Prosthetic versus native artery inflow for infrainguinal bypass.

BACKGROUND: Infrainguinal bypass performed after previous prosthetic inflow reconstruction offers a choice of where to perform the proximal anastomosis. The hood of a previous inflow bypass might be technically easier to isolate during reoperative surgery. However, the more distal native artery might offer better patency to the outflow revascularization. The purpose of the present study was to compare the outcomes of infrainguinal bypass using the hood of a previous inflow bypass vs the native artery as the inflow source. METHODS: A single vascular group's database was queried for all cases of infrainguinal bypass performed after previous prosthetic inflow bypass to a femoral artery from January 2006 to December 2016. The demographics, indications, operative details, and long-term results were recorded and analyzed. Two groups were compared stratified by the location of the proximal anastomosis for the distal bypass. In one group, the inflow source for the distal bypass was from the hood of a previous inflow graft (prosthetic). In the second group, the distal native arterial tree was used as the inflow source. A subset analysis of the patency of the distal bypass was also performed between the two groups for those in which the previous inflow reconstruction had become occluded. Patency was calculated using the Kaplan-Meier method. RESULTS: A total of 197 patients had undergone infrainguinal bypass after previous inflow bypass from 2006 to 2016. Of the 197 procedures, 59 (30%) had used the hood of the previous bypass as the inflow source (prosthetic group) and 138 (70%) had used the native artery distal to the hood of the inflow bypass as the inflow source (native group). The indications were similar between the two groups. The two groups had a similar proportion of men and a similar incidence of hypertension, hyperlipidemia, coronary artery disease, tobacco use, and renal disease. The previous inflow procedures were also similar between the two groups. The native artery used for the inflow source in the native group was the profunda femoris in 80 (58%), common femoral artery in 51 (37%), and superficial femoral artery in 7 (5.1%). Patency was significantly greater for the native group at 1 year (91% vs 75%; P = .0221). Also, the patency after inflow bypass occlusion significantly favored the native group at 1 year (87% vs 40%; P = .0035). CONCLUSIONS: Infrainguinal bypass performed after previous ipsilateral inflow bypass offers the option of using the hood of the bypass or a native artery as the inflow source. The present study demonstrated greater patency rates when using the distal native artery as the inflow source. The native artery option also offered continued patency when the inflow bypass occluded.

Long-term patency of venous and prosthetic conduits for ipsilateral internal carotid artery bypass.

OBJECTIVE: Ipsilateral internal carotid artery bypass has been used successfully to treat aneurysms, infection, tumor, and occlusive disease. The purpose of this study was to evaluate the long-term outcomes of autogenous and prosthetic conduits used for ipsilateral internal carotid artery bypass. METHODS: A retrospective review of a single-institution registry was performed to identify patients with ipsilateral carotid artery bypass. Demographics, complications, and patency were recorded and compared using χ2, Fisher's exact, and log-rank analysis. RESULTS: From 1994 to 2016, 105 patients underwent ipsilateral carotid artery bypass (86 prosthetic, 19 veins). The venous bypass group and prosthetic bypass group were different in terms of gender (8 males and 11 females vs 58 males and 28 females; P = .038), but similar in age (mean in the venous bypass group, 63 years [range, 18-80 years] vs mean in the prosthetic bypass group 68 years [range, 33-88 years], P = .052). The mean follow-up was 53 months (range, 1 month to 15 years). Diabetes, pulmonary disease, hypercholesterolemia, and tobacco use were not statistically different between the groups. Indications were different between the groups, with a prosthetic bypass being used more often for occlusive disease and a venous bypass used more often for infection, aneurysm, trauma, and tumor (Fisher's exact test, P = .004). Perioperative complications were few and similar between groups (restenosis, immediate occlusion, and neurologic morbidity). Patency rates, as determined by duplex ultrasound examination, were similar at 1 year (100% venous bypass group vs 99% prosthetic bypass group; P = .434). The 10-year follow-up with an estimated patency based on extrapolated survival curves to be 84% for the venous bypass group vs 88% for the prosthetic bypass group. CONCLUSIONS: Ipsilateral internal carotid artery bypass performed for a variety of indications using prosthetic and venous conduits have demonstrated excellent short-term results. Both types of conduits in this series have trended toward continued durability over long-term follow-up.

The incidence and fate of endoleaks vary between ruptured and elective endovascular abdominal aortic aneurysm repair.

