Clinical outcome of an extended proximal seal zone with the AFX endovascular aortic aneurysm system.

OBJECTIVE: Despite improvements in endograft technology, operator skill, and patient selection, endovascular aneurysm repair continues to be associated with device-related complications. A retrospective, observational study was undertaken to evaluate the clinical outcome and imaging findings of a unique device having externally-mounted, conformable graft material. METHODS: Infrarenal abdominal aortic aneurysms were treated with the Endologix, Inc AFX endovascular aortic aneurysm system (Irvine, Calif) endograft in 108 consecutive patients over a 25-month period at two U.S. clinical sites. Baseline characteristics and procedural outcomes were reviewed by independent monitors. Serial computed tomography (CT) imaging assessments were performed by an independent core laboratory. Aortic neck characteristics and graft apposition were analyzed from center line-reformatted CT data sets in 37 patients in an imaging cohort comprising subjects with high-resolution baseline and follow-up CT imaging for precise assessment of aortic neck characteristics. The mean follow-up was 11 ± 5 months overall, 9 ± 6 months in patients with core laboratory imaging, and 5 ± 2 months for patients in the imaging cohort. RESULTS: Among the 108 patients, 103 (95%) had intact aneurysms and five (4.6%) were treated for rupture; 80 (74%) were male and 28 (26%) were female. On average, 2.3 ± 0.7 endograft components were implanted per patient and no adjunctive proximal neck bare stents were used. There were no perioperative deaths in patients with intact aneurysms; two patients who presented with ruptured aortic aneurysms (40%) died. Major adverse events occurred within 30 days of implantation in two patients (1.9%) with intact aneurysms. Type II endoleaks were evident on completion angiography in 18 patients (16.7%). Core laboratory analysis of CT studies identified two patients with type Ia endoleaks (2.3%), two with type III endoleaks (2.3%), and five with type II endoleaks (5.7%). Aneurysm-related secondary procedures were required in five patients over the first year of follow-up (4.6%). No patient developed endograft limb occlusion or aneurysm rupture and there were no open surgical conversions. In the imaging cohort, 360° graft-to-aortic wall apposition was continuous over a length of 25 ± 17 mm and extended the seal zone an average of 5 mm beyond the end of the anatomic neck. Early sac regression was correlated with neck length (P = .019) and graft-to-aortic apposition surface area (P = .039). CONCLUSIONS: The real-world use of the AFX endograft was associated with a low rate of device-and procedure-related complications. The ability to achieve an extended seal zone beyond the anatomical neck might in part contribute to positive outcomes, including the low type Ia and type II endoleak rate. These findings suggest that the AFX device might offer some advantages over other currently marketed endografts, but confirmation awaits the availability of longer-term outcome data.

Endovascular repair of small abdominal aortic aneurysms: a paradigm shift?

Recent reports have documented poor long-term results following endovascular aneurysm repair (EVAR) of large abdominal aortic aneurysms (AAA). EVAR of small AAAs may result in improved long-term results compared to large AAAs. It is not known whether the frequency of anatomic suitability for EVAR is increased for small compared to large AAAs. This study compared the anatomic suitability of large and small AAAs for EVAR in an unselected patient population. Radiology reports for all computed tomography (CT) scans in a single hospital over a recent 3-year period were reviewed. AAAs diagnosed by contrasted CT scans with cuts >7 mm were excluded. Suitability for EVAR was determined by neck diameter, length, and angulation. In addition, iliac diameters and common iliac distal landing zone lengths were determined. Computerized 3-dimensional (3D) reconstruction was used to measure neck angulation and total aortic tortuosity. One hundred ninety-one patients were found to have AAAs with adequate CT scans for evaluation. Suitability for EVAR was highest in patients with AAA diameters of 3-4 cm and declined with increasing size of the AAA. Dividing AAAs into sizes greater than or less than 5.5 cm revealed that small AAAs had significantly longer necks, less neck angulation, longer common iliac landing zones, and less total aortic tortuosity. Multivariable analysis revealed that maximal aortic diameter was the only independent predictor of suitability for EVAR (p = 0.005, odds ratio 1.67, CI 95% = 1.17 to 2.38). The odds ratio predicts that with each 1 cm increase in size, the likelihood of suitability decreased by 5.3-fold. Small AAAs have less complex anatomy with longer aortic necks, less neck angulation, and less tortuosity. The poor outcomes following the treatment of large AAAs is thought to be due to complex anatomy. EVAR of less anatomically challenging small AAAs may improve long-term outcomes.

