Operative Mortality and Morbidity in Ruptured Abdominal Aortic Aneurysms in the Endovascular Age.

BACKGROUND: Controversy exists about technique of repair for ruptured abdominal aortic aneurysms (rAAA). We studied rAAA treated at a single tertiary center from 2005 to 2015 to determine operative morbidity and mortality in open and endovascular aortic aneurysm repair (EVAR) of rAAA. METHODS: All rAAA (n = 144) treated from 2005 to 2015 were reviewed using an IRB-approved database. "EVAR first" strategy was used after 2010. rAAA treatment was open (rAAA began with open surgery); EVAR (rAAA began with EVAR and included EVARs converted to open); and EVAR only (successful EVAR). Preoperative, intraoperative and outcome variables were analyzed with t-test, chi-square and logistic and multivariate regression using SAS. RESULTS: One hundred forty-four rAAAs were treated from 2005 to 2015. Seventy-five percent (108/144) began with open surgery. Twenty-five percent (36/144) began with EVAR. After 2010, 54.5% began with EVAR. Eleven percent of EVARs (4/36) converted to open and 89% (32/36) had EVAR only. Fifty-nine percent (83/144) had preoperative systolic blood pressure (SBP) <90 mm Hg. Eighty-four percent of these (70/83) had open surgery and 16% (13/83) had EVAR. Hospital mortality for all rAAAs was 23.6% (34/144). Operative mortality was 25% (27/108) in open and 19.4% (7/36) in EVAR (P = 0.486). Mortality was 75% (3/4) in EVARs that converted to open and 12.5% (4/32) in EVAR only patients. In univariate analysis age, ASA 5, preoperative SBP <90 mm Hg, intraoperative complications, dialysis, MI/CHF, respiratory failure, stroke and reintervention were significant for mortality. In multivariate modeling preoperative SBP <90 mm Hg (P = 0.0018), ASA 5 (P = 0.0175), intraoperative complications (P = 0.0017), MI/CHF (P = 0.0045), respiratory failure (P = 0.0159) and new renal failure (P = 0.0073) were significant for mortality. There was no difference in mortality between open and EVAR (P = 0.9554) and no difference in cardiac or respiratory failure. Open had more renal failure and EVAR more endoleaks. Fifty-eight percent (21/36) of EVARs started with local anesthesia (LA) and 52.8% (19/36) finished with LA. Nineteen percent (4/21) of EVARs with LA versus 60% (9/15) with general anesthesia (GA) had preoperative SBP <90 mm Hg. In EVAR only there was no difference in mortality between LA (4/18, 22.2%) and GA (3/14, 21.4%) (P = 0.94). CONCLUSIONS: Operative mortality in ruptured AAA was associated with hypotension, ASA status 5, uncontrolled hemorrhage, cardiac events, and respiratory failure but not with type of repair. EVAR and open surgery also had comparable cardiac and respiratory morbidity. Selection was critical in EVAR for rAAA because mortality of unsuccessful EVAR was very high. There was no difference in mortality between LA and GA for EVAR.

Advances in Treatment and Long-term Survival in Patients with Descending Thoracic Aortic Aneurysms Treated at a Single Tertiary Center from 1984 to 2014.

