Ability of ankle-brachial index to detect lower-extremity atherosclerotic disease progression.

BACKGROUND: Accurate determination of progression of lower-extremity arterial occlusive disease (LEAOD) is required for natural history studies and evaluation of therapies for atherosclerosis. OBJECTIVE: To determine if changes in the ankle-brachial index (ABI) correlated with progression of LEAOD as determined by arteriography or duplex scanning. DESIGN: In patients with prior suprainguinal or infrainguinal lower-extremity revascularization, progression of LEAOD in native arteries was determined by comparing a preoperative (baseline) arteriogram with late follow-up arteriography or duplex scanning. Superficial femoral and popliteal arteries were graded as having less than 50% stenosis, 50% to 99% stenosis, or as being occluded. Tibial arteries were graded as continuously patent or occluded. Operated and nonoperated extremities were included in the study. The baseline ABI was performed postoperatively and repeated at follow-up arteriography or duplex scanning. Progression of LEAOD by the ABI was defined as a decrease in the ABI of 0.15 or greater. Progression of LEAOD by imaging studies was defined as an increase in 1 category of stenosis. Extremities with suprasystolic pressures were excluded. SETTING: Tertiary vascular surgical service. EXTREMITIES AND PATIENTS: One hundred ninety-three extremities were studied in 114 patients during a mean follow-up of 3.3 years. RESULTS: Seventy-two lower extremities (37.3%) showed progression of atherosclerosis by late follow-up arteriography or duplex scanning. Using the imaging studies as the criterion standard, the ABI had 102 true negatives, 29 true positives, 42 false negatives, and 20 false positives (sensitivity, 41%; specificity, 84%; positive predictive value, 59%; negative predictive value, 71%; and accuracy, 68%) for determining the progression of LEAOD. CONCLUSIONS: The ABI is relatively insensitive in identifying the progression of LEAOD as demonstrated by the use of imaging studies. In studies of natural history or therapy for atherosclerosis, imaging studies should be used in preference to the ABI to evaluate the progression of LEAOD accurately.

Upper extremity thromboembolism caused by occlusion of axillofemoral grafts.

BACKGROUND: The axillofemoral bypass graft (AxFG) is increasingly accepted as treatment for lower extremity ischemia caused by aortoiliac occlusive disease in high-risk patients. The incidence of upper extremity (UE) thromboembolism caused by occlusion of an AxFG and the results of treatment form the basis for this report. METHODS: From 1984 to the present, all patients undergoing axillofemoral bypass grafting were followed up in a vascular registry. A standardized operative technique, using an externally supported 8-mm polytetrafluoroethylene graft, was used in performing 202 AxFGs in 182 patients. UE thromboembolism caused by occlusion of an AxFG was identified by retrospective patient record review. RESULTS: Occlusion of an AxFG occurred in 20 patients. Fifteen patients (75%) underwent immediate revision of the occluded graft. Two patients (10%) developed UE thromboembolism simultaneous with graft occlusion. One of these patients had immediate revision of the graft, and 1 had brachial embolectomy only. This patient and 4 others (25%) had the occluded AxFG left in place. Four of these 5 patients (80%) developed UE thromboembolism at 26 days, 2 years, 5 years, and 7 years, respectively, after occlusion. Overall, six UE thromboembolic complications occurred in 5 patients. CONCLUSIONS: UE thromboembolism represents a significant and specific complication of occluded AxFGs in our series (2.7% of patients, 25% of occluded grafts). It may be prudent to prophylactically detach the axillary portion of the graft and repair the axillary artery in patients who do not require immediate revision of an occluded AxFG.

Algorithm for the diagnosis and treatment of endoleaks.

