Long-term outcomes and sac volume shrinkage after endovascular popliteal artery aneurysm repair.

OBJECTIVES: The aim was to evaluate long-term outcomes and sac volume shrinkage after endovascular popliteal artery aneurysm repair (EVPAR). METHODS: This study was a retrospective review of all EVPAR cases between 1999 and 2012. Sac volume shrinkage, long-term patency, limb salvage, and survival were evaluated using Kaplan-Meier estimates. The association of anatomical and clinical characteristics with patency was evaluated using multivariate analysis. RESULTS: Forty-six EVPAR were carried out in 42 patients (mean age 78 years, 86% male; mean sac volume 45.5 ± 3.5 mL). In 93% of cases (n = 43) the procedure was elective, while in 7% of cases it was for rupture (n = 2) or acute thrombosis (n = 1). Of the 43 patients who underwent elective repair, 58% were asymptomatic and 42% symptomatic (14 claudication, 3 rest pain, and 1 compression symptoms). Technical success was 98%. Mean duration of follow-up was 56 ± 21 months. Primary patency at 1, 3, and 5 years was 82% (SE 2), 79% (SE 4), and 76% (SE 4), while secondary patency was 90% (SE 5), 85% (SE 4), and 82% (SE 1) respectively; at 5 years there was 98% limb salvage and an 84% survival rate. During follow-up 11 limbs had stent graft failure: six required conversion, one underwent amputation, and four continued with mild claudication. Of those with graft failure, 63% (7/11) occurred within the first year of follow-up. The mean aneurysm sac volume shrinkage between preoperative and 5-year post-procedure measurement was significant (45.5 ± 3.5 mL vs. 23.0 ± 5.0 mL; p < .001). Segment coverage >20 cm was a negative predictor for patency (HR 2.76; 95% CI 0.23; p = .032). CONCLUSIONS: EVPAR provides successful aneurysm exclusion with good long-term patency, excellent limb salvage, and survival rates. Close surveillance is nevertheless required, particularly during the first postoperative year. Patients requiring long segment coverage (>20 cm) may be at increased risk for failure.

Iliac conduits for endovascular repair of aortic pathologies.

OBJECTIVES: Challenging iliac access during thoracic endovascular aortic repair (TEVAR) is associated with a higher risk of access site complications such as injury or rupture of the iliac vessels. As a result, the use of iliac conduits is frequently used to facilitate access during TEVAR. This report evaluates the effect of iliac conduits on TEVAR outcomes. METHODS: The 2005-2010 American College of Surgeons Surgical Quality Improvement Program database was queried to identify vascular patients undergoing elective TEVAR. Patients without conduit (Group A) were compared to patients who underwent TEVAR with conduit (Group B). RESULTS: We identified 1037 patients (90%) in Group A (69 ± 12.7 years, 42% female) and 117 patients (10%) in Group B (70 ± 12.6 years, 68% female). Women received conduits more often than men (Male:5.8%, Female:15.7%, p < 0.001). There was no significant difference in the rate of non-surgical (A:19%,B:25%,p = 0.121), pulmonary (A:11%,B:16%, p = 0.115), renal (A:3.1%, B:1.7%, p = 0.4) and cardiovascular complications (A:8%, B:12%, p = 0.143) between groups. However, any complication (A:24%, B:33%. p = 0.025), surgical complications (A:10%, B:16%, p = 0.035) and mortality (A:4.5%, B:12%. p = 0.001) were significantly higher in Group B. In multivariate analysis, use of conduit was associated with a 3.8 times higher risk of death compared with no conduit after controlling for confounders. Length of in-hospital stay was similar for both groups (A:6.6 ± 8.8, B:7.6 ± 8 days, p = 0.247). The use of conduits had a declining rate over time from 17.9% in 2006 down to 6.5% in 2010. CONCLUSIONS: Female patients more frequently require iliac conduits during TEVAR compared to men. Conduits were associated with a higher rate of surgical complications and mortality. The incidence of conduit use has decreased threefold in the last five years. Safer access for TEVAR by use of a conduit should not be abandoned based on these results, but there should be a heightened awareness for the higher rate of mortality in these patients.

Use of dermagraft, a cultured human dermis, to treat diabetic foot ulcers.

