Recurrent carotid stenosis.

Twenty-nine patients developed recurrent stenosis of the carotid artery 5 months to 13 years following carotid endarterectomy. Thirty-two recurrent lesions were repaired. Recurrent atherosclerosis was present in 19 patients, intimal fibrosis occcurred in nine patients, and one patient had external stricture. All recurrent atheromas developed more than 2 years following original operation (mean, 5 years) and intinal fibrosis was seen in the first postoperative year in all but one patient (mean, 9 months). Reconstructive techniques included endarterectomy for atherosclerosis and patch angioplasty and resection and anastomosis for intimal fibrosis.

The critical manipulable variables of hemispheric low flow during carotid surgery.

A significant EEG change, 40% power attentuation in anesthetic-induced fast activity, was documented with a tracing record, compressed spectral analysis, and PSA-1 in this series of 195 patients. Interpretation of the change was simplified by the use of the compressed spectral analysis or PSA-1. Quantification of the change was aided by use of the PSA-1, and the graphic output form of this instrument minimized user error. Also, it provided the needed information to those members of the operative team not skilled in EEG interpretation. No immediate postoperative deficits were missed by the monitoring technique. There were no postoperative deficits upon awakening in the 138 patients without processed EEG change. Shunt placement, depth of anesthesia, and intraoperative blood pressure levels were accurately guided throughout the operative procedure by these monitoring techniques. Accurate documentation of an acute significant change permits prompt treatment for restoration of necessary collateral flow. The monitoring technique described continuously provides information for efficacy of treatment. Attention to blood pressure level, which seems to passively determine cerebral collateral flow during clamping, was a very important clinically manipulable variable. Manipulation of this variable with processed EEG control may prove efficacious not only in patients undergoing carotid procedures but in nonsurgical cases of acute carotid occlusion or middle cerebral stem occlusion. Manipulation of identifiable critical variables has a positive impact on the clinical outcome when continuous monitoring is employed. The detection of hemispheric low flow in 34 patients during the preclamp, clamp, and postclamp periods suggests that shunting will not prevent all low flow deficits. Finally, perfection of surgical therapy for stroke prevention necessitates detection and treatment of hemispheric low flow.

Arterial injuries in extremity shotgun wounds: requisite factors for successful management.

The extremity shotgun wound presents a surgical challenge in the treatment of peripheral arterial trauma. Adherence to specific principles of management is required for optimal limb salvage. Thirty-four vascular injuries in 31 patients were reported. Arteriography is mandatory since the presence of distal palpable pulses was an unreliable indicator of the absence of arterial injury in 13 patients. Intraoperative arteriography was essential to demonstrate distal sequential injuries. Arterial reconstruction was necessary in 28 patients who sustained 31 significant vascular injuries. Autogenous interposition grafts were required in 10 patients. Seventeen patients underwent resection of the injured arterial segment followed by an end-to-end anastomosis. Arteriovenous fistulas were ligated in two patients, while two sidewall injuries were treated with lateral repair. Delay of operative intervention with subsequent infection, failure to reconstruct all vessels injured, and inadequate initial fasciotomy were factors that contributed to an amputation in two patients. Successful management of arterial injuries in extremity shotgun wounds requires attention to the following requisite factors: preoperative and intraoperative arteriography, prompt operative intervention, fracture stabilization, repair of all injured major vessels, use of autogenous graft tissue, venous reconstruction, thorough debridement, and fasciotomy. Twenty-nine of 31 patients retained a functional limb by adhering to these principles of management.

Diagnosis of peripheral occlusive disease: comparison of clinical evaluation and noninvasive laboratory.

One hundred and two patients with peripheral vascular disease were evaluated by the attending surgeon, residents and students, and the vascular laboratory prior to arteriography to test their ability to make a correct anatomic diagnosis. The attending surgeons made a correct anatomic diagnosis in 98 patients and were at least partially correct in the other four. Surgical housestaff and students were 62% totally correct, 35% partially correct, and 3% totally wrong. The vascular laboratory results were almost identical with the attending surgeon, but two patients could not be evaluated because of calcified arteries. The operation that was eventually performed was suggested initially by the laboratory and the attending surgeon in 98% of the patients.

