E. John Harris

The association of elevated plasma homocyst(e)ine with progression of symptomatic peripheral arterial disease

Plasma homocyst(e)ine (the sum of free and bound homocysteine, homocystine, and the mixed disulfide homocysteine-cysteine, expressed as homocysteine) levels were determined by high performance liquid chromatography in 214 patients with symptomatic (claudication, rest pain, gangrene, amputation) lower extremity arterial occlusive disease and/or symptomatic (stroke, cerebral transient ischemic attacks) cerebral vascular disease and in 103 control persons. Mean plasma homocyst(e)ine was significantly higher in patients than in controls (14.37 +/- 6.89 nmol/ml vs 10.10 +/- 2.16, p less than 0.05). Thirty-nine percent of patients (83 of 214) had plasma homocyst(e)ine values greater than control mean + 2 standard deviations. Plasma homocyst(e)ine values were contrasted to age, male sex, diabetes, hypertension, smoking, renal failure, and plasma cholesterol. No difference was found in the incidence and/or level of any of these risk factors when patients with normal plasma homocyst(e)ine were compared to those with elevated plasma homocyst(e)ine, both by univariate and multivariate analysis. Patients with elevated plasma homocyst(e)ine were more likely to demonstrate clinical progression of lower extremity disease and of coronary artery disease, but not of cerebral vascular disease than were patients with normal plasma homocyst(e)ine, and the rate of progression was more rapid (p = 0.002). Progression of lower extremity disease as assessed in the vascular laboratory was also more common in patients with elevated plasma homocyst(e)ine (p = 0.01). We conclude that elevated plasma homocyst(e)ine is an independent risk factor for symptomatic lower extremity disease or cerebral vascular disease or both. Symptomatic patients with lower extremity disease and with elevated plasma homocyst(e)ine also appear to have more rapid progression of disease.

The importance of routine surveillance of distal bypass grafts with duplex scanning: A study of 379 reversed vein grafts ☆ ☆☆

To assess the utility of routine duplex surveillance, 379 infrainguinal reversed vein grafts performed at two independent teaching hospitals were prospectively entered into a surveillance protocol from March 1986 through August 1989. An average of 3.2 postoperative duplex graft flow velocity (GFV) measurements per graft was obtained during a mean follow-up interval of 21 1/2 months. Only 2.1% of 280 grafts with GFV measurements greater than 45 cm/sec failed within 6 months of a normal surveillance examination. GFV measurements less than 45 cm/sec in 99 grafts led to arteriography in 75 grafts, identifying 50 stenotic lesions in 48 bypasses (12.6% of series). Inflow lesions were present in 5%, outflow stenoses in 2%, and intrinsic graft stenoses in only 6% of bypasses. Only 29% of grafts identified as failing by duplex scan were associated with a reduction in ankle-brachial index of greater than 0.15. Secondary reconstructions were performed in 48 grafts based on detection of a reduced GFV measurement; all such reconstructions are patent after a mean follow-up of 5 months. Duplex surveillance is more reliable in identification of failing vein grafts than is determination of ankle-brachial index.

Operative Repair for Aortic Aneurysms: The Gold Standard

Surgical treatment of abdominal aortic aneurysm (AAA) is being challenged by newer, minimally invasive therapies. Such new treatment strategies will need to prove themselves against concurrent results of standard operative AAA repair, within defined medical risk and aneurysm morphological categories. We review the natural history of AAAs, the medical risk levels for elective AAA repair, aneurysm morphology and its impact on operative mortality, the issue of high-risk patient treatment, and the current standard of care for AAAs based on single-center, multicenter, and population-based statistics. In good-risk patients, aneurysms > 5 cm in diameter are best treated by replacement with a prosthetic graft. Operative mortality should be < 5% and 1-year survival > 90%. Aortic endograft techniques must meet or exceed these standards if they are to supplant standard surgical repair.

