Jeffrey L. Ballard

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 (

Endovascular stent infection

9383 versus

Complications of iliac artery stent deployment

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.

Subfascial endoscopic perforator vein surgery combined with saphenous vein ablation: results and critical analysis

We report a case of iliac stent infection. Nine days after a 24-hour infusion of urokinase and right iliac artery stent deployment, the patient had fever, in addition to severe groin pain and petechiae isolated to the stented limb. The hospital course was complicated by sepsis, adult respiratory distress syndrome, liver dysfunction, and renal insufficiency. Stent removal and iliac/femoral artery resection, as well as an above-knee amputation, were life-saving. Arterial and stent cultures grew Staphylococcus aureus. Stent infection with arterial necrosis is a devastating, rare endovascular complication. Given its potential seriousness, we would recommend the use of prophylactic antibiotics before stent deployment.

Duplex ultrasound of the superficial femoral artery is a better screening tool than ankle-brachial index to identify at risk patients with lower extremity atherosclerosis

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.

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

OBJECTIVE This study was undertaken to determine the results of subfascial endoscopic perforator vein surgery (SEPS) combined with ablation of superficial venous reflux. METHODS Clinical data were retrospectively analyzed for 74 consecutive limbs (65 patients) in which this combination treatment was performed at a university medical center. Preoperatively, 58 lower extremities had an open venous ulcer (CEAP clinical class 6 [C(6)]) and 16 had healed ulceration (C(5)). Preoperative and postoperative ulcer care remained constant. Main outcomes measured included perioperative complications, ulcer healing, and ulcer recurrence. Clinical severity and disability scores were tabulated before and after surgery. Mean patient follow-up was 44 months. RESULTS Greater saphenous vein (GSV) stripping and varicose vein excision accompanied SEPS in 57 limbs (77%), and SEPS was performed alone or with varicose vein excision in 17 limbs that had previously undergone GSV stripping. Postoperative complications occurred in 12 limbs (16%), all with C(6) disease (P =.04). Ulcer healing occurred in 91% (53 of 58) of limbs with C(6) disease at a mean of 2.9 months (range, 13 days-17 months). Multivariate analysis demonstrated that ulcer healing was negatively affected by previous limb trauma (P =.011). Ulceration recurred in 4 limbs (6%) at 7, 20, 21, and 30 months, respectively. This was associated with a history of limb trauma (P =.027) and preoperative ultrasound evidence of GSV reflux combined with deep venous obstruction (P(R,O); P =.043). Clinical severity and disability scores improved significantly after surgery (both, P <.0001). CONCLUSIONS Most venous ulcers treated with SEPS with ablation of superficial venous reflux heal rapidly and remain healed during medium-term follow-up. Ulcer healing is adversely affected by a history of severe limb trauma, and ulcer recurrence is similarly affected by a history of limb trauma in addition to superficial venous reflux combined with deep venous obstructive disease. Overall, there was marked improvement of postoperative clinical severity and disability scores compared with those obtained before surgery.

The diagnostic accuracy of duplex ultrasonography for evaluating carotid bifurcation

OBJECTIVES The purpose of vascular disease screening is early identification of atherosclerotic disease and the aim of an ankle-brachial index (ABI) is to identify lower extremity (LE) atherosclerosis as a marker for coronary artery disease (CAD). However, early evidence of atherosclerosis may be present in the superficial femoral artery (SFA) with a normal resting ABI. This study was performed to determine if SFA duplex ultrasound (DUS) could detect more patients with LE atherosclerosis than an ABI; be performed in the same or less time as the ABI measurement; and be associated with similar vascular disease markers as the ABI. METHODS From January through November 2006, 585 patients were screened for peripheral arterial disease. SFA DUS was included in this Institutional Review Board approved program and demographic/ultrasound data were collected prospectively. SFA DUS findings were divided into six categories. Plaque w/o color change or worse and ABI <0.90 or >1.20 were considered to be abnormal. Data were evaluated using decision matrix and logistical regression analysis. RESULTS Sensitivity and specificity of SFA DUS using the ABI as the benchmark was 100% and 88%, respectively. Sensitivity and specificity of ABI was 17% and 100%, respectively, using DUS as the standard. DUS detected atherosclerotic disease in 143 SFAs (93 patients) in which the ipsilateral ABI was normal, and there were no false negative SFA DUS studies. Multivariate logistic regression analysis demonstrated the following variables to be significantly and independently associated with an abnormal SFA DUS as well as an abnormal ABI: history of claudication, history of myocardial infarction, and an abnormal carotid DUS. Additional variables (current or past smoker and age >55) were also independently associated with an abnormal SFA DUS but not with an abnormal ABI. Mean time to complete bilateral testing was essentially the same for both tests. CONCLUSIONS SFA DUS is an accurate screening tool and can be utilized in screening protocols in place of the time-honored ABI without prolonging the examination. Traditional vascular disease markers that are found in patients with an abnormal ABI are also associated with an abnormal SFA DUS. SFA DUS identifies more patients with early LE atherosclerosis than does ABI without missing significant popliteal/tibial artery occlusive disease. Finally, an abnormal SFA DUS can be used as an indirect marker to identify more potentially at risk patients with CAD.

Autologous saphenous vein popliteal-tibial artery bypass for limb-threatening ischemia : a reassessment

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.

Inflammatory Abdominal Aortic Aneurysm Treated by Endovascular Stent Grafting A Case Report

BACKGROUND In many medical centers the standard preoperative study for patients undergoing carotid endarterectomy is four-vessel carotid arteriography, but duplex scanning of the carotid bifurcation is also reported to be highly accurate for detecting stenotic or occluded carotid arteries. METHODS The diagnostic accuracy of duplex ultrasonography was evaluated in a study of 774 carotid bifurcations, in 400 patients comparing the degree of predicted internal carotid artery (ICA) stenosis found using that technique, with that found by contrast arteriography. Agreement between the predicted degree of ICA stenosis and the arteriographic measurement was evaluated using the Spearman rank order correlation. Accuracy statistics for duplex scanning as a diagnostic modality were assessed using 2 x 2 tables. RESULTS The Spearman rank order correlation coefficient was 0.74 (P = 0) for the symptomatic group, 0.65 (P = 0) for the asymptomatic group, and 0.68 (P = 0) for the total group. The accuracy of duplex ultrasonography for detecting all grades of ICA stenosis ranged from 80% to 97%. CONCLUSIONS Duplex ultrasonography of the carotid bifurcation is a reliable diagnostic tool and can be used as the sole preoperative study for selected patients with extracranial cerebrovascular disease. Our current algorithm is discussed in conjunction with a critical analysis of this large database.