Aortorenal arterial autografts.

Forty-nine iliac artery autografts were used in the treatment of renovascular hypertension in 45 patients, including six children. The pathological process was fibromuscular dysplasia in 42, atherosclerosis in two, and Takayasu arteritis in one. The internal iliac artery was used as a graft in 39 patients. The common iliac bifurcation was used in two patients, and the external iliac artery in four patients. Common and external iliac artery continuity was restored with Dacron prostheses. Forty-three patients with 47 autografts have been followed up from one to ten years (average three years). Hypertension was cured or improved in 96% of the patients. Serial follow-up arteriograms as late as ten years after surgery have been obtained in 50% of the patients. No late occlusions occurred. Slight autograft dilation occurred seven years postoperatively in one child. Normal growth of the autograft was exhibited in the remaining five children. No evidence of dilation, aneurysm formation, or stenosis appeared in any other grafts, although one patient developed a new lesion distal to her graft.

Complications of small dose prophylactic heparinization.

The observations reported herein on the use of prophylactic small dose heparinization are in no way intended to diminish its value but are reported and reviewed so that certain precautions may be exercised in its use. In fact, the apparent difference in the incidence of pulmonary emboli in the controls and heparinized patients may lend credence to its value. The large controlled series now being studied at various medical centers will help to confirm or deny the value of this factor in the prevention of emboli. Careful preoperative scrutiny of the patient and meticulous intraoperative hemostasis remain important factors when a patient is receiving small dose heparin therapy. Other factors such as concomitant medications, weight of the patient, frequency and technic of administration and dosage must be considered. Additionally, monitoring the hemostatic mechanism with serial hematocrit determinations and laboratory coagulation tests appears to be an important adjunct in small dose prophylactic heparinization.

Extent of choledochoscopic utilization in common bile duct exploration.

Various reports have demonstrated that the intraoperative utilization of the choledochoscope has significantly reduced the incidence of unsuspected retained common duct stones from approximately 10 percent to 0 to 2 percent. Our series revealed a 4 percent incidence of retained stones before choledochoscopy was utilized. This incidence was reduced to 1.1 percent after it was employed. Since the availability of the choledochoscope is unknown, all hospitals in Alabama with 60 or more beds (total of 86) were surveyed to determine the rate of choledochoscopic utilization. Although this instrument was noted to be readily available in many of those institutions with greater than 150 beds (47 percent), only 25 (29 percent) of all the hospitals surveyed had the choledochoscope. Furthermore, only 17 (20 percent) of all hospitals used the instrument routinely for common duct exploration. Although the rate of retained common bile duct stones in Alabama is unknown, it is probably similar to the 10 percent average reported. Consequently, it is believed that wider acceptance of the choledochoscope will reduce the incidence and associated morbidity of retained common bile duct stones.

Surgical treatment of renovascular hypertension in children.

In fourteen children with renovascular hypertension the most prevalent lesion was fibromuscular dysplasia (nine patients). Nephrectomy was performed in four patients prior to the adoption of reconstructive vascular techniques. Revascularization of a variety of lesions was employed with autogenous arterial grafts, which gave excellent results over a long follow-up period in ten patients. Ex vivo microvascular repair was used in one patient rather than nephrectomy for management of branch artery lesions. These results indicate that careful and precise arterial repairs will yield a high cure rate in children with renovascular hypertension without the sacrifice of renal parenchyma.

Cholelithiasis and aortic reconstruction.

Identification of cholelithiasis during abdominal aortic reconstruction with placement of a vascular prosthesis provides cause for hesitation in performing a simultaneous cholecystectomy because of the potential contamination of the graft. However, the association of cholelithiasis with cholecystitis is well established and was observed in a group of patients who had known cholelithiasis following aortic reconstruction. Cholelithiasis was noted in 50 of 250 patients who underwent reconstruction of the abdominal aorta or its major branches. Seventeen of the 50 patients with cholelithiasis underwent a cholecystectomy prior to aortic reconstruction. Sixteen patients underwent a cholecystectomy at the time of aortic reconstruction and experienced no morbidity related to the cholecystectomy. Seventeen patients with cholelithiasis did not undergo cholecystectomy. All were asymptomatic. Nine of these individuals developed cholecystitis or symptoms related to their gallstones following aortic reconstruction. A subsequent cholecystectomy was performed in all nine patients. The interval between aortic reconstruction and cholecystectomy was from 2 weeks to 108 months. The remaining eight patients with cholelithiasis have been followed up for 17 to 50 months. Six of these patients remain asymptomatic. The two patients followed up for the longest period (42 and 50 months, respectively) have become symptomatic. If there are no mitigating circumstances, cholecystectomy is advised for patients undergoing aortic reconstruction with associated cholelithiasis.

