Chronic mesenteric ischemia.

Although chronic mesenteric ischemia is an infrequent, even rare, condition and a busy vascular surgeon may encounter only one such patient in a year, the associated morbidity and mortality are high, especially if the condition is not recognized. General and vascular surgeons must bear in mind the triad of postprandial pain, weight loss and diarrhea. Patients with mesenteric ischemia are at high risk and generally have diffuse peripheral vascular disease. Although surgery is hazardous, successful repair can result in long-term survival without morbidity. The author favours antegrade supraceliac bypass grafting over infrarenal grafting which is technically more difficult.

Peripheral nerve injuries during carotid endarterectomy.

Peripheral nerve injuries associated with carotid endarterectomy are fairly common but not emphasized in reported results of carotid endarterectomy. The sensory nerves to the submandibular skin and ear lobe are often damaged. Motor nerves VII, IX, X, XI and XII may be injured at surgery. The commonest motor injuries involve the facial, vagus and hypoglossal nerves. Carotid endarterectomy was studied prospectively over 1 year to document the incidence of nerve injury. Nerve injury occurred in 12% of patients, with facial and vagus nerves being involved in 4% each. Careful surgical technique based on appropriate anatomical knowledge can prevent most of these complications.

Inflammatory abdominal aortic aneurysm.

The inflammatory abdominal aortic aneurysm has received little attention in the literature. To date only four reports have addressed the subject specifically. Controversy remains as to whether this is a variant of the usual atherosclerotic aneurysm or a separate entity. The operative reports of 24 patients with inflammatory abdominal aortic aneurysms are reviewed; 21 were intact and 3 ruptured. Intact aneurysms ranged in diameter from 5 to 12 cm and the ruptured ones from 5 to 10 cm. Nine patients with intact aneurysms had symptoms of abdominal or back pain. Of 13 patients who underwent excretory pyelography before operation, only 3 had evidence of obstruction. Nine patients had tube grafts placed, 10 had aortoiliac grafts and 5 aortofemoral grafts. There was one intraoperative duodenal injury and in another patient it was necessary to divide the left renal vein for proximal exposure. No attempt was made to expose the ureters at operation. All patients were discharged from hospital. The authors believe that the inflammatory aneurysm is a variant of the abdominal aortic arteriosclerotic aneurysm. Intraoperative complications can be avoided by the recognition of the pathological features.

Graft infections in aortoiliac arterial reconstructions.

Twenty-four patients with 25 infected prosthetic grafts have been treated at the Health Sciences Centre in Winnipeg over the past 20 years. Nineteen primary operations were done for aortoiliac occlusive disease and 6 for abdominal aortic aneurysms. The patients presented from 2 weeks to 9 years after the first operation. In 16 of the graft infections there was a groin abscess, a draining sinus or a false aneurysm. The commonest method of treatment was excision of the entire graft with immediate extra-anatomic arterial reconstruction. Six patients died. Early diagnosis and aggressive surgical treatment are emphasized.

Carotid artery spasm. A cause of postendarterectomy thrombosis?

Carotid endarterectomy is generally regarded as a durable repair, with a low incidence of postoperative thrombosis. However, unexpected, inexplicable occlusions and pressure-flow aberrations have been reported to occur during the period immediately after operation period. We studied 245 operative angiograms obtained during a series of 335 carotid endarterectomies. Among the various defects noted were 24 instances of mild to severe spasm of the middle and distal extracranial carotid artery. This spasm was remote from the endarterectomy site and often was entirely beyond the field of operative exposure. Early and late postoperative angiograms demonstrated that this may be a transient phenomenon, and repeated intraoperative films documented that spasm may progress without further direct instrumentation of the involved segment. The patient who demonstrated the most severe spasm later suffered immediate postoperative occlusion and stroke despite a technically satisfactory repair.

Aortoiliac reconstruction for occlusive disease: comparison of end-to-end and end-to-side proximal anastomoses.

Between 1968 and 1979, 192 aortofemoral bifurcation grafts were placed for aortoiliac occlusive disease. The proximal anastomosis was end-to-end in 101 and end-to-side in 91 patients. Anastomoses were end-to-end in 38 (37%) of 104 patients from 1968 to 1976 and 63 (72%) of 88 patients from 1977 to 1979. Embolization occurred intraoperatively in four end-to-end and five end-to-side anastomoses. The grafts became occluded in the early postoperative period in two patients with end-to-end proximal anastomoses. There were two aortoduodenal fistulas, both associated with end-to-side proximal anastomosis. The cumulative patency rate at 5 years was 87% for end-to-end and 85% for end-to-side anastomoses. An end-to-end proximal anastomosis is indicated for associated aneurysmal disease or in the presence of aortic occlusion, while an end-to-side anastomosis is indicated when there are low-lying accessory renal arteries or in the presence of occlusive disease in the external iliac arteries. The author's experience suggests that there is no difference in the incidence of intraoperative embolization or late occlusion between end-to-side and end-to-end proximal anastomosis. The incidence of aortoduodenal fistula appears to be lower with end-to-end proximal anastomosis possibly because of better tissue apposition at the anastomosis.