BACKGROUND: Endoluminal grafting of abdominal aortic aneurysms (AAA) has shown promising early results. However, endoleaks present a new and challenging obstacle to successful aneurysm exclusion. We report our experience with primary, persistent endoleaks and provide an algorithm for their diagnosis and management. METHODS: Over a 19-month period, 73 patients underwent endoluminal repair of their AAAs using a modular bifurcated endograft as part of a US FDA Investigational Device Exemption trial. Spiral computed tomography (CT) scanning was performed prior to discharge after repair to evaluate for complete aneurysm exclusion. If no endoleak was present on that initial CT scan, color-flow duplex scanning was performed at 1 month, with repeat CT scanning at 6 months and 1 year. If the initial CT scan revealed the presence of an endoleak, repeat CT scanning was performed at 2 weeks, 1 month, and 3 months, or until the endoleak resolved. Any patient with an endoleak that persisted beyond 3 months underwent angiographic evaluation to localize the source of the leak. RESULTS: At 1 month, 62 patients (85%) had successful aneurysm exclusion. The remaining 11 patients (15%) had primary endoleaks, 8 (11%) of which persisted beyond 3 months, prompting angiographic evaluation. In 2 patients the endoleak was related to a graft-graft or graft-arterial junction. One was from the endograft terminus in the common iliac artery and was successfully embolized, along with its outflow lumbar artery. The other required placement of an additional endograft component across a leaking graft-graft junction to successfully exclude the aneurysm. The remaining six endoleaks were due to collateral flow through the aneurysm sac. In 4 cases this was lumbar to lumbar flow fed by hypogastric artery collaterals to the inflow lumbar artery. In the remaining 2 patients the endoleak was found to be due to flow between a lumbar and inferior mesenteric artery. Resolution of the endoleak by coil embolization of the feeding hypogastric artery branch in 1 patient was unsuccessful due to rapid recruitment of another hypogastric branch. Two of the six collateral flow endoleaks have resolved spontaneously without treatment, while the remaining cases have been followed up without evidence of aneurysm expansion. CONCLUSION: Systematic postoperative surveillance facilitates proper diagnosis and treatment of endoleaks. This involves serial CT scans to detect the presence of endoleaks, followed by angiography to determine their etiology and guide treatment, if clinically indicated.

The AneuRx modular endograft device for the treatment of abdominal aortic aneurysms. Overview of 7 years of clinical use.

Open surgical repair of abdominal aortic aneurysms (AAAs) has been performed for over 40 years now with good results. However, the procedure continues to be high-risk with numerous potential complications. The AneuRx modular bifurcated endograft was one of the first to be tested to exclude AAAs via an endovascular approach. Data from multiple clinical trials show that treatment of AAAs with the AneuRx device is comparable to open repair with regards to mortality and may have improved short-term and long-term morbidities rates. The following review discusses clinical use of the AneuRx stent graft system from the initial clinical trial in 1996 to its current commercial use.

Diagnosis and long-term clinical outcome in patients diagnosed with hand ischemia.

PURPOSE: The long-term clinical outcome of patients diagnosed with digital artery obstruction and symptomatic hand ischemia is largely unknown. Our long-term experience with the diagnosis of symptomatic digital artery obstruction and the long-term natural history of this condition forms the basis for this report. METHODS: From 1971 to 1985, 44 patients with symptomatic hand ischemia and palmar or digital arterial obstruction underwent arteriography and digital photoplethysmography (PPG). Patients were grouped according to severity of hand ischemia symptoms, including ulceration and digital amputation and the presence of a connective tissue disease (CTD). Arteriography was compared with PPG by creating an objective severity scale (digital obstruction index [DOI]). RESULTS: Average follow-up was 15.2 years (range 10 to 22 years). Initially 21 patients (48%) had moderate symptoms, and 23 patients (52%) had severe symptoms of hand ischemia. Follow-up symptoms in 28 patients improved (13 of 26 with CTD, 15 of 18 without CTD), in 15 patients (12 of 26 with CTD, 3 of 18 without CTD) remained unchanged, and in only 1 patient (1 of 26 with CTD) worsened. Seventeen (65%) patients with CTD (n = 26) had development of one or more ulcers, and six (24%) underwent one or more digital amputations. Four (22%) patients without CTD (n = 18) had finger ulceration (p < 0.012 compared with patients with CTD), and one patient (6%) underwent subsequent digital amputation (p = NS). The arteriography-DOI and PPG-DOI were equally accurate in determining severity of finger ischemia as manifested by severity of symptoms or ulcer development. CONCLUSIONS: The favorable long-term prognosis of symptomatic finger artery occlusion described herein mandates the avoidance of premature finger amputation. Patients with CTD fare worse, but even in this group tissue loss is modest. Finger PPG is as accurate as arteriography for determining severity of hand ischemia.

Clinical failure after percutaneous transluminal angioplasty of the superficial femoral and popliteal arteries.

