Endovascular-assisted versus conventional in situ saphenous vein bypass grafting: cumulative patency, limb salvage, and cost results in a 39-month multicenter study.

OBJECTIVE: In this retrospective multicenter study, the results of a minimally invasive method of endovascular-assisted in situ bypass grafting (EISB) versus "open" conventional in situ bypass grafting (CISB) were evaluated with a comparison of primary and secondary patency, limb salvage, and cost. METHODS: Enrolled in this study were 273 patients: 117 underwent CISB (42 femoropopliteal, 75 femorocrural) and 156 underwent EISB (41 femoropopliteal, 115 femorocrural). EISB was performed with an angioscopic Side Branch Occlusion system and an angioscopically guided valvulotome. All the patients underwent follow-up examination with serial color-flow ultrasound scanning. RESULTS: Both groups had similar comorbid risk factors for diabetes mellitus, coronary artery heart disease, hypertension, and cigarette smoking. The primary patency rates (CISB, 78.2% +/- 5% [SE]; EISB, 70.5% +/- 5%; P =.156), the secondary patency rates (CISB, 84.1% +/- 4%; EISB, 82.9% +/- 5%; P =.26), and the limb salvage rates (CISB, 85.8%; EISB, 88.4%; P =.127) were statistically similar, with a follow-up period that extended to 39 months (mean, 16.6 months; range, 1 to 40 months). In veins that were less than 2.5 to 3.0 mm in diameter, the EISB grafts fared poorly, with an increased incidence of early (12-month) graft thromboses (CISB, 10 grafts, 8.5%; EISB, 24 grafts, 15.3%). However, wound complications (CISB, 23%; EISB, 4%; P =.003), mean hospital length of stay (CISB, 6.5 days +/- 4.83; EISB, 3.2 days +/- 3.19; P =.001), and mean hospital charges (CISB, $25,349 +/- $19,476; EISB, $18,096 +/- $14,573; P =.001) were all significantly reduced in the EISB group. CONCLUSION: The CISB and EISB midterm primary and secondary patency and limb salvage rates were statistically similar. In smaller veins (< 2.5 to 3.0 mm in diameter), however, EISB is not appropriate because overly aggressive instrumentation may cause intimal trauma, with resultant early graft failure. With the avoidance of a long leg incision in the EISB group, wound complications and hospital length of stay were significantly reduced, which lowered hospital charges and justified the additional cost of the endovascular instruments. When in situ bypass grafting is contemplated, EISB in appropriate patients is a safe, minimally invasive, and cost-effective alternative to CISB.

Delayed rupture of aortic aneurysms following endovascular stent grafting.

BACKGROUND: Deployment of transfemoral, endovascular stent grafts for treatment of abdominal aortic aneurysms is appealing for several reasons: avoidance of abdominal incision, lack of aortic cross-clamping, potential for regional anesthesia, and shortened hospital stay. Concerns remain, however, regarding the ability of these devices to completely exclude the aneurysm and prevent aneurysm rupture and the long-term integrity of the device. The availability of endografts and the likely development of percutaneous devices have also raised the delicate issue of personnel training for patient selection, endograft implantation, and postoperative follow-up. PATIENTS AND METHODS: The cases of 2 patients are reported in which Dacron endovascular grafts, anchored proximally and distally by Palmaz stents, were deployed for treatment of infrarenal abdominal aortic aneurysms. RESULTS: In a patient with and absent distal cuff, choosing this procedure represented a clear error in patient selection. The endograft failed to reach the aortic bifurcation and the aneurysm ruptured, with the death of the patient 4 months postimplantation. In a patient with anatomy suitable for endograft placement, a perigraft leak persisted at the distal anastomosis following device placement. The aneurysm ruptured 14 days postprocedure. Although the patient survived emergent aneurysm repair, he developed acute renal failure. CONCLUSION: Careful preoperative assessment of aortic anatomy is crucial in selection of patients for transfemoral endovascular graft placement. Lack of a distal cuff of at least 1 cm precludes tube graft implantation. Patients with a perigraft leak are not protected by the endograft from aneurysm rupture. Vascular surgeons must be involved in the preoperative evaluation of these patients and are the only specialty group who can provide the prerequisite care in evaluation and management of postoperative complications.

