Ahmed M. Abou-Zamzam

Functional outcome after infrainguinal bypass for limb salvage

PURPOSE Functional outcome after infrainguinal bypass (IB) has recently been assessed with global health status questionnaires but not by criteria specific to the objectives of IB (i.e., maintenance of independent living and ambulation). Preoperative and postoperative living situation and ambulatory status were evaluated in patients who underwent IB for limb salvage (LS) indications. METHODS For patients in whom IB was performed for LS from January 1980 to July 1995, living situation (independent or dependent) and ambulatory status were assessed before the onset of the need for LS surgery and 6 months after surgery. The importance of risk factors (age, sex, diabetes, heart disease, hypertension, renal insufficiency or failure, previous leg bypass, indication for surgery, postoperative morbidity, graft patency) was assessed by multivariate analysis. RESULTS IB for LS was performed in 513 patients. Before the development of the indication for LS surgery, 92% lived independently and 91% were ambulatory. The operative mortality rate was 2.7%. At 6 months, 86% were alive and the assisted primary graft patency rate was 92%. Ninety-nine percent of survivors who lived independently before developing the need for LS surgery remained independent 6 months after surgery, and 97% of those who were ambulatory before developing the need for LS surgery were ambulatory 6 months after surgery. Only one of 25 survivors (4%) who were not living independently before surgery achieved independent living 6 months after surgery. Twenty-one percent of nonambulatory patients (6 of 29) became ambulatory. Multivariate analysis confirmed the importance of preoperative living situation and ambulatory status in predicting outcome at 6 months (p < 0.0001). Amputation and loss of primary patency were predictive of poor ambulatory status at 6 months (p < 0.0001, p = 0.025, respectively). The overall 5-year survival rate was 48.1%. CONCLUSIONS Preoperative independence and ambulation best predict postoperative independence and ambulation after IB for LS indications. IB procedures performed for limb salvage have a low operative mortality rate and maintain independent living and ambulation in 99% and 97% of patients, respectively. Poor overall long-term outcome and survival in LS patients results from intercurrent illness and not from IB.

Subfascial endoscopic perforator vein surgery combined with saphenous vein ablation: results and critical analysis

OBJECTIVE This study was undertaken to determine the results of subfascial endoscopic perforator vein surgery (SEPS) combined with ablation of superficial venous reflux. METHODS Clinical data were retrospectively analyzed for 74 consecutive limbs (65 patients) in which this combination treatment was performed at a university medical center. Preoperatively, 58 lower extremities had an open venous ulcer (CEAP clinical class 6 [C(6)]) and 16 had healed ulceration (C(5)). Preoperative and postoperative ulcer care remained constant. Main outcomes measured included perioperative complications, ulcer healing, and ulcer recurrence. Clinical severity and disability scores were tabulated before and after surgery. Mean patient follow-up was 44 months. RESULTS Greater saphenous vein (GSV) stripping and varicose vein excision accompanied SEPS in 57 limbs (77%), and SEPS was performed alone or with varicose vein excision in 17 limbs that had previously undergone GSV stripping. Postoperative complications occurred in 12 limbs (16%), all with C(6) disease (P =.04). Ulcer healing occurred in 91% (53 of 58) of limbs with C(6) disease at a mean of 2.9 months (range, 13 days-17 months). Multivariate analysis demonstrated that ulcer healing was negatively affected by previous limb trauma (P =.011). Ulceration recurred in 4 limbs (6%) at 7, 20, 21, and 30 months, respectively. This was associated with a history of limb trauma (P =.027) and preoperative ultrasound evidence of GSV reflux combined with deep venous obstruction (P(R,O); P =.043). Clinical severity and disability scores improved significantly after surgery (both, P <.0001). CONCLUSIONS Most venous ulcers treated with SEPS with ablation of superficial venous reflux heal rapidly and remain healed during medium-term follow-up. Ulcer healing is adversely affected by a history of severe limb trauma, and ulcer recurrence is similarly affected by a history of limb trauma in addition to superficial venous reflux combined with deep venous obstructive disease. Overall, there was marked improvement of postoperative clinical severity and disability scores compared with those obtained before surgery.