OBJECTIVE: To assess the effect of a tissue-engineered human dermis (Dermagraft) in healing diabetic foot ulcers. RESEARCH DESIGN AND METHODS: This controlled prospective multicenter randomized single-blinded pilot study evaluated healing over a 12-week period in 50 patients with diabetic foot ulcers. These patients were randomized into four groups (three different dosage regimens of Dermagraft and one control group). All patients received identical care except for the use of Dermagraft tissue. Ulcer healing was assessed by percentage of wounds achieving complete or 50% closure, time to complete or 50% closure, and volume and area measurements. RESULTS: Ulcers treated with the highest dosage of Dermagraft, one piece applied weekly for 8 weeks (group A), healed significantly more often than those treated with conventional wound closure methods; 50% (6 of 12) of the Dermagraft-treated and 8% (1 of 13) of the control ulcers healed completely (P = 0.03). The percentage of wounds achieving 50% closure was also significantly higher (75 vs. 23%; P = 0.018), and the time to complete or 50% closure was faster (P = 0.056). The group A regimen was more effective than other treatment regimens. All three were better than the control, however, and a dose-response was observed. There were no safety concerns. After a mean of 14 months of follow-up (range 11-22 months), there were no recurrences in the Dermagraft-healed ulcers. CONCLUSIONS: Dermagraft was associated with more complete and rapid healing in diabetic foot ulcers. The recurrence data may indicate an improved quality of wound healing.

Promotion and acceleration of diabetic ulcer healing by arginine-glycine-aspartic acid (RGD) peptide matrix. RGD Study Group.

OBJECTIVE: To determine the effectiveness and safety of arginine-glycine-aspartic acid (RGD) peptide matrix in the treatment of diabetic foot ulcers. RESEARCH DESIGN AND METHODS: This randomized placebo-controlled investigator- and patient-blinded prospective multicenter investigation was conducted at three institutional and three private U.S. clinics providing ambulatory care. Sixty-five diabetic patients with chronic full-thickness neurotrophic foot ulcers were enrolled. Six discontinued the study because of adverse events. RGD peptide matrix (Argidene Gel; formerly Telio-Derm Gel) was applied topically twice weekly for up to 10 weeks in patients who otherwise received standard care. Control group patients received topical saline as a placebo plus standard care. The primary method of assessment was the incidence and rate of ulcer closure. All patients enrolled were included in the data analysis. RESULTS: The percentage of patients whose ulcers healed completely in the RGD peptide matrix group (35%; 14 of 40 patients) was over fourfold greater (P = 0.02) than that in the placebo group (8%; 2 of 25 patients). By the study end point (either day of healing or week 10), 30 of 40 (75%) RGD peptide matrix patients had achieved > 50% ulcer closure compared with 12 of 25 (48%) placebo patients (P = 0.03). RGD peptide matrix also significantly (P = 0.03) increased the rate of ulcer closure over the 10 weeks of the study. CONCLUSIONS: RGD peptide matrix treatment promoted and accelerated the healing of chronic diabetic foot ulcers to a significant degree.

Seizures following carotid endarterectomy.

Cerebral infarction, headache, and hypertension are well-known complications of carotid endarectomy (CEA). Seizures are a less frequent, but important complication. We describe eight patients with focal and generalized seizures following CEA. Seizures occurred 6 to 13 days after CEA. All began as focal motor seizures contralateral to the side of the CEA, and six patients developed generalized tonoclonic seizures. Lorazepam and phenytoin sodium controlled the seizures. Five patients without evidence of stroke on computed tomographic scan were normal in follow-up and had no further seizures. The other three patients had mild deficits. One developed a chronic seizure disorder. The pathogenesis of this syndrome following CEA remains unclear, but may involve cerebral hyperperfusion, cerebral embolization, or both.

Influence of cadaveric organ source on delayed renal allograft function.

