bluuebunny/crossref_metadata_2025 huggingface dataset:
Common Iliac Artery Pseudoaneurysm Following Inguinal Hernia Repair
Authors: Teodorescu Victoria J. , Reiter Bruce P.
Published: June 2007

The authors report a patient presented with a ruptured infected iliac artery pseudoaneurysm 2 weeks after ipsilateral inguinal hernia repair. Pseudoaneurysms that occur because of infection develop rapidly and mandate ligation of the affected artery and extraanatomic bypass. Noninfected pseudoaneurysms are usually discovered incidentally and may be managed with either endovascular or standard surgical techniques. A percutaneously placed aortic occlusion balloon may prevent exsanguination, when used as an adjunct to surgical repair in cases of ruptured pseudoaneurysm.
Double-Layer Everted Saphenous Vein Patch Angioplasty for Carotid Endarterectomy
Authors: Danikas Dimitrios , Schmeler Kathleen M. , Ginalis Ernest M. , Stratoulias Constantinos , Shorten Suzanne M. , Constantinopoulos George
Published: June 2007

Saphenous vein patch angioplasty is the preferred method of closure of the arteriotomy site during carotid endarterectomies. A major early complication of the saphenous vein patch is rupture of the patch which can occur within the first few postoperative days. The reported incidence varies from 0.5% to 4%. Patch rupture can result in stroke or death. From May 1992 to April 1999, autogenous everted double-layer saphenous vein patch was used in 192 carotid endarterectomies performed on 168 patients; 96 males and 72 females. The age range was from 54 to 94 years with a mean age of 73 years. The saphenous vein is harvested from the ankle. It is everted and then used as a double-layer patch. The follow-up period was from 3 to 74 months, with a mean of 24 months. Postoperatively, there were no patch ruptures or late aneurysm formation. There was no perioperative mortality. Everted double-layer saphenous vein patch eliminates the risk of patch rupture and at the same time retains the benefits of an autologous nonprosthetic graft. Saphenous vein from the ankle can be safely used for carotid angioplasty as a double layer patch.
Spontaneous Late Carotid-Cutaneous Fistula Following Radical Neck Dissection
Authors: Rodriguez Filiberto , Carmeci Charles , Dalman Ronald L. , Lee W. Anthony
Published: June 2007

The authors present an unusual case of a spontaneous carotid-cutaneous fistula occurring as a late complication 4 years after radical neck dissection and postoperative radiation therapy for tonsillar squamous cell carcinoma in a 50-year-old patient. The etiologic factors predisposing patients to carotid artery rupture following radical neck dissection and a surgical option for carotid artery reconstruction instead of ligation are discussed.
Repair of Bilateral Iliac Artery Aneurysms Associated with a Congenital Pelvic Kidney
Authors: Rehrig Scott T. , Goff James M. , Hadro Neal C. , Gillespie David L. , O'Donnell Sean D. , Rich Norman M.
Published: June 2007

The association of iliac artery aneurysms with a congenital pelvic kidney is extremely rare. Although multiple techniques are well described for renal preservation with renal ectopia in the setting of aortic reconstruction, few reports exist describing techniques for renal preservation in the setting of bilateral iliac artery aneurysms. A case is presented of a middle-aged man with a 6-cm right common iliac artery aneurysm and a 3-cm left common iliac artery aneurysm and a right pelvic kidney. A double-proximal-clamp technique and temporary shunting to the pelvic kidney were used during the aneurysm repair. The technical aspects of this procedure are presented as well as a brief discussion of the various options for renal preservation with renal ectopia when repairing complex aneurysmal disease.
Mycotic Aneurysm and Aortic Graft Infection Presenting with Vertebral Body Destruction Requiring Debridement and Stabilization
Authors: Kahn Mark B. , DiMuzio Paul J. , Schmeider Frank , Cotler Jerome , Albert Todd , Carabasi R. Anthony
Published: June 2007

Vertebral osteomyelitis may occur with mycotic aneurysms or infected aortic grafts. A high index of suspicion for these concurrent processes as well as appropriate preoperative evaluation and interspecialty communication is critical for appropriate diagnosis and treatment. Extraanatomic bypass, wide debridement of necrotic soft tissue and bony structures, and concurrent bony stabilization are important aspects of treatment.
Visceral Patch Rupture after Repair of Thoracoabdominal Aortic Aneurysm
Authors: Gasparis Antonios P. , Da Silva Monica S. , Semel Lawrence
Published: June 2007

This is a unique case of a visceral patch rupture in a Marfan patient after a repair of a thoracoabdominal aneurysm. The patient presented with abdominal pain and in shock 6 years after repair. The retained aortic wall containing the origins of the celiac, mesenteric, and renal arteries was aneurysmal and had ruptured. Clinical presentation, diagnosis, and operative modalities are discussed.
Matrix Metalloproteinase Expressions in Arteriosclerotic Aneurysmal Disease
Authors: Saito Satoshi , Zempo Nobuya , Yamashita Akimasa , Takenaka Hiroaki , Fujioka Kentaro , Esato Kensuke
Published: June 2007

Medial degeneration of extracellular matrix (ECM) proteins in the wall of abdominal aortas results in smooth muscle cell destruction, a loss of architectural integrity, and abdominal aortic aneurysm (AAA) formation. It has been theorized that an imbalance between proteinases and their naturally occurring inhibitors is the cause of these observed histologic abnormalities. Therefore, the purpose of this investigation was to determine if differences in the matrix metalloproteinase (MMP) -2 and -9, tissue inhibitor of metalloproteinase-1 (TIMP-1), tissue-type plasminogen activator (tPA), and urokinase-type plasminogen activator (uPA) protein and activity levels existed between infrarenal AAA and normal abdominal aortic tissue specimens.

