Atherosclerosis and the hypoplastic aortoiliac system.

Between January, 1965, and December, 1975, 204 patients (138 men and 66 women) underwent aortoiliac reconstruction for atherosclerotic occlusive disease. Eighteen patients (9%) had a hypoplastic aortoiliac segment and an analysis of these 18 patients constitutes the basis of this report. There were 17 women and one man, and their ages ranged from 28 to 60 years, with an average of 43 years. Hyperlipidema was present in nine of 13 patients tested. All patients were heavy cigarrete smokers and had lower extremity claudication with weak or absent pulses. Carotid or subclavian artery disease was found in 50%. Angiography demonstrated hypoplasia of the aorta distal to the renal arteries with either occlusion, diffuse narrowing, or, most often, an "hourglass" stenosis. The iliac and femoral arteries also were narrowed. Reconstruction was achieved primarily by aortobilateral-iliac or femoral bypass. There were no operative deaths and all patients were improved initially. It appears that normally occurring atherosclerosis in this portion of the aorta, along with congenital narrowing, accounts for symptoms at an early age. The predominence in women is a puzzle. The prognosis does not appear to be too grim. This may be due to absence of diabetes mellitus and the infrequency of coronary artery disease. All patients are still alive; there has been one major amputation following graft infection 1 1/2 years after operation. When progression of atherosclerosis occurs, it seems to involve the superficial femoral, carotid, and subclavian arteries.

Duplex ultrasonography to diagnose failing arterial prosthetic grafts.

BACKGROUND: Although several reports have documented the usefulness of a surveillance program with duplex ultrasonography (DU) to diagnose failing autologous vein bypasses, the effectiveness of DU to detect failing arterial prosthetic grafts has not been confirmed. We attempted to determine whether our program, which included DU and other noninvasive techniques (NonDU), was useful for this purpose. METHODS: Between July 1, 1991, and September 30, 1994, 85 prosthetic bypasses in 59 patients performed for lower extremity ischemia were entered into a graft surveillance protocol. There were 35 femoropopliteal, 16 femorotibial, 15 iliofemoral, 13 axillofemoral, and 6 femorofemoral bypasses. Both DU and NonDU were performed 1 week and every 3 months after the initial bypass or after graft revision. NonDU criteria of a failing graft included changes in symptoms or pulses, decreased ankle/brachial index greater than 0.15, or diminution of ankle pulse volume recordings greater than 50%. Normal grafts were bypasses that had less than 50% stenosis documented by arteriography or remained patent. Problem grafts were those that required revision or thrombosed before intervention. Follow-up of patient grafts ranged between 3 and 36 months (mean, 11 months). RESULTS: DU predicted 17 (81%) of 21 problem grafts versus only 5 (24%) diagnosed by NonDU (p = 0.001). Lesions associated with these 21 grafts were perianastomotic in 10 cases, in adjacent inflow or outflow arteries in 8 cases, and intrinsic to the graft in 3 cases. The likelihood of a graft thrombosing in the presence of a normal test was 7% (4 of 58) for DU compared with 21% (16 of 76) for NonDU (p = 0.04). CONCLUSIONS: DU is more sensitive than NonDU in predicting failure of prosthetic grafts. This study suggests that DU should routinely be performed as part of a surveillance program for peripheral arterial prosthetic bypasses.

Venous aneurysms: surgical indications and review of the literature.

