Simulation case rehearsals for carotid artery stenting.

A case series of 5 patients is presented assessing the utility of simulation case rehearsals of individual patients for carotid artery stenting on an endovascular simulator. Simulated and operative device dimensions were similar. Results of subjective surveys indicated that face and content validity were excellent. The simulations predicted difficulty with vessel cannulation, however had difficulty predicting post-stent changes in bifurcation angulation. Our experience suggests that it may be feasible to use patient-specific CTA-derived data in the creation of a realistic case rehearsal simulation. The overall utility of this concept, including cost-benefit analysis, has yet to be determined.

Diagnosis and management of the "difficult" abdominal aortic aneurysm: pararenal aneurysms, inflammatory aneurysms, and horseshoe kidney.

All "difficult" abdominal aortic aneurysms-whether pararenal or inflammatory or associated with abnormal renal parenchymal anatomy-often best are approached with some combination of retroperitoneal exposure and supraceliac clamping. Preoperative recognition that an unusual case may exist, complete and appropriate imaging and formulation of a sensible plan before operation are absolutely critical to success. Following such a plan can convert a relatively complex situation into a relatively simple one.

Safety and efficacy of limited-dose tissue plasminogen activator in acute vascular occlusion.

OBJECTIVE: The purposes of this study were to evaluate the safety and efficacy of limited-dose tissue plasminogen activator (t-PA) in patients with acute vascular occlusion and to compare these results with those obtained in equivalent patients receiving urokinase. METHODS: We compared the results of 60 patients receiving catheter-directed urokinase from November 1997 to November 1998 (240,000 units/h x 4 h, 120,000 units/h thereafter for a maximum of 48 h) with those of 45 patients receiving catheter-directed t-PA from November 1998 to August 2000 (2 mg/h, total dose < or =100 mg) for acute arterial occlusion (AAO) and acute venous occlusion (AVO). Interventional approaches such as cross-catheter and coaxial techniques were used to reduce the dose of lytic agent needed to achieve pre-lysis-treatment goals (eg, complete lysis of all thrombus/unmasking graft stenosis or establishing outflow target). Statistical analysis was performed using Student t test and Fisher exact test. RESULTS: The urokinase and t-PA groups were comparable with regard to age, comorbidities (coronary artery disease, hypertension, diabetes, renal insufficiency, smoking), duration of ischemic or occlusive symptoms, location of occlusive process, pretreatment with warfarin, and thrombotic versus embolic and native versus graft occlusion in patients with AAO. In patients with AAO and in those with AVO, t-PA was equivalent to or better than urokinase with regard to percent of clot lysis, incidence of major bleeding complications, limb salvage, and mortality. Achievement of pretreatment goals (arterial patients only) was 50% for urokinase patients and 76% for t-PA patients (P =.02). Analysis of success in individual pretreatment-goal achievement showed urokinase and t-PA to be equivalent in unmasking stenoses (85% and 84%, respectively; P = NS), whereas t-PA was superior to urokinase in the more critical task of establishing run-off (39% versus 81% for urokinase and t-PA, respectively; P =.001). Additional interventions, either endovascular or surgical, were required in 60% and 51% (P = NS) of patients receiving urokinase and t-PA, respectively, for AAO, and in 54% and 62% (P = NS) of patients receiving urokinase and t-PA, respectively, for AVO. CONCLUSIONS: Limited-dose t-PA is a safe and effective therapy for AAO and AVO when administered by experienced teams using innovative but well-established interventional techniques.

External beam irradiation for inhibition of intimal hyperplasia following prosthetic bypass: preliminary results.

To determine whether external beam irradiation delivered immediately after graft implantation can inhibit anastomotic intimal hyperplasia (IH) 1 month following polytetrafluoroethylene (PTFE) bypass in a sheep carotid artery model, 23 sheep underwent bilateral bypass of the ligated common carotid artery with 8-mm PTFE immediately followed by a single dose of irradiation (15, 21, or 30 Gy) to one side. The 15 animals with bilaterally patent grafts were euthanized at 1 month and graft-arterial anastomoses harvested. Using computer-aided image analysis, IH areas and thicknesses were measured. Graft patency in this model was 83% at 1 month and did not differ according to treatment administered. In the control animals, IH was greatest at mid-anastomosis, but minimal within the native vessel. All three radiation doses markedly inhibited mid-anastomotic IH area and thickness. At the proximal anastomosis, 30 Gy reduced the IH area 20-fold, from 2.06 to 0.14 mm2 (p < 0.0001 by ANOVA), and IH thickness 70-fold, from 29.0 to 0.4 micron (p < 0.0002); similar effects were seen at the distal anastomosis. No adverse effects of radiation treatment were observed. External beam irradiation in doses of 15 to 30 Gy delivered in a single fraction immediately after operation markedly inhibits development of intimal hyperplasia 1 month following end-to-side anastomosis with PTFE in sheep.

