J. David Killeen

A prospective evaluation of transcutaneous oxygen measurements in the management of diabetic foot problems

PURPOSE To test the hypothesis that lower extremity transcutaneous oxygen (TcPO2) measurements can accurately predict severity of foot ischemia and can be used to select appropriate treatment (conservative versus operative) for patients with diabetes and tissue necrosis or ischemic rest pain. METHODS Fifty-five patients with 66 limbs were prospectively treated from June 1993 to July 1994. Noninvasive hemodynamic arterial assessment and TcPO2 mapping of the involved limb were obtained before treatment was selected. If the transmetatarsal TcPO2 level was 30 mm Hg or greater, the patients foot problem was managed conservatively with local wound care, debridement, or a minor foot amputation. If the transmetatarsal TcPO2 level was less than 30 mm Hg, arteriography was performed with the anticipated need for vascular reconstruction. The endpoints for determining treatment success or failure were complete wound healing or relief of ischemic rest pain. RESULTS Thirty-one of 36 (86%) limbs with an initial transmetatarsal TcPO2 level of 30 mm Hg or greater were treated successfully with conservative care, including 73% (11 of 15 feet) of limbs without a palpable pedal pulse. After either bypass or angioplasty, 20 of 24 (83%) limbs achieved a transmetatarsal TcPO2 level greater than 30 mm Hg and had complete resolution of their presenting foot problem. An initial or postintervention transmetatarsal TcPO2 level of 30 mm Hg or greater was more accurate (90%, p = 0.001) than a palpable pedal pulse (65%, p = 0.009), in predicting ultimate wound healing or resolution of rest pain. CONCLUSIONS TcPO2 mapping is a useful noninvasive modality that can prospectively determine severity of foot ischemia, aid in selecting appropriate treatment for patients with diabetes and foot salvage problems, and decrease the total cost of such care.

Aortoiliac stent deployment versus surgical reconstruction: Analysis of outcome and cost

PURPOSE The purpose of this study is to compare complication rate, primary patency, and cost of stent deployment with direct surgical reconstruction for the treatment of severe aortoiliac occlusive disease. METHODS From March 1, 1992, to May 31, 1996, 119 patients receiving treatment for aortoiliac occlusive disease were analyzed after exclusions. Sixty-five patients had stent deployment and 54 patients had surgical reconstruction. Data were evaluated within and between the groups by univariate and multivariate logistic regression, life-table, t-test, and cross tabulation with chi2 analysis. RESULTS There was no significant difference between the groups with regard to demographic features or presenting symptoms (all p values > 0.07). Incidence of procedure-related complications was similar (p = 0.30). However, there were more systemic complications in the surgery group (15 versus 2; RR = 5.5, p < 0.01) and more vascular complications in the stent group (16 versus 3; RR = 12, p < 0.002). Incidence and type of late complications were not appreciably different (all p values > 0.05). Cumulative primary patency rate of bypass grafts was significantly better than stented iliac arteries at 18 months (93% versus 77%), 30 months (93% versus 68%) and 42 months (93% versus 68%); p = 0.002, log rank. Multivariate analysis identified female gender (RR = 4.6, p = 0.03), ipsilateral SFA occlusion (RR = 5.6, p = 0.01), procedure-related vascular complication (RR = 9.7, p = 0.002), and hypercholesterolemia (RR = 5.0, p = 0.02) as independent predictors of bypass graft or stent thrombosis. Mean total hospital cost per limb treated did not differ significantly between surgery and stent deployment groups (

Complications of iliac artery stent deployment

9383 versus

Management of Symptomatic Spontaneous Isolated Visceral Artery Dissection: Is Emergent Intervention Mandatory?

8626, respectively; p = 0.66, t-test). CONCLUSIONS Treatment of severe aortoiliac occlusive disease by surgical reconstruction or stent deployment has a similar complication rate. Mean hospital cost per limb treated is essentially equal. However, cumulative primary patency rate of bypass grafts is superior to stents. Therefore, considering the elements of cost and patency, surgical revascularization has greater value. The benchmark for cost-effective treatment of severe aortoiliac occlusive disease is direct surgical reconstruction.

Percutaneous transluminal angioplasty of tibial arteries for limb salvage

PURPOSE This study was performed to determine the primary patency, foot salvage, and complication rates associated with iliac artery stent deployment. METHODS From March 1992 to May 1995, 147 iliac artery stents were deployed in 98 limbs of 72 patients for disabling claudication or limb-threatening ischemia. Procedure-related and late (> 30 days) complications, as well as adjunctive maneuvers required to correct a complication, were tabulated. Stented iliac artery cumulative primary patency and foot salvage rates were calculated with life-table analysis. Factors that impacted early complications, late complications, foot salvage rates, and stented iliac artery primary patency rates were identified with stepwise logistic regression analysis. RESULTS A procedure-related complication occurred in 19 (19.4%) limbs. Initial technical success, however, was achieved in all but three of 98 limbs (96.9%). Stented iliac artery cumulative primary patency rates were 87.6%, 61.9%, 55.3%, and foot salvage rates were 97.7%, 85.1%, 76.1%, at 12, 18, and 24 months, respectively. External iliac artery stent deployment, superficial femoral artery occlusion before treatment, and single-vessel tibial runoff before treatment negatively affected stented iliac artery cumulative primary patency rates. Stented iliac artery primary patency rates were not significantly affected by age, smoking, coronary artery disease, diabetes, hypercholesterolemia, hypertension, presenting symptom, early complication, number of stents deployed, type of stent deployed, or stent deployment for stenosis versus occlusion. CONCLUSIONS Limb-threatening and life-threatening complications can be associated with iliac artery stent deployment. Stented iliac artery primary patency rates are affected by distal atherosclerotic occlusive disease and the position of the deployed stent within the iliac system. Stent reconstruction of severe iliac artery occlusive disease is feasible but should be thoughtfully selected.