BACKGROUND: During the last 20 years we diagnosed five cases of venous aneurysm of the jugular (n = 4) and basilic (n = 1) veins. The purpose of this report was to determine the natural history and indications for surgery of venous aneurysms. METHODS: Our five cases were included in an English-language literature review performed through August 1993. RESULTS: In our series two aneurysms (one external jugular vein, one basilic vein) were excised for cosmetic reasons. Three internal jugular vein aneurysms were followed up for up to 4 years without complications with serial color duplex ultrasonography. Of 32 patients with abdominal venous aneurysms (18 portal, seven inferior vena cava, four superior mesenteric, two splenic, one internal iliac), 13 (41%) had major complications including five deaths. Of 31 patients with deep venous aneurysms of the extremity (29 popliteal, two common femoral), 22 (71%) had deep vein thrombosis or pulmonary embolism and in 17 recurrent deep vein thrombosis or pulmonary embolism developed when patients were treated with anticoagulation alone. CONCLUSIONS: Prophylactic surgery is cautiously recommended for low-risk patients with venous aneurysms of the abdomen and strongly recommended for most patients with lower extremity deep venous aneurysms. Other venous aneurysms should be excised only if they are symptomatic, enlarging, or disfiguring.

Five-step protocol for carotid endarterectomy in the managed health care era.

BACKGROUND: We developed a protocol combining 5 cost-effective strategies to determine whether elective carotid endarterectomy (CEA) could be performed safely without adversely affecting well-established low morbidity and mortality rates and with significant hospital cost savings. METHODS: Between April 1, 1995, and December 31, 1996, 109 of 141 patients were prospectively enrolled as candidates into a 5-step CEA protocol: (1) duplex ultrasonography (DU) performed at an accredited vascular laboratory as the sole diagnostic carotid preoperative study, (2) admission the day of operation, (3) cervical block anesthesia to eliminate intraoperative electroencephalogram monitoring, (4) transfer from the recovery room after a 4-hour observation period to the vascular ward, and (5) discharge the first postoperative morning. The other 32 patients were excluded from analysis; 16 patients were treated by vascular surgeons not participating in the protocol, 9 were treated concomitantly for other medical problems, and 7 were admitted emergently. RESULTS: One patient died of carotid hemorrhage the first postoperative morning, and one had an intraoperative embolic stroke for a combined mortality-stroke rate of 1.8% (2 of 109). Of the 109 patients, 70% (76) underwent operation using DU as the sole diagnostic study, 95% (104) were admitted the day of operation, 76% (83) had cervical block anesthesia, 59% (64) were transferred to the floor the day of operation, and 83% (90) were discharged the morning after operation. None of the 109 patients were adversely affected by these 5 cost-saving strategies except potentially the patient who bled the first postoperative morning. The predicted charges of a patient treated with a perioperative protocol that many vascular surgeons currently use (preoperative arteriography, general anesthesia with intraoperative electroencephalogram monitoring, overnight intensive care unit stay, discharge on postoperative day 2) was $16,073 compared with $10,437 for a patient who completed all 5 steps of the protocol detailed above. CONCLUSIONS: On the basis of these results documenting significant cost savings and acceptably low morbidity and mortality rates, this 5-step protocol may be considered the standard for performing CEA in this era of cost containment. These results may be compared with endovascular intervention, which has recently been proposed as a less expensive technique to treat carotid disease.

Sequential femoropopliteal and femorotibial bypasses. A ten-year follow-up study.

Since 1970, we have performed 33 sequential femoropopliteal bypass grafts (of 482 femoropopliteal bypasses [7%]) and 22 sequential femorotibial bypass grafts (of 153 femorotibial bypasses [14%]). Patients ranged in age from 51 to 90 years. Twenty-two (66%) of the sequential femoropopliteal bypass grafts, and all of the sequential femorotibial bypass grafts, were for limb salvage. By life table analysis, interval patency rates for both types of sequential procedures at 60 months, 72 months, and even longer are good (greater than 80% for both sequential femoropopliteal and sequential femorotibial bypasses). These two sequential bypasses are effective alternatives when the saphenous vein is inadequate. We assume that these results are due to excellent inflow (using a prosthetic graft proximally) and the use of a segment of autogenous saphenous vein over the knee joint.

Division of the left renal vein. Guidelines and consequences.

