Restenosis after Carotid Interventions and Its Relationship with Recurrent Ipsilateral Stroke: A Systematic Review and Meta-analysis.

OBJECTIVE: Do asymptomatic restenoses > 70% after carotid endarterectomy (CEA) and carotid stenting (CAS) increase the risk of late ipsilateral stroke? METHODS: Systematic review identified 11 randomised controlled trials (RCTs) reporting rates of restenosis > 70% (and/or occlusion) in patients who had undergone CEA/CAS for the treatment of primary atherosclerotic disease, and nine RCTs reported late ipsilateral stroke rates. Proportional meta-analyses and odds ratios (OR) at end of follow-up were performed. RESULTS: The weighted incidence of restenosis > 70% was 5.8% after "any" CEA, median 47 months (11 RCTs; 4249 patients); 4.1% after patched CEA, median 32 months (5 RCTs; 1078 patients), and 10% after CAS, median 62 months (5 RCTs; 2716 patients). In four RCTs (1964 patients), one of 125 (0.8%) with restenosis > 70% (or occlusion) after CAS suffered late ipsilateral stroke over a median 50 months, compared with 37 of 1839 (2.0%) in CAS patients with no significant restenosis (OR 0.87; 95% CI 0.24-3.21; p = .8339). In seven RCTs (2810 patients), 13 out of 141 (9.2%) with restenosis > 70% (or occlusion) after CEA suffered late ipsilateral stroke over a median 37 months, compared with 33 out of 2669 (1.2%) in patients with no significant restenoses (OR 9.02; 95% CI 4.70-17.28; p < .0001). Following data correction to exclude patients whose surveillance scan showed no evidence of restenosis > 70% before stroke onset, the prevalence of stroke ipsilateral to an untreated asymptomatic > 70% restenosis was seven out of 135 (5.2%) versus 40 out of 2704 (1.5%) in CEA patients with no significant restenosis (OR 4.77; 95% CI 2.29-9.92). CONCLUSIONS: CAS patients with untreated asymptomatic > 70% restenosis had an extremely low rate of late ipsilateral stroke (0.8% over 50 months). CEA patients with untreated, asymptomatic > 70% restenosis had a significantly higher risk of late ipsilateral stroke (compared with patients with no restenosis), but this was only 5% at 37 months. Overall, 97% of all late ipsilateral strokes after CAS and 85% after CEA occurred in patients without evidence of significant restenosis or occlusion.

Redo carotid endarterectomy versus primary carotid endarterectomy.

BACKGROUND AND PURPOSE: Several authorities have recently advocated carotid stenting for recurrent carotid stenosis because of the perception that redo surgery has a higher complication rate than primary carotid endarterectomy (CEA). This study compares the early and late results of reoperations versus primary CEA. METHODS: All reoperations for recurrent carotid stenosis performed during a recent 7-year period by a single vascular surgeon were compared with primary CEA. Because all redo CEAs were done with polytetrafluoroethylene (PTFE) or vein patch closure, we only analyzed those primary CEAs that used the same patch closures. A Kaplan-Meier life-table analysis was used to estimate stroke-free survival rates and freedom from >/=50% recurrent stenosis. RESULTS: Of 547 primary CEAs, 265 had PTFE or saphenous vein patch closure, and 124 reoperations had PTFE or vein patch closure during the same period. Both groups had similar demographic characteristics. The indications for reoperation and primary CEA were symptomatic stenosis in 78% and 58% of cases and asymptomatic >/=80% stenosis in 22% and 42% of cases, respectively (P<0.001). The 30-day perioperative stroke and transient ischemic attack rates for reoperation and primary CEA were 4.8% versus 0.8% (P=0.015) and 4% versus 1.1%, respectively, with no perioperative deaths in either group. Cranial nerve injury was noted in 17% of reoperation patients versus 5.3% of primary CEA patients; however, most of these injuries were transient (P<0.001). Mean hospital stay was 1.8 days for reoperation versus 1.6 days for primary CEA. Cumulative rates of stroke-free survival and freedom from >/=50% recurrent stenosis for reoperation and primary CEA at 1, 3, and 5 years were 96%, 91%, and 82% and 98%, 96%, and 95% versus 94%, 92%, and 91% and 98%, 96%, and 96%, respectively (no significant differences). CONCLUSIONS: Reoperation carries higher perioperative stroke and cranial nerve injury rates than primary CEA. However, reoperations are durable and have stroke-free survival rates that are similar to primary CEA. These considerations should be kept in mind when carotid stenting is recommended instead of reoperation.

