Technical complications of endovascular abdominal aortic aneurysm repair.

PURPOSE: Results from 34 endovascular repairs of abdominal aortic aneurysms are reviewed to identify technical complications and relate them to anatomic and technical features of the operation. METHODS: Twenty-one patients underwent attempted tube graft repair (mean follow-up, 13 months). Thirteen patients underwent placement of a bifurcated graft (mean follow-up, 7.2 months). RESULTS: Twenty-five patients (74%) underwent repair without technical complication (16 tube graft and nine bifurcated graft). Of five patients who had tube graft complications, two involved small iliac arteries and resulted in arterial injury. One of these patients needed a femorofemoral bypass procedure, and the other required conversion to standard operation. Two patients had distal leaks associated with the attachment system, and one patient had misplacement of the distal attachment system. The two patients who had leaks were followed-up; one required operation after 7 months, whereas the other leak sealed. The patient who had distal attachment system misplacement had a second endograft placed within the first to provide a distal seal. The four patients who had bifurcated graft complications involved two graft limb stenoses, one managed with a Palmaz stent and the other with balloon angioplasty. The patient treated with balloon angioplasty had graft thrombosis 1 week after the operation, which resulted in the need for a femorofemoral bypass procedure. Another bifurcated graft patient had a graft limb twist, which has resulted in chronic claudication. One patient had placement of a limb too proximal in the common iliac artery with chronic leak, and an open operation was performed 18 months later. CONCLUSIONS: Technical complications in this series seem to be associated with short distal necks, small iliac arteries, tortuous iliac arteries, and atherosclerosis at the aortic bifurcation. We believe that experience and understanding of these issues will reduce the risk of these complications in the future.

The pneumatic tourniquet: a useful adjunct in lower extremity distal bypass.

Pneumatic tourniquet techniques can facilitate numerous vascular surgical procedures by providing a bloodless surgical field and minimizing vessel wall trauma. Vessel dissection is simplified by requiring only a short segment of anterior vessel wall exposure, and trauma is avoided to the perianastomotic arterial branches and accompanying veins. Tourniquet use is particularly helpful for the distal anastomosis of infrapopliteal and pedal bypass procedures, but is also ideal for localized endarterectomy procedures. Correction of vein graft stenosis in upper extremity dialysis access procedures greatly facilitates removal of infected prosthetic grafts in the distal upper or lower extremity. The potential complications of nerve compression, ischemic skeletal muscle damage, and reperfusion problems associated with tourniquet use are not a clinical problem with the short occlusion times required for vascular procedures. The absence of clamps improves the anastomotic visualization and increases the mobility of the surgical site to aid surgical anastomotic techniques. The clinical use of pneumatic techniques among vascular surgeons continues to increase as surgeons become aware of its utility and expand its applications.

A new technique for hemodialysis access surgery: use of the pneumatic tourniquet.

The purpose of this study was to determine whether tourniquet occlusion could be safely used on the upper extremity for vascular control during hemodialysis access surgery. The hospital and outpatient records of 44 patients undergoing 105 hemodialysis access procedures were retrospectively reviewed. In 48 procedures tourniquet occlusion was used for vascular control, whereas in 57 procedures vascular clamps were used. In those procedures in which the tourniquet was used, the mean tourniquet time was 30 minutes and the mean tourniquet pressure was 242 mm Hg. The operative time was significantly less in the tourniquet group as compared to the clamp group (72.5 minutes vs. 84 minutes, respectively; p = 0.029). There was no statistically significant difference in the incidence of nerve injury, bleeding, hematoma, vascular steal, infection, or swelling between the two groups. There were no complications related specifically to the use of the tourniquet. There was no difference in primary patency in comparing the tourniquet control group with the clamp control group (p > 0.5). The use of a pneumatic tourniquet for vascular control during hemodialysis access surgery allows for a faster, technically easier operation with no increase in the complication rate and no effect on primary patency.

The current status of prosthetic-vein composite grafts for lower extremity revascularization.