OBJECTIVE: Anatomic patency after percutaneous transluminal angioplasty (PTA) of the superficial femoral and popliteal arteries does not guarantee clinical success. The aim of this report is to determine the causes of clinical failure after PTA. METHODS: The records of all patients who have undergone PTA of the femoropopliteal arterial segment by our vascular group were retrospectively reviewed. Only patients with complete records and at least one postprocedure clinical and anatomic assessment within the same 30-day time interval were included. Success was defined according to the Society for Vascular Surgery/International Society for Cardiovascular Surgery Ad Hoc Subcommittee on Reporting Standards for Endovascular Procedures. Anatomic cumulative patency and clinical success were calculated according to life table analysis on an intent-to-treat basis. RESULTS: We identified 85 patients who met inclusion criteria. We treated 112 lesions with an average stenosis of 80% +/- 16% and lesion length of 2.3 +/- 1.8 cm. Technical failure occurred in six (5.4%) of 112 lesions. Cumulative clinical success was 69% at 1 year, 54% at 2 years, 49% at 3 years, and 40% at 4 years. Anatomic patency was 74% at 1 year, 62% at 2 years, 57% at 3 years, and 52% at 4 years. There were 45 clinical failures; of these, twenty-seven (60%) occurred in conjunction with anatomic failure. Anatomic failure was due to restenosis in 12 patients (44%), occlusion in eight patients (30%), and restenosis with progression of disease in six patients (22%). Anatomic failure at the time of the procedure occurred in one patient (4%). Clinical failure occurred despite anatomic patency in the remaining 18 patients (40%). Etiology for clinical failure in this latter group included progression of disease within the treated vessel in 12 patients (67%), iliac disease in three patients (17%), tibial disease in two patients (11%), and bypass graft failure in one patient (5%). Fifty percent of all 45 clinical failures were successfully treated with supplemental percutaneous procedures. CONCLUSION: A PTA is an acceptable therapeutic option for the treatment of focal occlusive disease of the femoropopliteal arterial segment. Most clinical failures were due to anatomic failure, but a significant number occurred despite patency at the PTA site. Although primary clinical success rates were inferior to surgical bypass graft, supplemental PTA was possible in 50% of patients. Repeat percutaneous treatment may extend the interval of clinical success and may obviate the need for surgical bypass graft.

Long-term outcome of Raynaud's syndrome in a prospectively analyzed patient cohort.

PURPOSE: Knowledge of the long-term clinical outcome of Raynaud's syndrome (RS), essential both for patient counselling and formulation of optimal therapeutic recommendations, is conspicuously deficient in current medical literature. We have prospectively monitored 1039 patients with RS, 118 (11.4%) for more than 10 years to determine whether initial characterization was able to predict outcome. METHODS: At initial presentation, patients were divided into four groups on the basis of vascular laboratory and serologic testing results: vasospastic, serologically positive (spast,sero+) and negative (spast,sero-) and obstructive, serologically positive (obst,sero+) and negative (obst,sero-). RESULTS: Connective tissue disease (CTD) was present initially in 48.6% of patients with spast,sero+ results and 72.9% of patients with obst,sero+ results. Of the remaining patients in these groups, progression to CTD during follow-up occurred in 16.4% of patients with spast,sero+ results and 30.4% of patients with obst,sero+ results. In the > 10-year follow-up group, progression to CTD occurred in 81.8% of patients in the obst,sero+ group. Progression to CTD occurred in 2.0% of patients in the spast,sero-group and 8.5% of patients in the obst,sero- group. Digital ulcers occurred in 15.5% of patients in the spast,sero+ group, 5.2% of patients in the spast,sero- group, 55.6% of patients in the obst,sero+ group, and 48.2% of patients in the obst,sero- group. Digital or phalangeal amputations were required in 1.4%, 1.6%, 11.6%, and 19.0% of these patients, respectively. CONCLUSIONS: The long-term outcome of patients with RS can be predicted by initial serologic studies and separation into vasospastic and obstructive categories. Initial serologic positivity strongly predicts the development of CTD. Initial vascular laboratory classification of obstructive RS strongly predicts digital ulcerations, which occurred in half of these patients regardless of initial serologic study results. Amputations were required in 10% to 20% of patients with obstructive RS. These occurrences did not increase with increased duration of disease. Ulcerations and amputations were rare in patients initially with vasospastic RS.

Progression of atherosclerosis in arteries distal to lower extremity revascularizations.