Role of endogenous interleukin-10 in local and distant organ injury after visceral ischemia-reperfusion.

The anti-inflammatory cytokine interleukin (IL)-10 has been detected in serum after visceral ischemia-reperfusion injury and exogenous IL-10 administration has been shown to attenuate the associated distant organ injury. This study was designed to examine the role that endogenous IL-10 production plays on both local and distant organ injury after visceral ischemia-reperfusion injury. Wild-type and IL-10(-/-)-null C57BL/6 mice were subjected to 20 min of supraceliac aortic occlusion or sham laparotomy. Serum and lung tissue cytokine levels (tumor necrosis factor alpha, IL-1beta, IL-6, KC/GRO, and IL-10) were measured after reperfusion (1, 2, and/or 4 h) using either enzyme-linked immunoassay or bioassay. Lung neutrophil infiltration and injury were quantified after reperfusion injury using myeloperoxidase concentration (2 h) and mean capillary permeability (4 h), respectively, whereas the direct liver injury was quantified with serum aspartate aminotransferase levels (1, 2, and 4 h). A subset of IL-10(-/-)-null animals was administered human recombinant IL-10 before the visceral ischemia and lung MPO was measured after reperfusion (2 h). Visceral ischemia-reperfusion in the wild-type and IL-10(-/-)-null mice was associated with in an increase in both serum (IL-1beta, KC/GRO, IL-6) and lung tissue (IL-1beta, KC/GRO) cytokine levels and resulted in lung neutrophil infiltration (myeloperoxidase), lung injury (mean capillary permeability) and liver injury (aspartate aminotransferase). The magnitude of the lung tissue cytokine response (IL-1beta, KC/GRO), neutrophil infiltration, and injury were greater in the IL-10(-/-)-null mice. Exogenous IL-10 resulted in a decrease in the lung neutrophil infiltration in the IL-10(-/-)-null mice. The endogenous IL-10 response to visceral ischemia-reperfusion attenuates the associated lung neutrophil infiltration and injury but has no effect upon either the hepatic injury or the magnitude of the systemic inflammatory response. The beneficial effects of IL-10 may be mediated by the inhibition of IL-1beta and KC/GRO through an endocrine rather than paracrine signal.

Angiotensin II exerts positive feedback on the intrarenal renin-angiotensin system by an angiotensin converting enzyme-dependent mechanism.