When infrageniculate lower extremity vascular reconstructions are required in the face of inadequate or insufficient autogenous vein, prosthetic-vein composite grafts remain a viable alternative. Graft patency and limb salvage for composite grafts are intermediate between those of completely autogenous and prosthetic bypasses alone. The sequential technique may offer superior patency in patients with the appropriate anatomy. The addition of adjunctive techniques such as a distal arteriovenous fistula and/or anticoagulation may further improve results. An algorithm illustrating the proper role of composite grafts for distal lower extremity reconstructions is shown in Figure 6. Any significant interval of patency is important in this group of patients in whom limb salvage can often be achieved by healing ischemic lesions and in whom overall life expectancy is limited.

Coexistent abdominal aortic aneurysm and renal carcinoma: management options.

Renal carcinoma (RCA) presenting in association with abdominal aortic aneurysm (AAA) is extremely rare, with only sporadic case reports previously described. The management of six cases of AAA and concomitant RCA presenting to a single institution from March, 1991 through December, 1993 was reviewed and management options considered. AAAs ranged in size from 4.5-7.0 cm (mean, 5.6 cm). Three left renal carcinomas were resected via a retroperitoneal approach simultaneous to repair of the AAA. One right renal carcinoma was resected in combination with repair of an AAA through a transperitoneal approach. The fifth case was managed by left nephrectomy, followed by interval aneurysmectomy, and the sixth case was managed by nonsurgical methods because of the presence of widely metastatic disease. Renal malignancies included five renal cell carcinomas and one transitional cell carcinoma. Three patients remain free of disease 8-11 months postoperatively, and one patient had metastatic disease detected 19 months postoperatively. Two deaths have occurred; one due to a massive CVA 1 month following a combined aneurysmectomy and left nephrectomy, and a second due to unknown etiology in the patient managed non-surgically. No peripheral vascular or aortic graft related complications have occurred. The treatment of AAA and RCA should be governed by the size of the AAA, the location of the cancer, and the extent of malignant disease. Simultaneous resection is safe and effective in patients with coexistent AAA and renal cancer. Left sided tumors should be resected via a retroperitoneal approach that also provides excellent exposure for simultaneous AAA resection.(ABSTRACT TRUNCATED AT 250 WORDS)

Intraoperative iliac artery stents: combination with infra-inguinal revascularization procedures.

Iliac artery percutaneous transluminal angioplasty (PTA) can effectively provide in-flow for subsequent distal vascular reconstruction. Iliac artery stents may improve the initial hemodynamics and long term patency of PTA, and thus may be well-suited for combined proximal PTA with distal bypass procedures. This report reviews our preliminary experience with iliac artery stenting in combination with infra-inguinal vascular reconstruction. Thirteen iliac artery stent procedures combined with simultaneous distal revascularization were performed in 11 patients. Ten procedures were performed for limb salvage, two for disabling claudication, and one before planned orthopedic surgery. Distal revascularization procedures included seven femoropopliteal, four femorotibial bypasses, one common femoral endarterectomy, and one thrombectomy of a femoropopliteal bypass. Stent placement was technically successful in all patients. Mean pre-operative ankle-brachial index (ABI) was 0.41 (+/- 0.28), which improved to 0.91 (+/- 0.18) post-operatively (P < 0.0001). Mean systolic iliac artery gradients across the lesions improved from 27.1 (+/- 9.8) mm Hg to 2.7 (+/- 3.4) mm Hg after stent placement (P < 0.0001). Mean follow-up is 5.8 months (range 1-12 months). Two femoropopliteal bypass grafts occluded in the follow-up period. One occlusion was caused by a mid-vein graft stenosis that was repaired with subsequent graft patency. The other graft occlusion occurred in a patient with rest pain who did not require a second bypass procedure, as the ABI increased from 0.3 to 0.7 following stent placement with resolution of symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)

Vein harvest ischemia: a peripheral vascular complication of coronary artery bypass grafting.