Between November 1995 and January 1997, 10 patients undergoing elective infrarenal AAA repair had a portion of their aneurysm walls snap frozen in liquid nitrogen and processed for subsequent western blot or zymographic analysis. Tissue specimens from 6 normal abdominal aortas obtained from fresh cadaver specimens were similarly processed and served as controls. Protein levels for MMP-2, MMP-9, TIMP-1, uPA, and tPA were analyzed by western blotting. The degree of MMP-2 and MMP-9 gelatinolytic activity was analyzed by zymography. Detection and immunolocalization for MMP-2, MMP-9 and CD68 was performed on tissue sections of AAA and normal infrarenal abdominal aortas fixed in 10% formalin.

MMP-9 and tPA protein levels were increased in AAAs compared to controls by western blotting. However, uPA levels were slightly increased in controls. No differences in TIMP-1 protein levels were identified. Similarly, zymography demonstrated increased MMP-2 and MMP-9 gelatinolytic activity in AAAs compared to controls (p<0.05). CD68-positive cells (macrophages) in the adventitia and media demonstrated immunoreactivity to MMP-9.

This investigation demonstrated increased MMP-9 proteinase activity and tPA protein levels in the walls of AAAs, as well as inflammatory leukocyte invasion of the adventitia and media compared to controls. These data suggest that leukocyte-derived MMP-9 is associated with aortic wall degeneration and aneurysm formation. Furthermore, activation of MMP-9 may be caused by increased tPA levels in the walls of AAAs.
Carotid Artery Endarterectomy Solely Based on Duplex Scan Findings
Authors: Logason Karl , Karacagil Sadettin , Hårdemark Hans-Göran , Boström Annika , Hellberg Anders , Ljungman Christer
Published: June 2007

The purpose of this study was to review experience with carotid artery surgery based on findings obtained solely from duplex scanning with special regard to unexpected findings during surgery and the early outcome. From January 1993 through December 1999, 271 consecutive patients underwent 287 carotid endarterectomies (CEAs), 229 (80%) of which were performed solely based on duplex scan findings. During the study period 5,932 carotid artery duplex scans were performed in 4,466 patients. Of 589 patients with internal carotid artery (ICA) stenosis? 70%, 246 underwent CEA compared to 25 of 156 with 50-69% ICA stenosis. The indications for CEA were transient ischemic attack (TIA) in 88 (30.7%), amaurosis fugax in 60 (20.9%), previous stroke in 91 (31.7%) and asymptomatic disease in 48 (16.7%) cases.

There were no statistically significant differences between the groups operated on with and without preoperative angiography with respect to the indications for surgery, associated risk factors, or the degree of stenosis on the contralateral side. In patients undergoing surgery without angiography, there were no unexpected findings that influenced the performance of surgery, in all except 1. There were no significant differences in perioperative morbidity and mortality in patients undergoing surgery with and without conventional angiography. The combined mortality and major stroke rates were 3.4% and 2.2%, respectively.

It is concluded that CEA can safely be performed without preoperative angiography in cases with conclusive duplex scan findings.
Is Diabetes a Risk Factor for Patients Undergoing Open Abdominal Aortic Aneurysm Repair?
Authors: Rayan Sunil S. , Hamdan Allen D. , Campbell David R. , Akbari Cameron M. , Hook Shannon C. , Skillman John , LoGerfo Frank W. , Pomposelli Frank B.
Published: June 2007

A number of studies have compared results after aortic procedures in diabetics vs nondiabetics but few have focused specifically on abdominal aortic aneurysm surgery. An analysis of prospective data was carried out in the Vascular Surgery Registry (Beth Israel Deaconess Medical Center, Boston, MA) and identified 421 patients (422 grafts) who underwent elective open repair of an abdominal aortic aneurysm between 1990 and 1999. The influence of diabetes mellitus on outcome was assessed by dividing the patients into two groups: 52 diabetic and 370 nondiabetic patients. Postoperative mortality was 1.7% overall (n =7) and proportionally higher in the diabetic population, although this did not reach statistical significance (3.8% vs 1.4%, p = 0. 19). However, cumulative survival at 1 year and 3 years was essentially identical for diabetic vs nondiabetic patients (91.0% vs 92.6% and 70.0% vs 73.5%, respectively) and did not diverge until 5 years after surgery (25.0% vs 50.9% respectively [p>0.05]). Overall, major complications occurred in 1 1 diabetics (21.2%) vs 58 nondiabetics (15.7%, p = 0.32). Specific complications that were increased in the diabetic population included pancreatitis (5.8% vs 1.1%, p = 0.01) and pneumonia (1 1.5% vs 3.2%, p = 0.006). Notably, overall cardiac morbidity was not higher in patients with diabetes mellitus (1.9% vs 4.3%, p = 0.41). Our data suggest that after elective open abdominal aortic aneurysm repair, patients with diabetes mellitus may have a higher rate of certain complications when compared to patients without diabetes mellitus. These differences however, do not preclude the expectation of excellent results of open abdominal aortic aneurysm repair in patients with diabetes mellitus.
Comparison of the Use of Enoxaparin Versus Unfractionated Heparin in Patients Undergoing Lower Extremity Revascularization
Authors: Paramo Juan Carlos , Sendzischew Harry , Sivina Manuel
Published: June 2007

