A rare endobronchial neurilemmoma (Schwannoma).

Primary neurogenic tumors of the lung are rare. Often, their histologic behavior presents a treatment dilemma. We present a case of benign endobronchial neurilemmoma managed by means of YAG laser resection together with a brief discussion of the management options available for these tumors.

Operative strategies in patients with symptomatic internal carotid artery occlusion.

A 15-year experience with 98 patients who underwent extracranial artery reconstruction for symptomatic internal carotid artery occlusion is reviewed. Thromboendarterectomy of the occluded carotid artery resulted in unacceptably high mortality and morbidity rates, and long-term patency of the internal carotid artery was rarely achieved. Carotid endarterectomy on the side opposite the occlusion proved to be successful in relieving nonlateralizing symptoms of cerebral ischemia, whereas results were less encouraging in patients with focal symptoms in the hemisphere ipsilateral to the occlusion. External carotid artery reconstruction on the side of the occlusion was successful in relieving focal symptoms. Surgical treatment in patients with symptomatic internal carotid artery occlusion should be planned in each patient on the basis of symptoms and anatomic pattern.

Thoracic aorta as source of inflow in reoperation for occluded aortoiliac reconstruction.

We reviewed our experience with reoperations for recurrent obstruction occurring after aortoiliac or aortofemoral reconstruction. Patients who underwent successful transfemoral thrombectomy of the aortofemoral graft or femorofemoral crossover graft were excluded from the study. A more proximal source of inflow to revascularize the ischemic limbs was required in the remaining 35 patients. Bilateral reconstruction was performed in 22 patients. Operative indication was rest pain or necrosis in 36 limbs and severe claudication in 21 limbs. Preoperative ankle/brachial pressure index (API) ranged from 0.05 to 0.61. Thirteen patients (21 limbs, group I) underwent transabdominal reoperation. Since the transabdominal approach was considered hazardous because of multiple previous operations, the remaining patients underwent retroperitoneal descending thoracic aorta-femoral artery bypass (15 patients, 25 limbs; group II) or axillofemoral bypass graft (7 patients, 11 limbs; group III). No statistically significant difference was present between the three groups in regard to the operative indication, API, and angiographically determined outflow (analysis of variance, p greater than 0.2). Axillofemoral bypass was preferred in patients with severe chronic pulmonary disease. Postoperative deaths (2 of 35 patients) and morbidity (6 of 35 patients) had a similar incidence in the three groups (p greater than 0.2). Follow-up ranged from 3 to 120 months (mean 37 months). The 5-year actuarial patency rate was 80.5% for group I and 80.2% for group II. In group III it was statistically lower (32.9%, p less than 0.05). Serial measurement showed a significant decrease of API in group III compared with group I and group II. We conclude that retroperitoneal descending thoracic aorta-femoral artery bypass is a valid alternative to transabdominal reoperation when exposure or availability of the abdominal aorta poses a specific hazard and is preferable to axillofemoral bypass in terms of long-term patency and hemodynamic results.

Subclavian artery revascularization: a comparison between carotid-subclavian artery bypass and subclavian-carotid transposition.

Extrathoracic revascularization has become the most popular form of surgical treatment of symptomatic subclavian disease. Despite the many theoretical advantages, subclavian-carotid transposition (SCT) has not gained wide popularity. During a 15-year period, 46 patients underwent carotid-subclavian bypass (CSB) or SCT for symptoms referable to occlusion of the subclavian artery. Follow-up ranged from 2 to 148 months (mean, 46.9 months). Seven-year actuarial patency rate was 100% for SCT and 86% +/- 7% for CSB (p = NS). Mean operative time and intraoperative blood loss were significantly reduced for SCT (p less than 0.05). After CSB a continuous deterioration of the hemodynamic status of the reconstruction was noted, whereas there were no significant changes after SCT (p less than 0.05). Whenever feasible, SCT should be considered the operation of choice for patients with symptomatic severe subclavian artery disease.

Cystic adventitial degeneration of the femoral artery: is evacuation and cyst excision worthwhile as a definitive therapy?