From 1984 to 1987, 110 locally retrieved cadaveric kidneys were transplanted into 108 local recipients, including 50 kidneys from multiple-organ retrieval (MOR) procedures and 60 from kidney-only (KO) donors. Conventional multiple organ retrieval technique, iced Euro-Collins storage, and cyclosporine-prednisone immunosuppression were employed. Delayed graft function (DGF), defined as dialysis dependence after transplantation, was twice as high in the MOR allografts as in the KO allografts, 46% vs. 22%, P less than 0.01. DGF was associated with longer hospitalization postoperatively and reduced eventual allograft function. The greater concordance of DGF in allograft pairs from the MOR group (25% vs. 7% in the KO group) and the increased incidence of DGF when more complex forms of MOR were used (40% with liver or heart retrieval, 55% with liver and heart retrieval) suggested that retrieval-related factors influenced allograft function. DGF in the MOR allografts was unrelated to other differences in donor, preservation, or recipient characteristics in the comparative groups. Unrecognized warm ischemia during conventional MOR is a plausible cause of DGF in kidneys from multiple-organ donors.

Vascular reactivity in patients with peripheral vascular disease.

Noninvasive techniques have been used to demonstrate a specific pattern of impaired vasoactive response in the normal brachial artery of patients with clinical atherosclerosis. This is a physiologic reflection of the systemic nature of atherosclerosis and may be useful as a marker for identifying patients with preclinical atherosclerotic disease.

Case report: late rupture of a thrombosed abdominal aortic aneurysm.

A patient with a thrombosed aortic aneurysm, proved by angiography, died of aortic rupture 5 1/2 months after thrombosis. To our knowledge, this is the first reported case of late rupture of a thrombosed aortic aneurysm. This occurrence raises questions about the long-term safety of nonresective treatment of aortic aneurysms.

Revision of failed infrainguinal bypass graft: principles of management.

Our experience with 112 patients whose infrainguinal bypass grafts (IIBPGs) failed more than 30 days after insertion was reviewed. Cumulative patency rates (CPRs) after graft revision (GR) were 71% at 6 months, 62% at 12 months, 57% at 24 months, 54% at 36 months, and 46% at 48 months. CPRs of IIBPGs that failed more than 12 months after insertion were higher than those of grafts that failed earlier (60% vs. 36% at 36 months (p less than 0.05). Failure of the initial GR did not preclude a successful secondary revision. The 3-year CPR of the initial GR was 31% compared with 49% for secondary GR (p = no significance). The results of GR are significantly better when graft failure is diagnosed before graft thrombosis. Revision of the 37 hemodynamically failed but patent grafts resulted in a CPR of 89% at 12 months and 77% at 36 months compared with a CPR of 33% at 12 months and 26% at 36 months after revision of the 75 thrombosed grafts (p less than 0.01). Hemodynamically failed but patent grafts occurred in 36 of 68 patients (53%) with failed autogenous veins but only 1 of 44 patients (2%) with a failed prosthetic graft had GR before thrombosis of the graft. There is a significant improvement in early CPR when a new bypass graft is inserted as compared with original graft thrombectomy and angioplasty. The CPR for new bypass grafts at 6 and 12 months was 61% and 41%, respectively, compared with a CPR of 26% and 20% for the same time intervals with graft thrombectomy and angioplasty (p less than 0.05). The presence of thrombus in the outflow artery at the site of GR is a contraindication to anastomosis at that site even if arterial thrombectomy reestablishes backflow. When distal arterial thrombus was not present, the CPR after GR was 62% at 6 months, 42% at 12 months, and 33% at 36 months. When distal arterial thrombectomy was necessary, the CPR after GR was only 14% at 6 months and zero at 12 months (p less than 0.05).

Natural history of recurrent and residual stenosis after carotid endarterectomy: implications for postoperative surveillance and surgical management.

