The Management of Aneurysmal Degeneration of Lower Extremity Cryopreserved Saphenous Vein Bypass Grafts.

BACKGROUND: The use of cryopreserved saphenous veins (CSVs) for the treatment of lower extremity peripheral arterial disease is an attractive option when there is no available autogenous vein. Prior studies found CSVs are at risk for aneurysmal degeneration requiring reoperation. As the management of these complications and patient outcomes is not well described, the objective of this case series is to describe the open and endovascular management of degenerative CSVs at a tertiary community center. METHODS: All CSVs implanted for lower extremity bypass at our institution between 2001 and 2021 were retrospectively reviewed. All CSVs with evidence of aneurysmal change were included in this study. CSVs with evidence of active infection were excluded. The decision to intervene was left to the discretion of the operating surgeon. Demographic data, indications for the index operation, and details about subsequent interventions for degenerative CSVs were recorded. Study end points included limb salvage and continued patency. Demographic data, indications for the index operation, and details about subsequent interventions for degenerative CSVs were recorded. RESULTS: Seventeen bypasses were identified to have aneurysmal degeneration in 13 patients in the absence of infection between 2001 and 2021. Nine of the 13 patients were male, and the average age and body mass index during the index procedure were 72 and 28, respectively. Indications for the index bypass included acute limb ischemia (9), popliteal aneurysm (2), and chronic limb threatening ischemia with Rutherford's class IV (5) and V (1). The mean time between the index procedure and first graft revision due to aneurysmal changes was 4 years. Most of the aneurysms did not occur at the site of anastomosis with 13 occurring in the body of the graft. Thirteen grafts were managed with open surgery and 3 were managed with endovascular techniques. All endovascular repairs were managed via covered stenting. Patients were followed for an average duration of 7 years from the initial bypass and 2 years from their last aneurysmal repair. Limb salvage in this cohort was 87% with 2 limbs requiring amputation, all of whom underwent open reconstruction. The mortality rate in this series was 54% and no patients died due to complications from their graft. Continued patency on Kaplan Meier survival curve analysis was 79% at 6 months, 65% at 1 year, 54% at 3 years, and 27% at 5 years. CONCLUSIONS: In our experience, aneurysmal degeneration of CSV grafts was mostly managed with standard open surgical techniques, although endovascular therapy also proved acceptable. Limb salvage rates and continued patency of repair at 1 year in this cohort were acceptable. This case series highlights the importance of diligent surveillance for patients with CSVs.

Surgical pulmonary embolectomy in a community hospital.

BACKGROUND: Surgical pulmonary embolectomy (SPE) is indicated for a pulmonary embolism associated with hemodynamic instability. A review of the literature demonstrates that most studies of SPE are conducted at large academic medical centers. This series is from a 325-bed community hospital. METHODS: A retrospective chart review was performed of patients undergoing SPE from January 2008 to December 2012. All patients aged >18 years were reviewed for 30-day mortality, length of hospital stay, comorbidities, and preoperative hemodynamic parameters. RESULTS: Fifteen patients (7 men and 8 women; median age, 55.5 years; range, 20-72 years) underwent SPE. There were 2 deaths (13.3%). Four of the patients underwent catheter-directed interventions before SPE. The mean length of hospital stay was 12 days. CONCLUSIONS: These data suggest that SPE is associated with favorable outcomes in the appropriate community setting, and the mortality rate seen in this study compares favorably with the nationwide average of 27.2%.

Complication rates for percutaneous lower extremity arterial antegrade access.

HYPOTHESIS: The antegrade access (AA) for percutaneous arterial interventions is associated with a higher complication rate than is the retrograde access (RA). DESIGN: Retrospective case review. SETTING: A statewide consortium for peripheral vascular interventions consisting of 13 Michigan hospitals collecting data on their endovascular procedures. PATIENTS: Demographic and procedure data on all patients receiving a percutaneous peripheral arterial intervention were entered prospectively by a full-time clinical nurse specialist in each hospital site. MAIN OUTCOME MEASURES: We evaluated vascular complications as a composite of retroperitoneal hematoma, pseudoaneurysm, hematoma requiring blood transfusion, arteriovenous fistula, acute thrombosis, or the need for surgical repair of the access site. RESULTS: In a 2-year period, we collected 6343 cases, of which 5918 had complete data regarding arterial access; of these, 745 (12.6%) were performed via an AA. There were fewer women and smokers (P < .001) in the AA group but more diabetic patients (P < .001). The indications for intervention were more frequently rest pain (P < .001) and limb salvage (P < .001) in the AA group. Multivariate regression analysis showed that the odds of complications were significantly higher with a larger sheath (95% confidence interval, 1.53-4.06; P < .001). Also, the incidence of blood transfusion and subsequent amputation was significantly higher in the AA group (P < .001). CONCLUSION: Endovascular procedures performed via an AA are more likely to result in perioperative complications and therefore should be used cautiously.

Vascular procedures in nonagenarians and centenarians are safe.

BACKGROUND: An increasing number of elderly patients present for elective and emergent vascular procedures. The purpose of this study was to analyze the 30-day and long-term outcome of patients in their 10th decade of life undergoing vascular procedures. METHODS: We reviewed the outcomes of all patients in the 10th decade of life included in our registry. RESULTS: In a 15-year period, there were 176 patients, 102 women and 74 men, with a mean age of 92 (range 90-102) undergoing 196 vascular operations for acute and chronic limb ischemia, aortic and popliteal aneurysms, and carotid stenosis. Overall morbidity and mortality rates were comparable as well as the return to preoperative functional status. CONCLUSIONS: Patients in their 90s can safely undergo vascular procedures with reasonable early outcomes. Most patients return to their preoperative status. Age alone should not be a determinant in refusing surgery in this age group.