BACKGROUND: Plasma angiotensin II (ANG II) is not increased significantly in renovascular hypertension (RVH), but tissue ANG II levels are elevated in both kidneys of renovascular rats. Because the contralateral, non-ischemic kidney is critical for maintenance of hypertension in RVH, this study sought to understand the mechanism by which intrarenal ANG II levels are augmented in the non-ischemic kidney. This study tested the hypothesis that an incremental increase in plasma ANG II induces the intrarenal renin-angiotensin system (RAS) in the non-ischemic kidney by an angiotensin converting enzyme (ACE) dependent mechanism. METHODS: To simulate the incremental increase in plasma ANG II induced by the ischemic kidney in RVH, an ANG II infusion model was used. This model used a chronic infusion of ANG II (40 ng/min) or vehicle by osmotic minipump into uninephrectomized rats. Parallel groups were treated with the ACE inhibitor Enalaprilat (200 mg/kg/day). Intrarenal ACE activity was measured by radioenzymatic assay. ANG II levels were quantified by radioimmunoassay. RESULTS: Hypertension was evident in ANG II-infused rats, compared to control rats (155 +/- 4 versus 112 +/- 1 mmHg; P < 0.001). Concurrent treatment with Enalaprilat reversed the hypertension induced by ANG II infusion (98 +/- 3 versus 155 +/- 4 mmHg; P < 0.001). ANG II up-regulated intrarenal ACE activity in the non-ischemic kidney (59.2 +/- 11.9 versus 25.2 +/- 6.8 units/mg protein; P < 0.01). Enalaprilat significantly decreased renal ACE activity in ANG II-treated rats, compared to ANG II alone (11.4 +/- 1.0 versus 59.2 +/- 11.9 units/mg protein; P < 0.001). Intrarenal ANG II was increased in ANG II-infused rats, compared to control animals (52.9 +/- 7.1 versus 23.0 +/- 3.2 fmol/mg tissue; P < 0.001), and Enalaprilat prevented ANG II-induced increases in intrarenal ANG II (29.9 +/- 2.6 versus 52.9 +/- 7.1 fmol/mg tissue; P < 0.05). CONCLUSION: Incremental changes in plasma ANG II induce de novo production of ANG II in the non-ischemic kidney to augment intrarenal ANG II content. ACE inhibition blocks this positive feedback loop, suggesting that ANG II activates the intrarenal RAS by an ACE-dependent mechanism. The impact of ACE inhibition on blood pressure suggests that this feedback loop may be an important mechanism for maintenance of hypertension in RVH.

Duodenal perforation with an inferior vena cava filter: an unusual cause of abdominal pain.

The insertion of inferior vena cava (IVC) filters results in device migration at rates that exceed 50% in some studies, although the clinical significance of migration remains in question. These filters can also erode or penetrate the IVC wall, injuring adjacent retroperitoneal and abdominal structures. The risk of erosion or perforation is estimated to be as much as 25%, although clinical symptoms are observed far less frequently in patients with these complications. We describe the presentation, evaluation, and treatment of a patient with an IVC strut protruding into the duodenum. This case report discusses complications, presenting symptoms, and treatment of patients with IVC filters complications.

Correlation between ankle-brachial index, symptoms, and health-related quality of life in patients with peripheral vascular disease.

OBJECTIVE: Improving health-related quality of life (HRQL) is the main goal of surgery to treat peripheral vascular disease (PVD); however, HRQL is rarely measured directly. Rather, most surgeons use other measures, such as patient symptoms and ankle-brachial index (ABI) to determine the need for intervention in PVD. The accuracy of these surrogates in representing HRQL has been untested. The purpose of this study was to determine the correlation of these measures with HRQL in patients undergoing evaluation for intervention in symptomatic PVD. METHODS: Patients (n=108) referred to the vascular surgery service with symptoms of PVD were enrolled in a prospective study of HRQL. Patients completed two validated HRQL questionnaires: the short form-36 (SF-36) and the Walking Impairment Questionnaire (WIQ). All patients had symptoms consistent with PVD, including claudication (n=69; 63.9%), ischemic rest pain (n=17; 15.7%), or tissue loss (n=22; 20.4%). ABI was measured at presentation. RESULTS: The mean ABI was 0.53 (range, 0.00-0.98). The maximal correlation between SF-36 score and ABI was reflected in the Physical Component Summary score (r=0.25). WIQ score also exhibited modest correlation with ABI, with maximal correlation noted for stair climbing (r=0.26). Both SF-36 and WIQ scores exhibited a highly significant association with symptoms. Patients with more severe symptoms, such as lifestyle-limiting claudication or limb-threatening ischemia, had lower HRQL scores compared with patients with non-lifestyle-limiting claudication. Multivariate analysis demonstrated that SF-36 and WIQ physical summary scores are better predicted by symptoms than by ABI (P<.01). CONCLUSIONS: HRQL in patients with PVD correlates weakly with ABI, but exhibits a closer association with vascular symptoms. However, neither variable fully expresses patient HRQL. These data suggest that sole reliance on these surrogates may not accurately reflect the effect of PVD on HRQL, or the potential benefit of vascular surgery in improving HRQL.

