A simplified and efficient method for treating varicose veins.

Stripping the saphenous vein and manual excision of varicose veins has been the popular operative treatment for many years. During this 2- to 4-hour procedure, the patient must be rotated from the supine to the prone position in order to excise the collateral veins. These maneuvers are time-consuming and result in contamination, dozens of unsightly scars, and incomplete destruction of many of the small tortuous varicosities. In 705 patients we have substituted limited excision when possible and high-frequency cautery methods to destroy the venous tributaries. Cauterization, accomplished by introducing a probe subcutaneously through a 2 mm skin incision which requires no sutures for closure, affords excellent treatment for the troublesome smaller tortuous veins. The recurrence rate depends on the primary cause of the varicosities and is roughly the same in both types of operative procedures. The advantages of the latter procedure are shorter operating and anesthesia times, minimal infection rate, substantially less hospital time and cost, and essentially no cosmetic defects.

Negative phleborheography: clinical follow-up in 593 patients.

Approximately 500,000 cases of pulmonary embolism appear each year in the United States, with most having clots that originated in the deep veins of the lower extremities. Since the clinical diagnosis of deep venous thrombosis (DVT) is accurate only half the time, a safe method that affords immediate and definitive diagnosis of DVT is urgently needed. One diagnostic technique now available is phleborheography (PRG). We examined 1,076 patients (2,152 limbs) during the period of 1976 to 1979. By performing PRG before hospital admission, 392 patients who had negative study results were not hospitalized, resulting in an estimated savings of +960,400 and avoiding both the hazardous treatment and the stigma associated with a diagnosis of DVT. After one to three years of follow-up in 593 patients (1,186 limbs) who had had negative results from PRG, only three (0.5%) have shown evidence of postphlebitic swelling and one (0.2%) has had pulmonary embolus.

Expanded criteria for the diagnosis of deep venous thrombosis. Use of the pulse volume recorder and Doppler ultrasonography.

Over five years, we examined 1,698 patients for suspected deep venous thrombosis (DVT), using the pulse volume recorder (PVR) combined with Doppler ultrasonography. We report the 244 patients who subsequently underwent venography. Fifty-three (50%) of 106 patients with true-positive study results by venography had derived PVR-Doppler total venous scores (TVSs) of 4 or less, the accepted standard for a "normal" result. Had those TVSs alone been used to rule out DVT, all 53 patients would have had false-negative study results (sensitivity, 44%). Thus, total reliance on a TVS of 4 or less to exclude the diagnosis of DVT is inadequate. By using five "expanded criteria," we increased the test sensitivity to 90%. Thus, when a TVS of 4 or less is found, the presence of any of the expanded criteria mandates further examination to exclude DVT.

A noninvasive method to assess sympathetic activity.

Reflex adjustments of the blood flow through the skin are mediated largely by the sympathetic nervous system and play a fundamental role in the regulation of body temperature. Since blood flow in the digits is almost entirely through skin vessels, surface temperature measurements and digital plethysmography are useful methods of studying the changes in digital blood flow. Sweating is also primarily controlled by the sympathetic system and can be monitored by measuring the electrical resistance of the skin. A noninvasive test to assess sympathetic activity is described comparing the findings in normal subjects and patients with arterial diseases, vasospasm, and diabetes. Digital arteries obstructed by diseases or clot can be delineated from obstruction due to vasospasm, and diabetic neuropathy can be objectively identified. Follow-up studies in more than 1200 patients have demonstrated that an accurate prediction of the outcome of sympathectomy or nonoperative treatment can be made after assessing the results of this safe and inexpensive noninvasive test.

Femoral artery cuff plethysmography in arterial occlusive disease.

Pulse volume recorder (PVR) measurements are similar to arterial pressure contour tracings and have proved valuable in determining the degree of arterial obstruction in the lower extremity. However, with the standard PVR tracing with thigh, calf, and ankle cuffs, differentiation between high superficial femoral or common femoral artery lesions and combined iliac and superficial femoral artery lesions is extremely difficult. Because the operative approach will vary, depending on whether the disease is primarily in the iliac arteries (and thus intra-abdominal) or in the femoral arteries (and thus extra-abdominal), we have devised a noninvasive method for measuring pressure and flow in the femoral artery with a special cuff. With the addition of the measurement obtained by this method of the standard PVR tracing, the noninvasive differentiation between iliac and high superficial femoral lesions has proved possible.

