Retrograde thrombendarterectomy vs. ilio-femoral bypass in unilateral iliac TASC C and D lesions.

BACKGROUND: To compare short and long term results of retrograde Thrombendarterectomy (rTEA) and ilio-femoral Bypass (IFBP) to treat iliac TASC C and D lesions. PATIENTS AND METHODS: Retrospective analysis of 108 patients treated at a single vascular center by either rTEA (n = 42) or IFBP (n = 66) over a period of 4 years. RESULTS: Both methods did not significantly differ in 30-day (rTEA 0 % vs IFBP 2 %) or long-term mortality (rTEA 24 % vs IFBP 30 % at 4 years) with a median follow-up of 46 months. There were no procedure related deaths. Patency was similar for both groups (rTEA 93 % vs IFBP 98 % at 30 days; rTEA 83 % vs 92 % IFBP at 4 years). We could not find a significant difference in limb salvage rates (rTEA 93 % vs IFBP 100 % at 30 days and at 4 years). The incidence of prolonged lymphorrhea was significantly higher in the IFBP group (rTEA 0 % vs IFBP 21 %). In 4 IFBP patients a prosthetic graft infection occurred. CONCLUSIONS: Regarding short and long term results operative procedures as rTEA and IFBP still represent the gold standard in the treatment of TASC C and D lesions of the external iliac artery especially in patients with additional lesions in the common femoral and profundal femoral artery. Taking into account certain anatomical characteristics (heavily calcified lesions, narrow external iliac arteries or very tortuous iliac segments) and individual local conditions (prior vascular procedures involving the femoral bifurcation) the single incision retrograde approach to the EIA with rTEA may have advantages over IFBP, especially concerning postoperative complications like lymphorrhea and graft infection.

The impact of superficial femoral artery (SFA) occlusion on the outcome of proximal sartorius muscle transposition flaps in vascular surgery patients.

OBJECTIVES: To demonstrate the feasibility and safety of proximal sartorius muscle rotational flaps in patients with peripheral occlusive artery disease. METHODS: Retrospective analysis of 53 patients with 56 proximal sartorius muscle flaps. Indication for a flap procedure was postoperative calcitrant lymphorrhea in nine, graft at risk in 13, and graft infection in 34 procedures. Pre- and postoperative patencies of the superficial femoral artery (SFA) and profundal femoral artery (PFA) were documented. Flap viability, wound healing, and limb salvage were examined at follow-up. RESULTS: In 59% of the procedures in this series, the SFA was occluded. The PFA was patent in all patients. Flap viability (100% vs 94%), rate of new (4% vs 6%), and recurrent infections (9% vs 6%), loss of vascular reconstruction rate (9% vs 9%), and limb salvage rate (100% vs 88%) did not differ significantly between the SFA patent and the SFA occluded group. There were four new infections (7%) and three recurrent infections (5.5%) during follow-up, five of which led to a loss of reconstruction. In four of those five patients, the sartorius flap was viable. Two patients died during the immediate postoperative period from septic multi-organ failure (3%). At a median follow-up of 6.4 months, 54 flaps were viable and wound closure was achieved in all surviving 51 patients. Limb salvage rate was 93%. CONCLUSIONS: Biologic protection procedures as local muscle flaps are vital adjuncts to vascular surgery techniques in the treatment of complicated wounds in the groin. Occlusion of the SFA in the presence of a patent PFA is not associated with an increased risk of flap loss in proximal sartorius muscle rotational flaps.

Microbial spectrum and primary resistance to rifampicin in infectious complications in vascular surgery: limits to the use of rifampicin-bonded prosthetic grafts.

There are reports that rifampicin-bonded prosthetic grafts might be a suitable alternative to autologous grafts in vascular graft infections and infectious vascular complications. We characterize the spectrum of microbial agents and susceptibility to antibiotic treatment, especially to rifampicin, in these patients. We carried out a retrospective analysis of wound-swaps and blood cultures in 48 patients with infected prosthetic vascular grafts or primary infectious vascular complications. In 15 of 48 patients (31%), the analysis showed that the microbial organism causing the infection was resistant or not susceptible to rifampicin. Rifampicin-bonded prosthetic grafts should be used with caution in acute infectious complications in vascular surgery, because in about 30% of the cases, the initiating microbial organisms are resistant or not susceptible to rifampicin. Without preoperative confirmation of susceptibility to rifampicin, autologous reconstruction should be preferred.

Alert for increased long-term follow-up after carotid artery stenting: results of a prospective, randomized, single-center trial of carotid artery stenting vs carotid endarterectomy.