Lower-extremity ischemia can lead to impaired healing of saphenous vein excision sites in patients with significant peripheral vascular disease (PVD). Five patients who required infrainguinal revascularization for wound necrosis of the harvest site after coronary artery bypass grafting are described. The male/female ratio was 2:3 with a mean age of 67 (range 45-87) years. The most commonly associated problems were insulin-dependent diabetes mellitus (80%) and congestive heart failure (60%). The saphenous vein was harvested from the thigh and leg in three patients and exclusively from the leg in the others. Manifestations of ischemia ranged from persistent ulceration to complete wound disruption threatening limb loss. Impaired healing was isolated to infragenicular wounds in all patients. Pedal pulses were not detected in any of the affected extremities. Determination of the ankle/brachial pressure indices (ABI) revealed values of < 0.5 in three affected limbs. Non-compressible vessels resulted in falsely raised ABI of > 1.0 in the remaining two limbs; however, Doppler waveform analysis in these patients demonstrated significant PVD. Aggressive wound care and antibiotic therapy were continued for mean of 9 weeks before operative intervention. Infrainguinal reconstruction included femoropopliteal (two), femorotibial (two) and popliteal-tibial bypass (one). Autologous arm and saphenous veins in addition to expanded polytetrafluoroethylene grafts were used effectively. Limb salvage and wound healing were achieved in 100% of the patients without untoward sequelae. It is concluded that unrecognized PVD in patients undergoing coronary artery bypass grafting can lead to significant morbidity. Patients at risk may be identified with a combination of history, physical examination and non-invasive testing.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term follow-up for recurrent stenosis: a prospective randomized study of expanded polytetrafluoroethylene patch angioplasty versus primary closure after carotid endarterectomy.

PURPOSE: To determine the effect of primary closure (PC) versus expanded polytetrafluoroethylene patch graft angioplasty (PGA) on the incidence of recurrent stenosis (> 50% lumen diameter narrowing) after carotid endarterectomy (CEA), 87 patients undergoing 100 consecutive CEA were prospectively randomized into two groups. METHODS: Forty-four patients underwent 51 PC, and 43 patients underwent 49 PGA. All patients were evaluated after operation by duplex scanning at 1.5, 12, 24, and 36 months. There were no significant differences in the demographic characteristics or operative indications for CEA between the two patient groups. Complete follow-up was achieved in 86% (75/87) of the patients during the 36-month surveillance period. RESULTS: The perioperative permanent neurologic morbidity in the PC and PGA groups was noted to be 4% and 2%, respectively (PC = 2/51 vs PGA = 1/49, p = 0.58). Three additional reversible cerebral ischemic events occurred in the postoperative period (PC = 2/51 vs PGA = 1/49, p = 0.58). Other morbidity included immediate postoperative hemorrhage requiring reexploration (1/51) in the PC group and an infected expanded polytetrafluoroethylene patch requiring removal and replacement with autogenous vein (1/49). Long-term follow-up detected a single patient with significant bilateral restenoses of his primarily closed carotid arteries. None of the patients in the PGA group had restenoses (PC = 2/51 vs 0/49, p = 0.50). In addition, no postoperative dilation of the common or internal carotid arteries or perioperative death was observed. CONCLUSIONS: In patients undergoing CEA, these data demonstrate no significant difference in the perioperative morbidity or mortality between PC and PGA. Use of the patch did not engender patients to patch rupture or aneurysmal degeneration as previously described with vein patch angioplasty procedures. This series supports effective use of either technique to achieve minimal rates of restenosis.

Angioscopic evaluation of valvular disruption during in situ saphenous vein bypass.

Several valvulotomes are currently available to achieve valvular disruption; however, studies comparing the efficacy of these endoluminal instruments are lacking. This prospective study evaluates the efficacy and safety of the three most commonly employed valve cutters: the Hall, LeMaitre, and Mills valvulotomes. A total of 30 in situ greater saphenous vein bypass grafts were included in this investigation. Valvular disruption was attempted with either the LeMaitre (11 cases), Hall (12 cases), or Mills (7 cases) valvulotomes. Subsequently, angioscopy was employed to assess the completeness of valvulotomy and to identify vein wall injury. Incomplete disruption of one or more valve complexes was identified in 2 of 12 (17%) grafts in the Hall group, 10 of 11 (91%) grafts in the LeMaitre group, and 0 of 7 grafts in the Mills group (p < 0.01). Intact valve cusps were noted in 2 of 36 (5.5%) valves, 31 of 42 (74%) valves, and 0 of 38 valves after valvulotomy with the Hall, LeMaitre, and Mills instruments, respectively (p < 0.01). A total of three valvulotome-related injuries occurred; two injuries were noted in conjunction with the Hall instrument, one was associated with the Mills valvulotome, and no injuries were detected after use of the LeMaitre instrument (p = 0.33). These data demonstrated a significantly increased incidence of retained valve cusps when the LeMaitre valvulotome was used. No significant difference in the rate of vein wall injury was noted in the three groups. Thus this study suggests that the LeMaitre instrument is not as effective as either the Hall or Mills valvulotomes for achieving valvular disruption.

