Treatment of a late-appearing proximal type-1 endoleak after Ancure graft with an AneuRx cuff--a case report.

The authors describe the case of a patient who developed a type-1 proximal endoleak 10 months after Ancure stent graft placement, despite the lack of stent migration or measurable neck dilatation. The patient had been under observation for a persistent type-2 endoleak and was noted to have an increase in his aneurysm size. The use of an uncovered stent was unsuccessful, and he required a covered proximal extension cuff. This led to a resolution of the endoleak. Implications in terms of surveillance and possible etiologies are discussed.

Early duplex-derived hemodynamic parameters after lower extremity bypass in diabetics: implications for mid-term outcomes.

Early postoperative changes in the hemodynamic parameters of infrainguinal bypass grafts in diabetics have not been well defined. We undertook this study to better define such changes in duplex-derived velocities and waveforms, and correlate any observed changes with intermediate-term outcomes. A prospective study of 68 primary vein bypasses for limb salvage was carried out, with scans obtained intraoperatively, daily until discharge, and at 8- to 12-weeks intervals. During follow-up (12 +/- 6 months), 20 grafts developed stenoses, 17 occluded, and 8 limbs were amputated. Most grafts show a variant of a biphasic waveform intraoperatively at the mid-graft (MG) and distal graft (DG) levels (54% and 57%); 65% of waveforms remain unchanged during the first week, and 54% remain unchanged at 3 months. No duplex-derived factors were predictive of the development of stenoses. A number of parameters were predictive of ultimate graft thrombosis. Intraoperative MG velocity was higher in grafts that eventually remained patent (83 +/- 36 vs. 60 +/- 29 cm/sec; p <0.025). Grafts that remained patent also had a much lower decline in DG and distal native (DN) velocities from immediately postoperative to 8-12 weeks later, than grafts that eventually thrombosed (-3 +/- 35 vs. -44 +/- 43 cm/sec for DG, p <0.001; and -17 +/- 66 vs. -76 +/- 53 cm/sec for DN, p <0.04 respectively). In terms of limb salvage, when the MG or DG waveform worsened (from postoperation to 12 weeks later), amputation was more likely than when it remained unchanged or improved (MG 67% vs. 9% limb loss, p <0.04; DG 43% vs. 8% limb loss, p <0.04). We conclude that intensive graft duplex surveillance does not identify grafts likely to develop stenoses. However, a number of features allow the prediction of ultimate graft failure or limb loss.

Angiographic scoring of vascular occlusive disease in the diabetic foot: relevance to bypass graft patency and limb salvage.

OBJECTIVE: We graded the severity of occlusive disease in foot vessels of patients with diabetes and correlated the scoring obtained with graft patency and limb salvage. METHODS: In this retrospective review of 199 limbs studied by means of angiography in 117 patients with diabetes mellitus, 124 limbs underwent bypass grafting. Each dorsalis pedis (DP), lateral plantar (LP), and medial plantar (MP) artery was assigned a score according to the reporting standards of the Joint Vascular Societies Council (0, no stenosis > 20%; 1, 21%-49% stenosis; 2, 50%-99% stenosis; 2.5, < half the vessel length occluded; 3, > half the vessel length occluded.) A foot score (DP + MP + LP + 1) was calculated for each foot (1 to 10). The mean follow-up period was 14 months. RESULTS: For all 199 limbs and for the 124 limbs that underwent bypass grafting, the mean scores were similar for the DP, MP, and LP (1.8 +/- 1.0, 1.9 +/- 1.0, 1.9 +/- 1.0, respectively; P >.4). Only the MP and LP correlated with each other (r = 0.57; P <.0001). There were no scoring differences between limbs with symptoms and limbs that did not undergo bypass grafting. Bypass graft patency correlated with both the foot score and the MP score for tibial and inframalleolar grafts (P <.04). Patency correlated with the LP score only for inframalleolar bypass grafting procedures. The DP score alone did not differ between bypass grafts that remained patent and bypass grafts that failed. Bypass grafts in limbs with a foot score less than 7 and an MP score less than 2 had only a 2% failure rate. A foot score greater or equal to 7 was associated with a 30% failure rate for all bypass grafts (41% for inframalleolar grafts). Bypass grafts with low foot scores that failed did so much later than bypass grafts with high foot scores that failed (17 +/- 11 months vs 6 +/- 8 months; P <.02), possibly reflecting different etiologies for the failure. The limb salvage rate correlated with foot score (P <.05). The limbs that were saved had an average foot score of 6.4 +/- 2.0, versus 7.2 +/- 1.4 for limbs that required amputation. CONCLUSION: In patients with diabetes mellitus, the foot score is a useful tool for predicting the likelihood of graft patency and limb salvage for infrapopliteal revascularization. However, the relatively high bypass success rate (70%) in the presence of a high foot score (>or= 7) does not allow its use in identifying the subgroup of patients who are unlikely to benefit from bypass grafting surgery. It cannot be used as a means of selecting patients for primary amputation.