Improving survival and limb salvage in patients with aortic graft infection

A 15-year experience with 38 aortic graft infections, including 15 patients with graft enteric fistulas, is reviewed in order to analyze modern-day surgical results utilizing extra-anatomic bypass and aortic graft excision. Perioperative mortality was 14% during the most recent 7-year interval, which was a notable improvement compared with the earlier time interval (p = 0.06). Extended follow-up of the perioperative survivors demonstrated a 77% cumulative 5-year survival and a 76% cumulative 5-year limb salvage rate. Subsequent axillofemoral graft infection occurred in 22% of survivors and resulted in a significantly higher amputation rate compared with those patients with no axillofemoral graft infection (p less than 0.001). The results suggest good perioperative and long-term survival in patients with aortic graft infection, with excellent limb salvage if subsequent axillofemoral graft infection can be avoided.

Reoperation for carotid stenosis is as safe as primary carotid endarterectomy

PURPOSE Patients with recurrent carotid artery stenosis are sometimes referred for carotid angioplasty and stenting because of reports that carotid reoperation has a higher complication rate than primary carotid endarterectomy. The purpose of this study was to determine whether a difference exists between outcomes of primary carotid endarterectomy and reoperative carotid surgery. METHODS Medical records were reviewed for all carotid operations performed from September 1993 through March 1998 by vascular surgery faculty at a single academic center. The results of primary carotid endarterectomy and operation for recurrent carotid stenosis were compared. RESULTS A total of 390 operations were performed on 352 patients. Indications for primary carotid endarterectomy (n = 350) were asymptomatic high-grade stenosis in 42% of the cases, amaurosis fugax and transient ischemic symptoms in 35%, global symptoms in 14%, and previous stroke in 9%. Indications for reoperative carotid surgery (n = 40) were symptomatic recurrent lesions in 50% of the cases and progressive high-grade asymptomatic stenoses in 50%. The results of primary carotid endarterectomy were no postoperative deaths, an overall stroke rate of 1.1% (three postoperative strokes, one preoperative stroke after angiography), and no permanent cranial nerve deficits. The results of operations for recurrent carotid stenosis were no postoperative deaths, no postoperative strokes, and no permanent cranial nerve deficits. In the primary carotid endarterectomy group, the mean hospital length of stay was 2.6 +/- 1. 1 days and the mean hospital cost was

Will Endovascular Repair Replace Open Surgery for Abdominal Aortic Aneurysm Repair

9700. In the reoperative group, the mean length of stay was 2.6 +/- 1.5 days and the mean cost was

Outcome of infrainguinal arterial reconstruction in women

13,700. The higher cost of redo surgery is accounted for by a higher preoperative cerebral angiography rate (90%) in redo cases as compared with primary endarterectomy (40%). CONCLUSION In this series of 390 carotid operations, the procedure-related stroke/death rate was 0.8%. There were no differences between the stroke-death rates after primary carotid endarterectomy and operation for recurrent carotid stenosis. Operation for recurrent carotid stenosis is as safe and effective as primary carotid endarterectomy and should continue to be standard treatment.

Clinical results of axillobifemoral bypass using externally supported polytetrafluoroethylene

ObjectiveTo evaluate of the impact of endovascular aneurysm repair on the rate of open surgical repair and on the overall treatment of abdominal aortic aneurysms (AAAs). MethodsAll patients with AAA who were treated during two consecutive 40-month periods were reviewed. During the first period, only open surgical repair was performed; during the subsequent 40 months, endovascular repair and open surgical repair were treatment options. ResultsA total of 727 patients with AAA were treated during the entire period. During the initial 40 months, 268 patients were treated with open surgical repair, including 216 infrarenal (81%), 43 complex (16%), and 9 ruptured (3%) aortic aneurysms. During the subsequent 40 months, 459 patients with AAA were treated (71% increase). There was no significant change in the number of patients undergoing open surgical repair and no significant difference in the rate of infrarenal (238 [77%]) and complex (51 [16%]) repairs. A total of 353 patients were referred for endovascular repair. Of these, 190 (54%) were considered candidates for endovascular repair based on computed tomography or arteriographic morphologic criteria. Analyzing a subgroup of 123 patients, the most common primary reasons for ineligibility for endovascular repair were related to morphology of the neck in 80 patients (65%) and of the iliac arteries in 35 patients (28%). A total of 149 patients underwent endovascular repair. Of these, the procedure was successful in 147 (99%), and 2 (1%) patients underwent surgical conversion. The hospital death rate was 0%, and the 30-day death rate was 1%. During a follow-up period of 1 to 39 months (mean 12 ± 9), 21 secondary procedures to treat endoleak (20) or to maintain graft limb patency (1) were performed in 17 patients (11%). There were no aneurysm ruptures or aneurysm-related deaths. ConclusionsEndovascular repair appears to have augmented treatment options rather than replaced open surgical repair for patients with AAA. Patients who previously were not candidates for repair because of medical comorbidity may now be safely treated with endovascular repair.

