Asymptomatic carotid stenosis and unrelated operations: should we be more aggressive?

BACKGROUND: Carotid lesions will often remain asymptomatic during the perioperative period, so prophylactic carotid endarterectomy (CEA) has not been advocated before other operations. The purpose of this study was to characterize the clinical manifestations of new neurologic symptoms occurring in patients with previously asymptomatic carotid occlusive disease who have undergone recent operations. STUDY DESIGN: We performed a retrospective review of patients developing neurologic symptoms attributable to carotid occlusive disease after unrelated operations. RESULTS: Eleven patients (mean age 68+/-6.4 years, 8 men, 3 women) developed new neurologic symptoms from previously asymptomatic extracranial carotid stenoses after 11 unrelated procedures. Neurologic events included hemispheric stroke (n = 10) and amaurosis fugax (n = 1). Two intraoperative strokes occurred (one mastectomy, one prostatectomy). Other events occurred a mean of 5.8+/-5 (range 1 to 16) days after aortic surgery (n = 2), infrainguinal bypass (n = 3), contralateral CEA for symptomatic disease (n = 2), incisional herniorrhaphy (n = 1), and prostate surgery (n = 1). Responsible internal carotid artery lesions were all stenoses greater than 80%; seven were clearly greater than 90%. Those suffering intraoperative stroke or stroke within 24 hours of operation (n = 3) were not receiving antithrombotic therapy. All other events (n = 8) occurred despite the use ofantiplatelet or anticoagulant agents. Four underwent emergent CEA. Four had elective CEA performed after reaching a neurological recovery plateau. CONCLUSIONS: Critical, asymptomatic internal carotid artery stenoses may cause neurologic symptoms after unrelated surgical procedures.

Primary aortoduodenal fistula and Q fever: an underrecognized association?

We report a rare case of primary aortoduodenal fistula (ADF) secondary to a Coxiella burnetii (Q fever) infection in a patient with an abdominal aortic aneurysm. A review of the available literature on the vascular complications of Q fever is presented. Q fever should be suspected in vascular patients with close animal contact when a standard infectious work-up is unrevealing. Diagnostic steps and management strategies for primary ADF are also briefly reviewed.

The effect of withdrawal of drugs treating intermittent claudication.

BACKGROUND: Pharmacologic treatment for intermittent claudication is a management option. This study evaluated the effect of withdrawal of drug therapies, cilostazol and pentoxifylline, on the walking ability of peripheral artery disease patients. METHODS: Single-blind placebo crossover from a randomized, double-blind trial; 45 claudication patients received either cilostazol 100 mg orally twice daily (n = 16), pentoxifylline 400 mg orally three times daily (n = 13), or placebo (n = 16) for 24 weeks. After 24 weeks of double-blind therapy, treatment for all groups was placebo only, and follow-up continued through week 30. Treatment efficacy was established with treadmill testing. RESULTS: Profile analysis demonstrated a highly significant loss of treatment benefit after crossover (P = 0.001) for cilostazol-treated patients, but no significant change after crossover was observed with pentoxifylline. CONCLUSIONS: Drug withdrawal worsened the walking of claudicants who had benefited from cilostazol therapy. This decline with crossover to placebo suggests that the initial improvement with cilostazol treatment was due to the drug's action. Withdrawal of pentoxifylline did not adversely affect walking.

The correlation of early flow disturbances with the development of infrainguinal graft stenosis: a 10-year study of 341 autogenous vein grafts.