Ligation and division of the left renal vein is a reasonable safe procedure in selected patients when exposure of the perirenal aorta is crucial. This manipulation is possible because of extensive venous collateralization from the left kidney in man. Measurement of the venous stump pressure before ligation is recommended to assess the degree of collateralization, and the upper limit within which the vein may be divided safely is probably in the neighborhood of 60 cm of water. Reanastomosis of the vein is not necessary for preservation of renal function, although transient left renal dysfunction may occur. Examination of the urine and careful monitoring of renal function should be routine in the postoperative period. Intravenous urography and left spermatic venography later in the postoperative course can indicate the ultimate degree of function of the left kidney and the pathways of venous collateralization. Preservation of normal function and venous architecture at the renal hilum should be the rule.

The sequential femoropopliteal bypass graft. A five year experience.

(1) A five year experience with sequential bypass grafts for femoropopliteal tibial reconstruction is presented. (2) Twenty-nine consecutive grafts were performed in twenty-eight patients in whom the saphenous vein was absent or inadequate for grafting purposes. (3) The series contains a high percentage of women (57 per cent), diabetics (39 per cent), and patients requiring surgery because of rest pain or tissue necrosis (83 per cent). (4) There was no operative mortality and no significant operative morbidity. (5) The overall graft patency rate is 71 per cent, which is comparable to that obtained with standard bypass technics. (6) There was no late failures in the ten grafts that survived one year or more. (7) This procedure appears to be a useful method for bypass grafting to the popliteal or tibial arteries below the knee when the saphenous vein is absent or inadequate.

Revision of failing lower extremity bypass grafts.

BACKGROUND: Color-duplex ultrasound (CDU) surveillance of arterial bypass grafts has been validated, but the natural history of "failing" grafts remains poorly defined. Our purpose was to compare failing grafts having prophylactic revision with those that did not. METHODS: Postoperative duplex surveillance was performed in an accredited vascular laboratory for all lower extremity bypass grafts performed at a single institution. Eighty-five infrainguinal grafts (57 vein, 21 polytetrafluoroethylene (PTFE), and 7 composite grafts) in 83 patients were identified as failing by accepted criteria. Twenty-five grafts were revised early (early), 20 grafts revised more than 2 months after the initial CDU-abnormality (late), and 40 grafts were not prophylactically revised (no revision) at any time. RESULTS: The three groups were not different (P > 0.10) with regard to gender, age, level of bypass, type of conduit, location of stenoses, or timing of abnormality after surgery. No revision patients more frequently had diffuse low peak systolic flow velocity (PSV) as the CDU abnormality (P = 0.013). Cumulative primary patency was significantly better at 12 months (P = 0.028) in the no revision group (78.9%) compared with early grafts (43.1%) or late grafts (63.8%), and this difference remained significant when low PSV grafts were excluded from analysis. However, assisted primary patency, secondary patency, and limb salvage rates did not differ between the three groups (P > 0.10). CONCLUSIONS: Our experience in this retrospective study contradicts other reports supporting the efficacy of prophylactic graft revision for grafts identified as failing by currently accepted CDU criteria. Refinement of CDU criteria to more accurately predict graft thrombosis is needed.

Alternatives in the treatment of abdominal aortic aneurysms.

Most patients with abdominal aortic aneurysm can safely undergo aneurysmectomy. In poor-risk patients the mortality rate is greatly increased. A procedure which is a safe alternative for patients who might otherwise be denied an elective procedure is described. However, this technique for the management of abdominal aortic aneurysm is not a substitute for the classic surgical treatment.

Division of the left renal vein during aortic surgery.

