Ali F. AbuRahma

Complications of arteriography in a recent series of 707 cases: Factors affecting outcome

Seven hundred and seven consecutive arteriograms were analyzed regarding the effects of various factors on clinical outcome. Complication rates were assessed regarding age, inpatient or outpatient procedures, operator caseload, clinical indication, preoperative renal disease, approach site, graft puncture, selective injection of arteries, amount of contrast, and catheterization time. The major complication rate for arteriography was 7% and the mortality rate was 0.7%. The complication rates for femoral and axillary approaches, respectively, were local, 9% and 27%; nervous system, 1.4% and 11%; and major, 6% and 24% (p=0.0075,p<0.0001, andp<0.0001, respectively). Brachial plexus injury was noted in 13% of the patients undergoing the axillary approach. There was a trend toward a higher overall complication rate in four-vessel arch aortograms with selective vs. nonselective carotid injections, but both had similar neurologic complications. More contrast was used in patients with post-arteriogram renal failure, 224 ml vs. 168 ml. The complication rates were directly related to catheterization time, amount of contrast, and number of vessels punctured. There was a trend toward a higher complication rate in physicians with a lower caseload. In conclusion, arteriography is still associated with significant morbidity and mortality. The transfemoral approach is safer than the transaxillary route, even in patients with femoral graft punctures.

Prospective randomized trial of carotid endarterectomy with primary closure and patch angioplasty with saphenous vein, jugular vein, and polytetrafluoroethylene: Perioperative (30-day) results

PURPOSEnThe early outcomes of carotid endarterectomy (CEA) with primary closure (PC) versus vein patch closure (saphenous vein [SVP] and jugular vein [JVP]) and polytetrafluoroethylene patch closure (PTFE-PC) were compared.nnnMETHODSnThree hundred ninety-nine CEAs were randomized into the following groups: 135 PC, 134 PTFE-PC, and 130 vein patch closure (SVP alternating with JVP). Surviving patients underwent a carotid color duplex ultrasonographic scan 1 month after surgery. Demographic characteristics were similar in all groups.nnnRESULTSnThe incidence of perioperative cerebrovascular accidents (CVAs) was 4.4% for PC, 0.8% for PTFE-PC, and 0% for vein patch closure (PC vs vein patch, p = 0.0165; PC vs all patching [vein and PTFE], p = 0.007). The perioperative CVA and reversible ischemic neurologic deficit (RIND) combined rates for all patching were superior to PC (1.5% vs 5.2%; p = 0.04). These combined rates were also superior for vein patch closure when compared with PC (0.8% vs 5.2%; p = 0.037). The mean diameter of the internal carotid artery was similar in patients who had perioperative neurologic deficits and those who did not. After 1 month of follow-up, 11.9% of the PC arteries were narrowed 50% or more in contrast to 2.3% for PTFE-PC, 3.1% for SVP, and 10.3% for JVP.

Prospective controlled study of polytetrafluoroethylene versus saphenous vein in claudicant patients with bilateral above knee femoropopliteal bypasses

BACKGROUNDnAlthough several studies have compared the patency rates of polytetrafluoroethylene (PTFE) and saphenous vein grafts (SVG) for the above knee location, none have compared the 2 grafts when implanted in the same patient with claudication who needs bilateral above knee femoropopliteal bypasses.nnnMETHODSnForty-three patients (86 limbs) with bilateral disabling claudication who had superficial femoral artery occlusion and above knee reconstitution with 2- to 3-vessel runoff were analyzed. Patients were treated on one side with PTFE and on the other side with SVG. They were sequentially assigned to PTFE-SVG alternating with SVG-PTFE. All patients were followed using duplex ultrasound and ankle/brachial indexes at 1 month and every 6 months thereafer.nnnRESULTSnThe perioperative complication rates were 5% for PTFE and 12% for SVG. There was no operative death or perioperative amputation for either procedure. The Kaplan-Meier estimate of primary, assisted primary, and secondary patency rates at 72 months were 68%, 68%, and 77% for PTFE and 76%, 83%, and 85% for SVG. There were no statistically significant differences between primary and secondary patency rates for both grafts; however; the assisted primary patency rates were higher for SVG (P < .05). The crude limb salvage rate at 72 months was 98% for PTFE and 98% for SVG. There were no risk factors identified that had an impact on graft patency.nnnCONCLUSIONSnPTFE and SVG for above knee bypasses have comparable patency and limb salvage rates in claudicant patients with bilateral superficial femoral artery occlusion and 2- to 3-vessel runoff This may justify the use of PTFE for above knee locations in these selected patients.

