Brooke Roberts

Popliteal artery aneurysms: Current management and outcome

PURPOSE Thrombosis of popliteal artery aneurysms can produce limb-threatening ischemia. In this setting we have found preoperative thrombolytic therapy to be beneficial. METHODS Thirty-three patients with 54 popliteal artery aneurysms were studied (mean follow-up 62 months). Twenty-one patients (62%) had bilateral popliteal artery aneurysms, and 20 patients (61%) had extrapopliteal arterial aneurysms. Thirty-three (61%) aneurysms had symptoms of compression or ischemia, and 21 (39%) aneurysms had thrombosis. A trend toward thrombosis for larger aneurysms was noted (p < 0.068). RESULTS Forty-five aneurysms were treated with bypass grafting. Five-year graft patency and limb salvage rates were 71% and 90%, respectively. Factors favoring graft patency and limb salvage included presence of two- or three-vessel runoff compared with patients with single- or no-vessel runoff (p < 0.025 graft patency; p < 0.003 limb salvage) and presence of a patent aneurysm (p < 0.005 graft patency and limb salvage). Seven patients diagnosed with thrombosis of their aneurysm and all runoff vessels were treated with preoperative thrombolytic therapy. Complete clearing of thrombus from these arteries was achieved in six of these patients (and from two of these runoff vessels in the remaining patient). These patients had better graft patency (p < 0.005) and limb salvage (p < 0.01) than comparable patients treated with emergency operations. Six amputations were performed in the follow-up interval, none of which were performed in patients having undergone thrombolytic therapy. CONCLUSIONS It is concluded that popliteal aneurysms are managed best by elective repair of patent aneurysms with good runoff. In that difficult situation of the thrombosed popliteal artery aneurysm associated with acute leg ischemia, thrombolytic therapy safely and effectively provides patients with a more favorable alternative than emergency surgery.

Results of 100 consecutive femoropopliteal vein grafts for limb salvage.

One hundred consecutive patients with femoropopliteal autogenous vein grafts for limb salvage were reviewed five years later. In this group 40% died and 30% of the limbs had been lost at the end of five years. Limb survival correlated best with adequacy of distal run-off, but not with the presence or absence of diabetes. Forty-seven per cent of the grafts were still patent among surviving patients, and when combined with the limbs that were viable despite failure of the original graft, 70% of the limbs were salvaged among the survivors at five years. Temporary graft patency was effective in preserving ischemic tissue by facilitating healing of ulcers or limited amputations. Femoral-popliteal bypass grafting in the presence of advanced ischemia is capable of improving the quality of life for many of these patients.

Femoropopliteal vein grafts for claudication. Analysis of 100 consecutive cases.

One hundred consecutive femoropopliteal venous grafts in 85 patients with claudication were followed for five years. At this time, three limbs had been amputated, approximately one quarter of the patients had expired, and 70% of the grafts in surviving patients remained patent. It is concluded that this operation does not appear to increase the risk of amputation and in fact, may lessen it. Moreover, it is associated with minimal risk and generally provides long-term relief of claudication, thus enhancing the quality of life in most patients.

Transluminal Angioplasty of the Iliac, Femoral, and Popliteal Arteries

The recently developed Grüntzig balloon dilatation catheter has facilitated the performance of transluminal angioplasty. The authors used this catheter in 35 arteries supplying the lower extremities in 27 patients. Immediate relief of symptoms (claudication and rest pain) occurred in 30 vessels (86%) in 23 patients. The procedure was well tolerated by all patients. Over 90% of initially successful dilatations were patent at 3 to 10 months.

Early experience with percutaneous transluminal angioplasty using a vinyl balloon catheter.

The technique of transluminal dilatation of arterial stenoses has been greatly facilitated with the recent development of the vinyl balloon catheter by Gruntzig. Since these catheters became available to us in early 1978, we have utilized them to attempt dilatation of 62 arteries, including iliac, femoral and renal vessels. Immediate success was achieved in 57 of these vessels. There were five early complications (two distal embolizations and three prompt occlusions) and three late complications (two restenoses and one occlusion at ten days). The occlusions were all treated promptly surgically with good results and the stenoses redilated. Noninvasive pressure measurements were obtained on all patients whose iliac or femoral arteries were dilated both before and after the procedure, with objective improvement demonstrated by this method. The procedure itself is well tolerated by patients. It involves only minimal discomfort and risk and a markedly shortened hospital stay. The procedure can be easily accomplished by physicians who are thoroughly familiar with routine femoral catheterization techniques and it is believed that this technique will have a definite place in the future therapy of many cases of arterial stenosis.

Operative management of renovascular hypertension.

From 1966 to 1975, 38 patients underwent 42 procedures for renovascular hypertension; 35 operations were aortorenal bypasses and 7 were nephrectomies. Forty-five per cent of the patients were cured, 43% were improved and 12% were unimproved. There were no operative deaths and only three late deaths. Two grafts occluded and 2 became stenotic, giving a graft complication rate of 12%.Curability was best correlated with a short history of hypertension and a pathologic diagnosis of fibromuscular hyperplasia, but not with patient age. Most patients selected for surgery had elevated renal venous renin ratios, and of these 95% were cured or improved. Of those with normal renin ratios, 85% were still cured or improved. Postoperative aortography and peripheral renin measurements offered valuable information in predicting the ultimate response to surgery.Preservation of renal function was a principal indication for surgery in 11 patients. In 8, azotemia was documented preoperatively. Hypertension was cured or improved in every case and 5 patients demonstrated a 10–50% reduction in BUN and creatinine following revascularization.

Aortic Aneurysm: Report of 101 Cases

An evaluation of the management of patients with aneurysm of the aorta seems timely because of new and promising methods of treatment. The risks of nonoperative and operative treatment are presented from the experiences with 101 patients admitted to the Hospital of the University of Pennsylvania during the years 1950 through 1955. Follow-up data indicate that the mortality of nonoperative treatment is considerably greater than that of excision of the lesion, in spite of the poor operative risk of many patients in this group. The nonoperative mortality within 1 year of diagnosis was approximately 50 per cent. Many of these patients died of rupture of the aneurysm.

Long-Term Results of Transluminal Angioplasty of the Femoral Arteries

Percutaneous transluminal angioplasty (PTA) as a means of treating occlusive vascular disease of the lower extremities has become widespread. Within the last 3 years, reports of experience in centers across the United States and Europe have been published in both radiological and surgical literature [1–7]. Many of these reports have only dealt with short-term studies and small numbers of patients. Others fail to examine the variables that a vascular surgeon normally uses to evaluate surgical procedures. In this paper, we report the results of femoral artery PTA from the viewpoint of a vascular surgeon by examining those factors that are known to affect the outcome of surgical treatment of lower extremity occlusive arterial disease in order to provide a better way of comparing the results of angioplasty to those of surgery.

Thromboelastographic evaluation of the method of heparin administration

Abstract An attempt was made to detect differences in the clotting mechanism as related to the different routes of administration of heparin. The thromboelastogram was used for these determinations. There was a definite decrease in the maximal amplitude value of the thromboelastogram after a course of subcutaneous heparin. This could be interpreted as being consistent with a decrease in platelets associated with the formation of subclinical platelet thrombi with diminished cohesive properties. Some previous experimental work supporting this hypothesis is presented. Changes in the platelet count in patients and the influence of the route of heparin treatment on this change are also demonstrated. The correlation of these findings with the clinically observed problem of peripheral arterial emboli of the platelet thrombin type is mentioned.