Perirenal aortic exposure and control can be facilitated by division of the left renal vein (LRV), but only if adequate collateral venous drainage is present. When incremental elevations in LRV pressure were produced in nine dogs, we noted that left renal glomerular and tubular function (creatinine clearance, sodium retention, urine osmolality, and urine output) were virtually lost at pressures greater than 50 to 60 cm water. Between January 1967 and December 1989, 64 patients underwent LRV division during the performance of abdominal aortic aneurysm surgery (57 of 589 = 10%) or reconstruction for aortoiliac occlusive disease (7 of 506 = 1%). LRV stump pressures (LRVSPs) were measured in 44 of these patients and were less than or equal to 60 cm water in all but one instance. Ten of the 64 patients died, but none as a consequence of this maneuver. Post-operatively, all survivors had serial serum creatinine levels measured and either an intravenous pyelogram, renal scan, or arteriogram. One case of a non-functioning left kidney was identified. This occurred in the only patient who underwent re-anastomosis after LRV division. A LRVSP equal to or greater than 50 cm water and extreme venous distention after test clamping served as a contraindication to LRV division in seven other patients. We conclude that a LRVSP less than or equal to 50 to 60 cm water indicates that the LRV may be safely divided during juxtarenal aortic exposure. However, a pressure greater than or equal to 50 to 60 cm water suggests that LRV division should not be carried out unless absolutely essential and then only if right kidney function is known to be adequate.

Management and outcome of infrapopliteal arterial graft infections with distal graft involvement.

PURPOSE: The purpose of this study was to determine the outcome of patients with infrapopliteal artery graft infections (InfraPopGIs) who presented with graft infection distal to the popliteal artery. PATIENTS AND METHODS: Between July 1, 1979 and June 30, 1994, 27 patients presented with infrapopliteal artery graft infections (18 polytetrafluoroethylene [PTFE], 9 autologous vein). The infection involved the anastomosis in 22 cases (8 anterior tibial, 8 posterior tibial, 4 peroneal, 2 dorsalis pedis arteries) and was localized to the body of the graft in 5 cases (4 calf, 1 ankle). All bypasses were originally performed for limb salvage. Twelve patients with patent grafts and intact anastomoses were managed by complete graft preservation. Fifteen patients presented with occluded grafts (10), anastomotic hemorrhage (4), or systemic sepsis (1) and were treated by total or subtotal graft excision. RESULTS: The hospital mortality rate was 19% (5 of 27) and the amputation rate in survivors was 27% (6 of 22). These results were compared with a mortality rate of 13% (15 of 114; P > 0.05) and a limb loss rate of 10% (10 of 99)(P = 0.05) in 114 patients during this period who presented with infection proximal to the tibial arteries. Of 6 survivors with graft infections who required amputations, 5 lacked a suitable outflow artery for a secondary bypass and 1 developed progressive gangrene despite a patent secondary bypass. Among the other 16 survivors, 7 (44%) limbs remained viable without requiring a secondary bypass, 6 (37%) limbs were salvaged with successful preservation of patent grafts, and 3 (19%) required secondary bypasses to prevent limb loss. CONCLUSIONS: Patients presenting with infrapopliteal artery graft infections have higher amputation rates than patients with more proximal infected peripheral grafts. Selective graft preservation and selective revascularization when outflow arteries are available are essential adjuncts to minimize high rates of limb loss associated in patients with graft infections.

Artificial pancreas as an aid during insulinoma resection.

Blood glucose control by an artificial pancreas facilitated the intraoperative management of two patients with insulin-secreting pancreatic islet cell tumors (one had a large adenoma, the other diffuse islet-cell hyperplasia). The artificial pancreas is a glucose-controlled insulin and dextrose infusion system uniquely suited for the control of blood glucose concentrations during surgery. The artificial pancreas produced a stable glycemic baseline before surgery, prevented hypoglycemia during palpation of the pancreas and manipulation of the tumor, and indirectly amplified small decreases in the blood sugar level with large increases in the rate of dextrose infusion. The advantages and limitations of continuous glucose monitoring during surgery and the use of this instrument in locating occult insulin-secreting tumors are reviewed.

Carotid stump pressure, stump pulse, and retrograde flow.

