Hemodynamically significant early recurrent carotid stenosis: an often self-limiting and self-reversing condition.

PURPOSE: The natural history of hemodynamically significant (internal carotid systolic velocity more than 125 cm/s) early recurrent carotid stenosis was studied. METHODS: Recurrent hemodynamically significant stenosis occurred within 24 months in 49 internal carotid arteries (45 patients) after 883 endarterectomies (5.4%). These patients were then examined with serial scans. Subsequent redo endarterectomy and neurological events were recorded. RESULTS: Patients were observed for 9 to 84 months (mean, 53 months). Arteries with recurrent stenosis were grouped according to the maximal velocity recorded: group I, systolic velocity more than 125 cm/s and less than 280 cm/s (12); group II, systolic velocity more than 280 cm/s or diastolic velocity more than 80 cm/s (21); group III, systolic velocity more than 280 cm/s and diastolic velocity more than 120 cm/s (14); group IV, internal carotid artery occlusion (2). The mean time to a velocity of more than 125 cm/s was 11 months. The mean time to peak velocity was 16 months. During The Follow-UP Period, Five Stenoses Remained Stable. Nineteen Continued To Increase, With Two Eventual Asymptomatic Occlusions (4%). Six Recurrences Ultimately Had Redo Endarterectomy, Two For Symptoms. Three Of These Developed New Secondary Recurrent Lesions. However, In 25 Arteries (53%), The Velocity Profile Decreased By At Least One Group Classification. The Mean Time To The Lowest Velocity (TTL) Was 50 Months. Systolic Velocity Ultimately Fell Below 125 Cm/S In 13 Stenoses (SIX In Group I; Five In Group II; Two In Group III). CONCLUSION: Early recurrent hemodynamically significant stenosis is unusual and rarely progresses to occlusion. Even critical stenosis can regress to within normal limits. Redo endarterectomy is seldom necessary. The challenge remains to define which patients are at risk for symptoms and occlusion.

Color flow scan diagnosis of the carotid string may prevent unnecessary surgery.

Can the color flow scanner assist in the diagnosis and management of patients with preocclusive lesions of the carotid bifurcation (so-called 'string sign')? Twenty-three patients were identified as having a 'string' by duplex criteria. Seventeen patients underwent angiography, which confirmed the duplex findings in 14 patients. In three, the angiogram was originally misread as showing an occluded internal carotid Artery. Six patients were managed solely on the basis of the duplex findings. Based on arteriography and/or duplex criteria, 12 involved internal carotid arteries were not explored. One artery went on to occlude asymptomatically. The remaining 11 have remained patent and asymptomatic (follow-up 6-72 months). Five arteries were predicted operable and underwent successful endarterectomy. Six were predicted inoperable yet underwent exploration. All were ultimately treated by ligation +/- external carotid endarterectomy without subsequent neurological deficit. Duplex scans can identify internal carotid artery string signs, determine operability and may predict the functionally occluded artery that can be safely observed.

Isolated femoropopliteal bypass graft for limb salvage after failed tibial reconstruction: a viable alternative to amputation.

PURPOSE: Femoropopliteal bypass grafting procedures performed to isolated popliteal arteries after failure of a previous tibial reconstruction were studied. The results were compared with those of a study of primary isolated femoropopliteal bypass grafts (IFPBs). METHODS: IFPBs were only constructed if the uninvolved or patent popliteal segment measured at least 7 cm in length and had at least one major collateral supplying the calf. When IFPB was performed for ischemic lesions, these lesions were usually limited to the digits or small portions of the foot. Forty-seven polytetrafluoroethylene grafts and three autogenous reversed saphenous vein grafts were used. RESULTS: Ankle brachial pressure index (ABI) increased after bypass grafting by a mean of 0.46. Three-year primary life table patency and limb-salvage rates for primary IFPBs were 73% and 86%, respectively. All eight IFPBs performed after failed tibial bypass grafts remained patent for 2 to 44 months, with patients having viable, healed feet. CONCLUSION: In the presence of a suitable popliteal artery and limited tissue necrosis, IFPB can have acceptable patency and limb-salvage rates, even when a polytetrafluoroethylene graft is used. Secondary IFPB can be used to achieve limb salvage after failed tibial bypass grafting.

Routine carotid endarterectomy without a shunt, even in the presence of a contralateral occlusion.

