bluuebunny/crossref_metadata_2025 huggingface dataset:
Clinical Outcome of Patients Developing Transient Ischemic Attacks Following Carotid Endarterectomy
Authors: Mattos Mark A. , Hodgson Kim J. , Ramsey Don E. , Sumner David S.
Published: June 2007

Little is known about the clinical outcome of patients who develop ipsilateral transient ischemic attacks (TIAs) or amaurosis fugax (AF) following carotid endarterectomy (CEA). This review was undertaken to define the natural history of this group of patients and to formulate a rational approach for the evaluation and treatment of their symptoms. From April 1976 to December 1996, 1,121 CEAs were performed at the authors' institution. They reviewed the short- and long-term outcomes of 33 patients (34 CEAs) who developed ipsilateral AF or TIAs as their initial postoperative neurologic event following surgery. Mean follow-up after CEA was 77.0 ± 57.4 months (range 3-220 months), and 49.9 ±52.2 months after occurrence of the initial episode of TIA or AF.

Eleven patients suffered from an early initial ipsilateral TIA or AF within 30 days of CEA, and 23 patients developed late initial ipsilateral TIA or AF during later follow-up. Five secondary neurologic events (15%) occurred after initial ipsilateral TIA or AF. Two patients suffered ipsilateral strokes (one fatal and one nonfatal), one patient developed a recurrent ipsilateral TIA, another a contralateral stroke, and a fifth patient suffered nonhemispheric symptoms following postoperative ipsilateral AF or TIAs. Following the occurrence of initial ipsilateral TIA or AF, 1-, 2-, and 3-year ipsilateral stroke-free rates were 96%, 96%, and 89%, respectively. Recurrent carotid stenosis (>50% diameter reduction) as determined by color flow duplex scanning was present in 10 of 34 (29%) arteries at the time of the initial ipsilateral TIA or AF but correlated poorly with the development of secondary neurologic symptoms. Secondary CEA was performed on six arteries, two for ulcerated carotid lesions < 50%, two for recurrent lesions with 50-79%, and two for recurrent lesions with 80-99% stenosis. All six patients remained free of symptoms following their secondary operation.

These results suggest that the majority of patients who suffer initial ipsilateral TIAs or AF following CEA enjoy a favorable neurologic prognosis, are not associated with recurrent carotid stenosis, and enjoy a natural history similar to patients who develop TIA or AF with normal or minimal to mild internal carotid artery disease. The authors conclude that most patients with postoperative AF or TIA can be managed safely with medical therapy and routine clinical follow-up and that few require surgical treatment.
Successful Upper Limb Salvage After Aneurysm Rupture Due to Congenital Arteriovenous Malformation
Authors: Ohara Nobusuke , Miyata Tetsuro , Yasuhara Hiroshi , Shigematsu Hiroshi , Muto Tetsuichiro
Published: June 2007

This is a unique case of aneurysmorrhaphy and vascular isolation for an aneurysm rupture due to congenital arteriovenous malformation (AVM) of the upper extremity in that a surgical approach could be performed at the site of hematoma to allow successful ligation of arterial inflow and outflow. A 71-year-old woman, having been diagnosed as having AVM 20 years previously, visited the hospital with a chief complaint of progressive swelling of her left forearm with severe pain. Selective angiography showed aneurysmal dilatation and tortuosity of the arterial trunk with preserved anatomical structures in the left upper limb, as well as numerous arteriovenous fistuiae. The proximal portion of the radial artery had enlarged to 5 cm in diameter, forming an aneurysm. The angiogram also showed extravasation of contrast material from the aneurysm, indicating its rupture. At first, the patient was treated conservatively with external compression, since surgical management was considered to carry an unacceptably high risk of limb amputation due to uncontrollable hemorrhage. However, during hospitalization, the swelling worsened to such an extent that there was the possibility of bleeding from the skin. Therefore, a palliative surgical procedure was undertaken for symptom relief. Precise preoperative information from several diagnostic devices permitted performance of this surgery though a minimally invasive route to the aneurysm without any postoperative complications.
An Unusual Cause of Dysphagia: Coil of the Proximal Common Carotid Artery
Authors: Lin Peter H. , Bush Ruth L. , Reddy Pravin , Lumsden Alan B.
Published: June 2007

Although carotid artery redundancies such as kinks or coils are uncommon, they typically are asymptomatic when discovered. The authors report a unique case of proximal common carotid artery coil that caused esophageal compression resulting in symptomatic dysphagia. Following a carotid-shortening procedure in which the redundant artery was resected, the patient's dysphagic symptom resolved completely. This patient under scores the role of surgical resection of a carotid redundancy when it is associated with compressive symptoms.
Use of the Superficial Femoral-Popliteal Vein to Salvage Dialysis Access
Authors: Lee Eugene S. , Tretinyak Alexander S. , Santilli Steven M.
Published: June 2007

Long-term angioaccess for patients with chronic renal failure remains a serious challenge for the vascular surgeon. This report is of a 69-year-old man who had a well-functioning left Brescia fistula at the time of his pacemaker placement for life-threatening cardiac dysrhythmias. Following pacemaker placement, the patient developed left arm swelling, which involved the entire upper limb and failure of the hemodialysis access secondary to a left subclavian vein stenosis. After failed attempts at angioplasty and other endovascular procedures, the patient underwent successful placement of a left axillary vein to left internal jugular vein interposition graft using the left superficial femoral popliteal vein to salvage the dialysis access.
Acute Subclavian Artery and Vein Fistula with Pseudoaneurysm
Authors: Trisal V. , Young S. C. , Mittal V.
Published: June 2007