In order to obtain a more comprehensive intraoperative hemodynamic profile and to predict hypoperfusion during carotid endarterectomy, stump pressure, stump pulse, and retrograde internal carotid flow were measured in 261 patients. Our results show a significant correlation between stump pressure and retrograde flow (p < 0.001), stump pressure and the presence of a stump pulse (p < 0.001), and retrograde flow and the presence of a stump pulse (p < 0.001). We also demonstrated a significant correlation between stump pressure (lower), retrograde flow (less), and the absence of a stump pulse in patients with contralateral carotid artery occlusion. There was no correlation between the indication for carotid endarterectomy and any hemodynamic measurement. The triad of stump pulse, stump pressure, and retrograde flow accurately reflects collateral blood flow when the carotid is cross-clamped. These determinations can be obtained at low cost and are easily and rapidly performed. A protocol for selective shunting in patients undergoing carotid endarterectomy with general anesthesia is suggested.

Arterial and ischemic aspects of total knee arthroplasty.

Prospective and retrospective analyses of 1,182 consecutive patients undergoing primary total knee arthroplasty (TKA) were performed to determine (1) the incidence of chronic lower extremity ischemia (CLEI); (2) the effect of tourniquet occlusion; and (3) guidelines that will allow TKA to be performed safely. Despite the appropriately advanced age of our patients, the incidence of CLEI was only 2%. All ischemic complications occurred in six patients with CLEI (25%), but none resulted in death or amputation. The ischemic complications consisted of pressure-induced necrosis of toes, heel, or foot, atheroembolism, femoral-popliteal graft occlusion, and asymptomatic popliteal occlusion. Tourniquet compression in the 1,158 patients without CLEI produced no untoward effects. Patients with mild CLEI can have a TKA performed safely with a tourniquet if there is no femoropopliteal calcification. When the ischemia is severe or there is a femoropopliteal aneurysm, arterial reconstruction should precede the TKA. In patients with patent femoral-popliteal bypasses or calcification without ischemia, TKA should be performed without a tourniquet. Ischemic pressure necrosis is an additional mechanism of injury.

Management of infected lower extremity autologous vein grafts by selective graft preservation.

Between 1975 and 1991, we treated 16 patients with infected lower extremity autologous vein grafts performed for limb salvage by complete graft preservation. Traditional treatment of these infections includes immediate graft excision and complex revascularization procedures to prevent limb loss. The infection involved an intact anastomosis in 12 patients or the body of a patent graft in 4 patients. None of the patients was systemically septic. All patients were treated with appropriate intravenous antibiotics. Six patients were treated by placement of autologous tissue on the exposed graft (4 rotational muscle flaps, 2 skin grafts), and 10 were treated with antibiotic-soaked dressing changes and repeated operative débridements to achieve delayed secondary wound healing. This treatment resulted in a 19% (3 of 16) mortality rate and an 8% (1 of 13) amputation rate in survivors. Of the six patients managed by autologous tissue placement onto the infected graft, five patients had wounds that healed without complications, and one died of a myocardial infarction. Of the 10 patients treated by delayed secondary wound healing, 2 developed anastomotic hemorrhage, which resulted in death in 1 patient and above-knee amputation in the other, 1 died of a myocardial infarction, 1 developed graft thrombosis, and 6 had wounds that healed. Placement of autologous tissue to cover an exposed, infected patent vein graft with intact anastomoses may prevent graft dessication, disruption, and thrombosis, which renders graft preservation an easier, safer method of treatment compared with routine graft excision.

Recommendations for initial antibiotic treatment of extracavitary arterial graft infections.