PURPOSE: Although duplex surveillance of infrainguinal bypass grafts is widely accepted, the optimal frequency and intensity of graft surveillance remains controversial. Earlier reports have suggested that grafts can be stratified into high-risk and low-risk groups based on the presence or absence of early graft flow disturbances. The purpose of this study was to provide long-term data in determining whether early graft flow disturbances detected by means of duplex scanning can predict the development of intrinsic vein graft stenosis. METHODS: We reviewed a series of patients undergoing prospective duplex graft surveillance after autogenous infrainguinal bypass grafting procedures from 1987 to 1997. Patients included in the study underwent at least one duplex scan within 3 months of graft implantation and were observed for a minimum of 6 months. Grafts were categorized as abnormal when a focal flow disturbance with a peak systolic velocity greater than 150 cm/s was identified within 3 months of graft implantation. RESULTS: Of 341 vein grafts in 296 patients who met inclusion criteria, 89 grafts (26%) required revision for intrinsic stenosis; the mean follow-up period was 35 months (range, 6 months to 10 years). Early flow disturbances were detected in 84 (25%) grafts. Grafts with early flow disturbances were more likely to ultimately require revision (43% vs 21%; P =. 0001) and required initial revision earlier (8 months vs 16 months; P =.019). Eighty-two percent of initial graft revisions occurred in the first 2 postoperative years; 69% occurred in the first year. However, an annual 2% to 4% incidence of late-appearing graft stenosis persisted during long-term follow-up. An additional 24 patients (7% of grafts) required an inflow or outflow reconstruction. CONCLUSION: Grafts with early postoperative flow disturbances detected by means of duplex scanning have nearly three times the incidence of graft-threatening stenosis and an earlier requirement for revision, when compared with normal grafts. This suggests that the biology and etiology of these lesions may differ. These data support not only aggressive efforts to detect early graft lesions to stratify grafts at highest risk, but also continued lifelong graft surveillance to detect late-appearing lesions, inflow and outflow disease progression, and maximize graft patency.

Complex aortofemoral prosthetic infections: the role of autogenous superficial femoropopliteal vein reconstruction.

BACKGROUND: With increasing experience, we have encountered patients with complex aortofemoral prosthetic infections in whom extra-anatomic bypass (EAB) is not an option. HYPOTHESIS: Autogenous superficial femoropopliteal vein (SFPV) aortic reconstruction provides a limb-saving and lifesaving alternative with acceptable morbidity and mortality. DESIGN: Retrospective review. SETTING: University-based county, private, and Veterans Affairs hospitals. PATIENTS: Seventeen patients with infected aortofemoral bypasses in whom conventional EAB was impossible because of infection of previously placed EAB, massive groin and/or thigh sepsis, or both. MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: Multiple previous operations were common (mean, 4 per patient) and included EAB (n = 11), replacement aortofemoral bypass (n = 4), prosthetic femoropopliteal bypass (n = 7), and thoracobifemoral bypass (n = 1); all bypasses became infected. Overall, 11 patients had sepsis at the time of presentation. Of the patients with massive groin infection, 7 had extensive deep infections involving most of the proximal thighs or retroperitoneum, 4 had enterocutaneous fistulae, and 2 had necrotizing fasciitis of the lower abdomen and thigh. Polymicrobial infections were common (n = 9). Four patients (24%) died in the perioperative period, 8 (47%) suffered major complications, and 4 (24%) underwent major amputations. Mortality in this group of patients was 3 times that of all other patients undergoing autogenous SFPV aortic reconstruction for prosthetic infection (8%). Amputation rates were also increased (24% vs 6%). The mean+/-SD follow-up time is 23+/-21 months. All patients maintained patent SFPV reconstructions. CONCLUSIONS: In the setting of complex aortofemoral prosthetic infections, autogenous SFPV aortic reconstruction is a useful option for patients in whom EAB is impossible and limb loss and/or death would be inevitable without revascularization.

Venous morbidity after superficial femoral-popliteal vein harvest.