Management of vagus nerve injury afer carotid endarterectomy.

BACKGROUND: Inadvertent injury to the vagus nerve or its branches during carotid endarterectomy can result in adductor vocal cord paralysis (hoarseness) and cricopharyngeal dysfunction (dysphagia) with aspiration, known as "double trouble." This study describes our experience in the management of this complication in cases where conservative treatment failed. METHODS: All patients were examined by a vascular surgeon, a head and neck surgeon, and a speech therapist. Their examinations included comprehensive speech evaluation, video stroboscopy, video fluoroscopy, and methylene blue testing for aspiration. All patients underwent Teflon injections to medialize the paralyzed vocal cord and a cricopharyngeal myotomy to restore swallowing and alleviate aspiration. RESULTS: Fourteen patients, eight men and six women, were treated. The duration of dysfunction was 24 weeks in two patients, 6 weeks in four patients, 4 weeks in three patients, and 1 week in five patients. Five patients had severe dysfunction (defined as difficulty in swallowing both solid and liquid foods with more than 20% aspiration), seven patients had moderate dysfunction (defined as difficulty swallowing solid food with aspiration of less than 20%), and two patients had mild dysfunction (defined as difficulty in swallowing solids but with no aspirations). After the Teflon injections and myotomy, 13 of 14 patients had satisfactory outcomes, including normal voice and swallowing. CONCLUSIONS: Vagus nerve injury from a carotid endarterectomy can be a debilitating complication. Prevention, early recognition, and prompt correction of these injuries are important in the management of this complication.

Selective use of segmental Doppler pressures and color duplex imaging in the localization of arterial occlusive disease of the lower extremity.

BACKGROUND: The purpose of this study was to compare the abilities of segmental Doppler pressures (SDP) and color duplex imaging (CDI) to localize arterial stenosis and to assess the ability of CDI to accurately categorize the severity of disease. METHODS: We analyzed 134 patients (268 limbs) who underwent all three tests; SDP, CDI, and arteriograms. Results of SDP and CDI were examined to determine their accuracy in localizing high grade (greater than 50%) stenosis at three levels; aortoiliac-common femoral artery (level I), superficial femoral artery (SFA; level II), and popliteal artery (level III). RESULTS: The sensitivity, specificity, positive and negative predictive values, and overall accuracy for SDP and CDI were as follows: level I, 63%, 88%, 81%, 75%, and 77%; 93%, 99%, 98%, 95%, and 96%, respectively (p < 0.01); level II, 51%, 99%, 99%, 57%, and 70%; 94%, 98%, 99%, 92%, and 96%, respectively (p < 0.01); level III, 55%, 92%, 60%, 90%, and 85%; 78%, 100%, 97%, 95%, and 95%, respectively (p < 0.01). Exact agreement was noted between the CDI and arteriogram in regard to the severity of disease in 88% of the limbs (1170 segments). The presence of SFA disease in patients with level I disease or aortoiliac-common femoral artery disease in patients with level II disease did not significantly alter the ability of SDP to localize the disease. The presence of diabetes significantly affected the accuracy of SDP in localizing SFA and popliteal artery stenosis. An analysis of SDP's ability to detect any segment as abnormal, as confirmed by arteriogram, revealed a sensitivity of 88%, specificity of 82%, positive predictive value of 96%, negative predictive value of 60%, and overall accuracy of 87%. The average cost was $149 for an SDP and $472 for a CDI. CONCLUSIONS: CDI is superior to SDP in localizing arterial stenosis at all levels. However, because SDP is cheaper it can be used initially if no surgical or endovascular intervention is planned.