Angioplasty/stenting of the superior mesenteric artery and celiac trunk: early and late outcomes.

Purpose: To analyze the early results and durability of angioplasty/stenting of the superior mesenteric artery (SMA) and celiac trunk (CT). Methods: Twenty-two patients (19 women; mean age 69.2 years, range 52–88) with 24 symptomatic SMA or CT stenotic lesions were treated with dilation/stenting over a recent 4.5-year period. Two patients had lesions in both the SMA and CT treated. Clinical follow-up and duplex exams were done to evaluate long-term patency. Kaplan-Meier life-table analyses estimated the freedom from recurrent stenosis and recurrent symptoms, as well as survival rates. Results: The initial technical and clinical success rates were 96% (23/24) and 95% (21/22), respectively, with no perioperative mortality or major morbidity. During a mean follow-up of 26 months (range 1–54), the primary late clinical success rate was 61% (11/18; 4 lost to follow-up), and freedom from recurrent stenosis (≥70%) was 30% (6/20). The freedom from recurrent stenosis at 1, 2, 3, and 4 years were 65%, 47%, 39%, and 13%; freedom from recurrent symptoms was 67% at all 4 intervals. The survival rates were 93%, 93%, 80%, and 53% at 1 to 4 years, respectively. Conclusions: Angioplasty/stenting of SMA and CT stenoses has a high initial technical success rate and acceptable early and late clinical outcomes; however, it is associated with a high incidence of late restenosis based on strict Doppler criteria.

Sympathectomy for Reflex Sympathetic Dystrophy: Factors Affecting Outcome

This study includes our 12-year experience with chemical sympathetic blocks and surgical sympathectomies for causalgic pain of reflex sympathetic dystrophy (RSD) with emphasis on factors affecting clinical outcome. Medical records of patients undergoing sympathectomies for causalgic pain were analyzed. The patients were classified according to Drucker et al. as stage I, II, or III. Results of chemical and surgical sympathectomies were analyzed using both univariate and multivariate methods. Twenty-one patients had lumbar and seven had cervicodorsal sympathectomies for RSD. The mean duration between initial injury and chemical sympathetic block was 10 months with a mean of 11.4 months to surgical sympathectomy. Ten patients (36%) had overt extremity trauma as the precipitating event. Ten patients (36%) had a lumbar laminectomy, three of whom developed the syndrome bilaterally. There was no operative mortality; however, 25% had transient postoperative sympathetic neuralgia. The early and late (>6 months) satisfactory outcomes after surgical sympathectomy were 82% and 71%, respectively. Patients with stage II presentations were significantly more likely to have satisfactory early (92%) and late (79%) outcomes than stage III patients, 0% and 0% (p=0.019). Patients with an excellent response to chemical sympathetic block were more likely to have satisfactory early and late surgical outcomes. The time between injury and chemical block and surgical sympathectomy was significantly shorter in patients who had satisfactory early and late surgical outcomes (p<0.0001). Multivariate analyses demonstrated that the most important independent factor in determining early and late satisfactory outcomes of sympathectomy was the time between injury and sympathectomy (p=0.001). Surgical sympathectomy should be confined to patients with stage II disease who have had an excellent response to chemical sympathetic block and when relief from repeated sympathetic block becomes less effective and the response is dramatic but of shorter duration.