Alcohol withdrawal after open aortic surgery.

This study was designed to test the hypothesis that unexpected alcohol withdrawal-like syndrome (AWLS) is more common following aortic, but not other, vascular or nonvascular procedures. All patients undergoing open aortic surgery at our institution in 1997 who survived at least 48 hr were identified, as were those undergoing carotid endarterectomy, infrainguinal bypass, and total colectomy. AWLS was defined as prolonged confusion or agitation and response to conventional treatment for withdrawal, providing that all other sources had been ruled out or a significant history was present. Our results show that, for unknown reasons, AWLS is more common after aortic surgery than after other vascular and high-stress, nonaortic intraabdominal procedures at our institution, and is associated with increased length of stay and morbidity. Because prophylaxis may improve outcome, better efforts to identify patients at risk are required.

Reperfusion and compartment syndromes: strategies for prevention and treatment.

Reperfusion syndrome refers to the damage done by restoration of blood flow to ischemic tissues and is distinct from the original ischemic insult itself, whereas compartment syndrome refers to the damage resulting from increased pressure within an enclosed fascial compartment that occurs after blood flow has been restored. Despite extensive experimental work directed toward the treatment of established reperfusion injury and prevention of compartment syndrome, clinical outcome over the past decade has not appreciably changed. Although the systemic insult, thought to be an inevitable result of reperfusion injury, may be less injurious than "conventional wisdom" would suggest, no better strategy for treating compartment syndrome other than early recognition and decompression has yet been developed.

Reduction in wound morbidity rates following endoscopic saphenous vein harvest.

To determine whether less-invasive saphenous vein harvest reduces morbidity in patients undergoing infrainguinal bypass, we retrospectively compared 61 patients undergoing endoscopic harvest (ENDO) with 49 patients undergoing conventional harvest (OPEN) over the past 13 months. Patients were classified as potential short-stay if adjunctive suprainguinal inflow procedures or foot amputations were not required and the patient was ambulatory prior to elective operation. Mean endoscopic harvest time was 50+/-18 (range 25-90) min, and no more than three 5-cm incisions were required in 87% of cases. Szilagyi class II or III wound complications occurred after 1 of the 61 (2%) ENDO procedures and 7 of the 49 (14%) OPEN (p < 0.01), and any complication occurred in 13 (21%) vs. 25 (51%) of ENDO and OPEN procedures, respectively (p < 0.002). Mean postoperative length of stay was significantly shorter in the 24 short-stay ENDO (4.0+/-2.4 days) vs. 25 short-stay OPEN (6.0+/-3.2 days) patients (p < 0.02). Thirty-day patency rates between the two groups were not different. Endoscopic saphenous vein harvest is associated with a reduced incidence of serious wound complications and, in selected patients, shortened postoperative hospital stay.

Combined free tissue transfer and infrainguinal bypass graft: an alternative to major amputation in selected patients.

OBJECTIVES: The purpose of this study was to document outcome and adverse prognostic factors in patients requiring combined free tissue transfer and distal bypass grafting for otherwise nonreconstructible infrainguinal arterial occlusive disease and advanced tissue necrosis. METHODS: Between July 1990 and November 1999, 65 patients, all of whom would have required at least below-knee amputation, underwent free tissue transfer in conjunction with infrainguinal bypass grafting at the University of Rochester. Preoperative variables were assessed for their influence on outcome with chi(2) and outcome with life-table analysis with Cox proportionate hazard testing. RESULTS: Free tissue transfer was performed synchronously with arterial reconstruction with autologous vein in 49 patients and after a previous functioning venous bypass graft in 16 patients. The 30-day mortality rate was 5%, and major complications occurred in another 16% of patients. Flap location, weight-bearing status, preexisting osteomyelitis, and the timing of bypass grafting relative to flap construction had no effect on outcome. All five free flap failures occurred within the first 30 days. All other flaps subsequently survived, even in seven patients whose bypass grafts thrombosed. Five-year limb salvage and patient survival rates were 57% and 60%, respectively, and 65% of patients regained meaningful ambulation. The combination of diabetes and dialysis-dependent renal failure was the strongest predictor of overall limb loss (P <.005; relative risk = 4.0), and diabetes alone was the strongest predictor of death (P <.02; relative risk = 5.2). CONCLUSION: Free tissue transfer combined with infrainguinal bypass grafting in selected patients is safe and effective. The combination of diabetes and chronic renal insufficiency, particularly the need for dialysis, is a powerful predictor of failure and should be considered a strong contraindication for this procedure.

