bluuebunny/crossref_metadata_2025 huggingface dataset:
Ultrasound-Guided Nonsurgical Closure of Postangiographic Femoral Artery Injuries
Authors: Altstidl Robert , Lehmkuhl Hans B. , Voss Eckbert , Herold Christoph , Becker Dirk , Giinter Erwin , Bachmann Kurt
Published: June 2007

Postcatheterization injuries at the vascular access site include pseudoaneurysms and arteriovenous fistulas. Traditional treatment of this complication has been surgical repair. This study describes a recently developed method for closing femoral pseudoaneurysms and arteriovenous fistulas by using external compression guided by Doppler color flow imaging. Thirty-six femoral artery injuries (31 pseudoaneurysms, 5 arteriovenous fistulas) were detected by color flow imaging in 35 patients with enlarging groin hematomas and/or groin bruits. All patients underwent a full trial of compression therapy, with an extended compression time limit of 240 minutes and a tag-team approach of two operators to overcome manual fatiguing. The mechanical compression was titrated to obliterate the vascular tracts to the aneurysms or of the arteriovenous fistulas and to maintain an adequate flow in the femoral artery, as far as possible.

All postangiographic pseudoaneurysms were successfully treated with a compression time ranging from 10 to 110 minutes, even in patients receiving prolonged anticoagulant therapy. Follow-up ultrasound examination the following morning and 4 to 5 days later confirmed a continued closure in all patients, without side effects such as venous thrombosis or ischemia. In arteriovenous fistulas, compression therapy was successful in two cases without complications or recurrences during follow-up.

This study demonstrates that Doppler color flow ultrasound-guided compression of postangiographic femoral artery injuries is a safe and technically simple device and may be implemented as a cost-effective, first-line treatment, with a high rate of success in pseudoaneurysms.
Is Impedance Plethysmography a Safe Test After Total Joint Replacement?
Authors: Dixon David J. , Ricci Michael A. , Reid James G. , Possidente Carl , Incavo Stephen J. , Howe James G.
Published: June 2007

Screening for deep venous thrombosis (DVT) following total joint replacement (TJR) has been recommended as an adjunct to DVT prophylaxis. This study evaluates a structured protocol utilizing impedance plethysmography (IPG) as the primary screening modality. Over a 12-month period all patients undergoing TJR of the lower extremities had an IPG 3 to 5 days after surgery. Patients received primary DVT prophylaxis with warfarin. Minimal follow up of 6 weeks was obtained on all patients.

Three-hundred three TJRs were performed. The IPG appeared normal in 220 of 303 patients (73%), obviating further testing. During follow-up, two patients had thromboembolic disease (TED). Of the 83 seemingly abnormal IPGs, 81 were false positive compared to venous ultrasound, with significantly more after knee surgery (p < 0.001). There was one confirmed DVT in the abnormal IPG group and one patient died 2 weeks after discharge with an autopsy-proven pulmonary embolism. There was a low overall rate of TED (1.3%); three fourths of patients with TED presented 2-4 weeks after discharge.

These results indicate that it is clinically safe to discharge patients who have had a normal-appearing postoperative IPG. However, the large number of false-positive results reduces the utility of the test, particularly after knee replacement. While IPG is safe and cheaper than venous ultrasound, prophylaxis extended beyond the of hospitalization may obviate the need for screening.
Reoperation for Recurrent Carotid Stenosis: A Ten-Year Experience
Authors: Munn John S. , Jain Krishna M. , Simoni Eugene J.
Published: June 2007

Owing to the supposed risks of reoperation, carotid stenting has been proposed as a treatment for carotid restenosis. The purpose of this study is to determine the safety and efficacy of carotid reoperation. From March 1988 to March 1997, 40 patients, 18 men and 22 women (mean age: 65 years) underwent a total of 43 redo carotid procedures by our group. Two patients had both sides repaired and one required a second reoperation. Symptomatic recurrent carotid stenosis (>70%) was the indication in 25 reoperations and asymptomatic high-grade stenosis (>80%) was the indication in 18. The initial operation in 35 reoperations was carotid endarterectomy (CEA) with primary closure and in eight it was CEA with a prosthetic patch. The interval to recurrence was less in the 24 reoperations in patients who had myointimal hyperplasia (21 months) compared with 17 reoperations in patients with recurrent atherosclerosis (90 months). The other two reoperations were for an intimal flap 2 months after the original CEA, and for operative dilation of fibromuscular dysplastic bands missed on magnetic resonance angiography (MRA), distal to the site of a previous CEA.

The technique of reoperation included redo CEA in two, CEA with vein patch in eight, CEA with prosthetic patch in 22, vein interposition graft in five, and prosthetic interposition graft in five. In addition, operative dilation with an arterial dilator was used in one reoperation.

No perioperative strokes or deaths occurred other than one patient who died from cardiac complications following combined CEA and coronary artery bypass grafting. Operative morbidity consisted of pneumonia in one patient, reversible cranial nerve injury in four, and hematoma requiring evacuation in two. During follow-up (mean: 34 months), carotid occlusion resulted in a mild stroke in one patient, there were 10 late deaths not related to carotid disease, one patient required a reoperation, and three patients were lost to follow-up.

