Infected aortic aneurysms: aggressive presentation, complicated early outcome, but durable results.

OBJECTIVE: Infected aortic aneurysms are rare, difficult to treat, and associated with significant morbidity. The purpose of this study was to review the management and results of patients with infected aortic aneurysms and identify clinical variables associated with poor outcome. METHODS: The clinical data and early and late outcomes of 43 patients treated for infected aortic aneurysms during a 25-year period (1976-2000) were reviewed. Variables were correlated with risk of aneurysm-related death and vascular complications, defined as organ or limb ischemia, graft infection or occlusion, and anastomotic or recurrent aneurysm. RESULTS: Infected aneurysms were infrarenal in only 40% of cases. Seventy percent of patients were immunocompromised hosts. Ninety-three percent had symptoms, and 53% had ruptured aneurysms. Surgical treatment was in situ aortic grafting (35) and extra-anatomic bypass (6). Operative mortality was 21% (9/42). Early vascular complications included ischemic colitis (3), anastomotic disruption (1), peripheral embolism (1), paraplegia (1), and monoparesis (1). Late vascular complications included graft infection (2), recurrent aneurysm (2), limb ischemia (1), and limb occlusion (1). Mean follow-up was 4.3 years. Cumulative survival rates at 1 year and 5 years were 82% and 50%, respectively, significantly lower than survival rates for the general population (96% and 81%) and for the noninfected aortic aneurysm cohort (91% and 69%) at same intervals. Rate of survival free of late graft-related complications was 90% at 1 year and 5 years, similar to that reported for patients who had repair of noninfected abdominal aortic aneurysms (97% and 92%). Variables associated with increased risk of aneurysm-related death included extensive periaortic infection, female sex, Staphylococcus aureus infection, aneurysm rupture, and suprarenal aneurysm location (P <.05). For risk of vascular complications, extensive periaortic infection, female sex, leukocytosis, and hemodynamic instability were positively associated (P <.05). CONCLUSION: Infected aortic aneurysms have an aggressive presentation and a complicated early outcome. However, late outcome is surprisingly favorable, with no aneurysm-related deaths and a low graft-related complication rate, similar to standard aneurysm repair. In situ aortic grafting is a safe and durable option in most patients.

Intraoperative duplex ultrasound during carotid endarterectomy.

The purpose of this study was to examine the technical aspects of intraoperative duplex ultrasound (DUS) following carotid endarterectomy (CEA), suggest criteria to differentiate significant lesions requiring immediate surgical revision from normal or benign defects, and evaluate how frequently intraoperative DUS provides useful or unsuspected information. A retrospective study was performed on all patients who had both CEA and intraoperative carotid DUS between January 1, 1990, and January 1, 1995. A total of 155 DUS examinations were performed in 149 patients. Findings were grouped into three categories: normal; minor/insignificant lesions; and hemodynamically significant lesions based on the presence or absence of elevated peak systolic velocities, visible stenosis/thrombus, or intimal flap/dissection. Postoperative status was correlated with intraoperative DUS findings. Ninety-one (59%) examinations performed on 87 patients produced normal findings. Forty-seven (30%) examinations performed on 45 patients showed minor abnormalities consisting of insignificant residual plaque, residual external carotid artery stenoses, small intimal flaps, elevated velocities with no associated anatomic lesion, or an arterial kink. Fourteen patients (9%) had significant findings requiring immediate surgical revision. These consisted of large intimal flaps or dissection in six patients, marked residual plaque and significant stenosis in five patients, thrombus in two patients, and a kink in one patient. Three additional patients (2%) had significant findings but were not revised for various reasons. No significant difference was identified in morbidity or mortality rates between those patients with normal findings, those patients with minor technical defects, and those patients with significant abnormalities undergoing immediate surgical revision. However, two of three patients who had significant abnormalities within the common carotid artery that were not revised suffered perioperative ipsilateral strokes. Intraoperative DUS is a safe and accurate method to assess the technical adequacy of CEA. Intraoperative DUS showed significant lesions in 11% of patients. Identification and immediate repair of significant technical defects may decrease perioperative complication rate and long-term restenosis rate.

