The current management of isolated degenerative femoral artery aneurysms is too aggressive for their natural history.

BACKGROUND: Previous studies have combined anastomotic, catheter-induced, and atherosclerotic isolated femoral artery aneurysms (FAAs) to achieve adequate numbers for analysis and have recommended repair of asymptomatic FAAs with diameters ≥2.5 cm and all symptomatic FAAs. This study evaluated the contemporary management of isolated FAAs. METHODS: Patients with FAAs were evaluated using a standardized, prospectively maintained database by a research consortium. RESULTS: From 2002 to 2012, 236 FAAs were identified in 182 patients (mean age, 72 years; male-to-female ratio, 16:1) at eight institutions. The mean nonoperative mean diameter was 2.8 ± 0.7 cm, and the operative diameter was 3.3 ± 1.5 cm. FAA location was the common femoral artery in 191, superficial femoral artery (SFA) in 34, and profunda femoris artery in 11. Synchronous aneurysms (mean, 1.7 per patient) occurred in the aorta (n = 113), in the iliac (n = 109), popliteal (n = 86), and hypogastric (n = 56) arteries, and in the contralateral common femoral artery (n = 34), SFA (n = 9), and profunda femoris artery (n = 2). Of the aneurysms repaired, 66% were asymptomatic; other indications for repair were claudication (18%), local pain (8%), nerve compression (3%), rupture (2%), acute thrombosis (1%), and rest pain (0.5%). Acute aneurysm-related complications (rupture, thrombosis, embolus) were associated (P < .05) with FAA diameter >4 cm and intraluminal thrombus, but not location. Mean diameter of asymptomatic aneurysms that developed acute complications was 5.7 ± 1.3 cm for rupture, 4 ± 1.1 cm for thrombosis, and 3.5 cm for embolus. Repair was by interposition or bypass graft in 177 FAAs and by endovascular repair in three SFA aneurysms. Two perioperative deaths, of myocardial infarction and multisystem organ failure, occurred at 30 days. Operative complications included wound infection (6%), seroma (3%), and bleeding (2%). No amputations occurred through 5 years in the operative or nonoperative groups. Survival in operated-on patients was 99% (n = 138) at 3 months, 92% at 1 year, and 81% (n = 20) at 5 years. CONCLUSIONS: This largest study of isolated FAAs demonstrates that (1) acute complications did not occur in FAAs ≤3.5 cm, repair criteria of asymptomatic FAAs should be changed to >3.5 cm, and chronic intraluminal thrombus should reduce the threshold for repair, and that (2) current indications for symptomatic FAA repair result in low morbidity and should remain unchanged.

Anterior thoracolumbar spine exposure: critical review and analysis.