Prospective controlled study of polytetrafluoroethylene versus saphenous vein in claudicant patients with bilateral above knee femoropopliteal bypasses.

BACKGROUND: Although several studies have compared the patency rates of polytetrafluoroethylene (PTFE) and saphenous vein grafts (SVG) for the above knee location, none have compared the 2 grafts when implanted in the same patient with claudication who needs bilateral above knee femoropopliteal bypasses. METHODS: Forty-three patients (86 limbs) with bilateral disabling claudication who had superficial femoral artery occlusion and above knee reconstitution with 2- to 3-vessel runoff were analyzed. Patients were treated on one side with PTFE and on the other side with SVG. They were sequentially assigned to PTFE-SVG alternating with SVG-PTFE. All patients were followed using duplex ultrasound and ankle/brachial indexes at 1 month and every 6 months thereafer. RESULTS: The perioperative complication rates were 5% for PTFE and 12% for SVG. There was no operative death or perioperative amputation for either procedure. The Kaplan-Meier estimate of primary, assisted primary, and secondary patency rates at 72 months were 68%, 68%, and 77% for PTFE and 76%, 83%, and 85% for SVG. There were no statistically significant differences between primary and secondary patency rates for both grafts; however; the assisted primary patency rates were higher for SVG (P < .05). The crude limb salvage rate at 72 months was 98% for PTFE and 98% for SVG. There were no risk factors identified that had an impact on graft patency. CONCLUSIONS: PTFE and SVG for above knee bypasses have comparable patency and limb salvage rates in claudicant patients with bilateral superficial femoral artery occlusion and 2- to 3-vessel runoff This may justify the use of PTFE for above knee locations in these selected patients.

Brachiocephalic revascularization: a comparison between carotid-subclavian artery bypass and axilloaxillary artery bypass.

Sixty-seven patients who underwent carotid-subclavian bypass (CSBP) (28 CSBPs only and eight with carotid endarterectomy) or axilloaxillary artery bypass (n = 31) with polytetrafluoroethylene grafts were followed up for a mean of 69.2 and 71.9 months, respectively. Indications for surgery in the CSBP group included hemispheric transient ischemic attack (TIA)/cerebrovascular accident in five, nonhemispheric TIA in seven, upper extremity ischemia in 15, and combined TIA and arm ischemia in nine patients. In the axilloaxillary artery group, two patients had hemispheric TIA, five had nonhemispheric TIA, 12 had upper extremity ischemia, and 12 had combined TIA and arm ischemia. Graft patency was determined clinically and confirmed by segmental Doppler pressures, duplex ultrasonography, or angiography. The 30-day mortality rate was approximately 3% in both groups. The 30-day complication rate was 3% for the axilloaxillary artery group and 8% for the CSBP group (not statistically significant). Relief of symptoms was achieved in 100% of patients in both groups; however, 20% of the patients in the axilloaxillary artery group had a recurrence of symptoms, in contrast to 5.6% in the CSBP group. The cumulative 10-year primary and secondary patency rates, calculated by life-table analysis, were 66% and 84.6% for the axilloaxillary artery procedures and 93.8% and 93.8% for the CSBP procedures, respectively (statistically significant). Concomitant carotid endarterectomy with CSBP did not influence graft patency. In conclusion, both bypasses have comparable morbidity and mortality rates; however, the CSBP has a statistically significantly better primary patency rate than the axilloaxillary artery bypass. Therefore CSBP should be the procedure of choice and the axilloaxillary artery bypass should be restricted to high-risk patients.

Role of venous duplex imaging of the lower extremities in patients with fever of unknown origin.