BACKGROUND: The number of ruptured abdominal aortic aneurysm (r-AAA) patients who are treated by endovascular means is increasing as ruptured endovascular aneurysm repair (r-EVAR) enters the mainstream. However, even today, data on the incidence and behavior of endoleaks after r-EVAR are scarce. This study analyzed whether endoleaks behave differently after EVAR for rupture vs elective AAA repair. METHODS: From 2002 to 2013, there were 2052 patients who underwent EVAR for treatment of rupture (n = 166 [8.1%]) and elective repair (n = 1886 [91.9%]) of infrarenal AAA. Follow-up included computed tomography angiography at 1 month, at 6 months, and yearly thereafter. All type I and type III endoleaks were treated at the time of or shortly after the diagnosis. Persistent type II endoleaks at >6 months after EVAR without a decrease in AAA sac underwent translumbar or transfemoral embolization procedures. Data were prospectively collected in a vascular database. RESULTS: During a mean follow-up of 30 months, patients had a significantly lower incidence of type II endoleaks after r-EVAR compared with elective endovascular aneurysm repair (e-EVAR; n = 15 [9.0%] vs n = 380 [20.2%]; P < .01). Although the incidence of type I endoleaks is similar after r-EVAR (n = 9 [5.4%] and e-EVAR (n = 83 [4.4%]; P = .68), the r-EVAR patients required stent graft explantation more frequently (n = 9 [5.4%] vs n = 20 [1.1%]; P < .01). Whereas the need for secondary intervention was comparable in both r-EVAR (n = 33 [19.9%]) and e-EVAR (n = 439 [23.3%]; P = .37) groups, patients undergoing percutaneous embolization procedures trended toward significance between the two groups (n = 11 [6.6%] vs n = 216 [11.5%]; P = .06) with endoleaks. CONCLUSIONS: Compared with e-EVAR, patients who undergo r-EVAR experience a similar incidence of type I endoleaks and a significantly lower incidence of type II endoleaks. The endoleaks in both e-EVAR and r-EVAR patients can frequently be managed by endovascular means. However, r-EVAR patients with type I and type II endoleaks are at a significantly higher risk for stent graft explantation.

Regionalization of Emergent Vascular Surgery for Patients With Ruptured AAA Improves Outcomes.

OBJECTIVE: Safe and efficient endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (r-AAA) requires advanced infrastructure and surgical expertise not available at all US hospitals. The objective was to assess the impact of regionalizing r-AAA care to centers equipped for both open surgical repair (r-OSR) and EVAR (r-EVAR) by vascular surgeons. METHODS: A retrospective review of all patients with r-AAA undergoing open or endovascular repair in a 12-hospital region. Patient demographics, transfer status, type of repair, and intraoperative variables were recorded. Outcomes included perioperative morbidity and mortality. RESULTS: Four hundred fifty-one patients with r-AAA were treated from 2002 to 2015. Three hundred twenty-one patients (71%) presented initially to community hospitals (CHs) and 130 (29%) presented to the tertiary medical center (MC). Of the 321 patients presenting to CH, 133 (41%) were treated locally (131 OSR; 2 EVAR) and 188 (59%) were transferred to the MC. In total, 318 patients were treated at the MC (122 OSR; 196 EVAR). At the MC, r-EVAR was associated with a lower mortality rate than r-OSR (20% vs 37%, P = 0.001). Transfer did not influence r-EVAR mortality (20% in r-EVAR presenting to MC vs 20% in r-EVAR transferred, P > 0.2). Overall, r-AAA mortality at the MC was 20% lower than CH (27% vs 46%, P < 0.001). CONCLUSIONS: Regionalization of r-AAA repair to centers equipped for both r-EVAR and r-OSR decreased mortality by approximately 20%. Transfer did not impact the mortality of r-EVAR at the tertiary center. Care of r-AAA in the US should be centralized to centers equipped with available technology and vascular surgeons.

Chronic mesenteric ischemia outcome analysis and predictors of endovascular failure.

OBJECTIVE: Outcomes of open revascularization (OR) and endovascular revascularization (ER) for chronic mesenteric ischemia (CMI) were analyzed to identify predictors of endovascular failure. METHODS: A retrospective study was performed of all consecutive patients with CMI (161 patients, 215 vessels) treated from 2008 to 2012. Demographics, comorbidities, clinical presentation, etiology, and treatment modalities were compared. Outcomes included technical success, restenosis requiring reintervention, complications, mortality, and hospital length of stay. RESULTS: There were 116 patients who were first treated with ER (72%) and 45 patients with OR (28%). Overall mortality was 6.8% (11/161). Among the ER patients, 27 developed restenosis and required OR (23%). Patients treated with ER were older (73 vs 66 years; P = .014), had similar comorbidities, and had higher rate of short lesions (≤2 cm) on preoperative angiograms (23% vs 47%; P = .004). Primary patency at 3 years was higher in the OR group compared with the ER group (91% vs 74%; P = .018). Long-term survival rates were higher in the ER group (95% vs 78%; P = .003). Hospital length of stay and intensive care unit length of stay were shorter in the ER group (<.001). Perioperative mortality (30-day) was not statistically significant between the groups (5.2% vs 11%; P = .165). A subgroup analysis was performed between the patients with successful ER and failure of ER requiring OR. Patients with failure of ER had significantly higher rates of aortic occlusive disease (86% vs 49%; P = .005) and long lesions ≥2 cm on angiography (57% vs 12%; P < .001) that were close to the mesenteric takeoff. Perioperative mortality was higher in the ER failure group (15% vs 2%; P = .009). CONCLUSIONS: ER has similar perioperative mortality and shorter hospitalization but higher rate of restenosis requiring reintervention compared with OR. Patients with ER who required reintervention appear to have longer lesions as well as higher rates of aortic occlusive disease on preoperative angiography. Patients who crossed over from ER to OR had higher perioperative mortality than either primary open or endovascular patients. These findings may guide treatment selection in patients with CMI undergoing ER or OR.