BACKGROUND: Indications for anterior thoracolumbar spine interbody fusion have expanded because of safe and expeditious surgical exposure that can be provided by the approach surgeon. In our practice, previous anterior interbody instrumentation, multiple disc level exposure, patient age, and body habitus are not surgical deterrents despite the potential for increased complications. The arterial and venous complications of anterior spine exposure have been well documented; however, the purpose of this study is to document the incidence of other complications, such as deep vein thrombosis (DVT), lymphedema, seroma/hematoma, wound infection, and hospital readmission and to determine whether outcome is influenced by the factors mentioned above. METHODS: Six hundred seventeen consecutive patients had anterior thoracolumbar spine exposure performed by a single vascular surgeon between January 2007 and June 2012. Office and hospital records were reviewed with institutional review board approval. RESULTS: The mean patient age was 56 years, and 16% were >69 years of age. The mean body mass index (BMI) was 29.27 kg/m(2) (range: 16-53 kg/m(2)); 39% were considered obese, with BMI measurements of >30 kg/m(2). The overwhelming majority of cases were performed for varying grades of spondylolisthesis and/or degenerative disc disease; in 8 cases (1.3%), the indication for disc exposure was diskitis/osteomyelitis. One disc level was exposed in 36% of cases, 2 in 43%, and ≥3 in 21%. Six percent of patients had previous anterior spine exposure, 42% had previous posterior laminectomy and/or diskectomy, and 3% required anterior disc reexposure to remove hardware or an artificial disc. There was 1 major arterial dissection and 3 major venous injuries. Other complications included extensive DVT (2%), debilitating lymphedema (0.5%), wound seroma/hematoma requiring treatment (2%), wound infection (3%), and readmission within 60 days (8%). Multilevel (>2 levels) disc exposure was associated with an increased rate of lymphedema, posterior lumbar wound infection, and hospital readmission (all P values ≤ 0.01; chi-squared analysis). A BMI >30 kg/m(2) was associated with an increased rate of DVT, posterior lumbar wound infection, and hospital readmission (all P values ≤ 0.018; chi-squared analysis). Age >69 years was associated with an increased rate of wound hematoma (P = 0.002; chi-squared analysis). Logistic regression analysis revealed that BMI >30, multilevel disc exposure, and removal of an artificial disc or hardware were all associated with an increased rate of any nonvessel complication (P values < 0.001); however, no specific variable was associated with an increased rate of a major vessel complication, including those cases where the surgical indication was diskitis/osteomyelitis. CONCLUSIONS: The overall incidence of nonvessel injury complications after anterior thoracolumbar spine exposure is low. Redo anterior spine exposure and redo disc exposure cases, including those that require hardware or artificial disc removal, can be performed safely. Multidisc level exposure is, however, associated with an increased incidence of lymphedema, wound infection, and hospital readmission. Patients with BMI >30 kg/m(2) should be approached with caution because there is a significantly increased rate of DVT, wound infection, and hospital readmission.

Surgical management of critical limb ischemia.

At the present time, infrainguinal bypass using autogenous vein is the most effective and durable treatment for chronic limb ischemia caused by long-segment, diffuse, atherosclerotic occlusive disease. Quality of the vein conduit is the most important factor that determines operative success. Preoperative vein mapping is useful to identify an optimal vein conduit as well as to suggest vein segments that should not be explored due to occlusion, significant calcification, poor caliber, or sclerosis. Reversed, nonreversed, and in situ vein bypass grafts all perform equally well, and the choice of technique depends on anatomic considerations and surgeon preference. Bypass grafts originating from inflow sources distal to the common femoral artery may be appropriate in selected cases without compromising graft patency. All vein graft patients should be followed by postoperative, duplex-based graft surveillance. Antiplatelet therapy is indicated in all infrainguinal bypass patients; oral anticoagulation may be worthwhile in selected, high-risk patients, but hemorrhagic risks are significantly increased.

Thoracoabdominal aortic aneurysm repair: historical review and description of a re-engineered technique.

Most complications related to thoracoabdominal aortic reconstruction stem from ischemia-induced injury to the viscera, kidneys, and spinal cord. Pioneers in the treatment of thoracoabdominal aortic aneurysms recognized the danger of producing ischemic damage to these vital organs. In addition to adjunctive methods designed to minimize metabolic demands of the spinal cord during aortic cross-clamping, a variety of extracorporeal techniques have been developed that provide supplemental blood flow to vital end organs during the period of clamp-induced ischemia. This article reviews these extracorporeal methods and provides a historical perspective of thoracoabdominal aortic aneurysm repair. In addition, a reengineered technique for thoracoabdominal aortic aneurysm repair is highlighted.

A polymeric sealant inhibits anastomotic suture hole bleeding more rapidly than gelfoam/thrombin: results of a randomized controlled trial.

