Eversion carotid endarterectomy generates fewer microemboli than standard carotid endarterectomy.

OBJECTIVES: to test whether the occurrence of microembolism differed between eversion and standard carotid endarterectomy (CEA). DESIGN: prospective, non-randomised transcranial Doppler (TCD) monitoring study of 61 patients. MATERIALS AND METHODS: eversion CEA was performed in 27 and standard CEA in 34 patients. Surgery was performed under general anaesthesia. Three (5%) patients had a shunt inserted based on continuous EEG monitoring. Continuous middle cerebral artery TCD monitoring (EME, TC-4040) was performed intraoperatively and for 45 min postoperatively on day 1, day 2-3, day 4-5 and after 3 months. Unidirectional signals lasting >25 ms, having intensities of >9 dB were considered to represent embolic events. RESULTS: intraoperative embolic events were detected in 50 (93%) of 54 patients in whom successful intraoperative TCD monitoring was achieved. Events occurred most frequently immediately following clamp release (85%), without difference between the two techniques. Embolic events were encountered postoperatively in four (15%) and 16 (48%) patients having eversion and standard CEA, respectively (p< 0.02). Four patients developed new neurological symptoms equally distributed between eversion and standard CEA. Two (3%) deficits were permanent and two transient. The patency of the carotid bifurcation was confirmed in all instances with duplex scanning. CONCLUSION: we identified a surprisingly high number of postoperative embolic events as detected with transcranial Doppler in patients who had undergone carotid surgery using standard endarterectomy, as compared to patients who underwent eversion endarterectomy. Whether this difference has any clinical implication has yet to be proved.

[Vena saphena magna in situ bypass to the ankel and foot. A prospective assessment of results of 101 procedures in 94 patients with threatening amputation]. / Vena saphena magna in situ-bypass til ankel og fod. En prospektiv opg|relse af resultaterne af 101 procedurer hos 94 amputationstruede patienter]

The results of 101 in situ by-pass operations to the ankle and foot are given. Seventy-five percent of the patients had other arteriosclerotic manifestations and 55% were diabetics. Ninety-nine percent of the operations were limb salvage surgery. The accumulative secondary patency rate was 87% after one month and 65% after three years. The results did not differ from by-pass surgery to the crural arteries. The wound complication rate was 16% with an infection rate of 7% and the major amputation rate was 8% after one month and 10% after three years. The survival of this selected group of patients was lower than a group of sex- and age-matched controls. The long term results of this type of advanced by-pass surgery in limb threatening ischaemia are very satisfactory and should be a must in every vascular surgeon's armamentarium.

Inflammatory aortic aneurysms: regression of fibrosis after aneurysm surgery.

OBJECTIVES: To evaluate the fate of perianeurysmal fibrosis (PF) following aneurysm surgery. METHODS: In this single centre study, pre- and postoperative abdominal CT-scans on 21 consecutive patients with inflammatory abdominal aortic aneurysms were compared. CT-scans of 10 randomly chosen patients operated on for abdominal aortic aneurysms without PF in the same period, served as reference group. RESULTS: Preoperative thickness of PF was assessed as > 1 cm in 11 and < 1 cm in 10 patients. Ureterolysis was performed in seven patients where the fibrosis caused ureteral obstruction. Postoperative CT-scans performed at a median of 24 (range 3-108) months after surgery showed complete regression of the fibrosis in 29%, partial regression in 57% and no change in 14% of the patients. Progression of the fibrosis or persistence of hydronephrosis was not seen. No sign of fibrosis were seen in the 10 controls. CONCLUSION: This study supports the findings that PF tends to regress after repair of the abdominal aortic aneurysm.

[Percutaneous transluminal angioplasty of iliac occlusions]. / Perkutan transluminal angioplastik af iliacaokklusioner.

Percutaneous transluminal angioplasty (PTA) has become an established treatment modality for iliac artery stenosis. PTA of iliac artery occlusions, however, remains a topic of controversy due to difficulties with mechanical recanalization, a lower patency rate and a higher complication rate than obtained after PTA of iliac artery stenosis. During a three year period, we performed 31 PTA's of iliac artery occlusions. The primary recanalization rate was 71% (22 occlusions). Stents were applied in 16 patients. The cumulated patency rates were 95% and 85% after one and six months respectively. There was one late reocclusion after two years. We found a tendency towards inferior patency in the longer occlusions (> or = 5cm). The complication rate was 10% due to three episodes of distal embolisation, all of which were successfully treated immediately with additional PTA and stenting. These results are in accordance with the results of international studies, and suggest that PTA is a useful alternative to surgical treatment of iliac artery occlusions, albeit long occlusions involving both the common and the external iliac artery should be excluded.

[4 years of experiences with Karbase. A tool for quality development in vascular surgery]. / Fire års erfaringer med Karbase. Et redskab til kvalitetsudvikling i karkirurgi.

