F.G.M. Buskens

Arterial reconstruction for subclavian obstructive disease: a comparison of extrathoracic procedures

OBJECTIVES Comparison of the immediate and long-term results of three different extrathoracic arterial reconstruction procedures for subclavian obstructive disease. DESIGN Retrospective analysis of 51 extrathoracic subclavian artery reconstructions in 49 patients performed in a single centre over an 18-year period (mean follow-up 64 months, range 3-192). METHODS Carotid-subclavian bypass (CSB, n = 21), subclavian-carotid transposition (SCT, n = 21) and subclavian-subclavian or axillo-axillary cross-over bypass (COB, n = 9) was performed. Upper extremity ischaemic complaints were present in 45/49 patients (92%) and vertebrobasilar insufficiency in 25/49 patients (51%). Symptom relief, improvement of haemodynamic parameters and graft patency were compared. RESULTS Operation time was significantly shorter (p < 0.001, t-test) in SCT (80 +/- 5 min) compared to CSB (112 +/- 7 min) and COB (116 +/- 6 min). Symptom relief and improvement of haemodynamic parameters were similar for all groups. There were no differences in morbidity rate and there was no mortality. The cumulative patency of SCT was significantly better with 100% at 2, 5 and 10 years postoperatively compared to CSB (75.6%, 62.6% and 52.2%, respectively) (p < 0.005, log-rank test) and COB (76.5%, 63.7% and 63.7%, respectively) (p < 0.02, log-rank test). There was a tendency for a better patency in prosthetic grafts as compared to autologous vein grafts in CSB (NS, log-rank test). CONCLUSIONS Satisfactory immediate and long-term results were obtained with all of the above techniques. When technically feasible, SCT is the procedure of choice for extrathoracic arterial reconstruction in subclavian obstructive disease.

Unilateral vascular reconstruction for iliac obstructive disease

PURPOSE Controversy exists regarding the extent of vascular reconstructive surgery in the presence of unilateral symptomatic iliac obstructive disease. This study reviews the results of unilateral iliac reconstruction, with special emphasis on the need for consecutive contralateral intervention. METHODS The outcomes of 184 unilateral and 350 aortobilateral reconstructions for obstructive disease performed during the same period were retrospectively analyzed. Treatment allocation was based on hemodynamic parameters. Unilateral reconstruction was performed by a way of a retroperitoneal approach through a pararectal incision and bilateral reconstruction by way of a transperitoneal approach through a midline abdominal incision. RESULTS Symptom relief, improvement of noninvasively measured parameters, and graft patency were similar after unilateral and bilateral reconstruction. Both groups had a 10-year primary patency rate greater than 80%. There were no differences in morbidity rate, although respiratory complications occurred more often after bilateral reconstruction. Mortality rates were 1.6% after unilateral reconstruction and 4.9% after bilateral reconstruction. Secondary contralateral reconstruction was performed in only 6% of the patients who underwent an initial unilateral operation. CONCLUSIONS The unilateral vascular reconstruction for iliac obstructive disease is a well-tolerated procedure with an excellent long-term outcome. It is a valuable alternative to conventional aortobilateral reconstruction in carefully selected patients. Prophylactic reconstruction of an asymptomatic iliac stenosis without signs of significant hemodynamic impairment is most often not indicated.

Lumbar sympathectomy in critical limb ischaemia: surgical, chemical or not at all?

The value of surgical and chemical lumbar sympathectomy was studied in patients with critical lower-limb ischaemia without the option of vascular reconstruction. Clinical success rates, defined as improvement of ischaemia stage, and limb salvage rates were recorded for 76 limbs of 70 consecutive patients. Chemical lumbar sympathectomy patients were older and had more concomitant diseases than surgical lumbar sympathectomy patients. The short-term (6-week) success rate in 36 cases treated with surgical lumbar sympathectomy (44%) was better than in 40 cases treated with chemical lumbar sympathectomy (18%) (P = 0.01). The long-term (1-year) success rate was 47% for surgical lumbar sympathectomy and 45% for chemical lumbar sympathectomy (P = NS). The 1-year limb salvage rates were 61% for surgical lumbar sympathectomy and 58% for chemical lumbar sympathectomy (P = NS). Complications were minor in both groups. Lumbar sympathectomy still has a limited role in the treatment of critical limb ischaemia in patients without the option of vascular reconstruction. Both surgical and chemical lumbar sympathectomy can be performed with very little morbidity and may provide a benefit over the natural course of the arterial insufficiency.

