Chantel Hile

Medical Management of Spontaneous Celiac Artery Dissection : Case Report and Literature Review

Spontaneous visceral artery dissections are a rare occurrence. Here we report a case of spontaneous celiac artery dissection that was treated without surgery.

Bovine pericardial patch repair in infected fields

OBJECTIVE Bovine pericardial patches (BPP) are frequently used for arterial reconstruction, but little data exist regarding their ability to resist infection. We hypothesize that BPP would provide a reasonable alternative to autologous vein patches in infected fields. METHODS We used BPP to repair 51 arteriotomies (25 brachial, 23 femoral, three popliteal) in 48 consecutive patients (mean age, 68 years; 65% men, 75% diabetic, 67% dialysis dependent) undergoing removal of infected (33 gram-positive, three gram-negative, eight mixed flora, and four culture-negative) polytetrafluoroethylene grafts (35 arteriovenous grafts, nine femoral-distal bypasses, and four femoral patch angioplasties) between January 2007 and January 2011. Patient records were retrospectively reviewed and outcomes, including death, rupture, secondary reconstruction, and infection, were recorded. RESULTS Over a mean follow-up of 2.1 years (range, 3-48 months), 50 of 51 patches remained in place without evidence of recurrent infection, rupture, or revision. One patient had acute rupture of a popliteal arteriotomy 1 week postrepair and had subsequent ligation and above-knee amputation. Eight of the 48 patients died from unrelated causes during follow-up (three withdrew from dialysis, three myocardial infarction, and two unknown). CONCLUSIONS BPP provide a durable alternative to saphenous vein for arterial reconstruction following removal of infected arterial grafts.

Open surgical revision provides a more durable repair than endovascular treatment for unfavorable vein graft lesions.

OBJECTIVE Lower extremity bypass grafts that develop stenoses are commonly treated with either open surgical or endovascular revision. Vein graft stenoses with unfavorable lesions (multiple lesions, lesions >2 cm in length, lesions in grafts <3 months old, lesions in grafts <3 mm in diameter) fare worse than those with favorable lesions when treated with endovascular therapy. However, it is not known if unfavorable lesions fare better with surgical revision than with endovascular treatment or than favorable lesions treated with surgery. METHODS We performed a retrospective review of 175 vein graft revisions performed at a single institution from 2000 to 2010. Characteristics of lesions treated with surgical and endovascular revision were identified. Cox proportional hazard models were used to identify predictors of revision failure (restenosis >75%, revision, or amputation). RESULTS Ninety-one failing vein grafts (52%) were treated with surgical revision and 84 with endovascular treatment (48%), with a median follow-up of 30 months. Favorable lesions fared better than unfavorable lesions after endovascular treatment, with 12-month freedom from failure of 59% vs 34% (P < .01), but not after surgical revision (66% vs 62%; P = .90). Unfavorable lesions had better freedom from failure after surgery than endovascular treatment (62% vs 34%; P < .01), and results in favorable lesions were similar (66% vs 59%; P = .57). CONCLUSIONS For the treatment of failing vein grafts, endovascular therapy appears adequate for favorable lesions and surgical revision is more durable for unfavorable lesions.

Clinical Features and Diagnosis of Macrovascular Disease

Atherosclerotic peripheral vascular disease in patients with diabetes is a major factor in the progression of diabetic foot pathology. The rate of lower extremity amputation in the diabetic population is 15 times that seen in the nondiabetic population (1). A number of factors conspire in the patient with diabetes, each of which synergistically contributes to this extremely high amputation rate. Peripheral neuropathy, infection, microvascular changes, and macrovascular changes all have complex interplay. Peripheral neuropathy leads to structural and sensory changes within the foot, making the limb injury-prone. In addition, once it occurs, that injury is often not easily detectable and heals slowly if at all. Microvascular changes are nonocclusive changes in the microcirculation that lead to impairment of normal cellular exchange, again preventing easy healing. Infection in patients with diabetes can often be aggressive and polymicrobial. Macrovascular disease, atherosclerosis of the peripheral arteries, contributes to poor perfusion of the extremities. Although the underlying pathogenesis of atherosclerotic disease in patients with diabetes is similar to that noted in patients without diabetes, there are some significant differences. It is important to realize that the diabetic foot is more susceptible to moderate changes in perfusion than the nondiabetic foot, resulting in a greater sensitivity to atherosclerotic occlusive disease. Compounding this scenario is the fact that patients with diabetes are noted to have a fourfold increase in the prevalence of atherosclerosis as well as a propensity for accelerated atherosclerosis. This chapter will review the pathobiology and anatomic distribution of occlusive disease in the patient with diabetes, the usual clinical presentation of peripheral vascular disease, and the various diagnostic modalities useful in planning treatment. It will conclude with a diagnostic and treatment protocol that can be used in patients presenting with this multifactorial disease process.