Deep vein harvest: predicting need for fasciotomy.

OBJECTIVE: Deep thigh veins, including the superficial femoral, superficial femoropopliteal, and profunda femoris veins, are versatile autogenous conduits for arterial reconstruction. Although late venous complications are unusual, deep vein harvest may induce severe venous hypertension and predispose the limb to acute compartment syndrome. The purpose of this study was to define the frequency of fasciotomy in patients undergoing deep vein harvest and to identify clinical predictors of the need for fasciotomy after deep vein harvest. METHODS: Over 9 years, 162 patients underwent arterial reconstruction with deep vein harvested from 264 limbs. Indications for deep vein harvest included aortofemoral reconstruction in 127 patients, brachiocephalic arterial reconstruction in 22 patients, and visceral arterial reconstruction in 13 patients. RESULTS: Fasciotomy was performed in 47 of 264 limbs (17.8%) after deep vein harvest. The prevalence of fasciotomy after deep vein harvest was 20.6% for patients requiring aortofemoral reconstruction, whereas no patients underwent fasciotomy after deep vein harvest for mesenteric or brachiocephalic arterial reconstruction (P =.0068). Fasciotomy was performed in 20.7% of limbs after complete deep vein harvest to a level below the adductor hiatus, but no fasciotomies were performed in patients undergoing subtotal deep vein harvest, ending above the adductor hiatus (P =.0023). The mean preoperative ankle-brachial index (ABI) was significantly lower in limbs requiring fasciotomy (ABI, 0.39 +/- 0.05), compared with patients who did not require fasciotomy (ABI, 0.79 +/- 0.02; P <.0001). Fasciotomy was performed in 76.0% of limbs undergoing concurrent ipsilateral greater saphenous vein (GSV) and deep vein harvest, compared with 11.7% of patients undergoing deep vein harvest alone (P <.0001). The mean volume of intraoperative fluid administered to patients requiring fasciotomy was almost 50% higher than the fluid resuscitation received by patients who did not require fasciotomy (9.6 +/- 1.2 L vs 6.5 +/- 0.6 L; P <.0001). Logistic regression analysis determined that lower preoperative ABI (odds ratio [OR], 60.1; 95% confidence interval [CI], 12.5-289.3; P <.0001) and concurrent harvest of the ipsilateral GSV (OR, 9.9; 95% CI, 3.1-31.3; P <.0001) were predictors of the need for fasciotomy. CONCLUSIONS: One in four patients undergoing deep vein harvest for aortofemoral reconstruction may be expected to develop acute compartment syndrome and require fasciotomy. The risk appears to be greatest in patients with severe lower extremity ischemia and in patients undergoing simultaneous GSV and deep vein harvest. Prophylactic fasciotomy may be appropriate in patients with both risk factors, but vigilance for the development of compartment syndrome after deep vein harvest is required in all patients undergoing deep vein harvest for aortofemoral reconstruction.

Functional outcome after thoracoabdominal aortic aneurysm repair.