Transcatheter embolization facilitating surgical management of a giant inferior gluteal artery pseudoaneurysm

Spontaneous dissection of a visceral artery without associated aortic dissection is rare, although more cases have recently been reported because of the advancement of diagnostic techniques. The risk factors, causes, and natural history of spontaneous isolated visceral artery dissection are unclear. Treatment with open surgery, endovascular stenting, or anticoagulation therapy has been proposed; however, there is no consensus on the optimal management. We present three cases of spontaneous and isolated dissection of visceral arteries. Dissection involved the superior mesenteric artery in one and the celiac artery in two. All three patients presented with acute abdominal pain but lacked any peritoneal irritation. The patients were treated nonoperatively with anticoagulants or antiplatelets. No surgical or endovascular intervention was performed. Follow-up imaging studies demonstrated improvement of the dissection in two patients and no change in one patient. All patients were symptom-free over a mean follow-up of 17 months. Nonoperative treatment with close observation is an acceptable strategy in the management of spontaneous isolated dissection of visceral arteries. Emergent intervention is not mandatory in symptomatic patients without evidence of acute bowel ischemia or hemorrhage.

Staged endovascular stent grafts for concurrent mobile/ulcerated thrombi of thoracic and abdominal aorta causing recurrent spontaneous distal embolization

Percutaneous transluminal balloon angioplasty (PTA) was performed in 17 tibial arteries with an average cross-sectional area stenosis of 92% (range 75–99%) in 13 patients (14 limbs) for limb salvage. In 4 of 14 lower extremities, PTA of femoropopliteal arteries was also performed. Technical success with 50% or less residual stenosis was achieved in all 17 tibial vessels. At approximately 2 months after PTA, clinical improvement had occurred in 10 of 14 limbs; no patient was made worse. Most recent follow-up (mean 19 months, range 8–34 months) revealed continued satisfactory clinical success with no further vascular intervention in 9 of these 10 limbs (one patient died). Short segmental stenoses, residual stenoses less than 40% following PTA, and absence of diabetes or gangrene appear to be predictors of favorable clinical outcomes. Our results suggest that PTA of focal tibial stenosis is an effective and safe treatment modality in properly selected patients and that wider use of PTA may be justified.

Stenting Without Thrombolysis for Aortoiliac Occlusive Disease: Experience in 14 High-Risk Patients

This article is a report on a case of a giant pseudoaneurysm of the inferior gluteal artery where important features of the diagnosis, with special mention of magnetic resonance imaging and arteriography, are discussed. Surgical therapy is the treatment of choice for these lesions. Historically, proximal arterial control has been the main dilemma in the management of gluteal artery pseudoaneurysm. We found transcatheter embolization to provide optimal control and eliminate the need for preperitoneal or intraabdominal dissection. Surgical repair can then be carried out without risk of intraoperative hemorrhage.

The diagnostic accuracy of duplex ultrasonography for evaluating carotid bifurcation

Mobile thrombus of the thoracic aorta is an uncommon pathology with potentially catastrophic complications. Recurrent spontaneous distal embolization may also occur from an ulcerated thrombus of the abdominal aorta. The simultaneous presence of a mobile thrombus in the thoracic aorta and ulcerated thrombus of the abdominal aorta is extremely rare and poses a significant treatment dilemma. Although various approaches have been reported, there is no standard treatment. Direct replacement of the thoracoabdominal aorta is extremely morbid, while continued embolization despite anticoagulation mandate intervention. We herein present the first case report of successful treatment of symptomatic mobile/ulcerated thrombi of the thoracic and abdominal aorta using staged endovascular stent graft repair. Successful treatment of the thoracic component with a thoracic aortic graft (TAG, Gore-Tex, W. L. Gore & Assoc., Flagstaff, Ariz.) was followed one week later by exclusion of the infrarenal aortic lesion with a bifurcated stent graft. Endovascular stent graft exclusion of mobile/ulcerated thoracic and abdominal aortic thrombi is a minimal invasive operation. It can be employed as an alternative procedure in treatment of aortic thrombus with embolization in high risk patients. Long-term follow-up will be necessary to assess the durability of this technique.

Operative balloon angioplasty in the treatment of internal carotid artery fibromuscular dysplasia

Stenting without thrombolysis of 16 occluded iliac artery segments and one occluded infrarenal abdominal aorta was attempted in 14 patients. All patients were either considered to be prohibitive operative risks or had contraindications to thrombolytic therapy. Indications for limb reperfusion included rest pain, disabling claudication, or dry gangrene. Successful recanalization was achieved primarily in 13 patients with self-expandable Wallstents, balloon-expandable Palmaz stents, or a combination of the two stents. Follow-up was carried out in all patients in whom recanalization was successful. All stented patients showed symptomatic improvement, and the mean preprocedure ankle/brachial index, which was 0.31, improved to 0.78 after the procedure (p = 0).Complications included a vertebrobasilar stroke during the procedure in one patient, perforation during angioplasty of a stenotic but nonoccluded external iliac artery in one, and dissection of the distal external iliac artery in one. Distal embolization did not occur. Percutaneous recanalization of aortoiliac occlusions without initial thrombolysis is possible and has a high potential for technical success. Additional data and longer follow-up are still needed, but this procedure may provide a reasonable, less invasive option in some patients at high surgical risk or in patients who have contraindications to thrombolytic therapy.