Present available studies suggest that heparin prevents early vessel thrombosis in the immediate postoperative (POP) period after lower extremity bypass. Long-term anticoagulation with warfarin has also been used in these patients, based on its beneficial effect in preventing long-term graft failure. To compare the effectiveness between unfractionated heparin (UH) and low-molecular-weight heparin (enoxaparin) when used as transitional therapeutic POP anticoagulant therapy, a prospective study was performed. Seventy consecutive patients undergoing lower extremity bypass were studied. The initial 35 patients were started on a drip of UH 6 hours POP. The next 35 consecutive patients were treated with enoxaparin, the first dose starting 6 hours POP. All patients underwent subsequent anticoagulation with oral warfarin. There were no statistically significant differences between the two groups with regard to demographics, percentage of above/below the knee bypasses, type of conduit used, emergency operations, and overall complications. There was a significant difference in the length of stay (p = 0.05) in favor of the enoxaparin group, which also reflected a decreased overall cost in this group. In conclusion, POP anticoagulation with enoxaparin is as safe end effective as UH in patients undergoing lower extremity revascularization. Enoxaparin was associated with a decreased overall length of stay and hospital costs.
The Ehlers-Danlos Specter Revisited
Authors: Cikrit Dolores F. , Glover Jennifer R. , Dalsing Michael C. , Silver Donald
Published: June 2007

Ehlers-Danlos type IV is a major concern to vascular surgeons because it is often associated with spontaneous hemorrhage from arteries containing decreased type Ill collagen. Five members of a family with Ehlers-Danlos type IV and a review of another family of five with Ehlers-Danlos type IV are reported. Evaluation of the recent family included clinical evaluation as well as assay of collagen production. The age range of the three involved females and two males was 7 to 52 years. The father of the affected family had a spontaneous colon perforation at age 39. His son, at age 27, had a spontaneous rupture of the iliac artery. Revascularization was accomplished with difficulty. His daughter had a large cerebral bleed. Two granddaughters, ages 7, have not had any bleeding or aneurysmal events. The amount of type Ill collagen was only 10% of normal in the patient with the iliac artery rupture. The three females all exhibited similarly low levels of type Ill collagen. The father's type Ill collagen level was not sufficiently low to confirm Ehlers-Danlos type IV, although he had a spontaneous colon perforation. In the other Ehlers-Danlos type IV family of five, the three surviving members had type Ill collagen levels as low as 5% of normal. Two family members died after spontaneous iliac rupture at ages 24 and 33. Both families exhibited an autosomal dominant inheritance pattern. Ehlers-Danlos type IV remains a challenging problem for vascular surgeons. It is transmitted as an autosomal dominant inheritance with a high degree of penetrance. Spontaneous arterial and intestinal perforations should alert the clinician to the possibility of Ehlers-Danlos type IV. Patients should be evaluated noninvasively. Arterial repairs may not be successful in these patients because the vessels are extremely friable. Assays of collagen production are advisable in establishing the diagnosis.
Ischemic Jejunal Stricture Following Endovascular Abdominal Aortic Aneurysm Repair
Authors: Stein David E. , DiMuzio Paul J. , Cohen Murray J. , Carabasi R. Anthony , Bonn Joseph , Kahn Mark B.
Published: June 2007

Endograft repair has rapidly become an alternative to conventional open repair of abdominal aortic aneurysms. Various trials continue to show decreased morbidity when compared to open repair. However, as with any new procedure, complications specifically related to this technique are being described. Herein, we report a case of an isolated ischemic jejunal stricture presenting as a small-bowel obstruction secondary to cholesterol emboli following endograft repair of an abdominal aortic aneurysms.
Infrapopliteal-Lower Extremity Revascularization with Prosthetic Conduit: A 20-Year Experience
Authors: Kashyap MajorVikram S. , Ahn Samuel S. , Quinones-Baldrich William J. , Choi Byung-Uk , Dorey Frederick , Reil Todd D. , Freischlag Julie A. , Moore Wesley S.
Published: June 2007

The use of prosthetic conduits for lower extremity revascularization in the infrapopliteal location remains controversial. The objective of this report is to describe the immediate and long-term results in a series collected over two decades. Of the approximately 1,500 lower extremity revascularizations performed between 1978 and 1998, 81 infrapopliteal bypass cases using polytetrafluoroethylene (PTFE) as conduit in 77 patients were identified. Autogenous conduit was unavailable (86%) due to prior surgery: coronary artery bypass graft (25%), femoro-popliteal bypass (60%), or femoro-distal bypass (23%). All cases were done for critical ischemia using PTFE (6 mm, 95%; ring reinforced, 54%) under general (75%) or regional (25%) anesthesia. The distal anastomosis was to the anterior tibial artery (43%), posterior tibial artery (28%), tibioperoneal trunk (16%), or peroneal artery (12%), and vein patch was used in 25% of cases. Postoperative features included acute graft thrombosis in 11 cases (14%), all done under general anesthesia, perioperative death in 3 (4%), and a mean in-hospital stay of 17 days. Long-term follow-up has ranged from 1 to 144 months (mean, 22 months). At 36 months, primary patency was 20%, secondary patency 42%, and limb salvage 55% calculated by the Kaplan-Meier method. Univariate analyses revealed regional anesthesia was associated with prolonged primary patency (35% vs 15%, p = 0.026) while the use of ringreinforced PTFE conduit was associated with prolonged limb salvage (65% vs 40%, p = 0.042). All other variables including gender, smoking, diabetes mellitus, renal failure, decade of operation, use of vein patch or postoperative warfarin were not significantly associated with either prolonged patency or limb salvage. Despite poor primary patency, distal prosthetic bypass can lead to long-term limb salvage. These data suggest distal anastomotic vein patches and postoperative anticoagulation may not be beneficial adjuncts. However, the use of regional anesthesia may decrease the incidence of perioperative thrombosis and the use of ring reinforced conduit may prolong limb salvage.
Carotid Surgery Following Previous Carotid Endarterectomy Is Safe and Effective
Authors: Abou-Zamzam Ahmed M. , Moneta Gregory L. , Landry Gregory J. , Yeager Richard A. , Edwards James M. , McConnell Donald B. , Taylor Lloyd M. , Porter John M.
Published: June 2007