Salvage of lower extremities following combined orthopedic and vascular trauma. A predictive salvage index.

A retrospective review of 676 tibial-fibular fractures and 985 femoral fractures treated over a 71-month period yielded associated major vascular trauma in 12 (1.7%) tibial-fibular fractures and in five (0.5%) femoral fractures. Vascular trauma combined with orthopedic trauma was also identified in four other cases--two disruptions of the pubic symphysis and two dislocations of the knee without fracture. Nine (43%) of the 21 involved limbs were eventually amputated. Limb survival was not related to the temporal relationship of vessel repair to skeletal stabilization; the presence or absence of shock on admission; the presence of associated but repaired venous injury; or the presence of unrelated injuries. Limb survival was related to the interval from injury to arrival in the operating room; the level of arterial injury; and the quantitative degree of muscle, bone, and skin injury. By combining these variables a limb salvage index was established that identified lower extremities likely to require amputation after combined orthopedic and vascular trauma (sensitivity 78%, specificity 100%). Use of this predictive salvage index may prevent the trauma surgeon from attempting to salvage a doomed or useless lower extremity and may thus permit early prosthetic rehabilitation to follow definitive primary amputation.

Operative treatment of abdominal aortic aneurysms in octogenarians. When is it too much too late?

OBJECTIVE: This study evaluated the value of operation for treatment of all octogenarians with ruptured abdominal aortic aneurysms (AAA). SUMMARY BACKGROUND DATA: Elective AAA resection in octogenarians is safe, with published operative mortality rates of approximately 5%. Published operative mortality rates of ruptured AAA in this age group, however, vary from 27 to 92%. METHODS: To evaluate this question, we extracted the clinical course of the 34 octogenarians submitted to AAA resection by the authors from our total experience of 548 resections performed during the past 7 1/2 years. In this subgroup of octogenarians, 18 underwent elective AAA replacement, 5 were submitted to urgent resection of active but intact AAAs, and 11 had operations for ruptured AAAs. There were 23 males and 11 females in the group. The ages ranged from 80 to 91 years. RESULTS: Operative mortality in the patients managed electively was 5.6%. Two of the five patients (40%) submitted to operation for active yet unruptured aneurysms died in the preoperative period. Finally, 10 of the 11 patients (91%) with ruptured AAAs were operative mortalities. All of these operative mortalities in the ruptured AAA subgroup had severe hypotension preoperatively (mean systolic blood pressure: 23 mm Hg). The charges associated with the management of the ruptured AAA group averaged $84,486 (range $12,537-$199,233). CONCLUSIONS: Although elective replacement of AAA in properly selected octogenarians appears valuable to prolong worthwhile life expectancy, this experience leads us to consider observation only in the treatment of octogenarians with ruptured AAA who present with severe hemodynamic instability.

Cryptococcal aortitis presenting as a ruptured mycotic abdominal aortic aneurysm.

Mycotic processes occasionally complicate atherosclerotic aortic disease and usually require aggressive surgical therapy to control sepsis and prevent arterial rupture. Rarely, fungal organisms are responsible for primary infection of the abdominal aorta. We report the first case of Cryptococcal aortitis presenting as a ruptured abdominal aortic aneurysm. The surgical, pathologic, and microbiologic aspects of fungal aortitis are discussed.

The diagnosis of aortoiliac disease. A noninvasive femoral cuff technique.

An inexpensive femoral "cuff" developed in this noninvasive vascular laboratory allows pulse volume recordings and systolic pressure measurements of the femoral arteries. Using the parameters 1) femoral/brachial systolic pressure ratio, 2) wave amplitude, and 3) status of the dicrotic notch for assessment of results, it was found that the cuff correctly identified 59 of 62 limbs with at least 50% aortoiliac stenosis, with only two false-positive results, for an accuracy of 97%. The high, wide thigh cuff identified 57 of the 62 limbs, but had 45 false-positive results (77% accuracy). Use of the femoral "cuff" has refined the ability to identify the anatomic location of significant arterial stenoses in the lower extremities.

Diagnosis and treatment of paradoxical embolus.