PURPOSE: The characteristics of progression of atherosclerotic occlusive disease (AOD) of the lower extremities after revascularization are unknown. Duplex scanning or angiography were used to determine progression in 150 patients after they underwent revascularization for AOD. METHODS: Follow-up studies were compared with presurgical arteriograms. Superficial femoral (SFA) and popliteal arteries were graded as less than 50% stenosis, 50% to 99% stenosis, or occluded. Tibial arteries were graded with regard to whether they were continuously patent from the popliteal trifurcation to the ankle. Progression was defined as an increase in one stenosis category. RESULTS: At a mean follow-up of 4.8 years, 18% of native arteries, 39% of extremities, and 52% of patients demonstrated progression of AOD. Overall, 21% of arteries in patients undergoing infrainguinal bypass and 14% of arteries in patients undergoing suprainguinal bypass demonstrated progression (p = 0.004). Progression was more frequently detected in examinations performed more than 4 years after baseline arteriography (66%) than in examinations performed 6 months to 2 years (45%, p = 0.032) or 2 to 4 years (44%, p = 0.029) after baseline arteriography. Thirty percent of SFAs demonstrated progression, and 32% with 50% stenosis or greater at baseline became occluded. There was no difference in SFA, popliteal, or tibial artery progression in revascularized versus nonrevascularized extremities after suprainguinal bypass. There was no difference in tibial artery progression in operated and nonoperated limbs after femoropopliteal artery bypass. CONCLUSIONS: AOD progression occurs frequently in patients requiring revascularization and is more prevalent in patients requiring femoropopliteal than in patients requiring suprainguinal bypass. AOD progression in patients undergoing vascular surgery is associated with the pattern of disease producing lower extremity ischemia and does not appear to be worsened by arterial reconstruction.

Upper extremity thromboembolism after axillary-axillary bypass grafting.

Two patients experienced upper extremity thromboembolism after axillary-axillary bypass grafting (AxAG) for symptomatic subclavian artery stenosis. The first patient, a 67-year-old male, presented with left upper extremity thromboembolism 3 years after AxAG with 8 mm externally support PTFE. An arteriogram revealed a patent AxAG, thrombus in the proximal left subclavian arterial stump just distal to its occlusion, and multiple digital artery emboli. The patient was treated with warfarin for 8 months, with resolution of symptoms. The second patient, a 57-year-old male, occluded his AxAG (8 mm knitted Dacron) with minimal return of symptoms. Non-operative treatment was elected and 4 years later the patient presented with right upper extremity (donor side) thromboembolism. Arteriography revealed occlusion of the AxAG, radial artery, and digital arteries of the index, long and ring fingers. Thrombolytic therapy of the right arm was undertaken with minimal improvement. Subsequent detachment of the AxAG and placement of an interposition reversed saphenous vein graft was performed. Both patients continue to be asymptomatic during follow-up of 4.7 and 2.0 years, respectively.

Adverse consequences of internal iliac artery occlusion during endovascular repair of abdominal aortic aneurysms.

OBJECTIVE: Embolization of the internal iliac artery (IIA) may be performed during endovascular abdominal aortic aneurysm (AAA) repair if aneurysmal disease of the common iliac artery precludes graft placement proximal to the IIA orifice. The IIA may also be unintentionally occluded because of iliac trauma or coverage by the endograft. The purpose of this study was to determine the incidence, etiology, and consequences of IIA occlusion during endoluminal AAA repair. METHODS: Over 2 years, 96 patients have undergone endoluminal AAA repair. The details of the operative procedure, reasons for IIA occlusion, perioperative complications, and clinical follow-up were recorded. RESULTS: The IIA was intentionally occluded in 15 patients (16%) to treat 13 common iliac artery aneurysms, one IIA aneurysm, and one external iliac artery aneurysm. The IIA was unintentionally occluded in 9 patients (9%), resulting from traumatic iliac dissection in 5 patients and coverage of the IIA by the endograft in the remaining 4 patients. Three patients had colon ischemia. One patient with a unilateral IIA occlusion had sigmoid infarction necessitating resection. The other two patients underwent intentional occlusion of one IIA followed by unintentional occlusion of the contralateral IIA because of a traumatic iliac dissection. Both had postoperative abdominal pain and distention; rectosigmoid ischemia was revealed through colonoscopy. Conservative treatment with bowel rest and broad-spectrum antibiotics was successful in both cases. Nondisabling hip and buttock claudication occurred in seven patients (32%) at 1 month but resolved by 6 months in three of these patients. CONCLUSION: Embolization of the IIA for iliac aneurysmal disease and unintentional IIA occlusion due to trauma or graft coverage occurs in a considerable number of patients undergoing endoluminal AAA repair. Most patients with unilateral occlusion do not experience colon ischemia or disabling claudication. Therefore, unilateral embolization of the IIA is well tolerated and allows for the endoluminal treatment of patients with both an AAA and an iliac artery aneurysm, thereby expanding the number of patients who can be managed with an endovascular approach. Although acute, bilateral IIA occlusions should be avoided, significant consequences were not observed in our small series of patients.

Management of ectatic, nonaneurysmal iliac arteries during endoluminal aortic aneurysm repair.