The authors conclude that reoperation for recurrent carotid stenosis, using standard vascular techniques, is both safe and effective; it should continue to be the mainstay of treatment when intervention is required.
Calciphylaxis: Calcific Angiopathy Resulting in Acral Gangrene
Authors: Kasirajan Karthikeshwar , Obermeyer Robert J. , Lucarelli Maria R. , Hirko Mark K. , Turner John J. , Rubin Jeffrey R.
Published: June 2007

The role and success of peripheral vascular surgery in patients with end-stage renal disease (ESRD) remains controversial. Reduced survival, higher mortality, and lower limb salvage rates have led some authors to advocate primary amputation in this patient population. Until recently, the explanation for high failure and mortality in these patients could not be explained. The authors report five patients with ESRD initially diagnosed with acral gangrene secondary to calciphylaxis. Despite distal gangrene, only three of the five patients had significant peripheral arterial insufficiency. Poor surgical results in ESRD patients developing peripheral vascular disease (PVD) can sometimes be explained on the basis of calciphylaxis.
A Comparison of Compression Pumps in the Treatment of Lymphedema
Authors: Bergan John J. , Sparks Stephen , Angle Niren
Published: June 2007

Purpose: This study was done in order to ascertain which methods of mechanical compression would be optimum in treating patients with primary and secondary lymphedema.

Materials and Methods: Thirty-five patients (26 women, 9 men) were enrolled in the study. The women ranged in age from 36 to 82 years (mean 56.9 years). The men ranged in age from 31 to 83 years (mean 56.4 years). Ultimately, 32 patients completed the study. Each patient was treated by random assignment to each of the three types of compression pumps. The treatment arms were as follows: (1) unicompartmental nongradient pump with pressure of 50 mm Hg, (2) a three-compartment pump with segmental, nongradient pressures of 50 mm Hg in each of three cells, and (3) a multicompartmental gradient pressure pump with ten cells ranging in pressure from 80 at the most distal to 30 at the most proximal. There were 35 extremities treated by each of the three methods. Eleven had primary lymphedema and 24 had secondary lymphedema.

Results: The mean percentage volume change was +0.4% in the limbs treated with the unicompartmental pump, +7.3% in the three-compartment pump, and -32.6% in the ten-compartment pump. By use of Kruskal and Wallis, one-way ANOVA on ranks, a significant difference between the three treatments was detected (p < 0.001). In treatment of primary lymphedema there was no difference between the subgroups with regard to the effect of the three compression pumps. In treatment of secondary lymphedema, there was no reduction in the size of the limbs treated with the single-compartment, there was a -4.65% reduction in the three-compartment pump treatment, and -28.4% in the tencompartment pump. There were no differences in treatment of secondary limbs with and without radiation. In an analysis comparing primary to secondary lymphedema with and without radiation, the results were not statistically different from one another. Other factors such as severity of lymphedema, gender, duration of lymphedema, history of infection, and presence of radiation could not be implicated as having prognostic significance or having any effect on response to therapy.

Conclusions: Mechanical external pneumatic compression can produce a reduction in treated limb volumes in primary and secondary lymphedema. This is best achieved by multicompartment sequential compression. Limb volume reduction by single or three compartment devices is decidedly less effective in treatment of lymphedema.
“Hot Ulcer” of the Hand Caused by Retrograde Flow of Arterialized Blood from an Arteriovenous Fistula
Authors: Debus E. Sebastian , Sailer Marco , Voit Ronald , Franke Siegfried
Published: June 2007

Venous hypertension of the hand and forearm is a rare complication of upper extremity arteriovenous (AV) fistula operations for hemodialysis. In severe cases of hand venous hypertension, nonischemic skin ulceration may develop. Our observed case and systematic analysis of the literature show that these venous ulcers of the hand typically are associated with retrograde arterialization of distal fistula vein side branches. We suggest calling these hyperemic skin lesions “hot ulcers” in order to distinguish them from ischemic ulcers. In most instances, hot ulcers are curable by selective ligation of the venous tributaries. If proximal venous outflow is also obstructed, attempts of outflow reconstruction should be undertaken. If this is not feasible, the AV fistula needs to be completely reconstructed.
Myonephropathic Metabolic Syndrome After Bilateral Aortoiliac Bypass: A Pathogenic Role of Cholesterol Microemboli
Authors: Fujii Hirofumi , Ueda Yoshiaki , Oka Takanori , Miyamoto Takashi , Kawaguchi Hideki , Kido Masakuni , Ninomiya Hideki , Osako Motohiko , Kato Yasushi , Otani Hajime , Imanura Hiroji
Published: June 2007

A 72-year-old man was admitted to our hospital for management of intermittent claudication. A preoperative angiogram showed right common iliac artery occlusion with wellmaintained peripheral flow via collaterals and 50% stenosis of the aortic bifurcation through the left common iliac artery. The authors performed bilateral aortoiliac artery bypass surgery. Immediately following the operation, the left lower limb was cyanotic and cold despite a good pulse in the left dorsalis pedis artery. He suffered from severe pain throughout his entire left calf and part of his thigh. Thrombolytic therapy combined with anticoagulation therapy was started in an attempt to reduce limb ischemia. However, swelling of the left calf increased, and clinical and metabolic manifestations consistent with myonephropathic metabolic syndrome (MNMS) developed. Serum creatine kinase and creatinine rose to 21,600 u/L and 2.8 mg/dl, respectively. His toe became necrotic and a transmetatarsal amputation was done. A skin biopsy taken from the edge of the amputation revealed cholesterol crystals within the capillaries. This report suggests that massive cholesterol microemboli are responsible for MNMS in this patient.
Comparison of the Resistive Properties of Reversed and Nonreversed Saphenous Veins at Arterial Pressure and Flow: Implications for Optimal Graft Configuration
Authors: Moawad John , Glagov Seymour K. , Loth Francis , Brown Silas , Schwartz Lewis B.
Published: June 2007

Clinicians continue to debate the hemodynamic advantages of reversed vs nonreversed vein grafts in infrainguinal arterial reconstructions. Vein grafts placed in the reversed configuration do not require valve lysis but have the theoretical drawback of being smaller in caliber at the inflow end than the outflow end. The purpose of this study was to objectively determine the effect of vein valve lysis and flow direction on vein graft hemodynamics by using physiologic levels of pulsatile flow (Q), pressure gradient (AP), outflow resistance (Ro), and longitudinal impedance (ZL).