BACKGROUND: Carotid endarterectomy (CEA) has been shown to be effective in stroke prevention for patients with symptomatic or asymptomatic carotid artery stenosis. Although several prospective randomized trials indicate that carotid artery stenting (CAS) is an alternative but not superior treatment modality, there is still a significant lack of long-term data comparing CAS with CEA. This study presents long-term results of a prospective, randomized, single-center trial. METHODS: Between August 1999 and April 2002, 87 patients with a symptomatic high-grade internal carotid artery stenosis (>70%) were randomized to CAS or CEA. After a median observation time of 66 +/- 14.2 months (CAS) and 64 +/- 12.1 months (CEA), 42 patients in each group were re-evaluated retrospectively by clinical examination and documentation of neurologic events. Duplex ultrasound imaging was performed in 61 patients (32 CAS, 29 CEA), and patients with restenosis >70% were re-evaluated by angiography. RESULTS: During the observation period, 23 patients (25.2%) died (10 CAS, 13 CEA), and three were lost to follow up. The incidence of strokes was higher after CAS, with four strokes in 42 CAS patients vs none in 42 CEA patients. One transient ischemic attack occurred in each group. A significantly higher rate of restenosis >70% (6 of 32 vs 0 of 29) occurred after CAS compared with CEA. Five of 32 CAS patients (15.6%) presented with high-grade (>70%) restenosis as an indication for secondary intervention or surgical stent removal, and three presented with neurologic symptoms. No CEA patients required reintervention (P < .05 vs CAS). A medium-grade (<70%) restenosis was detected in eight of 32 CAS patients (25%) and in one of 29 CEA patients (3.4%). In five of 32 CAS (15.6%) and three of 29 CEA patients (10.3%), a high-grade stenosis of the contralateral carotid artery was observed and treated during the observation period. CONCLUSION: The long-term results of this prospective, randomized, single-center study revealed a high incidence of relevant restenosis and neurologic symptoms after CAS. CEA seems to be superior to CAS concerning the development of restenosis and significant prevention of stroke. However, the long-term results of the ongoing multicenter trials have to be awaited for a final conclusion.

Surgical strategy in aortoesophageal fistulae: endovascular stentgrafts and in situ repair of the aorta with cryopreserved homografts.

OBJECTIVE: The surgical treatment of aortoesophageal fistulae (AEF) has a high morbidity and mortality rate. We report our experience with the sequential use of endovascular thoracic stentgrafts and cryopreserved aortic homografts for in situ repair of the descending thoracic aorta. METHODS: In a 7-year period, 6 patients with AEF were treated at our center. After primary endovascular repair in all cases, 4 patients subsequently underwent in situ repair of the descending thoracic aorta with cryopreserved homografts. Long-term antibiotic therapy was given in all cases. Recent clinical status and radiologic findings on follow-up studies of each patient were analyzed. The mean follow-up time was 35 months (range, 2-76). RESULTS: Endovascular stentgraft repair was technically successful in all cases. Two patients were not candidates for open surgical repair because of their medical condition; they both died within 8 weeks after discharge from the hospital, 1 from recurrent septic episodes, and the other from upper gastrointestinal bleeding. One of 4 patients who had undergone open surgical repair died 1 year later from upper gastrointestinal bleeding that occurred presumably due to an infectious degeneration of the homograft after secondary infection with a methacillin-resistant Staphyloccocus aureus. In 1 case persistent paraplegia and in another case persistent renal failure occurred. CONCLUSION: The use of cryopreserved homografts is a valuable alternative to in situ repair with prosthetic vascular grafts or extra-anatomic reconstructions in the surgical treatment of AEF. Endovascular stentgraft placement plays a role as a bridging procedure in emergency situations.

Endovascular repair of proximal endograft collapse after treatment for thoracic aortic disease.

We report two cases of proximal endograft collapse with an almost complete aortic occlusion after endovascular tube-graft treatment of thoracic aortic disease (thoracic aneurysm after a type B dissection, traumatic blunt aortic rupture) using the TAG Gore system. Oversizing of endografts is known to cause this complication. In our two cases, however, the oversizing was between 12% and 21.7%, which is less than the allowed oversizing of 25% that is recommended by the manufacturer. This endograft-related complication might be due to a poor alignment of the currently available endografts in highly angulated and tight aortic arches. In the first case, a combined endovascular and open emergent repair procedure achieved a reopening of the proximal endograft by proximal extension (TAG Gore). In the second case, proximal extension was not considered owing to a precise positioning of the endograft distal to the left carotid artery. A balloon-expanding Palmaz stent was therefore placed interventionally in the proximal part of the TAG graft to expand the endograft and to avoid another collapse of the device. This proximal endograft collapse has to be acknowledged as a potentially hazardous complication. We therefore recommend that the proximal part of thoracic endografts in the aortic arch should be closely monitored and we offer two possible endovascular solutions for resolving the problem of proximal endograft collapse.