PURPOSE: Most endografts for an endoluminal AAA repair cannot achieve an adequate hemostatic seal in ectatic common iliac arteries larger than 14 mm. The extension of the endograft into the external iliac artery can alleviate this problem but requires sacrifice of the internal iliac artery. We have used the larger diameter aortic extension cuff to obtain adequate endograft to arterial wall apposition in patients with ectatic, nonaneurysmal common iliac arteries. Because of the resultant flared configuration of the iliac limb, the technique is termed bell-bottom. However, it is unknown whether subsequent enlargement of these ectatic common iliac arteries that will lead to endoleaks or endograft migration will occur. METHODS: The records of all 96 patients who have undergone endoluminal abdominal aortic aneurysm repair at our institution were reviewed. Fourteen patients were identified in whom aortic extension cuffs were placed into 18 ectatic (>14 mm, but <20 mm) common iliac arteries. The mean follow-up time was 14 months (range, 6-24 months). The maximal diameter of the common iliac artery on computed tomography scan before endograft placement was compared with the maximal diameter at the most recent follow-up. The incidence of endoleaks, ruptures, and endograft migration related to the "bell-bottom" technique were recorded. RESULTS: The mean preoperative common iliac artery diameter was 18 mm (range, 15-20 mm). Aortic extension cuffs of 20-mm diameter and 24-mm diameter were used in 14 and 4 common iliac arteries, respectively. The diameter did not change in 11 common iliac arteries (61%), increased by 1 mm in 4 common iliac arteries (22%), and decreased by 1 mm in 3 common iliac arteries (17%). No endoleaks, ruptures, or endograft migration related to this technique was identified. CONCLUSION: The use of aortic extension cuffs for ectatic common iliac arteries expands the number of patients who can be treated endoluminally without sacrifice of the internal iliac artery. Most common iliac arteries do not increase in diameter. When enlargement occurs, the degree of dilation is minimal. Therefore, the "bell-bottom" technique appears to be an acceptable option in the management of large, nonaneurysmal iliac vessels during endoluminal abdominal aortic aneurysm repair.

Patient recovery after infrainguinal bypass grafting for limb salvage.

PURPOSE: The outcome of infrainguinal bypass surgery for limb salvage has traditionally been assessed by graft patency rates, limb salvage rates, and patient survival rates. Recently, functional outcome of limb salvage surgery has been assessed by patient ambulatory status and independent living status. These assessments fail to consider the adverse long-term patient effects of delayed wound healing, episodes of recurrent ischemia, and need for repeat operations. An ideal result of infrainguinal bypass surgery for limb salvage includes an uncomplicated operation, elimination of ischemia, prompt wound healing, and rapid return to premorbid functional status without recurrence or repeat surgery. The present study was performed to determine how often this ideal result is actually achieved. METHODS: The records of 112 consecutive patients who underwent initial infrainguinal bypass surgery for limb salvage 5 to 7 years before the study were reviewed for operative complications, graft patency, limb salvage, survival, patient functional status, time to achieve wound healing, need for repeat operations, and recurrence of ischemia. RESULTS: The mean patient age was 66 years. The mean postoperative follow-up was 42 months (range, 0 to 100.1 months). After operation 99 patients (88%) lived independently at home and 103 (92%) were ambulatory. There were seven perioperative deaths (6.3%), and wound complications occurred in 27 patients (24%). By life table, the assisted primary graft patency and limb salvage rates of the index extremity 5 years after operation were 77% and 87%, respectively, and the patient survival rate was 49%. At last follow-up or death, 73% of the patients (72 of 99) who lived independently at home before the operation were still living independently at home, and 70% (72 of 103) of those who were ambulatory before the operation remained ambulatory. Wound (operative and ischemic) healing required a mean of 4.2 months (range, 0.4 to 48 months), and 25 patients (22%) had not achieved complete wound healing at the time of last follow-up or death. Repeat operations to maintain graft patency, treat wound complications, or treat recurrent or contralateral ischemia were required in 61 patients (54%; mean, 1.6 reoperations/patient), and 26 patients (23.2%) ultimately required major limb amputation of the index or contralateral extremity. Only 16 of 112 patients (14.3%) achieved the ideal surgical result of an uncomplicated operation with long-term symptom relief, maintenance of functional status, and no recurrence or repeat operations. CONCLUSIONS: Most patients who undergo infrainguinal bypass surgery for limb salvage require ongoing treatment and have persistent or recurrent symptoms until their death. A significant minority have major tissue loss despite successful initial surgery. Clinically important palliation is frequently achieved by bypass surgery, but ideal results are distinctly infrequent.