BACKGROUND: Although a fever of unknown origin (FUO) is most often due to other causes, the few caused by pulmonary emboli, pelvic thrombophlebitis, or lower extremity venous thrombosis (DVT) present a diagnostic challenge. The purpose of this study was to evaluate the role of venous duplex imaging of the lower extremity in evaluating a large series of patients with FUO. This has not been reported previously in the English-language literature. METHODS: Medical records were analyzed of patients with FUO who were referred to the vascular laboratory for venous duplex imaging of the lower extremities to rule out DVT as a cause of their fever. A FUO was defined as a temperature of greater than 38.3 degrees C on several occasions for at least 3 weeks' duration that defied 1 week of hospital evaluation. DVT was considered as a probable cause of FUO if the following criteria were met: (1) a positive venous duplex image for acute DVT, (2) subsequent fever resolution within 7 days of anticoagulation therapy, and (3) a fever that was resistant to prior treatment. RESULTS: A total of 114 duplex examinations, gathered during a 2-year period, were analyzed. The 89 patients had a mean age of 58 years. Infections were the most common cause of FUO (57 of 89, 64%), and unknown causes constituted 19%. There were seven cases of DVT (8%), five (6%) of whom met the criteria for probable cause of FUO. The overall cost of venous duplex imaging examinations was $51,300 ($450 x 114 tests), with an average cost of $10,260 for each case of DVT detected as probable cause of FUO. CONCLUSIONS: Consistent with the literature, infections remain the most common cause of FUO; however, DVT was found to be a more common cause of FUO in our present series (6%). The cost of venous duplex imaging of the lower extremities in establishing DVT as a probable cause of FUO should be borne in mind when the work-up of these patients is planned.

The correlation of ultrasonic carotid plaque morphology and carotid plaque hemorrhage: clinical implications.

BACKGROUND: This study examined the importance of ultrasonic plaque morphology and its correlation to the presence of intraplaque hemorrhage and clinical implications. METHODS: One hundred fifty-two carotid plaques associated with > or = 50% internal carotid artery stenoses in 135 patients who had carotid endarterectomies were characterized ultrasonographically into irregular/ulcerative, smooth, heterogeneous, homogeneous, or not defined. All plaques were examined pathologically for the presence of intraplaque hemorrhage. RESULTS: The ultrasonic morphology of the plaques included 63 with surface irregularity (41%), 48 smooth (32%), 59 heterogeneous (39%), 52 homogeneous (34%), and 41 not defined (27%). Intraplaque hemorrhage was present in 57 of 63 (90%) irregular plaques and 53 of 59 (90%) heterogeneous plaques, in contrast to 13 of 48 (27%) smooth plaques and 17 of 52 (33%) homogeneous plaques (P < .001). Fifty-three of 63 (84%) irregular plaques and 47 of 59 (80%) heterogeneous plaques had transient ischemic attack (TIA)/stroke symptoms, in contrast to 9 of 48 (19%) for smooth plaques and 15 of 52 (29%) for homogeneous plaques (P < .001). CONCLUSIONS: Irregular and/or heterogeneous carotid plaques are more often associated with intraplaque hemorrhage and neurologic events. Therefore, ultrasonic plaque morphology may be helpful in selecting patients for carotid endarterectomy.

A critical analysis of cerebral computed tomography scanning before elective carotid endarterectomy and its correlation to carotid stenosis.

