Transcatheter therapy of severe acute lower extremity ischemia.

PURPOSE: Transcatheter methods of revascularization were performed in 11 patients with severe acute lower extremity ischemia and extensive vascular occlusions in whom surgical revascularization was not possible (10 patients) or was not preferred (one patient). PATIENTS AND METHODS: The acute ischemia was considered category 2 in nine patients and category 3 in two. Vascular occlusions were located in the superficial femoral artery in four patients, popliteal artery in 10, all three crural arteries in 10, and two crural arteries in one. Transcatheter methods included accelerated thrombolysis with 325,000 to 1.75 million U of urokinase, adjunct angioplasty, use of intraarterial vasodilators, and creation of pedal arterial flow loops. RESULTS: Initial success was 100% in the nine patients with category 2 ischemia. Eight limbs were saved; one occlusion at 10 days necessitated below-knee amputation. For the two patients with category 3 ischemia, one procedure failed and the other reduced the level of amputation. CONCLUSION: In patients with severe acute ischemia, transcatheter revascularization is a viable treatment option when strategies for reperfusion establish both inflow and microcirculatory outflow.

Patient perspectives on smoking and peripheral vascular disease. A veteran population survey.

In keeping with the recent emphasis on smoking and health, we conducted a survey of patients with peripheral vascular disease in our institution. The objective of the survey was to examine the patient's perspective on a) the relative contribution of smoking to his disease, b) the value of alternative measures to encourage smoking cessation, and c) the smoker's role and responsibility in payment for future health care. One hundred sixty patients at the VAMC in Palo Alto, California, participated in the study. The participants were men who had visited the clinic with complaints related to vascular insufficiency. The "typical" smoker from our survey a) had smoked for more than 30 years, b) acknowledges the association between smoking and disease, and c) will not stop smoking until serious health problems intervene. The majority of respondents expected the same health care regardless of smoking history and did not endorse paying more for health services. Most patients identified serious heart and lung disease as potential sequelae of cigarette smoking, however only 44 per cent of active smokers attributed their peripheral vascular disease to smoking. Although the survey was conducted on patients with complaints related to vascular insufficiency, few respondents identified an association in smoking with gangrene of the lower extremity or leg amputations. It is unclear whether this represents a failure on the part of health professionals to stress this relationship or denial on the part of the smoker. Physicians should continue to advise against cigarette smoking. A strong relationship between continued smoking and lower extremity ischemia or amputation needs to be emphasized in the clinical setting and through public health information campaigns.

Semiclosed transfemoral iliac endarterectomy with an oscillating ring stripper.

The technique of endarterectomy for the removal of occlusive atherosclerotic lesions of the aorta and iliac arteries has been utilized successfully in the revascularization of ischemic limbs since its introduction in 1951. The oscillating loop endarterectomy device (Amsco-Hall arterial oscillator) has proven to be useful for endarterectomy of segmental occlusive disease as a substitute for bypass with prosthetic graft. For our elderly debilitated patients, we have adopted a new technique of semiclosed transfemoral iliac endarterectomy for management of occlusive external iliac disease with a patent common iliac artery. We report seven patients treated during May 1987 through May 1988 for external iliac artery occlusion by transfemoral oscillating loop endarterectomy. At 12 months for follow-up review, the cumulative limb salvage rate was 80% with no perioperative mortality. One patient required above-knee amputation eight months following endarterectomy to control forefoot sepsis. Two patients required subsequent leg bypass procedures to achieve full healing of foot level amputation. One patient required dilatation of residual stenosis at the iliac bifurcation by percutaneous balloon angioplasty. Semiclosed transfemoral endarterectomy with the Amsco-Hall oscillating loop device remains an attractive option to the vascular surgeon for recanalization of the iliac artery without the need for an extensive retroperitoneal dissection.

Digital manipulation of the thrombosed arterio-venous conduit.

The utility of a bedside technique for digital manipulation of the thrombosed arterio-venous conduit was retrospectively reviewed. During an 18 month period the records of all patients at this institution who were undergoing chronic hemodialysis, via a forearm modified arterial bovine heterograft, and who were successfully treated by digital manipulation for graft thrombosis were examined. Thirteen patients who underwent 30 successful graft manipulations constituted the study group. Bedside manipulation attempts were performed from one to 72 hours from the period of last known function. Complete response to the technique was indicated by the appearance of a pulse and panrhythmic bruit and thrill throughout the conduit. The average duration of restored flow was 58.6 days (range one to 430 days). No serious or life threatening complications (e.g. problems related to pulmonary thromboembolism) were observed. Conduit thrombosis secondary to faculty cannulation, prior hypotension, or extrinsic compression was amenable to the technique; however, when occlusion was secondary to an intrinsic problem in the graft (stenosis of the venous or arterial anastomosis), operative revision was required. If successful, the technique allows for immediate dialysis access without the need for additional measures. The procedure has negligible morbidity and can spare the patient considerable time and expense.

Carotid endarterectomy in a general surgical training program.

