Limb salvage in elderly patients. Is aggressive surgical therapy warranted?

With the continued increase in life expectancy in the United States, the number of elderly patients presenting with limb-threatening atherosclerotic occlusive disease will also rise. The risk of arterial reconstructive surgery has been considered prohibitive in many of these individuals. During a six-year period, 50 patients aged 80 years or greater underwent a total of 64 surgical procedures for limb-threatening ischemia: 17 men (34%) and 33 women (66%). Ages ranged from 80 to 97 with a mean of 84 years. The procedural mortality rate was 3.1%. Cumulative life table survival rates for these patients were at 1 year, 92%; at 2 years, 76%; and at 3 years, 76%. The cumulative life table limb salvage rates were 92%, 88%, and 83% at the same intervals. Of the patients who died during the follow-up periods, 79% still had their previously-threatened limb intact. The results in these patients, as well as those from other series, support an aggressive policy of arterial reconstruction for elderly patients with limb-threatening ischemia. Age, per se, is not a contraindication to revascularization.

A prospective comparison of intra-arterial digital subtraction and conventional angiography prior to lower extremity revascularization.

Prior to lower extremity revascularization, patients underwent CA or IADSA as the only radiologic study. A total of 30 patients were entered into each group and subsequently underwent a reconstructive procedure. Each study in the CA group was deemed accurate at the time of surgery, in assessing suitability of vessels for anastomosis. Of the patients undergoing surgery based exclusively on IADSA, 5 were noted in whom this examination provided insufficient detail or were misleading, resulting in attempted reconstructions at inappropriate sites. These results were statistically significant and indicate that IADSA should not be used as the only imaging technique in the preoperative evaluation of lower extremity vascular disease. IADSA is most useful as a complementary technique to CA and should be performed during the same examination when the latter fails to identify distal runoff vessels. In the majority of cases, CA alone will provide sufficient information and should be used as the initial contrast study.

Intraaortic balloon rupture.

To identify patients at risk and assess management strategies, nine Datascope intraaortic balloon (IAB) ruptures in 8 patients were reviewed. This is a 2.4% incidence for this complication (382 insertions over 75 months). Time to initial rupture was 4.7 days, range 1.1 to 6.8 days. This was 1.3 days after the average intact device was removed. Women were three times more likely to sustain rupture than men (4 vs. 1.3%, P less than 0.05). Rupturing IABs were characterized by a greater magnitude of diastolic augmentation than intact IABs, 69.4 +/- 24.9 vs. 25.5 +/- 12.6 Torr (P = 0.01). A hypertensive treatment history was more prevalent in patients rupturing (83 vs. 41%) (P less than 0.05). Rupture was diagnosed by finding blood in the safety chamber in all patients. There was no gas embolization nor did any patient become infected. Ruptured devices showed abrasion wear in the most distal portion of the IAB, where the aorta is smallest. In vitro testing with CO2 showed no driving gas loss but withdrawal of the surrounding fluid into the IAB system. Ruptured IAB replacement in four patients was associated with three survivors. In four patients the device was not replaced and two patients survived. There were no complications as a consequence of IAB rupture (all values +/- SD).

Spinal cord ischemia following elective aortoiliac reconstruction.

Spinal cord ischemia following abdominal aortic procedures is a rare complication. It occurs most commonly after operations for ruptured abdominal aortic aneurysms but has also been reported secondary to operations for aortoiliac occlusive disease. A 67-year-old man suffered spinal cord infarction following a routine, uncomplicated aortofemoral bypass. Although generally considered a rare and unpredictable complication of aortoiliac reconstruction, measures are discussed which might have prevented its occurrence in this case, and may further reduce its incidence in the future.

Aortoiliac reconstruction in obese patients.

In the patient with limb-threatening ischemia and aortoiliac occlusive disease surgical reconstruction with a prosthetic bypass, because of its safety and durability, has emerged as the treatment of choice. In obese patients, however, such therapy might be eschewed because of the frequent coexistence of multiple risk factors and the large size of these patients. In ten obese patients who had limb-threatening ischemia or rapidly worsening disabling claudication and aortoiliac occlusive disease, direct aortoiliac reconstruction was performed. There were no perioperative deaths, and only one major complication occurred in this group. The cumulative 5-year graft limb-patency and limb-salvage rates were each 90%. Despite the higher risk and unusual technical challenges that obese patients may present, direct reconstruction is the preferred treatment for aortoiliac occlusive disease and limb-threatening ischemia.

Mycotic aneurysm of the superior mesenteric artery.

The superior mesenteric artery is a frequent site of mycotic aneurysm formation. With the increasing popularity of parenteral drug abuse the incidence of superior mesenteric aneurysms is likely to increase. It should be suspected in any patient who has a history of bacterial endocarditis, sepsis, and abdominal pain. Abdominal CT scanning and visceral angiography are most useful in establishing the diagnosis, and surgical therapy should ensue with minimal delay. The various intraoperative methods of eradicating this lesion are described, with a review of the literature and report of successful management of one such case.