BACKGROUND: Cerebral computed tomography (CT) scanning has been suggested to play a role in the management of patients before carotid endarterectomy (CEA). This prospective study analyzes the value of CT scanning before elective CEA and the correlation of CT findings to significant carotid stenosis. METHODS: This study includes 131 consecutive patients considered for CEA during a 2-year period. All patients underwent carotid duplex ultrasonography, carotid arteriography, and CT scanning. RESULTS: Eighty patients (61%) had transient ischemic attacks or prior strokes, and 51 (39%) had nonhemispheric symptoms or were asymptomatic. The CT scan was abnormal in 36 (27%) patients; however, no brain tumors or abnormalities to affect clinical management were revealed. Ninety-two CEAs were performed on 87 patients. Twenty-nine (32%) in the operative group had abnormal CT scans, but these did not influence operative decisions. On the basis of this rate of 0% of patients with CT findings to change surgical management in 92 cases, a maximum true rate of occurrence of up to 5% could be detected with alpha equals 0.05 by sampling a population of this size. Four patients (4%) had postoperative cerebral vascular accidents, and all of these had normal preoperative scans. Patients with 50% or more carotid stenosis on arteriogram were significantly more likely to have abnormal CT scans than patients with less than 50% stenosis (20% versus 7%, p = 0.0034). As carotid stenosis became more significant, the frequency of abnormal CT scans increased (p < 0.01). The cost of CT scanning was $66,089.50 in this study. CONCLUSIONS: Significant carotid stenosis was associated with a higher frequency of abnormal CT scans; however, routine preoperative CT scanning was unnecessary before elective CEA.

Elective resection of 332 abdominal aortic aneurysms in a southern West Virginia community during a recent five-year period.

This study analyzed 33 variables that might potentially affect outcome in a series of 332 consecutive elective abdominal aortic aneurysm repairs in a southern West Virginia community. One of the interesting features of this series was that the repairs were done by 22 surgeons with varying degrees of experience. The mortality and complication rates were compared for various potential risk factors by both univariant methods (chi 2, Fisher's exact, and Student t tests) and multivariant methods of analysis. Our early mortality (2.1%) and postoperative complication rates were consistent with those of other series. With multiple linear regression models, five factors were selected as significant independent risk factors associated with an increasing number of postoperative complications: the number of blood transfusions (p less than 0.0001), left renal vein ligation (p less than 0.0001), the presence of greater than 50% renal artery stenosis (p = 0.0012), the lesser experience of the surgeon (p = 0.0203), and the history of prior cardiac catheterization (p = 0.0245). The only factor statistically correlated with mortality rate was an increased number of postoperative complications (p less than 0.0001). Neither postoperative complications nor mortality rate was found to be significant and independently influenced by other demographic, clinical, or operative factors. It is tempting to speculate that surgeons with less experience might be well served to refer patients with significant renal artery stenosis and coronary artery disease. Our mortality and complication rates were not increased by performing preoperative angiography and therefore prudent surgeons may find this helpful in selecting patients for safer repair.

Polytetrafluoroethylene grafts in infrainguinal arterial revascularization. Factors affecting outcome.

One hundred thirty-seven polytetrafluoroethylene infrainguinal bypass grafts were performed over 2 years. The results were analyzed using univariate and multivariate analyses. Our operative mortality was 3.2% and the post-operative amputation rate was 5.8%. Forty-eight reconstructions were done for claudication, with a 5-year secondary patency rate of 64%, no early amputations, and a 2.9% (one limb) late amputation rate. Sixty-six reconstructions were done for rest pain with a 5-year secondary patency rate of 58% and a 3-year limb salvage rate of 77%. The 5-year secondary patency rate for 23 patients with trophic changes was 30%, and the 3-year limb salvage rate was 71%. Multivariate analysis identified the ankle-brachial index as the most important independent factor predicting both primary and secondary graft patency. The cumulative primary and secondary patency rates for patients with an ankle-brachial index of less than 0.5 at 78 months was 37% and 46%, respectively; and 57% and 68%, respectively for patients with an ankle-brachial index of 0.5 or more.

The role of oculopneumoplethysmography in detecting acute carotid artery thrombosis in patients with neurologic deficits after carotid endarterectomy.