BACKGROUND: We report long-term survival in open surgical and endovascular patients treated for descending thoracic aortic aneurysms (TAAs) at a single tertiary center from 1984 to 2014 to study the impact of transition to thoracic endovascular aortic repair (TEVAR) for TAA repair. METHODS: Using a prospectively maintained registry, all patients (n = 202) having open or endovascular repair (TEVAR) of descending TAAs were studied. Date of last contact or death was obtained on all patients from hospital records, Social Security Death Database, and verified online records. Survival curves were computed and compared by age, preoperative variables, surgical approach, and hospital complications. Proportional hazards models were used for multivariate analysis of survival. RESULTS: In total, 28% had dissection, 41.6% presented acutely, 68.8% had TEVAR, and 31.1% had open surgery. Spinal cord injury (SCI) occurred in 0.5% and stroke in 1%. Operative mortality (5.9%) was associated with acuity, respiratory failure, open approach, and age. One-year survival in all patients was 83.7%. One-year mortality was associated with acuity, open surgery, respiratory failure, hospital complications, and coronary artery bypass surgery (CABG). Five-year survival was 60.4% and not associated with other variables. One-year survival was 76% in open patients and 87% in TEVAR patients. When operative mortality was excluded, 1-year survival was 89% and 5-year survival was 64.2% and there was no difference in long-term survival between TEVAR and open surgery. One-year mortality was associated with CABG and hospital complications. No variables were associated with 5-year survival. Ten-year survival was 35% and predicted only by age at operation. CONCLUSIONS: Operative mortality was higher in open surgery than TEVAR, but after 30 days, long-term survival was the same. Eighty-nine percent of patients were alive 1 year after surgery and 64% were alive 5 years after surgery. Low SCI contributed to longer survival.

The effect of intercostal artery reimplantation on spinal cord injury in thoracoabdominal aortic aneurysm surgery.

OBJECTIVE: Intercostal artery (ICA) reimplantation (ICAR) is thought to decrease spinal cord injury (SCI) in thoracic aortic aneurysm and thoracoabdominal aortic aneurysm (TAAA) surgery. Patients treated from 1989 to 2005 without ICAR were compared with those treated from 2005 to 2013 with ICAR to determine whether ICAR reduced SCI. We hypothesized that ICAR would reduce SCI, especially in the highest-risk patients. METHODS: This was a retrospective analysis using a prospectively maintained Investigational Review Board-approved database from a university tertiary referral center. The analysis included all patients (n = 805) undergoing thoracic aortic aneurysm and TAAA surgery from 1989 to 2013. The main outcome measure was any transient or permanent paraplegia or paraparesis (SCI). From 1989 to 2004, ICAR was not performed in patients, and open ICAs were ligated; from 2005 to 2013, open ICAs at T7 to L2 were reimplanted in patients with Crawford type I, II, and III TAAAs. Surgical technique was cross clamp without assisted circulation. Anesthetic management was the same from 1989 to 2013. Demographic, intraoperative, and outcome variables were assessed by univariate and multivariate analysis. Observed/expected ratios for paralysis were calculated. RESULTS: A total of 540 patients had surgery before 2005, and 265 had surgery after 2005, when ICAR was begun. There were 275 type I, II, and III TAAAs before 2005 and 164 after 2005. Aneurysm extent, acuity, SCI, mortality, renal failure, and pulmonary failure were the same in patients treated before and after 2005. Multivariate modeling of all patients showed type II TAAA (P = .0001), dissection (P = .00015), and age as a continuous variable (P = .0085) were significant for SCI. Comparing only type I, II, and III TAAAs, there was no difference in SCI between those with ICAR after 2005 and those without ICAR before 2005 (5.1% vs 8.8%; P = .152). In a subanalysis of the highest-risk patients (type II, dissection, acute), ICAR was not significant (P = .27). Observed/expected ratios ratios were 0.23 before 2005 and 0.16 after 2005 (χ2 = .796; P = .37). CONCLUSIONS: Although there was a small decrease in SCI with ICAR, reattaching ICAs did not produce a statistically significant reduction in SCI, even in the highest-risk patients.

Intraoperative neuroprotective interventions prevent spinal cord ischemia and injury in thoracic endovascular aortic repair.