Karbase, a Danish register for vascular surgery is presented with data from four years experience. The register consists of 65 variables centered on risk factors, the perioperative course as well as follow-up information. During the four-year period 1989-1992 a total of 4902 admissions were registered in 3810 patients. Surgery was performed during 4005 admissions. Output data from Karbase is presented with results on survival and postoperative complications, related to preoperative risk factors. The incidence of surgical wound infections was 3.9%, with a significant reduction during the years (p = 0.004). Karbase is now used by all vascular surgical units in Denmark. We conclude that the establishment of a continuous registration has been beneficial to the department. We have achieved valid data on treatment, outcome and complications in relation to individual risk factors. In the future the use of Karbase will be extended with the aim of further quality development, locally as well as nation wide.

[Vascular surgery in patients with impaired renal function]. / Karkirurgisk behandling hos patienter med påvirket nyrefunktion.

The purpose of the study was to evaluate the effect of surgery for renal artery stenosis in patients with impaired renal function. The design was a retrospective investigation with follow-up. The material consisted of 42 such patients operated at Rigshospitalet between 1980 and 1990. Renal function and blood pressure status was evaluated preoperatively and at follow-up. The perioperative mortality was 5% (n = 2) and morbidity 21% (n = 9). At discharge from hospital renal function was maintained in 38 patients (90%), including three patients who at the time of operation were without diuresis and had been in dialysis for up to 28 days. Twenty-three patients were still alive at postoperative follow-up at a median of 66 months. The cumulative five-year survival was 62%, which was significantly lower than that of a sex- and age-matched population. Eleven patients developed terminal renal insufficiency during the follow-up period. The cumulative preservation of renal function was 77% after five years. In conclusion, reconstruction of the renal arteries in patients with declining renal function and renal artery stenosis or occlusion can save renal function such that dialysis may be avoided in most cases.

Revascularisation of atherosclerotic mesenteric arteries: experience in 90 consecutive patients.

OBJECTIVES: Visceral artery surgery is well known to vascular surgeons, but most have limited personal experience. We report our experience with 90 patients treated for atherosclerotic lesions of the visceral arteries during a 25-year period 1968-1993. DESIGN: Retrospective study. SETTING: Department of Vascular Surgery, University Hospital Rigshospitalet, Copenhagen, Denmark. MATERIALS: 54 women and 36 men, aged 56 (median; range: 34-78 years) underwent 109 consecutive mesenteric reconstructions. The indication in 90 primary procedures was acute mesenteric ischaemia of non-embolic origin in 25 patients, chronic ischaemia in 53 and prophylactic reconstruction in connection with aortic surgery in 12 patients. The superior mesenteric artery (SMA) was revascularised in 87 patients and the coeliac axis or common hepatic artery in six. Thus, only three patients had both territories revascularised. Thromboendarterectomy was performed in 15 patients, transposition of the SMA directly into the infrarenal aorta in 30 and bypass in 48 patients. CHIEF OUTCOME MEASURES: Cumulative symptom-free and survival rates. MAIN RESULTS: The overall perioperative (30 days) mortality rate was 13%, mainly caused by the high mortality rate of 44% (11 patients) in the acutely operated, as the mortality was 0% in patients operated on electively and only one out of 12 patients (8%) died after a prophylactic operation. Nine of the twelve deaths were due to progressive mesenteric infarction. Cumulated survival rates were 81, 60 and 35% after 5, 10 and 20 years, respectively which indicated a mortality rate three times that of an age- and sex-matched Danish population. During follow-up symptoms recurred in 30 patients, more often following emergency surgery and SMA transposition. CONCLUSIONS: Mesenteric revascularisation may yield long lasting results. However, surgery for acute ischaemia carries a high mortality rate, emphasising the importance of early surgery.

Abdominal aortic aneurysm surgery: survival and quality of life in patients requiring prolonged postoperative intensive therapy.

The goal of this study was to identify patients who need longer care in the ICU (more than 48 hours) following abdominal aortic aneurysm (AAA) surgery and to evaluate the influence of perioperative complications on short- and long-term survival and quality of life. AAA surgery was performed in 553 patients, 51 (9%) of whom died within the first 48 hours. Of the 502 patients who survived for more than 48 hours, 109 required ICU therapy for more than 48 hours, whereas 393 patients were in the ICU for less than 48 hours. The incidence of preoperative risk factors was similar for the two groups. The cumulated survival rates for the two groups were 68% and 92% at 1 months, 52% and 88% at 1 year, and 60% and 33% at 6 years, respectively. This significant difference was primarily related to renal, pulmonary, and cardiac complications. However, assessment of the most severe complications and risk factors combined failed to permit identification of patients in whom the perioperative survival rate was 0%. Even 20% of patients with multiorgan failure survived for 6 months. Of those patients who needed ICU therapy for more than 48 hours, 41 (38%) were alive at the end of 1988. In response to a questionnaire, 78% stated that their quality of life had improved or was unchanged after surgery and had resumed working. These data justify a therapeutically aggressive approach, including ICU therapy following AAA surgery, despite failure of one or more organ systems.