Mediastinal mass following esophageal surgery.

In this Radiology Rounds, the authors report the computed tomographic findings of a patient with an infected esophageal mucocele that formed within one month after repair of a perforated paraesophageal hiatus hernia. The patient was a 78-year old male.

Duplex imaging and incidence of carotid radiation injury after high-dose radiotherapy for tumors of the head and neck.

Radiation-induced carotid artery disease following high-dose (greater than 50-Gy) radiotherapy for head and neck cancer may become more common as improved treatment results in longer survival. Duplex ultrasound scans were obtained in 91 consecutive patients to determine whether increased incidence and severity of extracranial carotid disease correlate with prior radiotherapy. Fifty-three patients who underwent radiotherapy an average of 28 months previously and 38 patients who received no radiotherapy were studied. Thirty percent of the irradiated group had lesions of the carotid arteries that were either moderate or severe vs only 6% of the control patients. Five patients were symptomatic; all had undergone radiotherapy. Long-term follow-up with sequential duplex ultrasound examinations is indicated in patients receiving high-dose radiotherapy for head and neck tumors, to detect radiation-induced carotid artery disease and prevent late sequelae.

Chronic central vein catheterization for intraoperative and long-term venous access in swine.

Chronic venous access and repeated blood sampling for research purposes in large swine ideally should be possible without sedation, restraint or direct venipuncture of deep vessels. An operative technique of cranial vena cava catheterization and chronic catheter maintenance methods are described which were used successfully in the placement of 11 silicone rubber catheters in 10 animals. All were used for repeated blood sampling, as well as intraoperative infusion of medications and large fluid volumes. Long term patency was excellent with 10 catheters patent at the end of the study interval, up to 14 weeks after insertion. Serial blood sampling was accomplished easily without restraint. Catheter damage, infection or malfunction was rare. Proper maintenance and careful aseptic blood sampling render the cranial vena cava catheter a safe and reliable alternative to direct venipuncture in swine.

Surgical therapy in two patients with pedunculated hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) occurring as an appendage from the main hepatic parenchyma is a rare entity, of which two cases are herein described. Because proper surgical management of this tumor (pedunculated HCC) is unclear, the world's literature was reviewed to determine optimal therapy. Thirty-four cases were documented, including the two cases reported herein. Diagnosis was usually obscure, despite modern invasive and noninvasive methods, and laparotomy or autopsy were required for specific identification of tumor type. Sixteen resections were reported among 18 explorations. One patient had transarterial embolization. Fifteen received medical therapy only. Surgically treated patients usually died of metastatic disease, whereas most medically treated patients died of gastrointestinal or tumor hemorrhage. Pedunculated HCC may be more amenable to curative resection than ordinary HCC due to its unique localization and growth pattern.

Primary iliac artery aneurysm in a two-year-old girl.

Isolated idiopathic iliac artery aneurysm in the pediatric population is extremely rare. Aneurysms in children may be secondary to connective tissue disease, arteritis, or mycotic causes. Presented here is the case of a 2 1/2-year-old female child who, despite the absence of these predisposing factors, presented with a single large iliac artery aneurysm which was successfully resected. The literature on this subject is reviewed. Only two other cases have been reported.

The natural history of carotid fibromuscular dysplasia.