BACKGROUND: Noninvasive surveillance of patients after carotid endarterectomy is practiced routinely to detect recurrent stenoses. Many authors advocate repair of asymptomatic severe stenoses so detected. The likelihood of these lesions causing neurologic symptoms is unknown. Our aims were to (1) define the incidence of lesions, (2) determine the frequency of associated neurologic symptoms, and (3) identify patient-dependent factors that might predict restenosis. METHODS: Data on the status of 449 carotid arteries after endarterectomy were reviewed. The number of recurrent and residual severe (greater than or equal to 80%) stenoses was identified. Interval to development of symptoms was determined by life-table analysis. Patient-dependent factors (age, gender, smoking, diabetes, and patch closure) were evaluated by univariate and multivariate analysis to identify possible associations with severe lesions. RESULTS: Severe (greater than or equal to 80%) stenoses were seen in 35 patients (7.9%). Residual lesions were seen in 17 cases (eight occlusions and nine stenoses); recurrent lesions were identified in 18 patients (3.9%). Symptoms developed in five cases (14%) (one residual and four recurrent) 35, 48, 68, 98, and 103 months after surgery. The likelihood of developing symptoms associated with stenosis at 5 years was 6%. No factors correlated with residual stenosis. Age less than 60 years, female gender, primary closure, and absence of diabetes were more common in patients with recurrent lesions. CONCLUSIONS: Severe lesions can be found after carotid endarterectomy in at least 8% of patients and consist of residual defects, as well as recurrent stenoses. Recurrent lesions are more common in specific patient subgroups. These lesions are stable for long periods and the majority remain asymptomatic. Operation is not indicated unless symptoms develop in these patients. Intraoperative completion evaluation may be indicated to reduce the incidence of residual disease. Early noninvasive evaluation is useful as a quality-control measure. Repeated surveillance may provide data on the course of restenosis or contralateral disease progression but is of limited clinical benefit.

Angiographic and pathologic correlates in carotid artery disease.

Eighty-four consecutive intact atheromata from the carotid bifurcation were examined macroscopically and by standard microscopic techniques. Preoperative angiograms of these cases were reviewed by a single radiologist with special attention to detecting the presence of ulceration. Pathologic and angiographic findings were compared and correlated with the patient's clinical presentation. Macroscopic findings of ulceration were present in 43 cases (51%). Thirty-four specimens contained intramural hemorrhage and 27 showed evidence of mural thrombus. Mural thrombus was significantly associated with evidence of ulceration (p less than 0.01). Intramural hemorrhage was commonly associated with ulceration (25/34) but was also seen in nonulcerated plaques (p greater than 0.05). Angiographic diagnosis of ulceration was made in 54 cases (64%). While angiography identified 78% of macroscopic ulcers (34/43; p = 0.05), seven typical ulcerations were missed angiographically and there were 18 angiographic false positive results (18/54:33%). Macroscopic ulcerations were most common in patients with symptoms of hemispheric ischemia (p less than 0.1). The angiographic diagnosis of ulceration did not correlate with the patient's clinical presentation (i.e., hemispheric ischemia, nonhemispheric ischemia, or asymptomatic stenosis). These results support the thesis that macroscopic ulceration is an important cause of hemispheric ischemia. Angiography does not reliably predict the presence of macroscopic ulceration and this limitation should be kept in mind when patients with hemispheric symptoms are evaluated. Such patients should not be denied consideration for endarterectomy simply because the angiogram fails to demonstrate ulceration.

Dimethylsulfoxide-treated, cryopreserved venous allografts in the arterial and venous systems.

Autologous saphenous vein is the preferred conduit for most vascular reconstructive procedures; however, many authorities have emphasized the need for a reliable alternate. This study was designed to assess the short-term patency of dimethylsulfoxide-treated, cryopreserved saphenous vein allografts in both high- and low-flow states. An early patency rate of 58.3% was found for such allografts interposed in the arterial system. No instance of aneurysm formation was noted. Allografts interposed in the venous system uniformly occluded within 5 weeks. However, in animals treated with aspirin and dipyridamole there was an 83% early patency rate for cryopreserved allografts in the venous system. These studies suggest that dimethylsulfoxide cryopreservation is a viable technique for venous allograft preservation as demonstrated by satisfactory short-term patency of grafts implanted in the arterial system. The results also suggest that treatment with aspirin and dipyridamole has a beneficial effect on the early patency of such grafts placed in the venous system.

Effect of prostaglandin E1 on blood flow in normal and ischemic canine hindlimbs.