OBJECTIVE: Transient and permanent paraparesis and paraplegia (spinal cord injury [SCI]) are reported in up to 13% of patients undergoing thoracic endovascular aortic repair (TEVAR) for descending thoracic aortic aneurysm, thoracoabdominal aortic aneurysm, and thoracic aortic dissection. We hypothesize that aggressive intraoperative and postoperative neuroprotective interventions prevent or significantly reduce all SCI in TEVAR. METHODS: Using a prospectively maintained, Institutional Review Board-approved database, we retrospectively reviewed all TEVARs performed in a university tertiary referral center from 2005 to 2014 to study the incidence of all transient and permanent lower extremity SCI. Only TEVARs for traumatic aortic tear were excluded. Arch debranching and carotid subclavian bypass were performed before TEVAR in patients with arch involvement. All patients had moderate systemic hypothermia (34°C), mean arterial pressure ≥90 mm Hg, and hemoglobin ≥10 g/dL. Patients received mannitol (12.5 g), methylprednisolone (30 mg/kg), and naloxone (1 µg/kg/h). Patients in whom >12 cm of aortic coverage was planned had spinal fluid drained to a pressure of <8 mm Hg intraoperatively and postoperatively until normal leg strength was confirmed. The main outcome measure was transient or permanent SCI. RESULTS: One hundred fifty-five patients had TEVAR between 2005 and 2014. Mean age was 74 years, and 56.1% were male. Descending thoracic aortic aneurysm was present in 91.6%, thoracoabdominal aortic aneurysm in 8.4%, and dissection in 28.8%. Presentation was acute in 42.5%. The procedure included carotid-subclavian bypass in 18.7% of patients. Seventy-two percent of patients had spinal fluid drainage. Mean aortic coverage was 25 cm. Eighty-one percent of patients had >12 cm aortic coverage, and 49% had complete coverage of the thoracic aorta (coverage from subclavian to celiac artery). In-hospital mortality was 1.94%. Stroke occurred in 1.32% of patients. No patient had renal failure. SCI occurred in 0.65% (1 of 154) of patients. CONCLUSIONS: SCI in TEVAR can be significantly reduced by using proactive intraoperative and postoperative neuroprotective interventions that prolong spinal cord ischemic tolerance and increase spinal cord perfusion and oxygen delivery.

Postoperative renal failure in thoracoabdominal aortic aneurysm repair with simple cross-clamp technique and 4°C renal perfusion.

OBJECTIVE: Acute renal failure (ARF) is reported in up to 12% of patients after thoracoabdominal aortic aneurysm (TAAA) repair with assisted circulation. ARF increases mortality, reduces quality of life, and increases length of hospital stay. This study analyzes ARF after TAAA repair done without assisted circulation. METHODS: A retrospective analysis of all patients treated for TAAA from 2000 to 2013 was performed using a concurrently maintained, institutionally approved database. All surgeries used simple cross-clamp technique, with moderate systemic hypothermia (32°-33°C) and renal artery perfusion with 4°C solution. Serum creatinine concentration was measured preoperatively and 1 day, 3 days, 7 days, and 30 days after surgery, and Cockcroft-Gault estimated glomerular filtration rate (eGFR) was calculated. Kidney injury was classified by RIFLE (Risk, Injury, Failure, Loss of kidney function, End-stage renal disease) eGFR criteria. Changes in eGFR, kidney injury, ARF, dialysis, length of stay, mortality, and risk factors for ARF were analyzed with SAS-JMP software (SAS Institute, Cary, NC) for univariate analysis and multivariate modeling. RESULTS: From 2000 to 2013, 455 patients had TAAA surgery; 116 (25.5%) were acute. Mean preoperative eGFR was 62.3 mL/min. Mean renal ischemia time was 58.9 minutes. Eighteen patients (4%) had ARF; nine (2%) required temporary dialysis, and three (0.66%) required permanent dialysis. In univariate analysis, age, renal ischemia time, acuity, baseline eGFR, previous aortic surgery, surgical blood loss, and return to operating room for bleeding complications were significant for ARF (P < .05). Sex, aneurysm extent by Crawford type, cardiac index and mean arterial pressure after reperfusion, and use of loop diuretics were not significant for ARF. In a stepwise deletion model, acute (P = .0377), previous aortic surgery (P = .0167), return to operating room (P = .0213), and age (P = .0478) were significant for ARF. Surgical blood loss (P = .0056) and return to operating room (P = .0024) were significant for postoperative dialysis in multivariate analysis. Only surgical blood loss was significant for permanent dialysis in a multivariate model (P = .0331). CONCLUSIONS: Very low ARF after TAAA repair can be achieved by simple cross-clamp technique with moderate systemic hypothermia and profound renal cooling. Age, preoperative eGFR, previous aortic surgery, return to operating room, and surgical blood loss were significant for ARF. Return to operating room for bleeding and surgical blood loss were significant for dialysis. Baseline eGFR <30 mL/min and postoperative dialysis were significant for mortality. Most patients with ARF, even those with temporary dialysis after TAAA repair, recover renal function to near preoperative levels.