PURPOSE: The superficial femoral-popliteal vein (SFPV) is a reliable conduit for aortoiliac, infrainguinal, and venous reconstructions. In this prospective study, we characterized the anatomic and physiologic changes in SFPV harvest limbs and their relationship to the development of late venous complications. METHODS: Since 1990, we have studied 61 patients after harvest of 86 SFPVs at 6-month intervals with clinical examinations, lower-extremity venous duplex, and venous function tests. The CEAP system was used as a means of categorizing clinical changes. RESULTS: Mean (+/- SEM) follow-up was 37 +/- 3 months. Less than one third of harvest limbs had edema without skin changes (C3). No patient had major chronic venous changes (C4 to C6) or venous claudication. There were no significant differences in limb measurements between harvest and non-harvest limbs, except in a subgroup of patients with unilateral harvest in which there was a small but significant (P =.046) increase in harvest limb thigh and calf circumference, compared with the opposite non-harvest limb. These clinical results were not affected by the presence or absence of an intact greater saphenous vein (GSV). Large, direct collaterals (4 to 6 mm in diameter) between the popliteal vein stump and profunda femoris vein (PFV) were seen by means of duplex ultrasonography in 29 harvest limbs (34%). The remainder appeared to have smaller, less direct collaterals to the PFV. Mild venous reflux with rapid cuff deflation was present at the popliteal or posterior tibial vein in nine of 79 harvest limbs (11%). Six of these nine limbs (67%) with reflux were clinical class C3, compared with only 19 of the 70 limbs without reflux (27%; P =.02). Ambulatory venous pressure (AVP) with exercise was significantly increased in harvest limbs (60 +/- 4.7 mm Hg), compared with non-harvest limbs (47.8 +/- 5.2 mm Hg; P =.049). The AVP recovery time of harvest limbs (14.0 +/- 1.0 seconds) was reduced, compared with non-harvest limbs (23.5 +/- 4.5 seconds; P =.02). AVPs (exercise) remained stable or decreased in six of 10 harvest limbs measured serially. Venous refill time in harvest limbs (15.1 +/- 1.1 seconds) was shortened, compared with non-harvest limbs (22.3 +/- 2. 1 seconds)(P =.002). Venous outflow obstruction measured by means of plethysmography was present in 93% of harvest limbs, compared with 36% of non-harvest limbs (P =.001). CONCLUSION: SFPV harvest results in minimal mid-term to late-term lower-extremity venous morbidity despite outflow obstruction. The most likely mechanisms preserving clinical status include the low incidence of mild reflux, the presence of collateral venous channels, and the lack of progression in abnormal harvest limb physiology. The absence of the ipsilateral GSV does not adversely affect clinical outcome.

Gastrointestinal complications after aortic surgery.

BACKGROUND AND PURPOSE: A major gastrointestinal complication (GIC) after aortic surgery may be disastrous, but these complications have received scant attention. This study was performed to determine the risk factors, associated events, and outcomes for patients with GIC. METHODS: We performed a secondary analysis of a prospective study that examined 120 consecutive patients who underwent transperitoneal aortic revascularization for aneurysmal or occlusive disease. RESULTS: The following 29 GICs developed in 25 patients (21%) within 30 days of aortic surgery: paralytic ileus that required replacement of nasogastric tubes (n = 12), upper gastrointestinal bleeding (n = 5), Clostridium difficile enterocolitis (n = 5), acute cholecystitis (n = 2), mechanical obstruction (n = 2), ascites (n = 2), and colon ischemia (n = 1). Seven patients required operations for GICs after aortic revascularization. A comparison of patients with and without GICs showed no differences in the prevalence of risk factors, presence of mesenteric artery stenoses, coexisting medical illnesses, antecedent gastrointestinal history, operative indication, preoperative fluid administration, or duration of operation. However, patients with GICs had more intraoperative complications (P = .004), greater intraoperative blood loss (P = .02), and more fluids during the postoperative period (P = .008). The mean duration of mechanical ventilation was 71 +/- 23 hours for patients with GICs versus 7 +/- 2 hours for patients without GICs (P = .006). A higher prevalence of pulmonary (P = .004) and renal (P = .001) complications was seen in the patients with GICs. The mean stay in the intensive care unit was 16 +/- 2 days for patients with GICs as compared with 5 +/- 0.4 days for patients without GICs (P < .001). Four deaths occurred, all caused by multisystem organ failure: 3 patients had GICs, and 1 did not have a GIC (P = .007). CONCLUSIONS: These results show that GICs are prevalent in transperitoneal aortic surgery and are associated with severe morbidity rates, increased hospital costs because of prolonged stay, and increased mortality rates. Some GICs appear to be associated with intraoperative events that lead to visceral hypoperfusion, and others can be attributed to mechanical causes. However, none of the variables examined in this study were predictive of GICs. In all, GICs should be considered serious adverse sequela after aortic revascularization. Because no risk factors for GICs have been identified, these complications currently cannot be prevented.