Treatment options for delayed AAA rupture following endovascular repair.

PURPOSE: Delayed abdominal aortic aneurysm (AAA) rupture is a well recognized complication of endovascular aneurysm repair (EVAR). We wanted to evaluate the frequency, etiology, and outcomes of delayed AAA rupture following EVAR, and identify treatment options that facilitate improved survival. METHODS: From 2002 to 2009, 1768 patients underwent elective and emergent EVAR. At a mean follow-up of 29 months, 27 (1.5%) patients presented with delayed AAA rupture and required repair by either open surgical conversion or endovascular means. All data were prospectively collected in a vascular registry, and outcomes analyzed. RESULTS: Over a mean follow-up of 29 months, the incidence of delayed AAA rupture after elective EVAR was 1.4% (24 of 1615 patients), and after emergent EVAR for ruptured AAA was 2.8% (3 of 106 patients). Of the 27 delayed AAA rupture patients, 20 (74%) were considered "lost to follow-up," and, at presentation, 17 (63%) patients had Type 1 endoleak with stent graft migration, three (11%) had Type 1 endoleak without stent graft migration, five (19%) had Type 2 endoleak, and two (7%) had undetermined etiology for aneurysm rupture. Fifteen (55%) patients underwent open surgical repair via retroperitoneal approach with partial (n = 8; 53%) or complete (n = 7; 47%) stent graft explants and aortoiliac reconstruction, 11 (41%) patients underwent a second EVAR, and one (4%) patient refused treatment and died. Supraceliac aortic clamp was required in three (20%) patients with open surgical conversion, and supraceliac occlusion balloon was required in two (18%) patients with EVAR. There were three (11%) postoperative deaths; two following open surgical conversion and one following EVAR. One additional redo-EVAR patient has undergone successful elective conversion to open surgical repair for persistent type II endoleak and increase in AAA size. CONCLUSIONS: Delayed AAA rupture following EVAR can be successfully managed in most patients by open surgical conversion or secondary EVAR. The approach to each patient should be individualized; complete stent graft explant is not necessary in most patients; a secondary EVAR for delayed AAA rupture with or without an elective conversion to open surgical repair remains a viable option. Vigilant routine follow-up is needed for all patients after EVAR.

Ruptured abdominal aortic aneurysm: endovascular program development and results.

Improvements in endovascular technology and techniques have allowed us to treat patients in ways we never thought possible. Today endovascular treatment of ruptured abdominal aortic aneurysms is associated with markedly decreased morbidity and mortality when compared to the open surgical approach, yet there are several fundamental obstacles in our ability to offer these endovascular techniques to most patients with ruptured aneurysms. This article will focus on the technical aspects of endovascular aneurysm repair for rupture, with particular attention to developing a standardized multidisciplinary approach that will help ones ability to deal with not just the technical aspects of these procedures, but also address some of the challenges including: the availability of preoperative CT, the choice of anesthesia, percutaneous vs. femoral cut-down approach, use of aortic occlusion balloons, need for bifurcated vs. aorto-uniiliac stentgrafts, need for adjunctive procedures, diagnosis and treatment of abdominal compartment syndrome, and conversion to open surgical repair.

Strategies to improve spinal cord ischemia in endovascular thoracic aortic repair: Outcomes of a prospective cerebrospinal fluid drainage protocol.