A case of cystic adventitial degeneration of the left common femoral artery in a patient with localized left groin pain, normal distal pulses, and normal arteriographic findings is reported. This patient was first treated with evacuation and cyst excision. Recurrence was noted after 20 months, and an excision of the cyst and a segment of the common femoral artery with graft interposition was required. At gross examination, the cyst was unilocular and contained gelatinous material. The cyst appeared to be situated in the tunica adventitia and did not communicate with the vascular lumen. No synovial lining was present. Histologically, it was similar to a ganglion cyst with contents rich in hyaluronic acid. A review of the literature was undertaken to determine the results of treating this lesion. The disease is rare. All senior authors of case reports were contacted to construct follow-up information. A high incidence of recurrence was noted in patients treated by evacuation and cyst excision. We believe that total cyst excision with the involved artery and graft interposition at the femoral site can be done easily, safely, and with virtually no chance for recurrence.

Aortoiliofemoral bypass graft in young adults: long-term results in a series of sixty-eight patients.

BACKGROUND: The aim of this study was to investigate surgical indications and the long-term outcomes of aoroiliofemoral reconstructions in adults younger than 45 years. METHODS: Between 1973 and 1990, 1256 patients underwent infrarenal abdominal aortic reconstruction for aortoiliofemoral occlusive disease. Sixty-eight (5.4%) patients (group 1) were less than 45 years old and form the basis of the analysis. They were retrospectively compared with two additional groups of patients 45 years and older selected from the entire series. Patients in group 2 (n = 100) were randomly chosen to determine differences in risk factors, associated diseases, operative indications, preoperative findings, and outcomes. Patients in group 3 (n = 70) were matched with those in group 1 for gender, risk factors, associated diseases, preoperative findings, and operative indications to assess the importance of age in determining the short- and long-term outcomes of aortoiliofemoral reconstructions. RESULTS: Postoperative mortality rates (1.5%, 4%, and 4.3% for groups 1, 2, and 3, respectively) and major complication rates (4.4%, 7%, and 7.1% for groups 1, 2, and 3, respectively) were comparable among the three groups. Ten-year secondary patency rates were 84.6%, 70.6%, and 80.3%, for groups 1, 2, and 3, respectively (p = not significant). Ten-year limb salvage rates were 86.9%, 78.2%, and 80.6%, for groups 1, 2, and 3, respectively (p = not significant). During follow-up a significantly higher percentage of myocardial infarction was recorded in group 1 as compared with group 2 (p < 0.03) and group 3 (p < 0.04). The 10-year survival rate for group 1 was significantly lower than that of group 2 (29.0% versus 46.9%; p < 0.005). CONCLUSIONS: Aortoliofemoral reconstruction in patients younger than 45 years is a safe procedure with low operative risks and good long-term results in patency and limb salvage rates. However, life expectancy is poor because of the high incidence of deaths related to coronary artery disease.

Long-term outcome after transaxillary approach for thoracic outlet syndrome.

BACKGROUND: Recurrence or persistence of neurologic symptoms after surgical treatment of patients with thoracic outlet syndrome (TOS) are reported to be as high as 25%. To identify factors affecting the long-term outcome of surgical treatment of patients with TOS, we reviewed our 20-year experience. METHODS: One hundred thirty-four transaxillary first rib resections were performed on 118 patients (43 men, 75 women, mean age 38 +/- 13 years). Eighty-three operations (61.9%) were undertaken to relieve symptoms resulting from compression of the lower roots of the brachial plexus, 37 (27.6%) for compression of both lower and upper roots, and 14 (10.5%) for lower root and vascular symptoms. All patients underwent a transaxillary extraperiosteal first rib resection with transection of the scalene muscles. In 73 cases (54.5%) a resection of the anterior scalene muscle was also performed. A cervical rib was removed in 28 cases (20.1%), and anomalous fibrous bands adjacent to the neurovascular bundle were resected in 41 cases (30.6%). RESULTS: No major complications were observed. Of 105 patients (118 procedures) followed up (mean follow-up, 99 +/- 72 months), good to excellent results were obtained in 96 cases (81.4%) and fair to poor results were recorded in 22 cases (18.6%). The presence of a long posterior first rib stump, measured from the chest x ray films, was the strongest determinant of the long-term results among the variables examined (p < 0.0001). Reoperation, consisting of neurolysis and resection of the stump, was performed in 16 patients. The results were excellent in all cases at a mean follow-up of 66 +/- 46 months. Primary and secondary 10-year, actuarial freedom rates from recurrent symptoms were 80.9% and 93.1%, respectively. CONCLUSIONS: Our results suggest that the long-term outcome after surgery for TOS was strongly influenced by the extent of the first rib resection.