Spontaneous popliteal vascular injury in the morbidly obese.

PURPOSE: Morbidly obese patients who sustained popliteal vascular injury after spontaneous knee dislocation (KD) were studied. METHODS: Seven morbidly obese patients (body mass index [BMI] >35 kg/m2 and >100 lb over ideal body weight) who sustained spontaneous KD while upright were reviewed. RESULTS: Severe popliteal arterial injury accompanied all spontaneous KD. The mean age of patients was 34.1 +/- 6.7 years; the mean weight was 354 +/- 150 lb (range, 220-702 lb); and mean BMI was 53 +/- 21 kg/m2 (range, 37-98.4). All had arterial avulsion and thrombosis. Three had concomitant venous injury. All underwent operative repair. Morbid obesity presented unique challenges to surgical management. Limited positioning, specialized operative tables, large incisions, deep exposure, special retraction, long operative times (mean, 537 +/- 134 minutes), and major blood loss (mean, 2.5 +/- 3 L) were standard. Five arterial injuries were repaired with interposition vein grafts, and 2 required tibial bypass. Venous repairs included thrombectomy and primary repair (n = 2) and interposition grafting (n = 1). Many complications were related to morbid obesity, including deep wound infection (n = 3), diabetic ketoacidosis (n = 2), and cor pulmonale from sleep apnea (n = 1). Despite patent grafts in all patients, 2 above-knee amputations were required for extensive neuromuscular loss. CONCLUSION: Morbid obesity is a specific risk factor for spontaneous KD and vascular injury. In addition, morbid obesity presents unique challenges to operative repair and predisposes patients to unusual major postoperative complications.

Effectiveness of pulmonary artery catheters in aortic surgery: a randomized trial.

PURPOSE: To evaluate the routine use of pulmonary artery catheters (PAC) in patients who undergo aortic surgery. METHODS: One hundred twenty patients were randomized to placement of PACs for perioperative monitoring and hemodynamic optimization (tune up) in the intensive care unit on the night before aortic operation, or to intravenous hydration in the ward and perioperative monitoring without PACs. Before randomization, all patients underwent routine adenosine thallium-201 scintigraphy. RESULTS: To meet predetermined endpoints, 30 PAC patients (50%) received nitrates, inotropic agents, or both. PAC patients received more fluid in the preoperative period (p < 0.001) and in the first 24 hours after operation (p = 0.002) than control subjects. Eleven PAC patients (18%) and three control subjects (5%) had adverse intraoperative events (p = 0.02). There were 20 adverse postoperative events in 15 PAC patients (25%; nine cardiac, seven pulmonary, four acute tubular necrosis), which was not different compared with 11 postoperative events in 10 control subjects (17%; five cardiac, five pulmonary, one acute tubular necrosis). There were also no differences in duration of mechanical ventilation, intensive care unit stay, or hospital stay between groups. Postoperative cardiac complications were more common among patients who had a history of congestive heart failure (p = 0.02; odds ratio, 3.75; confidence interval, 1.3 to 11) or reperfusion defects on adenosine thallium scintigraphy (p = 0.01; odds ratio, 3.4; confidence interval, 1.2 to 9.4), regardless of group. CONCLUSIONS: Routine use of PACs for perioperative monitoring with the above protocol during aortic surgery is not beneficial and may be associated with a higher rate of intraoperative complications. Preoperative tune up does not prevent postoperative cardiac, renal, and other complications. Variables such as cardiac risk factors and adenosine thallium scintigraphy may be more important predictors of cardiac events in patients who undergo aortic operations.

Abdominal aortic aneurysms and malignant neoplasia: double jeopardy.