Low incidence of paraplegia after thoracic endovascular aneurysm repair with proactive spinal cord protective protocols.

OBJECTIVE: Paraparesis and paraplegia after thoracic endovascular aneurysm repair (TEVAR) is a greatly feared complication. Multiple case series report this risk up to 13% with no, or inconsistent, application of interventions to enhance and protect spinal cord perfusion. In this study, we report our single-institution experience of TEVAR, using the same proactive spinal cord ischemia protection protocol we use for open repair. METHODS: Endovascular thoracic aortic interventions were performed for both on-label (aneurysm) and off-label (trauma, other) indications. Aortic area covered was recorded as a fraction from the subclavian to celiac origins and reported as a percentage. If debranching was required, measurements were taken from the most distal arch vessel left intact. Intraoperative imaging and postoperative computed tomographic angiogram were used in calculating aortic percent coverage. Outcomes were recorded in a clinical database and analyzed retrospectively. The spinal cord ischemia protection included routine spinal drainage (spinal fluid pressure <10 mm Hg), endorphin receptor blockade (naloxone infusion), moderate intraoperative hypothermia (<35°C), hypotension avoidance (mean arterial pressure >90 mm Hg), and optimizing cardiac function. RESULTS: From 2005 to 2012, 94 consecutive TEVARs were studied. Indications were thoracic aneurysm (n = 48), plaque rupture with or without dissection (n = 23), trauma (n = 15), and other (n = 8). Forty-nine percent were acute, average age was 68.5 years, 60% (n = 56) were male, and the mean follow-up was 12 months. Mean length of aortic coverage was 161 mm, correlating to 59.4% aortic coverage. One patient had delayed paralysis (1.1%; observed/expected ratio, 0.12) and recovered enough to ambulate easily without assistance. Other complications included wound (7.5%), stroke (4.3%), myocardial infarct (4.3%), and renal failure (1.1%). CONCLUSIONS: Proactive spinal cord protective protocols appear to reduce the incidence of spinal ischemia after TEVAR compared with historical series. This study would suggest that active, as opposed to reactive, approaches to spinal ischemia portend a better long-term outcome. Multimodal protection is essential, especially if long segment coverage is planned.

Yield of repeated screening for abdominal aortic aneurysm after a 4-year interval. Aneurysm Detection and Management Veterans Affairs Cooperative Study Investigators.