Haploinsufficiency for one COL3A1 allele of type III procollagen results in a phenotype similar to the vascular form of Ehlers-Danlos syndrome, Ehlers-Danlos syndrome type IV.

Mutations in the COL3A1 gene that encodes the chains of type III procollagen result in the vascular form of Ehlers-Danlos syndrome (EDS), EDS type IV, if they alter the sequence in the triple-helical domain. Although other fibrillar collagen-gene mutations that lead to allele instability or failure to incorporate proalpha-chains into trimers-and that thus reduce the amount of mature molecules produced-result in clinically apparent phenotypes, no such mutations have been identified in COL3A1. Furthermore, mice heterozygous for Col3a1 "null" alleles have no identified phenotype. We have now found three frameshift mutations (1832delAA, 413delC, and 555delT) that lead to premature termination codons (PTCs) in exons 27, 6, and 9, respectively, and to allele-product instability. The mRNA from each mutant allele was transcribed efficiently but rapidly degraded, presumably by the mechanisms of nonsense-mediated decay. In a fourth patient, we identified a point mutation, in the final exon, that resulted in a PTC (4294C-->T [Arg1432Ter]). In this last instance, the mRNA was stable but led to synthesis of a truncated protein that was not incorporated into mature type III procollagen molecules. In all probands, the presenting feature was vascular aneurysm or rupture. Thus, in contrast to mutations in genes that encode the dominant protein of a tissue (e.g., COL1A1 and COL2A1), in which "null" mutations result in phenotypes milder than those caused by mutations that alter protein sequence, the phenotypes produced by these mutations in COL3A1 overlap with those of the vascular form of EDS. This suggests that the major effect of many of these dominant mutations in the "minor" collagen genes may be expressed through protein deficiency rather than through incorporation of structurally altered molecules into fibrils.

Ruptured abdominal aortic aneurysms: the excessive mortality rate of conventional repair.

OBJECTIVE: Rupture of abdominal aortic aneurysms (AAAs) remains lethal. In a report of patients treated in the 1980s, we recommended aggressive management. Our continued experience prompted us to reevaluate this policy. METHODS: We reviewed clinical variables affecting outcome, morbidity, mortality, and trends in mortality of all patients managed at our institution with ruptured AAAs between January 2, 1980, and November 30, 1998. RESULTS: The study group included 413 consecutive patients, 339 men and 74 women. The mean age was 74.3 years (range, 49-96); 116 (28%) patients were older than 80 years. AAA was diagnosed before rupture in 119 (29%) patients. Eighty (19%) patients had preoperative cardiac arrest. Twenty-nine (7%) patients died before operation; 65 (17%) died during the operation. The surgical mortality rate (30-day) was 37%; the overall mortality rate was 45% and was higher in women (68%) than in men (40%) (P <.001). Advanced age, APACHE (Acute Physiology and Chronic Health Evaluation) II score, initial hematocrit, and preoperative cardiac arrest were associated multivariately with 30-day mortality rates by means of stepwise logistic regression (P <.05). Twelve (23%) of 53 patients with cardiac arrest survived the operation. Logistic regression, adjusted for age, sex, and APACHE II score, demonstrated a decrease in overall and 30-day mortality rates (P <.001) over 18 years. The mean overall mortality rate was 51% from 1980 to 1984 and 42% from 1994 to 1998. CONCLUSIONS: The mortality rate of ruptured AAAs remains excessive, despite improvement over 18 years. Patients older than 80 years with shock or cardiac arrest have the highest mortality rate and should be evaluated for possible endovascular treatment. Because the diagnosis of AAA was unknown in more than 70% of patients, screening of the high-risk population and elective repair are recommended.

Surgical reconstruction of iliofemoral veins and the inferior vena cava for nonmalignant occlusive disease.