Although graduated internal dilatation has proved to be an effective, safe, and durable operation for the treatment of symptomatic patients with fibromuscular dysplasia of the extracranial internal carotid artery, the role of surgical treatment in this entity remains unclear because the natural history is not well defined. Forty-nine patients, aged 29 to 82 years (mean, 58.5 years), with angiographically proven fibromuscular dysplasia of 88 internal carotid arteries have been evaluated since 1969. Twenty patients showed symptoms of focal cerebral or retinal ischemia, 10 patients had nonlateralizing neurologic symptoms, three patients sustained intracerebral hemorrhage, five patients complained of nonischemic symptoms, and 11 patients were asymptomatic. The three patients with intracranial hemorrhage and one person who suffered a massive stroke after angiography died within weeks of admission; no surgical therapy was performed. Initial management of the other patients included four internal carotid endarterectomies in four patients for associated atherosclerosis, one with simultaneous graduated internal dilatation; seven graduated internal dilatations in five patients; and one extracranial-to-intracranial bypass in a patient with occlusion occurring after graduated internal dilatation. Seventy-three nondilated arteries in 42 patients have been followed for up to 16 years (mean, 6.8 years). During this time only three patients have undergone surgical therapy; one carotid endarterectomy was done for an asymptomatic atherosclerotic lesion and two graduated internal dilatations in patients with nonfocal ischemia. Through follow-up of all 49 patients, none has had a new neurologic deficit. Fourteen patients who initially presented with focal ischemia were not treated surgically and all but one are now asymptomatic.(ABSTRACT TRUNCATED AT 250 WORDS)

Survival after malignant melanoma in a black child. A case report and review of the literature.

A malignant melanoma of clinical and pathologic State I but deep microstage that occurred on the lower extremity of a prepubertal black male child, who is free of recurrence 3 years following surgical excision, regional node dissection, and BCG adjuvant immunotherapy, is reported. Previously described cases of malignant melanoma in black children indicate that it is a rare and virulent lesion, since all patients expired due to their tumors within 6 months. The judicious use of principles derived from management of adults with such lesions may prolong survival and disease-free interval in this patient population.

Role of cytoplasmic and releasable ADP in platelet aggregation induced by laminar shear stress.

We examined the extent of lytic and sublytic platelet injury after exposure of platelets to shear stress and the role in shear-induced PAG of ADP liberated from platelets as a result of shear-induced platelet dense body release and/or platelet damage. Platelets in C-PRP or TAS were subjected to well-defined, laminar shear stress in a rotational viscometer, and PAG (loss of single, nonaggregated platelets), 14C-serotonin release, and loss from platelets of LDH and 51Cr were determined. Increased PAG with increasing shear stresses was associated with progressive loss of LDH and 51Cr. Loss of 51Cr was consistently in excess of that of LDH, indicating sublytic platelet injury, which was confirmed by electron microscopy. At the lowest shear stress used (50 dynes/cm2), PAG in C-PRP was observed in the absence of detectable loss of 51Cr or LDH. When platelets in TAS were sheared in the presence of CP/CPK, an enzyme system capable of removing extracellular ADP, PAG was only partially (approximately 40%) inhibited. However, when platelets were preincubated with CP/CPK and ATP (to saturate platelet ADP receptors), shear-induced PAG was almost completely suppressed. Similar results were obtained with PAG induced by collagen in the aggregometer. The findings indicate that (1) shear-induced PAG in this system may occur without measurable lytic or sublytic platelet damage and (2) ADP liberated from platelets as a result of shear-induced release or damage may represent the major if not sole mediator of shear-induced PAG.

Complications of Denver peritoneovenous shunting.

The records of 49 consecutive patients treated with Denver peritoneovenous shunts were reviewed to determine the incidence of complications and length of patient survival. Thirty-eight complications (16 types) were identified in 22 (45%) of the patients and, in 10 instances, contributed to subsequent death. Ten percent of shunts failed during long-term follow-up. The 54% one-year survival by life-table analysis of patients with cirrhosis treated with the Denver shunt matched results previously reported for similar patients treated with the LeVeen shunt. Patients with intra-abdominal malignant neoplasms had an 11% one-year survival overall. Although it too is associated with significant complications, the Denver peritoneovenous shunt seems to have a lower failure rate and a lower incidence of complications than the LeVeen peritoneovenous shunt. Thus, the Denver shunt offers advantages in the treatment of intractable ascites.