Unrecognized carotid artery stenosis discovered by calcifications on a panoramic radiograph.

BACKGROUND: Approximately 730,000 strokes occur each year in the United States, costing an estimated $40 billion annually. One-half of all strokes are the result of atherosclerotic plaques found in the carotid artery. Such plaques frequently are heavily calcified and can be identified on a panoramic radiograph by the incidental finding of calcifications overlying the carotid bifurcation. CASE DESCRIPTION: The authors found that a 67-year-old asymptomatic woman had calcium deposits overlying both carotid bifurcation regions on a panoramic radiograph. Subsequent duplex ultrasonic examination indicated bilateral, high-grade carotid arterial stenoses. The patient underwent uneventful bilateral carotid endarterectomy. CLINICAL IMPLICATIONS: The patient had critical carotid arterial stenoses associated with significant risk of stroke that had not been identified otherwise. The findings on the panoramic radiograph led to appropriate and potentially life-saving treatment. While the positive predictive value of this finding has yet to be defined, the authors believe that calcifications overlying the carotid system region seen on panoramic radiography in an asymptomatic patient should be followed by formal evaluation of the carotid bifurcation.

An endoluminal method of hemorrhage control and repair of ruptured abdominal aortic aneurysms.

PURPOSE: To report our initial experience with endovascular grafting to treat ruptured abdominal aortic aneurysms (AAAs). METHODS: Three consecutive patients with severe comorbid illnesses and symptoms of aneurysm rupture and hemodynamic instability were treated with aortomonoiliac grafts. The Z-stent-based devices were implanted with the assistance of an occlusion balloon placed in the distal descending thoracic aorta. RESULTS: All patients survived the procedure with successfully excluded AAAs. Two patients had relatively short hospital stays (4 and 14 days), while the third required prolonged treatment for pre-existing conditions. All patients required blood transfusions; 2 developed significant coagulopathies. Definitive management was delayed significantly by imaging protocols and graft construction. CONCLUSIONS: Endovascular repair of ruptured aortic aneurysms is feasible. Proximal aortic control is readily attainable with the use of an aortic occlusion balloon placed through the left axillary artery. The absence of a laparotomy, extensive retroperitoneal dissection, and aortic cross-clamping likely contributes to patient survival; however, the delay in operative therapy to obtain adequate imaging and construct an endograft could be a hindrance to the ultimate success of this approach. The concepts of alternative aortic imaging techniques and endograft design, construction, and storage must be addressed.

Irradiation for intimal hyperplasia: implications for peripheral arterial bypass.

Irradiation has been shown to inhibit postangioplasty intimal hyperplasia ("restenosis") in unbranched tubes. It seems likely that irradiation will similarly be able to inhibit intimal hyperplasia after a surgical anastomosis at a biochemical and cellular level, but whether it will produce a clinically relevant or even clinically detectable difference is unproved. One possibility is that no clinical effect may occur; the search for a "cure" for intimal hyperplasia has been long and, as yet, unsuccessful. On the other hand, if a strong effect without insurmountable logistical problems could be produced, one major cause of bypass graft failure would be preventable. Not only would the incidence of late graft occlusion, need for reoperation, and limb loss be reduced, but, if patency of prosthetics could be sufficiently improved, the initial operation could be made much easier, faster, and perhaps safer.

Photoplethysmography and calf muscle pump function after subfascial endoscopic perforator ligation.