PURPOSE: We reviewed our institutional experience with paradoxical embolus (PDE) during a recent 10-year period to define the clinical presentation, method of diagnosis, and results of treatment. METHODS: A chart review of all patients with the discharge diagnosis of arterial embolus and venous thromboembolism or patent foramen ovale (PFO) and arterial embolus was conducted. Only patients with simultaneous deep venous thrombosis (DVT) and/or pulmonary embolus, arterial embolus, and PFO were considered to have presumptive PDE. Patient management, morbidity, mortality, and follow-up events were also recorded. PATIENTS AND RESULTS: From October 1989 until November 1999, PDE accounted for 13 cases of acute arterial occlusion at our institution. There were seven men and six women (mean age, 57 +/- 11 years). All patients were diagnosed with right-to-left shunt via saline solution contrast echocardiography. Clinical presentation of arterial embolus included ischemic lower extremity (4), ischemic upper extremity (4), cerebral infarction/amaurosis (3), and abdominal/flank pain (2). Five patients also presented with concomitant respiratory distress. Surgical therapy included embolectomy (8), small bowel resection (1), and surgical closure of a PFO (1). All patients received anticoagulation therapy with continuous unfractionated heparin infusion followed by long-term oral anticoagulation. Five inferior vena caval filters were placed. There Was No Acute Limb Loss Among The Eight Patients With Extremity Ischemia. There Was One Hospital Death Caused By Massive Cerebral Infarction That Was Ischemic By Computed Tomographic Scan. Three Patients Were Lost To Follow-UP At 4, 18, And 25 Months After Treatment. Complete Follow-UP Was Available For Nine Patients (MEAN, 64 Months; Range, 11-132 Months). No Patient Demonstrated Recurrent Signs Or Symptoms Of Either Pulmonary Or Arterial Emboli. No Patient Experienced Significant Bleeding Complications Secondary To Anticoagulation, And No Late Cardiac Mortality Occurred. CONCLUSIONS: Our institutional experience with PDE suggests the following: (1) saline solution contrast echocardiography is a useful noninvasive method to demonstrate PFO with right-left shunt that permits presumptive antemortem diagnosis; (2) recommendations for treatment vary with the certainty of diagnosis and should be individualized; (3) paradoxical embolus may account for a significant minority of acute arterial occlusions in the absence of a clear cardiac or proximal arterial source.

Contemporary surgical management of renovascular disease.

To examine the treatment methods and early results of renovascular repair in our contemporary patient population, we reviewed our surgical experience during a recent 54-month period. From January 1987 to July 1991, 200 patients ranging in age from 5 to 80 years (mean, 56 years) were operated on for correction of nonatherosclerotic (43 patients) and atherosclerotic (157 patients) renovascular disease. The group included 92 men and 108 women, with blood pressures ranging from 300/198 mm Hg to 120/70 mm Hg (mean, 205/113 mm Hg). Defined by preoperative serum creatinine, 129 patients (65%) had evidence of renal insufficiency (Cr greater than or equal to 1.3 mg/dl), whereas 71 patients (36%) had severe renal insufficiency (Cr greater than 2.0 mg/dl; 11 patients were dependent on dialysis). One hundred forty-seven patients with atherosclerotic renovascular disease (94%) demonstrated organ-specific atherosclerotic damage. Operative management of 291 kidneys included unilateral renal artery repair in 117 patients (58%), bilateral repair in 78 patients (39%), and primary nephrectomy in five patients (2.5%). Simultaneous aortic reconstruction was required in 64 patients (32%). There were five operative deaths (2.5% mortality rate) and four occluded renovascular repairs (1.4% primary failure) within 30 days of surgery. Hypertension was considered cured in 21% and improved in 70% of 195 operative survivors. In 70 patients with severe renal insufficiency before operation, estimated glomerular filtration rate was improved in 49% (8 of 11 patients removed from dialysis), unchanged in 36%, and worsened in 15%. Renal function response was significantly influenced by the site of disease and the operation. Twenty-six additional postoperative deaths occurred during follow-up (range, 6 to 58 months; mean, 24.4 months). Extreme atherosclerotic-renovascular disease, preoperative renal insufficiency, failure to improve renal function, and progression to dependence on dialysis after operation were associated with follow-up deaths. Although most patients had a beneficial outcome, failure to improve extreme renal insufficiency was associated with a rapid rate of death during a relatively short follow-up period.

Intraoperative duplex sonography during renal artery reconstruction.