BACKGROUND: Initial antibiotic treatment of extracavitary arterial graft infections is usually empiric or based on Gram's stain findings. Increasing virulence of bacteria causing extracavitary arterial graft infections may render previous choices of antibiotics obsolete. The purposes of this study were to correlate Gram's stain findings of gram-positive bacteria and gram-negative bacteria with wound cultures and provide a microbiologic basis for appropriate initial antibiotic therapy. METHODS: Between July 1, 1979 and June 30, 1994, specimens obtained on the day of admission from purulent wounds involving 113 extracavitary arterial graft infections were retrospectively reviewed for Gram's stain and culture and sensitivity results. RESULTS: Gram's stain findings correlated with final cultures on only 28 of 113 cases (25%), including 20 of 48 pure gram-positive, 2 of 24 pure gram-negative, and 6 of 41 mixed bacterial cultures. Staphylococcus aureus was the most common gram-positive bacteria cultured (43 isolates) and Pseudomonas species was the most common gram-negative bacteria (25 isolates). Bacteria were sensitive to a first-generation cephalosporin in only 32% (36 of 113) of infections. A combination of vancomycin and either ticarcillin-clavulanic acid or ceftazidime, which have minimal toxicity and provide excellent coverage against staphylococci, Pseudomonas, and other gram-negative bacteria, would have covered 96% (109) and 95% (107) of cultured organisms, respectively. CONCLUSIONS: Regardless of Gram's stain findings, current recommendations for initial treatment of extracavitary arterial graft infections should include vancomycin and ceftazidime or ticarcillin-clavulanic acid until final culture and sensitivity results dictate the use of more selective antibiotics.

Reoperative approaches to failed procedures confined entirely to the abdominal aorta.

Options do exist when the vascular surgeon is faced with failed procedures confined to the abdominal aorta. Knowledge of the various techniques outlined previously allows an orderly and minimal-risk approach in these patients. Use of the original graft is often the first choice to revascularize ischemic lower extremities in low-risk patients. Extra-anatomic bypasses are generally reserved for high-risk patients. The exception is hepatorenal and splenorenal bypasses that are the revascularization method of choice in most patients with failed unilateral aortorenal bypasses.

Primary aortoduodenal fistula due to septic aortitis.

We report the second case of a primary aortoenteric fistula resulting from septic aortitis with a contained aortic leak into the retroperitoneum and finally erosion into the duodenum. An emergency laparotomy revealed a fistula between the third part of the duodenum and a decompressed sac (false aneurysm) arising from a nonaneurysmal, grossly infected pararenal aorta. The purpose of this report is to present this rare case in detail and to review primary aortoenteric fistulas reported in the English language literature. Most fistulas form in association with an abdominal aortic aneurysm and rarely are due to infection. Only 6% of patients presented with the classic triad of abdominal pain, a palpable mass, and gastrointestinal bleeding. Although 29% of patients presented with massive hemorrhage, adequate time usually existed for surgical treatment of these complications. A patient with ill-defined abdominal pain and fever who suddenly develops a palpable abdominal mass should have an emergency ultrasound or CT scan to exclude the possibility of an infected aortic aneurysm or a contained rupture of an infected nonaneurysmal aorta. If the symptoms are associated with bleeding and the patient is hemodynamically stable, emergent endoscopy should also be performed. If a primary aortoenteric fistula or an aortic pseudoaneurysm is confirmed, emergent surgery should be undertaken to avoid rupture into the bowel or retroperitoneum.

Do you know the treatment of choice in peripheral arterial occlusive disease?

Five early warning signs can alert you to the presence of acute arterial occlusive disease, which can come on abruptly. It is crucial to differentiate between embolism and thrombosis, since treatment of the former is relatively simple, whereas the latter requires a more complicated surgical procedure.

Role of nursing personnel in implementing clinical pathways and decreasing hospital costs for major vascular surgery.

Collaboration with key nursing personnel is essential to successfully implement clinical pathways, establish a dedicated vascular wing, and achieve significant hospital cost savings while still maintaining quality care with low morbidity and mortality rates. Key nursing personnel met once a month during a 1-year period with vascular surgeons, hospital administrators, and health care advisors to plan strategies to develop clinical pathways and establish a dedicated vascular ward. The pathways were then implemented. We compared morbidity, mortality, readmission rates, adn hospital costs among two groups of patients admitted for major vascular surgery. Nursing personnel, attending staff, and surgical residents found that treating patients who had undergone major vascular surgery was more straightforward and efficient after clinical pathways and a dedicated vascular wing were established. In addition, there were no significant differences between the groups in terms of overall mortality or pulmonary, neurologic, or cardiac complications despite shorter hospital stay and decreased hospital costs. Also there were no significant differences in readmission rates within 30 days.