Prostaglandin E1 (PGE1) is a potent vasodilator that will increase peripheral blood flow. After infusion of PGE1, little is known about the distribution of flow between skin and muscle or the effect of PGE1 on an ischemic leg. We infused intra-arterially PGE1 (5 ng/kg/min) into normal and ischemic canine hindlimbs. Radioactive microspheres were used to measure nutrient flow to skin and muscle and flow shunted through arteriovenous connections. Intra-arterial PGE1 caused significant increases in skin blood flow in both normal and ischemic hindlimbs. Shunted flow did not increase. Muscle flow increased in normal canine hindlimbs, but this increase was prevented by femoral artery ligation. We conclude that PGE1 increases absolute nutrient flow rather than opening arteriovenous shunts in the canine hindlimb. Skin flow is most sensitive to prostaglandin infusion. Muscle flow is increased in normal but not ischemic limbs. PGE1 may be useful in situations where vasospasm is a prominent feature. The role of PGE1 in atherosclerotic ischemic disease remains unclear.

Failure of immunosuppression to prolong venous allograft survival.

The role of allograft veins in vascular reconstruction remains ill defined. The present experiment was undertaken to evaluate the role of immunosuppression in maintaining allograft patency in the canine femoral venous circulation. Twenty-seven mongrel dogs had segments of both femoral veins excised and each dog received one allograft and one autograft. The dogs were randomly assigned to a control group or to one of three treatment regimens of azathioprine. Low doses of azathioprine were of no benefit in improving patency of venous alografts. Microscopic evaluation of these grafts suggests that substantial intimal repopulation by host cells occurs by six to eight weeks in the canine model. Other methods of preserving patency until intimal repopulation occurs deserve further investigation.

Limb salvage using high-pressure intermittent compression arterial assist device in cases unsuitable for surgical revascularization.

HYPOTHESIS: Intermittent compression therapy for patients with inoperable chronic critical ischemia with rest pain or tissue loss may have beneficial clinical and hemodynamic effects. STUDY DESIGN: Case series of 14 consecutive ischemic legs that underwent application of a 3-month treatment protocol during a 2(1/2)-year study. SETTING: Veterans Administration Hospital. PATIENTS: Thirteen patients with 14 critically ischemic legs (rest pain, n = 14; tissue loss, n = 13) who were not candidates for surgical reconstruction were treated with rapid high-pressure intermittent compression. The patients had a mean age of 76.2 years, 8 were diabetic, and they represented 10% of referrals for chronic critical ischemia. They were not amenable to revascularization owing to lack of outflow arteries (n = 7), lack of autogenous vein (n = 5), or poor general medical condition (n = 3). INTERVENTION: All patients were instructed to use the arterial assist device for 4 hours a day at home for a 3-month period. MAIN OUTCOME MEASURES: Limb salvage and calibrated pulse volume amplitude. RESULTS: After 3 months, 9 legs had a significant increase in pulse-volume amplitude (P< .05). These legs were salvaged, whereas the 4 amputated legs demonstrated no hemodynamic improvement. We noted a direct correlation between patient compliance and clinical outcome. Patients in whom limb salvage was achieved used their compression device for longer periods of time (mean time, 2.38 hours a day) compared with those who underwent amputation (mean time, 1.14 hours a day) (P< .05). These mean hours of use were derived from an hour counter built into the compression units. CONCLUSIONS: Intermittent high-pressure compression may allow limb salvage in patients with limb-threatening ischemia who are not candidates for revascularization. Further studies are warranted to assess intermittent compression as an alternative to amputation in an increasingly older patient population.

Upper extremity claudication 10 years after a Blalock-Taussig shunt treated with a carotid-to-subclavian graft.

A case of progressive upper extremity vascular insufficiency, which occurred 10 years after the construction of a Blalock-Taussig anastomosis, is described. It was successfully managed with a carotid-to-subclavian bypass graft.

Coronary and carotid operations under prospective standardized conditions: incidence and outcome.

