Christer Ljungman

Popliteal Venous Aneurysm—A Systematic Review

Popliteal vein aneurysm is a rare but potentially problematic disease with a risk of pulmonary embolism. A systematic literature search was performed. A total of 105 popliteal vein aneurysms were identified, with a slight female and left-sided preponderance. Dominating symptoms are caused by pulmonary embolism, followed by local symptoms with a palpable mass. In four patients arterial symptoms were reported. The most frequently used diagnostic test was phlebography, increasingly replaced by duplex ultrasonography in recent years. Because pulmonary embolism is a potential, it motivates surgical removal. In most cases excision and lateral suture is possible. Four fatal cases were reported. Unfortunately follow-up time and results are poorly documented. Popliteal venous aneurysm is rare but should be considered as a local source of pulmonary embolism when no other explanation is found.

Carotid Artery Endarterectomy Solely Based on Duplex Scan Findings

The purpose of this study was to review experience with carotid artery surgery based on findings obtained solely from duplex scanning with special regard to unexpected findings during surgery and the early outcome. From January 1993 through December 1999, 271 consecutive patients underwent 287 carotid endarterectomies (CEAs), 229 (80%) of which were performed solely based on duplex scan findings. During the study period 5,932 carotid artery duplex scans were performed in 4,466 patients. Of 589 patients with internal carotid artery (ICA) stenosis? 70%, 246 underwent CEA compared to 25 of 156 with 50-69% ICA stenosis. The indications for CEA were transient ischemic attack (TIA) in 88 (30.7%), amaurosis fugax in 60 (20.9%), previous stroke in 91 (31.7%) and asymptomatic disease in 48 (16.7%) cases. There were no statistically significant differences between the groups operated on with and without preoperative angiography with respect to the indications for surgery, associated risk factors, or the degree of stenosis on the contralateral side. In patients undergoing surgery without angiography, there were no unexpected findings that influenced the performance of surgery, in all except 1. There were no significant differences in perioperative morbidity and mortality in patients undergoing surgery with and without conventional angiography. The combined mortality and major stroke rates were 3.4% and 2.2%, respectively. It is concluded that CEA can safely be performed without preoperative angiography in cases with conclusive duplex scan findings.

Amputation risk and survival after embolectomy for acute arterial ischaemia. Time trends in a defined Swedish population.

OBJECTIVES To assess the outcome of embolectomy over an 19 year period. METHODS Time trends in the outcome of acute arterial thrombo-embolectomy of the extremities were analysed in a population-based cohort of 1190 patients operated on between 1965-83. RESULTS A total of 262 (22%) initial amputations were performed. The limb salvage rates at 5 years postoperatively were lower between 1975-79 (61%) than between 1965-69 (81%). A proportional hazards model revealed a relative hazard (RH) of amputation of 2.2 (95% confidence interval (CI) 1.3-3.3) for 1975-79 compared with 1965-69. Operation at any district hospital entailed a 70% higher risk of amputation (RH 1.7; 95% CI 1.3-2.5) compared with the University hospital. The relative survival rate at 5 years postoperatively decreased towards the end of the study period (33% between 1975-79 compared with 43% between 1965-69). Younger age-groups had a considerably lower risk of death in the University hospital compared with the county and district hospitals. CONCLUSIONS Contrary to the results in other hospital based reports no improvement in amputation or survival rates since 1965 could be demonstrated in this large series with no patient selection.

The Role of Duplex Scanning in the Selection of Patients with Critical Lower-Limb Ischemia for Infrainguinal Percutaneous Transluminal Angioplasty

AbstractPurpose: To investigate the role of duplex scanning in the selection of patients with critical lower-limb ischemia (CLI) for infrainguinal percutaneous transluminal angioplasty (PTA). Methods: One hundred and sixty-two limbs with CLI (150 patients) that underwent duplex scanning within 3 months prior to conventional diagnostic angiography (n = 88) or infrainguinal PTA (n = 74) were retrospectively studied. The findings obtained from duplex scanning and angiography were analyzed in a masked fashion by two different investigators. Results: The accuracy, sensitivity, specificity, and negative and positive predictive values of duplex scanning in the selection of patients for infrainguinal PTA were 86%, 84%, 89%, 86%, and 87% respectively. Forty-two procedures (57%) were performed at multiple arterial segments. The accuracy of duplex scanning in the selection of femoropopliteal and crural lesions for PTA was over 85%. However, the sensitivity of duplex scanning in the selection of popliteal and crural lesions for PTA was 49% and 38% respectively, compared with 80% for superior femoral artery lesions. In 39% of patients who were correctly selected for PTA, duplex scanning misdiagnosed one of the multiple lesions treated by PTA. Conclusion: Duplex scanning can safely be used for the selection of patients for infrainguinal PTA. The sensitivity of duplex scanning in the selection of lesions for PTA was less satisfactory in the popliteal and crural arteries compared with the femoropopliteal arteries.

2D inflow MR angiography in severe chronic leg ischemia

Purpose: the aim of this study was to compare 2D inflow MR angiography (MRA) with selective X-ray angiography (XRA) in patients with severe chronic leg ischemia. Material and Methods: In a blinded prospective study, 2D inflow MRA and XRA were compared with regard to evaluation of the arteries distal to the knee in 24 patients (median age 72 years) with severe ischemia; 23 of them had either rest pain or tissue loss. Statistics were calculated with XRA as the reference method. Results: the interpretations of 2D inflow MRA and XRA showed moderate agreement in the calf arteries but poor agreement in the foot arteries. of the discrepancies, two-thirds were observer-related and only one-third method-related. of all the comparable arteries, 9% showed method-related differences between the two methods. An assessment of MRA using only maximum intensity projections (MIP) resulted in 19% of findings being judged inconclusive whereas all the arteries could be classified when the cross-sectional images were studied on the viewing console. Conclusion: the agreement between MRA and XRA was good in the calf but questionable in the foot.