UNLABELLED: A 10-year prospective experience with routine non-shunting, even in the presence of a contralateral internal carotid artery occlusion, is reviewed. METHOD AND RESULTS: Carotid endarterectomy was performed without a shunt in 654 consecutive patients: group 1, 513 patients with contralateral stenosis of less than 79%: group 11, 74 patients with a greater than 80% contralateral stenosis; and group 111, 67 patients with a contralateral occlusion. Average cross-clamp time was 23 min. Neurological complications occurred within 30 days in 20 (3.0%) patients (10 strokes, seven transient ischemic attacks in group I, one transient ischemic attack in group II, and one stroke and one transient ischemic attack in group III). Immediate postoperative strokes, i.e. those five cases that could be implicated as caused by lack of a shunt, were rare (0.76%). There were five perioperative deaths (0.76%). CONCLUSION: Carotid endarterectomy may be performed safely without a shunt even in the presence of a contralateral occlusion. Age, sex, preoperative indication, anesthetic agent and contralateral stenosis were not associated with an increased risk of postoperative neurological deficit.

Is thigh saphenectomy a necessary adjunct to high ligation and stab avulsion phlebectomy?

BACKGROUND: Controversy still exists as to whether the thigh saphenous vein should be stripped concomitant with high ligation and phlebectomy. METHOD: A total of 218 procedures were retrospectively grouped into three groups: group 1, 10 limbs with visible, duplex scan-confirmed varicose veins of the thigh saphenous vein; group 2, 13 saphenous veins with varices that were not clinically evident; group 3, 195 limbs with incompetent saphenous veins without thigh saphenous varices. RESULTS: Five limbs in group 1 were treated by high ligation, phlebectomy, and thigh saphenectomy. All did well. Five had high ligation and phlebectomy only. Two developed painful phlebitis, and two had residual varices in the saphenous vein. Group 2 and group 3 were treated by high ligation and phlebectomy. One group 2 limb developed saphenous phlebitis. Five limbs in group 3 developed recurrent veins that were removed in the office. CONCLUSION: Thigh saphenectomy is only required when there are visible, duplex scan-confirmed varices of the thigh saphenous itself, or when the procedure is performed for severely symptomatic patients or those with advanced stasis changes.

After the blue toe: prognosis of noncardiac arterial embolization in the lower extremities.

PURPOSE: To better understand the prognosis of atheroembolic disease, we reviewed the outcomes of 41 patients with embolization to the viscera and lower extremities. METHODS AND RESULTS: All cases involved emboli that originated from a radiographically identified proximal arterial source. There were 30 men and 11 women (mean age 65 years; mean follow-up time 2 years), and all had been first treated for this condition within the past 6 years. The overall mortality rate was 17% (7/41) and the rate of recurrent embolization 15% (6/41). To compare outcomes associated with supradiaphragmatic versus subdiaphragmatic disease, we defined two groups: group 1 comprised patients (n = 5) in whom the identified embolic source extended above the diaphragm, and group 2 comprised patients (n = 36) in whom the source remained below the diaphragm. The mortality rates in groups 1 and 2 were 60% (3/5) and 11% (4/36), respectively (p < 0.05). Recurrent embolization was also significantly higher in group 1 (60% vs 8%, p < 0.025). There were two amputations in group 1 and six in group 2 (p = not significant). Group 2 patients were then divided into two subgroups: those with limited disease (n = 19) in which the emboli had a single, radiographically identified source (i.e., aneurysm or single area of ulcerated plaque) and those with diffuse disease (n = 17) in which the emboli had multiple, radiographically identified potential sources. In the subgroup of patients with limited disease, no deaths or episodes of recurrent embolization occurred, whereas four deaths and three episodes of recurrent embolization occurred in the subgroup of patients with diffuse disease. The differences in these outcomes, however, were not statistically significant. Thirty selected patients (one from group 1 and 29 from group 2) underwent operation on or bypass of the imputed lesion. Only one (7%) of these 30 patients had recurrent embolization. In contrast, recurrent embolization was noted in four (36%) of the 11 patients who did not have an operation directed at the lesion (p < 0.025). No significant difference in mortality was found between patients who underwent operation and those who did not. CONCLUSIONS: Patients with atheroemboli have a substantial mortality rate and risk of recurrent embolization, especially if the disease process extends above the diaphragm; but in selected patients, operation may decrease the frequency of recurrence without increasing mortality.