Operative intervention for carotid restenosis is safe and effective.

Carotid stenting has been proposed as an alternative to reoperative carotid endarterectomy (rCEA) for recurrent carotid stenosis. The purpose of this study is to prove the safety, effectiveness and durability of reoperation in long term follow up of 18 years in a community hospital setting. From March 1988 to April 2005 80 patients, 46 men and 34 women (mean age: 64.1 years) underwent a total of 83 operations. Symptomatic recurrent stenosis (>70%) was the indication in 32, asymptomatic high-grade stenosis (>80%) in 49, intimal flap in one and fibromuscular dysplasia (F.M.D), in one. The initial operation was carotid endarterectomy with primary closure in 60 and prosthetic patch in 23. The mean recurrences were at 23.3 months in 33 with myointimal hyperplasia, 105.4 months in 29 with recurrent atherosclerosis, 61.4 months in 19 with both hyperplasia and atherosclerosis, 2 months in one with intimal flap and 8 months in one with F.M.D bands. Reoperation utilized primary closure (3), vein patch (14), prosthetic patch (55), Gore-Tex interposition grafts (7), vein interposition grafts (3) and intraoperative dilation (1). No perioperative strokes or deaths occurred. One patient died from cardiac complications following combined rCEA and coronary artery bypass grafting. Operative morbidity consisted of reversible nerve injury (5), irreversible recurrent laryngeal nerve injury (1) and hematoma requiring evacuation (3). During follow up (3-153 months; mean: 50.9) carotid occlusion resulted in mild ipsilateral stroke in one patient, and one non-hemispheric stroke. There were 26 late deaths due to all causes, one due to CVA. Eight patients required reoperation (mean 53.4 months). Seven of these were hypertensive. Kaplan-Meier analysis of long-term follow up shows relatively high stroke free rates; at 153 months (12.75 years) the hemispheric stroke free rate was 98.67% and the all-stroke free rate was 95.85%. The survival estimate following redo surgery was 69.97% at 5 years and 40.23% at 10 years. We found that individuals on statin therapy (p-value=0.0042), and those on combination of statin and aspirin (p-value=0.0320), had significantly increased interval between primary and secondary operation. Increased age was correlated to a decreased time to redo surgery (p-value=<0.0001). We conclude that reoperation for recurrent carotid stenosis using standard vascular techniques is safe, effective, durable and cost effective. It should continue to be the mainstay of treatment when secondary intervention is required. Statins have a salutary effect on durability of the procedure and should be used when indicated.

Axillobifemoral bypass: elective versus emergent operation.

Axillobifemoral bypass (AxBFB) is considered an inferior operation because of comparatively poor long-term results. One factor that has not been considered in the literature is whether or not the operation is performed electively or for acute ischemia (< 24 hours duration). This may be a more important predictor of poor results than previously recognized. During the last 10 years, we have performed 59 AxBFB. In Group A, 41 patients (mean age 71) underwent elective AxBFB and in Group B, 18 patients (mean age 65) had emergency AxBFB. Indications for surgery in Group A were limb-threatening ischemia (30), infected aortic graft (5), and severe claudication (6); in Group B, indications for surgery were acute limb ischemia (16), and aortoduodenal fistula (2). Primary patency (p < 0.002), limb salvage (p < 0.002), and survival (p < 0.03) were significantly better in Group A versus Group B. We conclude that an AxBFB performed electively provides satisfactory palliation of severe vascular disease in high-risk patients. The indications for operation and timing of the operation may explain the widely disparate clinical results reported in the literature.

Long-term follow-up of bypasses to the brachial artery across the shoulder joint.

BACKGROUND: Most atherosclerotic lesions in the subclavian artery are successfully treated with carotid to subclavian bypass. The need to bypass to the brachial artery (BA) is rare. We reviewed our experience with this bypass. METHODS: Over a 10-year period, we have performed 13 bypasses to the BA originating from an artery proximal to the shoulder joint. In this retrospective study, the demographic and clinical risk factors were evaluated. Long-term results were analyzed. RESULTS: Thirteen operations were performed in 10 patients, aged 47 to 80 years. The operations were carried out for acute severe ischemia in 1 limb, effort discomfort in 9, and rest pain in 3 limbs. Donor arteries were axillary (7), carotid (4), and subclavian (2). All bypasses were to the BA proximal to the elbow joints. Life-table analysis showed 100% patency in the first 3 years and 88% at 7 years. There were 2 deaths in follow-up. Average preoperative brachial to brachial index was 0.59 and postoperative index was 1.1. In patients with bilateral occlusions, mean preoperative brachial artery pressure was 62 mm Hg, which improved to 142 mm Hg postoperatively. There were no neurological complications and no 30-day mortality. CONCLUSIONS: Bypass across the shoulder joint to the BA using expanded polytetrafluoroethylene (ePTFE) or vein is a safe operation with excellent long-term patency. The carotid artery can be used as a donor vessel without complications. Hypertension and female gender appear to be risk factors for extensive disease in proximal upper extremity arteries.