PURPOSE: Although endovascular repair of thoracic aortic aneurysm has been shown to reduce the morbidity and mortality rates, spinal cord ischemia remains a persistent problem. We evaluated our experience with spinal cord protective measures using a standardized cerebrospinal fluid (CSF) drainage protocol in patients undergoing endovascular thoracic aortic repair. METHODS: From 2004 to 2006, 121 patients underwent elective (n = 52, 43%) and emergent (n = 69, 57%) endovascular thoracic aortic stent graft placement for thoracic aortic aneurysm (TAA) (n = 94, 78%), symptomatic penetrating ulceration (n = 11, 9%), pseudoaneurysms (n = 5, 4%) and traumatic aortic transactions (n = 11, 9%). In 2005, routine use of a CSF drainage protocol was established to minimize the risks of spinal cord ischemia. The CSF was actively drained to maintain pressures <15 mm Hg and the mean arterial blood pressures were maintained at >/=90 mm Hg. Data was prospectively collected in our vascular registry for elective and emergent endovascular thoracic aortic repair and the patients were divided into 2 groups (+CSF drainage protocol, -CSF drainage protocol). A chi(2) statistical analysis was performed and significance was assumed for P < .05. RESULTS: Of the 121 patients with thoracic stent graft placement, the mean age was 72 years, 62 (51%) were male, and 56 (46%) underwent preoperative placement of a CSF drain, while 65 (54%) did not. Both groups had similar comorbidities of coronary artery disease (24 [43%] vs 27 [41%]), hypertension (44 [79%] vs 50 [77%]), chronic obstructive pulmonary disease (18 [32%] vs 22 [34%]), and chronic renal insufficiency (10 [17%] vs 12 [18%]). None of the patients with CSF drainage developed spinal cord ischemia (SCI), and 5 (8%) of the patients without CSF drainage developed SCI within 24 hours of endovascular repair (P< .05). All patients with clinical symptoms of SCI had CSF drain placement and augmentation of systemic blood pressures to >/=90 mm Hg, and 60% (3 of 5 patients) demonstrated marked clinical improvement. CONCLUSION: Perioperative CSF drainage with augmentation of systemic blood pressures may have a beneficial role in reducing the risk of paraplegia in patients undergoing endovascular thoracic aortic stent graft placement. However, selective CSF drainage may offer the same benefit as mandatory drainage.

Primary revision of mid-vein stenoses in venous bypass conduits: venous patch versus interposition vein.

PURPOSE: Patients after infrainguinal vein bypasses are a group at risk of graft stenosis and occlusion. Revision of failing grafts has been shown to significantly improve bypass patency and limb salvage. Options for surgical revision of mid bypass stenosis includes either patch angioplasty (PA) or interposition grafting (IG). We reviewed our experience with surgical revision of vein bypass stenosis. METHODS: From April 1968 to March 2006, 7557 autogenous vein bypasses were performed at Albany Medical Center and its affiliated institutions, of these 316 required single or multiple revision of vein grafts with patch angioplasty or interposition vein grafting. Excluded were proximal and distal anastomotic revisions. Only 235 bypasses had single revisions as either patch angioplasty (n = 108) or interposition grafting (n = 127) and are the focus of this review. The initial bypass revisions in these two groups are analyzed for indications, clinical parameters, operative strategies, and long-term patencies and clinical outcomes. RESULTS: There were no significant differences in mean age, gender, or frequency of comorbid conditions (coronary artery disease, pulmonary disease, hypertension, and diabetes) between the two patient groups. Secondary patency of patch angioplasty revision at 5 years was 79%. Patencies for interposition grafting revision at 5 years were equivalent to patch angioplasty group at 75%. When bypasses were evaluated on the basis of initial reconstructions (ie, in situ vs excised vein bypass), the results showed that in situ bypasses that required initial revision had similar 5-year patencies when interposition grafting was used as the first revision strategy vs patch angioplasty (80% vs 73%). Excised vein bypasses had similar patency when patch was their first revision strategy vs interposition grafting (4 year secondary patency 92% vs 75% respectively). CONCLUSION: Autogenous vein bypasses are at risk for developing significant stenosis and occlusion with time. Bypass stenosis that develops in the main body of the graft can be effectively repaired using either patch angioplasty or interposition grafting. Depending on the host of other factors, such as availability of autogenous venous conduit, location of stenosis, accessibility for operative repair, and the patient's anatomic characteristics, either operative strategy is effective in prolonging the patency of the bypass.

Establishing a protocol for endovascular treatment of ruptured abdominal aortic aneurysms: outcomes of a prospective analysis.