HYPOTHESIS: An experimental polymeric sealant (CoSeal [Cohesion Technologies, Palo Alto, Calif]) provides equivalent anastomotic sealing to Gelfoam (Upjohn, Kalamazoo, Mich)/thrombin during surgical placement of prosthetic vascular grafts. DESIGN: Randomized controlled trial. SETTING: Nine university-affiliated medical centers. PATIENTS: One hundred forty-eight patients scheduled for implantation of polytetrafluoroethylene grafts, mainly for infrainguinal revascularization procedures or the creation of dialysis access shunts, who were treated randomly with either an experimental intervention (n = 74) or control (n = 74). INTERVENTION: Following polytetrafluoroethylene graft placement, anastomotic suture hole bleeding was treated intraoperatively in all control subjects with Gelfoam/thrombin. Subjects in the experimental group had the polymeric sealant applied directly to the suture lines without concomitant manual compression. MAIN OUTCOME MEASURES: Primary treatment success was defined as the proportion of subjects in each group that achieved complete anastomotic sealing within 10 minutes. The proportion of subjects that achieved immediate sealing and the time required to fully inhibit suture hole bleeding also were compared between treatment groups. RESULTS: Overall 10-minute sealing success was equivalent (86% vs 80%; P =.29) between experimental and control subjects, respectively. However, subjects treated with CoSeal achieved immediate anastomotic sealing at more than twice the rate of subjects treated with Gelfoam/thrombin (47% vs 20%; P<.001). Consequently, the median time needed to inhibit bleeding in control subjects was more than 10 times longer than for experimental subjects (16.5 seconds vs 189.0 seconds; P =.01). Strikingly similar findings for all comparisons were observed separately for subgroups of subjects having infrainguinal bypass grafting and for those undergoing placement of dialysis access shunts. CONCLUSIONS: The experimental sealant offers equivalent anastomotic sealing performance compared with Gelfoam/thrombin, but it provides this desired effect in a significantly more rapid time frame.

New approaches for the treatment of varicose veins.

New, minimally invasive techniques for the treatment of varicose veins including radiofrequency ablation (RFA), endovenous laser therapy (EVLT), and transilluminated power phlebectomy (TIPP) represent effective and possibly superior alternatives to traditional saphenous vein stripping and stab avulsion of varicose veins. Further experience with these procedures will help to determine which ones will become the method of choice for treating this complex disease process. Some of these new techniques may not prove to be effective in the hands of all treating specialists. However,it is very likely that some of these techniques, such as foam sclerotherapy and RFA, will replace the procedures that we currently use today.

Immunogenicity and safety of re-exposure to recombinant human thrombin in surgical hemostasis.

BACKGROUND: This Phase 4, open-label study evaluated the immunogenicity and safety of a second exposure to recombinant human thrombin (rThrombin) in adult patients with previous exposure to rThrombin. STUDY DESIGN: Topical rThrombin was applied as a hemostatic aid during a surgical procedure (day 1). Adverse events and clinical laboratory abnormalities were monitored to day 29 (study end). Immunogenicity samples were collected on days 1 and 29. Thirty-one patients were treated at 9 study sites; 30 patients completed the study. RESULTS: Mean age was 59.5 years; 61.3% of patients were male. Study operations types included spinal (n = 23 of 31; 74.2%), arterial reconstruction or peripheral arterial bypass (n = 4; 12.9%), arteriovenous vascular access procedure (n = 3; 9.7%), and other (n = 1; 3.2%). A median of 10 mL rThrombin (1,000 IU/mL; range 5 to 60 mL) was prepared per patient. Median elapsed time since previous rThrombin exposure was 1.3 years (range 19 days to 3.3 years). Recombinant human thrombin was not observed to be immunogenic; no patients (n = 0 of 30, 0%; 95% CI 0.0%, 11.6%) became positive for anti-rThrombin product antibodies at day 29, approximately 1 month after the second exposure to rThrombin. The most commonly reported adverse events were procedural pain (n = 23 of 31, 74.2%), constipation (n = 8, 25.8%), and nausea (n = 8, 25.8%) All adverse events and clinical laboratory abnormalities were considered unrelated to treatment. For the majority of patients, maximal severity of any adverse event was mild or moderate. CONCLUSIONS: The immunogenicity and safety results of this Phase 4 rThrombin trial suggest that patients with known previous exposure may be safely re-exposed to topical rThrombin.

Safety and immunogenicity observations pooled from eight clinical trials of recombinant human thrombin.