BACKGROUND: This study was performed to determine whether there is a significant association between abdominal aortic aneurysms (AAAs) and malignancy and to determine the impact of malignancy on late survival in patients with AAA. METHODS: We studied 126 men undergoing AAA repair and compared them with 99 men undergoing aortofemoral bypass (AFB) for occlusive disease and with 100 men undergoing herniorrhaphy during the same period. RESULTS: Fifty-one (40%) patients with AAA, 23 (23%) patients undergoing AFB, and 21 (21%) patients undergoing herniorrhaphy were diagnosed with cancer (p = 0.002). By life table analysis the proportion of subjects remaining cancer free at 5 years was 0.60 +/- 0.05 for AAA, 0.83 +/- 0.04 for AFB, and 0.81 +/- 0.04 for herniorrhaphy (p = 0.004). Multivariate analysis selected four independent risk factors for cancer: presence of AAA (p = 0.003, odds ratio 1.4, confidence interval [CI] 1.2 to 1.7), age (p = 0.001, odds ratio per year 1.1, CI 1.0 to 1.1), smoking (p = 0.04, odds ratio 1.5, CI 1.0 to 2.2), and hypertension (p = 0.04, odds ratio 0.73, CI 0.5 to 1.0). Cancer deaths accounted for 32% of late deaths in patients with AAA, which was not different compared with 26% of late deaths in patients undergoing AFB and 36% of late deaths in patients undergoing herniorrhaphy. Five-year cancer-free survival was 0.44 +/- 0.05 for patients with AAA, 0.64 +/- 0.05 for patients undergoing AFB, and 0.70 +/- 0.05 for patients undergoing herniorrhaphy (p < 0.001, AAA versus herniorrhaphy only). CONCLUSIONS: Cancer is more prevalent in men with AAA than in men undergoing AFB or herniorrhaphy. The presence of AAA appears to be an independent risk factor for cancer. Despite the higher cancer prevalence in patients with AAA, cardiovascular disease accounted for the largest number of late deaths in this series, minimizing differences in cancer-free survival between patients with AAA and patients undergoing AFB.

Venous reconstructions using the superficial femoral-popliteal vein.

PURPOSE: To demonstrate the feasibility of venous reconstructions with the superficial femoral-popliteal vein (SFPV). METHODS: Seven patients who underwent a variety of major venous reconstructions using SFPV were reviewed in a retrospective, observational study. RESULTS: Three central venous reconstructions (thoracic and abdominal) and four peripheral major venous reconstructions were performed with SFPV autografts. In all patients, the SFPV grafts provided an excellent size match and were of adequate length without the need for enlargement by paneling or spiraling techniques. Postoperative anticoagulation medication was not used. There were no early graft failures, and patency was documented by duplex ultrasound, venogram, or both in all patients at a mean of 20 months follow-up. Venous thromboembolism has not occurred, and lower extremity venous morbidity has been minimal. CONCLUSIONS: The SFPV graft demonstrates versatility and durability in selected patients who require large-caliber conduits for venous reconstruction. Because of its size and availability, the SFPV is an excellent conduit for major venous reconstruction.

Supraceliac aortorenal bypass.

PURPOSE: To determine the efficacy and durability of supraceliac aortorenal bypass grafting for symptomatic atherosclerotic renal artery disease. METHODS: Retrospective review of a 10-year, single-institution experience. RESULTS: Seventeen patients underwent 27 bypass procedures (seven unilateral, 10 bilateral) for atherosclerotic renovascular hypertension. The patients' mean age was 62.7 +/- 8.8 years. Diffuse aortoiliac and visceral atherosclerosis was confirmed on arteriogram; most (88%) celiac axis branches and all infrarenal aortas and common iliac arteries were found unsuitable for use as a donor vessel. Twenty-six bypass procedures (96%) were performed with autologous vein grafts. Seventeen bypass procedures (63%) were performed during partial aortic occlusion. There were no operative deaths or early occlusions. Postoperative complications occurred in four patients (24%). The mean duration of follow-up was 28 +/- 19 months (range, 2 to 69 months). By life table analysis, the 5-year primary patency and assisted primary patency rates were 95% and 100%, respectively. The mean systolic blood pressure decreased from 180 +/- 38 mm Hg to 135 +/- 20 mm Hg (p = 0.0003), and the mean diastolic blood pressure decreased from 96 +/- 16 mm Hg to 77 +/- 9 mm Hg (p = 0.0002). The number of antihypertensive medications decreased from 2.8 +/- 1.2 to 1.4 +/- 1.0 (p = 0.002). Significant improvement in serum creatinine level was seen among patients with preoperative renal insufficiency. Hypertension was cured in 29%, improved in 53%, and unchanged in 18%. During late follow-up, only four patients (24%) required subsequent aortic reconstruction. CONCLUSION: Supraceliac aortorenal bypass grafting is a safe and durable alternative for renal artery revascularization. This technique should be considered in patients who have diffuse infrarenal aortoiliac and visceral artery occlusive disease and require renal revascularization procedures.

