Remote superficial femoral artery endarterectomy.

The advent of minimally invasive procedures such as percutaneous transluminal angioplasty with or without stent, laser-assisted balloon angioplasty, and atherectomy, whose results have proven disappointing in the treatment of long-segment (> more than 15 cm) superficial femoral artery (SFA) occlusive disease, stimulated a reassessment of SFA endarterectomy. With the evolution of remote superficial femoral artery endarterectomy (RSFAE) a minimally invasive technique became available which could be performed through a single incision, allowed, debulking of the arterial plaque, and placement of an endovascular stent. We report results of RSFAE in an initial trial, results of RSFAE in concert with the aSpire Covered Stent which is a flexible ePTFE covered Nitinol stent with significant radial strength to withstand torsional stresses at the knee joint, and RSFAE and distal vein bypass for limb salvage.

Remote superficial femoral artery endarterectomy: Multicenter medium-term results.

OBJECTIVE: The results of percutaneous transluminal angioplasty, atherectomy, and laser angioplasty for the treatment of long-segment (>10 cm) superficial femoral artery (SFA) occlusive disease have proved disappointing. Remote superficial femoral artery endarterectomy (RSFAE) is a minimally invasive procedure, performed through a single limited groin incision that may offer patency rates comparable with those of above-knee femoropopliteal (AKFP) bypass graft. In this retrospective multicenter study the medium-term results of RSFAE are examined. METHODS: Sixty patients were included in this study. Indications for the procedure were claudication in 52 patients and limb salvage in eight patients. RSFAE was performed with the MollRing Cutter device through a femoral arteriotomy. The distal "flap" of atheroma was anchored by balloon/stent angioplasty through the femoral arteriotomy. All patients underwent a follow-up examination with serial color flow ultrasound scanning. RESULTS: Ten patients with heavily calcified SFAs failed as "intentions to treat"; these patients underwent AKFP bypass grafting. The mean length of the endarterectomized SFAs was 22.3 cm (range, 8-37 cm). The primary cumulative patency rate by means of life-table analysis was 61.4% +/- 9% (SE), (mean, 12.9 months; range, 3-36 months). During follow-up, percutaneous transluminal angioplasty was necessary in 14 patients, for a primary-assisted patency rate of 82.6% +/- 8%. The locations of the restenoses after RSFAE were evenly distributed along the endarterectomized SFAs. There were no deaths and one wound complication (hematoma), and the mean hospital length of stay was 1.4 days +/- 0.8 days. CONCLUSIONS: RSFAE is a safe and moderately durable procedure. If long-term patency rates are similar to those of AKFP bypass graft, RSFAE may prove to be a minimally invasive adjunct for the treatment of SFA occlusive disease that will lower operative morbidity, reduce hospital LOS, and shorten recuperation.

Assessment of pressure gradient by Doppler ultrasound: experimental and clinical observations.

Three methods for estimating peripheral artery pressure gradients from ultrasound data were assessed by means of an acute canine aortic coarctation with a variable stenosis and retrospective data from 18 patients with iliac stenoses who had duplex scanning studies and pressure measurements at the time of angiography. The measured pressure difference was correlated with end-diastolic velocity, the presence or absence of reverse flow in diastole, and a pressure difference calculated with the modified Bernoulli equation. Although the calculated pressure gradients correlated well with measured values in animal studies (11 animals, r = 0.78, n = 224, SD = 8.1), they did not in the clinical studies (r = 0.54, n = 33, SD = 28). In both cases, pressure gradients were consistently overestimated for mild stenoses. There was a strong correlation between end-diastolic velocity and pressure gradient (r = 0.71, n = 94, SD = 5.2 for animal studies; r = 0.81, n = 36, SD = 23 for clinical studies), but the data were too variable to provide useful pressure estimates. In clinical studies the absence of reverse flow in diastole at the site of the stenosis was the best indicator of a resting pressure gradient of greater than 15 mm Hg. We conclude that the modified Bernoulli equation and end-diastolic velocity correlate highly with the pressure gradient but are not clinically useful because the variability is too great. The absence of reverse flow in diastole is a more reliable indicator of hemodynamically significant stenosis.

Supraceliac aortofemoral bypass.

Increasing numbers of patients with aortoiliac disease are seen with contraindications to standard infrarenal aortofemoral reconstruction. Although axillofemoral bypass is possible in these patients, the decreased patency rate associated with this operation makes alternate procedures desirable. This report details our experience with prosthetic bypass from the supraceliac aorta to the femoral arteries in seven patients with limb-threatening ischemia of the lower extremity, all of whom had undergone multiple previous aortic operations. The operations were performed through thoracoabdominal or flank incision, and the preferred graft configuration consisted of a single Dacron tube from the aorta to the left groin with a standard subcutaneous femorofemoral graft to the right groin. No surgical deaths occurred. At 3 1/2 years' mean follow-up, there has been one graft limb occlusion that resulted in amputation for an overall life table patency and limb salvage rate of 93%. We conclude that supraceliac to femoral artery bypass is a useful procedure for the treatment of patients who have had multiple previous aortic reconstructions fail.

Intermittent subclavian venous obstruction: utility of venous pressure gradients.

A 22-year-old-man with intermittent obstruction of the subclavian vein at the thoracic outlet was evaluated by a pullback venous pressure gradient measurement and phlebography. The use of venous pressure gradient measurement allowed precise definition of the site of venous obstruction in the thoracic outlet and guided appropriate surgical therapy. The gradient information is of potential importance as many normal individuals have positional phlebographic venous compression at the thoracic outlet. Early identification of subclavian compression syndromes may avoid venous thrombosis with its attendant morbidity.