PURPOSE: Venous reconstructions are rarely performed, and factors affecting long-term results of bypass grafts implanted in the venous system are not well defined. In this report we updated our experience. METHODS: The clinical data of all patients who underwent venous reconstruction for iliofemoral or inferior vena caval (IVC) occlusion due to nonmalignant disease between January 1985 and June 1999 were retrospectively reviewed. Patients were classified, and outcomes were compared according to the guidelines of the Joint Vascular Societies. RESULTS: Forty-two patients, 23 males and 19 females (mean age, 40 years; range, 16-81), underwent 44 venous reconstructions. Thirty-six patients had limb swelling or venous claudication, 38 had pain, and 14 had healed or active ulcers. The cause of obstruction was congenital in two and acquired in 40 (deep vein thrombosis, 25; trauma, 5; retroperitoneal fibrosis, 4; IVC occlusion devices, 4; others, 2). Eighteen patients underwent saphenous vein crossover grafts (Palma procedure), 17 had expanded polytetrafluoroethylene (ePTFE) grafts implanted (femorocaval, 8; iliocaval, 5; crossfemoral, 3; cavoatrial, 1), 6 patients had spiral vein grafts (5 iliac/femoral and 1 cavoatrial), and 1 underwent femoral vein patch angioplasty. Clinical follow-up averaged 3.5 years (median, 2.5), and graft follow-up with imaging studies averaged 2.6 years (median, 1.6). Seven patients were lost to follow-up. The secondary 3-year patency rate for all reconstructions was 62%. Palma procedures had a 4-year patency rate of 83%. The secondary patency rate of iliocaval and femorocaval ePTFE bypass grafts at 2 years was 54%. The secondary patency was lower in patients with an arteriovenous fistula (P =.023). All ePTFE grafts had a 45% patency rate at 2 years, not significantly different from saphenous vein grafts (83%, P =.16). Clinical scores improved with graft patency (median, 0.0 vs 1.5; P =.044). CONCLUSIONS: Venous reconstructions for iliofemoral or IVC obstruction offer 3-year patency rates of 62%. The Palma procedure with autologous saphenous vein had the best long-term patency, whereas long-term success with ePTFE was moderate. The use of an arteriovenous fistula to improve graft patency remains controversial.

Surgical treatment of venous malformations in Klippel-Trénaunay syndrome.

PURPOSE: Klippel-Trénaunay syndrome (KTS) is a complex congenital anomaly, characterized by varicosities and venous malformations (VMs) of one or more limbs, port-wine stains, and soft tissue and bone hypertrophy. Venous drainage is frequently abnormal because of embryonic veins, agenesis, hypoplasia, valvular incompetence, or aneurysms of deep veins. We previously reported on the surgical management of KTS. In this article, we update our experience. METHODS: Twenty patients with KTS underwent surgical treatment for VMs between July 1, 1987, and January 1, 2000. This group represented 6.9% of 290 patients with KTS who were seen at our institution during this 12.5-year study period. Surgical indications, venous anatomy (determined with duplex scan, contrast phlebography, magnetic resonance imaging or magnetic resonance phlebography), operative procedures, and complications were reviewed, and outcomes were recorded. RESULTS: Twelve male and eight female patients (mean age, 23.4 years; range, 7.7-40.6 years) underwent 30 vascular surgical procedures in 21 lower limbs. All 20 patients (100%) had varicose veins or VMs, 13 (65%) had port-wine stains, and 18 (90%) had limb hypertrophy. Pain was the most common complaint, which was present in 16 patients (80%), followed by swelling in 15 (75%), bleeding in 8 (40%), and superficial thrombophlebitis and cellulitis in 3 (15%). Imaging confirmed patent deep veins in 18 patients, hypoplastic femoral vein in 1, and entrapped popliteal veins bilaterally in 1. Four patients (20%) had large persistent sciatic veins (PSVs). The CEAP clinical classification was C-3 for 17 patients (85%), C-4 for 1 patient (5%), and C-6 for 2 patients (10%). Stripping of large lateral veins, avulsion, and excision of varicosities or VMs were performed on all limbs. Three patients required staged resections. The release of entrapped popliteal veins was performed in both limbs of one patient; another underwent a popliteal-saphenous bypass graft. One patient underwent excision of a PSV. Open and endoscopic perforator vein ligation was performed in one patient each. Two patients (12%) had hematomas that required evacuation. No patients had caval filter placement; none had postoperative deep venous thrombosis or pulmonary embolus. The mean follow-up was 63.6 months (range, 0-138 months). All patients reported initial improvement, but some varicosities recurred in 10 patients (50%), an ulcer did not heal in one, and a new ulcer developed in one, 8 years after surgery. Three patients underwent reoperation for recurrent varicosities. Follow-up CEAP scores were C-2 in 10 patients (50%), C-3 in 6 patients (30%), C-4 and C-5 in 1 patient each (5%), and C-6 in 2 patients (10%). Clinical scores improved from 4.3 +/- 2.2 to 3.1 +/- 2.3. (P =.03). CONCLUSIONS: The management of patients with KTS continues to be primarily nonoperative, but those patients with patent deep veins can be considered for excision of symptomatic varicose veins and VMs. Although the recurrence rate is high, clinical improvement is significant, and reoperations can be performed if needed. Occasionally, deep vein reconstruction, excision of PSVs, or subfascial endoscopic perforator surgery is indicated. Because KTS is rare, patients should receive multidisciplinary care in qualified vascular centers.