With the perceived high risk of repeat carotid surgery, carotid angioplasty and stenting have been advocated recently as the preferred treatment of recurrent carotid disease following carotid endarterectomy. An experience with the operative treatment of recurrent carotid disease to document the risks and benefits of this procedure is presented. A review of a prospectively acquired vascular registry over a 10-year period (Jan. 1990-Jan. 2000) was undertaken to identify patients undergoing repeat carotid surgery following previous carotid endarterectomy. All patients were treated with repeat carotid endarterectomy, carotid interposition graft, or subclavian-carotid bypass. The perioperative stroke and death rate, operative complications, life-table freedom from stroke, and rates of recurrent stenosis were documented. During the study period 56 patients underwent repeat carotid surgery, comprising 6% of all carotid operations during this period. The indication for operation was symptomatic disease recurrence in 41 cases (73%) and asymptomatic recurrent stenosis? 80% in 15 cases (27%). The average interval from the prior carotid endarterectomy to the repeat operation was 78 months (range 3 weeks-297 months). The operations performed included repeat carotid endarterectomy with patch angioplasty in 31 cases (55%), interposition grafts in 19 cases (34%), and subclavian-carotid bypass in 6 cases (11%). There were three perioperative strokes with one resulting in death for a perioperative stroke and death rate of 5.4%. One minor transient cranial nerve (CN IX) injury occurred. Mean follow-up was 29 months (range, 1-1 16 months). Life-table freedom from stroke was 95% at 1 year and 90% at 5 years. Recurrent stenosis (? 80%) developed in three patients (5.4%) during follow-up, including one internal carotid artery occlusion. Two patients (3.6%) underwent repeat surgery. Repeat surgery for recurrent cerebrovascular disease following carotid endarterectomy is safe and provides durable freedom from stroke. Most patients are candidates for repeat endarterectomy with patching, but interposition grafting is often required. These results strongly support the continued role of repeat carotid surgery in the treatment of recurrent carotid disease.
A Contemporary Assessment of Carotid Body Tumor Surgery
Authors: Dardik Alan , Eisele David W. , Williams G. Melville , Perler Bruce A.
Published: June 2007

Carotid body tumor resection remains a surgical challenge traditionally associated with a 15-30% incidence of cranial nerve injury. The authors reviewed their experience with carotid body tumor surgery to determine whether contemporary awareness of carotid body tumors is leading to earlier detection and operation, resulting in a lower incidence of postoperative cranial nerve injury. Twenty-seven carotid body tumors were resected in 25 patients between 1990 and 2000. No patient died and no patient had postoperative baroreflex failure syndrome. There was 1 stroke (4%) in a patient who required ligation of the internal carotid artery. There were 9 cranial nerve injuries (33%), most commonly to the vagus or hypoglossal nerves, which was not significantly different from the rate of cranial nerve injury (44%) in the 9 patients operated upon between 1984 and 1989 (p = 0.37, Fisher's exact test). Multivariate analysis demonstrated that tumor size was the only significant factor predicting cranial nerve injury (p = 0.045, logistic regression). Since carotid body tumors with large size or higher Shamblin grades had predictably high operative blood loss and rates of postoperative cranial nerve injury, a high index of suspicion and aggressive surgical management may lead to earlier detection and operation on smaller tumors, ultimately reducing the risk of nerve injury. Nevertheless, carotid body tumor surgery appears to be relatively free of mortality and major morbidity in contemporary practice.
Repeat Surgery Without Preoperative Angiography in Limbs With Patent Infrainguinal Bypass Grafts
Authors: Boström Annika , Karacagil Sadettin , Jonsson Marie-Louise , Andren Bertil , Östholm Görel
Published: June 2007