Femorofemoral bypass grafts: Factors influencing long-term patency rate and outcome.

BACKGROUND: Crossover femorofemoral bypass graft (CFFBG) was proposed in the early days of modern vascular surgery to treat patients affected with unilateral iliac artery disease who were a high surgical risk. We investigated factors influencing short- and long-term outcomes of CFFBG: METHODS: The study was designed as a retrospective clinical study in a university hospital setting with a base of 228 patients. Of these patients, 154 (67.5%) presented a high surgical risk. The indication for operation was limb-threatening ischemia in 188 (82.5%) patients. All patients underwent CFFBG: The procedure was performed in 150 patients as the primary operation and in 78 patients after previous vascular graft failure or infection, or both. A preoperative percutaneous transluminal angioplasty was performed in 57 patients (25%) to correct donor iliac artery disease. In 127 patients (55.7%), an associated vascular procedure was performed to improve the outflow. Postoperative complications; 5- and 10-year primary, secondary, and limb salvage rates; and factors influencing short- and long-term results were assessed. RESULTS: Thirteen (5.7%) postoperative deaths occurred. Postoperative mortality and morbidity rates were significantly higher in patients aged more than 65 years (7.9% versus 3.5% and 18.6% versus 6.1%, respectively, P <.03). Primary and secondary patency rates at 5 and 10 years were 70.2% and 48.1%, 82.8% and 63.2%, respectively; 5- and 10-year limb salvage and survival rates were 85.5% and 80.1%, 63.3% and 31.0%, respectively. Ten-year primary and secondary patency and limb salvage rates were significantly lower when the procedure was performed after previous vascular graft failures (50.2% versus 26.5%, P <.007; 74.1% versus 44.1%, P <.01; and 84.3% versus 72.5%, P <.03, respectively). Five- and 8-year patency rates of autogenous vein CFFBG (34.3% and 22.8%, respectively, P <.03) were significantly lower than those of expanded polytetrafluoroethylene (71.1% and 59.8%, respectively) and polyester (77.3% and 50.3%, respectively) CFFBG: Moreover, 5- and 10-year primary and secondary patency rates were significantly better when externally supported grafts were used as compared with those without external support (80.1% and 69.9% versus 61.1% and 21.1%, P <.01; 88.8% and 75.9% versus 78.9% and 45.4%, P <.05, respectively). Multivariate analysis showed that the only variable associated with poor primary and secondary patency and limb salvage rates was the operation performed after previous vascular graft failures (P <.04, P <.03 and P<.05, respectively). CONCLUSIONS: CFFBG allows early and long-term results similar to those obtained with reconstructions originating from the aorta when it is performed as a primary operation when an adequate outflow is provided and externally supported prosthetic material is used.

Ultrasonographic features of carotid plaque and the risk of subsequent neurologic deficits.

In a prospective study, 214 consecutive patients considered not to be candidates for surgical intervention were evaluated by means of duplex scanning. Of the patients, 135 had no symptoms and 79 had a history of previous neurologic symptoms. In 139 sides duplex scanning demonstrated nonhemodynamic stenosis (lumen diameter reduction, less than 50%) and in 99 sides, hemodynamic stenosis (lumen diameter reduction, 50% or greater). Of the 238 carotid artery plaques examined, 167 were homogenous and 71 were heterogenous. During a mean follow-up of 34 months, 27 new focal neurologic deficits occurred. Patients with previous symptoms had a higher incidence of new deficits (18/79 vs 9/135) (p less than 0.01). The severity of the stenosis and the presence of a heterogenous plaque were statistically correlated with the occurrence of new deficits (p less than 0.001). Multivariate analysis showed that the ultrasonographic pattern and the severity of the stenosis were independent variables. We conclude that a heterogenous plaque should be considered an unstable plaque with the possibility of causing cerebral ischemia.

Combined aortofemoral and extended deep femoral artery reconstruction. Functional results and predictors of need for distal bypass.