Aortic fenestration for acute or chronic aortic dissection: an uncommon but effective procedure.

BACKGROUND: Aortic fenestration is rarely required for patients with acute or chronic aortic dissection. To better define its role and the indications for its use and to evaluate its success at relieving organ or limb malperfusion, we reviewed our experience with direct fenestration of the aorta. METHODS: A retrospective analysis of all consecutive aortic fenestrations performed between January 1, 1979, and December 31, 1999, was performed. Fourteen patients, 12 men and two women (mean age, 59.6 years; range, 43-81), underwent fenestration of the aorta. All patients were hypertensive and had a history of tobacco use. By Stanford classification, there were three type A and 11 type B patients. In the acute dissection group (n = 7), indications for surgery were malperfusion in six patients (leg ischemia, 4; renal ischemia, 5; bowel ischemia, 3) and intra-abdominal bleeding from rupture in two. In the chronic dissection group (n = 7), indications for surgery were abdominal aortic aneurysm in 4 patients (infrarenal, 3; pararenal, 1), thoracoabdominal aneurysm in 1, hypertension from coarctation of the thoracic aorta in 1, and aortic occlusion with disabling claudication in 1. RESULTS: Emergency aortic fenestration was performed in seven patients (surgically for 6 and percutaneously for 1). Fenestration level was infrarenal in four and pararenal in three. Concomitant abdominal aortic graft replacement was performed in four patients, combined with ascending aortic replacement (n = 1) and bilateral aortorenal bypasses (n = 1). In two patients, acute fenestration was performed for organ malperfusion after prior proximal aortic replacement (ascending aorta, 1; descending thoracic aorta, 1). Seven elective aortic fenestrations were performed for chronic dissection (descending thoracic aorta, 2; paravisceral aorta, 2; infrarenal aorta, 2 and pararenal aorta, 1). Concomitant aortic replacement was performed in six patients (abdominal aorta, 5; thoracoabdominal aorta, 1). Fenestration was successful at restoring flow in all 10 patients with malperfusion. Operative mortality for emergency fenestration was 43% (3/7). The three deaths that occurred were of patients with anuria or bowel ischemia, or both. There were no postoperative deaths for elective fenestration. At a mean follow-up of 5.1 years, there were no recurrences of malperfusion and no false aneurysm formations at the fenestration site. CONCLUSION: Fenestration of the aorta can effectively relieve organ or limb ischemia. Bowel ischemia and anuria are indicators of dismal prognosis and emergency fenestration in these patients carries a high mortality. Elective fenestration combined with aortic replacement can be performed safely in chronic dissection. Aortic fenestration is indicated for carefully selected patients with malperfusion and offers durable benefits.

Replacement of the inferior vena cava for malignancy: an update.