Utility of carotid duplex in young adults with lower extremity atherosclerosis: how aggressive should we be in screening young patients?

The purpose of this study was to determine the prevalence and degree of carotid disease in patients with premature lower-extremity atherosclerosis. Seventy-six young men (mean age at onset of symptoms 42+/-0.5 years with premature lower extremity atherosclerosis who underwent complete carotid duplex scans were studied. The mean lowest ankle: brachial index was 0.49+/-0.02. Forty-seven patients (62%) required interventions to treat advanced leg symptoms, and 18 (24%) experienced disease progression during the study period. Carotid duplex scans showed internal carotid occlusions in eight (11%); advanced or critical plaque disease (60-99% diameter loss) in 14 (18%); moderate plaque disease (40-59% diameter loss) in 16 (21%); mild plaque disease (intimal thickening or 1-39% diameter loss) in 18 (24%); and normal carotid arteries in 20 (26%). Comparing the 20 subjects with normal carotid arteries to the S6 with any evidence of disease, there were no differences in age of onset, risk factors, coronary artery disease, mean ankle: brachial index, number of interventions, disease progression, amputation, or death. Fifteen (27%) of the patients with carotid atherosclerosis ultimately developed transient ischemic attack or stroke; 13 of these had advanced carotid stenoses or carotid occlusions. In conclusion, carotid plaque disease is prevalent among patients with premature atherosclerosis of the lower extremity. The presence of carotid atherosclerosis is not related to the degree of lower extremity atherosclerosis, nor to the rate of disease progression. Carotid duplex scans are indicated to screen these young patients for compelling lesions that might warrant prophylactic carotid endarterectomy.

Aortic corset syndrome.

The majority of proximal anastomotic complications of aortofemoral bypass grafts are related to the formation of pseudoaneurysms or true proximal aneurysmal dilation of the residual infrarenal aorta. The late development of occlusive disease at the proximal anastomosis is an extremely rare event. We report two patients in whom symptomatic stenoses developed involving the proximal anastomoses of aortofemoral bypass grafts originally placed for aortoiliac occlusive disease. Surgical exploration demonstrated the presence of a constricting prosthetic corset wrapped around the proximal suture line of each graft. Exuberant neointimal hyperplasia was responsible for both stenoses.

Acalculous cholecystitis after aortic reconstruction.

BACKGROUND: Acute acalculous cholecystitis is rare in patients undergoing aortic surgery; but, this condition is associated with a high mortality rate. With their comorbid medical problems, patients undergoing aortic reconstruction may have a higher mortality associated with acute acalculous cholecystitis. STUDY DESIGN: By retrospectively reviewing patient charts, we studied the prevalence, demographics, details of antecedant aortic procedures, hospital course, and outcome of patients with acute acalculous cholecystitis after aortic surgery. RESULTS: In the past 10 years, 7 of the 996 patients who underwent aortic reconstruction at our institution developed postoperative acute acalculous cholecystitis. These patients were all nondiabetic men with a mean age of 66 +/- 4 years (range, 50 to 76 years). Previous aortic operations included four infrarenal aneurysmorrhaphies (three elective, one urgent for a ruptured aneurysm), two aortofemoral bypasses for occlusive disease, and a removal of an infected aortic prosthesis. Six patients had prolonged intraoperative hypotension and increased blood transfusion requirements. All patients had postoperative multiorgan dysfunction. The patients developed fever, leukocytosis, elevated liver function test levels, and other signs and symptoms of acute acalculous cholecystitis a mean of 32 days (range, 9 to 90 days) after operation. Preoperative diagnosis was made in five patients based on clinical examination, laboratory test results, and adjunctive noninvasive test results. Two patients required laparotomy to make the diagnosis of acute acalculous cholecystitis. Five patients underwent cholecystectomy, and two had placement of cholecystostomy tubes. Gangrene or perforation was evident in most. Overall mortality was 71 percent. CONCLUSIONS: Acute acalculous cholecystitis is the most common postoperative biliary complication after aortic surgery. The diagnosis should be entertained in patients with signs of abdominal sepsis after aortic surgery, especially those with a complicated postoperative course. Even if acute acalculous cholecystitis is diagnosed before exploration, mortality remains high.