Nine cryopreserved human greater saphenous veins (length=23 ±1 cm) were perfused via an in vitro circuit utilizing a variable pulsatile perfusion pump, Windkessel, and clamp resistor. Levels of Q and AP were chosen to simulate the known physiologic conditions of infrainguinal bypass grafting while holding Reynolds numbers <2,400. Veins were studied in the reversed configuration prior to valve lysis, after valve lysis by use of a catheter-directed valvulotome with 3 mm cutting head, and in the nonreversed configuration. Ultrasonic transit-time flow and proximal and distal intraluminal pressure were continuously recorded while Ro and pump rate were varied. Waveforms were digitally stored at 200 Hz at pump rates of 60, 100, 140, and 180 beats per minute at a Q of 154 ± 1 and 253 ± 1 mL/min while Pprox was maintained at 100 mmHg. Veins were perfusion fixed at 100 mmHg, sectioned at 2 cm intervals, and analyzed morphometrically. Inner diameter (id) and outer diameter (od) were determined by light microscopy after correction for shrinkage artifact by comparing to outer diameter measured by digital calipers at 2 cm intervals at the time of perfusion. Percent vein taper was calculated as (idmax7idmin)/idmax and wall thickness (t) as (od-id)/2. After Fourier transformation, ZL was calculated as AP/Q at each harmonic and the curves compared by use of Wilcoxon signed-ranks test.

There were one to four valves per vein (idmean=3.6 ±0.3 mm; range 2.3-6.2) with an average taper of -8 + 12% (range: -46-36%) and mean wall thickness of 0.51 ±0.03 mm (range 0.42-0.68 mm). ZL curves were smooth and reproducible over the measured frequency range. Neither valve lysis nor flow direction had an effect on ZL at any level of Q or Ro, even in veins with a taper >25%. Mean wall thickness correlated with ZL (r2=0.43; p=0.05).

In this in vitro system, saphenous vein graft impedance (ZL) was independent of valve lysis, flow direction, and the degree of vein taper but was weakly dependent on wall thickness. In veins of adequate size, hemodynamic considerations should not influence the decision to use the reversed vs nonreversed configuration.
Circadian Variation in the Rupture of Abdominal Aortic Aneurysms
Authors: Meissner Mark H. , Beach Kirk W. , Johansen Kaj H. , Nicholls Stephen C.
Published: June 2007

Circadian variations in the incidence of myocardial infarction, sudden death, and stroke have been attributed to diurnal fluctuations in catecholamine release, blood pressure, heart rate, fibrinolytic activity, and platelet aggregation. As similar factors could precipitate the rupture of an abdominal aortic aneurysm, a retrospective chart review was undertaken in an effort to define the timing of aneurysm rupture and any associated circadian variation.

One hundred forty-three patients with a ruptured abdominal aortic aneurysm (rAAA) and a documented time of presentation were evaluated. Eighty-one patients (56.7%) presented within 2 hours of the onset of symptoms and were examined for diurnal variability in their presentation. The hourly rate of rAAA presentation between 8 AM and 10 PM (4.3 per hour) was more than twice that observed during the night (2.1 per hour, p<0.001). The distribution of presentation times among this group was significantly different from uniform (p=0.05), implying circadian variability to aneurysm rupture. The time-dependent rate of rAAA presentation could be predicted (R2=0.77) with cosinor regression methods, although this model was not statistically significant (F= 4.9, p >0.10).

Abdominal aortic aneurysm rupture occurs with a diurnal variation having a peak during waking hours. The relationship of aneurysm rupture to known physiological circadian rhythms may give further insight into the underlying pathophysiology and has implications for patient management.
Popliteal Sarcomas Masquerading as Popliteal Aneurysms
Authors: Bigatel David A. , Franklin David P. , Meschter Steven C. , Elmore James R. , Youkey Jerry R.
Published: June 2007

Popliteal masses are frequently referred to vascular surgeons with a presumptive diagnosis of popliteal aneurysm. Evaluation by the vascular surgeon must exclude other diagnoses such as Baker's cyst or neoplasm. This case report focuses on two patients referred to the vascular surgery service with popliteal masses. The first patient had a prior popliteal aneurysm repair and the second patient was thought to have a popliteal aneurysm without palpable pedal pulses. Evaluation included duplex ultrasound scanning and imaging with either computed tomography or magnetic resonance. After these studies were performed, both patients underwent fine needle aspiration (FNA) to determine the cytologic features of the masses. Final diagnosis for each patient was a soft tissue sarcoma. The differential diagnosis of a popliteal mass should include both nonneoplastic and neoplastic etiologies. If a neoplasm is suggested, FNA can help differentiate between benign versus malignant and primary versus metastatic disease. Many soft tissue lesions can then be treated based on clinical, radiologic, and cytologic data without the need for open biopsy. Since FNA has a low morbidity rate, the authors recommend early FNA in the evaluation of soft tissue popliteal masses. These cases are reported so that vascular surgeons will be prepared to evaluate patients with popliteal masses for diagnoses other than popliteal aneurysms.
Reverse C-Graft Configuration for Retrograde Aorta Celiac and Superior Mesenteric Bypass Via the Left Retroperitoneal Approach
Authors: Papanicolaou George , Darling R. Clement , Chang Benjamin B. , Paty Philip S. K. , Kreienberg Paul B. , Lloyd William E. , Shah Dhiraj M.
Published: June 2007