[Surgical treatment of renovascular hypertension caused by renal artery stenosis. A retrospective study]. / Kirurgisk behandling af renovaskulaer hypertension forårsaget af nyrearteriestenose. En retrospektiv opgørelse.

During a 10 year period 58 patients with renovascular hypertension due to renal artery stenosis were treated surgically. A retrospective analysis of the results was carried out. No perioperative mortalities occurred. Ten percent of the patients developed hypertension again after an average of 27 months. At follow-up (median 65 months), 85% of the patients had normal blood pressure or either no, modest or considerably reduced anti-hypertensive medication. It is concluded that surgical treatment of renovascular hypertension is a safe and effective procedure.

[In situ bypass and diabetes]. / In situ bypass og diabetes.

From 1986 through to 1990 a total of 483 in situ bypass procedures were performed in 444 patients. Preoperative risk-factors were equally distributed among diabetic (DM) and non-diabetic (NDM) patients, except for smoking habits (DM:48%, NDM:64%, p = 0.002) and cardiac disease (DM:45%, NDM:29%, p = 0.005). Critical limb-ischaemia was more often present in diabetic than non-diabetic patients (DM:57%, NDM:36%, p = 0.0002). Diabetic patients had a significantly lower distal anastomosis than non-diabetic patients (p = 0.00001). There were no differences among diabetic and non-diabetic patients regarding three years primary and secondary patency (58% and 64% respectively), and regarding major amputations. However, the rate of minor amputations was higher in insulin-dependent compared with non-insulin-dependent diabetics, who in turn had a higher rate than non-diabetics (p < 0.00001). A markedly decreased survival rate was found in diabetics (p < 0.00005). We found the in situ bypass technique very useful in the treatment of critical ischaemia of the lower limb in diabetic patients. The overall results in diabetic patients, whether insulin-dependent or not, were equal to those in non-diabetic patients.

[Prognosis for the critically ischemic lower extremity when surgical revascularization is not possible]. / Prognosen for den kritisk iskaemiske underekstremitet som ikke kan revaskulariseres karkirurgisk.

Of 427 patients with chronic critical ischemia of the lower extremity admitted for infrapopliteal bypass surgery, thirty-four (8%) were considered technically inoperable: in 26 cases due to total occlusion of the runoff vessels, and in eight due to a poor runoff and no suitable vein. The symptoms were rest pain in 24 cases and gangrenous ulceration in ten. During a follow-up of eight to twenty-eight months five (15%) patients improved significantly, and complained only of claudication. Three patients, suffering rest pain, were unchanged at nine months follow-up, and 25 (74%) patients had a major amputation performed during the follow-up period. The remaining patient died the day after admission. The mortality rate of these patients was significantly increased compared to that of the 393 patients who underwent infrapopliteal bypass surgery, who in turn had a higher mortality rate than that of an age- and sex-matched Danish population. The group of patients who preserved their limb could not be identified by either ankle- and toe-pressure measurements or clinical evaluation.

Natural history of abdominal aortic aneurysm: a survey of 63 patients treated nonoperatively.

During a 10-year period in which 735 patients presented with abdominal aortic aneurysms to our clinic, 63 were not offered operative treatment. The primary reason for choosing conservative treatment was concomitant diseases that increased the risk of operation. After 2 years of followup, half of the patients died, and the cumulative 5-year survival rate was 15%. Aneurysm rupture was the primary cause of death. The cumulative 5-year mortality hazard rate from rupture was 0.36, corresponding to an annual risk of rupture of 7%. The cumulative 5-year hazard rate of death from all other causes was 1.53, corresponding to an annual risk of 30%. Diameter of the aneurysm was found to be the only factor with a significant impact on the rate of rupture. The cumulative 5-year hazard rate of rupture among patients with aneurysms < 6 cm and > or = 6 cm was 0.2 and 0.6, respectively, corresponding to an annual risk of rupture of less than 5% and 10% to 15%, respectively. However, neither diameter nor other risk factors had significant influence on the time of rupture. In our opinion, once the diagnosis is confirmed the patient should be offered aneurysm resection if the general health status permits anesthesia.

Intra-arterial papaverine and leg vascular resistance during in situ bypass surgery with high or low epidural anaesthesia.