Late clinical and hemodynamic sequelae of isolated calf vein thrombosis.

PURPOSE: Despite the frequent occurrence of isolated calf vein thrombosis (ICVT), little is known about the long-term clinical and hemodynamic sequelae of this condition. This study was conducted to determine late clinical symptoms and vascular laboratory abnormalities in patients after ICVT. METHODS: Of 146 patients in whom ICVT was documented by color flow duplex scanning between 1989 and 1994, 37 were reexamined. Data included history, physical examination, venous recovery time (VRT), and duplex valve closure time (DVCT). A control group with no history of venous disease also underwent identical clinical and hemodynamic testing. RESULTS: Thirty-seven patients (18 male and 19 female) with a median age of 56 years (range, 22 to 76 years) were examined at a mean follow-up of 3.4 years (range, 2.2 to 5.8 years) after the diagnosis of ICVT in 39 extremities. Seventeen subjects (34 extremities) were recruited as normal controls. Presenting symptoms at the time of ICVT included calf pain in 17 patients, calf swelling in seven, pain and swelling in seven, pulmonary symptoms in four, pulmonary symptoms and calf pain in one, and no symptoms in one. In the patients with ICVT, VRT was abnormal in 23% of extremities with ICVT and in 9% of extremities without ICVT. None of the extremities in the control group had an abnormal VRT (p < 0.05). DVCT was abnormal in one or more venous segments in 26% of extremities diagnosed with ICVT and in 6% of control extremities (p < 0.05). Follow-up clinical examination in patients with ICVT revealed 13 (35%) with reticular veins, 10 (27%) with varicose veins, two (5.4%) with edema, one (2.7%) with pigmentation and ulcer (contralateral extremity to ICVT with a previous history of proximal deep venous thrombosis), 13 (35%) with mild discomfort, and one (2.7%) with severe pain. All symptoms attributable to ICVT were mild in nature except in one patient who had severe pain and no physical or hemodynamic vascular laboratory abnormalities at follow-up. CONCLUSION: At an average of 3.4 years after ICVT, approximately one third of patients showed evidence of mild to moderate venous valvular insufficiency, but mostly in segments not involved with ICVT, and few had significant clinical symptoms attributable to venous disease.

Duplex scanning alone is not sufficient imaging before secondary procedures after lower extremity reversed vein bypass graft.

PURPOSE: Duplex surveillance of lower extremity reversed vein bypass grafts (LERVG) is a means of identifying patients at risk for occlusion. The perceived accuracy of duplex scan as a means of identifying stenoses has led many surgeons to perform graft revision on the basis of duplex scan alone. This may result in missing additional lesions that are threatening patency. To assess the role of duplex scan as the sole imaging method before revision of LERVGs, we reviewed consecutive patients undergoing revisions who underwent preoperative arteriography after identification of duplex scan abnormalities. METHODS: Duplex scan results, operative reports, and preoperative arteriograms for patients undergoing LERVG revision from January 1990 to December 1997 were reviewed. A standard duplex scan surveillance protocol was followed, and attempts were made to survey the entire graft, including inflow and outflow. Duplex scan results were compared with the results of preoperative arteriograms and the operation performed to determine if all significant lesions were identified by means of duplex scan alone. RESULTS: Two hundred five LERVG revisions were performed. The 5-year assisted primary patency rate was 91%. In 119 cases (58%), arteriography did not contribute significantly to duplex scan findings. Arteriography significantly contributed to operative planning in 86 cases (42%). In 38 cases (19%), only a low-flow state was identified by means of duplex scan, and a correctable stenosis was identified by means of arteriography. In 48 cases (23%), additional significant lesions corrected at operation were identified by means of arteriography. These included 26 inflow, 16 graft, and 8 outflow lesions. Arteriography was most useful as a means of determining the revision procedure performed when there were inflow lesions (P <.05) or when the proximal anastomosis was to the profunda or superficial femoral arteries (P <.05). All frequently performed bypass graft configurations had some discrepancy between arteriographic and duplex scan findings. CONCLUSION: Available data do not permit prediction of which LERVG are immune from missed lesions in a duplex scan surveillance protocol. This suggests to us that arteriography is mandatory before LERVG revisions.

Carotid endarterectomy in women: challenging the results from ACAS and NASCET.