BACKGROUND: This study analyzes the role of oculopneumoplethysmography (OPG/Gee) in detecting acute carotid thrombosis (CAT) after carotid endarterectomy (CEA) in a timely fashion for immediate exploration, and minimizing unnecessary surgery. PATIENTS AND METHODS: Fifty-three patients with neurologic deficits that were noticed after CEA in the operating or recovery room had immediate OPG/Gee. Patients with a positive OPG underwent immediate exploration. Patients with a negative OPG had a duplex ultrasound (DU), and if positive for >/=50% stenosis, the patient underwent exploration. If the DU was negative, the patient underwent cerebral computed tomography scanning and angiography. RESULTS: Thirty-one of 53 (58%) had a positive OPG, 30 (97%) of whom had CAT on exploration. Twenty-two of 53 (42%) with a negative OPG had a DU, 4 of whom had >/=50% stenosis (1 thrombosis) that was confirmed by exploration. The remaining 18 patients had a negative DU that was confirmed by angiography. OPG had an overall accuracy of 96% in detecting acute CAT, with a sensitivity of 97%, specificity of 95%, positive predictive value (PPV) of 97%, and a negative predictive value (NPV) of 95%. Combined OPG and selective DU had an overall accuracy of 98% in detecting surgically correctable lesions, with 100% sensitivity, 95% specificity 97% PPV, and 100% NPV. Mandatory exploration in all 53 patients would have resulted in 19 (36%) unnecessary surgeries versus 1 of 53 (2%) if exploration had been done based on OPG with selective DU (P <0.05). Even if exploration was done based only on the OPG, 30 of 34 surgical lesions would have been explored within a few minutes; only 4 would have been delayed until a DU was performed. CONCLUSIONS: OPG/Gee is very sensitive and timely in detecting acute CAT, and carotid exploration in these patients can improve the results of CEA. It also minimizes unnecessary explorations. Patients with a negative OPG should undergo DU, and if positive, they should undergo exploration.

Effects and limitations of pentoxifylline therapy in various stages of peripheral vascular disease of the lower extremity.

One hundred one patients with peripheral vascular disease of the lower extremity were entered into a study of the efficacy of oral pentoxifylline to determine if the response to therapy varied with the severity of disease. Ninety-three patients were evaluated before and after 8 weeks of therapy with pentoxifylline, while 8 did not complete the entire course due to adverse drug reactions. Resting and post-stress ankle/arm Doppler indices (AAIs) were measured and, in those patients who could walk on a treadmill, treadmill walking distances were measured. Patients were classified according to pretreatment clinical and treadmill measurements and according to pretreatment resting AAIs. Resting and post-stress AAIs, as well as treadmill walking distances, increased in patients with moderately severe claudication. Patients in this group responded better to therapy than did patients with rest pain or ischemic ulcers, severe claudication, or mild claudication. Patients with a pretreatment resting AAI greater than or equal to 0.5 responded better than those with an AAI less than 0.5. Only 5% of patients reported satisfaction with the results of treatment. These results support the findings that pentoxifylline may be useful only in selected patients with moderately severe peripheral vascular disease of the lower extremity and may not be useful in those with severe or mild disease.

The role of paradoxical arterial emboli of the extremities.

BACKGROUND: The heart is the main source of arterial emboli (> 80%). The majority of remaining sources are arterioarterial or of unknown origin, with each accounting for 5% to 10% of cases. This study covers an 8-year period and analyzes the etiology of arterial emboli of the extremities, with emphasis on patients with paradoxical emboli. METHODS: The hospital records of all patients were reviewed, with emphasis on patients with paradoxical emboli. The sources of emboli were classified as cardiac, arterioarterial, paradoxical emboli (fulfilled Johnson's criteria triad with cardiac defect and right-to-left shunting), possible paradoxical emboli (met two of Johnson's criteria), or unknown. RESULTS: This series included a total of 406 cases, and the sources of emboli were as follows: 248 (61%) cardiac, 62 (15%) arterioarterial, 6 (2%) paradoxical emboli, 8 (2%) possible paradoxical emboli, and 82 (20%) had an unknown source or incomplete work-up. The mean age of paradoxical emboli patients was 39 years, in contrast to a mean of 68 years for the entire series. All 6 paradoxical emboli patients presented with acute ischemia of an extremity, symptoms of deep vein thrombosis or pulmonary embolism or both, and a documented patent foramen ovale with right-to-left shunting. None of the patients had evidence of cardiac or peripheral atherosclerotic disease. Their treatment included one or more of the following: embolectomy, lytic therapy, anticoagulation, caval filters, or closure of a patent foramen ovale. CONCLUSIONS: Paradoxical emboli should be considered when the source of emboli is unknown, particularly in young patients. A complete work-up on these patients should include contrast saline or transesophageal echocardiography, lung scan, and peripheral venous imaging, particularly if conventional echocardiography and arteriography did not lead to a diagnosis.