BACKGROUND: No randomized trial has yet evaluated the hypothetical benefit of carotid endarterectomy with coronary artery bypass grafting. This prospective review was undertaken to determine the differences between observed and predicted complication rates, as well as to define new predictors and assess costs in a standardized population. METHODS: A prospective nonrandomized study was undertaken over a 4-year period involving all coronary artery bypass graftings done at one institution. Operative procedure was standardized. All patients underwent preoperative screening for carotid disease. If 80% or more stenosis was present, combined coronary artery bypass grafting and carotid endarterectomy was performed. RESULTS: Of 2,071 patients, 1,987 had coronary artery bypass grafting only. In that group there were 34 strokes (1.7%) and 41 deaths (2.0%). Eighty-four patients underwent combined coronary artery bypass grafting/carotid endarterectomy and in that group there were four strokes (4.7%) and five deaths (5.9%). Independent risk factors for postoperative stroke were age (odds ratio 1.09; 95% confidence interval 1.04, 1.3), hypertension (odds ratio 2.67; 95% confidence interval 1.22, 5.23), extensively calcified aorta (odds ratio 2.82; 95% confidence interval 1.34, 5.97), and bypass time (odds ratio 1.01; 95% confidence interval 1.00, 1.02). Cost of a stroke was significant (p < 0.05) in both groups. CONCLUSIONS: Patients with carotid disease fall into a higher risk group than patients without it. This increased risk is not because of carotid disease alone. Patients without significant carotid disease, who suffered a perioperative stroke, fell into an even higher risk category. Furthermore, carotid endarterectomy was not a significant risk factor by either the univariate or the multivariate analysis.

Is routine carotid ultrasound surveillance after carotid endarterectomy worthwhile?

BACKGROUND: Periodic ultrasound studies are routinely performed after carotid endarterectomy with the aim of detecting recurrent stenosis or progression of contralateral disease. The frequency with which these studies should be performed and their clinical utility is at present unclear. Our experience with ultrasound surveillance after carotid endarterectomy was reviewed. METHODS: We performed a retrospective analysis of our carotid registry as a follow-up on patients who had undergone primary endarterectomy between 1982 and 1995. The database was searched for events referable to the contralateral carotid artery including incidence of contralateral endarterectomy, progression of contralateral stenosis, and development of new neurologic symptoms. Data was analyzed by life-table methodology. RESULTS: A total of 562 patients underwent 660 endarterectomies during the study interval with a postoperative stroke rate of 3.6% and a mortality of 1.1%. Of these, 496 patients had data available on the contralateral artery. There were 384 patent, nonoperated contralateral arteries available for long-term clinical follow-up, of which 276 had serial Doppler examinations. At the time of initial presentation, 30% of patients (141 cases) had greater than 50% diameter stenosis in the contralateral artery including 45 occlusions. There were 67 contralateral endarterectomies performed within 6 months of the original surgery. An additional 15 endarterectomies were performed within 24 months of the original surgery and only 16 subsequent endarterectomies were performed up to the 8-year follow-up. Progression of contralateral stenosis from less than to greater than 50% occurred in 10.1% of the patient population. The rate of disease progression was 5.1% at 3 years, 17.8% at 5 years, and 30% at 7 years. Stroke-free survival in patients without progression was 94.7% at 3 years and 93.3% at 5 years. CONCLUSIONS: Significant contralateral disease occurs in about one third of patients, most of whom are candidates for early contralateral endarterectomy. In patients who present with minimal contralateral disease, the incidence of progression is low over time. Follow-up duplex examinations on a biennial schedule is sufficient to detect clinically significant disease progression in these patients.

Completion angiography, is it really necessary?

BACKGROUND: Routine completion imaging after carotid endarterectomy (CEA) has been advocated by many investigators to detect and repair unsuspected defects with the goal of reducing perioperative morbidity and residual disease. However, completion imaging has been performed rarely in our practice. Our carotid registry was interrogated to determine whether omitting routine completion imaging adversely affected outcome. METHODS: A retrospective review of 229 consecutive CEAs performed by one vascular surgeon during 1988 to 1996 was completed. Duplex follow-up was used to identify persistent residual defects, which were classified as 50% to 74%, 75% to 99%, and occlusion in the common (CCA), internal (ICA), and external (ECA) arteries and was available in 192 cases. RESULTS: During the study period, eight completion angiograms were performed (3.5%) and 5 arteries were reopened. Combined stroke and death rate was 3.1% (7 of 229). Duplex follow-up, available on 192 patients, showed residual lesions in 29 patients (15%), but only 7 (3.6%) involving the internal or common carotid. CONCLUSION: Routine completion imaging is not required to achieve acceptable morbidity and mortality and minimize residual problems after CEA. Attention to operative details with selective imaging will give excellent results.