Successful management of traumatic false aneurysm of the extracranial vertebral artery by duplex-directed manual occlusion: a case report.

A 32-year-old man was transferred to our hospital after a 2.0 by 2.5 cm traumatic false aneurysm of the distal extracranial vertebral artery was noted after a stab wound of the posterior side of the neck. To obviate the need for operative exposure of the distal vertebral artery at the base of the skull, we elected to perform duplex-directed manual occlusion of the lesion. Angiography before and after the procedure, as well as 10-month follow-up duplex ultrasonography, demonstrated satisfactory thrombosis of the false aneurysm without evidence of a residual arterial defect. There was no morbidity associated with the procedure. We conclude that duplex-directed manual occlusion, a new technique recently described for the nonoperative management of postcatheterization femoral false aneurysms, can be applied safely and effectively to false aneurysms in other locations in which the risks and technical difficulties of operative repair render surgery less desirable.

Color-flow duplex-directed manual occlusion of femoral false aneurysms.

PURPOSE: During the past 14 months we conducted a prospective clinical trial to evaluate the efficacy of duplex-directed manual occlusion (DDMO) of iatrogenic femoral false aneurysms (FFAs) as an alternative to standard operative management. METHODS: In all cases DDMO was performed with real-time color-flow imaging while steady, continuous external pressure was applied manually to the neck of the FFA by an experienced vascular technologist for a period of 10 minutes. RESULTS: Ten of the 11 FFAs treated with DDMO in this series were thrombosed successfully, requiring a mean of 30 minutes of compression per aneurysm (three compressions of 10 minutes each). DDMO was unsuccessful in one patient, whose session was terminated because of severe discomfort as a result of the procedure. All 10 patients with successfully thrombosed FFAs are without recurrence at 1-month follow-up color-flow duplex examination, and there has been no morbidity attributable to DDMO. CONCLUSIONS: We conclude that DDMO of postcatheterization FFA can be performed safely and is an inexpensive, effective, nonoperative method of managing such lesions. The precise role of this technique would appear to be as a first-line treatment for uncomplicated iatrogenic FFAs.

The ischemic window: a method for the objective quantitation of the training effect in exercise therapy for intermittent claudication.

Twenty-two patients with intermittent claudication were prospectively enrolled in a 12-week program of supervised, graded treadmill exercise therapy. Severity and distribution of arterial occlusive disease were ascertained by noninvasive determination of segmental lower extremity blood pressures and waveforms. No attempt was made to modify risk factors for atherosclerotic occlusive disease. The exercise-induced reduction of the ankle pressure and its recovery were recorded over time, and the area under this curve, the "ischemic window," represents the severity of the ischemic deficit. Absolute systolic ankle pressure, ankle-brachial index, maximum walking time, claudication pain time, and the ischemic window were measured before and after exercise training in all subjects. Maximum walking time and claudication pain time increased 659% and 846%, respectively, among the 19 patients completing the 12-week program (p = 0.001; p = 0.0002). These patients underwent a mean reduction of 58.7% in the ischemic window after a standardized workload (p less than 0.05), and this correlated with the degree of symptomatic improvement. Absolute ankle pressure and ankle-brachial index were unchanged after exercise training. This study confirms the utility of supervised exercise therapy in the treatment of intermittent claudication. The ischemic window is a useful method for quantifying the ischemic deficit produced by exercise and provides a reproducible means of documenting functional improvement in patients undergoing exercise training.

Mycotic aneurysm of the suprarenal abdominal aorta.

We report on the successful treatment of a patient with a mycotic aneurysm of the suprarenal aorta. The aorta was resected and reconstructed using an in-situ polytetrafluoroethylene graft with a side arm branch to the left renal artery. The use of polytetrafluoroethylene graft for aortic reconstruction after suprarenal mycotic aneurysm resection has not been previously reported. The etiology, bacteriology, diagnosis, and principles of management of mycotic aneurysms of the suprarenal aorta are discussed.