PURPOSE: In our transition from elective abdominal aortic aneurysm (AAA) to emergent ruptured AAA (r-AAA) repair with endovascular techniques, we recognized that the availability of endovascularly trained staff in the operating rooms and emergency departments, and adequate equipment were the limiting factors. To this end, we established a multidisciplinary protocol that facilitates endovascular repair (EVAR) of r-AAA. METHODS: In January 2002, we instituted a multidisciplinary approach that included the vascular surgeons, emergency department physicians, anesthesiologists, operating room staff, radiology technicians, and availability of a variety of stent-grafts to expedite EVAR of r-AAAs. Five patients with symptomatic, not ruptured AAAs suitable for EVAR underwent simulation of patients presenting to the emergency department with r-AAAs. Emergency department physicians alerted the on-call vascular surgery team (vascular surgeon, vascular resident or fellow) and the operating room staff, emergently performed an abdominal computed tomography (CT) scan in only hemodynamically stable patients with systolic blood pressures > or =80 mm Hg, and transported the patient to the operating room. The vascular surgeon informed the operating room staff to set up for EVAR and open surgical repair in an operating room equipped with interventional capabilities. The operating room setup was rehearsed with the anesthesiologists, operating room staff, and radiology technicians who were knowledgeable of the sequence of steps involved. Since then, 40 patients have undergone emergent EVAR for r-AAAs with general anesthesia. RESULTS: No complications developed in any of the symptomatic (simulation) patients, and 40 (95%) of 42 patients with r-AAAs had a successful EVAR with Excluder (n = 27, 68%), AneuRx (n = 9, 23%), or the Zenith (n = 4, 10%) stent-grafts. The mean age was 73 years (range, 54 to 88 years), and pre-existing comorbidities included coronary artery disease in 26 (65%), hypertension in 23 (58%), chronic obstructive pulmonary disease in 7 (18%), renal insufficiency not on dialysis in two (5%), and diabetes in nine (23%). Fourteen (38%) patients were diagnosed with r-AAAs at another hospital and subsequently were transferred to us, and 26 (62%) presented directly to the emergency department at our institution. At the initial presentation, 30 patients (75%) were hemodynamically stable and either had a CT scan at an outside hospital or in the emergency department, and 10 (25%) hemodynamically unstable patients with systolic blood pressures <80 mm Hg were rushed to the operating room for EVAR without a preoperative CT scan. The mean time from the presumptive diagnosis of a r-AAA in the emergency department to the operating room for EVAR was 20 minutes (range, 10 to 35 minutes), and the mean operative time from skin incision to closure was 80 minutes (range, 35 to 125 minutes). Seven patients (18%) needed supraceliac aortic occlusion balloon, and six (15%) needed aortouniiliac stent-grafts. The mean blood loss was 455 mL (range, 115 to 1100 mL). Two patients each (5%) developed myocardial infarction, renal failure, and ischemic colitis, seven (18%) developed abdominal compartment syndrome, and seven (18%) died. Over a mean follow-up of 17 months, three patients with endovascular r-AAA repair required four secondary procedures. CONCLUSIONS: The early results show that emergent endovascular treatment of hemodynamically stable and unstable patients is associated with a limited mortality of 18% once a standardized protocol is established. There is an increased recognition of emerging complications with an endovascular approach, and a synchrony of disciplines must be developed to initiate a successful program for endovascular treatment of r-AAAs.

Combined carotid endarterectomy and coronary artery bypass grafting in patients with asymptomatic high-grade stenoses: an analysis of 758 procedures.

PURPOSE: Surgical treatment of hemodynamically significant carotid artery stenoses has been well documented, especially in the asymptomatic patient. However, in those patients presenting with hemodynamically significant asymptomatic carotid artery disease who are to undergo cardiac surgery, optimal treatment remains controversial. In this study, we analyze our experience with patients who underwent synchronous carotid endarterectomy (CEA) and coronary artery bypass graft procedures (CABG) for hemodynamically significant (>70%) asymptomatic carotid artery stenosis and coronary artery disease (CAD). METHODS: Demographics and outcomes of all patients undergoing synchronous CEA/CABG for asymptomatic carotid stenosis between April 1980 and January 2005 were reviewed from our vascular registry and patient charts. We included patients who underwent standard patching of their carotid artery and those undergoing eversion CEA. All neurologic events within the first 30 days that persisted >24 hours were considered a stroke. For purposes of comparison, we also reviewed outcomes for patients undergoing synchronous CEA/CABG for symptomatic carotid stenosis. RESULTS: Asymptomatic carotid artery stenosis (>70%) was the indication in 702 patients (276 women and 426 men) undergoing 758 CEAs. In the asymptomatic group, 22 patients, of which 21 succumbed to cardiac dysfunction, and one died from a hemorrhagic stroke. The overall mortality rate was 3.1%. Seven permanent nonfatal neurologic deficits occurred in this series (1 woman, 6 men). The combined stroke mortality was 4.3%. This compares to a 30-day stroke mortality of 6.1% in 132 symptomatic combined CEA/CABG patients. The difference in stroke mortality in women compared with men was not significant. CONCLUSION: In this experience, patients presenting with hemodynamically significant (>70%) asymptomatic carotid artery stenosis can undergo synchronous CEA/CABG with low morbidity and mortality.

Factors associated with abdominal compartment syndrome complicating endovascular repair of ruptured abdominal aortic aneurysms.