OBJECTIVES: Resection and replacement of the inferior vena cava (IVC) to remove malignant disease is a formidable procedure. Since our initial report with IVC replacement for malignancy, we have maintained an aggressive approach to these patients. The purpose of this review is to update our experience with regard to patient selection, operative technique, and early and late outcome. METHODS: All patients who had IVC replacement for primary (n = 2) or secondary (n = 27) vena cava tumors from April 1990 to May 1999 were reviewed. Tumor location and type, clinical presentation, the segment of IVC replaced, graft patency, performance status of the patient, and tumor recurrence and survival data were collected. Late follow-up data were available for all but one patient. The IVC was replaced in 28 patients with large diameter (> or =14 mm) externally supported ePTFE grafts and with a panel graft of superficial femoral vein in the other. Three patients had a femoral arteriovenous fistula. Graft patency was determined before hospital dismissal and in follow-up by vena cavography, computed tomography, ultrasonography, or magnetic resonance imaging. RESULTS: There were 18 women and 11 men, with a mean age of 53.1 years (range, 16-88 years). Over one half of patients had symptoms from their tumor. IVC replacement was at the suprarenal segment in 15 patients, of whom 13 had concomitant major hepatic resection, at the infrarenal segment in 10, at both caval segments in three, and at the renal vein confluence in one. There were two early deaths (6.9%). One patient died intraoperatively of coagulopathy during liver resection and suprarenal IVC replacement. The other death occurred 4 months postoperatively, from multisystem organ failure that resulted in graft infection and occlusion. Twelve patients had one or more major complications- cardiopulmonary problems in five; bleeding in five; chylous ascites or large pleural effusions in two patients each; and lower extremity edema with tibial vein thrombosis in one. The mean follow-up was 2.8 years (range, 2.7 months to 6.3 years). Two late graft occlusions occurred: one at 7.5 months, the other, from tumor recurrence, at 6.3 years. There have been no other late graft-related complications. All 11 late deaths were caused by the progression of malignant disease. Of 16 survivors, 12 have no evidence of disease and four have either regional or distant metastatic recurrence. Initial postoperative performance status was good or excellent for most survivors. CONCLUSIONS: Aggressive surgical management may offer the only chance for cure or palliation of symptoms for patients with primary or secondary IVC tumors. Our experience suggests that vena cava replacement may be performed safely with low graft-related morbidity and good patency in carefully selected patients.

Aortic-origin reconstruction of the great vessels: risk factors of early and late complications.

OBJECTIVE: Great vessel reconstruction for arterial occlusive disease has been shown to be a durable procedure. The purpose of this report is the examination of the influence of cause and risk factors on outcomes for the identification of patients who may be better treated with endovascular techniques or other surgical approaches. METHODS: Data for patients who underwent aortic-origin great vessel reconstruction between 1988 and 1998 were reviewed. The data were analyzed with Fisher exact test, life-table analysis, and log-rank test. RESULTS: Ninety-two vessels underwent revascularization in 58 patients (15 men, 43 women; mean age, 54 years; age range, 20 to 82 years). Etiology was atherosclerosis obliterans (n = 40; 69%), Takayasu's arteritis (n = 13; 22%), radiation arteritis (RA; n = 4; 7%), and mediastinal fibrosis (n = 1; 2%). The symptoms were cerebrovascular (n = 25), upper extremity (n = 8), or both (n = 23), and two patients were asymptomatic. The bypass grafting was performed with single-limb synthetic grafts (n = 23) or grafts plus side arms (n = 28). Seven patients underwent innominate endarterectomy. The mean follow-up period was 45 months (range, 0 to 126 months). The perioperative stroke (n = 4; 7%) and death (n = 2; 3%) rates were not related to the cause of disease. The patients with creatinine levels of 2 or more (n = 4) had a combined perioperative stroke/death rate of 50% (vs 7% for patients with healthy creatinine levels; P <.05). The patients with hypercoagulable states (ie, thrombophilia; n = 6) had an increased perioperative stroke rate (33% vs 4% for patients without hypercoagulable states; P <.05) and an increased late thrombosis rate. The primary and secondary graft patency rates at 5 years were 80% +/- 7% and 91% +/- 5%, respectively. Patients with RA had a greater risk of stroke or death at 3 years (33% free of stroke or death vs 79% for patients with atherosclerosis obliterans and 92% for patients with Takayasu's arteritis; P =.02) and an increased major late infection rate (50% vs 2% for all others; P =.01). CONCLUSION: Patients with thrombophilia and renal insufficiency have increased perioperative stroke and stroke/death rates, respectively. Patients with RA have an increased incidence rate of late major infection, which directly contributes to an increased rate of stroke or death. Patients with thrombophilia have an increased rate of late graft thrombosis. These patient conditions should be approached cautiously, and some patients may benefit from endovascular therapy.