The authors report a case of simultaneous elective aortic aneurysm repair and visceral revascularization via the left retroperitoneal approach in a 75-year-old woman. The patient presented with a 5.8 cm infrarenal aneurysm by computed tomography scan. A preoperative arteriogram demonstrated an infrarenal abdominal aortic aneurysm extending to the bifurcation and a left common iliac artery aneurysm. Lateral views showed high-grade stenosis of the celiac artery origin and complete occlusion of the proximal superior mesenteric artery (SMA) with distal reconstitution. The infrarenal aneurysm was repaired via the extended left retroperitoneal approach with an exclusion bypass graft to the iliac arteries. The proximal celiac and superior mesenteric arteries were approached anterior to the left kidney. An 8 mm side arm polytetrafluoroethylene (PTFE) graft was anastomosed to the aortic graft and was brought retrograde posterior to the hilum of the kidney in a reverse C-configuration to the proximal celiac artery where an end-to-side anastomosis was performed. A short 6 mm side arm PTFE from the celiac graft was used to bypass the proximal SMA. The postoperative course was uneventful and the patient was discharged in 5 days. A repeat arteriogram demonstrated patent grafts without kinking.
Heparin-Induced Thrombocytopenia
Authors: Dupont Elisabeth L. , Gahtan Vivian , Mills Joseph L.
Published: June 2007

Serious limband life-threatening thromboembolic complications may result from immune-mediated, heparin-induced thrombocytopenia (HIT) type II. The authors describe three such cases associated with devastating outcomes. The clinical diagnosis of HIT II was based on (1) falling platelet count on heparin (< 150,000/mm3), (2) thromboembolic events on heparin, and (3) absence of new thrombotic events after heparin discontinuation. These distinct case presentations are discussed to broaden clinical awareness of HIT II. A high index of suspicion is warranted to prevent this catastrophic complication.
Quantitative Evaluation of Abdominal Aortic Aneurysm
Authors: Kanaoka Yasushi , Ohgi Shigetsugu , Mori Tohru
Published: June 2007

Rupture of an abdominal aortic aneurysm (AAA) is usually predicted on the basis of measuring the maximum diameter. However, since the size of a normal aorta varies depending on each individual, this indicator does not seem to be ideal. The authors propose a new indicator for the enlargement of aorta and have started clinical application of this technique.

The abdominal aortic diameter was measured by using two-dimensional ultrasonography in 261 adults (aged 20 and over). The control group consisted of subjects with no evident aortic dilatation. Patients with AAA were divided into the nonruptured group and the ruptured group.

Analysis of the data from the control group revealed that the abdominal aortic diameter could be defined by the following equation: Diameter (mm) = 0.147 x age (years) + 0.169 x height (cm) - 15.9. The baseline diameters of the abdominal aorta were calculated by applying the age and height of individual subjects in this equation. The measured diameter was divided by the baseline diameter to obtain the aortic expansion index (AEI). If a cut-off value of the aneurysm diameter and the AEI (calculated by using age 20) for the prediction of significant risk of rupture is set at 44.2 mm (= mean - 2SD of the aneurysm diameter in the ruptured group) and at 2.7 (= mean - 2SD of the AEI in the ruptured group), the risk of rupture based on the diameter in the nonruptured group is underestimated in 11% of cases. However, when the risk of rupture is based on the AEI, the risk is not underestimated in any case in the nonruptured group.

The authors conclude that the AEI is a useful indicator for quantitatively evaluating the risk of rupture of an AAA.
Acute Abdominal Aortic Embolism Caused by Primary Cardiac Echinococcus Cyst
Authors: Tacyildiz Ibrahim H.
Published: June 2007

A 55-year-old woman who had been operated on for liver hytatid disease presented with nausea, vomiting, abdominal pain, and ischemia of both lower extremities. On laparotomy, all small and large bowel segments except the proximal 100 cm of the small intestine were found to be necrotic and were resected. Arteriotomies of both iliac arteries showed hytatid daughter cysts obstructing the blood flow. Circulation was restored, but the patient died from ventricular fibrillation.
Development of Vascular Surgery Skills During General Surgery Training
Authors: Kwolek Christopher J. , Donnelly Michael B. , Endean Eric D. , Sloan David A. , Schwarcz Thomas H. , Hyde Gordon L. , Schwartz Richard W.
Published: June 2007

Purpose: We previously have shown that performance on the National Board of Medical Examiners (NBME) part II examination does not reflect clinical skills. Many training programs use the American Board of Surgery In-Service Training Examination (ABSITE) as the only objective measure of clinical knowledge. This study evaluates the utility of the ABSITE and an objective structured clinical examination (OSCE) in measuring vascular clinical skills during general surgery residency training.

Methods: Residents' mean scores on the vascular section of an OSCE were compared with their mean overall scores on the OSCE by using a two-way analysis of variance (ANOVA). Residents' performance on each clinical section of the ABSITE (body as a whole; gastrointestinal, cardiovascular, and respiratory systems; genitourinary/head and neck/musculoskeletal, and endocrine) and a vascular subsection (VASC) were evaluated by using ANOVA.

