Improved patency after axillofemoral bypass for aortoiliac occlusive disease.

OBJECTIVE: Axillofemoral bypasses (AxFBs) have been used since 1962 to treat aortoiliac disease. In the past, reported patency rates (37%-76%) for these extra-anatomic grafts have been inferior to those for anatomic aortic grafting. Reported low survival rates after AxFB (40%-50%) have confirmed that these procedures have been used primarily in patients at high risk for complications from aortofemoral bypass. However, modern medical and anesthesia management, preoperative scanning, donor artery preparation, postoperative graft surveillance, and graft technology may improve outcomes after AxFB, possibly supporting expansion of its use. We therefore report our last 15-year experience with AxFB. METHODS: Ring-reinforced, 8-mm expanded polytetrafluoroethylene grafts were used in all cases. The cross-femoral limb of axillobifemoral bypass (AxBFB) grafts was preconstructed. Heparin was administered intraoperatively, with protamine reversal. Loss of primary patency was defined as graft thrombosis of part or all of the inserted graft. Five-year primary patency rates were calculated by Kaplan-Meier analysis. RESULTS: Between February 1991 and June 2016, a total of 161 grafts were inserted (85 AxBFBs and 76 axillounifemoral bypasses [AxUFBs]) in 91 male and 70 female patients (median age, 72.6 years; mean age, 73 years; range, 41-94 years). Indications for treatment were rest pain (49.6%), ischemic lesions (26%), claudication (22.3%), failed prior revascularization (9.3%), infection (3.7%), and dissecting aneurysm (1.2%). Reasons for performing AxFB rather than aortofemoral bypass were hostile aorta (44.1%), high risk (19.2%), prior failed reconstruction (12.4%), advanced age (8.7%), infection (4.3%), hostile abdomen (4.3%), aortic dissection (0.6%), and morbid obesity (0.6%). During follow up, 63 patients died, 17 within the first year; but only 3 patients died within 30 days of surgery (performed to treat an acute aortic occlusion). The 5-year survival rate was 55%. Five-year patency rates were 83.7% for all procedures, 81.8% for AxBFB, and 85.5% for AxUFB; the difference between AxBFB and AxUFB was not significant. CONCLUSIONS: Our data indicate that AxBFB and AxUFB performed with the use of modern protocols and technology may render them an acceptable valid primary intervention in patients in whom endovascular treatment has failed or is unlikely to offer long-term success. The simplicity of performing these grafts and their low mortality and morbidity lend their application to surgeons with limited open aortic experience. Because AxUFB and AxBFB have similar patency rates, AxBFB should be reserved for bilateral indications.

Heparin-bonded expanded polytetrafluoroethylene femoropopliteal bypass grafts outperform expanded polytetrafluoroethylene grafts without heparin in a long-term comparison.

OBJECTIVE: Expanded polytetrafluoroethylene (ePTFE) grafts have become an acceptable prosthetic alternative to autologous vein for infrainguinal arterial reconstructions. Recently, heparin bonding to the graft's luminal surface has been used as an adjunctive method of improving graft patency. We retrospectively evaluated a prospective experience with heparin-bonded ePTFE (HePTFE) vs the results of a prior experience with standard ePTFE (SePTFE) to compare patency rates in above-knee (AK) and below-knee (BK) femoropopliteal bypass through the 5-year follow-up. METHODS: Prosthetic femoropopliteal bypasses performed by our four-surgeon group were constructed using 6-mm SePTFE grafts before August 2007. Subsequently, all such bypasses were constructed using 6-mm HePTFE (Propaten graft; W. L. Gore & Associates, Flagstaff, Ariz). The surgical technique used in all cases throughout the study was similar irrespective of surgeon or graft material. Loss of primary patency was defined by graft thrombosis; duplex scan confirmed graft failure. Descriptive estimation of patency rates was carried out using standard Kaplan-Meier methods. Cox proportional hazards regression was used to analyze relationships between predictors and time to loss of patency. RESULTS: There were 192 AK (87 Propaten, 105 SePTFE) and 60 BK (42 Propaten, 18 SePTFE) grafts. Overall primary patency for Propaten was statistically better than SePTFE at years 1 (93.6% vs 84.2%), 2 (79.7% vs 73.8%), 3 (79.7% vs 69.5%), 4 (74.5% vs 59.9%) and 5 (74.5% vs 56.2%; log-rank test, P = .036). Five-year primary patency was superior for Propaten AK grafts (85.2% vs 59.3%; log-rank test, P = .028) and for Propaten BK grafts (59.6% vs 0.0/undeterminable; log-rank test, P = .016). Variables significantly associated with loss of patency for Propaten and SePTFE were claudication (hazard ratio [HR], 0.41), age (HR, 0.95), isolated popliteal artery (HR, 3.1-4.4), and ankle-brachial index after the procedure (HR, 0.10). Controlling for conduit effect, clopidogrel use did not significantly affect patency (P = .076). No grafts were associated with heparin-induced thrombocytopenia. CONCLUSIONS: These data show that the Propaten HePTFE graft offered significantly better long-term patency over the SePTFE graft, suggesting Propaten as the prosthetic graft of choice for bypasses to the femoropopliteal artery when autologous vein is unavailable or inappropriate.