The aim of this study was to assess the feasibility and results of repeat surgery without preoperative angiography in limbs with patent infrainguinal bypass grafts. Between January 1995 and December 1999, 73 surgical interventions were performed for correction of inflow, graft, or runoff-related lesions in limbs with patent infrainguinal bypass grafts. Fifty-six of the 73 cases were operated on based on the findings obtained from duplex scanning alone. There were 53 vein and 3 prosthetic grafts in the series. The indications for intervention without angiography were stenotic or occlusive lesions in 35, graft aneurysm in 7, and arteriovenous fistulae in 14. There were no deviations from the preoperatively planned surgical strategy in patients undergoing surgery without preoperative angiography. Cumulative life table primary, (stenosis free) and primary-assisted patency rates, at 12 months following graft revisions (excluding arteriovenous fistulae ligatures) without preoperative angiography, were 64% and 85%, respectively. The corresponding figures for revisions performed with preoperative angiography were 58% and 84%, respectively. There were no significant differences between patients undergoing surgery with or without preoperative diagnostic angiography with regard to patency rates. Surgical interventions for correction of infrainguinal graft-related stenotic or aneurysmal lesions can be safely performed based on findings obtained from duplex scanning.
Electrical Stimulation Promotes Angiogenesis in a Rabbit Hind-Limb Ischemia Model
Authors: Chekanov Valeri , Rayel Ramon , Krum David , Alwan Iman , Hare John , Bajwa Tanvir , Akhtare Masood
Published: June 2007

In previous investigations, it was shown that applying a modest regimen of electrical stimulation (ES), even in severely ischemic tissue, improves the healing process, accelerates neovascularization, and enhances angiogenesis in muscle tissue. Our objective in this current report was to further understand ES as a potential alternative treatment for severe muscle ischemia. Immediately after the left distal external iliac artery and the femoral artery were excised, ES (30 contractions per minute [cpm], 2 V, single impulses per burst) was applied to rabbit adductor muscle near the site of the excised femoralis artery for 24 hours daily over 1 month. Three other series served as controls: ES without arterial excision; arterial excision without ES or lead implantation; and arterial excision with lead implantation but no ES. Histologic study of capillary density was performed by angiography (employing a grid template) and by measuring the lower limb-calf blood pressure ratio. At the end of 30 days in the ES series, 10.5 ±1.2 contrast-medium opacified arteries (COAs) crossed a specific grid section segment compared with 7.2 ± 1.5 in the control series without ES (p < 0.05); 68.2 ±9.3 COAs crossed a grid section compared with 43.2 +6.4 in controls (p< 0.05); 27.3 ± 1.2 grids contained COAs compared with 29.3 ±3.5 in controls (p<0.05); lower limb-calf blood pressure ratio was 0.81 ±0.06 compared with 0.31 ±0.07 in controls (p <0.05); and capillary density was 283.7 ±24.5 mm2 compared with 91.4 ±20.9 mm2 in controls (p <0.001). These preliminary results show that cautious ES enhances and accelerates muscle revascularization in severely ischemic tissue.
A Survey of Physicians' Knowledge and Management of Venous Thromboembolism
Authors: Zierler Brenda K. , Meissner Mark H. , Cain Kevin , Strandness D. Eugene
Published: June 2007

A review of all patients diagnosed with venous thromboembolism (VTE) at an academic medical center from 1996 to 1998 revealed a wide variation in management and subsequent patient outcomes and a 30% increase in utilization of the vascular laboratory from the previous 2-year period. The purpose of this study was to determine physicians' knowledge and management strategies before the implementation of integrated care pathways for VIE. Mail surveys were sent to 650 physicians covering 3 academic medical centers. The disciplines targeted were from those physicians who had previously referred patients for any VTE screening examination. One-hundred and twenty-eight physicians (20%) completed the survey. Only 12% of the physicians were able to correctly identify all of the veins routinely imaged as either deep or superficial veins. Fifty-nine percent of the physicians incorrectly identified the superficial femoral vein of the thigh as a superficial vein, and 23% believed the popliteal vein to be a superficial vein. Only 17% of the respondents correctly classified the tibial-peroneal veins as deep veins. Approximately 70% of the physicians stated that they would not treat symptomatic isolated calf vein thrombosis, and, of those, only 42% said that they would obtain serial duplex scans to monitor for proximal propagation. Physicians underestimated the charges for all diagnostic screening tests, and only 14% were able to correctly identify the range of charges for a venous duplex scan. This survey of physicians demonstrated a lack of basic knowledge regarding lower extremity venous anatomy, charges for the different diagnostic tests used to diagnose VIE, and, most importantly, current treatment standards for VTE.
Duplex Saphenous Vein Mapping: Venous Occlusion and Dependent Position Facilitate Imaging
Authors: Hoballah Jamal J. , Corry David C. , Rossley Nancy , Chalmers Roderick T. A. , Sharp William J.
Published: June 2007

The purpose of this study was to develop an optimal technique for greater saphenous vein distention during preoperative duplex assessment. An Acuson 128 scanner with a 7.5-MHz sector probe was used to assess the effects of venous occlusion and dependent position on the diameter of the greater saphenous vein in 20 male volunteers. The greater saphenous vein was imaged 10 cm above and 10 cm below the knee with the subject lying horizontal, horizontal with a thigh tourniquet inflated to 40 mm Hg, inclined at 15 degrees of reversed Trendelenburg, and inclined at 15 degrees of reversed Trendelenburg combined with the tourniquet inflated to 40 mm Hg. Maximal vein diameters and circumferences were measured by a sonographer blinded to the conditions of vein measurement to avoid interpretation bias. Using a t test assuming equal variances, the increases in vein circumferences and diameters achieved by dependency and tourniquet combined were significantly greater than those achieved by dependency alone (p = 0.004). The technique of dependency combined with tourniquet inflation to 40 mm Hg facilitates greater saphenous vein imaging and provides an optimal method of venous distention.
Vena Cava Filter Placement Using a Cutdown of the Superficial Epigastric Vein
Authors: Danikas D. , Theodorou S. J. V. , Ginalis E. M. , Stratoulias C. , Singh R. , Constantinopoulos G.
Published: June 2007