Results: Mean vascular scores were significantly lower than mean overall scores for residents at all levels of training (P < 0.0001). Fischer's PLSD (plausible least significant difference) post hoc test revealed that significant improvement occurred between the intern and junior years (P < 0.05), but not between the junior and senior years. In contradistinction, VASC ABSITE scores were better than all other scores for both junior and senior residents, but not for interns (senior: VASC = 96%, other = 79%, P = 0.04; junior: VASC = 84%, other = 64%, P = 0.02; intern: VASC = 63%, other = 50%, P = 0.12).

Conclusions: It is assumed that residents completing residency training are competent to perform clinical vascular examinations. Our findings paradoxically showed that although residents scored highest on the clinical vascular section of the ABSITE, they scored lowest on the vascular section of the OSCE. Although both tests found evidence of improvement between the intern and junior years, neither test found a significant improvement in vascular performance between the junior and senior years. These results emphasize that ABSITE scores do not necessarily correlate with clinical competence, and they demonstrate the need for providing more objective measures of clinical performance.
Is Preoperative Cardiac Testing Indicated Prior to Elective Carotid Endarterectomy?
Authors: Brown O. William , Meltser Steven , Bendick Phillip , Glover John
Published: June 2007

The high incidence of coronary artery disease in patients with peripheral and cerebrovascular occlusive disease has been well established. While preoperative cardiac evaluation has been shown to be beneficial in patients undergoing elective aortic reconstruction, the role of preoperative cardiac testing in patients undergoing elective carotid endarterectomy has not been defined. In this study, the charts of 289 consecutive patients undergoing elective carotid endarterectomy between January 1, 1995, and December 31, 1995, were evaluated to determine the need for cardiac “clearance” prior to surgery. Ages ranged from 48 to 98, with a mean of 70.4 years. The male-to-female ratio was 165:124. Risk factors for coronary artery disease were also assessed: 203 patients (70%) were hypertensive, and 162 patients (56%) gave a history of smoking. An abnormalappearing preoperative EKG was identified in 139 patients (48%). Sixty-seven patients (23%) presented with a history of angina pectoris, and 80 patients (28%) had sustained a myocardial infarction in the past. No patient presented with unstable angina or angina at rest. No patient underwent coronary artery bypass grafting or coronary artery angioplasty immediately prior to carotid endarterectomy. Of the 289 endarterectomies 154 (53%) were performed under regional anesthesia. All patients were monitored with intraoperative arterial pressure catheters. There were no postoperative deaths. No patient sustained a documented postoperative myocardial infarction. One patient experienced chest pain for 24 hours postoperatively. This patient had a history of angina pectoris and a previous myocardial infarction. One patient had an episode of shortness of breath postoperatively. There were two postoperative strokes. These data suggest that patients with known or suspected coronary artery disease can safely undergo elective carotid endarterectomy without extensive cardiac testing prior to surgery.
Popliteal Angioplasty as an Adjunct to Above-the-Knee Synthetic Femoropopliteal Bypass: Comparison of Long-Term Results with Below-the-Knee Bypass
Authors: Onohara Toshihiro , Arnold Thomas E. , Maekawa Takafumi , Matsumoto Teruo , Kerstein Morris D.
Published: June 2007

Long-term results of 27 above-the-knee (AK) synthetic femoropopliteal (SYN-FP) bypasses with simultaneous intraoperative popliteal angioplasty (Group A) were reviewed and compared with 23 below-the-knee (BK) SYN-FP bypasses performed during the same time interval (Group B). Twenty-six of the 27 (96%) popliteal arteries were angioplastied successfully. One patient died postoperatively. Twenty-five limbs had no early occlusions (<30 days), and the postoperative ankle:brachial ratio increased from 0.40 to 0.81 (p < 0.01). The one-year primary patency, secondary patency, and limb salvage rates were 69%, 82%, and 95% in Group A, and 66%, 66%, and 81% in Group B, respectively (p < 0.05). Intraoperative popliteal angioplasty as an adjunct to femoropopliteal bypass was effective. Five-year primary patency, secondary patency, and limb-salvage rates for Group A were 51%, 58%, and 76%, and 34%, 46%, and 59% for Group B, respectively. The mortality rate at five years was 59% (16/27) for Group A and 65% (15/23) for Group B.
Is the Use of Suboptimal Saphenous Veins Justifiable for Limb Salvage?
Authors: Kasirajan Karthikeshwar , Hirko Mark K. , Turner John J. , Rubin Jeffrey R.
Published: June 2007

In situ saphenous vein bypass (ISSV) techniques are preferable when the “target vessel” for arterial reconstruction is below the knee. There is no minimally acceptable vein; however, it must be large enough to generate a physiologic increase in ankle pressure following bypass. This retrospective chart review sought to determine success rates for limb salvage and long-term graft patency in individuals with “less than optimal” saphenous veins. Over a 24-month period, 76 below-the-knee ISSV bypasses were performed and 17 veins were described as “suboptimal.” Of those, three had evidence of prior thrombophlebitis, one had severe varicose changes throughout the graft length, and two were too small to be used for reconstruction. Of the 11 small saphenous veins used, the smallest diameter measured after establishment of arterial flow ranged from 0.9 to 1.6 mm (mean=1.2). Target vessels included the below-the-knee popliteal artery (n= one), posterior tibial artery (n= two), peroneal artery (n= four), anterior tibial artery (n=two), and the dorsalis pedis artery (n=two). Following arterial anastomosis, a 15% or greater increase in ankle-brachial index was achieved in all cases. Limb salvage was achieved in eight of 10 limbs. However, amputation was required in three patients and one died secondary to chronic renal failure. Follow-up ranged from 3 to 24 months (mean= 13). Four bypasses thrombosed despite aggressive surveillance, two had multisegmental graft stenoses requiring revision, and five remained patent (mean follow-up: 9.6 months). Short-term patency was satisfactory and immediate limb salvage was achieved. However, long-term limb salvage was not improved. On the basis of these results, the authors would not recommend the use of saphenous veins less than 2 mm minimum diameter for ISSV bypass.
Angioscope-Assisted Percutaneous Suture Ligation of Venous Tributaries: A Pilot Study
Authors: Erzurum Victor , Hirko Mark K. , Schmidt Steven P. , Rubin Jeffrey R.
Published: June 2007