A case report of an arteriovenous fistula between the subclavian artery and vein as a result of a single gunshot wound to the right side of the chest is presented. There was no intrathoracic injury. The patient was diagnosed and treated within hours of sustaining the injury.
Simple Clamping and Temporary Bypass for Surgery of the Descending Thoracic Aorta
Authors: Shindo Shunya , Kubota Kenji , Kojima Atsuo , Iyori Keiji , Ishimoto Tadao , Kobayashi Masahiro , Kamiya Kihachiro , Tada Yusuke
Published: June 2007

Descending thoracic aortic aneurysms are usually repaired with adjunctive techniques to maintain distal perfusion for the prevention of organ ischemia. The authors have developed a simple technique for this purpose, in which combined simple aortic clamping and temporary bypass were used. The proximal anastomosis was performed with simple aortic clamping, while the distal anastomosis was performed under temporary bypass, which had been anastomosed between the aortic graft and the left femoral artery. This technique was used in four patients. The mean duration of simple aortic clamping was 9 minutes (range:7 to 12 minutes). All patients were discharged without complications. This technique is simple, safe, and less expensive in selected patients.
Retrograde Sartorius Muscle Transposition in Popliteal Fossa Infection
Authors: Ebner Heinrich , DeSantis Francesco , Haumer Stefan
Published: June 2007

Regional rotation muscle flaps have often been proposed with good results for the conservative in situ management of graft infections. In this report, we present a case of recurrent posttraumatic venous graft infection in the popliteal fossa, treated with retrograde sartorius muscle flap transposition. This particular surgical technique offers new scope for management of severe graft infections in this area, where, for technical and anatomic reasons, other proposed muscle flaps are not available.
Dorsal Pedal Venous Oximetry as an Outcome Index of Lower Extremity Revascularizations
Authors: Ener Behçet K.
Published: June 2007

Dorsal pedal venous blood gas analysis was performed in 24 patients with arterial occlusive disease requiring revascularizations of the lower extremities. After the reconstructive surgical procedure, measurements were repeated. It has been observed that this method is useful before surgery since it proves the severity of tissue hypoxia due to perfusion impairment of the foot. Postoperative measurements have detected the effectiveness of the vascular restorations. The results of the trial showed a mean increase in partial pressure of venous blood oxygen (Pvo2) and pH of 30.3% and 13.7% (p<0.05), respectively and a mean decrease in partial pressure of arterial carbon dioxide (Pco2) of 12.9% (p<0.05) between initial and postsurgical measurements in involved legs. In the healthy, unoperated on side, there was no significant (p>0.05) change in response to arterial reconstructions. Symptoms decreased markedly in direct proportion to the increase in dorsal pedal venous Po2 induced by changes in blood flow. This method can be reliably used for assessing the treatment to ensure adequate oxygen delivery to the foot as a result of improved pedal perfusion.
Reversal by Controlled Limb Reperfusion
Authors: Ihnken Kai , Wildhirt Stephen , Ihnken Olaf , Hill Bradley , Meier Andreas , Zarins Christopher , Reitz Bruce
Published: June 2007

Despite successful surgical revascularization of ischemic limbs, a local and systemic reperfusion injury may occur after normal blood reperfusion. Recent experimental and clinical application of controlled limb reperfusion in Europe has demonstrated superior results, with lower morbidity and mortality. This new surgical technique includes modification of the reperfusate (calcium, pH, substrates, osmolarity, free radical scavenger) and the circumstances of initial reperfusion (time, temperature, pressure). This report describes the first application of controlled limb reperfusion after reperfusion injury.

A 16-year-old boy underwent femoral access cardiopulmonary bypass for repeat cardiac repair with an ischemic time of 245 minutes. Postoperatively, severe ischemia/ reperfusion syndrome developed with muscle contracture, immobility, and anesthesia of the right leg with a second ischemic time of about 6 hours. The systemic creatine phosphokinase level was 88,000 U/L; myoglobin was 27,000 ng/mL. He underwent controlled limb reperfusion by withdrawing blood from the aorta and mixing it with a crystalloid solution (calcium-reduced, hyperosmolaric, hyperglycemic, alkalotic, glutamateand aspartate-enriched, and containing a free radical scavenger) under controlled conditions (blood:crystalloid solution 6:1, for 30 minutes, reperfusion pressure < 50 mm Hg, and normothermia) before establishing normal blood reperfusion.

Metabolic data from the central and femoral vein demonstrated a significant reduction of all previous elevated enzyme levels, avoidance of hyperkalemia, normalization of acidosis, and avoidance of systemic reperfusion injury with no multiorgan failure. Limb salvage was accomplished and functional recovery almost complete. To the authors' knowledge, this is the first application of controlled limb reperfusion reported in North America. With this surgical technique we were able to prevent metabolic local and systemic reperfusion changes after prolonged ischemia and also reduced previous reperfusion changes. This report confirms former experimental data, and further clinical studies are warranted.
Prospective Controlled Study of Carotid Endarterectomy with Hemashield Patch: Is It Thrombogenic?
Authors: AbuRahma Ali F. , Robinson Patrick A. , Hannay R. Scott , Hudson Julie , Cutlip Leigh
Published: June 2007