Vascular operations in nonagenarians.

This is a retrospective study describing our experience with vascular surgical procedures performed in patients 90 years of age or older. Thirty-four procedures, including major and minor vascular reconstruction and amputation, were performed in 20 patients. The 30-day mortality rate was 6% for planned surgical procedures. The 24-month survival rate was 82% for elective major revascularizations and limb salvage was 80% in these patients. We believe that vascular reconstruction can be carried out with acceptable morbidity and mortality when the operations are planned and the patients have been chosen carefully.

Improvement in suction catheter efficiency and safety in arterial operations.

The Blood Shield is a new device which has been developed to attach easily to the tip of a conventional suction catheter. Two experiments were performed to determine if the Blood Shield could limit the degree of splash which occurs during vascular graft flushing and whether it could increase the efficiency of a standard suction tip in collecting shed blood for autotransfusion. The results of the experiments indicate that the Blood Shield, when added to a conventional suction catheter, diminishes the amount of spray which may occur during anastomotic flushing. Secondly, it more effectively collects blood from a flushed anastomosis or arteriotomy in comparison with a suction catheter alone.

Aortoiliac bypass in a renal transplant patient using a new technique.

There are only 18 patients described in the English literature who had a preexisting renal transplant and underwent aortic surgery for aortoiliac occlusive disease. We describe an additional patient who was treated with a new technique using a Sundt shunt and a GraftAssist. This technique provides antegrade flow and minimal ischemic time and avoids exploration of arteries not involved in the anastomosis.

Routine completion study during carotid endarterectomy is not necessary.

The results of many studies have suggested the need for a completion study during carotid endarterectomy (CE). This paper describes our experience not routinely using completion studies. We retrospectively reviewed the charts of 417 patients who underwent 455 CEs. Demographic features, risk factors, ipsilateral neurologic events during the first 30 days, and mortality data were identified. There were 14 neurologic events and 4 deaths. No technical defects were found in 13 patients; 1 patient did not have exploratory surgery after an occlusion. Long-term follow-up shows 10 of the 14 arteries are open. Two patients were lost to follow-up, 1 patient died, and 1 artery was not explored. We conclude that CE may be carried out without routinely using a completion study, with an acceptable postoperative neurologic complication rate. Careful technique is mandatory.

A new technique to correct vascular steal secondary to hemodialysis grafts.

Three patients are described who developed symptomatic steal distal to hemodialysis grafts, documented by angiodynography. Intraoperatively, the graft was plicated to increasing depths while using angiodynography over the radial and ulnar artery. When the flow became antegrade, the plication was stopped, resulting in salvageable grafts. Using the technique, all three patients had long use of the graft after the steal was corrected.

Selective non-operative management of pseudoaneurysms and arteriovenous fistulae complicating femoral artery catheterization.

Femoral arterial pseudoaneurysms or arteriovenous fistulae may sometimes complicate percutaneous femoral artery catheterization procedures. Most surgeons recommend prompt operative repair because of the unfavorable natural history of pseudoaneurysms or arteriovenous fistulae secondary to violent or accidental arterial trauma. However, the natural history of catheterization-induced pseudoaneurysms and arteriovenous fistulae has not been well documented. Accordingly, we prospectively studied the natural history of 22 pseudoaneurysms, 8 arteriovenous fistulae, and 3 combined lesions, identified by duplex scan in 32 patients following trans-femoral cardiac, peripheral vascular, or vascular access arterial catheterization procedures. Angiographic procedures were performed with the use of 5-8F introducer sheaths. A femoral artery complication was significantly more likely to result from coronary balloon angioplasty (9/304; 3.0%) than from diagnostic cardiac catheterization (21/2476; 0.8%) (p less than 0.003; chi square). Fourteen patients (13 pseudoaneurysms, 1 combined pseudoaneurysm/fistulae) underwent surgical repair. Pain and/or enlarging hematoma resulted in repair within two days of the diagnosis in 8 patients. The need for chronic anticoagulation prompted elective repair in 2 patients. A pseudoaneurysm was repaired in one patient five days following catheterization when it became painful. In three stable patients, asymptomatic pseudoaneurysms were repaired electively during another surgical procedure. There were no operative deaths. One patients (7%) developed a wound infection postoperatively. Eighteen patients (19 arterial lesions: 9 pseudoaneurysms, 8 arteriovenous fistulae, 2 combined pseudoaneurysms/arteriovenous fistulae) with improving symptoms and stable physical signs were followed by serial clinical evaluation and duplex scans. Seventeen of 19 (89%) of these lesions resolved spontaneously within 5-90 days (mean 30.7 days).(ABSTRACT TRUNCATED AT 250 WORDS)

The impact of angiodynography on infrainguinal bypass graft surveillance.