This study was undertaken to evaluate the feasibility of “incision-free” angioscopeassisted suture ligation of venous tributaries in in-situ nonreversed canine veins. Ten procedures were performed on six dogs. Tributaries were successfully ligated without complication in 79% of the attempts. The large size of the tributaries, perforation leading to hematoma, and problems with visualization led to failure in the remainder. This study demonstrates that percutaneous suture ligation is a feasible method of occluding venous tributaries for in-situ femoropopliteal bypass. Theoretically, “incision-free” angioscopic procedures would allow for decreased trauma to the vein, decreased wound complication rates, and decreased hospitalization. This pilot study will allow the investigators to continue seeking avenues to perfect this technique.
Nonoperative Management of Venous Leg Ulcers: Evolving Role of Skin Substitutes
Authors:   Skin Substitute Consensus Development Panel
Published: June 2007

Chronic venous leg ulcers markedly influence the physical, financial, and psychologic wellbeing of patients and result in an estimated 2 million lost workdays annually. Despite a wide variety of therapeutic options, venous leg ulcers remain a substantial management challenge to health care professionals. Although no consensus on compression therapy exists, it remains a primary treatment of edema and ulceration secondary to venous disease. Recently, biotechnology-derived skin substitutes have been developed to help stimulate local wound healing. These range in composition from an epidermal or dermal layer to a complete, bilayered living skin construct. This review focuses on nonoperative treatment options for venous ulcers, particularly the evolving roles of newer treatment options including skin substitutes and growth factor/cytokine preparations. The development and characteristics of these emerging therapies as well as clinical experience with and options for their use in the treatment of chronic venous ulcers are reviewed.
Bypassing Carotid Restenosis Following Percutaneous Angioplasty and Stenting
Authors: Russell Sean , Swenson Wayne M. , Gaskill William
Published: June 2007

A surgical approach for the treatment of carotid restenosis when a carotid stent is in place is presented. The procedure has proved to be safe and effective with excellent results.
Ambulatory Venous Hypertension: Component Analysis in 373 Limbs
Authors: Raju Seshadri , Neglén Peter N. , Carr-White Paige A. , Fredericks Ruth K. , Devidas Meenakshi
Published: June 2007

Purpose: We studied factors contributing to ambulatory venous hypertension in patients with symptoms of chronic venous insufficiency in order to delineate the contribution of each to global venous hypertension.

Methods: A total of 373 consecutive limbs with ambulatory venous hypertension were studied. Simultaneous ambulatory venous pressure and air plethysmography measurements allowed compliance calculations. With reactive hyperemia, maximal arterial inflow was measured. Air plethysmography provided calf venous pump capacitance and ejection fraction data. Reflux was quantified by a point system based on Duplex, venous filling index on airplethysmography (VFI-90), Valsalva foot venous pressure, and ambulatory venous pressure recovery time (VFT). Multiple regression analysis was used to model ambulatory venous pressure in terms of these variables.

Results: Six major causes of ambulatory venous hypertension were identified and quantified: 1. reflux, 2. increased arterial inflow, 3. reduced venous capacitance, 4. poor ejection fraction, 5. poor compliance of the calf venous pump, and 6. a combination of factors. Of the total, 91% of the limbs had at least two of these factors, 57% had three factors, and 24% had four factors contributing to ambulatory venous hypertension. Reflux was present in 97% of limbs but was significant (VFT <15 seconds) in only 57%, suggesting that other factors were dominant in the remainder.

Conclusion: Ambulatory venous hypertension is a multifactorial entity. Many of the contributing factors are interrelated in a complex fashion. Regression analysis indicates that even though reflux followed by arterial inflow and capacitance were important as single contributing factors, a combination of factors is more important than any single individual factor in the genesis of ambulatory venous hypertension. VFT was found to be superior to other measurements in quantifying global reflux.
Aortoduodenal and Aortocaval Fistula with an Accessory Left Renal Artery Aneurysm Presenting with Heart Failure and Chronic Anemia Due to Hematemesis
Authors: Sultan S. , Madhavan P. , Timlin M. , Doyle M. , Colgan M. P. , Moore D. , Shanik G.
Published: June 2007

The authors present what they think to be the first successfully managed case of a leaking abdominal aortic aneurysm associated with an aortocaval and aortoenteric fistula and an accessory left renal aneurysm reported in the English literature.
Acute Aortic Dissection Involving a Fusiform Abdominal Aortic Aneurysm
Authors: Van Schil Paul E. Y. , Rodrigus Inez E. R. , Haenen Luc R. D. , Van den Brande Filip , Vanmaele Rudolphe G. M. T. , Moulijn Adriaan C.
Published: June 2007

