Bertram L. Smith

Mesenteric angioplasty in the treatment of chronic intestinal ischemia

PURPOSE This study was undertaken to determine the safety and efficacy of percutaneous transluminal angioplasty (PTA) in the treatment of chronic mesenteric ischemia (CMI) in very high-risk surgical patients. METHODS Twenty-four focal mesenteric stenoses treated from 1984 to 1994 by PTA in 19 patients with CMI were reviewed. All 19 patients were considered poor surgical candidates. Seventeen patients had classic symptoms of CMI, and two patients had atypical abdominal complaints. Vessels dilated included the superior mesenteric artery (18), celiac artery (3), inferior mesenteric artery (1), aorta-superior mesenteric artery vein graft (1), and aorta-splenic artery vein graft (1). Complete follow-up was possible in all patients, with the exception of one patient who had no symptoms when last seen 17 months after the procedure. RESULTS PTA was technically successful in 18 of 19 patients (95%) and 23 of 24 stenoses (96%). The lone technical failure resulted in superior mesenteric artery dissection with thrombosis and bowel infarction; the patient died despite emergent laparotomy and revascularization (mortality rate, 5%). Complete symptomatic relief was attained in 15 patients (79%), with follow-up showing continued relief of symptoms for a mean of 39 months (range, 4 to 101 months). Partial symptomatic relief was attained in three patients. Recurrent symptoms developed in three patients (20%) at a mean interval of 28 months (range, 9 to 43 months). Repeat PTA performed in two patients provided good technical results and relief from clinical symptoms. One patient had a symptomatic axillary sheath hematoma that required surgical decompression. CONCLUSIONS Mesenteric PTA is a valuable treatment option in patients who have CMI and are considered very high operative risks. The initial technical success rate is excellent, with the majority of patients having complete symptomatic improvement and continued relief of symptoms at short-term follow-up.

Arterial Embolectomy: A 34-Year Experience with 400 Cases

A series of 400 peripheral arterial embolectomies performed in 326 patients over a 34-year period is presented. Operative mortality was 11.0 per cent overall and 10.0 per cent in patients after the introduction and use of Fogarty catheters. The plateau in mortality is related to the association with serious underlying cardiac disease. The amputation rate was 9.5 per cent, with a corresponding 90.5 per cent limb salvage rate. Cardiac disease was the most common cause of emboli and was responsible for the majority of deaths. Mortality was considerably higher in patients with aortic and iliac emboli and in patients with recent myocardial infarcts. Amputation rates were higher with femoral and popliteal emboli and correlated directly with the time delay from onset of symptoms to performance of embolectomy. Higher amputation rates in the second half of the series are related to liberalization of the indications for embolectomy. Prompt operative management of patients with peripheral arterial emboli remains the treatment of choice. Low mortality and amputation rates can be achieved with early embolectomy and routine use of heparin.

Hypertension following carotid endarterectomy: the role of cerebral renin production.

The cause of hypertension in the immediate postoperative period after carotid endarterectomy is unknown. In order to elucidate the etiology of hypertension following carotid endarterectomy, blood samples were drawn intraoperatively from internal jugular vein and external carotid artery prior to and subsequent to carotid endarterectomy in 20 patients. Renin measurement in these samples produced a ratio of internal jugular vein (cerebral) to external carotid artery (systemic). In pre-endarterectomy samples, this cerebral-to-systemic ratio was 1.0 +/- 0.17. However, in the six patients hypertensive postoperatively, this ratio was significantly (p less than 0.02) higher at 1.39 +/- 0.4 than in 14 patients not hypertensive, 0.99 +/- 0.28. Although this ratio in hypertensive patients reverted to 1.12 +/- 0.24 in the postoperative period, the present study suggests a relation between hypertension after carotid endarterectomy and renin production by the brain.

Persistent Sciatic Artery: Collective Review and Management

One of the rarer anatomic variants is persistent sciatic artery. Only 93 cases have been reported since the first description of this anomaly. The earlier reports were mainly pathologic descriptions, whereas the more recent have been clinically oriented. There is a slight male predominance, and the average age of presentation is 49 years old (range 6 months to 85 years). The majority of patients have symptoms of a mass, ischemia, or gluteal pain. There is no preference for the right or left side, and one in four patients has both legs affected. In this anomaly the sciatic vessel acts as the principal blood supply to the lower limb. One half of all patients develop aneurysms that are characteristically located caudal to the sciatic notch as opposed to gluteal aneuryms that are cephalad to this landmark. Various methods (some now obsolete) have been tried to treat these aneurysms, but the best results were obtained through aneurysm ablation and vascular reconstruction. Arterial bypasses succeeded when used for ischemic complications of persistent sciatic artery. Optimal management of this condition requires prompt recognition, an understanding of the developmental anatomy, exclusion and bypass of aneurysms, appropriate vascular intervention for ischemic sequelae, and close observation of asymptomatic individuals.

Persistent sciatic artery and vein: An unusual case

Persistent sciatic artery is a rare anomaly that has been reported in 48 patients in the North American literature. No report has contained more than two cases. This article discusses the first reported case of bilateral persistent sciatic arteries in a patient who also has normally developed superficial femoral arteries. This unique situation allowed removal of the superficial femoral artery for a malignant femoral nerve schwannoma without a concomitant reconstructive arterial procedure. A similar anomaly of the venous system permitted the operation to be done without compromising venous outflow.