We have followed 64 lower extremity in situ grafts and 56 selected vein or prosthetic grafts with serial angiodynography since 1988 (Quantum Color-flow Duplex) and ankle/brachial indices (ABI). Each graft can be scanned in 20 minutes. Scan results affected clinical decision making in 26 cases. There were ten graft stenoses, 10 distal stenoses, 5 large arteriovenous fistulas (AFV), and one limb with a stenosis and AFV. Four other limbs had incompressible vessels and normal angiodynograms. There were no false positives. Twenty-eight graft revisions were performed in 24 patients. Seven stenoses detected by angiodynogram were not accompanied by changes in ABI. Cumulative patency of revised grafts were 61% at 3 years. The detection of graft or distal arterial stenoses by color flow changes is accurate and rapid. Scanning is recommended for all lower extremity bypass grafts. ABI alone is not sufficient. Scanning helps in planning the surgical incision and may obviate arteriography in selected cases.

Retroperitoneal versus transperitoneal approach for repair of abdominal aortic aneurysms.

We, as well as other authors, believe that the retroperitoneal approach is an excellent alternative to the transperitoneal route for the repair of abdominal aortic aneurysms. This approach is associated with a significant decrease in pulmonary and cardiac complications and therefore can be used in selected high-risk patients with expanding aneurysms. A well-controlled randomized multicenter trial should answer the question: "Is this approach the surgical access of choice for the elective repair of abdominal aortic aneurysms?"

Needle biopsy of nodular thyroid disease.

To evaluate nodular thyroid disease, 150 patients underwent 169 fine needle biopsies (FNB) and recently 28 have also had core needle biopsies (CNB). Multiple biopsies were required in 19 patients because of multiple lesions, reaccumulation of cysts, follow-up of nodules failing to regress, or inadequate material. Adequate material was obtained in 97 per cent of FNB and 92 per cent of CNB. FNB and CNB agreed in 20 of 28 cases. There were no complications with FNB and one patient (4%) hemorrhaged with CNB. Forty nine patients underwent thyroidectomy. Postoperative diagnoses include papillary carcinoma (9), follicular carcinoma (2), lymphoma (2), medullary carcinoma (1), metastatic carcinoma (1), benign nodular goiter (14), follicular neoplasm (15), and thyroiditis (5). Sixty per cent of patients avoided surgery, 61 per cent of operated specimens contained neoplasia and 31 per cent contained malignancy. Eighty seven per cent of malignancies were identified at the initial evaluation. FNB had 86 per cent sensitivity for neoplasia and 44 per cent specificity for neoplasm (94% for papillary carcinoma). CNB had 89 per cent sensitivity and 67 per cent specificity for neoplasm. FNB and CNB are useful means of assessing thyroid nodules for the presence of cancer. They can decrease the need for diagnostic thyroidectomy. However, clinical evaluation must still be used in conjunction when determining the need for thyroidectomy.

Recurrent sympathetic dystrophy: successful treatment by contralateral sympathectomy.

Reflex sympathetic dystrophy comprises a group of disorders characterized by disabling pain and vasomotor disturbances. Sympathectomy has become a mainstay of therapy. Recurrent symptoms following sympathectomy have been attributed to incorrect diagnosis, delayed treatment, or secondary gains. This report concerns a case of lower-extremity reflex sympathetic dystrophy that recurred following an initially curative sympathectomy and that responded to treatment with contralateral sympathectomy. We suggest that these recurrent symptoms may be due to reinnervation from the contralateral lumbar sympathetic chain.

Simultaneous treatment of chronic pancreatitis and pancreatic pseudocyst.

Records from 87 consecutive patients undergoing lateral pancreaticojejunostomy (LPJ) for chronic pancreatitis were reviewed to determine the incidence of pseudocyst and the safety of combined pancreatic duct and pseudocyst drainage. Twelve patients had undergone previous pancreatic pseudocyst drainage; four of them also had pancreatic pseudocysts present at the time of LPJ. In addition, 22 patients had pseudocysts identified preoperatively and/or confirmed at operation. The overall incidence of pseudocyst was 39%. Twenty-six patients (group 1) underwent pancreaticojejunostomy combined with pseudocyst drainage. Sixty-one patients (group 2) underwent pancreaticojejunostomy only. Operative morbidity and mortality results (19% and 8%, respectively, in group 1; 18% and 2%, respectively, in group 2) were similar. Patient outcome was also similar in the two groups (81% and 84% of patients obtained pain relief in groups 1 and 2, respectively). There were no pseudocyst recurrences in either group. Thus, there is a high incidence (39%) of pancreatic pseudocyst in patients undergoing LPJ for chronic pancreatitis. Combined drainage of the pancreatic duct and pseudocyst is safe and effective.

Ruptured abdominal aneurysm subsequent to cystic medial necrosis: a case report.

The majority of abdominal aortic aneurysms are the result of atherosclerosis. Cystic medial necrosis is a pathologic finding classically associated with thoracic aortic dissection, particularly in patients with Marfan's syndrome. The presence of cystic medial necrosis in other segments of the aorta or its branches is unusual. We report a case of a ruptured abdominal aortic aneurysm in a 38-year-old woman without Marfan's syndrome.