Diagnostic and therapeutic strategies of white clot syndrome.

This study describes our experience with 12 patients with white clot syndrome encountered during a recent 36-month period. The diagnosis was based on the following criteria: (1) development of thrombocytopenia of less than 100,000/mm3 during administration of heparin therapy, (2) normalization of the platelet count after an interruption in heparin therapy, (3) exclusion of other causes of thrombocytopenia, (4) a positive heparin-induced platelet aggregation test, (5) detection of white clots on pathologic examination, and (6) the presence of thrombotic complications. Of 2,500 patients who received heparin therapy, 12 (0.48%) developed white clot syndrome. Various indications, routes of administration, and types of heparin were implicated. The mean platelet nadir was 26,900/mm3, and the mean time to onset of heparin-induced thrombocytopenia was 5 days. Thrombotic complications included arterial occlusions of the legs in 11 patients, deep vein thrombosis of the legs in 9 patients (4 had pulmonary embolism), and combined arterial and venous thrombosis in 8 patients. Treatment strategies included discontinuation of heparin in all patients and intravenous infusion of dextran, followed by arterial thrombectomy in four patients, urokinase therapy in two patients for arterial complications, and insertion of Greenfield filters in six patients. All patients were given warfarin. The mortality rate was 25% and the morbidity rate was 50%. An initial platelet count should be obtained on all patients prior to receiving heparin, followed by repeat platelet counts every 2 to 3 days. Once thrombocytopenia or thrombosis is diagnosed, heparin should be discontinued and other methods of therapy considered.

Prospective study of safety of lower extremity phlebography with nonionic contrast medium.

BACKGROUND: Lower extremity deep venous thrombosis (DVT) following hig h osmolar ionic contrast phlebography has been reported to vary between 9% to 31%. The purpose of this study was to determine the incidence of minor and major adverse reactions and postphlebographic DVT when using nonionic contrast (iopamidol). PATIENTS AND METHODS: One hundred fifty-seven patients with clinically suspected DVT were studied prospectively. One hundred eleven patients had prephlebography duplex ultrasound, and 102 patients were examined in the vascular laboratory for delayed side effects 1 week after phlebography. The presence of phlebography induced DVT was assessed using color duplex ultrasound. The mean amount of contrast used 102 ml. RESULTS: Minor adverse reasons, including nausea, local pain, and dizziness, occurred in 11 (7%) of 157 patients; however, no major complications or postphlebographic DVT was found in the 102 patients who underwent postphlebography duplex ultrasound. Phlebography and pre- and postphlebography duplex ultrasound showed no acute DVT in 70 patients. The maximum hypothetical true rate of major complications (ie, postphlebography DVT) that would result in no detectable events in a population of 102 patients with follow-up (for a probability of P <0.05) is 2.9. CONCLUSION: lower extremity phlebography using nonionic contrast material is safe, with no incidence of postphlebography DVT in our series. Its utilization should be encouraged if duplex ultrasound is not available.

Lumbar sympathectomy for causalgia secondary to lumbar laminectomy.