Edema after femoropopliteal bypass surgery: Lymphatic and venous theories of causation

Edema of a lower extremity after femoropopliteal bypass surgery is a common problem. To study the causes of this phenomenon we evaluated 72 patients before and after surgery with noninvasive venous testing and venography. We also obtained postoperative lymphangiograms of a sample of 16 patients, eight with and eight without postoperative edema. Patients were sequentially assigned to one of four treatment groups: group A, a lymphatic-preserving inguinal dissection with conventional popliteal dissection; group B, a lymphatic-preserving popliteal dissection with conventional inguinal dissection; group C, lymphatic-preserving inguinal and popliteal dissections; group D, conventional inguinal and popliteal dissections. Twenty-nine (40%) of the 72 patients had postoperative edema. A similar proportion of patients with edema had deep venous thrombosis as patients without edema (3/29 [10%] vs 3/43 [7%], respectively). Patients in group D showed the highest incidence of edema, 17/20 or 85%, a rate significantly higher than the rates in the other three groups (p less than 0.001). Results of lymphangiograms were normal in six of the eight patients without edema (the other two had slight disruption), whereas they showed severe lymphatic disruption in all eight patients with edema. No association was found between edema and type of graft used or severity of preoperative symptoms. This study indicates that deep venous thrombosis is not an important cause of edema that occurs after bypass surgery and that intraoperative lymphatic disruption probably causes most cases of this complication.

Safety and durability of redo carotid endarterectomy for recurrent carotid artery stenosis

We retrospectively reviewed the records of patients who underwent redo carotid endarterectomies during a 5-year period. Patients were followed by duplex ultrasound to assess late patency of the carotid artery. Reoperations for recurrent carotid stenosis were performed in 46 of 973 patients who had carotid endarterectomies (5%). Indications for surgery were hemispheric transient ischemic attacks (TIA) in 33 (72%) and asymptomatic greater than 80% stenosis in 13 (28%). Pathologic findings revealed that the cause of recurrence was myointimal hyperplasia in 11 patients (24%), with a mean recurrence interval of 12.8 postoperative months, and atherosclerosis in 35 (76%), with a mean recurrence interval of 84 postoperative months (P = 0.0002). Redo endarterectomy with patch angioplasty was used for reconstruction in 32 cases (70%), patch angioplasty alone in 11 (24%), and endarterectomy with primary closure in 3. There were 3 perioperative strokes (7%). Late follow-up (mean 30.9 months) revealed no strokes and 1 TIA. Of 40 patients, 34 (85%) were alive and stroke free. Although six late deaths occurred, none were stroke related. One patient (2%) had late significant second recurrent carotid stenosis. Redo carotid endarterectomy for symptomatic patients and asymptomatic high-grade stenosis is safe and durable.

Management of vagus nerve injury after carotid endarterectomy

BACKGROUNDnInadvertent injury to the vagus nerve or its branches during carotid endarterectomy can result in adductor vocal cord paralysis (hoarseness) and cricopharyngeal dysfunction (dysphagia) with aspiration, known as double trouble. This study describes our experience in the management of this complication in cases where conservative treatment failed.nnnMETHODSnAll patients were examined by a vascular surgeon, a head and neck surgeon, and a speech therapist. Their examinations included comprehensive speech evaluation, video stroboscopy, video fluoroscopy, and methylene blue testing for aspiration. All patients underwent Teflon injections to medialize the paralyzed vocal cord and a cricopharyngeal myotomy to restore swallowing and alleviate aspiration.nnnRESULTSnFourteen patients, eight men and six women, were treated. The duration of dysfunction was 24 weeks in two patients, 6 weeks in four patients, 4 weeks in three patients, and 1 week in five patients. Five patients had severe dysfunction (defined as difficulty in swallowing both solid and liquid foods with more than 20% aspiration), seven patients had moderate dysfunction (defined as difficulty swallowing solid food with aspiration of less than 20%), and two patients had mild dysfunction (defined as difficulty in swallowing solids but with no aspirations). After the Teflon injections and myotomy, 13 of 14 patients had satisfactory outcomes, including normal voice and swallowing.nnnCONCLUSIONSnVagus nerve injury from a carotid endarterectomy can be a debilitating complication. Prevention, early recognition, and prompt correction of these injuries are important in the management of this complication.