Treatment and outcomes of aortic endograft infection

OBJECTIVE This study examined the medical and surgical management and outcomes of patients with aortic endograft infection after abdominal endovascular aortic repair (EVAR) or thoracic endovascular aortic repair (TEVAR). METHODS Patients diagnosed with infected aortic endografts after EVAR/TEVAR between January 1, 2004, and January 1, 2014, were reviewed using a standardized, multi-institutional database. Demographic, comorbidity, medical management, surgical, and outcomes data were included. RESULTS An aortic endograft infection was diagnosed in 206 patients (EVAR, n = 180; TEVAR, n = 26) at a mean 22 months after implant. Clinical findings at presentation included pain (66%), fever/chills (66%), and aortic fistula (27%). Ultimately, 197 patients underwent surgical management after a mean of 153 days. In situ aortic replacement was performed in 186 patients (90%) using cryopreserved allograft in 54, neoaortoiliac system in 21, prosthetic in 111 (83% soaked in antibiotic), and 11 patients underwent axillary-(bi)femoral bypass. Graft cultures were primarily polymicrobial (35%) and gram-positive (22%). Mean hospital length of stay was 23 days, with perioperative 30-day morbidity of 35% and mortality of 11%. Of the nine patients managed only medically, four of five TEVAR patients died after mean of 56 days and two of four EVAR patients died; both deaths were graft-related (mean follow-up, 4 months). Nineteen replacement grafts were explanted after a mean of 540 days and were most commonly associated with prosthetic graft material not soaked in antibiotic and extra-anatomic bypass. Mean follow-up was 21 months, with life-table survival of 70%, 65%, 61%, 56%, and 51% at 1, 2, 3, 4, and 5 years, respectively. CONCLUSIONS Aortic endograft infection can be eradicated by excision and in situ or extra-anatomic replacement but is often associated with early postoperative morbidity and mortality and occasionally with a need for late removal for reinfection. Prosthetic graft replacement after explanation is associated with higher reinfection and graft-related complications and decreased survival compared with autogenous reconstruction.

Management of Symptomatic Spontaneous Isolated Visceral Artery Dissection: Is Emergent Intervention Mandatory?

Spontaneous dissection of a visceral artery without associated aortic dissection is rare, although more cases have recently been reported because of the advancement of diagnostic techniques. The risk factors, causes, and natural history of spontaneous isolated visceral artery dissection are unclear. Treatment with open surgery, endovascular stenting, or anticoagulation therapy has been proposed; however, there is no consensus on the optimal management. We present three cases of spontaneous and isolated dissection of visceral arteries. Dissection involved the superior mesenteric artery in one and the celiac artery in two. All three patients presented with acute abdominal pain but lacked any peritoneal irritation. The patients were treated nonoperatively with anticoagulants or antiplatelets. No surgical or endovascular intervention was performed. Follow-up imaging studies demonstrated improvement of the dissection in two patients and no change in one patient. All patients were symptom-free over a mean follow-up of 17 months. Nonoperative treatment with close observation is an acceptable strategy in the management of spontaneous isolated dissection of visceral arteries. Emergent intervention is not mandatory in symptomatic patients without evidence of acute bowel ischemia or hemorrhage.

Staged endovascular stent grafts for concurrent mobile/ulcerated thrombi of thoracic and abdominal aorta causing recurrent spontaneous distal embolization