Percutaneous placement of vena cava filters through the femoral vein has been associated with insertion site venous thrombosis. Reported incidence varies from 2% to 41%. In the majority of placements, sequential dilators are used to create the venotomy and subcutaneous tract. This technique disrupts all layers of the vein wall. The injured area may extend as far proximal as the dilator or sheath is placed. The authors present their experience with placement of vena cava filters using a cutdown of the superficial epigastric vein. During a 5-year period, 27 patients underwent placement of the LGM-Vena Tech vena cava filter via a femoral approach. A cutdown of the superficial epigastric vein was performed. The guidewire, dilator, and introducer sheath were inserted under direct fluoroscopic examination. After removal of the dilator, the LGM-Vena Tech filter was placed through the introducer. There were no wound infections and no clinical signs of insertion site venous thrombosis in the postoperative period. Insertion site venous thrombosis is a well-documented complication of percutaneous filter placement. Superficial epigastric vein cutdown is a reasonable alternative technique, which allows gentle atraumatic manipulation of the femoral vein. It is a simple, safe procedure that can be performed without any significant increase in operative time and no additional morbidity.
Carotid Endarterectomy in Octogenarians with Symptomatic High-Grade Internal Carotid Artery Stenosis: Long-Term Clinical and Duplex Follow-up
Authors: Metz R. , Teijink J. A. W. , van de Pavoordt H. D. W. M. , Ackerstaff R. G. A. , de Borst G. J. , Kelder J. C. , Moll F. L.
Published: June 2007

The objective of this study was to evaluate the clinical and duplex outcome after carotid endarterectomy (CEA) in recently symptomatic patients aged 80 years or older. Information was assembled from a prospective data collection of all CEAs performed from January 1986 to December 1999. Included were all patients with recently symptomatic carotid artery stenosis who were aged 80 years or older at time of operation. Thirty-two patients, with a mean age of 82 years, were included. Outcome events were stroke, death, and restenosis (more than 50% diameter reduction) during routine duplex scan follow-up. Conventional surgical technique was used regarding anesthesia and selective shunting or patching. None of the operated-on patients suffered a stroke at any time during follow-up. One patient (3.1%) died in the early postoperative phase (< 30 days). An additional 8 patients died during follow-up. None of these deaths were of cerebrovascular origin. Survival at 3 years was 73% (life table analysis). Routine duplex scan follow-up showed 2 patients with a diameter reduction of more than 50%, both 3 months after CEA. Restenosis rate on duplex scan was 7.4% after 1 year. The authors conclude that there seems to be no reason to deny the very elderly the benefits of CEA. Stroke-free survival and survival rates show that carotid surgery is a safe procedure in patients aged 80 and over who are in apparently good health. These findings are supported by a low incidence of restenosis on duplex scan follow-up, indicating a durable repair.
Enhanced Platelet Force Development Despite Drug-Induced Inhibition of Platelet Aggregation in Patients with Thromboanglitis Obliterans
Authors: Carr Marcus E. , Hackney Mary H. , Hines Susan J. , Heddinger Steven P. , Carr Sheryl L. , Martin Erika J.
Published: June 2007

Thromboangiitis obliterans (TAO) is a nonatherosclerotic, nonnecrotizing, nonspecific, segmental inflammatory obliterative vasculitis, characterized by decreased flow to the distal extremities and increased risk of amputation. While smoking cessation is viewed as critical to successful treatment, various therapeutic options have been employed. While many treatment regimens seek to diminish platelet function, there are relatively few studies of platelet function in this disease entity and even fewer that have offered evidence of increased platelet activity. The authors report here 2 cases of TAO in which evaluations for hypercoagulable states and of platelet function were performed. Platelet contractile force (PCF) was found to be 82% higher than a normal control in 1 TAO patient and 340% higher than normal in the second patient. This was true despite the fact that platelet aggregations confirmed suppression of aggregation by antiplatelet medications. Elevated PCF has been seen in a variety of conditions, such as coronary artery disease and diabetes mellitus, in which endothelial function is abnormal. Whether high PCF values play a role in the pathogenesis of these diseases or simply serve as markers of enhanced platelet function and/or endothelial dysfunction awaits additional evaluations.
Controversies in the Management of Type 11 “Branch” Endoleaks Following Endovascular Abdominal Aortic Aneurysm Repair
Authors: Maldonado Thomas S. , Gagne Paul J.
Published: June 2007

Successful endovascular aortic aneurysm repair (EVAR) is often defined as complete exclusion of blood flow within the aneurysm sac. Perigraft flow, also known as endoleak, is the most common complication following EVAR. Attachment site related endoleaks (type 1) are generally considered to warrant some form of intervention due to the belief that they represent a risk for future rupture. Management of type 11 endoleaks, also known as branch or collateral endoleaks, is more controversial. Some advocate a policy of watchful-waiting whereas others treat all type 11 endoleaks as soon as they are discovered. The following review explores the controversies pertaining to the management, diagnosis and surveillance imaging, and treatment of type 11 endoleaks.
Limb Salvage Angioplasty in Poor Surgical Candidates
Authors: Tefera Girma , Turnipseed William , Tanke Timothy
Published: June 2007