Two patients with a combined acute aortic dissection and a fusiform abdominal aortic aneurysm (AAA) are described. The dissection involved the aneurysm, which is rarely diagnosed during life. An aortic bifurcation graft was inserted, but both patients died of persisting septic shock. An acute aortic dissection involving an existing AAA is a major catastrophic event that should be considered as a complicated aortic dissection for which urgent surgical treatment is advised.
Helical CT Angiography Replaces Conventional Aortography in the Preoperative Evaluation of Abdominal Aortic Aneurysm
Authors: Serna Dan L. , Lee Andrew Y. , Pham Hanh , Chang David , Boos John , Wilson Samuel Eric
Published: June 2007

Conventional aortography accurately defines arterial anatomy for the preoperative assessment of abdominal aortic aneurysms (AAA). Helical computed tomography angiography (CTA) allows enhanced visualization of the aneurysm using less invasive, conventional, computed tomography (CT) methods. Also, three-dimensional (3-D) images may be reconstructed which provide perspective not possible with biplanar arteriograms. The authors tested the hypothesis that helical CTA matches the utility of conventional aortography in the preoperative evaluation of infrarenal AAA. Thirty-one patients with a suspected AAA were evaluated by helical CTA, which included 3-D reconstructions using the maximum intensity projection (MIP) technique. Seven of these patients also received conventional aortography after CTA. Three radiologists and 1 surgeon evaluated all the radiographs for the location and size of the aneurysm or thrombus, for patency of the renal and mesenteric vessels, and for iliac artery patency. In the 7 patients for whom both CTA and aortography were performed, the mesenteric and renal arteries were visualized in both tests. The inferior mesenteric artery (IMA) was recorded in 4 of 7 patients by aortography and in 2 of 7 patients by CTA. In addition, CTA provided detail regarding aneurysm size, presence of aneurysm thrombus, and vessel wall calcification that was not provided by conventional angiography. Of the 31 patients who had CTA, 16 received conventional surgical aneurysm repair after their imaging procedure with no significant intraoperative findings that were not present on CTA. These results suggest that helical CTA is a useful technique in the preoperative evaluation of AAAs. The arteriograrn should be reserved for patients with peripheral occlusive disease or for further evaluation of and possible percutaneous transluminal angioplasty of renal or visceral arterial disease.
The Use of Modified Umbilical Vein Graft as Vascular Access in Chronic Hemodialysis
Authors: Kostakis Alkis , Bokos John , Kyriakidis Stelios , Stamatiadis Demetrios , Sigala Fragiska , Vaiopoulos George , Tzortzis George
Published: June 2007

The selection of material of an arteriovenous graft employed for maintenance hemodialysis when natural veins are lacking is of major importance for its patency rate because of rough handling during hemodialysis, because of multiple needling, and because of other risk factors related to the patient's physical condition. The authors studied 148 umbilical vein grafts implanted in the last 7 years in 123 patients for maintenance hemodialysis. During a 3-year follow up, 83 grafts were lost because of a total number of 137 complications in 103 grafts, despite the invasive and noninvasive attempts at graft rescue. The most frequent cause of graft loss was thrombosis, observed in 87 grafts, causing graft loss in 57. The remaining 50 complications observed were bleeding in seven, aneurysm formation in six, infection in 16, and venostasis or steal syndrome in 21 grafts. Twenty-four of these were rescued, while seven patient deaths were seen with functioning graft. The good biocompatibility of the umbilical vein grafts allowed for multiple interventional and surgical procedures toward graft rescue, which prolonged patency rate. The cumulative patency rate was 72.2 ± 5.9%, 54.4 ± 6.2%, and 31.7 ± 9.2% for the first, second, and third year, respectively. The patency rate is considered satisfactory in view of the prolonged time under hemodialysis and the advanced age of the patients of our study.
Carotid Artery Endarterectomy in the Octogenarian: A Community Hospital Experience
Authors: Goldman Kenneth A. , Singhal Arun , Kahn Steven P. , Davidson J. Thomas , Patel Nilesh , Patel Tushar , Patel Munjal
Published: June 2007

Between May 1995 and April 1998 three vascular surgeons performed 310 consecutive primary carotid endarterectomies (CEAs) in a 224-bed community hospital. Seventy-six CEAs were performed in octogenarians (Group 1) and 234 CEAs were performed in nonoctogenarians (Group 2). Demographic information, indication for surgery, and outcomes were compared. There were no strokes or deaths in Group 1; there was a single death and three strokes in Group 2. The overall rates of death, stroke, and combined stroke and death were 0.3%, 1%, and 1% respectively. No statistically significant difference existed in rates of morbidity and mortality in Groups 1 and 2. On follow-up (mean = 18 months), 94% of the patients were alive without stroke, 5% were dead, and 1% were alive with stroke. These data demonstrate that CEA can be performed safely in the octogenarian in the community hospital setting.
Evaluation of Common Femoral Endarterectomy for the Management of Focal Atherosclerotic Disease
Authors: Hoch J. R. , Turnipseed W. D. , Acher C. W.
Published: June 2007