The use of patch angioplasty after carotid endarterectomy (CEA) has been shown to have superior results to CEA with primary closure. Polytetrafluoroethylene (PTFE) patches have been shown to have comparable results to autogenous vein patching; however, PTFE has the disadvantage of prolonged hemostasis time. Therefore, many surgeons are using collagenimpregnated Dacron patches (Hemashield TM [HP]). We believe this is the first prospective controlled study of the use of HP in carotid endarterectomy. This study included 144 consecutive patients who had 151 CEAs with HP. Postoperative duplex ultrasounds were done at 1 month and every 6 months thereafter. The mean follow-up was 12 months (range: 1-30 months). Indications for CEA included symptomatic (64%) and asymptomatic (36%) stenoses. The overall incidence of ipsilateral stroke was 5% (4% perioperative), with a combined TIA and stroke rate of 12%. Incidence of ≥50% recurrent stenosis was 21% (7% symptomatic TIA/stroke) and ≥80% recurrent stenosis was 9%. Kaplan-Meier analysis showed that at 1 year and 2.5 years freedom from ≥50% recurrent stenosis was 78% and 57%, respectively, freedom from ≥80% recurrent stenosis was 92% and 77%, respectively, and a stroke-free survival rate of 94% and 72%, respectively. Women had a 22% and men a 14% recurrent stenosis rate (p=0.04). There was no correlation between other specific risk factors and recurrent stenosis except for hypertension (33% vs 12%, p=0.003). The authors concluded that CEA with HP had a higher incidence of recurrent stenosis (21%), and a higher perioperative stroke rate (4%) after a mean follow-up of 12 months than previously reported using PTFE or saphenous vein patching (2% and 9% recurrent stenosis rates, respectively, and I1% and 0% perioperative stroke rates, respectively after a mean follow-up of 30 months). This raises the question as to whether this patch is thrombogenic in this location. Therefore, a randomized controlled trial comparing this patch with other patches (PTFE or vein) is warranted.
Atraumatic Acute Upper Limb Ischemia
Authors: Sultan Sherif , Evoy Denis , Eldin Ahmed Saad , Eldeeb Maged , Elmehairy Nabil
Published: June 2007

This paper documents the various causes of upper limb ischemia in a series of 64 Egyptian patients presenting to a tertiary referral center over a 4-year period and offers a diagnostic dissertation and review of the pertinent literature. Atraumatic upper limb ischemia is an uncommon entity. It has a broad etiology with diverse management pathways. Nineteen patients presented with severe and immediate limb-threat ening ischemia. These patients underwent immediate surgical exploration: an embolus was diagnosed in 15 and thrombosis in 4. Twenty-eight patients presented with ischemia of lesser severity, allowing preoperative angiography. Of these 28 patients, 6 had an embolus, 14 had thrombosis, 4 had thoracic outlet syndrome, the remainder had miscellaneous causes. Fifteen patients had upper limb ischemia secondary to arteritis, and 2 patients with dissection of the ascending thoracic aorta presented with upper limb ischemia. Forty-seven patients underwent a surgical procedure, with a morbidity rate of 21% and mortality rate of 19%. Patients presenting with upper limb ischemia tend to have significant co-existing disease. Management of upper limb ischemia requires preoperative and/or peroperative angiography with careful application of vascular surgical expertise.
Changing Pattern of Access Site Complications with the Use of Percutaneous Closure Devices
Authors: Toursarkissian Boulos , Mejia Alejandro , Smilanich Robert P. , Shireman Paula K. , Sykes Mellick T.
Published: June 2007

The authors report their experience with 15 cases of groin complications associated with the use of percutaneous closure devices following femoral arterial catheterization over a 2-year period. The complication rate was 1.7% for catheterizations in which a closure device was used. The 15 cases included 7 uncomplicated pseudoaneurysms (PSA), 3 infected pseudoaneurysms, 4 nonarterial groin infections (infected hematomas and/or abscesses), and 1 case of femoral artery occlusion. These complications presented at an average of 5 ±4 days postcatheterization. One patient with an infected PSA required a below-the-knee amputation. During the same time interval, there were no infectious complications in patients not receiving closure devices. We conclude that groin complications associated with such devices tend to present late and include a higher percentage of infections as opposed to complications occurring in patients not receiving closure devices. An aggressive surgical approach to these problems appears warranted.
Abdominal Aortic Aneurysm Repair
Authors: Cruz Carlos P. , Drouilhet John C. , Southern Fredrick N. , Eidt John F. , Barnes Robert W. , Moursi Mohammed M.
Published: June 2007