In situ saphenous vein arterial bypass flow was studied in 16 patients with respect to level of epidural anaesthesia. Arterial pressure and electromagnetic flow were used to evaluate arterial tone by intra-arterial (i.a.) papaverine. Eight patients had a low epidural block (< or = Th. 10) and eight patients were operated during high epidural anaesthesia (> Th. 10). Flow increased and arterial pressure decreased after i.a. papaverine in all patients. When compared with patients operated during high epidural anaesthesia, flow increase and decrease in vascular resistance took place in patients operated during low epidural anaesthesia (P < 0.02). Increase in arterial flow after i.a. papaverine was not significantly different in patients operated in low epidural and general anaesthesia (n = 8). In eight patients with insulin-dependent diabetes mellitus who had low epidural anaesthesia, the increase in flow after i.a. papaverine was not significantly different to that noted during high epidural anaesthesia. The results indicate that the level of analgesia influences graft flow after i.a. papaverine, probably reflecting differences in the effect of epidural anaesthesia on sympathetic tone to the leg.

In situ saphenous vein bypass surgery in diabetic patients.

From 1986 through to 1990 a total of 483 consecutive in situ infra-inguinal vein bypass procedures were performed in 444 patients, of whom 112 (25%) were diabetics (57 insulin dependent diabetes mellitus and 55 non-insulin-dependent diabetes mellitus). Based on a prospective vascular data registry this material was analysed to determine the influence of diabetes on the outcome. Preoperative risk factors were equally distributed among diabetic and non-diabetic patients, except for smoking habits (diabetics: 48%; non-diabetics: 64%, p = 0.002) and cardiac disease (diabetics: 45%; non-diabetics: 29%, p = 0.005). Indication for surgery was gangrene or ulceration in 57% of diabetics, as opposed to 36% in non-diabetic patients (p = 0.0002). A femoro-popliteal bypass was performed in 18% of patients, whereas 82% received an infrapopliteal procedure, of which 42% were to the distal third of the calf or foot. Diabetic patients had a significantly lower distal anastomosis than non-diabetic patients (p = 0.0001). The overall 3-year primary and secondary patency rates were 58 and 64%, respectively, with no differences between non-diabetics, non-insulin-dependent diabetics and insulin-dependent diabetics. Neither did limb survival differ among the three groups. However, the rate of minor amputations was significantly higher in insulin-dependent compared with non-insulin-dependent diabetics, who in turn had a higher rate than non-diabetic patients (p less than 0.00001). A markedly decreased survival rate was found in diabetics (p less than 0.0005).(ABSTRACT TRUNCATED AT 250 WORDS)

[Excimer laser-assisted balloon angioplasty of the femoro-popliteal segment]. / Excimer-laser-assisteret ballonangioplastik af det femoropopliteale segment.

In the Department of Vascular Surgery RK, The University Hospital in Copenhagen, the authors have treated 16 patients with ischaemia in the lower limb by means of laser-assisted balloon angioplasty. A pulsed ultraviolet excimer-laser was employed. It proved possible to break down the occluding arterial lesion in 12 patients (75%). In one patient, this was not followed-up by balloon angioplasty and, in another patient, the reconstruction closed on the first day after operation. The primary success of the procedure, defined as breaking down of the occlusion with the laser-catheter followed by balloon angioplasty and an increase in the ankle/brachial index of greater than 15%, was found to be 10/16 or 62%. The remaining four patients, in whom it did not prove possible to break down the arterial lesion with laser, were treated by means of conventional vascular surgical reconstruction. On follow-up examination after an average of nine months, nine out of the ten patients (90%) still had a patent reconstruction after laser-assisted balloon angioplasty. This new endovascular laser-procedure appears to be suitable for selected patients, but must be assessed more meticulously before it is possible to determine its future placing in the vascular surgical therapeutic armamentarium.

Surgery for abdominal aortic aneurysms. A survey of 656 patients.

Between 1979 and 1988, 656 patients were operated upon for abdominal aortic aneurysm. Elective operation was performed in 287 patients (44%) and acute operation in 369 patients. A ruptured aneurysm was found in 218 patients (33%). Patients with arteriosclerotic heart disease, hypertension, impaired renal function or chronic pulmonary disease showed an increased perioperative mortality. Development of postoperative cardiac and renal complications could not be related to previous cardiac or renal diseases. The major postoperative complications were renal failure in 81 patients (12%), pulmonary insufficiency in 77 patients (11%) and cardiac complications in 96 patients (13%). Failure of one or more organs occurred in 153 patients (23%) and the mortality rate for patients with multiorgan failure was 68%. Complications leading to reoperation occurred in 93 patients (14%). The perioperative mortality was 18.8%. The mortality for elective cases was 4.8%, for symptomatic cases 17.2% and 37% for ruptured aneurysms. The five-year survival rate was 48% for ruptured aneurysms, 70% for symptomatic cases and 75% for elective cases. After six months the life expectancy in these three groups of patients were identical and comparable to the expected survival for a sex and age matched control population.