This study was conducted to evaluate the potential for percutaneous catheter based limb salvage angioplasty in patients who have no surgical bypass option. Twenty patients, 12 males and 8 females, with end-stage limb ischemia (Rutherford category 4 and 5) were treated with balloon angioplasty. Antegrade femoral access, coronary guidewire, and balloons were used. The aim of intervention was to prevent major amputation with low morbidity and mortality. Technical success was based on intent to treat and radiologic patency after the procedure. Clinical success was based on healing of ischemic ulcers, resolution of rest pain, improvement of ankle-brachial index (ABI) > 0.10, or healing of a minor amputation site. Limb salvage is defined as preservation of functional foot without a need for prosthesis for ambulation. The mean age of the patients was 67.5 years. Mean follow-up was 8.8 months. Indications for revascularization were rest pain (2), ischemic ulcers (9), and gangrene (9). The indications for percutaneous revascularization were lack of a distal surgical target vessel in 10 (2 did not have adequate vein), poor surgical risk in 7 (1 without adequate vein), and short segment lesions in 3. Technical success was achieved in 18 (90%). One of the technical failures required a below-the-knee amputation (BKA). Clinical success was achieved in 15 patients (75%). There was 1 death due to myocardial infarction, and 4 BKAs within 6 weeks of angioplasty. Two patients had recurrent lesions within 6 months. Infra-inguinal arterial angioplasty can achieve limb salvage in patients who are at high surgical risk, or do not have good target vessels or adequate conduits for distal revascularization.
Surgical Treatment of Celiac Artery Aneurysm: In Situ Aortoceliac Artery Reanastomosis
Authors: Sugimoto Takaki , Nishikawa Hironobu , Koyama Takashi , Maeda Hiromi , Umeki Masahiko , Hatta Ken , Kurisu Sigeru , Sano Nobuya
Published: June 2007

The authors present a rare case of celiac artery aneurysm treated by aneurysmectomy and vascular reconstruction, and they review the past literature. A 57-year-old man was referred to their hospital with a complaint of epigastric discomfort. Abdominal echography, 3-dimensional computed tomography, and selective angiography showed a sole celiac artery aneurysm. At operation, the origin of the celiac artery and adjacent aorta was exposed through a midline transperitoneal approach alone. A 25 x 20 x 25 mm fusiform aneurysm of the celiac artery was found 5 mm distal from its origin. Aneurysmectomy and in situ aortoceliac artery reanastomosis was performed buttressed with a doughnut-shaped Teflon felt under the partial clamp of the abdominal aorta. The left gastric artery arising from the aneurysm was ligated. Postoperative angiography showed good patency of the splenic and common hepatic arteries. He had an uneventful postoperative course with no aggravation of the liver function and was discharged 11 days after operation. Pathological examination of the aneurysmal wall revealed medial degeneration with a tear of the internal elastic lamina and intimal edema. In situ aortoceliac artery reanastomosis after aneurysmectomy, as was done in this case, has not been previously documented in the past literature.
Local Versus General Anesthesia for Carotid Endarterectomy: Report of 329 Cases
Authors: Guirer Onur , Yaplcl Fikri , Enq Yavuz , Qinar Bayer , Ketenci Builend , Özler Azmi
Published: June 2007

Since stroke is an important cause of morbidity and mortality, carotid endarterectomies are used frequently to reduce the risk of stroke and death. Unfortunately, an inherent risk of the carotid endarterectomy procedure is that surgery itself may result in stroke. At this point the question is which method of anesthesia, local or general, is better to protect and monitorize the brain function during cross-clamp period in carotid endarterectomies? In the authors' center, 365 carotid endarterectomies were applied to 329 patients between 1990 and 2001; 165 operations were done under general anesthesia and the other 200 operations were done under local anesthesia. These 2 groups, general (group 1) and local anesthesia (group 11), were studied retrospectively according to preoperative and postoperative data. In group 1, the rate of major stroke was 7.3%, but this rate was 1% in group 11 (p <0.05). Intraoperative shunts were used in 50 (30.3%) operations of group 1, but the usage of shunt was 8% (16 operations) in group 11 (p< 0.000 1). The hospitalization period was also much shorter in group 11 than in group 1. The time of hospitalization was 4.1 ± 1.9 days in group I and 2.4 ± 1.1 days in group 11 (p < 0.0001). In terms of cost analysis, the mean costs were $1007.14 ± $135.71 in group I and $885.71 ± $78.57 in group 11 (p < 0.0001). In short, the local procedure was more cost-effective. As a result, in carotid endarterectomy procedures, the authors prefer local anesthesia to achieve better brain function monitoring and to reduce hospitalization time and cost.
Arterial Compromise Caused by Lower Limb Osteochondroma
Authors: Andrikopoulos Vassilios , Skourtis Georgios , Papacharalambous Gerasimos , Antoniou Ioannis , Tsolias Konstantinos , Panoussis Panagiotis
Published: June 2007