Newer, minimally invasive catheter-based endovascular technology utilizing stent grafts are currently being evaluated for abdominal aortic aneurysm (AAA) repair. A retrospective review of all (3 years) consecutive, non-ruptured elective AAA repairs was undertaken to document the results of AAA surgical repair in a modern cohort of patients to allow a contemporary comparison with the evolving endoluminal data. One hundred twenty-one AAAs were identified in a male veteran population. Mean age was 68.5 ±7.7 years. Medical history review showed hypertension in 55%, heart disease in 73.5%, peripheral vascular disease in 21%, stroke and transient ischemic attacks in 22%, diabetes mellitus in 7%, renal insufficiency in 10%, and smoking history in 80%. The AAA size was documented with ultrasound (5.2 +1.3 cm, n = 40) and computed tomography (5.6 +1.3 cm, n= 100). Fifty-nine percent had angiography. Intraoperative end points included an operative time of 165 ±6.3 minutes from incision to dressing placement. A Dacron tube graft was used in 78%, the remaining were Dacron bifurcated grafts. A suprarenal clamp was used in 8% for proximal aortic control with juxtarenal aneurysms. A pulmonary-artery catheter was placed in 69%. A transverse incision was used in 69% of patients and a midline incision was used in the rest. Estimated blood loss was 1505 +103 mL; cell saver blood returned 754 +53 mL; crystalloid/Hespan 4771 ±176 mL; banked packed red blood cells 0.75 ±0.1 1 U. Time to extubation was, in the operating room (78.5%), on the day of the operation (5.0%), postoperative day (POD) 1 (12.4%), POD2 (1.7%), POD3 (0.8%), and one case was performed with epidural anesthesia only. Postoperative end points included a 30-day mortality rate of 1.6% (two patients). Postoperative morbidity included wound dehiscence 0.8%; sepsis, urinary tract infection, wound infection, leg ischemia, ischemic colitis, and stroke each had an incidence of 1.6%; myocardial infarction, congestive heart failure, pneumonia, re-operation for suspected bleeding, and ileus or bowel obstruction occurred with an incidence of 3.3%. No significant increase in serum creatinine levels was noted. Time to enteral fluids/nutrition was 3.5 +0.08 days. Patients were out of bed to a chair or walking by 1.3 +0.06 days postoperatively. The length of stay in the intensive care unit (ICU) was 2.0 +0.12 days and postoperative hospital stay was 6.6 + 0.33 days. Transfusion requirement for the hospital stay was 1.6 +0.2 U per patient. This review highlights a cohort of male veteran patients with significant cardiac co-morbidity who have undergone repair with a conventional open technique and low mortality and morbidity rates. This group had rapid extubation, time to oral intake, and ambulation. In addition, ICU and hospital stays were relatively short.
Abdominal Aortic Aneurysm: Association Between Haptoglobin Phenotypes, Elastase Activity, and Neutrophil Count in the Peripheral Blood
Authors: Wiernicki Ireneusz , Gutowski Piotr , Ciechanowski Kazimierz , Millo Barbara , Wieczorek Piotr , Cnotliwy Miloslaw , Michalak Tomasz , Hamera Tomasz , Piatek Jaroslaw
Published: June 2007

To investigate the role of genetic factors on susceptibility to atherosclerotic arterial disease, the influence of haptoglobin phenotypes (Hp) on serum elastase activity, neutrophil count, and elastin concentration in the aorta was measured in patients with abdominal aortic aneurysm (AAA; n=52) and aortoiliac atherosclerotic occlusive disease (AOD; n=37). Findings (serum elastase activity, peripheral blood neutrophil count) were compared to a control group (CG) of 37 subjects without atherosclerosis. Hp phenotyping performed by starch-gel electrophoresis produced a haptoglobin-hemoglobin complex of three phenotypes: Hp1-1, Hp2-2, and Hp2-1.

Distribution of Hp phenotypes was similar in the three study groups (AAA, AOD, CG). Significant increases in serum elastase activity and neutrophil count was measured in Hp2-1 phenotype of AAA patients. Although the aorta wall of aneurysm patients contained less (p<0.001) elastin than that of AOD patients, no significant difference of aorta elastin concentration between the three Hp phenotypes, including Hp2-1, was measured. The postulated association of AAA susceptibility with Hp2-1 phenotype was supported by the study data that demonstrated an increase in serum elastase activity in patients undergoing AAA repair.
Knitted Dacron Grafts Used for Abdominal Aortic Reconstruction: Sizing References
Authors: Alonso-Pέrez Manuel , Segura Ramon J. , Lujάn Salvador , Vidal Eduardo D. , Cachaldora Jose A. , Vidal Juan , Sanchez Javier
Published: June 2007

This study was undertaken to analyze immediate and mid-term knitted Dacron graft dilation and to establish which parameters should be taken as a reference when aortic graft dilation is evaluated. A Dacron knitted microvel double velour vascular graft (Hemashield Gold) was implanted in 30 patients with aneurysmal (19 cases, 63%) or occlusive (1 1 cases, 37%) aortic disease. The stems of bifurcated prostheses (27 patients, 90%) and tube grafts (3 patients, 10%) were measured. The package sizing (labelled size) was compared with the external diameter measured intraoperatively with a slide caliper, prior to implantation and after complete clamp release. Additional measurements were obtained by ultrasound 1 and 6 months after implantation, and in 16 cases (53% of the patients) ultrasound and computed tomography (CT) were performed at the end of the first year. The means of the measurements were compared using Student's t test for matched pairs. The statistical significance level was set at p values <0.05. There was a statistically significant difference between the package sizing (15.3 + 1.1 mm) and the external diameter measured prior to implantation (18.7 +1.3 mm); and with the external diameter following implantation (19.6 ±1.4 mm), (p < 0.01). External diameters measured prior to grafting and following implantation (after complete clamp release), when compared with the manufacturer's size, showed a mean increase in graft diameter of 3.4 mm (22%) and 4.3 mm (28%), respectively. There were no statistical differences between the external diameter measured after clamp release (19.6 +1.4 mm) and the size determined by ultrasound 4 weeks (19.3 ±1.2 mm) and 6 months (19.8 ±1.5 mm) following surgery (p values 0.11 and 0.56, respectively). Considering size after clamp release as a reference (19.6 +1.4 mm), an almost significant (p = 0.08) increase in the diameter (0.7 ±1.5 mm) was obtained at the end of the first year when the measurement was performed with ultrasound. However, when the measurement was performed by CT at the end of the first year, the differences (0.9 ± 1.6 mm) revealed statistical relevance (p = 0.04). There was no statistically significant difference between the sizes obtained by ultrasound (20.3 ±2.1 mm) and by CT (20.5 ±2.2 mm) at the end of the first year (p values 0.07). The package sizing is not a reliable parameter for choosing the size of knitted Dacron grafts. Immediate increase in diameter noted in Dacron grafts is caused by discrepancies between the package sizing and the measured diameter after clamp release during implantation, and by an initial adaptation of the textile structure. This must be taken into account for an accurate investigation of the immediate graft dilation rate, and if further follow-up is contemplated, a measurement to be taken as a reference should be performed by ultrasound or CT in the immediate postoperative period.
Simultaneous Carotid Endarterectomy and Excision of Ipsilateral Branchial Cleft Fistula
Authors: Tzarnas Chris D. , Tzilinis Argyrios
Published: June 2007