OBJECTIVE: To evaluate and compare the short- and long-term outcomes in female and male patients after carotid endarterectomy (CEA). SUMMARY BACKGROUND DATA: Randomized carotid trials have clearly shown the benefits of CEA in specific symptomatic and asymptomatic patients. However, the short- and long-term benefits in women appear to be less clear, and the role of CEA among women with carotid disease remains uncertain. METHODS: During a 21-year period, 1,204 CEAs were performed, 464 (39%) in women and 739 (61%) in men. Complete follow-up was available in 70% of patients. RESULTS: Women were less likely to have evidence of coronary artery disease, were more likely to be hypertensive, and had a significantly greater incidence of diabetes. The mean age at CEA was 68.5 +/- 9.5 years for women and 68.0 +/- 8.5 years for men. There were no significant differences in the use of shunts, patching, tacking sutures, or severity of carotid stenoses between men and women. Surgical death rates were nearly identical for asymptomatic and symptomatic patients. Perioperative stroke rates were similar for asymptomatic and symptomatic patients. Life-table stroke-free rates at 1, 5, and 8 years were similar for asymptomatic women and men and symptomatic women and men. Long-term survival rates at 1, 5, and 8 years were higher for asymptomatic women compared with men and for symptomatic women compared with men. As a result, stroke-free survival rates at these follow-up intervals were greater for asymptomatic women compared with men, and for symptomatic women compared to men. CONCLUSIONS: The results from this study challenge the conclusions from the Asymptomatic Carotid Endarterectomy Study and the North American Symptomatic Carotid Endarterectomy Trial regarding the benefits of CEA in women. Female gender did not adversely affect early or late survival, stroke-free, or stroke-free death rates after CEA. The authors conclude that CEA can be performed safely in women with asymptomatic and symptomatic carotid artery disease, and physicians should expect comparable benefits and outcomes in women and men undergoing CEA.

Outcome of venous stasis ulceration when complicated by arterial occlusive disease.

OBJECTIVE: to report the outcome of patients with venous stasis ulceration (VSU) and severe arterial occlusive disease (AOD). DESIGN: retrospective study. METHODS: using the International Classification of Diseases (ICD-9), codes for VSU and AOD were cross-matched to identify patients from 1989 to 1999 at two tertiary hospitals. Entry into the study required the presence of a VSU and an ipsilateral procedure to improve AOD or major amputation during the same hospitalisation. RESULTS: fourteen patients (15 extremities) with a mean age of 80 years (range: 47-93) were identified as having VSU and AOD. Mean duration of VSU up to the time of revascularisation or amputation was 6.4 years (range: 4 months-21 years). The mean number of VSUs per extremity was 2.1 and mean wound area was 71 cm(2). Mean ankle-brachial index was 0.46 (range: 0.10-0.78). Nine extremities (60%) had a bypass procedure, 3 (20%) had an interventional procedure, 1 (0.6%) had a lumbar sympathectomy, and 2 (13%) had an amputation. Over a mean follow-up of 2.8 years, 3 extremities (23%) healed of which 2 recurred. On last review, 11 patients with 12 afflicted extremities had expired. Nine of the remaining 10 extremities were not healed at the time of death. Eight of nine bypass grafts remained patent in follow-up or at death and subsequent limb salvage was 100%. CONCLUSIONS: combined VSU and AOD represents a rare condition predominantly found in elderly patients with multiple comorbidities. Few patients had complete healing despite an arterial inflow procedure and mortality was high over the short term.

A prospective study of discharge disposition after vascular surgery.

OBJECTIVE: The purpose of this study was to determine what factors are predictive of a decline in independent living after vascular surgery during recovery. METHODS: Demographics, risk factors, operations, complications, wound status, and discharge disposition for all patients admitted to a tertiary vascular surgery service for any surgical procedure were prospectively recorded at the time of discharge. The declining order of dispositions at discharge were home (no professional assistance), home (professional assistance), rehabilitation facility, and skilled nursing facility. RESULTS: Over a 15-month period, 380 patients underwent 442 primary operations. Primary operations included 74 (17%) carotid procedures, 38 (8%) aortic procedures, 186 (42%) extremity revascularizations, 29 (7%) major amputations, 45 (10%) minor amputations, and 70 (16%) other. There were 148 (33%) complications and 85 (20%) subsequent operations (same hospitalization); 159 (36%) open wounds occurred. Forty-six percent of the patients were discharged to home (no professional assistance), 28% to home (professional assistance), 3% to a rehabilitation facility, and 18% to a skilled nursing facility; 5% died. At discharge, 51% of patients required professional assistance, 39% had a decline in disposition, and 12% went from home (+/- professional assistance) to a facility. By multivariate regression analysis, a hospital stay more than 6 days, emergency operation, open operative wound, systemic complications, and minor amputation were significantly associated (P <.001) with a decline in disposition at discharge (odds ratios: 5.5, 3.7, 3.6, 3.6, and 2.8, respectively). CONCLUSIONS: Prospective study reveals that a large proportion of patients (39%) had a decline in disposition after vascular surgery. A hospital stay more than 6 days, emergency operation, open operative wound, systemic complications, and minor amputation were strong independent predictors of decline. This information suggests modifications in treatment strategies may improve independent living status after vascular surgery and decrease the intense use of extended care resources required for this patient population during recovery.