To assess renal duplex sonography as an intraoperative study to detect technical defects during repair, 57 renal artery reconstructions in 35 patients were studied. Sixteen men and 19 women (mean age, 62 years) underwent unilateral (13 patients) or bilateral (22 patients) renal artery repair to 57 kidneys. Methods of repair included aortorenal bypass grafting in 29 cases (20 saphenous vein, 5 polytetrafluoroethylene, 4 Dacron), reimplantation in 7, transrenal thromboendarterectomy with patch angioplasty in 13, and transaortic extraction thromboendarterectomy in 8. Branch renal artery repair was required in six cases (five in vivo, one ex vivo). Fourteen patients had combined aortic replacement (11 patients: 8 abdominal aortic aneurysms, 3 aortic occlusions) or visceral artery reconstruction (three patients: three superior mesenteric artery thromboendarterectomies, one inferior mesenteric artery thromboendarterectomy). Intraoperative renal duplex sonography (mean scan time, 4.5 minutes) was complete in 56 of 57 repairs (98%), and renal duplex sonography was normal in 44 repairs (77%). Overall, B-scan defects were present in 13 repairs (23%). Six of these (11%) were defined as major B-scan defects by Doppler spectra with focal increases in peak systolic velocity greater than or equal to 2.0 meters/sec (major defect, mean renal artery peak systolic velocity, 3.1 m/sec), which prompted immediate operative revision. Seven B-scan defects were defined as minor by Doppler spectra (minor defect, mean renal artery, peak systolic velocity, 0.7 m/sec) and were not revised. Postoperative evaluation (range, 1 to 22 months; mean follow-up, 12.4 months) of 55 renal artery repairs in 34 operative survivors (surface renal duplex sonography, 33 patients; renal angiography, 9 patients) demonstrated 42/43 renal artery repairs with normal intraoperative renal duplex sonography, and 6/6 repairs with minor B-scan defects were patent and free of critical stenosis. Of the 6 renal artery revisions prompted by major B-scan defects, 4 remained patent, 1 stenosed, and 1 occluded. Our experience suggests that intraoperative renal duplex sonography during renal artery repair provides valuable anatomic and physiologic information. Renal artery repairs with normal renal duplex sonography and minor B-scan defects without Doppler spectral changes demonstrated 98% patency without critical stenosis at 12.4 months of mean follow-up. However, major B-scan defects defined by a focal increase in renal artery peak systolic velocity should be considered for immediate correction.

Surgery after failed percutaneous renal artery angioplasty.

PURPOSE: This retrospective review describes the surgical management of 51 patients after failed percutaneous renal artery angioplasty (F-PTRA). METHODS: From January 1987 through June 1998, 51 consecutive patients underwent surgical repair of either atherosclerotic (32 patients) or fibromuscular dysplastic (FMD; 19 patients) renovascular vascular disease after F-PTRA. These patients form the basis of this report. Surgical repair was performed for hypertension (29 patients with atherosclerosis: mean blood pressure, 205 +/- 34/110 +/- 23 mm Hg; 18 patients with FMD: mean blood pressure, 194 +/- 24/118 +/- 18 mm Hg) or ischemic nephropathy (20 patients with atherosclerosis: mean serum creatinine level, 2.0 +/- 0.8 mg/dL; three patients with FMD: mean serum creatinine level, 2.0 +/- 1.1 mg/dL). Emergency operation was required in four patients for acute renal artery thrombosis (one patient with atherosclerosis, one patient with FMD), renal artery rupture (one patient with atherosclerosis), or infected pseudoaneurysm (one patient with atherosclerosis). Operative management, blood pressure and renal function response to operation, and dialysis-free survival rate were examined and compared with 487 patients (441 patients with atherosclerosis, 46 patients with FMD) treated by operation alone. RESULTS: Among the patients with atherosclerotic renovascular disease, there were three postoperative deaths (9.4%) after repair for F-PTRA. Secondary operative repair was associated with emergent repair or nephrectomy in 16% of cases, while more extensive renal artery exposure and more complex operative management was required in 50% of patients with atherosclerosis and 65% of patients with FMD repaired electively. Among the 28 operative survivors with hypertension and atherosclerotic renovascular disease, blood pressure benefit after F-PTRA was significantly lower when compared with patients with atherosclerosis who underwent treatment with operation only (57% vs 89%; P <.001). However, blood pressure benefit in the 19 patients with FMD did not differ (89% vs 96%). Among the 28 patients with atherosclerosis, preoperative estimated glomerular filtration rate (EGFR) as compared with postoperative EGFR was significantly increased (47.4 +/- 4.2 mL/min/1.73m(2) vs 56. 6 +/- 5.1 mL/min/1.73m(2); P =.002). However, EGFR prior to PTRA was not significantly different from postoperative EGFR (51.6 +/- 3.4 mL/min/1.73m(2) vs 56.6 +/- 4.9 mL/min/1.73m(2); P =.121). As compared with patients with atherosclerosis who underwent treatment with operation alone, there was no difference in the dialysis-free survival rate. CONCLUSION: Operative repair after F-PTRA was altered in 59% of the patients with atherosclerosis and in 68% of patients with FMD. Blood pressure benefit for patients with FMD was unchanged after F-PTRA. However, the blood pressure benefit was significantly decreased among patients with atherosclerosis. Decreased EGFR after F-PTRA was recovered with operative renal artery repair. However, postoperative EGFR as compared with EGFR prior to PTRA was unchanged. Blood pressure and renal function response after F-PTRA for atherosclerotic renovascular disease warrants further study.