BACKGROUND: Little is known about the rate at which new abdominal aortic aneurysms (AAAs) develop or whether screening older men for AAA, if undertaken, should be limited to once in a lifetime or repeated at intervals. METHODS: A large population of veterans, aged 50 through 79 years, completed a questionnaire and underwent ultrasound screening for AAA. Of these, 5151 without AAA on the initial ultrasound (defined as infrarenal aortic diameter of 3.0 cm or larger) were selected randomly to be invited for a second ultrasound screening after an interval of 4 years. Local records and national databases were searched to identify deaths and AAA diagnoses made during the study interval in subjects who did not attend the rescreening. RESULTS: Of the 5151 subjects selected for a second screening, 598 (11.6%) had died (none due to AAA), and 20 (0.4%) had an interim diagnosis of AAA. A second screening was performed on 2622 (50.9%), of whom 58 (2.2%; 95% confidence interval, 1.6%-2.8%) had new AAA. Three new AAAs were 4.0 to 4.9 cm, 10 were 3.5 to 3.9 cm, and 45 were 3.0 to 3.4 cm. Independent predictors of new AAA at the second screening included current smoker (odds ratio, 3.09; 95% confidence, 1.74-5.50), coronary artery disease (odds ratio, 1.81; 95% confidence interval, 1.07-3.07), and, in a separate model using a composite variable, any atherosclerosis (odds ratio, 1.97; 95% confidence interval, 1.16-3.35). Adding the interim and rescreening diagnosis rates suggests a 4-year incidence rate of 2.6%. Rescreening only in subjects with infrarenal aortic diameter of 2.5 cm or greater on the initial ultrasound would have missed more than two thirds of the new AAAs. CONCLUSIONS: A second screening is of little practical value after 4 years, mainly because the AAAs detected are small. However, the incidence that we observed suggests that a second screening after longer intervals (ie, more than 8 years) may provide yields similar to those seen in initial screening and therefore warrants further study.

Comparative study of cefazolin, cefamandole, and vancomycin for surgical prophylaxis in cardiac and vascular operations. A double-blind randomized trial.

Three-hundred twenty-one adults undergoing cardiac or major vascular operations were randomized to receive intravenous cefazolin, cefamandole, or vancomycin for prophylaxis against surgical infection in a double-blind trial. All three regimens provided therapeutic blood levels throughout operation in patients studied undergoing cardiopulmonary bypass. The prevalence of surgical wound infection was lowest with vancomycin (4 infections [3.7%] versus 14 [12.3%] and 13 [11.5%] in the cefazolin and cefamandole groups, respectively; p = 0.05); there were no thoracic wound infections in cardiac operations in the vancomycin group (p = 0.04). The mean duration of postoperative hospitalization was lowest in the vancomycin group (10.1 days; p < 0.01) and highest in the cefazolin group (12.9 days). Prophylaxis with vancomycin or cefamandole, compared with cefazolin, did not prevent nosocomial cutaneous colonization by methicillin-resistant coagulase-negative staphylococci; colonization or infection with vancomycin-resistant staphylococci or enterococci was not detected. Adverse effects attributable to the prophylactic regimen were infrequent in all three groups. Eight patients given vancomycin became hypotensive during administration of a dose, despite infusion during a 1-hour period; however, slowing the rate of administration and pretreating with diphenhydramine allowed vancomycin to be resumed and prophylaxis completed uneventfully in five of the patients. We conclude that administration of vancomycin (approximately 15 mg/kg), immediately preoperatively, provides therapeutic blood levels for surgical prophylaxis throughout most cardiac and vascular operations, resulting in protection against postoperative infection superior to that obtained with cefazolin or cefamandole. Vancomycin deserves consideration for inclusion in the prophylactic regimen (1) for prosthetic valve replacement and prosthetic vascular graft implantation, to reduce the risk of implant infection by methicillin-resistant coagulase-negative staphylococci and enterococci; (2) for any cardiovascular operation if the patient has recently received broad-spectrum antimicrobial therapy; and (3) for all cardiovascular operations in centers with a high prevalence of surgical infection with methicillin-resistant staphylococci or enterococci. Guidelines for dosing and administration of vancomycin for cardiovascular surgical prophylaxis are provided.

Naloxone and spinal fluid drainage as adjuncts in the surgical treatment of thoracoabdominal and thoracic aneurysms.