The results of in situ prosthetic replacement for infected aortic grafts.

BACKGROUND: Treatment of aortic graft infection with graft excision and axillofemoral bypass may carry an increased risk of limb loss, aortic stump blowout, and pelvic ischemia. A review of patients with aortic graft infection treated with in situ prosthetic graft replacement was undertaken to determine if mortality, limb loss, and reinfection rates were improved with this technique. METHODS: The clinical data of 25 patients, 19 males and 6 females, with a mean age of 68 years (range 35 to 83), with aortic graft infection, treated between January 1, 1989, and December 31, 1998, by in situ prosthetic graft replacement were reviewed. Follow-up was complete in the 23 surviving patients and averaged 36 months (range 4 to 103). RESULTS: Twenty aortofemoral, 3 aortoiliac, and 2 straight aortic graft infections were treated with excision and in situ replacement with standard polyester grafts in 16 patients (64%), or with rifampin-soaked collagen or gelatin-impregnated polyester grafts in 9 patients (36%). Fifteen patients (60%) had aortic graft enteric fistulas, 8 patients (32%) had abscesses or draining sinuses, and 2 patients (8%) had bacterial biofilm infections. Thirty-day mortality was 8% (2 of 25). There were no early graft occlusions or amputations. There was one late graft occlusion. There were no late amputations. The reinfection rate was 22% (5 grafts). All reinfections occurred in patients operated upon for occlusive disease. Only one reinfection occurred in the rifampin-soaked graft group (11% versus 29%, P = NS). Reinfection tended to be lower in patients with aortoenteric fistulas and without abscess. Autogenous tissue coverage provided statistically significant protection against reinfection. There were no late deaths related to in situ graft infection. CONCLUSIONS: Patients treated with in situ graft replacement had an 8% mortality and 100% limb salvage rate. Reinfection rates were similar to those of extra-anatomic bypass, but a trend of lower reinfection rates with rifampin-impregnated grafts was apparent. Patients with aortoenteric fistula and without abscess appear to be well treated by the technique of in situ prosthetic grafting and autogenous tissue coverage.

Endovascular repair of abdominal aortic aneurysms: where do we stand?

Endovascular repair of abdominal aortic aneurysms has evolved dramatically within the past few years. In light of the potential to reduce morbidity and mortality associated with open surgical repair, endoluminal grafting offers therapeutic options to patients who are not surgical candidates because of comorbidities. With the development of bifurcated devices, more complex aneurysms may be treated by endovascular grafting. Although successful placement of endovascular grafts requires a pronounced learning curve, including appropriate patient selection, midterm results seem consistent with those of traditional open repair of aneurysms. This review describes the current indications, minimal requirements, different devices and associated techniques, and potential complications of endoluminal repair of abdominal aortic aneurysms. Future aspects of endoluminal grafting are also discussed.

Management of true aneurysms distal to the axillary artery.

OBJECTIVE: To delineate management strategies and outcomes for true aneurysms involving arteries of the upper extremity distal to the axillary artery. The management of these rare lesions has not been well established in the literature. METHODS: Retrospective chart review was performed at tertiary referral centers. All patients who received the diagnosis of true upper extremity aneurysms distal to the axillary artery between 1975 and 1995 were included in the review. Nineteen patients were found; seven were excluded because no confirmatory diagnostic imaging study or operative exploration was performed. This represents the largest reported series of true upper extremity arterial aneurysms. RESULTS: Twelve patients (9 men or boys) had 12 confirmed true aneurysms of the brachial or more distal arteries. The average diameters were as follows: brachial artery 4.6 cm, radial artery 2.0 cm, ulnar artery 1.4 cm, and digital artery 0.8 cm. The mean age was 51 years (range, 10 to 86 years). The most common presentation was the presence of a mass. This occurred among eight patients (67%). Four patients (33%) reported pain or paresthesia. One patient (8%) had cold intolerance only. Three patients (25%) had thromboembolic complications. Complications did not consistently correlate with size or presence of intramural thrombus. Three aneurysms (25%) were initially managed nonoperatively and followed for a mean period of 71 months. One of these required operative repair after 5 months because of progressive pain. Ten patients (83%) were treated surgically as follows: five underwent ligation and excision only, and five underwent excision and revascularization. Morbidity was minimal, and there were no perioperative deaths. CONCLUSION: True arterial aneurysms of the upper extremity distal to the axillary artery are rare and most commonly caused by blunt trauma. Fifty-eight percent of these lesions present with symptoms or complications. Thirty-three percent of asymptomatic lesions later become symptomatic. These factors combined with the minimal morbidity associated with repair suggest that operative repair should be routinely performed for these aneurysms. Revascularization can be performed selectively.