OBJECTIVE: Subfascial endoscopic perforator surgery (SEPS) results in acceptable healing and recurrence rates. The role of hemodynamic venous testing in this situation, however, is poorly understood and inconsistently used. Our ongoing experience was reviewed to explore how SEPS affects the photoplethysmographic assessment of the leg. METHODS: Preoperative and postoperative venous refill times (VRTs) were measured with photoplethysmography in 30 limbs in 28 patients who underwent SEPS and superficial ablation, when indicated, with complete clearing of the anterolateral surface of the tibia, thus opening the deep posterior compartment from mid calf to close to the malleolus. Postoperative healing and duplex scanning were used to assess clinical and anatomic success, respectively. The VRTs were classified as "interpretable" if the leg emptied or "uninterpretable" if the calf could not empty. The "interpretable" study results were further classified as "normal" if the refill took 20 seconds or more or "abnormal" if less. RESULTS: Before the patients underwent SEPS, six study results (20%) showed inability of the calf to empty and thus were judged uninterpretable. After the patients underwent SEPS, 12 study results (40%) were uninterpretable (NS; P =.09 with the chi(2) test). Of the 24 preoperative interpretable study results, two (8%) were normal, and of the 18 postoperative interpretable study results, seven (39%) were normal (P <.03). With the consideration of only interpretable study results, the mean VRT increased slightly from 12.0 +/- 5.1 seconds (mean +/- standard deviation) to 14.3 +/- 8.1 seconds (NS). Seventeen of 19 ulcers (89%) had healed at a mean follow-up period of 8.6 +/- 4.8 months. CONCLUSION: Although VRT is unpredictably affected by SEPS, the most consistent finding is the inability of the calf to empty, which invalidates the remainder of the test. In addition, most ulcers heal, even with uninterpretable or abnormal postoperative VRTs. This suggests that photoplethysmography is a poor method of assessment of venous reflux after SEPS.

Prosthetic above-knee femoropopliteal bypass.

One of the classic and as yet unresolved arguments in vascular surgery is whether using prosthetic for a first-time above-knee femoropopliteal bypass, to "save the vein" for a later, more distal bypass, is of net benefit. Most of the arguments supporting use of prosthetic for a first bypass in this situation are, in fact, not supported by the literature, whereas most of the arguments in favor of using vein first are. In addition, decision analysis shows that overall amputation-free survival and number of operative procedures required are clearly better if vein is used first under essentially all conditions--the overwhelmingly strongest determinant of outcome is patency of the first bypass, and the superior patency of initial bypass with vein mathematically outweighs the ability of the "preserved" vein to salvage failures after an initial bypass with prosthetic. Theoretical, empirical, and mathematical arguments all strongly favor preferential use of vein for a first bypass to the above-knee popliteal artery.

Intracerebral hemorrhage after carotid endarterectomy: incidence, contribution to neurologic morbidity, and predictive factors.

PURPOSE: With a diminishing rate of cardiac and neurologic events after carotid endarterectomy, intracerebral hemorrhage is gaining increasing importance as a cause of perioperative morbidity and mortality. To date, information has been largely anecdotal, and there has been no comparison with a control group of patients. METHODS: The records of all patients experiencing symptomatic intracerebral hemorrhage after carotid endarterectomy were reviewed and compared with data from 50 randomly selected patients who did not experience intracranial bleeding. Univariate analyses were performed, using the Fisher exact test for dichotomous data and the Student t test for continuous data. RESULTS: During a 6-year period, symptomatic intracranial hemorrhage developed in 11 (0.75%) of 1471 patients undergoing carotid endarterectomy, accounting for 35% of the 31 total perioperative neurologic events. Hemorrhage occurred a median of 3 days postoperatively (range, 0 to 18 days). Signs and symptoms included hypertension in all 11 patients, headache in 7 conscious patients (64%), and bradycardia in 6 patients (55%). Massive hemorrhage with herniation and death occurred in 4 patients (36%). Moderate hemorrhage developed in 5 patients (45%); 3 of these patients had partial recovery, and 2 had complete recovery. Petechial hemorrhage occurred in the remaining 2 patients (18%), 1 with partial and 1 with complete recovery. In comparison with the control group, there were no differences in respect to sex, indication for operation, smoking or diabetic history, and antiplatelet therapy or perioperative heparin management. Patients with intracranial hemorrhage were, however, younger, more frequently hypertensive, had a higher degree of ipsilateral and contralateral carotid stenosis, and had a higher rate of contralateral carotid occlusion. CONCLUSION: Intracranial hemorrhage occurs with notable frequency after carotid endarterectomy and accounts for a significant proportion of neurologic morbidity and mortality. Younger patients, hypertensive patients, and patients with severe cerebrovascular occlusive disease appear to be at greatest risk for the complication.

Clinical review: irradiation for lower extremity arterial occlusive disease.

Lower extremity atherosclerosis, a disease of aging, is both widespread and increasing in prevalence-it is estimated that almost 100,000 patients per year in the United States require operative bypass for lower extremity ischemia. It is an axiom of vascular surgery that essentially every bypass graft will eventually fail. Many if not most such failures are due to the process of intimal hyperplasia at one or both anastomoses. The search for a "cure" for intimal hyperplasia has been long, but thus far unrewarding. Recent advances in therapeutic irradiation, however, offer a potential solution to this problem. This review is designed to acquaint the radiation oncologist with the basic concepts behind lower extremity atherosclerosis and its treatment, and to introduce briefly the special problems inherent in considering irradiation of an end-to-side anastomosis.