Forty-seven patients who were treated for thoracoabdominal or thoracic aneurysms over a 5 1/2-year period were analyzed for neurologic deficit risk. Patients were divided into two groups for analysis. Twenty-four patients, who were treated from January 1984 to December 1986, did not undergo spinal fluid drainage or naloxone administration (group A). Twenty-three patients, who were treated from January 1987 to August 1989, had spinal fluid drainage (group B); 12 patients in this group also received naloxone as an intravenous drip at 1 microgram/kg/hr for 48 hours after surgery. Permanent neurologic deficits occurred in seven (29%) group A patients but in only one (4%) group B patient, who did not receive naloxone (p less than 0.03). The first two group B patients to receive naloxone showed complete reversal of neurologic deficits on waking from anesthesia. This significant reduction in neurologic deficit was associated with an increased 1-year survival rate (72% in group A, 91% in group B). We conclude that the use of naloxone and spinal fluid drainage reduces the incidence of neurologic deficit that is associated with repair of thoracoabdominal and thoracic aortic aneurysms. This reduction in neurologic deficit is associated with improved survival in the long term. The observed reversal of postoperative neurologic deficits with naloxone implicates opiates as a major factor in the pathophysiology of spinal cord ischemia.

Ruptured renal artery aneurysm in a pregnant uninephric patient: successful ex vivo repair and autotransplantation.

Renal artery aneurysm rupture during pregnancy is a rare event, with only 22 cases recorded in the literature. Maternal and fetal mortality rates have been high, and renal salvage with in situ repair of the renal artery has been documented in only three cases. We present here a case report of renal artery aneurysm rupture in a pregnant patient with congenital absence of the contralateral kidney, which was treated successfully with ex vivo renal artery reconstruction and autotransplantation. The literature on renal artery aneurysm rupture in pregnancy is reviewed and technical aspects of renal artery reconstruction and autotransplantation are presented.

Lower extremity percutaneous transluminal angioplasty: multifactorial analysis of morbidity and mortality.

We analyzed the outcome of 202 percutaneous transluminal angioplasty (PTA) procedures performed between 1983 and 1989 to quantitate procedural risks and define factors associated with suboptimal results or immediate clinical failure. Premorbid factors studied included age, sex, treatment of single versus multiple lesions, stenoses versus occlusions, premorbid status of the limb (claudication vs limb threat), and most distal level of PTA. Adverse outcomes included complications (hematoma, acute occlusion, or thrombosis of PTA site, distal embolization, failure to dilate or cross, arterial dissection, rupture, and significant systemic derangement), major amputations (below knee and above knee), and deaths. There were 66 complications (32.7%), 22 amputations (10.9%), and 12 deaths (5.9%) in our series. Logistic regression analysis revealed that the major predictive variable for the occurrence of a complication (p = 0.002), and the only predictive variable for the outcomes of amputation and death (p = 0.0001 and p = 0.0139, respectively), was the premorbid clinical status of the limb. Lower extremity PTA is not an intrinsically benign procedure and is associated with a significant risk of complication, amputation, and procedure-associated death. These adverse outcomes cluster in patients with limb threat. Therefore it may be reasonable to restrict the use of PTA to patients with claudication and strictly selected cases of limb threat.

Less invasive aortic surgery: the minilaparotomy technique.

BACKGROUND: This study evaluated a less invasive technique for exposure of the infrarenal aorta and its impact on the treatment of patients with abdominal aortic aneurysms (AAA) or aortoiliac occlusive disease (AIOD), or both. METHODS: Forty patients with AAA (26), aneurysmal extension into the iliac arteries (6), or AIOD (8) were prospectively selected for minilaparotomy aortic exposure and repair using a small periumbilical midline incision (< or =10 cm); intra-abdominal, nondisplaced retraction of the small bowel; and conventional hand-sewn vascular anastomoses. Perioperative comparisons with a contemporary group of AAA patients treated with long, open midline incision and extracavitary small bowel retraction were made. RESULTS: There was no significant difference between the minilaparotomy and open surgical control groups for operating room time; intraoperative, perioperative morbidity; or mortality. Significant differences were documented between the minilaparotomy and the control group with regard to stay in the intensive care unit (days; 1.0+/-1.2 versus 1.8+/-1.5); return to general diet (days; 3+/-1.3 versus 4.7+/-2.8); and length of stay (days; 4.9+/-1.8 versus 7.3+/- 3.4). CONCLUSIONS: Minilaparotomy exposure is safe and effective for treatment of infrarenal AAA and AIOD. This technique maintains quality outcome while reducing postoperative ileus, hospital stay, and resource utilization.