Duplex scanning for the intraoperative assessment of infrainguinal arterial reconstruction: a useful tool?

Duplex scan, arteriography, and graft flow rates were used intraoperatively to assess 56 infrainguinal arterial reconstructions for technical error. Intraoperative duplex scan identified a technical defect or low graft flow velocity in 22 of 56 (39%) grafts. Eleven of the defects were judged to be clinically significant and were corrected. Four of these defects were missed by the completion arteriogram. One technical defect identified by completion arteriography was missed by duplex scan. Fifty percent (5/10) of grafts with an abnormal intraoperative duplex scan which were not corrected occluded within 30 days. Graft flow rates measured by the electromagnetic flowmeter were neither predictive of technical defect nor early graft outcome. Although the sensitivity of arteriography and duplex scan (88% sensitivity for both) were both high for predicting early graft occlusion, the combination of duplex scan and completion arteriography was significantly more accurate (p less than .0001) in predicting early graft outcome than either study alone. Duplex scan identified significant graft defects which were not detected by completion arteriography or graft flow rate measurement. The duplex scan also provided hemodynamic information which was predictive of early graft outcome. The duplex scan can be an important adjunct to completion arteriography for the intraoperative assessment of infrainguinal arterial reconstruction.

Experience with laser-assisted balloon angioplasty and a rotary angioplasty instrument: lessons learned.

Favorable early results with mechanical angioplasty devices and laser-assisted balloon angioplasty have resulted in aggressive marketing and a rapid increase in the use of these devices for the treatment of femoropopliteal occlusive disease. Recent reports, however, have questioned the durability of these less invasive procedures. Since 1986 we have been involved in the clinical investigation of the Kensey dynamic angioplasty instrument and laser-assisted balloon angioplasty. One hundred two balloon angioplasty procedures assisted by the Nd:YAG laser (n = 56) and the Kensey dynamic angioplasty instrument (n = 46) were performed for the treatment of femoropopliteal occlusive lesions. Both Kensey dynamic angioplasty instrument and laser-assisted balloon angioplasty groups were similar with regard to age, operative indication, preoperative ankle-brachial index, lesion length, and distal runoff. Mean follow-up was 19 months in the Kensey dynamic angioplasty instrument group and 15 months in the laser-assisted balloon angioplasty group. Technically successful recanalization was achieved in 67% of Kensey dynamic angioplasty instrument-assisted balloon angioplasty procedures and 82% of laser-assisted balloon angioplasty procedures. Early hemodynamic and clinical improvement was obtained in 59% of Kensey dynamic angioplasty instrument-assisted balloon angioplasty procedures and 57% of laser-assisted balloon angioplasty procedures. Two-year clinical success by life-table analysis was 37% in the Kensey dynamic angioplasty instrument group and 19% in the laser-assisted balloon angioplasty group. The level of subsequent surgical revascularization was not altered in any patient by Kensey dynamic angioplasty instrument-assisted balloon angioplasty or laser-assisted balloon angioplasty.(ABSTRACT TRUNCATED AT 250 WORDS)

Spontaneous carotid dissection: duplex scanning in diagnosis and management.

The clinical, duplex, and angiographic findings in six patients with seven spontaneous extracranial carotid artery dissections are reported. Four dissections resulted in internal carotid artery occlusion. These patients complained of ipsilateral headache followed by contralateral hemiplegia. The other three dissections involved the common carotid artery and resulted in dual (one true and one false) lumens. Two of these dissections were asymptomatic. All dissections were treated nonoperatively with anticoagulant therapy. Neurologic deficits improved or disappeared in all symptomatic patients. On follow-up studies, one of the four internal carotid occlusions completely resolved with normalization of the duplex examination. All three dual lumen dissections remained patent on serial studies. Diagnostic duplex characteristics, both conclusive and supportive, of carotid dissections are described. Duplex scanning is shown to be accurate in diagnosing and ideally suited for serially following spontaneous carotid dissections.

Thoracic aortic ectasia in a patient with Takayasu's disease.