Autogenous aortoiliac/femoral reconstruction from superficial femoral-popliteal veins: feasibility and durability.

PURPOSE: Autogenous aortoiliac/femoral reconstruction with superficial femoral-popliteal veins (SFPVs) has been successfully used to treat prosthetic infection and failure, but outcome data are scant. In this prospective, observational study, we hypothesized that (1) replacement of the aortoiliac/femoral system with SFPVs could be performed with perioperative morbidity and mortality rates equal to those of conventional methods; (2) long-term patency rates would be excellent; (3) limb salvage rates would be correspondingly high; (4) aneurysmal degeneration would not occur, and (5) venous morbidity would be minimal. METHODS: Since 1990, 41 patients have undergone complete or partial aortoiliac/femoral reconstruction with 63 SFPVs with a mean (+/-SD) follow-up time of 32 +/- 21 months. With the exception of two patients lost to follow-up, all have been observed at 6-month intervals with clinical examination and noninvasive tests. RESULTS: There were no immediate operative deaths, but three patients (7.3%) died of multisystem organ failure after 1 month. Forty-nine percent of patients had significant perioperative complications including amputation (5%), compartment syndrome (12.3%), and pulmonary embolism (2.4%). Most patients (85%) had multilevel occlusive disease, and the mean SVS/ISCVS runoff score for the group was 4.9 +/- 2.6 (1 = normal, 10 = no runoff). Fifty-eight percent of all distal anastomoses were end-to-end, and in 68% of limbs the profunda femoris artery or superficial femoral artery was the sole runoff vessel. At 5 years, the cumulative secondary patency rate was 100%; primary patency rate, 83%; limb retention rate, 86%; and survival rate, 69%. Four patients had permanent limb edema controlled by compression stockings but none have had venous ulceration. There has been no aneurysmal dilation of SFPV grafts, and mean diameter shown by serial duplex imaging at 6 months (10.8 +/- 1.1 mm) was not significantly different from that at 60 months (7.8 +/- 1.1 mm). CONCLUSIONS: Aortoiliac/femoral reconstruction with SFPVs is a successful and durable option for infection and other complex aortic problems.

Steal syndrome complicating hemodialysis access.

The purposes of this study were to examine potential causes for arterial steal syndrome in patients with hemodialysis shunts and to evaluate the results of treatment. A retrospective analysis was performed on all hemodialysis patients who presented with arterial steal syndrome over a 3-year period. Medical records were reviewed to determine demographic data, time to development of symptoms, operative details, and treatment outcome. Results of upper-extremity arteriography in the last five patients were also documented. Eighteen patients presented with steal syndrome at a mean of 7(4) months after shunt placement. Four patients had prior ipsilateral grafts. Fifteen (83%) patients had forearm shunts in loop configuration between the main brachial artery and a superficial vein, and three had straight upper-arm shunts. Graft sizes were 6 mm in five patients and 4- to 7 step grafts in 13. Graft banding was used to treat steal in 11 shunts, one of which remained patent. All five patients who underwent upper-extremity arteriography had arterial stenoses demonstrated in the inflow circulation. In conclusion, arterial steal is an uncommon complication of hemodialysis shunts. Shunt location and choice of graft do not appear to be major factors: steal can develop regardless of access site, configuration, or use of straight versus step graft. Banding is an ineffective method of treatment. Arteriography may be important to detect unsuspected inflow stenoses in patients with steal syndrome.

A case of Pott's disease of the spine eroding into the suprarenal aorta.

