta and the iliac arteries.

Durability of cross-femoral grafts after aortic graft infection: the fate of autogenous conduits.

PURPOSE: Revascularization for the treatment of aortic graft infection is usually accomplished by remote prosthetic axillofemoral bypass combined with cross-femoral bypass. When infection at the femoral level precludes placement of a prosthetic cross-femoral graft, we have used a variety of autogenous tissue conduits to restore circulation to the contralateral leg. To determine which of these conduits offers the most durable reconstruction, we have reviewed 78 patients treated for aortic graft infection. METHODS: Between 1980 and 1991 we used either autogenous saphenous vein (ASV, n = 34), endarterectomized superficial femoral artery (SFA, n = 14), or direct ilioiliac anastomosis (iliac, n = 10) to provide cross-femoral flow. We compared the performance of these tissue conduits with a concurrent patient group with aortic graft infection in whom a prosthetic cross-femoral graft was used (prosthetic, n = 20). RESULTS: Follow-up was available for 98.7% of patients, average 3.8 +/- 2.9 years, and was not different between the four groups. Bleeding complications occurred exclusively in the ASV group (n = 3, 8.8%) and were all in the perioperative period. In addition one ASV and one iliac conduit developed multiple false aneurysms. Hemodynamic conduit failure (thrombosis or stenosis) occurred in nine (26.5%) ASV conduits, six (42.8%) SFA conduits, and one iliac conduit, but not in the prosthetic group. When all of these adverse events were combined for each conduit group, both ASV and SFA conduits had a higher rate of conduit failure when compared with the prosthetic conduits (p < 0.05, log-rank test). Limb loss resulting from cross-femoral conduit failure occurred in six (17.6%) patients in the ASV group, four (28.6%) patients in the SFA group, and one patient each in the iliac and prosthetic groups. These differences were not significant. CONCLUSIONS: We conclude that ASV and SFA conduits do not provide stable long-term cross-femoral revascularization and should be regarded as bridge grains until femoral infection is eradicated. When femoral infection mandates their use, frequent postoperative conduit surveillance is required. If ASV or SFA caliber is marginal, consideration should be given to the use of a larger autogenous conduit, such as superficial femoral vein.

The case for renal revascularization.

This report reviews renovascular disease, hypertension and renal parenchymal dysfunction. The primary lesions responsible are discussed as well as the strategies for restoring normal renal perfusion. The natural history studies document progressive impairment of renal perfusion and the consequence of renal dysfunction. Renal revascularization interrupts this pathway by relieving or lessening hypertension and preserving renal function which are the therapeutic options.

Secondary aortoenteric fistula: contemporary outcome with use of extraanatomic bypass and infected graft excision.

PURPOSE: The standard treatment for secondary aortoenteric fistula (SAEF) has been infected graft removal (IGR) and extraanatomic bypass (EAB), an approach criticized for its high rate of death, amputation, and disruption of aortic closure. Recently, graft excision and in situ graft replacement has been proposed as a safer treatment alternative. Because the current outcome that can be achieved by use of the standard treatment of SAEF has really not been established, we reviewed the records of 33 patients treated for SAEF at our institution during a contemporary time interval (1980 to 1992). METHODS: Thirteen patients (39.4%) were admitted with evidence of gastrointestinal bleeding and infection, whereas nine (27.3%) only had bleeding, 10 (30.3%) only had signs of infection, and one SAEF was entirely occult (graft thrombosis). Four patients required emergency operation. The fistula type was anastomotic in 13 (39.4%) patients, paraprosthetic in 15 (45.5%), and not specified in 4 cases. Thirty-two patients underwent EAB followed immediately by IGR (n = 16, 48.5%) or followed by IGR after a short interval, averaging 3.9 days (n = 16, 48.5%). The final patient underwent IGR, followed by EAB. RESULTS: Follow-up on 31 patients (93.9%) averaged 4.4 +/- 3.7 years. There were nine deaths (27.3%) resulting from the SAEF, six perioperative and three late. Three patients (9.1%) had disrupted aortic closure. There were four amputations in three patients (9.1%), two perioperative and two late. Late EAB infection occurred in five patients (15.2%), leading to one death and one amputation. EAB failure occurred in six patients, two during operation and four late, leading to one amputation. The cumulative cure rate for this SAEF group was 70% at 3 years and thereafter. Compared with our earlier SAEF experience, this is a decline of 21% in the mortality rate, 19% in aortic disruption, and 27% in limb loss. CONCLUSIONS: We conclude that outcome reports based on SAEF series extending over long time intervals do not accurately represent the results that are currently achieved with standard SAEF treatment with use of EAB plus IGR. This improved outcome is attributed to wide debridement of infected tissue beds, reduced intervals of lower body ischemia, and advances in perioperative management. To determine whether any new treatment approach actually offers improved outcome in the management of SAEF, comparison with EAB plus IGR should be limited to patients treated within the last decade at most.