Arterial aneurysm formation occurs in 15 to 20% of patients with Takayasu's disease. The timing of surgical intervention of these aneurysms is controversial. A case of ectasia of the descending thoracic aorta in a patient with Takayasu's disease is presented. The diagnosis and timing of surgical intervention of aneurysms associated with Takayasu's disease are discussed.

The use of composite grafts in femorocrural bypasses performed for limb salvage: a review of 108 consecutive cases and comparison with 57 in situ saphenous vein bypasses.

We retrospectively reviewed the results of 108 consecutive femorocrural bypasses performed with prosthetic/autogenous composite graft material and compared these with the results of 57 crural bypasses using greater saphenous vein by the in situ technique. Indication for operation in all cases was the salvage of an otherwise imminently threatened limb. Polytetrafluoroethylene-composite grafts (n = 87) and human umbilical vein-composite grafts (n = 21) were placed only in patients lacking suitable autogenous material for in-line reconstruction. Patient groups were similar with respect to mean age, prevalence of arterial disease risk factors, quality of the distal runoff, and location of the distal anastomosis. Cumulative patency rates at 1 year by life-table analysis were 81.9%, 34.6%, and 12.1% for the in situ, polytetrafluoroethylene-composite and human umbilical vein-composite groups, respectively. At 2 years these were 63.9%, 29.9%, and 6.0%, respectively (p less than 0.025). Cumulative limb salvage at 1 year was 70.6%, 62.3%, and 32.7%, respectively. Wound-related complications occurred in 52.4% of human umbilical vein-composite, 38.6% of in situ, and 18.3% of polytetrafluoroethylene-composite bypasses (p less than 0.05). On the basis of these results, we conclude that femorocrural bypass with polytetrafluoroethylene-composite graft is an acceptable form of distal reconstruction for limb salvage in patients lacking sufficient lengths of autogenous vein. We no longer use human umbilical vein for composite construction.

Unilateral sudden hearing loss as a result of anomalous carotid anatomy.

The term sudden hearing loss refers to hearing losses of sensorineural origin that evolve over a short period of time and are often of unknown origin. Common causes include damage to the cochleovestibular nerve by viral infection, autoimmune disease, vascular insult, and labyrinthine membrane rupture. A 70-year-old man had a history of recent diplopia, dysarthria, syncopal episodes, dysequilibrium, and the sudden onset of deafness in his right ear. Angiography demonstrated severe ulcerative stenosis of the right internal carotid origin and an anomalous vessel (probable remnant of hypoglossal artery) originating from the distal right internal carotid artery that perfused the entire distal vertebral and basilar artery circulation. Arch angiograms confirmed the absence of a proximal right vertebral artery and revealed a small left vertebral artery that ended in the cervical region without reaching the posterior fossa. Standard right carotid endarterectomy with patch angioplasty resolved all neurologic symptoms except for persistent unilateral deafness at 9 months' follow-up. Presumed embolization through this anomalous vessel to the internal auditory artery and subsequent cochlear and vestibular branches represents the first reported case of sudden hearing loss as a result of anterior circulatory ulcerative disease.

Initial results and subsequent outcome of laser thermal-assisted balloon angioplasty of 56 consecutive femoropopliteal lesions.

Laser thermal-assisted balloon angioplasty (LABA) was prospectively applied in the treatment of 56 atherosclerotic femoropopliteal occlusive lesions in 51 consecutive patients. All procedures were performed in the operating room using a neodynium:yttrium-aluminum-garnet (Nd:YAG) laser source, and patients were evaluated for immediate and long-term hemodynamic and clinical improvement. Technically successful recanalization was achieved in 82% of cases, with 57% of all patients (32 of 56) obtaining early hemodynamic and clinical improvement. Long-term clinical success (by life-table analysis) was obtained by only 22.5% at 6 months, and only 13.5% at 12 months. Patients presenting with intermittent claudication did significantly better than those presenting for limb salvage (p = 0.01), and trends toward improved outcome were noted for short versus long lesions as well as for patients with "good" versus "poor" distal runoff (NS). Procedure-related morbidity occurred in 14%, and there was one peri-procedural mortality (1.8%). We conclude that the use of LABA is associated with long-term clinical success in only a small proportion of patients, and that widespread clinical application of this technique is not indicated at the present time.