Spinal tuberculous osteomyelitis eroding into the aorta is an extremely rare entity. The case of an 80-year-old man with a large proximal anastomotic pseudoaneurysm above an aortobiiliac prosthesis involving the suprarenal aorta is reported. A periaortic and perigraft fluid collection was found to be contiguous with an osteolytic process of the anterior bodies of the T12 and L1 vertebrae. Staged extraanatomic axillobifemoral bypass, graft excision, and viscerorenal revascularization with superficial femoral-popliteal veins were performed. The pathologic diagnosis of spinal tuberculous osteomyelitis was made. The rare entity of Pott's disease of the spine involving the suprarenal aorta and an aortic prosthesis presented significant challenges in resection and revascularization. The use of the deep veins of the legs as large-diameter autogenous conduit facilitated visceral and renal arterial bypass in an infected field.

Late outcome of patients with premature carotid atherosclerosis after carotid endarterectomy.

BACKGROUND AND PURPOSE: The durability of carotid endarterectomy (CEA) in young adults with premature carotid atherosclerosis has not been adequately assessed. This study examined the late recurrence and mortality rates in young adults undergoing CEA. METHODS: We studied 42 young patients (mean age, 45.5 +/- 0.5 years) who underwent CEA and compared them with 110 older control subjects (mean age, 65.8 +/- 0.4 years) undergoing CEA during the same period. Data were collected regarding demographics, operative indications, follow-up carotid duplex studies, recurrent symptoms, and deaths. RESULTS: Demographics and atherosclerotic risk factors were similar between the two groups. During a mean follow-up of 57.9 +/- 6.0 months, 10 (24%) young patients and 3 (3%) control subjects developed significant, recurrent ipsilateral stenoses (> or = 50% diameter loss) (P < .001). Six (14%) young patients and 1 control subject had recurrent ipsilateral symptoms (P = .002). Nine (21%) young patients and 26 (24%) older control subjects required contralateral CEA; 8 (18%) young patients and 18 (16%) older control subjects underwent lower extremity revascularization procedures. Cumulative 5-year survival by life-table analysis was 0.83 (95% confidence interval [CI], 0.71 to 0.95) for study patients and was 0.67 (95% CI, 0.58 to 0.77) for control subjects (P = .06). CONCLUSIONS: These data demonstrate a trend toward more favorable survival in young versus older patients after CEA; however, survival differences did not achieve statistical significance. Young patients are far more likely to develop recurrent symptoms and recurrent carotid stenoses than older counterparts. Close follow-up with serial duplex ultrasound may be important in young patients after CEA.

Does infrapopliteal arterial runoff predict success for popliteal artery aneurysmorrhaphy?

BACKGROUND: A 6-year experience with surgical management of popliteal artery aneurysms (PAAs) was examined to determine the influence of infrapopliteal outflow vessel patency on the long-term success of popliteal artery aneurysmorrhaphy. METHODS: Arteriograms were reviewed to characterize the anatomy of the infrapopliteal arterial runoff. Regular clinical evaluation and prospective serial duplex scan surveillance assessed graft patency. RESULTS: A total of 28 patients underwent 45 popliteal aneurysmorrhaphies. Elective repair was performed in 32 limbs (71%); emergency treatment was needed for 13 limbs (29%) because of acute limb-threatening ischemia. All patients were managed with PAA exclusion and reversed saphenous vein grafting. Only 20 limbs (44%) had a patent trifurcation with three continuous vessels to the ankle, 13 (29%) had two continuous tibial vessels, 10 (22%) had one patent runoff artery, and 2 (4%) had no vessel continuous to the foot. With a mean follow-up of 19.1 months, the 5-year primary graft patency by life-table analysis was 95 +/- 12.3%, with a 5-year assisted primary patency of 97 +/- 10.0%. One vein graft underwent elective secondary revision. Another graft thrombosed, requiring a secondary bypass. Outcome did not correlate with the status of the runoff anatomy. Limb salvage was 100%. CONCLUSION: The use of autologous reversed vein grafting and attention to technical details yielded normal graft hemodynamics and excellent long-term patency and limb salvage despite the suboptimal runoff anatomy associated with PAAs.