Changing practice patterns in peripheral arterial disease.

The development of interventional radiologic techniques during the past decade has changed our approach to the treatment of lower extremity peripheral arterial disease (LE-PAD). Balloon and laser-assisted angioplasty, atherectomy (rotary and directional devices), stent implantation, and thrombolysis as well as combinations of all of these approaches, at times with concomitant or secondary surgery, have been used in our institution. A review of our practice patterns during the past 5 years was performed to analyze changing attitudes and results with these newer techniques. All new patients seen in consultation for LE-PAD during three alternate years were reviewed with regard to demographics, initial complaints, initial treatment modality, initial outcome, indications for and results of secondary treatment, and ultimate outcome (at 1 year). The 603 patients were seen during the following three 12-month periods: 1987 to 1988, 1989 to 1990, and 1991 to 1992. An intention-to-treat analysis revealed (1) the number of patients seen for peripheral arterial disease has increased steadily; (2) in the last year more were initially treated with intervention as the primary modality; (3) the results of such catheter-based procedures improved only slightly over this 5-year period, despite our learning curve and the fact that we discarded several ineffective interventional approaches; (4) the fraction of patients primarily operated on and the excellent results of surgery have not changed; and (5) the number of operations for proximal (aortoiliac) disease has decreased markedly, with a corresponding increase in distal reconstructions. The evolution of our current approach to the treatment of LE-PAD is based on this continuing experience.

The improving long-term outlook for patients over 70 years of age with abdominal aortic aneurysms.

During the past decade, selective criteria for elective surgery for abdominal aortic aneurysms have been refined based on natural history and aneurysm expansion information. Using these criteria, contemporary preoperative preparation and newer intraoperative technical adjuncts, 123 consecutive patients underwent elective resection with 1 death (mortality rate: 0.8%). These include all patients operated on with both elective and urgent aneurysms at this institution since 1978, with the exception of those with frank rupture. Most importantly, however, the 5-year life-table survival of all of these patients (average age: 71.3 years, range 46-96 yr) was 72%, including both hospital and late mortality rates. More than half of the patients were over 70 years old (78 cases), with no hospital deaths and a 5-year life-table survival probability of 67%. For those under 70 years of age at the time of operation, the 5-year life-table probability of survival was 79%. We believe that these accomplishments were a direct result of an aggressive policy of screening for and selectively treating coronary disease and carotid stenosis preoperatively and the utilization of such intraoperative adjuncts as routine Swan-Ganz monitoring, autologous blood transfusion, the cell saver, and the frequent use of the tube grafting (50%). Thus, with proper selection, the outlook for the patient over 70 years old with an elective abdominal aortic aneurysm resection now approaches that of the normal population (67% vs. 69%).