Aorto-caval and ilio-iliac arteriovenous fistulae.

BACKGROUND: To determine optimal management of major abdominal arteriovenous fistulae and define factors affecting outcome. METHODS: We reviewed clinical data of 18 patients, 16 males and 2 females, who underwent repair of major abdominal arteriovenous fistulae between 1970 and 1997. RESULTS: Sixteen patients had primary fistula, caused by rupture of an atherosclerotic aortic or aortoiliac aneurysm into the inferior vena cava (IVC), iliac, or left renal vein. Two had secondary, iatrogenic arteriovenous fistulae. Seventeen patients (94%) were symptomatic, 11 (62%) had acute presentation. Fistula was diagnosed preoperatively in 8 (44%). Fistula closure (direct suture 16, patch 1, iliac vein ligation 1) was followed by aortoiliac reconstruction in all patients. Caval clip was placed in 3 patients. Early mortality was 6%; 7 patients had major complications. During follow-up (mean 6.1 years) 2 patients died of causes related to fistula closure. CONCLUSIONS: Rupture of aortoiliac aneurysms into the iliac veins or IVC carries a better prognosis than intraperitoneal, retroperitoneal, or enteric rupture. Although preoperative diagnosis is ideal, a high index of suspicion, careful repair avoiding pulmonary embolization, and blood salvage were all helpful in keeping morbidity and mortality low. Our data suggest that IVC interruption is seldom warranted.

Long-term survival and late complications after repair of ruptured abdominal aortic aneurysms.

PURPOSE: Long-term survival and late vascular complications in patients who survived repair of ruptured abdominal aortic aneurysms (RAAA) is not well known. The current study compared late outcome after repair of RAAA with those observed in patients who survived elective repair of abdominal aortic aneurysms (AAA). METHODS: The records of 116 patients, 102 men and 14 women (mean age: 72.5 (8.3 years), who survived repair of RAAA (group I) between 1980 to 1989 were reviewed. Late vascular complications and survival were compared with an equal number of survivors of elective AAA repair matched for sex, age, surgeon, and date of operation (group II). Survival was also compared with the age and sex-matched white population of west-north central United States. RESULTS: Late vascular complications occurred in 17% (20/116) of patients in group I and in 8% (9/116) in group II. Paraanastomotic aneurysms occurred more frequently in group I than in group II (17 vs. 8, p = 0.004). At follow-up, 32 patients (28%) were alive in group I (median survival: 9.4 years) and 53 patients (46%) were alive in group II (median survival: 8.7 years). Cumulative survival rates after successful RAAA repair at 1, 5, and 10 years were 86%, 64%, and 33%, respectively. These were significantly lower than survival rates at the same intervals after elective repair (97%, 74%, and 43%, respectively, p = 0.02) or survival of the general population (95%, 75%, and 52%, respectively, p < 0.001). Coronary artery disease was the most frequent cause of late death in both groups. Vascular and graft-related complications caused death in 3% (3/116) in group I and 1% (1/116) in group II. Cox proportional hazards modeling identified age (p = 0.0001), cerebrovascular disease (p = 0.009), and number of days on mechanical ventilation (p = 0.01) to be independent prognostic determinants of late survival in group I. CONCLUSIONS: Late vascular complications after repair of RAAA were higher and late survival rates lower than after elective repair. These data support elective repair of AAA. As two-thirds of the patients discharged after repair of RAAA are alive at 5 years, aggressive management of RAAA remains justified.

Reconstruction of the superior vena cava: benefits of postoperative surveillance and secondary endovascular interventions.