Adjunctive use of the balloon dilatation catheter during vascular reconstructive procedures.

Intraoperative balloon angioplasty was performed on 80 patients undergoing a concomitant vascular reconstructive procedure during the past 30 months. All angioplasties were performed by the operating surgeon with the aid of fluoroscopy and in conjunction with the vascular reconstruction. The primary purpose of balloon angioplasty was to either increase inflow (66%) or outflow (23%) in association with a planned vascular procedure. The remaining patients had a variety of other arterial dilatations. Dilatation obviated the need for additional arterial reconstructions in these elderly patients. One episode of peripheral embolization constituted the only operative complication. Follow-up ranged from 1 to 30 months (mean, 13.4 months). Sixty-four patients remained asymptomatic during the follow-up period. Sixteen patients became symptomatic in the postoperative period and underwent angiography. One iliac and three superficial femoral arteries had restenosed. The remaining 12 patients had additional vascular problems not associated with the dilatation or previous operation. The intraoperative use of the balloon catheter by the vascular surgeon broadens the therapeutic armamentarium available for the correction of multiple, symptomatic, arterial lesions. Balloon angioplasty as a separate procedure was thus avoided, resulting in decreased morbidity and expense. The scope of arterial reconstructions was expanded without expansion of the operation. The balloon catheter should be used intraoperatively as adjunctive therapy in appropriate circumstances.

Directional atherectomy and balloon angioplasty for lower extremity arterial disease.

This study was undertaken to evaluate the use of directional atherectomy, balloon angioplasty, and video angioscopy in highly selected patients with superficial and popliteal artery stenoses. Directional atherectomy and balloon angioplasty for superficial femoral and popliteal artery stenosis (> 80%) were performed in 96 limbs (88 patients) between 1990 and 1994. All procedures were performed by the authors with angioscopy and C-arm angiography. Society for Vascular Surgery/International Society for Cardiovascular Surgery (SVS/ISCVS) categorical classification of chronic limb ischemia and run off scoring was utilized pre- and postoperatively to assess outcome. The indicators for atherectomy were moderate claudication (category 2, 15% of limbs), severe claudication (category 3, 65%), ischemic rest pain (category 4, 12%), and tissue loss (category 5, 12%). Morbidity was 6.0% with no perioperative mortality. All technically and (angiographically) successfully treated patients demonstrated postoperative improvement. Clinical assessment, vascular laboratory studies (outcome criteria), and/or angiography were monitored at follow-up visits. Intraoperative failures occurred in 6% of limbs due to inability to pass a guide wire (3%), impacted atherectomy catheter (1%), or vessel perforation (2%). In the remaining 90 limbs, 23% failed due to either progression of disease (7.7%) or restenosis at the original site (15.3%). Seventy-one percent of limbs maintained their postoperative categorical improvement at a mean follow up of 24 months. Combining atherectomy and balloon angioplasty may be more durable than angioplasty or atherectomy alone. A long-term prospective study of the role of directional atherectomy and balloon angioplasty by vascular surgeons appears to be warranted utilizing SVS/ISCVS guidelines for lower extremity chronic ischemia categories, run-off score, and outcome criteria for patency.

Concomitant renal endarterectomy and aortic reconstruction.