OBJECTIVE: Repair of thoracoabdominal aortic aneurysms (TAAAs) is performed for the improvement of long-term survival and the preservation of function. The determination of functional outcome and the identification of predictors of survival and functional recovery after TAAA repair are key to proper patient selection. METHODS: This retrospective review of clinical data was performed in an academic medical center. The demographics, Crawford aneurysm type (I-18, II-33, III-22, IV-28), preoperative risk factors, operative characteristics, and postoperative complications and outcomes were recorded from the medical records for 101 consecutive patients who underwent TAAA repair (58 elective and 43 urgent/emergent). Functional status and living situation at hospital discharge and 12 months after discharge were determined from follow-up examination records or telephone contact with surviving patients. The patients then were categorized into "good" (survival, home, discharge to rehabilitation center, ambulatory) or "bad" (death, discharge to or residence in a long-term care facility, non-ambulatory) outcomes. RESULTS: The postoperative mortality rate was 17.8% (10% in elective cases and 28% in urgent cases), and significant postoperative complications occurred in 77% of the cases (pulmonary complications in 41%, renal complications in 28%, and cord injury in 12%). The mean length of stay was 22.8 + 23.6 days, and at discharge, 80% of the patients were sent to home or rehabilitation and 20% were sent to long-term care facilities. At 1 year, 15 additional patients had died. All but two patients who had been initially discharged to rehabilitation had returned home, but only two patients who had been discharged to long-term care facilities had returned home and both were nonambulatory. Therefore, the survival rate at 1 year was 67%, and only 52.4% of the patients had a "good" outcome at 1 year (survival rate was 78% and rate of "good" outcome was 63% in patients who underwent elective TAAA repair). Independent predictors of postoperative death and "bad" outcome were age more than 75 years, preoperative heart disease, duration of visceral ischemia, use of left atrial femoral bypass graft, postoperative renal dysfunction, and number of organs failing after surgery. CONCLUSION: Survival and good functional outcome after TAAA repair is significantly less common than expected and is primarily predicted with intraoperative factors and postoperative complications. Improved operative techniques and limitation of visceral ischemia reperfusion injury may improve outcome after TAAA repair.

Upregulation of autocrine-paracrine renin-angiotensin systems in chronic renovascular hypertension.

INTRODUCTION: The mechanism by which hypertension is maintained in renovascular hypertension remains poorly defined. Because plasma angiotensin II does not correlate with blood pressure in RVH, we postulated that activation of tissue-specific autocrine-paracrine renin-angiotensin systems may upregulate local production of angiotensin II and maintain hypertension in chronic RVH. METHODS: RVH was induced with a two-kidney one-clip (2K1C) rat model. Animals were killed at 1 or 12 weeks after surgery (acute or chronic RVH). Angiotensin II was quantitated with radioimmunoassay. Angiotensin II-type 1 (AT(1)) receptor density was determined with immunoblotting and immunohistochemistry. RESULTS: Blood pressure was significantly elevated in 2K1C animals compared with sham animals at 1 week (141 +/- 5 mm Hg versus 98 +/- 3 mm Hg; P <.0005) and at 12 weeks (164 +/- 14 mm Hg versus 110 +/- 7 mm Hg; P <.0005) after surgery. No significant difference was seen in plasma angiotensin II levels between 2K1C and control animals during acute (38.2 +/- 6.5 fmol/mL versus 27.6 +/- 6.8 fmol/mL; P = not significant) or chronic (40.1 +/- 17.4 fmol/mL versus 27.1 +/- 6.5 fmol/mL; P = not significant) RVH. During acute RVH, intrarenal angiotensin II was significantly increased in both the clipped (126.0 +/- 16.2 fmol/g versus 62.0 +/- 6.2 fmol/g; P <.005) and unclipped (78.9 +/- 6.3 fmol/g versus 39.9 +/- 2.5 fmol/g; P <.05) kidneys of 2K1C animals compared with control animals. Increased intrarenal angiotensin II levels persisted in chronic RVH in the clipped (147.4 +/- 37.7 fmol/g versus 59.2 +/- 8.7 fmol/g; P <.05) and unclipped (130.8 +/- 31.8 fmol/g versus 63.0 +/- 11.0 fmol/g; P <.05) kidneys of 2K1C animals compared with controls. Adrenal angiotensin II content of 2K1C animals was unchanged in acute RVH (493.7 +/- 51.4 fmol/g versus 522.6 +/- 80.5 fmol/g; P = not significant) but increased nearly three-fold over control animals during chronic RVH (1129.0 +/- 149.3 fmol/g versus 400.6 +/- 59.1 fmol/g; P <.0005). No significant difference in AT(1) receptor density was noted in renal tubules of clipped and unclipped kidneys or in the adrenal glands of 2K1C animals during acute or chronic RVH compared with control animals. CONCLUSION: Tissue angiotensin II production is upregulated in the kidneys and adrenal glands in chronic RVH, and AT(1) receptor density is maintained in these tissues, providing a potential mechanism for maintenance of hypertension in RVH.

