D. Courtney

Subintimal angioplasty as a primary modality in the management of critical limb ischemia: comparison to bypass grafting for aortoiliac and femoropopliteal occlusive disease.

Purpose: To compare the 30-day morbidity, mortality, length of hospital stay, and patency rates in patients with critically ischemic limbs treated with subintimal angioplasty (SA) versus standard bypass surgery. Method: Between October 2001 and August 2003, 137 patients (74 women; mean age 70 years, range 43–92) with critical limb ischemia underwent subintimal angioplasty (n=88) or bypass surgery (n=49) for superficial femoral artery (SFA) or aortoiliac lesions. All patients had lesions classified as C or D according to the TransAtlantic Inter-Society Consensus. Data was retrieved from hospital inpatient inquiry and VascuBase. Parallel group comparison was used in performing a prospective observational study. Results: Primary technical success was 100% for both SA and bypass grafting. Thirty-day survival was 100% in the SFA-SA and aortoiliac bypass groups and 96% and 93%, respectively, in the SFA bypass and aortoiliac SA groups. Limb salvage was 97% and 82% in the SFA-SA and SFA bypass groups, respectively; at the aortoiliac levels, the rates were 100% and 86% for SA versus bypass. Subintimal angioplasty significantly reduced hospital stay (p<0.001). Primary patency was not statistically different in the SA versus bypass groups; however, secondary patency was higher in the SFA bypass group. Conclusions: Frequent clinical follow-up and a duplex surveillance program are necessary to maintain patency in this cohort. Subintimal angioplasty is increasingly replacing bypass surgery in the management of critical limb ischemia without compromising primary patency, limb salvage, patient survival, or subsequent vascular intervention.

Survival of ruptured abdominal aortic aneurysms in the west of Ireland: do prognostic indicators of outcome exist?

Ruptured abdominal aortic aneurysm (RAAA) is a demanding vascular surgical problem and the cause of significant morbidity and mortality. The aim of this study was to identify prognostic factors that influence outcome. Over 6 years, 42 ruptured abdominal aortic aneurysms were operated on with a mean diameter of 7.2 cm. RAAA was defined as free intraperitoneal rupture. Data were collected retrospectively from hospital medical records. The male:female ratio was 8:1 and the mean age was 74 years (range 55–89). Fifteen were in hypovolemic shock and 27 patients were clinically stable. The perioperative mortality rate for the 15 shocked patients was 60% (9 patients) and the 1-year cumulative survival rate was 33%. The perioperative mortality rate for the 27 clinically stable patients was 40% (11 patients) and the 1-year cumulative survival rate was 56%. Survival curves were constructed for these groups to compare male versus female, age =70 versus age <70, shocked versus stable, and preoperative hemoglobin (Hb) =10 vs >10. No patient with preoperative cardiac arrest survived more than 24 hours. With VassarStats, the confidence interval for age, gender, hemodynamic status, and preoperative Hb were calculated. The standard weighted mean analysis by ANOVA gave a p value of <0.001. The overall 30-day mortality rate was 47% (20 of 42) and the 1-year mortality rate was 52% (22 of 42). Male patients over 70 years with RAAA in hypovolemic shock with low Hb have a higher 30-day mortality rate and few survive more than 1 year. The study suggests that each of these 4 parameters separately was not a strong prognostic indicator. Collectively, however, they strongly influence the prognosis of patients with RAAA. These findings strengthen the case for selective treatment for RAAA.

Endovascular Repair of Early Rupture of Dacron Aortic Graft: Two Case Reports

Complications after open aortic surgery pose a challenge both to the vascular surgeon and the patient because of aging population, widespread use of cardiac revascularization, and improved survival after aortic surgery. The perioperative mortality rate for redo elective aortic surgery ranges from 5% to 29% and increases to 70–100% in emergency situation. Endovascular treatment of the postaortic open surgery (PAOS) patient has fewer complications and a lower mortality rate in comparison with redo open surgical repair. Two cases of ruptured abdominal aortic aneurysm (AAA) were managed with the conventional open surgical repair. Subsequently, spiral contrast computer tomography scans showed reperfusion of the AAA sac remnant mimicking a type III endoleak. These graft-related complications presented as vascular emergencies, and in both cases endovascular aneurysm repair (EVAR) procedure was performed successfully by aortouniiliac (AUI) stent graft and femorofemoral crossover bypass. These 2 patients add further merit to the cases reported in the English literature. This highlights the crucial importance of endovascular grafts in the management of such complex vascular problems.

Salvage of critical limb ischemia with the "trellis reserve'' of subintimal superficial femoral-popliteal artery occlusion: a new modality in managing critical limb ischemia--a case report.

Subintimal angioplasty is a safe, effective, but nondurable procedure in treating long superficial femoral artery occlusions in patients with severe lower limb ischemia. The authors report a case of acute thrombosis that presented 16 weeks after subintimal angioplasty. The “Trellis” percutaneous thrombolytic infusion system permitted a controlled site-specific infusion of recombinant tissue-type plasminogen activator (rtPA). The unique design of the “Trellis” allowed complete aspiration of thrombus and avoiding regional and systemic thrombolytic side effects. The “Trellis” system is effective in percutaneous management of thrombotic lesions; however, intimal dissection may need to be addressed.

Comparative parallel group study of bypass surgery versus endovascular approach in aorto-iliac and femoro-popliteal occlusive disease in a tertiary referral centre. Does the introduction of peripheral angioplasty increase the workload and improve the 30-day outcome?

ConclusionPTA managed higher risk patients with lower morbidity where bypass surgery used to be deferred. The cost and economic implications of introducing PTA must be viewed according to the changing face of vascular surgery. We recommend trials using Quality Adjusted Life Year measurement to determine short and long term outcome.

Ruptured abdominal aortic aneurysm: prognostic indicators for outcome

ConclusionMale patients over 70 years with RAAA in hypovolaemic shock with low Hb have a higher 30 day mortality and few survive more than one year. Our study suggests that each of these four parameters separately was not a strong prognostic indicator. Collectively, however, they strongly influence the prognosis of patients with RAAA. These findings strengthen the case for selective treatment for RAAA.

Aortic surgery: do pre-operative cardioselective β-blockers improve clinical outcome?

ConclusionIn spite of the apparent decrease in post-operative complications and 30 day mortality in the pre-operative β-blocker group, statistics were not supportive of the same; p< 0.4 for the 30 day mortality with confidence interval 95% (−0.439 −0.154). A controlled study with a larger sample is recommended.