In patients with combined aortoiliac and femoropopliteal occlusive disease, severe involvement of the deep femoral artery (DFA) has often been considered an indication for simultaneous aortofemoral and femorodistal bypass grafting. In 73 patients (87 limbs) with multilevel disease, extended DFA reconstruction was performed with aortofemoral bypass. Five-year actuarial patency of the reconstructions and overall five-year actuarial limb salvage were 62.2% and 60.2%, respectively. Of 20 variables tested, four were significantly associated with the functional outcome of the procedures. Multivariate analysis identified two factors as predictive of outcome independently from other variables: preoperative ankle-brachial pressure index and angiographic status of the below-knee popliteal artery. However, in case of reoperation for occluded aortofemoral graft, these factors lost their validity. Extended DFA reconstruction is a valuable and durable procedure able to provide an adequate outflow and distal perfusion. Careful judgment in each clinical situation will aid in selecting a small group of patients in which simultaneous femorodistal bypass is required.

Superficial femoral-profunda femoris artery transposition.

Generally, either reconstruction of or bypassing the femoropopliteal artery is used in lower-limb ischemia. During the last three years, five patients with advanced aortoiliac atherosclerotic occlusive disease, occlusion of the superficial femoral arteries, and multiple stenotic lesions of the profunda femoris artery underwent aortofemoral bypass, superficial femoral artery eversion endarterectomy, and superficial femoral-profunda femoris artery transposition. Three patients have been followed up to four years with patent grafts. One patient died in the immediate postoperative period of a cerebrovascular accident and another required amputation because of persistent ischemic changes and severe "distal" vessel disease. Revascularization of the profunda is necessary when there is concurrent superficial femoral artery occlusion and stenotic lesions of the profunda femoris artery. Transposition of an endarterectomized superficial femoral artery to distal undiseased profunda femoris artery affords on alternative revascularization procedure in the multisegmental diseased profunda where a long segmental endarterectomy of the profunda femoris artery would be hazardous.

Early and late results in patients with carotid disease undergoing myocardial revascularization.

A ten-year review of 1,360 patients undergoing coronary artery bypass grafting (CABG) by the same surgeon was undertaken. Sixty-two patients with symptoms of coronary artery insufficiency underwent carotid endarterectomy prior to or at the time of CABG (Group I). Ninety-seven patients had asymptomatic carotid bruits but did not undergo carotid endarterectomy (Group II). Sixty of these patients were studied by ultrasonic duplex scanning or ocular pneumoplethysmography or both, and hemodynamically significant stenosis was detected in 50 (Group IIa). Group III included 80 patients without carotid artery disease matched with Group II for sex, age, and clinical status. Group IV consisted of 200 patients without carotid artery disease randomly selected from our series. Follow-up ranged from 3 to 120 months (median, 41 months). In patients with proven carotid artery disease (Groups I and IIa), operative mortality was greater than in the patients randomly selected (Group IV) (p less than 0.05) but similar to that in the matched Group III. Late neurological deficits were greater in patients with carotid disease not undergoing carotid endarterectomy (p less than 0.01). Patients with carotid artery disease had lower survival than Group IV patients (p less than 0.01) but similar survival to that in the matched Group III. This study suggests that (1) asymptomatic patients with carotid artery disease who undergo CABG are not at increased risk of perioperative stroke; (2) these same patients are at increased risk of late neurological deficit; and (3) carotid artery disease is an indirect sign of severe associated disease and therefore is associated with increased operative mortality and decreased life expectancy.

Extrathoracic and transthoracic management of vascular disease of the aortic arch branches: a 16-year experience.

To determine factors influencing results of operation for proximal brachiocephalic arterial disease, a 16-year review of 74 consecutive patients was undertaken. A total of 62 subclavian, 14 common carotid, 6 innominate, and 2 vertebral arteries were revascularized during 79 procedures. The approach was transthoracic in 12 operations and extrathoracic in 67. Mean follow-up was 57 +/- 45 months. Two patients (2.5%) died of stroke after extrathoracic revascularization of the common carotid artery. Cumulative 5-year and 10-year freedom from neurological events was 81% and 75%, respectively. The best results were obtained with transthoracic procedures, with revascularization of the subclavian artery rather than the common carotid artery, and in operations performed in patients without associated distal carotid disease. In view of the recent progress in operative techniques and postoperative surgical care, the choice between the transthoracic approach and the extrathoracic approach should not be biased; rather, they should remain equal and viable alternatives based on anatomical and clinical features of the individual patients.