Propositions for Refinement of the Hybrid Surgical Technique for Treatment of Thoraco-Abdominal Aortic Aneurysm

Traditional open repair of thoraco-abdominal aortic aneurysms Crawford type II-IV carries a high perioperative risk and mortality. The hybrid technique for combined surgical and endovascular treatment offers an interesting alternative with reduced risk of paraparesis and possibly a reduced mortality rate. Propositions for refinement of this approach are outlined based on a single centre experience.

Selection of patients with lower limb arterial occlusive disease for endovascular treatment of the iliac arteries with duplex scanning

The aim of this study was to evaluate the role of duplex scanning in selection of patients with lower limb arterial occlusive disease for endovascular treatment of the iliac arteries. From January 1995 through May 2000, 183 patients having chronic lower limb arterial insufficiency who underwent duplex scanning of the lower extremity arteries with available aortoiliac scans within 3 months before conventional aortoiliac diagnostic angiography and/or endovascular intervention of the iliac arteries were studied retrospectively. The findings obtained from duplex scanning and angiography were analyzed in a blinded manner by 2 investigators. Limbs having category 1, 2, and 3 lesions according to duplex scan findings were interpreted as being suitable for endovascular intervention. The comparison between duplex scan findings and angiography was analyzed by the third investigator. During 93 percutaneous transluminal angioplasty (PTA) procedures, 133 arterial segments, common or external iliac, were dilated with stent placement in 70. Bilateral interventions were performed in 25 cases, and of 68 unilateral interventions, 57 were at only 1 arterial segment. The accuracy, sensitivity, specificity, and negative and positive predictive values of duplex scanning to appropriately categorize the iliac artery lesions into suitable or unsuitable for endovascular intervention were 90%, 95%, 83%, 90%, and 92%, respectively when the inconclusive duplex scans were excluded (11%). In 6 patients with lesions suitable for PTA according to duplex scanning and angiography, PTA was not performed owing to clinical reasons. The accuracy of duplex scanning in predicting the performance of endovascular intervention was 88%. It is concluded that iliac artery endovascular procedures in limbs with chronic occlusive disease can be reliably planned according to duplex scan findings.

The influence of distal runoff on patency of infrainguinal vein bypass grafts

This retrospective study was conducted to analyze a new concept of evaluation of the effect of distal runoff on patency in infrainguinal bypass surgery for arterial insufficiency. Distal runoff was evaluated on postreconstruction angiograms in 191 limbs undergoing femoropopliteal and femorodistal reconstruction. Runoff was characterized as good, fair, or poor. Determination of graft patency was made by clinical examination, ankle-brachial index measurement, or duplex scanning at 1 month and thereafter at 6-month intervals. Cumulative patency rates were calculated according to the actuarial life table method. Patency rates in limbs with good runoff were better than in limbs with fair and poor runoff; at 6 months, patency rates were 88.2%,70.9%, and 21.8%, respectively (p<0.01). Similar patency rates were found for good runoff in femoropopliteal and femorodistal reconstructions (84.7% in femoropopliteal and 75% in femorodistal reconstructions) at 6 months. The authors conclude that this method of angiographic evaluation accurately predicts patency in infrainguinal bypass reconstructions.

The Effect of Postocclusion Reactive Hyperaemia, Papaverine and Nifedipine on Duplex Derived Haemodynamic Parameters of Infrainguinal Bypass Grafts

OBJECTIVES The aim of the present study was to analyse the effects of various vasodilating stimuli on postoperative infrainguinal graft haemodynamics. DESIGN Duplex derived haemodynamic parameters of infrainguinal bypass grafts were measured at rest and after postocclusion reactive hyperaemia, intraarterial papaverine (40 mgm) injection and peroral nifedipine (10 mg) administration. SETTING Department of Surgery, University Hospital. MATERIALS Twenty-nine patients with infrainguinal bypass grafts were studied by Duplex scanner after a median of 25 months postoperatively. CHIEF OUTCOME MEASURES Peak systolic velocity (PSV), mean velocity (MV) and volume flow (VF) were measured at rest and after various stimuli. MAIN RESULTS VF at rest increased from 125 +/- 16 ml/min (mean +/- S.E.M.) to 271 +/- 26 ml/min after papaverine administration and to 205 +/- 19 ml/min during reactive hyperaemia (p < 0.001). PSV, MV and VF increased significantly during postocclusion reactive hyperaemia and papaverine injection. After nifedipine administration VF increased to 154 +/- 21 ml/min after 30 min (p < 0.001) and there was a significant increase in MV (p < 0.05). CONCLUSIONS Duplex derived flow measurement of infrainguinal bypass grafts can evaluate graft and limb haemodynamics in the postoperative period. Pharmacological manipulations, such as vasodilation, can influence the physiological runoff with subsequent increase in volume flow through the graft.

Treatment Options for Abdominal Aortic Aneurysm (AAA)

This chapter will focus on how to deal with AAA from a practical point of view and also give hints on how to cor- rect some of the complications that may occur. The two principal options to treat AAA are by: (1) open repair or (2) endovascular aneurysm repair (EVAR). Both can be used irrespective of whether the AAA is ruptured or treat- ed electively, although the experience on EVAR in the case of rupture so far is limited. A third option, laparoscopic repair, can still be considered as non-established, and its role remains to be seen. It will not be further discussed in this chapter. Today there are no pharmacological means to treat AAA or reduce expansions, although α-blockade and antibiotics have been tried. A better understanding of the cause of AAA may, however, lead to other treatment options in the future.