Branchial cleft sinuses are congenital anomalies that usually present in childhood or early adulthood. It is uncommon that such a sinus will remain asymptomatic to the sixth decade of life. This case describes the presence of a second branchial cleft sinus in the setting of carotid artery disease, where both were treated surgically simultaneously without complication.
Ten-Year Outcome After Saphenous Vein Patch Angioplasty in Males and Females After Carotid Endarterectomy
Authors: Chang John B. , Stein Theodore A.
Published: June 2007

Many surgeons use a vein-patch angioplasty after endarterectomy of small (< 4 mm) diameter carotid arteries in males and females. Because evidence suggests that females may have a poorer outcome than males after revascularization, the long-term success of carotid endarterectomy may be different among the genders. The 10-year outcome after a saphenous vein-patch angioplasty in females was studied. Endarterectomies were performed on 708 carotid arteries of 615 patients, who had evidence of symptomatic disease or had asymptomatic greater than 80% stenosis. A segment of proximal greater saphenous vein was harvested for the patch. The 247 females had a mean age of 69.1 ±9.8 (SD) years and a follow-up time of 4.0 ±4.0 (SD) years. The 368 males had a mean age of 69.2 ±8.8 (SD) years and a follow-up time of 4.4 ±4.0 (SD) years. After endarterectomy, survival, the ipsilateral stroke-free rates and the restenosis-free rates were determined by life table analyses with 73 endarterectomies in 66 patients being at risk at 10 years. The 5- and 10-year survival rates in males were 81.9% and 62.2%, respectively. The 5- and 10-year survival rates in females were 82.6% and 73.0%, respectively. The 5- and 10-year ipsilateral stroke-free rates after carotid endarterectomy were 98.3% and 93.9% in males and 96.7% and 95.6% in females. The respective 5- and 1 0-year restenosis-free rates were 96.7% and 93.3% in males and 88.6% and 82.8% in females; p <0.0002, by the Mantel-Cox test. Although survival and the incidence of an ipsilateral stroke were similar in females and males, the hemodynamic restenosis rate was higher in females. It is especially important to use routine duplex scanning to follow the postendarterectomy health of the carotid artery in females.
Subfascial Endoscopic Perforator Vein Surgery in Patients with Post-Thrombotic Venous Insufficiency - Is It Justified?
Authors: Kalra Manju , Gloviczki Peter , Noel Audra A. , Rooke Thom W. , Lewis Bradley D. , Jenkins Greg D. , Canton Linda G. , Panneton Jean M.
Published: June 2007

Previous results following subfascial endoscopic perforator vein surgery were reported to be worse in post-thrombotic syndrome than in limbs with primary valvular incompetence. This report comprises a larger patient cohort with longer follow-up. The goal of this study was to determine if subfascial endoscopic perforator vein surgery is justified in patients with postthrombotic venous insufficiency. The clinical data of 91 consecutive patients who underwent subfascial endoscopic perforator vein surgery with or without superficial reflux ablation over a 7-year period from May 1993 to June 2000 were retrospectively analyzed. Fifty-four females and 37 males (median age, 53 years; range, 20-77) underwent 103 subfascial endoscopic perforator vein surgery procedures. Forty-two limbs were classified as C6 (active ulcer), 34 as C5 (healed ulcer), and 24 as C4 (lipodermatosclerosis). Thirty procedures were performed in post-thrombotic limbs. Concomitant superficial reflux ablation was performed in 74 limbs (72%); saphenous vein stripping had been previously performed in 29 (28%). Deep venous incompetence was present in 89% of limbs; 13% had venous outflow obstruction on plethysmography. Cumulative ulcer healing in post-thrombotic limbs was not significantly different from limbs with primary valvular incompetence; 30-, 60-, and 90-day healing rates were 44%, 72%, and 72% vs 39%, 70%, and 87%, respectively (p = 0.35). On univariate analysis, the presence of ulcer greater than 2 cm in diameter was associated with delayed ulcer healing (p = 0.02). Cumulative ulcer recurrence in all limbs was 4%, 20%, and 27% at 1, 3, and 5 years, respectively. Ulcer recurrence in post-thrombotic limbs was higher than in limbs with primary valvular incompetence at 1, 3, and 5 years; 16%, 47%, and 56% vs 0%, 8%, and 15%, respectively (p = 0.001). Recurrent ulcers were small, superficial, and easier to heal. Clinical improvement was significant even in post-thrombotic limbs; median clinical score decreased from 9.5 to 3 (p=0.001), and median outcome score was +2 (mean 1.9; range, -I to 3). Median clinical score in patients with primary valvular incompetence improved from 6 to 1.5 (p = 0.0001). Subfascial endoscopic perforator vein surgery with superficial reflux ablation promoted ulcer healing, improved clinical outcome, and resulted in a low long-term ulcer recurrence rate in limbs with primary valvular incompetence. Despite good clinical outcome in post-thrombotic limbs, ulcer recurrence was high. These results imply that the role of subfascial endoscopic perforator vein surgery with superficial reflux ablation in patients with post-thrombotic limbs continues to be controversial.
Ruptured Abdominal Aortic Aneurysm and Quality of Life
Authors: Joseph Abed Y. , Fisher Jay B. , Toedter Lori J. , Balshi James D. , Granson Marc A. , Meir-Levi David
Published: June 2007