Intermediate follow-up of carotid artery stent placement

BACKGROUND Carotid artery stent placement (CAS) is becoming more popular among various specialties for the treatment of primary and recurrent carotid artery disease. The morbidity associated with this procedure is improving but the intermediate- and long-term follow-up remains unknown. We report our restenosis rates and follow-up associated with CAS. METHODS Thirty-one interventions on 29 patients from May 1998 to January 2002 were reviewed. All patients have undergone serial follow-up using Doppler ultrasound at 3 and 6 months and every 6 months thereafter. Ten interventions (32%) were performed on patients with recurrent carotid artery disease and 21 (68%) on patients with primary disease. RESULTS Five periprocedural complications occurred (transient ischemic attack, n = 3; major stroke, n = 1; immediate intrastent restenosis requiring lysis, n = 1) for a total immediate complication rate of 16%. No deaths occurred. Follow-up was achieved in all 29 patients (mean 28 months; range 20 to 46). Twenty-seven patients (29 vessels; 94%) remain asymptomatic with less than 50% stenosis. Two vessels (6%) have been found to have a critical restenosis of greater than 90%. Both patients were symptomatic from their recurrence (transient ischemic attack, n = 1; acute stroke, n = 1). Cumulative major stroke and death rate including all follow-up was 6%. CONCLUSIONS CAS can be performed with an acceptable stroke/death rate (3%) in a properly selected patient population. In our small series of patients, the restenosis rate at a mean of 28 months after CAS is 6%.

Carotid endarterectomy in patients less than 50 years old

PURPOSE The purpose of this study was to compare the results of carotid endarterectomy (CEA) in a young population with premature atherosclerosis with the results of an older control group, examining perioperative morbidity and mortality data, recurrent stenosis and symptoms, late stroke, and survival data. METHODS We retrospectively studied 26 patients less than 50 years old (mean, 43.2 +/- 3.8 years) and 30 patients greater than 55 years old (mean, 69.1 +/- 7.4 years) who underwent CEA during the same time period. Data were obtained regarding demographics, atherosclerotic risk factors, indication for CEA, perioperative complications, recurrent stenosis and symptoms, late stroke, and survival. RESULTS Smoking was more prevalent among young patients who underwent CEA (92% vs 70%; p = 0.036). Young patients were also more likely to be symptomatic at presentation (92% vs 57%; p = 0.003). The perioperative mortality rate (0% vs 0%) and neurologic morbidity rate (0% vs 3%; p = 1.000) were low for the study patients. During a mean follow-up of 67 +/- 42.7 months, there was no significant difference in survival rate (5-year survival rate, 93% vs 81%; p = 0.373), rate of late ipsilateral (4% vs 3%) and contralateral (4% vs 3%) stroke, restenosis and occlusion (26.9% vs 14.3%), recurrent symptoms (22% vs 17%), reoperation (11.5% vs 5.7%), or contralateral disease (17% vs 23%) development that required surgery for the study or the control cohorts. CONCLUSIONS Our data show that there is a high incidence of smoking and symptomatic presentation among young patients in whom carotid occlusive disease develops. CEA may be performed in young patients with low perioperative morbidity and mortality rates. Recurrent disease, late stroke, and survival rates are not significantly different than for older patients. Follow-up with serial duplex ultrasound and reoperation for symptomatic and high-grade asymptomatic restenosis may decrease the risk of late stroke.

Treatment of proximal vertebral artery disease.

Vertebral arterial disease (VAD) is a less commonly recognized and treated source of cerebrovascular ischemia compared with carotid artery disease. Patients are often referred for treatment after they have developed symptoms in the form of transient ischemic attacks or had a posterior hemispheric stroke. Traditional treatment of VAD has been surgical. More recently, endovascular treatment of VAD has been utilized. We performed a retrospective review of our institutional experience in treating VAD from 2001 to 2010. For treatment of proximal VAD, perioperative morbidity is lower for the endovascular group than for the surgical group, but six-week mortality was higher for the endovascular group. Complete resolution of symptoms occurred more frequently with surgery than with endovascular therapy. Therefore surgical reconstruction appears to be preferable to angioplasty and stenting for treatment of proximal vertebral artery occlusive disease.

Occurrence of a type 2 proatlantal intersegmental artery during carotid endarterectomy for symptomatic stenosis

A 63-year-old female patient presented with transient right hand weakness and left amaurosis fugax. A computed tomography angiogram demonstrated a 75% to 90% internal carotid artery (ICA) stenosis and a persistent proatlantal intersegmental artery (PAIA) originating from the external carotid artery (ECA), passing lateral to the internal jugular vein (A), and joining the ipsilateral vertebral artery. The PAIA was the major contributor to the basilar artery. Also noted were an absent left cervical vertebral artery and a hypoplastic right vertebral artery terminating as the posterior inferior cerebellar artery. Intraoperatively, the PAIA was identified as a posterior-oriented branch of the ECA (B). A shunt was placed from the common carotid artery to the ICA. Pulsatile back-bleeding was seen from the ECA/PAIA origin, and this was not shunted. Endarterectomy and patch was performed, and the ECA/PAIA was treated with an eversion endarterectomy only. The patient had a normal convalescence and was discharged the following day. A follow-up three-dimensional computed tomography angiogram demonstrated a satisfactory patch repair with patency of all intracranial and extracranial arteries (C/ Cover).

Endovascular “Repair” of Abdominal Aortic Aneurysm and Iliac Artery Aneurysm

Endovascular aneurysm repair is currently being developed as an alternative to traditional surgical repair for patients with abdominal aneurysms. The divisions of vascular surgery and interventiona...