PURPOSE: Superior vena cava (SVC) reconstructions are rarely performed; therefore the need for surveillance and the results of secondary interventions are unknown. METHODS: During a 14-year period 19 patients (11 male, 8 female; mean age 41.9 years, range 8 to 69 years) underwent SVC reconstruction for symptomatic nonmalignant disease. Causes included mediastinal fibrosis (n = 12), indwelling foreign bodies (n = 4), idiopathic thrombosis (n = 2), and antithrombin III deficiency (n = 1). Spiral saphenous vein graft (n = 14), polytetrafluoroethylene (n = 4), or human allograft (n = 1) was implanted. RESULTS: No early death or pulmonary embolism occurred. Four early graft stenoses or thromboses (spiral saphenous vein graft, n = 2, polytetrafluoroethylene, n = 2) required thrombectomy, with success in three. During a mean follow-up of 49.5 months (range, 4.7 to 137 months), 95 imaging studies were performed (average, five per patient; range, one to 10 studies). Venography detected mild or moderate graft stenosis in seven patients; two progressed to severe stenosis. Two additional grafts developed early into severe stenosis. Four of 19 grafts occluded during follow-up (two polytetrafluoroethylene, two spiral saphenous vein graft). Computed tomography failed to identify stenosis in two grafts, magnetic resonance imaging failed to confirm one stenosis and one graft occlusion, and duplex scanning was inconclusive on graft patency in 10 patients. Angioplasty was performed in all four patients with severe stenosis, with simultaneous placement of Wallstents in two. One of the Wallstents occluded at 9 months. Repeat percutaneous transluminal angioplasty was necessary in two patients, with placement of Palmaz stents in one. Only one graft occlusion and one severe graft stenosis occurred beyond 1 year. The primary, primary-assisted, and secondary patency rates were 61%, 78%, and 83% at 1 year and 53%, 70%, and 74% at 5 years, respectively. CONCLUSION: Long-term secondary patency rates justify SVC grafting for benign disease. Postoperative surveillance with contrast venography is indicated in the first year to detect graft problems. Endovascular techniques may salvage and improve the patency of SVC grafts.

Graft-related complications after abdominal aortic aneurysm repair: reassurance from a 36-year population-based experience.

PURPOSE: Graft-related complications must be factored into the long-term morbidity and mortality rates of abdominal aortic aneurysm (AAA) repair. However, the true incidence may be underestimated because some patients do not return to the original surgical center when a problem arises. METHODS: To minimize referral bias and loss to follow-up, we studied all patients who underwent AAA repair between 1957 and 1990 in a geographically defined community where all AAA operations were performed and followed by a single surgical practice. All patients who remained alive were asked to have their aortic grafts imaged. RESULTS: Among 307 patients who underwent AAA repair, 29 patients (9.4%) had a graft-related complication. At a mean follow-up of 5.8 years (range, < 30 days to 36 years), the most common complication was anastomotic pseudoaneurysm (3.0%), followed by graft thrombosis (2.0%), graft-enteric erosion/fistula (1.6%), graft infection (1.3%), anastomotic hemorrhage (1.3%), colon ischemia (0.7%), and atheroembolism (0.3%). Complications were recognized within 30 days after surgery in eight patients (2.6%) and at late follow-up in 21 patients (6.8%). These complications were observed at a median follow-up of 6.1 years for anastomotic pseudoaneurysm, 4.3 years for graft-enteric erosion, and 0.15 years for graft infection. Kaplan-Meier 5- and 10-year survival free estimates were 98% and 96% for anastomotic pseudoaneurysm, 98% and 95% for combined graft-enteric erosion/infection, and 98% and 97% for graft thrombosis. CONCLUSIONS: This 36-year population-based study confirms that the vast majority of patients who undergo standard surgical repair of an abdominal aortic aneurysm remain free of any significant graft-related complication during their remaining lifetime.

Predictive value of carotid artery stump pressures during carotid endarterectomy.

The ideal method of monitoring cerebral perfusion during carotid endarterectomy remains controversial. This article reviews many of the larger studies in the literature that have attempted to evaluate the usefulness of carotid artery stump pressure. Topics discussed include stump pressure alone, regional anesthesia, stump pressure and EEG, and stump pressures and transcranial Doppler ultrasonography.