This study was undertaken to examine the community hospital experience in managing ruptured abdominal aortic aneurysm, and to assess the quality of life in survivors of the abdominal aortic aneurysm procedure. Study parameters included a retrospective chart review with prospective follow-up at a 369-bed, university-affiliated, community teaching hospital. Eighty-one consecutive patients undergoing surgery for ruptured abdominal aortic aneurysm between 1991 and 2000 were included. Main outcome measures included mortality and quality of life, as assessed by the SF-36 health survey. The overall perioperative mortality rate was 34.6%, significantly less (p < 0.005) than the 50% mortality rate reported in the literature. Predictor variables significantly related to mortality were age (p <0.002), preoperative creatinine (p< 0.026), use of suprarenal clamp (p< 0.0001), acute renal failure (p< 0.0001), myocardial infarction (p < 0.0001), respiratory failure (p < 0.0001), and tobacco use (p < 0.05). Multiple regression analysis found that three predictor variables-myocardial infarction, respiratory failure, and use of a suprarenal clamp-predicted 25% of the variability in mortality (p < 0.0001). The quality-of-life analyses showed that the majority of the patients for whom follow-up data could be obtained (n = 26), reported the same or better quality of life compared to SF-36 norms for age-matched individuals. Results from this community hospital sample suggest that ruptured abdominal aortic aneurysm repair can be accomplished in this setting with an acceptable survival rate, and subsequent quality of life that meets or exceeds that of an age-matched sample.
Infrarenal Rupture of an Abdominal Aortic Aneurysm, Previously Repaired Using an Endoaneurysmorrhaphy Technique
Authors: Zatina Michael A. , Wilkerson Donald K.
Published: June 2007

Unusual as well as well-known complications can occur after aortic reconstruction. In an effort to heighten awareness of these possibilities, a case is presented of a 71-year-old male who was brought to the emergency department with severe back pain of 2 days duration and hypotension. He had undergone repair of an infrarenal abdominal aortic aneurysm 6 years earlier. An emergency computed tomography scan demonstrated a 10-cm abdominal aortic aneurysm extending from just above the celiac axis, through the aortic bifurcation, with retroperitoneal and intraperitoneal hematoma. He was found at operation to have extension of his aneurysmal disease proximally, with complete separation of the proximal suture line, and rupture of the distal aortic wall. Since the aneurysm had been closed around the graft at the time of the original operation, his aneurysm had essentially been restored, and the diseased wall was again exposed to the tensile stresses from the pulsatile column of blood. Emergency repair was successful, despite postoperative complications including myocardial infarction, and later rupture of an iliac artery aneurysm. Patients presenting with signs and symptoms consistent with a ruptured abdominal aortic aneurysm after previous repair should be addressed aggressively with computed tomography if it is immediately available and the diagnosis is in doubt. The patient should then undergo an immediate operation. Such recurrence, although rare, must always be considered a possibility. Similar scenarios may be encountered secondary to endoleaks occurring after endoluminal aortic repairs.
The Treatment of Varicose Veins with External Stentding to the Saphenofemoral Junction
Authors: Lane Rodney James , Cuzzilla Michael Luciano , Coroneos John Christopher
Published: June 2007

Presented are the experiences with 1,516 external valvular stents (Venocuff™ and Venocuff II™) implanted at the saphenofemoral junction (SFJ) between 1985 and 2000. To assess the applicability of the procedure it was found that the appropriate implantation was performed in 34% of 310 consecutive venous procedures. To assess patient preference between external valvular stenting and simultaneous contralateral stripping, 56 consecutive patients were followed up at 3 months postoperatively. Four percent preferred stripping, 4% had no preference, and 92% preferred Venocuff II™ implantation. Competence at the SFJ with specific duplex ultrasound indicators was 94% at 3 months (n= 100) and 90% at 4.8 years (n= 107). Minimal residual reflux (less than 50 mL/minute with maximum Valsalva) was present in the remainder but did not produce symptoms and very rarely progressed over the mean time of 5 years. The internal diameter (ID) of the long saphenous vein (LSV), 3 cm distal to the SFJ, changed from 7.6 ±2.3 mm to 4.9 ±1.1 mm (p<0.001) and at the knee from 6.9 ±1.9 mm to 3.7 ±1.0 mm (p<0.001). Patients presenting with underlying deep venous disease began with significantly higher ID, ie, 9.0 ±2.1 mm at the upper end of the LSV and 7.1 ±2.0 mm at the knee, but postoperatively the IDs reverted to those of postoperative patients with a normal deep venous system. To assess patients with recurrences, 366 limbs had simultaneous stripping and contralateral SFJ repair with the Venocuff II™. Of these 33 (9%) had recurrences at 4.9 years, 82% of them on the stripping side, and on the repair side half of the recurrences had a competent SFJ (9%). Limbs with an incompetent lateral or anterior accessory system, with an incompetent SFJ (168), were compared with 11 matched randomized controls where stripping was performed. The recurrence rate was 1.2% versus 36% on the strip side. The follow-up for these cases was 6.4 years. Pregnancy (n = 14) produces a high recurrence rate, but stripping and valve repairs were not significantly different, ie, despite small numbers, there was a very strong tendency toward higher recurrence rates on the stripped side. The complication rate was small and the cost of the device is low. The method allows a repairable nonablative approach that can be offered in patients where no other surgical treatment can or should be offered. External stenting to the SFJ is the preferred option for early to moderate varicose veins involving the LSV where the clinical and ultrasonic indicators have been fulfilled.
Assessment of Gut Mucosal Perfusion and Colonic Tissue Blood Flow During Abdominal Aortic Surgery with Gastric Tonometry and Laser Doppler Flowmetry
Authors: Nakatsuka Mitsuru
Published: June 2007