BACKGROUND: We evaluated safety and immunogenicity observations pooled from 8 clinical trials of recombinant human thrombin (rThrombin), an active topical hemostatic agent. STUDY DESIGN: Recombinant thrombin was applied with an absorbable gelatin sponge or spray applicator during a surgical procedure (day 1). Adverse events and laboratory parameters were monitored until study end (day 29). Immunogenicity was evaluated after study completion on plasma samples collected at baseline and on day 29. RESULTS: Studies included 583 rThrombin-treated patients (median age, 59 years; 54% men). Surgical procedures included: spinal, 33% of patients; hepatic resection, 14%; peripheral arterial bypass, 23%; arteriovenous graft formation for hemodialysis access, 18%; and skin graft after burn wound excision, 12%. Adverse events reported for >or= 10% patients included incision site pain, procedural pain, nausea, constipation, pyrexia, anemia, insomnia, vomiting, and pruritus. Five of 552 patients developed antibodies to rThrombin (0.9%; 95% CI, 0.3 to 2.1; day 29); antibodies did not neutralize the biologic activity of native human thrombin. At baseline, 12 patients had pre-existing, antibodies recognizing rThrombin (12 of 552; 2.2%; 95% CI, 1.1 to 3.8); these patients had no previous exposure to rThrombin and their antibody titer did not increase >or= 1.0 unit (>or= 10-fold) at day 29. CONCLUSIONS: Results from 8 clinical trials collectively demonstrated that rThrombin is well tolerated in numerous surgical settings when used as a topical adjunct to hemostasis. Adverse events and changes in laboratory parameters were consistent with commonly reported postoperative events. Less than 1% of patients developed antibodies to rThrombin; the antibodies did not neutralize native human thrombin.

A phase 3b, open-label, single-group immunogenicity and safety study of topical recombinant thrombin in surgical hemostasis.

BACKGROUND: The immunogenicity and safety of recombinant human thrombin (rThrombin) were evaluated in this phase 3b, open-label, single-group, multisite study of 209 adult vascular and spinal operation patients at high risk for preexisting anti-bovine thrombin product antibodies. STUDY DESIGN: Patients received rThrombin applied as a topical hemostat during a surgical procedure (day 1). Immunogenicity samples were collected at baseline and approximately 1 month after operation (day 29) and were analyzed after study participation. RESULTS: Mean patient age was 61.5 years; median number of previous surgical procedures was 5.0 (range, 1 to 25). Operation types included spinal (n = 89 of 209 [43%]), arterial reconstruction (including peripheral arterial bypass; n = 75 of 209 [36%]), and arteriovenous vascular access procedures (n = 45 of 209 [22%]). All patients had confirmed or highly likely previous bovine thrombin exposure; at baseline, 15.6% of patients (n = 32 of 205) had preexisting anti-bovine thrombin antibodies. Of 200 patients with complete immunogenicity evaluations, 31 had preexisting anti-bovine thrombin antibodies (15.5%), and 4 had preexisting anti-rThrombin product antibodies (2.0%). None of the 200 patients became antibody positive for rThrombin antibodies on day 29 (seroconversion or > or = 10-fold increase in titer). Adverse events and laboratory results were consistent with a surgical population with substantial comorbidities. Patients with preexisting antibodies to bovine thrombin were older (p = 0.04) and had undergone more surgical procedures previously (p < 0.001) than patients without preexisting antibodies. CONCLUSIONS: Results of this study confirm the low immunogenicity of rThrombin and suggest that rThrombin can be used safely as an aid to hemostasis in patients with or without preexisting anti-bovine thrombin antibodies. A sizeable proportion of this vascular and spinal operation patient population (15.6%) had preexisting anti-bovine thrombin antibodies; these patients are at risk for immune responses after reexposure to bovine thrombin.

Duplex ultrasound of the superficial femoral artery is a better screening tool than ankle-brachial index to identify at risk patients with lower extremity atherosclerosis.