BACKGROUND: This study reviews 12 patients (15 limbs) who underwent lumbar sympathectomies (LS) (after a series of chemical sympathetic blocks) for causalgia following a lumbar laminectomy (LL). To our knowledge, using LS to treat causalgia after LL has only been reported once before in the English literature. PATIENTS AND METHODS: Patients were classified (Drucker) as Stage I, II, or III. Sympathetic block results were graded as excellent, fair, or poor. Early and late responses to LS were classified as complete relief, partial relief (patient satisfied or unsatisfied), or no relief. RESULTS: The mean duration between LL and the first sympathetic block was 8.4 months, with a mean of 9.5 months to LS. There were no operative deaths; however, 13% of limbs (2/15) had transient postoperative sympathetic neuralgia. Eighty percent (12 limbs) had an early satisfactory outcome after LS, and 73% (11 limbs) had a late satisfactory outcome. Stage II patients were more likely to have satisfactory early and late outcomes (92% and 85%) than Stage III patients (0%, P<0.01). Limbs with an excellent response to sympathetic block were more likely to have satisfactory early and late surgical outcomes (11/11, 100%). The time among LL and sympathetic block and L was shorter in patients who had satisfactory early and late surgical outcomes (P<0.0001). A multivariate analysis demonstrated that the most important independent factor in determining early and late outcomes of sympathectomy was the time between LL and LS (P=0.01). CONCLUSIONS: LS for causalgia following LL should be confined to Stage II patients who have had an excellent response to sympathetic block.

Adjunctive intraoperative linear extrusion (Fogarty-Chin) balloon angioplasty.

Eighty-nine patients with 94 stenotic segments (mostly iliac or femoral) underwent balloon angioplasty with the first-generation (no guidewire) linear extrusion (Fogarty-Chin) system, in an adjunctive mode, and the overall long-term patency rate (mean follow-up: 21 months) was 81%. Patients were grouped into those having iliac or superficial femoral artery (SFA) lesions and subdivided according to the length of lesions. The overall primary and late success rates for iliac lesions were 95% and 86%, respectively, and for SFA lesions 91% and 76%, respectively. The primary and late success rates for iliac lesions less than 2 cm were 100% and 96%, respectively, and for iliac lesions 2 cm to less than 5 cm 92% and 80%, respectively. The primary and late success rates for SFA lesions less than 2 cm were 100% and 100%, respectively; for lesions 2 cm to less than 5 cm 100% and 83%, respectively; and for lesions 5 to 10 cm 83% and 67%, respectively. A stratified analysis by vessel and segment length reveals that, in SFA lesions with a segment length greater than 5 cm, there is a significantly lower patency rate (67%) when compared with the combined results of the Fogarty-Chin balloon angioplasty system in iliac and femoral artery lesions less than 5 cm (92%). In comparing the composite results presented in a recent text on endovascular surgery by Moore and Ahn as the base data for the standard coaxial (Gruntzig) balloon system, our results (short and long term) are similar.

Safety of arteriography by direct puncture of a vascular prosthesis.

A total of 122 catheterizations were performed in 105 patients with femoral grafts. Ninety-five femoral grafts were punctured. The mean follow-up time was 21 months. Sixty-one patients had follow-up duplex ultrasounds of the graft puncture site at 6 months. The complication rates for patients with direct graft puncture were comparable to those of patients without grafts undergoing femoral catheter arteriography. Twenty-seven cases with femoral grafts had arteriography using the transaxillary technique. The overall complication rate for the 95 cases with graft puncture was 12% (8% were minor complications) in contrast to 30% (22% were major complications) for the 27 cases with the transaxillary approach. The local, nervous system, and major complication rates were all significantly less in patients with graft puncture than in patients with the transaxillary approach. There was no evidence of early or late pseudoaneurysm formation, disruption of the suture line, or late graft infection in patients with graft puncture. Direct graft puncture arteriography is safe and preferable to the transaxillary approach.