Femoropopliteal arterial reconstruction with intraoperative iliac transluminal angioplasty for disabling claudication: Results of a combined approach

Seventeen patients with disabling claudication resulting from multilevel arteriosclerotic disease were treated by combined intraoperative iliac transluminal angioplasty and femoropopliteal arterial reconstruction. Clinical improvement or total relief of ischaemic symptoms was observed in 15 out of 17 patients. Iliac pressure gradients were reduced with balloon dilatation to < 2 mmHg in all cases. The mean (+/- S.D.) resting ankle-brachial systolic pressure index increased from 0.42 +/- 0.14 to 0.87 +/- 0.21. Complications from intraoperative angioplasty were not encountered and no early graft failures were seen. The primary actuarial graft patency at 1, 2 and 5 years was 100, 88 and 67%, respectively. Combined intraoperative iliac transluminal angioplasty and femoropopliteal arterial reconstruction is a useful alternative to conventional surgical revascularisation in the treatment of selected patients with disabling claudication in the presence of multilevel arteriosclerotic disease.

Relevance of bacterial cultures of abdominal aortic aneurysm contents.

BACKGROUND To establish further insight into the relevance of intraoperative bacterial cultures of abdominal aortic aneurysm contents a study was performed of the rate of occurrence of prosthetic graft infection after aneurysm repair. METHODS Bacterial cultures were obtained from 216 patients, who were followed up for more than 3.5 years after operation and studied retrospectively in a single center analysis. RESULTS Thrombus cultures yielded bacteria in 55 of 216 (25.5%) cases, including 11 of 44 (25%) cases with ruptured aneurysms. Prosthetic infections (4 of 216; 1.9%) occurred more frequently (p < 0.02) in patients with positive thrombus cultures (3 of 55; 5.5%) than in patients with negative cultures (1 of 161; 0.6%). In two patients the species isolated from the thrombus was also cultured from the vascular prosthesis, although in one graft infection other organisms were also isolated. CONCLUSIONS The presence of bacteria in the intraluminal thrombus does not appear to be an important factor in the development of graft infection after primary elective and urgent abdominal aortic aneurysm repair. Therefore routine intraoperative cultures are unnecessary unless clinical signs of infective aortitis are present.

Doppler spectrum analysis versus direct femoral artery pressure measurement for rapid assessment of aortoiliac obstruction.

Adequate patient selection is required to limit the clinical workload and improve the cost‐effectiveness of noninvasive hemodynamic evaluation of the aortoiliac system. In a prospective blinded fashion the traditional invasive technique of direct femoral artery pressure measurements and the computerized Doppler spectrum analysis of blood flow velocities in the common femoral artery were studied. Both tests for rapid assessment of aortoiliac obstruction were compared with duplex ultrasonographic imaging, using a peak systolic velocity ratio of 2.5 to demonstrate stenoses of 50% or more. In a series of 17 consecutive patients (34 aortoiliac segments) with suspected aortoiliac obstructive disease, a good level of agreement (kappa = 0.6) was found for both methods when compared with duplex scanning. Analysis of deviations from the duplex registrations indicated an overestimation of the pathologic cases using femoral artery pressure measurements and an underestimation using Doppler spectrum analysis of blood flow velocities in the common femoral artery. Both methods were well tolerated, but femoral artery pressure measurements had a higher technical failure rate. Because of its noninvasive character and its feasibility the Doppler technique is preferred for the selection of patients for more extensive duplex sonographic investigation.

Relaparotomies after ruptured abdominal aortic aneurysm repair

The outcome of ruptured abdominal aortic aneurysm repair was reviewed in 83 consecutive patients with special emphasis on the influence of subsequent laparotomy. The overall 30-day mortality was 47%. Causes of death were exsanguination in six, cardiac failure in 15, uncontrolled hypotension in six, multiple organ failure (MOF) in nine, adult respiratory distress syndrome in one and sepsis in two patients. Thirty-three relaparotomies were performed in 21 patients after a mean interval of 10 days. Suspected intraabdominal haemorrhage was the indication in 15 and sepsis in 18 cases. The preoperative diagnosis proved to be correct in 12/15 (80%) and 11/18 (61%) instances, respectively. Negative explorations were mainly performed in patients with an established MOF syndrome. Relaparotomies were associated with a significantly (p < 0.05) increased mortality of 76%. The complications that give rise to the need for surgical reintervention are usually accompanied by a clinical deterioration of the patient and inevitably reduce the chances of survival. However, until a reliable predictor of mortality is developed, treatment should not be denied in individual cases.