Thoracic aorta-femoral artery bypass: indications, technique, and late results.

Retroperitoneal descending thoracic aorta-femoral artery bypass was performed in 18 patients over an 11-year period. The reconstruction was carried to both femoral arteries in 12 patients; in the other 6, only a single femoral artery was revascularized. The operative indication in Group 1 (3 patients) was infection of a previous aortoiliac reconstruction; in Group 2 (12 patients), occlusion of a previous aortoiliac reconstruction; and in Group 3 (3 patients), aortoiliac occlusive disease in which a direct transabdominal procedure was considered hazardous. Follow-up ranged from 6 months to 9 years (mean, 40 months). Cumulative patency rate was 96 +/- 3.9% at 1 year and 85 +/- 8.1% at 5 years. No alterations of serum creatinine and blood urea nitrogen values were recorded seven days and 6 months after operation. Retroperitoneal thoracic aorta-femoral artery bypass is a useful technique for accomplishing lower limb revascularization in patients in whom exposure or availability of the abdominal aorta poses a specific hazard.

The effect of extend of caval resection in the treatment of inferior vena cava leiomyosarcoma.

BACKGROUND: A wide and complete surgical resection is the principle modality of therapy in the management of retroperitoneal sarcomas. It is current opinion that, also for inferior vena cava (IVC) leiomyosarcomas, an extended resection of either retroperitoneal tissue and vena cava should be performed. The aim of the study was to investigate the influence of the venous extent of resection on local recurrence and longterm outcome. METHODS: Up to August 1994, 218 patients were enrolled into The International Registry of Inferior Vena Cava (IVC) Leiomyosarcomas. For the purpose of this study we considered 120 patients who underwent a radical resection of the IVC tumor (i.e. removal of all gross disease with microscopic tumor-free margins and no evidence of distant metastases). Resection included an IVC rim in 53 patients and an IVC segment in 67. RESULTS: There were 3 (2.5%) early postoperative deaths and 7 (5.8%) major complications. Postoperative deep venous thrombosis of the lower limbs was diagnosed in 21 (17.5%) patients and was treated by anticoagulant therapy and/or elastic stocking without long-term sequelae. Overall, tumor recurrence was observed in 67 (57.3%) patients at a mean follow-up of 32 +/- 4 months. Seven, 13 and 4 patients who underwent caval wall resection and 9, 29 and 5 patients submitted to a caval segmental resection had either local recurrences, distant metastases or local and distant metastases (p = NS). Survival rates of the two groups were 55% and 37% at 5-year and 42% and 23% at 10-year, respectively (p = NS). CONCLUSION: An extended venous resection in IVC leiomyosarcoma does not influence local recurrence rate nor long-term outcome.

International registry of inferior vena cava leiomyosarcoma: analysis of a world series on 218 patients.

In 1992 The International Registry of Inferior Vena Cava (IVC) Leiomyosarcomas was established to study the pathogenesis and natural history of the tumor and to support the most rational treatment. We collected 218 patients through a literature review and personal communications. We corresponded with several Authors to obtain up-to-date follow-up and any other data lacking at the initial review. The series was analyzed to identify predictive factors for clinical outcome. Tumors arose from the IVC lower segment in 80 patients, from the middle in 94 and from the upper in 41. A radical tumor resection was undertaken in 134 (61.5%) patients, 26 (11.9%) had a palliative resection and 58 (26.6%) were inoperable. An increased risk of death was associated with upper IVC segment involvement (p < 0.001), lower limb edema (p < 0.001), Budd-Chiari's syndrome (p < 0.001), intraluminal tumor growth (p < 0.001) and IVC occlusion (p < 0.001). Radical tumor resection was associated with better 5- and 10-year survival rates (49.4% and 29.5%). Tumors which arose from the middle segment fared better (56.7% and 47.3%) than those of the lower segment (37.8% and 14.2%) (p < 0.002). No palpable abdominal mass and abdominal pain were associated, in patients radically operated, with a better outcome and longer survival (p < 0.03 and p > 0.04 respectively). Despite the high rate of recurrence, radical tumor resection is the only long-term cure.

Identification of abdominal aortic aneurysm patients with different clinical features and clinical outcomes.