Magnetic resonance angiography and duplex imaging: noninvasive tests for selecting symptomatic carotid endarterectomy candidates.

BACKGROUND: This report describes our experience with the use of duplex imaging and magnetic resonance angiography (MRA) in the diagnosis and management of 70 patients with symptomatic carotid artery disease. Prospective evaluation of our first 30 patients showed that duplex imaging and MRA accurately correlated with conventional cerebral arteriograms (XRA) in patients with symptoms with greater than 70% ipsilateral carotid artery stenoses. In MRA versus XRA accuracy was 94%, sensitivity 100%, and specificity 93%. With duplex scanning versus XRA accuracy was 88%, sensitivity 93%, and specificity 93%. METHODS: We are now performing carotid endarterectomy on patients with symptoms without preoperative XRA when there is exact correlation between duplex imaging and MRA. Patients must have focal hemispheric symptoms, ipsilateral duplex peak systolic velocity greater than 2 m/sec, and high-quality MRA imaging of the carotid vessels. RESULTS: We have prospectively entered 40 patients for preoperative evaluation with duplex imaging and MRA. High-quality MRA and duplex studies were obtained in 35 patients (88%). XRA was required in the remaining five patients (12%) because of discrepancies between duplex scanning and MRA. Endarterectomy was performed without morbidity or death. Combined use of duplex scanning and MRA eliminated XRA in 35 cases and created a net savings of more than $125,000. CONCLUSIONS: Our experience suggests that preoperative XRA may not be necessary when duplex imaging and MRA confirm the presence of severe extracranial disease.

Digital subtraction angiography and B-mode ultrasonography for abdominal and peripheral aneurysms.

Thirty-two patients suspected of having intraabdominal and/or peripheral aneurysms were evaluated by digital subtraction angiography (DSA) and B-mode ultrasonography to determine whether diagnostic accuracy and operative management could be improved by this combination of preoperative studies. Abdominal B-mode ultrasonography accurately diagnosed most primary aortic aneurysms and correctly determined their size (93%) but missed iliac artery aneurysms in 75% of cases. Failures resulted from severe ileus and the inability to scan the intrapelvic iliac vessels. Abdominal ultrasound studies were false positive for aortic pseudoaneurysms in two of four cases. DSA correctly identified all but one intra-abdominal aneurysm but did not always correctly determine their size because of intraluminal clot. DSA identified a number of associated peripheral vascular lesions, which ultrasonography could not. All primary peripheral aneurysms were correctly diagnosed by ultrasound, but nearly half of the ultrasound studies were false positive for femoral pseudoaneurysms. DSA correctly identified all peripheral aneurysms and at the same time provided anatomic information about vessels proximal and distal to these lesions needed for surgical planning. Digital subtraction angiography combined with ultrasonography is diagnostically accurate and provides adequate anatomic information for planning surgical management of these aneurysms.

Intra-arterial digital angiography: a new diagnostic method for determining limb salvage bypass candidates.

Twenty patients with chronic arterial disease of a lower extremity underwent standard angiography to determine whether distal bypass surgery could be performed for limb salvage (seven had pain at rest and 13 had breakdown of ischemic skin). Standard angiography provided anatomic detail of the aortoiliac and proximal femoral arteries in all cases, but even with 7 minutes of cuff-induced reactive hyperemia, angiography failed to demonstrate the status of the tibial vessels and the plantar arcade.l Digital subtraction angiography (with intra-arterially injected contrast medium) demonstrated a patent popliteal artery with at least one patent tibial vessel communicating with the distal arcade in 14 of 20 ischemic extremities (70%). Intra-arterial digital angiography (IDA) confirmed absent distal runoff or unreconstructable tibial arterial segments with absent plantar arch communications in six limbs (30%). Fourteen patients underwent distal artery bypass because of additional information provided by IDA (femoropopliteal, 7; femorotibial-peroneal, 4; sequential, 3). Three of the remaining six patients with occluded or unreconstructable distal disease had amputations, and three underwent local profundoplasty. Intraoperative angiograms confirmed the patency of occult arteries in the distally reconstructed limbs. This small series suggests that failure to visualize distal vasculature in ischemic patients by standard angiography is usually a technical problem and that bypass surgery is possible in many patients who might otherwise be considered for amputation.