Upper extremity arterial bypass distal to the wrist

PURPOSE The outcome of leg bypass in women is unknown. To date, most series of lower extremity bypass have included few women, and the results in women compared with those in men have not been reported. The experience with infrainguinal arterial reconstruction in women treated at the Oregon Health Sciences University has been greater than previously reported. We have reviewed our recent experience with lower extremity bypass to determine whether results in women differ significantly from those in men. METHODS In the past 11 years we have performed 823 infrainguinal arterial reconstructions for lower extremity ischemia in 585 patients, of which 357 procedures were performed in women and 466 procedures were performed in men. The mean ages were 65 years for men and 68 years for women. Diabetes was present in 59% of the men and 48% of the women. Among men, 84% had a history of tobacco use compared with 66% of the women. Bypasses in men were performed for limb salvage in 73%, claudication in 22%, and a failing bypass graft in 5% of cases. Bypasses in women were performed for limb salvage in 79%, claudication in 15%, and a failing graft in 6% of cases. Previous revascularizations had been performed in 63% of the men and 71% of the women. Autogenous vein was used in 97% of the bypasses in men and 96% of bypasses in women. Graft distribution among infrainguinal arterial target sites was similar between the groups. Bypasses in men were femoral to above-knee popliteal in 11%, femoral to below-knee popliteal in 40%, femoral to tibial in 38%, popliteal to tibial in 10%, and tibial to tibial in 1% of cases. Bypasses in women were femoral to above-knee popliteal in 14%, femoral to below-knee popliteal in 43%, femoral to tibial in 33%, popliteal to tibial in 9%, and tibial to tibial in 1% of cases. RESULTS Perioperative 30-day mortality rates were 3.7% overall, 4.3% in men, and 2.9% in women. Long-term survival at 1, 3, and 5 years in men was 80%, 59%, and 44%, respectively. Long-term survival at 1, 3, and 5 years in women was 83%, 69%, and 44%, respectively. Life-table primary patency rates at 1, 3, and 5 years were 86%, 77%, and 71% for men and 87%, 74%, and 67% for women. Limb-salvage results at 1 and 5 years were 93% and 91% for men and 96% and 96% for women. CONCLUSIONS These results indicate that long-term graft patency and limb salvage results in women are identical to those obtained in men in this experience with autogenous vein. Infrainguinal arterial reconstruction can be performed in women with mortality rates similar to those of men. In this series long-term survival was similar for both men and women.

The effects of cooling on human saphenous vein reactivity to adrenergic agonists.

Seventy-six axillobifemoral grafts with externally supported polytetrafluoroethylene prostheses were performed since 1983. The indications for operation were absolute (aortic sepsis) in 20 (26%) patients and relative (excessive operative risk or technical difficulty) in 56 (74%) patients. The life-table primary patency for these operations at 4 years follow-up (mean follow-up, 2 years, 4 months) was 85%. We conclude that the patency results achieved in this patient series are sufficiently satisfactory to warrant use of axillobifemoral grafts in an expanded number of patients with high operative risk and need for bypass of aortoiliac occlusive disease.