Hypoplastic aortoiliac syndrome: An entity peculiar to women.

Hypoplastic aortoiliac syndrome (HAIS) is a unique disorder that occurs almost exclusively in women. Because reports in the literature are scant, we reviewed our own experience. The criteria for definition were high bifurcation of the abdominal aorta, straight course of the iliac arteries without the normal characteristic bowing, acute angle of the aortic bifurcation, aortic diameter of 14 mm or less, and iliac artery diameter of 7 mm or less. Nineteen patients with HAIS were identified in a 14-year period. All 19 patients were heavy smokers. Most had significant associated arterial disease, and all were women. Fifteen patients were selected as candidates for operation. Two were treated conservatively, one refused surgery, and one died of a myocardial infarction before operation. Reconstruction was performed by aortoiliac thromboendarterectomy with vein patch for segmental disease (four patients) and Dacron bifurcating graft for diffuse disease (11 patients). There were no deaths during operation. Four patients required reoperations for graft failure and three patients eventually required amputations. The four patients who underwent reconstructions by thromboendarterectomy with vein patch had uniformly good results. From this experience, the following approach and management are recommended: conservative nonoperative exercise program with close follow-up if symptoms are tolerable, aortoiliac thromboendartectomy and vein patch if disease is segmental, aortofemoral bifurcating graft for patients with diffuse disease with graft size closely approximating vessel size, and concomitant femoral-to-popliteal graft to ensure adequate runoff and graft patency if there is significant femoral disease. The etiology of HAIS remains obscure. Early onset of symptoms seems to be due to small vessels with superimposed atherosclerotic plaques. Addiction to smoking in these women is extreme (paralleling that seen in Buerger's disease) and may be of etiologic significance.

The efficacy of routine completion operative angiography in reducing the incidence of perioperative stroke associated with carotid endarterectomy.

Routine operative angiography was performed during a 14 1/2-year period ending June 1982, during which 603 consecutive carotid endarterectomies were performed. For the purpose of standardization, a functional classification of stroke in terms of severity was established: class I--minimal, class II--moderate, class III--marked, class IV--severe, and class V--coma or death. Patients were analyzed to determine the cause of the stroke, the severity of the stroke, and the efficacy of routine operative angiography in reducing the incidence of perioperative stroke caused by technical error. Perioperative stroke occurred in 18 patients (2.9%), with only one having been caused by technical error. Fifteen patients underwent revision of the endarterectomy before wound closure because of unsatisfactory operative angiography results. None of the patients developed permanent neurologic deficits. Permanent perioperative neurologic deficits resulted from embolization (six patients), hypertensive episodes with cerebral hemorrhage (three patients), conversion of ischemic to hemorrhagic infarcts (two patients), spontaneous thrombosis (one patient), clamp ischemia (two patients), and other factors (three patients). Nine patients died, two of myocardial infarction and seven of stroke, for a combined mortality and morbidity rate of 3.3%. There were three class II, five class III, two class IV, and eight class V strokes that were determined to be related to the procedure. In this series stroke may have been prevented in 15 patients who underwent revision of the endarterectomy because of an unacceptable technical error demonstrated on operative angiography.

The causes and prevention of stroke associated with carotid artery surgery.

Four hundred eighty-eight consecutive carotid endarterectomies were performed on 417 patients. Stroke, as a procedure-related complication, occurred in 12 patients, or 2.4 per cent of cases. Five causes of operative or postoperative stroke were identified: 1) operative embolization, 2) postoperative hypertensive episodes with cerebral hemorrhage, 3) technical error, 4) conversion of ischemic infarct to hemorrhagic infarct, and 5) clamp-time ischemia. The use of several modalities evolved as routine in an effort to reduce mortality and morbidity: 1) minimal manipulation of the artery until after cross clamping to prevent microembolization; 2) routine direct arterial blood pressure monitoring and control during and after surgery; 3) routine operative arteriography to detect and correct technical errors at the time of surgery; 4) liberal use of CAT scans preoperatively to avoid surgery on patients with small, unrecognized infarcts; and 5) stump pressure measurement and selective shunting to prevent ischemia during the endarterectomy. The anatomical-pathological combination of a high bifurcation and high plaque is identified as a high-risk situation.

Oblique incision of the groin for vascular reconstruction at the femoral level.

Exposure of the common femoral artery and its branches for vascular reconstruction has most often been accomplished with a vertical or hockey stick incision which crosses the inguinal folds. An oblique skin incision placed parallel to, and slightly above, the inguinal ligament affords adequate exposure, possesses better healing characteristics and, in the obese, avoids a potentially inflamed inguinal skin crease.