OBJECTIVES: The purpose of vascular disease screening is early identification of atherosclerotic disease and the aim of an ankle-brachial index (ABI) is to identify lower extremity (LE) atherosclerosis as a marker for coronary artery disease (CAD). However, early evidence of atherosclerosis may be present in the superficial femoral artery (SFA) with a normal resting ABI. This study was performed to determine if SFA duplex ultrasound (DUS) could detect more patients with LE atherosclerosis than an ABI; be performed in the same or less time as the ABI measurement; and be associated with similar vascular disease markers as the ABI. METHODS: From January through November 2006, 585 patients were screened for peripheral arterial disease. SFA DUS was included in this Institutional Review Board approved program and demographic/ultrasound data were collected prospectively. SFA DUS findings were divided into six categories. Plaque w/o color change or worse and ABI <0.90 or >1.20 were considered to be abnormal. Data were evaluated using decision matrix and logistical regression analysis. RESULTS: Sensitivity and specificity of SFA DUS using the ABI as the benchmark was 100% and 88%, respectively. Sensitivity and specificity of ABI was 17% and 100%, respectively, using DUS as the standard. DUS detected atherosclerotic disease in 143 SFAs (93 patients) in which the ipsilateral ABI was normal, and there were no false negative SFA DUS studies. Multivariate logistic regression analysis demonstrated the following variables to be significantly and independently associated with an abnormal SFA DUS as well as an abnormal ABI: history of claudication, history of myocardial infarction, and an abnormal carotid DUS. Additional variables (current or past smoker and age >55) were also independently associated with an abnormal SFA DUS but not with an abnormal ABI. Mean time to complete bilateral testing was essentially the same for both tests. CONCLUSIONS: SFA DUS is an accurate screening tool and can be utilized in screening protocols in place of the time-honored ABI without prolonging the examination. Traditional vascular disease markers that are found in patients with an abnormal ABI are also associated with an abnormal SFA DUS. SFA DUS identifies more patients with early LE atherosclerosis than does ABI without missing significant popliteal/tibial artery occlusive disease. Finally, an abnormal SFA DUS can be used as an indirect marker to identify more potentially at risk patients with CAD.

Visceral/renal artery debranching for complex thoracoabdominal hybrid procedures via retroperitoneal abdominal aortic exposure: a preliminary report.

Visceral/renal artery debranching can lengthen the distal landing zone in patients with complex thoracoabdominal aortic disease, thus enabling endograft repair. Initial reports of "hybrid" procedures are promising, but they usually describe transperitoneal visceral/renal artery exposure. This clinical series describes four complex thoracoabdominal aortic aneurysm/dissection cases in which the visceral and renal artery debranching procedure was accomplished via a retroperitoneal approach.

Medical benefits of a peripheral vascular screening program.

We present preliminary results and analysis of a screening program that has been offered at a community-based hospital since July 2004. The program includes a quick carotid ultrasound study, abdominal aortic ultrasound imaging, and measurement of bilateral ankle/brachial indices (ABI). From July 2004 through January 2006, 1,719 patients were screened, including 1,094 (64%) women and 652 (36%) men. The majority of carotid screens were normal; however, 28.9% (497 patients) had 15-40% stenosis, 1.4% (24 patients) had 40-60% stenosis, and 0.3% (six patients) had >60% stenosis. Sixteen patients (1%) had infrarenal aortic dilation (>3 cm), and an abnormal ABI (<0.90) was detected in at least one limb in 100 patients (5.8%). No procedures resulted from carotid screening; however, two patients underwent urgent repair for 9.3 and 7.5 cm diameter abdominal aortic aneurysms. Abnormal ABI in conjunction with symptoms led to arteriography in three patients, one of whom had iliac stent deployment. This nonselective vascular screening program attracted many new patients into the health-care system. The open/endovascular procedure yield was low, but early disease detection was significant, causing numerous patients to be referred for additional testing and risk factor modification programs. These preliminary data suggest that community-based vascular screening programs play a key role in early vascular disease detection and provide the potential for prevention of disease progression while, at the same time, building sustainable business for hospitals and physicians.

Long-term results of 442 consecutive, standardized carotid endarterectomy procedures in standard-risk and high-risk patients.