Endovascular brachytherapy for renal artery in-stent restenosis.

OBJECTIVE: Renal artery in-stent restenosis (RAISR) is not an infrequent occurrence and may be in part responsible for the failure of renal stents to improve clinical outcome. A variety of treatments have been used to restore patency, with mixed results. These include repeated percutaneous transluminal renal angioplasty (PTRA), repeated PTRA with bare-metal stents, and repeated PTRA with drug-eluting stents or covered stents. Endovascular brachytherapy (EVBT) has been proven effective in preventing recurrent neointimal hyperplasia in coronary bare-metal stents. This prompted our group to study the effect of EVBT on RAISR. METHODS: From 2004 to 2012, 21 patients (23 renal arteries) developed RAISR ≤ 30 months after the initial procedure and were subsequently treated with EVBT. Five patients had at least one prior PTRA for recurrent restenosis. Renal artery duplex scanning was performed as a baseline study within a few days of the EVBT and then every 6 months. All patients who had EVBT were concurrently treated by PTRA and EVBT on the basis of existing protocols. Patency of the treated stents was evaluated by Kaplan-Meier survival curves. RESULTS: The average onset of the original RAISR was 11 ± 9 months (range, 2-30 months; median, 8 months). The initial technical success of combined PTRA and EVBT was 100%. Mean follow-up was 44 ± 18 months (range, 14-84 months). Of five patients who had PTRA before EVBT, four were available for long-term follow-up. These four patients had a combined total number of five PTRAs before EVBT, with recurrent stenosis developing on average by 12 months. After EVBT, three stents were patent at 39, 48, and 65 months, and one stent restenosed at 42 months. This was the only patient in the entire series to develop restenosis after EVBT. CONCLUSIONS: This retrospective experience with a relatively small number of patients undergoing concurrent EVBT/PTRA for recurrent stenosis in stents placed to treat atherosclerotic renal artery stenosis suggests that EVBT is safe and provides long-term freedom from recurrent stenosis.

Essentials of negotiating for employment in a changing environment.

Evolving changes in health care in the United States are causing new graduates and self-employed physicians to consider employment with large groups and health systems. Familiarity with the principles, proper conduct, and mechanics of negotiating an employment agreement will be important for vascular surgeons making such a decision. The various components of compensation packages and contract language need to be critically evaluated. To facilitate an understanding of the complexities involved in employment contracts, strategies to avoid making negotiating mistakes are discussed.

Contralateral carotid artery occlusion is not a contraindication to carotid endarterectomy even if shunts are not routinely used.

OBJECTIVE: Although controversial, carotid artery stenting (CAS) has been proposed as being safer than carotid endarterectomy (CEA) for patients with a contralateral internal carotid occlusion (CCO). Arguably, with a CCO, CAS should be even safer than CEA if a shunt is not used. Accordingly, we reviewed our experience with 2183 CEAs performed routinely without a shunt to evaluate the risk of CEA performed in a subset of 147 patients with a CCO. METHODS: Between 1988 and 2011, 147 CEAs (111 men [75%], 36 women [25%]) were routinely performed without a shunt despite CCO. Of these patients, 76% were asymptomatic. CEAs were performed by seven surgeons using standard techniques (not eversion), with patients under general anesthesia and blood pressure maintained at >130 mm Hg. All patients received heparin (7500 U), and protamine reversal was routine. Median cross-clamp time was 20 minutes (range, 14-40 minutes). RESULTS: Three neurologic events occurred ≤ 30 days (2.0%). One transient ischemic attack (TIA) occurred immediately, and one occurred on the first postoperative day due to occlusion of the endarterectomy site. One patient sustained an immediate stroke and died of a large computed tomography-documented atheroembolic shower. CONCLUSIONS: Our data demonstrate the safety of CEA in the presence of a CCO, even when performed without a shunt. It is unlikely that the stroke or delayed TIA could be attributed to nonshunting or CCO. Even if so, the stroke and death rates would be lower than those previously reported for patients undergoing CEA in the presence of a CCO. This may be due to short cross-clamp times, careful technique, general anesthesia, and blood pressure support. Given these low adverse event rates, our experience refutes the assumption that patients with a CCO are at such a high risk for CEA that the only alternative is CAS.

The role of completion imaging following carotid artery endarterectomy.

A variety of completion imaging methods can be used during carotid endarterectomy to recognize technical errors or intrinsic abnormalities such as mural thrombus or platelet aggregation, but none of these methods has achieved wide acceptance, and their ability to improve the outcome of the operation remains a matter of controversy. It is unclear if completion imaging is routinely necessary and which abnormalities require re-exploration. Proponents of routine completion imaging argue that identification of these abnormalities will allow their immediate correction and avoid a perioperative stroke. However, much of the evidence in favor of this argument is incidental, and many experienced vascular surgeons who perform carotid endarterectomy do not use any completion imaging technique and report equally good outcomes using a careful surgical protocol. Furthermore, certain postoperative strokes, including intracerebral hemorrhage and hyperperfusion syndrome, are unrelated to the surgical technique and cannot be prevented by completion imaging. This controversial subject is now open to discussion, and our debaters have been given the task to clarify the evidence to justify their preferred option for completion imaging during carotid endarterectomy.