Fetal internal iliac artery: case report and embryologic review.

A 25-year-old woman with anomalous circulation to the right leg was seen with a symptomatic aneurysm of the abnormal vessel. The artery, which did share some features of the classic persistent sciatic artery, also had important differences that were not previously described in the literature. The patient manifested several associated vascular and nonvascular congenital anomalies. She underwent resection of the aneurysm and primary operative repair of the artery without difficulty. An embryologic interpretation is offered, and the clinical implications and management strategy are discussed.

A condemnation of subcutaneous fasciotomy.

Controversy exists regarding the indications and methods for lower-extremity fasciotomy. Two recent cases at our institution in which recurrent, acute limb-threatening ischemia occurred despite adequate fascial division have convinced us that in certain situations subcutaneous fasciotomy is clearly inadequate. In both patients, both of whom were young, intact healthy skin between the lower extent of the incision and the malleolus acted as a tourniquet, causing recurrent compartment syndrome as reperfusion edema occurred after initial repair. We believe that therapeutic fasciotomy in young patients with relatively noncompliant skin should include division of skin from the knee to the ankle on at least one side to prevent a tourniquet effect by intact skin at the ankle.

Value of preoperative EEG for carotid endarterectomy.

PURPOSE: This study was designed to determine whether the preoperative, baseline electroencephalogram (EEG) can be used for intraoperative decision making during carotid endarterectomy, and to identify circumstances where the EEG can be eliminated. METHODS: The charts of all patients undergoing carotid endartectomy at the authors' institution from June 1991 to May 1995 were reviewed to identify those patients that had adequate pre- and intraoperative EEG monitoring. EEGs during 331 carotid endartectomies in 303 patients were coded without knowledge of outcome; primary and secondary endpoints were EEG changes with clamping and clinical outcome, respectively. RESULTS: The incidence of mortality and major neurological morbidity was 1.8%. Baseline-EEGs were abnormal in 105 patients (32%). Whereas baseline-EEG changes were highly predictive of EEG changes after anesthetic induction (P < .0001), they were not predictive of EEG changes with clamping or of clinical outcome. Prior stroke (CVA) predicted abnormal baseline-EEGs (P < .0001) and abnormal post-anesthetic EEGs (P < .0001) but did not predict changes with clamping or perioperative CVA. EEG changes with clamping occurred during 18% of operations; such changes were predicted only by contralateral occlusion (P < .0016) and EEG changes during a prior contralateral carotid endartectomy (P < .0001). The only variable that predicted an adverse neurological outcome was the presence of contralateral occlusion, which increased the likelihood of a perioperative neurological event seven-fold (P = .0038). Clinical outcomes in the 57 of 105 patients with abnormal baseline-EEGs and the 49 of 83 with prior CVA who were shunted were not different from those who were not. CONCLUSIONS: baseline-EEG is not of value for the prediction of adverse events during carotid endartectomy and can be eliminated. Because contralateral occlusion is highly predictive of changes with clamping, and patients undergoing a second carotid endartectomy will usually manifest EEG changes identical to those at the first, operative EEG monitoring can also be eliminated from both these circumstances. Finally, prior stroke does not lead to a higher incidence of clamp-induced EEG changes, and thus is not an indication for shunting in and of itself.

Ruptured popliteal artery aneurysm.

Popliteal artery aneurysms rarely rupture. We treated a 91-year-old man who presented with a deep venous thrombosis and anemia; rupture of a popliteal artery aneurysm was suspected only after compartment syndrome isolated to the thigh developed as the result of bleeding. Although fasciotomy was required on the basis of the clinical examination alone, the cause of the problem, operative strategy, and definitive treatment (i.e., resection and bypass) were clarified by the preoperative computed tomography scan. Ruptured popliteal aneurysm can manifest as a massively swollen leg with anemia and should be suspected if no other cause is evident.

Optimal diagnosis of splenic vein thrombosis: brief clinical report.

The presence of splenic vein thrombosis is sometimes very difficult to diagnose. We present a patient in whom the splenic vein was thought to be patent by ultrasound and conventional celiac angiography. Because of high clinical suspicion and continued bleeding, he underwent a selective intra-arterial digital splenic angiogram. The venous phase clearly showed proximal (hilar) splenic vein occlusion with filling via collaterals in real time. Splenectomy confirmed the diagnosis. We believe that a selective intra-arterial digital splenic angiogram is the radiographic study of choice for suspected splenic vein thrombosis.