The objective of this study was to investigate the effect of infrarenal aortic cross-clamping and unclamping on gut mucosal perfusion by gastric tonometry and on sigmoid colonic tissue blood flow by laser Doppler flowmetry during abdominal aortic surgery. This was a prospective before-and-after intervention comparison study in a university hospital of 8 male patients, aged 57-87, undergoing elective infrarenal abdominal aortic surgery. Each patient was pretreated with ranitidine. Following general anesthesia, a nasogastric tonometer was inserted into the stomach. The balloon of the tonometer was filled with 2.5 mL of normal saline for gas tension and pH analysis. This process was repeated before and after aortic cross-clamping and unclamping. Gastric mucosal pHi was calculated with the Henderson-Hasselbalch equation from the arterial Hco3 and the tonometrically measured mucosal Pco2. A laser Doppler flow probe was placed in contact with the serosa of the sigmoid colon against the mesentery after the abdomen was opened. Sigmoid colonic tissue blood flow (SCBF) was assessed by the laser Doppler flowmeter. Gastric mucosal pHi by gastric tonometry and colonic tissue blood flow by laser Doppler flowmetry were measured before and after aortic cross-clamping and unclamping. Gastric mucosal pHi decreased significantly 30 minutes after aortic cross-clamping (7.37 +0.07) (p<0.0 1), 60 minutes after aortic cross-clamping (7.39 +0.08) (p<0.05), and 30 minutes after aortic unclamping (7.37 ±0.08) (p < 0.01), compared with pHi before aortic cross-clamping (7.50 ±0.06). Gastric mucosal pHi increased to the original level 60 minutes after aortic unclamping (7.46 ±0.08). Since a gastric mucosal pH above 7.35 is considered normal, these mean values of pHi were clinically insignificant. However, gastric mucosal pHi decreased below 7.32 in 5 patients during abdominal aortic surgery. Gastric mucosal pHi decreased further to 7.30 in 1 patient following aortic cross-clamping and below 7.30 in 3 patients 30 minutes after aortic unclamping. SCBF decreased significantly after aortic cross-clamping (28.1 ±4.8 mL/min/l 100 g) compared with the value before aortic cross-clamping (51.9 ± 11.3 mL/min/l 00 g) (p<0.01). Following aortic unclamping, SCBF returned to 41.7 ±7.4 mL/min/100 g.

It is concluded that transient episodes of significant intestinal mucosal ischemia may have been encountered occasionally in patients undergoing abdominal aortic surgery, but a sigmoid
Safety and Cost Savings of Endovascular Procedures: Are Outpatient Interventions Feasible when Combined with Open Surgery?
Authors: Lombardi Joseph V. , Calligaro Keith D. , Dougherty Matthew J.
Published: June 2007

As increasing experience and comfort with endovascular interventions performed in an outpatient setting has occurred, the safety and cost effectiveness of performing these procedures without an overnight stay were analyzed, especially when endovascular procedures were combined with open vascular operations requiring an arteriotomy and surgical closure. Ninety patients underwent endovascular procedures alone or concomitantly with open, minor vascular operations to salvage a failing graft between February 1994 and June 1999. Patients undergoing endovascular interventions during primary lower extremity bypass or other major surgical procedures were not included in this review because they were not candidates for outpatient procedures. Balloon angioplasty alone (79) or angioplasty with stent placement (1 1) was performed to treat stenoses in 50 failing grafts, 16 iliac, 14 femoral, 5 tibial, and 5 axilla/subclavian arteries. A significant increase in outpatient procedures was accomplished as more experience was garnered with these techniques: 19% (8/42) between 1994 and 1996 vs 57% (28/48) between 1997 and 1999 (p = 0.001). Age and comorbidity did not play a role in determining the need for admission because there were no significant differences in patients with diabetes mellitus, hypertension, smoking, or hyperlipidemia and those admitted or discharged the same day (p>0.05). Patients admitted for overnight observation tended to have longer mean operative times and more complex revascularizations than outpatients (1 10 vs 69 min, respectively; p<0.0001). Twenty-seven patients underwent surgical exposure of the access vessel: 63% (17) were admitted and 37% (10) were discharged the same day. Sixtythree patients underwent a percutaneous procedure: 42% (27) were admitted and 58% (37) were discharged the same day. Outpatients were more likely to receive only local anesthesia (83%; 30/35) compared to patients admitted overnight (67%; 36/53); the remaining patients received spinal or epidural anesthesia. Complications included graft thrombosis within 30 days in 6% (5/90) of patients and arterial graft infection in 2% (2). No patient required surgery for bleeding. The average charges for outpatient interventions were $1980 compared to $10,026 for patients who stayed overnight (p<0.0001). As vascular surgeons become more experienced and comfortable with outpatient endovascular procedures, especially when performed in combination with open minor vascular surgery, significant cost savings can be realized without sacrificing patient safety. Even when open surgical exposure is planned, patients should be instructed preoperatively to anticipate discharge the day of their procedure to minimize resistance to this strategy.
Infrainguinal Bypass Conduit: Autogenous or Synthetic - A National Perspective
Authors: Merrell Greg A. , Gusberg Richard J.
Published: June 2007