To determine the clinical characteristics and factors influencing outcome in patients with atherosclerotic abdominal aortic aneurysms (AAA), 526 patients who underwent aneurysmal resection were retrospectively reviewed: Group I had clinical evidence of atherosclerotic occlusive disease; Group II had no evidence of atherosclerotic occlusive disease. The incidence of ruptured AAA, multiple aneurysms, and a family history of AAA was higher in Group II patients. We concluded that patients with AAA and without atherosclerotic occlusive disease in other areas represent a subgroup with peculiar clinical characteristics. In planning operative treatment and during the follow-up period, it should be kept in mind that Group II patients have a higher incidence of aneurysm rupture; the incidence of late pseudoaneurysm is higher; and there is a greater possibility of aneurysm in other arterial segments. It remains to be seen if the pathogenetic mechanism of AAA formation in Group II patients is different from that in Group I patients.

Percutaneous transluminal angioplasty versus surgery for subclavian artery occlusive disease.

Twenty-one patients who underwent percutaneous transluminal angioplasty (PTA) for proximal stenosis of the subclavian artery were compared with 15 patients who underwent carotid subclavian reconstruction. This represents the first attempt to directly compare the two procedures. All patients had routine Doppler examination during follow-up. Mean follow-up was 30 +/- 24 months after PTA and 40 +/- 25 months after surgery. The incidences of procedural complications were similar (PTA one complication, surgery two complications). Although better early results were achieved in patients who underwent PTA (actuarial patency: PTA 91 percent, surgery 87 percent), after dilatation, we observed a continuous deterioration of the hemodynamic status of the artery, which led to a high rate of late restenosis (actuarial patency: PTA 54 percent, surgery 87 percent). There were no significant changes postoperatively. The specific role of each procedure is analyzed in view of the new acknowledgment of the clinical importance of proximal subclavian artery disease.

Eversion endarterectomy of the superficial femoral artery and end-to-side anastomosis to the deep femoral artery. An alternative to extended profundoplasty.

The success of aortofemoral reconstruction in patients with superficial femoral artery occlusion depends on the restoration of a satisfactory pulsatile flow to the deep femoral artery. In 18 patients with multilevel disease, widespread involvement of the deep femoral artery, and poor distal outflow, we performed an eversion endarterectomy of the proximal segment of the superficial femoral artery and constructed an end-to-side anastomosis between this segment and the distal deep femoral artery. In 10 patients, the reconstruction was performed after thrombectomy of the occluded aortofemoral graft, and in 8 the two reconstructions were simultaneous. The actuarial patency rate was 93.5 percent at 1 year and 75.2 percent at 5 years. Four late femorodistal bypasses were performed that gave an actuarial limb salvage rate of 68.8 percent at 1 year and 61.6 percent at 5 years. In selected cases, this technique is a valid alternative to an extended profundoplasty or to a femorodistal bypass.

Comparative long-term results of laser-assisted balloon angioplasty and atherectomy in the treatment of peripheral vascular disease.

BACKGROUND: Early results of laser-assisted balloon angioplasty (LABA) and peripheral directional atherectomy (PDA) are encouraging. The true value of these procedures has remained in doubt, however, because of the absence of data on long-term objective patency rates. PATIENTS AND METHODS: From August 1988 through October 1993, LABA and PDA were performed on 151 limbs of 124 patients. Presenting symptoms were mild-to-severe claudication in 128 limbs (63 LABA, 65 PDA) and rest pain or necrosis in 23 (7 LABA, 16 PDA). Seventy-seven percent of the atherosclerotic lesions were localized in the iliofemoral tract (77% LABA, 76% PDA). Seventy limbs were treated with LABA and 81 with PDA. RESULTS: Initial hemodynamic and arteriographic success was achieved in 46 LABA limbs (66%) and 75 PDA limbs (93%) (P < 0.002). Mean follow-up was 16 +/- 2 months after LABA and 18 +/- 1 months after PDA. During this time, 32 failures were recorded in limbs treated with LABA, and 29 in limbs treated with PDA. The patency rate at 40 months was 23% in the LABA group and 45% in the PDA group (P < 0.005). Patency rates were not affected by the length or site of the arterial lesion or the runoff score. CONCLUSIONS: PDA had a better long-term patency rate than LABA, but long-term results were dismal with both techniques. PDA appears to have a limited role and LABA no role in the treatment of lower extremity occlusive disease.