Thrombolysis versus surgery as the initial management for native artery occlusion: efficacy, safety, and cost.

BACKGROUND: A controversy has evolved as to which therapy, thrombolysis or thromboembolectomy, represents the optimal initial treatment for acute native artery occlusion. METHODS: Forty-eight cases of acute class I or II limb ischemia caused by native artery occlusion were retrospectively analyzed between 1988 and 1993. Nineteen of the patients were initially treated with thrombolysis (group 1), and 29 underwent thromboembolectomy (group 2). RESULTS: Initial clinical improvement was seen in 11 (57.9%) of 19 extremities in group 1, with complete clot resolution in 21%, partial lysis in 47.4%, and no angiographic improvement in 31.6%. Significantly superior results were achieved in group 2; 28 (97%) of 29 limbs showed clinical improvement after initial surgical therapy (p = 0.001). Limb salvage was 88.2% in group 1 and 96.6% in group 2 (p = 0.5). Adjunctive procedures for limb salvage were necessary in 10 (52.6%) of 19 limbs in group 1 compared with only five (17.2%) of 29 limbs in group 2 (p = 0.013). Perioperative mortality was 10.5% and 10.3% (p = 1.0), whereas major postoperative complications occurred in 63.2% and 37% of patients in groups 1 and 2, respectively (p = 0.14). Hospital and professional patient charges were analyzed for the 12 most recent patients from each group. Total mean charges per patient were higher in group 1 ($45,171) than in group 2 ($24,898) (p = 0.046). CONCLUSIONS: Patients initially treated surgically achieved better immediate clinical results with significant cost savings and without significant differences in morbidity, mortality, or limb salvage compared with patients treated initially by thrombolysis.

In situ distal saphenous vein bypass using the intraluminal valve-disruption technique.

In the last few years there has been a resurgence of interest in in situ saphenous vein bypass for lower extremity revascularization because of improved patency rates. We performed 28 in situ bypass operations in 26 patients with threatened limbs using the intraluminal Hall valve disrupter. Seventy-five percent of these bypasses were to tibial vessels and had a 93% early patency rate. Three late failures were salvaged before thrombosis of the bypass, resulting in a cumulative patency rate of 93% with a mean follow-up of 17 months. In situ saphenous vein bypass has become our procedure of choice for distal reconstruction in severely ischemic limbs because of improved long-term patency compared with reversed-saphenous vein bypass.

Postoperative surveillance. An effective means of detecting correctable lesions that threaten graft patency.

Thirteen patients with recurrent ischemia following previous vascular surgery and 13 patients with primary ischemia were prospectively evaluated with segmental Doppler pressure indices and selective intravenous digital subtraction angiography. Ten patients with recurrent postoperative ischemia had thrombosed bypasses, and three had stenosed but patent grafts. Eight (62%) of the 13 patients had successful vascular repair, the rest had amputations. All patients with previous vascular surgery and those with primary bypasses were prospectively followed up with segmental Doppler pressure indices. Falling segmental Doppler pressure index values occurred in eight patients and in six patients prior to onset of recurrent ischemia. Intravenous digital subtraction angiography demonstrated correctable stenotic lesions in the six asymptomatic patients and untreatable host vessel occlusion in two symptomatic patients. Corrective surgery successfully preserved patency of all stenosed grafts. In summary, postoperative surveillance can detect occlusive changes before recurrent symptoms occur. Repair of stenosed grafts is more successful than repair of occluded grafts.