Fate of Endoleaks Detected by CT Angiography and Missed by Color Duplex Ultrasound in Endovascular Grafts for Abdominal Aortic Aneurysms

Purpose: To analyze the clinical implications of endoleaks documented by computed tomographic angiography (CTA) and missed by color duplex ultrasound (CDU). Methods: During a recent 5-year period, 232 patients underwent endovascular aortic reconstruction (EVAR) and were followed according to a protocol that included CTA and CDU at 1 month and every 6 months thereafter. CTA was the gold standard for determining the presence of endoleaks. The size of the AAA sac at the latest postoperative follow-up was compared to the preoperative size and correlated to the type of endoleak and clinical outcome. This study analyzed only patients with endoleak documented by CTA and CDU and specifically analyzed the outcome of patients with false negative CDU studies for endoleaks. Results: Thirty-nine endoleaks were documented in 35 (15%) of 232 patients using CTA. Four patients had both early and late endoleaks. The mean follow-up was 25 months (range 1–64). CDU was more helpful in detecting type I endoleaks than type II endoleaks (89% versus 58%, p<0.05). There were 18 (46%) type I endoleaks (12 early, 6 late) detected by CTA; 16 (89%) of these were detected by CDU (2 late endoleaks missed). Nineteen (49%) type II endoleaks (16 early, 3 late) were diagnosed using CTA, 11 (58%) of which were detected by CDU (6 early and 2 late missed). Of the 2 (5%) early type IV endoleaks found on CTA, 1 (50%) was missed by CDU. Overall, CDU failed to identify endoleak in 11 (28%) of 39 endoleaks [2 late type I, 8 type II (6 early, 2 late), and 1 early type IV]. Consequences to treatment occurred in 2 (20%): 1 type I endoleak required treatment and 1 type II endoleak would have missed treatment. Conclusion: CDU has a lower sensitivity in detecting endoleak, particularly type II; therefore, EVAR surveillance should not be based solely on CDU. Although a significant number of type II endoleaks resolved spontaneously, intervention can be offered for type II endoleaks if associated with an increasing sac size.

Effort Subclavian Vein Thrombosis: Evolution of Management

Purpose: To analyze changes in the management of effort subclavian vein thrombosis at our institution. Methods: Records of 23 patients with effort subclavian vein thrombosis treated over a 10-year period were analyzed to compare the results of conventional therapy (heparin/warfarin) used in the first half of this period to a multimodality treatment strategy (thrombolysis and other adjunctive treatment as indicated, e.g., first rib resection, angioplasty/stenting, and vein reconstruction). Diagnostic testing included duplex ultrasound and venography. All patients had at least 1-year follow-up. Results: Eight patients (7 men; mean age 34 years, range 15–54) had conventional treatment (group A) and 15 patients (14 men; mean age 36 years, range 17–55) had multimodality therapy (group B). Demographics and clinical characteristics were comparable for both groups. Initial thrombolysis was achieved in 14 (93%) group B patients; 10 received adjunctive treatment to relieve external compression or vein stenosis. Four patients had successful first or cervical rib resection and scalenectomy, and first rib resection followed by angioplasty/stenting was successful in 2. However, angioplasty and stenting alone failed in 2 patients, while venous reconstruction was successful in only 1 of 2 cases. Mean follow-up was 72 months in group A patients and 59 months in group B. One (13%) group A patient and 12 (80%) group B patients demonstrated total venous recanalization and symptom resolution (p = 0.003). Overall, clinical resolution (total and partial symptom relief) was achieved in 3 (38%) group A patients and 13 (87%) group B patients (p = 0.026). Conclusions: Initial lytic therapy followed by adjunctive treatment to relieve external venous compression or venous stenosis is effective in treating patients with effort subclavian vein thrombosis.