BACKGROUND: Endovascular treatment of ruptured abdominal aortic aneurysms (r-AAAs) has the potential to offer improved outcomes. As our experience with endovascular repair of r-AAA evolved, we recognized that the development of abdominal compartment syndrome (ACS) led to an increase in morbidity and mortality. We therefore reviewed our experience to identify risk factors associated with the development of ACS. METHODS: From January 2002 to December 2004, 30 patients underwent emergent endovascular repair of r-AAA by using commercially available stent grafts. All patients who developed ACS underwent emergent laparotomy. Physiological and clinical parameters were analyzed between patients with and without ACS after endovascular r-AAA repair. RESULTS: Over the past 3 years, 30 patients underwent endovascular r-AAA repair, and 6 (20%) patients developed ACS. Patients with ACS had a higher incidence of the need for aortic occlusion balloon (67% vs 12%; P = .01), a markedly longer activated partial thromboplastin time (128 +/- 84 seconds vs 49 +/- 31 seconds; P = .01), a greater need for blood transfusion (8 +/- 2.5 units vs 1.8 +/- 1.7 units; P = .08), and a higher incidence of conversion to aortouni-iliac devices because of ongoing hemodynamic instability and an inability to expeditiously cannulate the contralateral gate (67% vs 8%) when compared with patients without ACS. The mortality was significantly higher in the patients with ACS (67%; 4 of 6) compared with patients without ACS (13%; 3 of 24; P = .01). CONCLUSIONS: ACS is a potential complication of endovascular repair of r-AAA and negatively affects survival. Factors associated with the development of ACS include (1) use of an aortic occlusion balloon, (2) coagulopathy, (3) massive transfusion requirements, and (4) conversion of bifurcated stent grafts into aortouni-iliac devices. We recommend that, after endovascular repair of r-AAA, these patients undergo vigilant monitoring for the development of ACS.

Sepsis and the scalpel: anatomic compartments and the diabetic foot.

The foot comprises 3 compartments bounded by bone and fascia, each compartment containing muscle and vascular and nervous structures. Infection leading to an increase in pressures in the compartments results in rapid necrosis, a pathologic process characteristic of diabetic feet. Treatment involves fasciotomy and complete debridement of devitalized tissue with possible amputation of the involved digits. Knowledge of the anatomic structure of the foot and its compartments is therefore essential in effectively managing the diabetic foot.

Safety and efficacy of eversion carotid endarterectomy for the treatment of recurrent stenosis: 20-year experience.

Current options for treating recurrent carotid stenosis (RCS) include standard longitudinal arteriotomy and patch angioplasty with or without carotid endarterectomy (s-PCEA), carotid-carotid bypass, or carotid angioplasty and stent (CAS). Eversion carotid endarterectomy (e-CEA) is an effective procedure for treating primary carotid stenosis, yet it has not been reported for treating RCS. We evaluated the feasibility and outcome of e-CEA for treating of RCS in comparison to s-PCEA. The records of all patients undergoing elective CEA for symptomatic and asymptomatic high-grade RCS from January 1981 to July 2002 were reviewed. Although during the earlier period s-PCEA was performed preferentially, this paradigm changed to e-CEA being the preferred technique for treatment of RCS. During the course of postoperative follow-up when duplex sonography suggested high-grade RCS, the diagnosis was confirmed via arteriography. Data on cranial nerve injury, recurrent stenosis, stroke, and death were prospectively collected into a vascular registry database and analyzed retrospectively, Students' t-test and chi-square analysis were used to compare the group's baseline characteristics and outcomes. Over a 21-year period, 7001 patients underwent primary CEA for symptomatic (n = 2405, 34%) or asymptomatic (n = 4596, 66%) high-grade stenosis via standard (n = 1501, 21%) or eversion (n = 5500, 79%) techniques. Fifteen (25%) patients had 70 to 80% stenosis, 30 (51%) had 81 to 90% stenosis, and 14 (24%) had 91 to 99% stenosis. During this time period, 59 patients presented with symptomatic (n = 18, 31%) or asymptomatic (n = 41, 69%) high-grade RCS and underwent operative repair via s-PCEA (n = 22, 37%) or eversion (n = 37, 63%) techniques. The mean time interval for repeat carotid surgery for RCS was 49 months in the s-PCEA group and 48 months in the e-CEA group. Permanent cranial nerve injuries, stroke, and recurrent restenosis occurred in one (4.5%), one (4.5%), and one (4.5%) of the patients undergoing s-PCEA, respectively. In the e-CEA group, these events occurred in one (27%), none (0%), and one (2.7%) patients, respectively, There were no deaths during the 30-day postoperative period. Eversion CEA is a feasible option for the treatment of many RCSs and can be performed safely with a low rate of cranial nerve injury, recurrent stenosis, stroke, and death.

Does sac size matter? Findings based on surgical exploration of excluded abdominal aortic aneurysms.