Carotid endarterectomy: early and late results in 161 patients.

Over a 15-year period, 161 patients underwent 186 carotid endarterectomies. Of these patients, 97% had symptoms preoperatively. The incidence of new neurologic deficits appearing immediately postoperatively was 7% (13 of 186), and 1.6% (3 of 186) were major permanent strokes. Nineteen patients were lost to follow-up. The cumulative patient survival was 83% at 5 years and 59% at 10 years. The cause of death in the late postoperative period was ascertained in 22 of 24 patients; it was related to ischemic cardiac disease in 16. There were no late deaths from neurologic complications. New or recurrent neurologic symptoms developed in the late postoperative period in 22 patients. There were no disabling strokes in this group. The cumulative rate of freedom from new neurologic symptoms was 82% at 5 years and 71% at 10 years. Repeat angiography was carried out in 12 patients who had new or recurrent neurologic symptoms in the late postoperative period. The repaired artery was found to be widely patent in nine, stenosed in one and occluded in two. Reoperation of the same carotid was not performed in this series. Routine intraoperative angiography aided the detection and correction of potential technical problems.

The accuracy of the supraorbital Doppler examination in the diagnosis of hemodynamically significant carotid occlusive disease.

The supraorbital Doppler technique was used to study 102 carotid arteries prior to arteriography. A carotid stenosis was defined as being hemodynamically significant if the diameter of the lumen were reduced by more than 50 percent. The Doppler examination gave a false-positive result in only two of the 61 arteries which did not demonstrate significant stenoses. False-negative Doppler results occurred in 22 percent of the 41 significant carotid lesions. The presence or absence of significant carotid lesions were predicted in 96 percent of 67 arteries for which the results of the supraorbital examination and carotid auscultation were in agreement. False-negative results occurred in association with significant ipsilateral external and common carotid stenoses and in the presence of unusually efficient collateral circulation via the circle of Willis. The supraorbital Doppler examination is a valuable technique for the identification of patients with hemodynamically significant carotid stenoses.

The effects of femoropopliteal vein graft failure on limb function.

Twenty-one patients were followed for an average of 40 months following occlusion of femoropopliteal vein grafts. Serial recordings of the resting ankle pressure index and treadmill walking time were correlated with the patient's clinical status, and compared to the preoperative values. Graft failure resulted in a return to preoperative status in ten of 11 limb salvage patients. There were 5 amputations, 3 died of unrelated causes, and 2 were subsequently improved by further reconstructions. At last followup, 3 of 10 patients who were operated on for claudication were unchanged, 6 were improved, and one became worse. In no case did graft failure result in the development of advanced ischemia. Femoropopliteal graft failure did not have a significantly adverse effect on limb function or survival in patients presenting with claudication, nor did it complicate the subsequent course of patients in whom the initial aim was limb salvage.

The transcutaneous measurement of the elastic properties of the human saphenous vein femoropopliteal bypass graft.

The pressure-strain elastic modulus and compliance of 20 reversed saphenous femoropopliteal vein grafts have been measured by a noninvasive, ultrasonic method. The grafts had been in place for an average of 33.6 months, 11 days to 128 months. In this study no correlation was demonstrated between wall stiffness and duration of implantation. It is concluded that the elastic properties of vein grafts may remain stable for considerable periods of time.

Aortorenal arterial autografts.

Forty-nine iliac artery autografts were used in the treatment of renovascular hypertension in 45 patients, including six children. The pathological process was fibromuscular dysplasia in 42, atherosclerosis in two, and Takayasu arteritis in one. The internal iliac artery was used as a graft in 39 patients. The common iliac bifurcation was used in two patients, and the external iliac artery in four patients. Common and external iliac artery continuity was restored with Dacron prostheses. Forty-three patients with 47 autografts have been followed up from one to ten years (average three years). Hypertension was cured or improved in 96% of the patients. Serial follow-up arteriograms as late as ten years after surgery have been obtained in 50% of the patients. No late occlusions occurred. Slight autograft dilation occurred seven years postoperatively in one child. Normal growth of the autograft was exhibited in the remaining five children. No evidence of dilation, aneurysm formation, or stenosis appeared in any other grafts, although one patient developed a new lesion distal to her graft.