OBJECTIVES: The objectives of this study were to determine the results of a specific technique in the performance of carotid endarterectomy (CEA) and to compare results using this technique between standard-risk and high-risk patients eligible for Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) and between asymptomatic and symptomatic patients. METHODS: A total of 391 patients underwent 442 consecutive CEA procedures under general anesthesia with the intent to shunt, patch, and perform intraoperative completion duplex ultrasound imaging. Indications included 272 asymptomatic patients (61.5%) with carotid stenoses > or =60% and 170 symptomatic patients (38.5%) with carotid stenosis > or =50%. Data were analyzed to determine the early (< or =30 days) and long-term morbidity and mortality overall in standard-risk and high-risk procedures and in asymptomatic and symptomatic patients. The primary end points were the occurrence of all strokes or death or myocardial infarction (MI) in the first 30 postoperative days (100% follow-up) and the occurrence by life-table analysis of ipsilateral stroke or death or MI (SDMI) out to 93 months (mean, 31.4 months). RESULTS: A total of 441 (99.7%) procedures included shunting, 440 (99.5%) included patching, and 442 (100%) had completion duplex ultrasound imaging. Of these, 235 procedures were standard risk and 207 procedures were high risk. At the 30-day follow-up, there were two ipsilateral central neurologic deficits (1 major stroke, 1 minor stroke), no death, and one MI (0.45% for all strokes or death; 0.68% for all strokes or death or MI). After 30 days of follow-up, an additional 16 strokes (9 ipsilateral, 7 contralateral), eight MIs, and 38 deaths had occurred. No statistically significant difference was found between standard-risk and high-risk groups or between asymptomatic and symptomatic groups for stroke, death, MI, stroke or death, or stroke or death or MI at 30 days or during long-term follow-up at any interval up to 93 months. CONCLUSION: CEA performed with intent to treat using general anesthesia, shunting, patching, and completion duplex scanning results in extremely low 30-day and long-term morbidity and mortality in asymptomatic, symptomatic, standard-risk and high-risk patients. These results are substantially superior to those reported in carotid stenting trials for both carotid stenting and CEA and do not support the contention that there is a high-risk group for CEA.

Retroperitoneal aortic aneurysm repair: long-term follow-up regarding wound complications and erectile dysfunction.

The long-term impact of retroperitoneal aortic exposure regarding wound complications in all patients and erectile dysfunction in men was studied in a consecutive group of 107 patients (81 males and 26 females). Postoperative wound complications were classified into the following groups: none, flank bulge, hernia, and chronic pain. Patient demographic features including body mass index (BMI) were statistically analyzed in relation to the incidence of long-term wound problems. Information regarding erectile dysfunction was obtained before surgery in all men and stratified into three groups after surgery: no change, inability to consistently obtain an erection, and retrograde ejaculation. Mean patient follow-up was 2.9 years (range 1-4.36, median 2.8). Flank bulge was the only long-term wound complication, and this was noted in nine patients (8%). The incidence of true hernia and chronic pain was 0%. BMI >28 was the only factor that positively impacted the incidence of wound complications (p < 0.0001). Erectile dysfunction prior to surgery was noted in 37 men (46%), while 44 (54%) reported normal erectile function. Erectile function improved after surgery in one patient but remained unchanged in the rest. Postoperative retrograde ejaculation occurred with a frequency of 9% (four of 45 patients). Retroperitoneal abdominal aortic aneurysm (rAAA) exposure with incision based on the twelfth rib tip and rectus abdominis muscle sparing results in an overall low incidence of long-term wound complications. Postoperative flank bulge is associated with patient BMI >28. In addition, erectile function is not worsened by infrarenal autonomic nerve sparing rAAA exposure. However, a small percentage of potent men will experience postoperative retrograde ejaculation.

Two-graft repair of very proximal superior mesenteric artery aneurysms: a technical note.

Visceral artery aneurysms are found in only 0.2% of the general population. Among these, aneurysms of the superior mesenteric artery (SMA) are very unusual and account for only 5.5 % to 8 %. Risk of rupture or embolization is the impetus for their definitive treatment and this should be performed in acceptable candidates. These aneurysms are typically located distal to the origin of the SMA and this situation lends itself to interposition grafting as a means of both aneurysm repair and reestablishment of prograde SMA blood flow. However, SMA origin aneurysms that arise directly from the abdominal aorta add a degree of complexity because the vascular reconstruction must include the diseased visceral aorta as well as the SMA. In this article we report successful operative treatment of large aneurysms at the origin of the superior mesenteric artery using a two-graft technique in two elderly patients.