PURPOSE: To prospectively examine the outcomes of excluded abdominal aortic aneurysms (AAA) that continue to expand without evidence of endoleak. METHODS: From 1984 to 1998, 1218 patients underwent operative retroperitoneal exclusion of AAA and aortoiliac reconstructions. During the procedure, the aneurysm sac was ligated proximally, as well as distally, which created an ideal in-vivo model of excluded AAA sacs with or without endoleaks. From January 2002 to June 2003, 15 of these patients were identified as having an increase in AAA sac size with or without an endoleak on duplex ultrasonography. These patients were prospectively evaluated by computed tomography and diagnostic arteriography. Patients with a demonstrable endoleak underwent embolization, and the remainder underwent open surgical exploration. RESULTS: Eight patients had arteriographically demonstrated endoleaks that were treated with coil embolization. The remaining 7 patients (6 men; mean age 76 years, range 68-81) without a demonstrable endoleak underwent elective surgical exploration and sac endoaneurysmorrhaphy. The mean time interval between the original surgery and aneurysm sac exploration was 76 months (range 52-92); during this time, the mean aneurysm sac size increased by 2.7 cm (range 1.3-5.2). The mean sac pressure was 53 mmHg, and the sac walls were noticeably thickened, with markedly dilated vasa vasorum. The sac contained yellow, fibrinous material with clear serous fluid (5 patients without any evidence of retrograde flow) or liquefied thrombus with serosanguinous fluid (2 patients with retrograde flow from lumbar arteries). No AAA sacs were pulsatile. CONCLUSIONS: Continued expansion of excluded AAA sacs can occur from causes other than a missed endoleak. Exudation of fluid from thickened sac wall and vasa vasorum, as well as local enzymatic activity, might lead to the formation of a sac hygroma. Furthermore, these findings raise questions as to the need for surgical exploration of all patients with an enlarging AAA sac in the setting of low sac pressures and no definable endoleak.

Infrarenal abdominal aortic aneurysm repair via endovascular versus open retroperitoneal approach.

The beneficial effects of open surgical abdominal aortic aneurysm (AAA) repair via a left retroperitoneal approach have been established. We compared the short-term outcome of infrarenal AAA repair via an endovascular approach with that of an open retroperitoneal approach. From October 2001 to April 2003, patients with infrarenal AAA >5 cm were offered repair via an endovascular approach (group I) with a variety of industry-made stent grafts or with an open retroperitoneal surgical approach (group II). Data were prospectively collected in the vascular registry and complications were analyzed. Data comparison between the two groups was done by using chi-squared analysis and two-tailed Students t-test. Statistical significance was identified at p < 0.05. Over an 18-month period, 492 patients underwent evaluation for AAA. Of these, 446 patients had infrarenal AAA and underwent either endovascular (group I: n = 175, male 85%, female 15%) or open surgical repair (group II: n = 232, male 74%, female 26%) via a left retroperitoneal approach. Group I patients had a higher incidence of coronary artery disease (66% vs. 35%, p < 0.05), hypertension (74% vs. 43%, p < 0.05), chronic obstructed pulmonary disease (29% vs. 12%, p < 0.05), and diabetes mellitus (20% vs. 7%, p < 0.05), a lower mean amount of intraoperative blood loss (277 cc vs. 1452 cc, p < 0.05), and shorter length of stay in the hospital (1.7 days vs., 7.3 days, p < 0.05). Group I also had fewer complications of myocardial infarction (1.7% vs. 5.2%, p = NS), renal failure (0% vs. 2.6%, p < 0.05), pulmonary failure (1.7% vs. 2.6%, p = NS), ischemic colitis requiring colectomy (0.6% vs. 2.6%, p < 0.05), multisystem organ failure (0% vs. 1.3%, p = NS), and death (0.6% vs. 1.3%, p < 0.05). Despite increased preexisting comorbidities, patients undergoing endovascular aneurysm repair had less morbidity, mortality, and blood loss and a shorter in-hospital length of stay than patients undergoing open surgical aneurysm repair via a left retroperitoneal approach.

Sepsis and the scalpel: Anatomic compartments and the diabetic foot

The foot comprises 3 compartments bounded by bone and fascia, each compartment containing muscle and vascular and nervous structures. Infection leading to an increase in pressures in the compartments results in rapid necrosis, a pathologic process characteristic of diabetic feet. Treatment involves fasciotomy and complete debridement of devitalized tissue with possible amputation of the involved digits. Knowledge of the anatomic structure of the foot and its compartments is therefore essential in effectively managing the diabetic foot.

Outcome of popliteal artery aneurysms after exclusion and bypass: significance of residual patent branches mimicking type II endoleaks.