PURPOSE: This retrospective study is to determine the efficacy and durability of renal endarterectomy in patients undergoing simultaneous aortic reconstruction. In addition, the operative risk to patients with symptomatic and asymptomatic renal artery stenosis is evaluated. METHODS: The results of a retrospective study of 101 patients who underwent combined procedures are presented. All patients demonstrated at least a 75% stenosis of the renal artery ostium by arteriography and underwent surgical repair of aneurysmal (n = 33) or aortic occlusive (n = 68) disease. The indications for renal revascularization were hypertension necessitating multiple medications (47%), hypertension combined with renal insufficiency (18%), renal insufficiency alone (5%), and asymptomatic stenosis (30%). Blood pressure and antihypertension medications were monitored during the follow-up period (mean 3.3 years). RESULTS: The perioperative mortality rate was 1%, with a postoperative morbidity rate of 15%. The conditions of 74% of patients with hypertension were improved or cured, 23% were unchanged, and 3% were worse after surgery. Systolic and diastolic blood pressure in all patients remained significantly diminished during follow-up visits at 3 months, 6 months, 1 year, 3 years, and 6 years (p < 0.01). There was no significant improvement in serum creatinine levels in patients with preexisting renal insufficiency. A small but statistically significant decrease in systolic blood pressure and serum creatinine level was noted after operative intervention in the symptom-free patients (p < 0.005). There were no deaths in the asymptomatic subgroup, and significant azotemia did not develop in any of these patients after operation. CONCLUSIONS: Renal endarterectomy is an effective and durable method of renal revascularization. Furthermore, it is a technique that can be safely combined with aortic surgery and can be considered in the treatment of high-grade, asymptomatic lesions in patients undergoing aortic reconstruction.

The power spectrum analyser as an indicator of cerebral ischaemia during carotid endarterectomy.

Stroke is a potential major complication of carotid endarterectomy and may be caused by cerebral ischaemia or embolisation from the operative site. Conventional EEG monitoring has been used intraoperatively to identify periods of cerebral ischaemia, but this monitoring technique can be difficult to operate and interpret in the operating room. This study reports the use of a new signal analyser, the power spectrum analyser (PSA-1, Neurologics, Inc., Nashville, Tennessee), and its impact on active patient management. Thirty-six patients undergoing carotid endarterectomies were monitored with the PSA-1 in conjunction with routine EEG. Eight patients (22%) showed evidence of ischaemia 22 times on both PSA-1 and routine EEG. At no time did the routine EEG show evidence of ischaemia when the PSA-1 did not. The PSA-1 has proven to be a reliable neurophysiologic monitor for the identification of periods of cerebral ischaemia. Use of this small, easily operated and interpreted machine could enhance safety in operating rooms lacking sufficient resources to use conventional EEG machines.

Secondary recurrent carotid stenosis.

PURPOSE: Recurrent carotid stenosis after carotid endarterectomy has been extensively reported. The occurrence, however, of another ipsilateral restenosis that requires a third carotid operation is rare. The purpose of this study was to evaluate possible risk factors and the most efficacious management of the patient with "secondary" recurrent carotid stenosis. METHODS: A survey of the Southern Association for Vascular Surgery was performed, and 31 patients who had had surgery for secondary recurrent carotid stenosis were identified. RESULTS: The mean interval between the recurrent stenosis operation and secondary recurrent carotid stenosis was 39.8 months (range, 9 to 83 months). At the third operation, 21 patients underwent carotid patch angioplasty and 10 underwent carotid resection with an interposition saphenous vein graft. No postoperative strokes or deaths occurred; three patients (10%) had a peripheral nerve injury. Nine early (< 24 mo) secondary recurrent carotid stenoses occurred, and these patients underwent patch angioplasty. Twenty-three female, cigarette-smoking patients and 20 patients with elevated lipid levels had early restenosis and were identified as being at high risk for the development of another stenosis. A fourth significant stenosis developed in five of these high-risk patients who had saphenous vein patch angioplasty at their third carotid operation; eight other high-risk patients had carotid resection with an interposition saphenous vein graft, and no other stenosis developed. CONCLUSION: Patients who have secondary recurrent carotid stenoses can safely undergo a third carotid operation. Female habitual smokers with elevated lipid levels and an early restenosis appear to be at high risk of secondary recurrent carotid stenoses. When surgery is necessary, carotid resection with an interposition saphenous vein graft appears more durable than patch angioplasty.