Mobile thrombus of the thoracic aorta is an uncommon pathology with potentially catastrophic complications. Recurrent spontaneous distal embolization may also occur from an ulcerated thrombus of the abdominal aorta. The simultaneous presence of a mobile thrombus in the thoracic aorta and ulcerated thrombus of the abdominal aorta is extremely rare and poses a significant treatment dilemma. Although various approaches have been reported, there is no standard treatment. Direct replacement of the thoracoabdominal aorta is extremely morbid, while continued embolization despite anticoagulation mandate intervention. We herein present the first case report of successful treatment of symptomatic mobile/ulcerated thrombi of the thoracic and abdominal aorta using staged endovascular stent graft repair. Successful treatment of the thoracic component with a thoracic aortic graft (TAG, Gore-Tex, W. L. Gore & Assoc., Flagstaff, Ariz.) was followed one week later by exclusion of the infrarenal aortic lesion with a bifurcated stent graft. Endovascular stent graft exclusion of mobile/ulcerated thoracic and abdominal aortic thrombi is a minimal invasive operation. It can be employed as an alternative procedure in treatment of aortic thrombus with embolization in high risk patients. Long-term follow-up will be necessary to assess the durability of this technique.

Is a single preoperative duplex scan sufficient for planning bilateral carotid endarterectomy

PURPOSE Duplex scanning is often the sole imaging study before carotid endarterectomy (CEA). Patients with bilateral severe internal carotid artery (ICA) stenosis may be considered for bilateral CEA. High-grade ICA stenosis, however, may artifactually elevate velocity measurements used to quantify stenosis in the contralateral ICA. It is unknown whether ipsilateral CEA will influence duplex determination of the presence of a contralateral 60% to 99% ICA stenosis. This study was performed to determine whether a single preoperative duplex scan is sufficient to plan bilateral CEA. METHODS Preoperative and early postoperative carotid duplex scans in patients with bilateral ICA stenosis who underwent unilateral CEA were reviewed. Changes in duplex scans that determined stenosis in the ICA contralateral to the CEA were analyzed. Previously validated criteria used to determine 60% to 99% ICA stenosis were a peak systolic velocity (PSV) of 260 cm/sec or more combined with an end diastolic velocity (EDV) of 70 cm/sec or more. RESULTS Over an 8-year period, 460 patients underwent CEA; 107 patients (23.3%) had an asymptomatic 50% to 99% contralateral ICA stenosis by standard criteria (PSV, >125 cm/sec) and an early postoperative duplex scan examination. Of these 107 patients, 38 patients (35.5%) had duplex scan criteria for 60% to 99% contralateral ICA stenosis. In these 38 patients, there was a mean postoperative PSV decrease of 47.7 cm/sec (10.1%) and a mean EDV decrease of 36.0 cm/sec (19.3%) in the ICA contralateral to the CEA. Eight of 38 (21.1%) preoperative contralateral 60% to 99% ICA lesions were reclassified as less than 60% on postoperative duplex scanning. Six of 69 (8.7%) preoperative lesions of less than 60% were reclassified as 60% to 99% on postoperative duplex scan. These six preoperative examinations were all close to the criteria for 60% to 99% stenosis (mean PSV, 232.5 cm/sec; mean EDV, 62.5 cm/sec). CONCLUSION One-fifth of patients with apparent 60% to 99% contralateral ICA lesions before the operation have less than 60% stenosis when restudied with duplex scan after unilateral CEA. Lesions below but near the cutoff for 60% to 99% may be reclassified as 60% to 99% on the postoperative duplex scan. These findings mandate that when duplex scanning is used as the sole imaging modality before CEA, patients with severe bilateral carotid stenosis must have an additional carotid duplex examination before operation on the second side.

Inflammatory Abdominal Aortic Aneurysm Treated by Endovascular Stent Grafting A Case Report

Despite complications inherent to open surgical repair of inflammatory abdominal aortic aneurysms, there is expected resolution of the retroperitoneal inflammatory process following graft replacement. An endovascular approach could also exclude the aneurysm while potentially avoiding injury to vital structures in the hostile operative field. However, data are limited regarding the role of endovascular stent grafts in the management of inflammatory abdominal aortic aneurysms. Furthermore, postoperative regression of perianeurysmal inflammation is rarely discussed in the few published accounts of endovascular repair of inflammatory aortic aneurysms. The case presented demonstrates successful endovascular treatment of an infrarenal inflammatory aneurysm with resolution of the retroperitoneal inflammation and hydronephrosis.

Carotid Surgery Following Previous Carotid Endarterectomy Is Safe and Effective

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.