Osteochondromas occasionally cause arterial complications, mainly concerning the distal superficial femoral and popliteal arteries. The authors present 1 1 patients (12 cases) with arterial disorders caused by exostoses who were hospitalized in their Vascular Clinic. All but 1 had signs or symptoms of peripheral arterial disease such as intermittent claudication or diminished peripheral pulses, and 1 also presented serious neurologic sequelae. All were examined by radiography, ankle-brachial index (ABI), computed tomography scan, color duplex scan, arteriography, and scintigraphy. The popliteal artery was the most commonly affected vessel in 7 cases. In addition to the removal of the offending osteochondroma, 7 patients underwent excision of the diseased arterial segment and replacement by a saphenous vein interposition graft. The remaining 5 cases received a vein graft patch. The authors achieved good results with no serious complications detected in the immediate postoperative period and subsequent follow up. Surgical treatment of the vascular complications caused by exostoses is mandatory. Even in the absence of vascular symptoms, such bony lesions in close proximity to a vessel should be on a close follow-up in order to prevent permanent arterial damage.
Endovascular Treatment of Innominate Artery Stenosis in a Bovine Aortic Arch
Authors: D'Ayala Marcus , Toursarkissian Boulos , Ferral Hector , CannonLewis W. M. , Jones W. Tracey , Wholey Michael H.
Published: June 2007

Recent reports have established the feasibility and safety of percutaneous transluminal angioplasty and stent placement in the treatment of innominate artery occlusive disease. Although the long-term durability of these endovascular approaches has not been clearly established, they are particularly attractive in patients who are not considered good candidates for surgical reconstruction. The authors present a case involving a morbidly obese Hispanic woman who had undergone previous coronary artery bypass and complained of right visual symptoms, dizziness, and right upper extremity claudication. Because of her unusual bovine anatomy and the desire to avoid reoperating in her chest, a unique approach with a left subclavian-to-carotid bypass and innominate artery angioplasty and stenting was used.
Aorto Uni-iliac Modification of a Bifurcated Stent Graft for Endovascular Aneurysm Repair: Expanding the Versatility of a Modular Device
Authors: Sampaio Sergio M. M. , Panneton Jean M. , Brink Jeromy S. , Andrews James C. , McKusick Michael C. , Gloviczki Peter
Published: June 2007

As endografting technology advances, anatomical constraints limiting access and deployment have become less of a burden. While unsuitable candidates for endografting exist, these patients are becoming less frequent. To broaden the applicability of endovascular abdominal aortic aneurysm repair (EVAR), we have modified the bifurcated AneuRx™ device into a unilimb modular prosthesis, by placing an aortic extender cuff across the flow divider, thus excluding its contralateral limb. This technique was used with success in 3 groups of patients: with occlusion of 1 iliac artery, with a nontraversable iliac stenosis, or with a small calcific aortic bifurcation. In these patients, anatomy can make it difficult, if not impossible, to place a bifurcated stent graft. Whether as a planned preoperative procedure or as a ‘bail-out’ maneuver, this procedure has been successful in avoiding open surgical conversion.
Incidence and Distribution of Lower Extremity Deep Vein Thrombosis in Rehabilitation Patients: Implications for Screening
Authors: Sachdev Ulka , Teodorescu Victoria J. , Shao Michael , Russo Theresa , Jacobs Tikva S. , Silverberg Daniel , Carroccio Alfio , Ellozy Sharif H. , Marin Michael L.
Published: June 2007

Patients admitted to in-patient rehabilitation programs have an increased risk for developing deep venous thrombosis (DVT). However, the utility of screening for lower extremity DVT using duplex ultrasound in this high-risk population is not well characterized. The purpose of this study is to identify whether or not screening lower-extremity duplex exams are indicated in this high-risk population. Screening lower extremity duplex exams were performed on all patients admitted to the rehabilitation center at Mt. Sinai Hospital over a 3-year period. Charts were reviewed for patient age, gender, diagnosis, date of screening and follow-up duplex exams, presence and location of venous thrombosis at each duplex exam, history of anticoagulation, and medical DVT prophylaxis. The presence of DVT at screening, the location of DVT along the lower extremity, and the outcome of calf DVT were analyzed in terms of gender, underlying diagnosis, and history of DVT prophylaxis. Lower extremity DVT was detected in 34% of patients. Twenty-three percent of patients had isolated calf vein thrombosis. Men were more likely than women to have DVT. Calf DVTs progressed in 3% of patients over an average follow-up of 2 weeks. The presence of DVT, its location along the lower extremity, and the outcome of calf vein DVT had no significant relationship to underlying diagnosis or history of prophylaxis. Screening duplex exams to detect lower extremity DVT in rehabilitation patients is useful. Screening altered management in 26% of patients, prompting either anticoagulation or repeat duplex exam.
A True Posterior Tibial Artery Aneurysm
Authors: Tshomba Yamume , Papa Maurizio , Marone Enrico Maria , Kahlberg Andrea , Rizzo Nathalie , Chiesa Roberto
Published: June 2007

Aneurysms of infrapopliteal arteries are rare. The etiology is usually traumatic, and most aneurysms are false. The English-language literature reports only 33 cases of infrapopliteal arterial true aneurysms, of which 8 involve the posterior tibial artery. The etiology of these lesions is unclear; a fibromuscular fibrodysplasia similar to ulnar aneurysm may be hypothesized, but traumatic, atherosclerotic, inflammatory, and other pathological processes are also probably involved. The natural history seems to be related to thrombosis and distal embolism more than to rupture. Surgical indications are debated. Aneurysm repair with a complete restoration of the blood flow through the affected artery is particularly challenging owing to the small size of the vessels, and ligation may be required. We report, to the best of our knowledge, the first case of an atherosclerotic posterior tibial artery true aneurysm successfully treated with aneurysmectomy and end-to-end direct reconstruction with a documented good long-term patency. Clinical features, imaging findings, and surgical management are described; indications and treatments (open or endovascular) are discussed.