PURPOSE: Popliteal aneurysms (PAs) often are treated with exclusion and bypass. However, excluded aneurysms can transmit systemic pressure from persistent flow through collateral arteries (endoleak), resulting in aneurysm growth and rupture. We used duplex ultrasound scanning for postoperative surveillance more than 2 years after PA repair with exclusion and bypass, to determine the presence of flow and aneurysm growth. METHODS: From 1995 to 2001, 23 patients with 26 PAs (mean diameter, 3.2 cm; range, 1.6-5.6 cm) underwent surgical repair and were available for more than 2 years of follow-up. The popliteal artery was ligated proximal and distal to the aneurysm, and autogenous revascularization was performed. All patients who underwent PA endoaneurysmorrhaphy through a posterior approach were excluded from the study. During long-term follow-up, aneurysm sac flow and size were evaluated with duplex ultrasound scanning, computed tomography, or magnetic resonance angiography, and standard angiography. Patients with increased PA size and persistent flow were offered repair through a posterior approach. RESULTS: Over 7 years, 26 PAs (symptomatic, 11; asymptomatic, 15) treated with aneurysm exclusion and bypass were available for more than 2 years of follow-up (mean, 38 months; range, 24-78 months). In the postoperative period 16 PAs (62%) became thrombosed, 10 (38%) had persistent collateral flow through geniculate vessels, 6 (23%) increased in size, and 3 (12%) ruptured; 1 (4%) resulted in limb loss. Operative findings for all ruptured PAs and 3 of 6 PAs with increased sac size that underwent aneurysm sac exploration and endoaneurysmorrhaphy revealed retrograde flow through geniculate vessels, mimicking type II endoleak. CONCLUSIONS: These findings question the effectiveness of PA exclusion through proximal or distal ligation and bypass. In addition, retrograde flow into the aneurysm sac (ie, type II endoleak after endovascular abdominal aortic aneurysm repair) may transmit systemic pressure that can result in aneurysm rupture. We recommend PA treatment with aneurysm sac decompression and ligation of geniculate vessels whenever possible and routine postoperative surveillance of the excluded aneurysm sac.

Effects of bilateral hypogastric artery interruption during endovascular and open aortoiliac aneurysm repair.

PURPOSE: Hypogastric artery interruption is sometimes required during aortoiliac aneurysm repair. We have not experienced some of the life-threatening complications of pelvic ischemia reported by others. Therefore we analyzed our experience to identify factors that help minimize pelvic ischemia with unilateral and bilateral hypogastric artery interruption. METHODS: From 1995 to 2003, 48 patients with aortoiliac aneurysm required interruption of both hypogastric arteries as part of endovascular (n = 32) or open surgical (n = 16) repair. During endovascular aneurysm repair coils were placed at the origin of the hypogastric arteries, and bilateral hypogastric artery interruptions were staged at 1 to 2 weeks when possible. Open surgery necessitated oversewing or excluding the origins of the hypogastric arteries and extending the prosthetic graft to the external iliac or femoral artery. Collateral branches from the external iliac and femoral arteries were preserved, and patients received systemic heparinization (50 units/kg). RESULTS: There was no buttock necrosis, ischemic colitis requiring colon resection, or death with the bilateral hypogastric artery interruption. Initially buttock claudication developed in 20 patients (42%), but persisted in only 7 patients (15%) at 1 year. New onset of impotence occurred in 4 of 28 patients (14%), and there were no neurologic deficits. CONCLUSIONS: Bilateral hypogastric artery interruptions can be accomplished with limited morbidity. When hypogastric artery interruption is needed during endovascular aneurysm repair, certain principles help minimize pelvic ischemia. These include hypogastric artery interruption at its origin to preserve the pelvic collateral vessels, staging bilateral hypogastric artery interruptions when possible, preserving collateral branches from the femoral and external iliac arteries, and providing adequate heparinization of the patient during these procedures.

Analysis of factors contributing to improved outcome for carotid endarterectomy.

Since carotid endarterectomy was revitalized following the North American Symptomatic Carotid Endarterectomy Trial and Asymptomatic Carotid Atherosclerosis Study, results have improved. However, types of carotid endarterectomy, indications, risk factors, surgical factors, techniques, and other treatment modalities may be associated with outcomes of carotid endarterectomy. The purpose of this study was to identify those factors in a broad-based carotid endarterectomy patient. This study involved review of the data from 3,644 patients undergoing carotid endarterectomy in New York State hospitals. A multivariate statistical model was used to identify significant patient risk factors to examine the association of the process of care and surgical factors, including surgical specialty for outcome of carotid endarterectomy. In-hospital death and stroke rate overall was 1.84%. After adjustment for patient risk factors, specific processes of care, such as eversion endarterectomy, protamine, heparin, or shunt, were associated with lower adverse outcomes relative to patients undergoing carotid endarterectomy without these processes. Similarly, patients undergoing carotid endarterectomy by vascular surgeons had lower adverse outcomes compared to neurosurgeons and general surgeons. This retrospective review showed that processes of care and surgical specialty were significant factors that contributed to outcomes following carotid endarterectomy.