Arteriovenous fistula construction using femoral vein in the thigh and upper extremity: single-center experience.

The objective of this study was to determine the outcome of femoral vein (FV) access as either a FV thigh transposition or upper extremity FV translocation. This is a retrospective review of all end-stage renal disease (ESRD) patients who underwent FV access at the University of Colorado Health Sciences Center from December 2004 to May 2007. Demographics, number of prior access procedures, FV dialysis access procedure, periprocedural complications, mean follow-up, secondary access-related procedures, and access function were recorded. Complications were subdivided into FV harvest site- and ischemia-related. Nineteen patients underwent FV access during the study period: 10 underwent FV thigh transpositions and nine underwent upper extremity FV translocations. The median number of prior access procedures was two. The median hospital stay was 3 days, and there were no perioperative deaths. Eight patients had FV harvest site complications: six lymphoceles, one AVF infection requiring ligation, and one compartment syndrome requiring fasciotomy. Three (16%) patients had ischemic complications: one required ligation of the AVF and two required distal revascularization interval ligation. Seventy-nine percent of patients had a functioning access at a mean follow-up of 6 months (range 23 days to 3 years). Four FV arteriovenous accesses required one or more endovascular procedures to maintain function at 12 months. The use of FV access in ESRD is durable at intermediate follow-up but has significant morbidity. FV access should be reserved for good-risk patients who have exhausted other autogenous options.

Patterns of artery disease in 450 patients undergoing revascularization for critical limb ischemia: implications for clinical trial design.

OBJECTIVE: The pattern and distribution of arterial occlusions and stenoses in patients with critical limb ischemia presenting at two academic medical centers was described. METHODS: From January 1998 to December 2006, 450 consecutive critical limb ischemia patients who underwent arteriography and infrainguinal revascularization at the University of Colorado Health Sciences Center or Southern Illinois University were retrospectively evaluated. Demographics, clinical morbidities, and Fontaine stage were recorded. The arterial tree was categorized into three groups: the aorta and iliac arteries (A-I); the common femoral, superficial femoral, and profunda femoral arteries (Fem); and the popliteal and tibial arteries (Pop-Tib). Arterial segments within groups were categorized as subcritical stenoses (patent or <50% stenoses), critical stenoses (single or multiple >50% stenoses), or occluded (segmental occlusions of any length). Patients with diabetes mellitus, end-stage renal disease, and Fontaine stage (III vs IV) were analyzed for differing disease patterns according to their chart history. RESULTS: Occlusive disease was present in 5% in all arterial segments (A-I + Fem + Pop-Tib), in 1% in the A-I + Fem group, in 2% in the A-I + Pop-Tib group, in 3% in A-I group, in 4% in the Fem group, in 30% in the Fem + Pop-Tib group, and in 55% in the Pop-Tib group. Descriptive comparisons among subgroups demonstrated a 61% to 69% prevalence of popliteal and tibial occlusive patterns in patients with diabetes mellitus, end-stage renal disease, and Fontaine stage IV. Furthermore, 65% of patients with Pop-Tib occlusions had associated critical stenoses in the proximal arterial groups. CONCLUSION: More than half of critical limb ischemia patients undergoing infrainguinal revascularization have arterial occlusions in the popliteal or tibial arterial segments, or both, with associated critical stenoses in the femoral arterial segments, which is even greater in the subgroups with diabetes mellitus, end-stage renal disease, and Fontaine stage IV. Knowledge of such occlusive patterns is important for the development of novel infrainguinal endovascular and angiogenesis therapies for critical limb ischemia.

Endovascular therapy of superior gluteal artery aneurysms: case report and review of literature.

We report two cases of superior gluteal artery aneurysms successfully treated with coil embolization and review treatment options for these lesions. Our experience in the treatment of three total aneurysms, two likely post-traumatic in etiology and one mycotic, suggests that endovascular therapy is an effective alternative to open surgery when treating superior gluteal artery aneurysms.

Wound healing and functional outcomes after infrainguinal bypass with reversed saphenous vein for critical limb ischemia.

OBJECTIVE: To examine wound healing and the functional natural history of patients undergoing infrainguinal bypass with reversed saphenous vein for critical limb ischemia (CLI). METHODS: Consecutive patients undergoing infrainguinal bypass for CLI were retrospectively entered into a technical and functional outcomes database. The patients were enrolled from the tertiary referral vascular surgery practices at the University of Colorado Health Sciences Center and Southern Illinois University Medical School. Main outcome variables included wound healing, self-assessed degree of ambulation (outdoors, indoors only, or nonambulatory), and living status (community or structured) after a mean follow up of 30 +/- 23 months. These outcome variables were assessed relative to the preoperative clinical characteristics (symptom duration before vascular consultation, lesion severity, and serum albumin level) and graft patency. RESULTS: From August 1997 through December 2004, 334 patients (253 men; median age, 68 years) underwent 409 infrainguinal bypasses (157 popliteal, 235 tibial, and 17 pedal) for CLI (159 Fontaine III and 250 Fontaine IV). Perioperative mortality was 1.2%. At 1 and 3 years, respectively, the primary patency was 63% and 50%, assisted primary patency was 80% and 70%, limb salvage was 85% and 79%, and survival was 89% and 74%. Complete wound healing at 6 and 12 months was 42% and 75%, respectively. Thirty-four patients (10%) died before all wounds were healed. Multivariate analysis indicated that extensive pedal necrosis at presentation independently predicted delayed wound healing (P < or = .01). At baseline (defined as the level of function within 30 days before the onset of CLI), 91% of patients were ambulatory outdoors, and this decreased to 72% at 6 months (P < or = .01). Similarly, 96% of patients lived independently at baseline, and this decreased to 91% at 6 months (P < or = .01) Graft patency was associated with better ambulatory status at 6 months. A longer duration of symptoms before vascular consultation was associated with a worse living status at 6 months. CONCLUSIONS: Despite achieving the anticipated graft patency and limb salvage results, 25% of patients did not realize wound healing at 1 year of follow-up, 19% had lost ambulatory function, and 5% had lost independent living status. Prospective natural history studies are needed to further define the functional outcomes and their predictors after infrainguinal bypass for CLI.

The effects of intraoperative fenoldopam on renal blood flow and tubular function following suprarenal aortic cross-clamping.

This study evaluated the effect of fenoldopam, a selective dopamine (DA1) agonist, on renal blood flow and renal tubular function following renal ischemia induced by suprarenal aortic cross-clamping. Twenty anesthetized research pigs received either fenoldopam (10 micro g/kg/min; n = 10) or saline ( n = 10) beginning 20 min before suprarenal aortic cross-clamping and continuing for 20 min after clamp release, for a total infusion time of 160 min (120-min cross-clamp). Recordings of renal blood flow, mean arterial pressure, and heart rate were taken at baseline, during cross-clamping, and immediately postclamp. Ischemic renal injury was evaluated by serum creatinine and by histologic grading of acute tubular necrosis. Treatment with fenoldopam increased renal blood flow in comparison to that in the control group ( p = 0.03). The mean creatinine increase from baseline at 6 hr and 18 hr after cross-clamp removal for the fenoldopam-treated group was significantly less than that in the control group ( p < 0.001). On histologic evaluation, the mean score for the degree of tubular necrosis was significantly higher in the control group ( p = 0.02), indicating less derangement of tubular morphology in the fenoldopam group. This study demonstrated that the intraoperative use of a continuous infusion of fenoldopam during suprarenal aortic cross-clamping results in increased renal blood flow, less postoperative rise in creatinine, and better preservation of tubular histology in the pig model.