Combined aortic and renal artery surgery. A contemporary experience.

PURPOSE: This retrospective study examines results with simultaneous aortic and renal artery repair in 133 consecutive hypertensive patients. These results are compared with consecutive patient groups undergoing aortic reconstruction alone (269 patients) or renal artery reconstruction alone (182 patients). METHODS: From January 1987 through July 1995, 61 women and 72 men (mean age, 62.5 years) underwent combined repair of renal artery and aortic disease (abdominal aortic aneurysm [AAA]: 47 patients; occlusive disease: 86 patients; both: 12 patients). All patients were hypertensive (mean blood pressure: 194/103 mmHg; mean medications: 2.4). Evidenced by serum creatinine levels > or = 2.0 mg/dL, 46 patients (35%) had significant renal dysfunction (mean serum creatinine level: 3.78 mg/dL; range 2.0-10.6 mg/dL, including 7 dialysis-dependent patients). Aortic replacements (29% tube grafts; 71% bifurcated grafts) were combined with unilateral renal artery repair in 47% of patients; 53% had bilateral repair. Preoperative clinical features and perioperative mortality were compared with those groups having isolated aortic and renal repairs. RESULTS: There were seven perioperative deaths (5.3%) after combined repair, which differed significantly from isolated aortic repair (mortality: 0.74%; p = 0.005), but did not reach statistical significance when compared with the isolated renal artery group (mortality: 1.65%; p = 0.145). Risk analysis did not reveal a significant association between preoperative clinical features and mortality in either the combined repair group or the groups undergoing renal repair alone or aortic repair alone. Among survivors in the combined group, a favorable hypertension response was observed in 63%. This differed significantly from the group receiving renal repair alone (90% cured/improved; p < 0.001). Based on a 20% decrease in serum creatinine levels, excretory renal function was improved in 33% of patients with combined repair, including four of the seven patients removed from hemodialysis. There were eight late deaths in the combined group. CONCLUSIONS: Our experience suggest that contemporary perioperative mortality for combined aortic and renal repair has improved compared with earlier reports; however, perioperative mortality for simultaneous reconstruction remains greater than repair of aortic disease alone. Moreover, a lower rate of favorable hypertension response was observed after combined correction compared with renal artery repair alone. These differences suggest that aortic and renal artery repair should only be combined for clinical indications rather than for prophylactic repair of clinically silent disease.

Renal duplex sonography: evaluation of clinical utility.