Numerous studies have compared autogenous versus synthetic grafts for infrainguinal bypasses. Synthetic grafts are associated with shorter operating times, comparable reimbursement, and despite inferior patency rates, remain in frequent use. Therefore, this study was undertaken in an effort to characterize, from a national perspective, the practice patterns and the drivers of practice variation in the use of synthetic grafts for infrainguinal bypass. Two data sets were obtained: 1) Medicare billings of infrainguinal bypasses in 49 states, years 1995 through 1997 (number of procedures, 254,677). Procedures were defined by nine CPT billing codes. 2) Hospitals over 150 beds in six states (CA, CO, CT, IA, MN, MS) were asked for volume statistics on the same CPT codes. Data were received from 27 institutions, comprising 1,063 procedures. Variations in graft use were analyzed by hospital type (teaching versus nonteaching) and correlated with the prevalence of diabetes mellitus and smoking. Nationwide, 41% of infrainguinal bypasses in 1997 were performed using synthetic grafts. Interstate synthetic conduit use ranged from 27% to 80%. These differences were similar for bypasses to popliteal or infrapopliteal vessels. Admission to a teaching hospital was associated with a lower use of synthetic grafts (21% vs 51%, odds ratio 0.26, p<0.0001). No correlation was seen between the prevalence of diabetes mellitus or smoking, and synthetic graft use. Synthetic graft use was significantly lower at teaching hospitals, and there was substantial interstate and intrastate variations. These findings suggest that there is wide variation in practice patterns. Further studies appear warranted to define the role of patient demographics and physician preference in explaining these differences.
The Influence of Obesity on Chronic Venous Disease
Authors: Danielsson Gudmundur , Eklof Bo , Grandinetti Andrew , L. Kistner Robert
Published: June 2007

The authors investigate the impact of overweight in patients with chronic venous disease and determine if the eventual effect can be explained by increased venous reflux alone. Patients with chronic venous disease who underwent duplex-ultrasound scanning at the Vascular Center, Straub Clinic and Hospital during 1999 were classified according to the clinical, etiologic, anatomic, and pathophysiologic (CEAP) system and body mass index (kg/M2) was calculated. Reflux duration was measured in seconds and peak reverse flow velocity in cm/second. Multisegment reflux score (total score) was calculated for both reflux duration and peak reverse flow velocity. The reflux pattern and body mass index were correlated to the clinical presentation. Four hundred and one lower extremities (204 right, 197 left) in 272 patients (173 female) with a mean age of 60 years (range 14-90) were investigated. The mean body mass index was 28.9 (±7.76). One hundred sixty-seven patients (61%) were overweight (body mass index 25 kg/M2 or more). There was a significant association between body mass index and the clinical severity (p < 0.001). This association persisted after adjustments for total peak reverse flow velocity and total reflux score were made (p <0.001). Overweight patients were more likely to have skin changes and ulceration (p < 0.001) than patients with a body mass index less than 25 kg/m2, despite similar values for total reflux time (p = 0.92) and total peak reverse flow velocity (p = 0.98). There was an ethnic difference, with Pacific Islanders being significantly heavier and younger compared to patients of white, Asian and Filipino ancestries. The variations in the frequency of skin changes were consistent with ethnic differences in body mass index. The correlation of body mass index with clinical severity independent of reflux measurements indicates that the effect of overweight may involve a mechanism separate from local effects on venous flow. Overweight appears to be a separate risk factor for increased severity of skin changes in patients with chronic venous disease.
Endovascular Stent-Graft Placement for the Management of a Traumatic Axillary Artery Pseudoaneurysm
Authors: Oktar G. Levent , Balkan M. Erkan , Akpek Sergin , Ilgit Erhan
Published: June 2007

A 24-year-old woman with a right infraclavicular gunshot wound developed an axillary artery pseudoaneurysm. She was successfully treated by using a 5 cm Hemobahn stent-graft with a diameter of 6 mm. Postimplantation arteriography revealed normal flow through the axillary artery without evidence of leakage of contrast medium. Five months after the procedure, stenoses developed within the stent-graft owing to intimal hyperplasia and were treated by balloon angioplasty. The patient has been followed up symptom-free for 6 months after the second procedure.
Low Dose Intraarterial Thrombolysis with Tissue Plasminogen Activator: Does It Deliver as Promised?
Authors: Madhavan P. , Sultan S. , McDonnell C. O. , Cowman J. P. , Colgan M. P. , McEniff N. , Molloy M. , Moore D. J. , Shanik G.
Published: June 2007

The widespread use of intraarterial thrombolytic therapy has been based on perceived benefits over operative treatment and the downgrading of the magnitude of subsequent surgery. Thirty-three patients who had thrombolysis for peripheral artery occlusion were retrospectively analyzed at St. James's Hospital from 1991 to 1997. One patient received streptokinase unsuccessfully. Five other patient's records were inadequate for analysis. Twenty-seven patient's notes were analyzed for risk, duration of occlusion, duration of treatment, dosage of tissue plasminogen activator (tPA) and conduits thrombolysed. There were 15 males and 12 females. The mean age was 62 years (range, 20-87). Fourteen were current or reformed smokers. Five were diabetic. Indications for treatment included acute graft occlusion (n = 13), embolus (n = 6), and primary and secondary arterial thrombosis (n = 8). Duration of occlusion was less than 24 hours in seven, 1 to 7 days in ten, and more than 7 days in ten patients. Twelve (44.44%) patients had complete clot lysis, four (14.81%) had partial clearance, and 1 1 (40.74%) remained occluded. Eight (29.63%) had serious complications including one death. Eighteen (66.66%) patients needed further surgical intervention to maintain graft patency. Data were analyzed using the chi-square and pooled t test. No significant difference was observed in results from thrombolysis from different conduits, gender, etiology, or smoking history. Increased duration of tPA administration was associated with an increased risk of failure. Administration of total dosages greater than 60 mg was associated with a higher risk of failure. Diabetics had a poor outcome (p=0.0520). Only 44% of patients successfully underwent lysis. A primary surgical option may be a more sensible course than lysis, given that the vast majority of patients ended up having surgery anyway.