Comparison of superficial femoral vein and saphenous vein as conduits for mesenteric arterial bypass.

PURPOSE: Gangrenous bowel, intraabdominal sepsis, and previous failed mesenteric bypass are indications for use of an autogenous conduit for mesenteric arterial reconstruction. Saphenous vein (SV) is often used as the autogenous conduit of choice, but it may be prone to graft stenosis or occlusion. Recent experience with superficial femoral vein (SFV) suggests that it is an excellent alternative conduit for major arterial reconstruction. The purpose of this study was to compare the outcomes of SV and SFV for mesenteric arterial bypass. METHODS: During a 7-year period, 26 patients underwent 43 mesenteric arterial bypass procedures with autogenous conduit. SV was used for 23 bypasses (53%), and SFV was used for 20 bypasses (47%). Indications for revascularization included chronic mesenteric ischemia (n = 15; 58%), acute mesenteric ischemia (n = 9; 35%), and mycotic aneurysm of the paravisceral aorta (n = 2; 7%). Three patients (11%) underwent revascularization with SV grafts and two patients (8%) with SFV grafts after previous failed mesenteric bypass. RESULTS: The 30-day mortality rate was 15%. Three deaths occurred after SV bypass for acute mesenteric ischemia, and one death occurred after a SFV bypass for a ruptured paravisceral mycotic aneurysm. Twenty-two surviving patients were followed for a mean of 31 +/- 6 months. Three of 11 patients (27%) who survived after SV bypass had recurrent mesenteric ischemia develop (acute, n = 1; chronic, n = 2) from graft thrombosis at a mean interval of 32 +/- 22 months after surgery. No patient had recurrent symptoms develop after SFV bypass. One of the three patients with SV graft failure died of acute mesenteric ischemia, and the other two patients underwent successful bypass with SFV. Symptomatic graft failure was significantly more likely to occur in patients receiving SV grafts compared with SFV grafts (P <.05). CONCLUSION: SFV yields acceptable clinical outcomes for mesenteric arterial bypass compared with SV. SFV is a viable alternative to SV when autogenous conduit is indicated for mesenteric arterial reconstruction.

Emerging role of endovascular grafts in complex aortoiliac occlusive disease.

BACKGROUND: Aortobifemoral bypass is the standard therapy for complex aortoiliac occlusive disease. The purpose of this study was to examine the use of endovascular grafts as an alternative to aortobifemoral bypass in patients with advanced aortoiliac occlusive disease at high risk. METHODS: Endovascular grafts were placed in 23 limbs in 22 patients with TransAtlantic Inter-Society Consensus document (TASC) type C and D lesions. All procedures were performed in the operating room, and images were obtained with portable digital fluoroscopy. Surgical exposure of the ipsilateral common femoral artery was performed to enable safe closure of 9F to 12F sheath sites and to facilitate ipsilateral interventions in the distal external iliac artery. Concomitant infrainguinal outflow procedures were performed in 6 patients. RESULTS: Twenty of 22 patients were men; mean patient age was 63.2 +/- 3.2 years. Indications for intervention were rest pain in 12 of 23 limbs and tissue loss in 9 of 22 limbs. Risk factors included hostile abdomen or pelvis in 8 patients, coronary artery disease in 11 patients, end-stage renal disease in 3 patients, and severe chronic obstructive pulmonary disease in 3 patients. Each patient received a mean of 1.6 grafts. Initial technical success was 95.2%, with one technical failure. There was no 30-day mortality. All patients experienced at least one grade improvement per Society for Vascular Surgery reporting standards. Primary patency at 24 months was 84.2% +/- 8.0%, with a limb salvage rate of 95.3% +/- 5.0%. Mean (+/- SD) ankle brachial index improved from 0.49 +/- 0.22 to 0.87 +/- 0.26 (P <.001). CONCLUSION: Endovascular grafting to treat advanced aortoiliac occlusive disease can be accomplished with good clinical outcome and acceptable short-term patency. This endovascular technique can be a viable alternative to conventional surgical revascularization in patients with advanced aortoiliac occlusive disease at high risk.