Effects of Prior Abdominal Surgery, Obesity, and Lumbar Spine Level on Anterior Retroperitoneal Exposure of the Lumbar Spine

OBJECTIVE To evaluate the effects of prior abdominal surgery and obesity and the level of spine exposure on the technical aspects and complications of anterior retroperitoneal exposure of the lumbar spine (ARES). DESIGN Retrospective review of prospective database. SETTING Academic vascular surgery practice. PATIENTS Patients undergoing ARES from 2001 to 2011. MAIN OUTCOME MEASURES Influence of prior abdominal surgery, obesity, and level of exposure on time to spine exposure and incidence of vascular and perioperative complications. RESULTS Four hundred seventy-six patients underwent ARES. Mean (SD) age was 47.7 (12.6) years; 46.6% had undergone prior abdominal surgery. Mean (SD) body mass index (BMI) was 28.3 (5.5); 61.6% of procedures included the L4-5 disk. Mean (SD) time to exposure was 70.0 (25.5) minutes. Vascular injury occurred in 23.3% (3.8% major). Perioperative complications occurred in 16.4% of cases. Prior abdominal surgery had no effect on time to exposure, vascular injury, and perioperative complications. A BMI of 30 or more had no effect on time to exposure compared with a lower BMI. A BMI of 30 or more led to higher rates of vascular injury (30.8% vs 19.7%; P = .007) and overall complications (21.4% vs 14.0%; P = .04). Exposures involving L4-5 led to increased time to exposure (77.0 vs 56.2 minutes; P < .001) and higher rates of vascular injury (29.7% vs 13.1%; P < .001) but had no effect on overall complications compared with exposures for other levels. CONCLUSION Prior abdominal surgery should not be considered a contraindication to ARES. Caution is warranted in obese patients and exposures involving L4-5.

Carotid duplex ultrasound changes associated with left ventricular assist devices.

BACKGROUND Carotid duplex ultrasound (CDUS) is often used as a screening test in cardiac patients. Significant cardiac dysfunction may affect the accuracy of CDUS because of alterations in the cardiac cycle. Left ventricular assist devices (LVADs) are frequently implanted as a bridge to cardiac transplant. A review of CDUS in patients with LVADs was performed to assess their influence on arterial waveforms and velocities. METHODS Patients with LVADs undergoing carotid duplex in our Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL)-accredited vascular laboratory were identified. The carotid waveforms were analyzed qualitatively and quantitatively. Common carotid artery (CCA) and internal carotid artery (ICA) peak-systolic and end-diastolic velocities (PSV and EDV) were recorded as ICA/CCA velocity ratios. In patients with prior CDUS, the changes between these values were analyzed before and after LVAD placement. RESULTS Of the 14 patients with LVADs treated in our institution over the past 2 years, 4 had CDUS (8 ICAs). Mean age was 57 years, and 3 of the 4 patients were men. All patients were free of cerebrovascular symptoms. Qualitatively, there was significant blunting of the CCA and ICA waveforms noted in all 8 ICAs. The degree of stenosis was reported as ≤15% in 7 ICAs and 15-45% in 1 ICA. The mean ICA PSV was 61.8 cm/sec. Two patients (4 ICAs) had CDUS before and after LVAD placement. Comparing pre- and post-LVAD values, the mean ICA PSV decreased by 42% (54 cm/sec; P = 0.04) and EDV increased by 51% (17 cm/sec; P = 0.3). The PSV and EDV ratios were unchanged. Overall assessment of category of stenosis was unchanged in 2 ICAs (≤15%), one decreased from moderate to mild (45-70% to 15-45%), and one ICA changed from 45-70% to ≤15% based on the decreased ICA PSV. CONCLUSIONS The presence of an LVAD has a significant influence on CDUS findings. There is a qualitative change in the ICA with blunting of the waveform, and a quantitative change with a decreased PSV and an increased EDV. Compared with pre-LVAD placement, there is a significant decrease in PSV which may affect the accuracy of CDUS using velocity-based criteria. Further study into the accuracy of CDUS in patients with LVADs is necessary.