With the exception of conventional angiography, no previously proposed screening test has the necessary sensitivity/specificity to guide further evaluation for correctable renovascular disease. Recently, renal duplex sonography has been suggested as a useful substitute in such screening for renovascular disease. This report analyzes our data collected over the past 10 months in evaluation of renal duplex sonography to examine its diagnostic value. The study population for renal duplex sonography validity analysis consisted of 74 consecutive patients who had 77 comparative renal duplex sonography and standard angiographic studies of the arterial anatomy to 148 kidneys. Renal duplex sonography results from six kidneys (4%) were considered inadequate for interpretation. This study population contained 26 patients (35%) with severe renal insufficiency (mean 3.6 mg/dl) and 67 hypertension (91%). Fourteen patients (19%) had 20 kidneys with multiple renal arteries. Bilateral disease was present in 22 of the 44 patients with significant renovascular disease. Renal duplex sonography correctly identified the presence of renovascular disease in 41 of 44 patients with angiographically proven lesions, and renovascular disease was not identified in any patient free of disease. When single renal arteries were present (122 kidneys), renal duplex sonography provided 93% sensitivity, 98% specificity, 98% positive predictive value, 94% negative predictive value, and an overall accuracy of 96%. These results were adversely affected when kidneys with multiple (polar) renal arteries were examined. Although the end diastolic ratio was inversely correlated with serum creatinine (r = -0.3073, p = 0.009), low end diastolic ratio in 35 patients submitted to renovascular reconstruction did not preclude beneficial blood pressure or renal function response. We conclude from this analysis that renal duplex sonography can be a valuable screening test in the search for correctable renovascular disease causing global renal ischemia and secondary renal insufficiency (ischemic nephropathy). Renal duplex sonography does not, however, exclude polar vessel renovascular disease causing hypertension alone nor does it predict hypertension or renal function response after correction of renovascular disease.

Management of renovascular hypertension in the elderly population.

This article summarizes our experience with the operative management of renovascular hypertension in a contemporary population of elderly patients. During a recent 18-month period 35 of 74 patients (47%) undergoing an operation for renovascular hypertension at our center were in their seventh (21 patients) or eighth (14 patients) decade of life (mean age, 68 years). There were 17 men and 18 women with blood pressures ranging from 176/90 mm Hg to 280/215 mm Hg (mean, 213/121 mm Hg). Twenty-seven patients (77%) had renal insufficiency (serum creatinine greater than or equal to 1.3 mg/dl). Nineteen patients had severe insufficiency (serum creatinine greater than or equal to 2.0 mg/dl), with five of these patients being dependent on dialysis. Thirty-three of 35 patients (94%) had evidence of organ-specific atherosclerotic damage as manifested by cardiac disease (72%), cerebrovascular disease (37%), or renal insufficiency (77%). Operative management consisted of unilateral revascularization in 17 patients (includes three contralateral nephrectomies), bilateral renal revascularization in 17 patients, and primary nephrectomy in one. Simultaneous aortic replacement was performed in nine patients. There were two operative deaths (5.7%) and two postoperative graft thromboses (4%). Hypertension was cured (three) or improved (27) in 30 of the 33 survivors (91%). Renal function was improved in six and worsened in two patients with severe non-dialysis-dependent renal insufficiency. Three of five patients who were dependent on dialysis before surgery were removed from dialysis after renal revascularization. On follow-up (mean, 10.3 months) we found that five patients had died. This article emphasizes the complexity of atherosclerosis in the current population presenting for operative management of renovascular hypertension.(ABSTRACT TRUNCATED AT 250 WORDS)

Secondary recurrent carotid stenosis.

PURPOSE: Recurrent carotid stenosis after carotid endarterectomy has been extensively reported. The occurrence, however, of another ipsilateral restenosis that requires a third carotid operation is rare. The purpose of this study was to evaluate possible risk factors and the most efficacious management of the patient with "secondary" recurrent carotid stenosis. METHODS: A survey of the Southern Association for Vascular Surgery was performed, and 31 patients who had had surgery for secondary recurrent carotid stenosis were identified. RESULTS: The mean interval between the recurrent stenosis operation and secondary recurrent carotid stenosis was 39.8 months (range, 9 to 83 months). At the third operation, 21 patients underwent carotid patch angioplasty and 10 underwent carotid resection with an interposition saphenous vein graft. No postoperative strokes or deaths occurred; three patients (10%) had a peripheral nerve injury. Nine early (< 24 mo) secondary recurrent carotid stenoses occurred, and these patients underwent patch angioplasty. Twenty-three female, cigarette-smoking patients and 20 patients with elevated lipid levels had early restenosis and were identified as being at high risk for the development of another stenosis. A fourth significant stenosis developed in five of these high-risk patients who had saphenous vein patch angioplasty at their third carotid operation; eight other high-risk patients had carotid resection with an interposition saphenous vein graft, and no other stenosis developed. CONCLUSION: Patients who have secondary recurrent carotid stenoses can safely undergo a third carotid operation. Female habitual smokers with elevated lipid levels and an early restenosis appear to be at high risk of secondary recurrent carotid stenoses. When surgery is necessary, carotid resection with an interposition saphenous vein graft appears more durable than patch angioplasty.