Aortofemoral bypass in young patients with premature atherosclerosis: is superficial femoral vein superior to Dacron?

PURPOSE: Previous studies have documented poor patency rates in "young" patients (age 55 years or younger) with premature atherosclerosis undergoing aortofemoral bypass (AFB) to treat aortoiliac occlusive disease. Given the high reported graft patency rates with superficial femoral vein (SFV) grafts performed because of aortic graft infection, we evaluated the role of SFV grafts for AFB as primary therapy for premature atherosclerosis in a case-control study. METHODS: Over 10 years 31 patients aged 55 year or younger underwent AFB with use of SFV (V-AFB). Case controls consisted of all patients 55 years of age or younger who underwent AFB with use of Dacron (D-AFB) during the same period (n = 80). In all cases this was the initial therapy (no repeat operations). The two groups were well matched for age, sex, weight, preoperative ankle-brachial index, and the comorbid conditions of smoking, coronary artery disease, chronic obstructive pulmonary disease, hyperlipidemia, hypertension, and renal insufficiency. There were more patients with diabetes in the V-AFB group (34% vs 16%; P =.05). Patients in the V-AFB group had more advanced disease, and the surgical indication was more frequently critical ischemia compared with the D-AFB group (90% vs 46%; P <.001). RESULTS: There was only one perioperative death in each group. There were no differences in cardiac, pulmonary, or gastrointestinal complications. However, fasciotomy occurred more frequently with V-AFB (44% vs 1%; P <.001). Surgery time was longer with V-AFB (7.3 vs 4.5 hours; P <.001). Despite these short-term drawbacks, V-AFB proved superior at long-term follow-up. The 5-year primary patency rate was significantly higher with V-AFB than with D-AFB (100% vs 56%; P =.013). There was also a trend for higher limb salvage at 5 years (90% vs 62%). Four graft infections occurred with D-AFB, and none with V-AFB (P =.32). CONCLUSIONS: AFB performed with SFV grafts is a far more durable operation than standard D-AFB in young patients with aortoiliac occlusive disease. However, V-AFB is far more likely to require lower extremity fasciotomy, and takes almost twice as long to perform.

Ocular findings as predictors of carotid artery occlusive disease: is carotid imaging justified?

OBJECTIVES: Hemispheric neurologic symptoms, amaurosis fugax, and Hollenhorst plaques at eye examination are standard indications for carotid imaging to identify carotid artery occlusive disease (CAOD). Previous reports have suggested that other ocular findings, such as retinal artery occlusion and anterior ischemic optic neuropathy, are associated with CAOD. However, the predictive value of ocular findings for the presence of CAOD is controversial. The purpose of this study was to define the predictive value of ocular symptoms and ophthalmologic examination in identifying significant CAOD. METHODS: Over 3 years 145 patients were referred for carotid imaging on the basis of ocular indications in 160 eyes. Forty patients were excluded because of concurrent non-ocular indications for carotid imaging, leaving 105 patients referred exclusively for ocular indications to evaluate. Ophthalmologic history and eye examination were correlated with carotid duplex ultrasound findings. RESULTS: Amaurosis fugax was associated with a positive scan in 20.0% of carotid arteries (P =.022). Hollenhorst plaques at fundoscopic examination were associated with a positive scan in 18.2% of carotid arteries (P =.02). Ocular findings exclusive of Hollenhorst plaques were particularly poor predictors of CAOD, inasmuch as only 1 of 64 arteries (1.6%) had significant ipsilateral internal carotid artery stenosis (P =.022). Venous stasis retinopathy was the only ocular finding other than Hollenhorst plaques with any predictive value (1 of 5 scans positive; positive predictive value, 20.0%). CONCLUSIONS: Ocular symptoms and findings are poor predictors of CAOD. Amaurosis fugax, Hollenhorst plaques, and venous stasis retinopathy demonstrated moderate predictive value, whereas all other ocular findings demonstrated no predictive value in identifying CAOD.