Endovascular treatment of a blunt traumatic abdominal aortic injury with a commercially available stent graft.

Abdominal aortic injuries are rarely encountered in blunt abdominal trauma. The traditional treatment of these injuries has been surgical exploration and repair. Endografts are commonly used in the repair of abdominal aortic aneurysms. We present a case of a blunt abdominal aortic injury treated successfully with a commercially available endograft. A 26-year-old male was involved in a rollover motor vehicle collision. Evaluation revealed an aortic injury as well as a concomitant small bowel injury. No treatment of the aorta was undertaken initially; however, on 6-month follow-up, the patient developed bilateral hip and buttock claudication. Computed tomography and aortography revealed two areas of stenosis with an associated pseudoaneurysm. The patient was treated with three 22 mm AneuRx (Medtronic, Sunnyvale, CA) aortic extender cuffs. Balloon angioplasty of the stenosis was also performed. The patient's symptoms resolved, and he was well at 9 months postprocedure. We report the use of aortic extender cuffs to treat a blunt abdominal aortic injury. The potential to treat these injuries with aortic extender cuffs emergently or electively at any institution represents an advance in the management of vascular trauma.

Aorto-left renal artery bypass as an adjunct to suprarenal abdominal aortic aneurysm repair.

Renal ischemia remains a vexing issue in the repair of suprarenal abdominal aortic aneurysms (SR-AAAs). Multiple reconstruction methods have been described, including fish-mouth anastomoses, renal artery reimplantation, and aortorenal interposition grafts. We present an alternative method of SR-AAA repair that minimizes renal ischemia time. We describe our approach in two patients with SR-AAAs. Both patients had normal preoperative renal function. Maximal aneurysm diameters were 6.0 and 7.4 cm. In each case, the abdominal aorta was exposed via the retroperitoneal approach and the supraceliac aorta was dissected from the surrounding tissue. A partially occluding side-biting aortic clamp was placed at this level to facilitate placement of a synthetic 6 mm interposition graft that was sewn in an end-to-side fashion to the suprarenal aorta first. These grafts were then sewn end-to-end to the left renal artery, completing the aorto-left renal bypass. Left renal ischemia times were 12 and 14 min. The aneurysm was then repaired with a beveled proximal anastomosis, accommodating the right renal artery orifice. Both patients had minimal postoperative renal dysfunction, with peak creatinine levels of 1.9 and 1.4 mg/dl. At discharge, both patients had a creatinine level of 1.1 mg/dl. Urinary output remained normal throughout the hospital stays, and neither patient required dialysis. Retroperitoneal aortic exposure with preliminary aorto-left renal artery bypass is an effective method of treating SR-AAAs. Proximal anastomosis can be done with less urgency and minimal right renal ischemia, by revascularizing the left kidney first.

Major lower extremity amputation in an academic vascular center.

Major lower extremity amputations continue to be performed despite an aggressive policy of revascularization. Factors leading to amputation were analyzed to determine whether a reduction in the limb loss rate is possible. A retrospective analysis of a prospectively maintained vascular registry was performed to identify patients undergoing above-knee amputation (AKA), below-knee amputation (BKA), and lower extremity revascularization (LER) for limb salvage between January 1, 1999 and January 1, 2002. Patient demographics, comorbidities, insurance carriers, and indications for operative intervention were analyzed. Greater than one-half of all major lower extremity amputations are performed in patients who have failed attempts at revascularization or who are not candidates for LER due to anatomic factors. However, one-quarter of eventual amputees present very late to the vascular surgeon with extensive gangrene or infection that precludes limb salvage. Prompt patient referral and treatment may improve outcome in this group of patients. In our study, insurance issues did not appear to affect treatment. Renal failure continues to play a major role in limb loss.