Although uncommon, focal atherosclerotic lesions of the common femoral artery (CFA) are frequently responsible for disabling ischemic symptoms owing to their proximal location. The authors retrospectively identified 51 patients who between 1983 and 1995 underwent 53 common femoral endarterectomies (CFE) for occlusion (19) or hemodynamically significant (< 70%) stenoses (34). Operative indications included disabling claudication (21%), rest pain (45%), and nonhealing ulcers (34%). In Group 1, patients underwent CFE alone (37 limbs); in Group 2, CFE was combined with a distal bypass (16 limbs). CFA patency was ascertained by physical examination, limb pressures, and pulse volume recordings, with a mean follow-up of 40 months. Cumulative life-table CFA primary patency rates for all extremities were 95%, 85%, and 82% at 1, 3, and 5 years. CFA patency at 1, 3, and 5 years was 94%, 82%, and 77% in Group 1, compared to 100%, 92%, and 92% in Group 2 (p = 0.33, p = 0.34, p = 0.26). Sixty percent of patients with late failures were found to have an inherited hypercoagulable state. The 5-year limb salvage rate was 90% in Group 1 and 94% in Group 2 (p = 0.9). Postoperatively, limbs became asymptomatic, clinically improved, or deteriorated in 35%, 46%, and 19%, respectively of Group 1, compared with 44%, 50%, and 6% of Group 2 (p = 0.6). Focal atherosclerotic lesions of the common femoral artery can be successfully managed by common femoral endarterectomy with acceptable 5-year patency, limb salvage rates, and relief of symptoms.
Management of Hand Ischemia in Patients with Hemodialysis Access by Distal Arterial Ligation and Revascularization
Authors: Lin Peter H. , Chen Changyi , Suroweic Scott M. , Conklin Brian , MacDonald Julie , Weiss Victor J. , Dodson Thomas F. , Lumsden Alan B.
Published: June 2007

Hand ischemia due to arterial steal syndrome is an infrequent but potentially serious complication of hemodialysis access procedures. Correction of symptomatic steal syndrome typically involves fistula ligation, arterial banding, or graft lengthening, each of which provides varying degrees of success. The purpose of this study is to evaluate experience in the treatment of dialysis-associated hand ischemia by distal artery ligation and revascularization. A retrospective review was performed on 14 patients over a 6-year period who developed hand ischemia following hemodialysis access construction and underwent distal artery ligation and revascularization. Patient demographic data, operative indications, risk factors, and treatment outcome were noted. There were 10 men and four women, with a mean age of 52 years (range 21 to 73). Hand ischemia occurred in nine patients with arteriovenous grafts and five patients with arteriovenous fistulas. Nine patients developed steal syndrome within 1 month following the hemodialysis access procedure. All 14 patients underwent a surgical procedure for hand ischemia, which included ligation of the artery distal to arteriovenous fistula and arterial bypass, with reverse saphenous vein grafts in 10 patients, reversed cephalic vein grafts in three patients, and polytetrafluoroethylene graft in one patient. One patient with severe digital gangrene also required amputation. There was no perioperative morbidity or mortality. Following operation, all showed immediate improvement of the affected hand and remained free of symptoms. The cumulative patency rates of the hemodialysis access following the corrective procedure at 1, 3, and 5 years were 85.7%, 64.2%, and 42.9%, respectively. All arterial bypasses remained patent during follow-up, which ranged from 1 month to 5 years (mean 35 months). Distal arterial ligation with revascularization is an effective and durable treatment for patients with arterial steal syndrome following hemodialysis access construction. This technique can be performed with minimal morbidity and maintains a continuous access for hemodialysis.
Chronic Carotid Dissection Producing New Neurologic Symptoms: An Alternative Method of Autogenous Reconstruction
Authors: Wittgen C. M. , Kasperson E.
Published: June 2007

A case of chronic carotid dissection associated with new neurologic symptoms was treated with occipital artery to internal carotid artery bypass. After surgery, the patient remained without neurologic symptoms with a widely patent anastomosis. This novel reconstruction has not previously been reported and provides a suitable alternative for patients with inadequate greater saphenous vein. The mechanism causing this injury and management algorithms are discussed with a review of the literature.
Subfascial Endoscopic Perforator Surgery Conserves Hospital Resources
Authors: Pigott John P. , Beebe Hugh G. , Salles-Cunha Sergio X. , Kellermeyer Gregory F. , Kriegel Andrew V. , Schriefer Cynthia , Dosick Steven M. , Whaleul Ralph C. , Gale Steven S.
Published: June 2007

Innovations in the management of venous disorders have included subfascial endoscopic perforator surgery (SEPS). Information on resource utilization of this procedure is limited. Comparison of sequential cohorts of patients treated for leg venous hypertension by SEPS versus open perforating vein ligation (OPL) was performed to quantify the impact on hospital resource utilization and length of stay. At the Jobst Vascular Center, the last OPL was performed in June 1995 and the first SEPS was performed in January 1994. The authors compared the last 34 consecutive OPL procedures with the first 33 consecutive SEPS operations. Both groups had similar clinical indications. Variables describing utilization of hospital resources were assessed from a computer database compiled at time of treatment and compared by use of t test and chi-square statistics. Charges were selected as representation of hospital resources. SEPS length of stay, 2.3 ±1.8 (sd) days was significantly less than OPL, 4.5 ±2.7 days (p < 0.001) with concomitant reduction in physician bedside visits, 4.8 ±3.9 for SEPS versus 8.0 ±5.3 for OPL (p = 0.007). Total hospital charges in dollars, adjusted for sequential annual increments, were similar: 8,093 +3,811 for OPL versus 7,278 ±1,716 for SEPS (p=0.27). When OPL and SEPS were compared respectively, there were no significant differences in patient age, 58 ±14 versus 53 ±12 years; gender distribution, 62% women versus 42%; active ulcer status, 88% versus 85%; advanced admission testing, 41% versus 58%; use of venography, 97% versus 88%; use of general anesthesia, both 82%; or concomitant vein stripping, 65% versus 58% (p >0.1). SEPS anesthesia time was longer, 136 ±10 versus 122 ±28 minutes (p = 0.01), but not clinically significant. SEPS reduced length of hospital stay and number of physician bedside visits compared with OPL. Total hospital charges may be further reduced as experience with this procedure accumulates.