Concern regarding the quality of surgical treatment performed within resident training programs and the need for direct, active involvement of the attending surgeon have been issues of interest to surgeons and the public. To provide specialized training in the diagnosis and treatment of vascular disease, vascular surgical fellowships have been established. In institutions with established vascular fellowships, one may question whether general surgical residents or vascular surgical fellows should perform carotid endarterectomies. The majority of carotid reconstructive procedures are performed at our institution by the chief general surgical resident under direct supervision. We elected to review our experience with surgical treatment of the carotid artery in an effort to examine the safety of this practice. The record of all patients who underwent carotid endarterectomy or reconstruction from April 1980 to July 1984 were reviewed. One hundred and twenty-nine patients who underwent 153 reconstructions of the carotid artery constituted the study group. The indication for operation was symptomatic carotid atheromatous disease in 96 and asymptomatic disease in 57. Ninety-three per cent of the procedures were performed by the chief general surgical resident under the supervision of one attending surgeon. Although the incidence of associated systemic problems (hypertension, diabetes and coronary artery disease) was significant in the study group, postoperative cardiovascular and cranial nerve and central neurologic deficits were 1.3 per cent, respectively, with no operative mortality. At our institution, the performance of carotid endarterectomy under close supervision provides an excellent context in which the resident in training may learn precise and careful dissection of the tissue and arterial repair. The need for formal vascular surgical fellowships to develop proficiency in judgment, technique and management of vascular disease is not questioned. However, as a learning experience for the general surgical resident, we believe this practice is both safe and effective, and a high standard of patient care is not compromised.

Magnetic resonance angiography by selective inversion recovery using a compact gradient echo sequence.

We have studied a pulse sequence using compact imaging gradients for MR angiography by selective inversion recovery. By acquiring signals approaching a half-echo, we achieve significant immunity to artifacts from flow-induced dephasing. Initial clinical results on carotid arteries accurately depict stenoses without the problems of signal dephasing.

Ventral hernia following abdominal aortic reconstruction.

An unexpectedly high frequency of ventral incisional hernia in our aortic reconstruction patients prompted us to review a recent three year period. Of 76 aortic reconstruction patients, 66 were evaluable for at least one year following their aortic procedure. In these 66 patients, ventral incisional hernias occurred in 14 (21.2%). Of statistical significance (P less than .01) was that ten of the 14 hernias occurred in the 27 aneurysm patients (37%) and four occurred in the 39 occlusive disease patients (10%). Though a comparison group of aneurysm patients is not available in the literature, the incidence of hernia in our occlusive disease population is consistent with the literature experience when careful long-term follow-up is employed. These observations may represent another manifestation of previously reported differences between aortic aneurysm and occlusive atherosclerotic populations.

Amputation level and distal bypass salvage of the limb.

The feasibility of revascularization of the lower extremity for salvage of the limb with grafts to the tibial and peroneal arteries has been well established. The results of prior reports have suggested that a failed distal bypass may convert a lower extremity amputation to a higher level than afforded by primary amputation. We reviewed all distal, tibial or peroneal artery bypasses performed at our institution during the period of March 1980 through October 1986. Fifty-three patients with 59 threatened lower extremities underwent distal bypass for salvage of the limb. No patient was excluded from review. Thirty-eight patients in the study group had diabetes, and 41 had a prior smoking history. In the postoperative period, six patients were lost to follow-up study, nine patients died, with follow-up data complete in 47 of the study group. The maximum length of follow-up study was 78 months, and the average length was 24 months. Data were examined by life table analysis with respect to cumulative salvage of the limb and graft patency. During the period of review, 12 major amputations were required (nine below-knee and three above-knee) for a cumulative salvage rate of 59 per cent. Of the distal grafts which failed (n = 27), three of 27 of the limbs required above-knee amputation. We conclude that a failed tibial or peroneal artery bypass does not preclude the possibility of salvage of the limb and does not predispose to a subsequent amputation.

Subclavian venous stenosis. A complication of subclavian dialysis.

Subclavian hemodialysis catheters are widely employed for temporary hemodialysis access, but there are few reports of serious complications. We report three cases in which the prolonged (greater than 15 days) use of subclavian dialysis catheters ipsilateral to the permanent vascular access was associated with the development of subclavian vein (SCV) stenosis three to six months after the temporary catheter was removed. In one case, the use of the permanent access was severely limited by massive arm edema. We conclude that, in addition to the usual complications of SCV cannulation, long-term use of SCV hemodialysis catheters can be associated with major late obstructive complications that may compromise permanent vascular access. We recommend that, wherever possible, temporary dialysis catheters and other subclavian lines be placed contralateral to the permanent vascular access site in patients undergoing hemodialysis.

Aortoiliac-graft infection. Detection by leukocyte scan.

Infection of a vascular synthetic graft in the aortoliac position is a lethal complication of vascular reconstructive surgery. Difficulties in diagnosis and the subsequent delays in treatment are significant factors in the excessive mortality. Currently available diagnostic methods are extremely limited in their ability to detect infection in the retroperitoneal position, particularly at an early stage. A case is reported in which an aortoiliac-graft infection was detected by a leukocyte scan using indium 111 while the infection was at a relatively subtle clinical stage, and possible future application of leukocyte scanning to this difficult diagnostic problem is discussed.