Raynaud's syndrome in workers who use vibrating pneumatic air knives.

PURPOSE: The use of vibrating tools has been shown to cause Raynaud's syndrome (RS) in a variety of workers, including those who use chain saws, chippers, and grinders. The diagnosis of RS in workers who use vibrating tools is difficult to document objectively. We studied a patient cohort with RS caused by the use of a vibrating pneumatic air knife (PAK) for removal of automobile windshields and determined our ability to document RS in these workers by means of digital hypothermic challenge testing (DHCT), a vascular laboratory study that evaluates digital blood pressure response to cooling. METHODS: Sixteen male autoglass workers (mean age, 36 years) with RS were examined by means of history, physical examination, arm blood pressures, digital photoplethysmography, screening serologic studies for underlying connective tissue disorder, and DHCT. RESULTS: No patient had RS before they used a PAK. The mean onset of RS (color changes, 100%; pain, 93%; parathesias, 75%) with cold exposure was 3 years (range, 1.5 to 5 years) after initial PAK use (mean estimated PAK use, 2450 hours). Fifty-six percent of workers smoked cigarettes. The findings of the physical examination, arm blood pressures, digital photoplethysmography, and serologic testing were normal in all patients. At 10 degrees C cooling with digital cuff and patient cooling blanket, a significant decrease in digital blood pressure was shown by means of DHCT in 100% of test fingers versus normothermic control fingers (mean decrease, 75%; range, 25% to 100%; normal response, less than 17%; P <.001). The mean follow-up period was 18 months (range, 1 to 47 months). No patient continued to use the PAK, but symptoms of RS were unchanged in 69% and worse in 31%. CONCLUSION: PAK use is a possible cause of vibration-induced RS. The presence of RS in workers who use the PAK was objectively confirmed by means of DHCT. Cessation of PAK use in the short term did not result in symptomatic improvement.

Hypothenar hammer syndrome: proposed etiology.

PURPOSE: Finger ischemia caused by embolic occlusion of digital arteries originating from the palmar ulnar artery in a person repetitively striking objects with the heel of the hand has been termed hypothenar hammer syndrome (HHS). Previous reports have attributed the arterial pathology to traumatic injury to normal vessels. A large experience leads us to hypothesize that HHS results from trauma to intrinsically abnormal arteries. METHODS: We reviewed the arteriography, histology, and clinical outcome of all patients treated for HHS in a university clinical research center study of hand ischemia, which prospectively enrolled more than 1300 subjects from 1971 to 1998. RESULTS: Twenty-one men had HHS. All had occupational (mechanic, carpenter, etc) or avocational (woodworker) exposure to repetitive palmar trauma. All patients underwent upper-extremity and hand arteriography, unilateral in eight patients (38%) and bilateral in 13 patients (62%). By means of arteriogram, multiple digital artery occlusions were shown in the symptomatic hand, with either segmental ulnar artery occlusion in the palm or characteristic "corkscrew" elongation, with alternating stenoses and ectasia. Similar changes in the contralateral asymptomatic (and less traumatized) hand were shown by means of 12 of 13 bilateral arteriograms (92%). Twenty-one operations, consisting of segmental ulnar artery excision in the palm and vein grafting, were performed on 19 patients. Histology was compatible with fibromuscular dysplasia with superimposed trauma. Patency of arterial repairs at 2 years was 84%. One patient (5%) required amputative debridement of necrotic finger tips. No other tissue loss occurred. There have been no recurrences of ischemia in patients with patent bypass grafts. CONCLUSION: To our knowledge, this is the largest reported group of HHS patients. The characteristic angiographic appearance, histologic findings, and striking incidence of bilateral abnormalities in patients with unilateral symptoms lead us to conclude that HHS occurs when persons with preexisting palmar ulnar artery fibrodysplasia experience repetitive palmar trauma. This revised theory for the etiology of HHS explains why HHS does not develop in most patients with repetitive palmar trauma.