John I. Iliopoulos

The critical hypogastric circulation

Eleven patients had ischemic complications secondary to ligation, hypoperfusion, exclusion, or thrombosis of the hypogastric arteries after aortoiliac reconstruction or spontaneous aortoiliac thrombosis. Ligation of one hypogastric artery resulted in persistent ipsilateral buttock claudication in three patients. Bilateral acute hypogastric artery ischemia occurred in eight patients and resulted in paralysis in all eight patients, buttock necrosis in four patients, anal and bladder sphincteric dysfunction in two patients, and colorectal ischemia in three patients. Five of these patients (63 percent) died. The mortality rate was 100 percent when buttock necrosis developed. In most of these patients, the neurologic deficit suggested ischemic injury of the lumbosacral plexus rather than spinal cord ischemia. These complications occurred despite patent bypass grafts to the iliac or femoral vessels. These observations suggest that it is essential to maintain patency of the hypogastric vessels in all aortoiliac reconstructions.

Hemodynamics of the hypogastric arterial circulation

This study was designed to assess the major sources of collateral supply to the hypogastric arterial bed (HGA). Peak systolic HGA and radial arterial pressure were obtained before and after clamping a patent HGA and after additional clamping of the contralateral HGA, the contralateral external iliac artery (EIA), or the ipsilateral EIA both selectively and in combinations. These procedures were performed in 10 patients with aortoiliac (AI) aneurysms or occlusive disease. In seven patients with aneurysms, clamping the contralateral HGA decreased the HGA stump pressure index from 0.57 to 0.49 (p less than 0.05), and clamping only the ipsilateral EIA decreased the stump pressure index to 0.38 (p less than 0.001). In three patients with occlusive disease, clamping the contralateral HGA did not decrease the stump pressure index, clamping both the contralateral HGA and EIA decreased the index from 0.61 to 0.57 (p greater than 0.05), and clamping only the ipsilateral EIA decreased the pressure index to 0.40 (p less than 0.01). These data suggest that branches of the ipsilateral EIA femoral arterial system provide a more significant collateral pathway than the contralateral HGA. These results suggest that it is important to relieve occlusive disease in the ipsilateral EIA femoral arterial system if a patent HGA is ligated or bypassed during AI reconstructions. Conversely, it is especially important to preserve forward perfusion in a patent HGA in a patient with compromised ipsilateral EIA femoral runoff.

Thrombolytic therapy for catheter-related thrombosis.

Thrombosis of the central venous system (CVT) occurs in 20% to 30% of patients with indwelling catheters. This complication is usually treated with anticoagulation, extremity elevation, and catheter removal. Thirty-eight patients with CVT at our institution were treated with thrombolytic therapy to rapidly resolve symptoms and avoid removal of the catheters. Complete clot lysis occurred in 36 of 38 patients (95%) within 1 to 5 days (mean: 2.4 days). Symptoms resolved with clot resolution. Thrombolytic therapy detected stenoses in 22 patients. Angioplasty was successful in 64% of these patients. Five catheters were removed. Complications occurred in six patients: nonfatal pulmonary embolus, three bleeding episodes, pain with infusion of urokinase, and an episode of septic phlebitis. This experience suggests that thrombolytic therapy is safe, rapidly resolves symptoms of thrombosis, uncovers anatomic abnormalities amenable to angioplasty, and allows central venous catheters to remain in place despite central venous thrombosis.

Aortoiliac reconstruction combined with nonvascular operations

Seventy-six patients with aortoiliac reconstruction and associated intraabdominal procedures were compared with 445 patients with aortoiliac revascularization alone to provide information about the associated morbidity and mortality of adding a nonvascular procedure to aortic reconstruction. Patients with aortoiliac reconstruction for limb salvage had a significant increase in complications when an abdominal procedure was performed in association with aortoiliac reconstruction (66 percent versus 14 percent, p less than 0.01). Additionally, patients with elective aortoiliac reconstruction had a significant increase in mortality when an abdominal procedure was performed in addition to aortoiliac reconstruction (9 percent versus 3 percent, p less than 0.01). A small bowel obstruction and a pancreatic pseudocyst occurred as a direct result of the associated abdominal procedure. None of the deaths could be directly attributed to a concomitant abdominal procedure. The demonstration of an increase in morbidity and mortality with the addition of nonvascular procedures to aortoiliac reconstruction, even though certain subgroups of patients underwent aortic revascularization, suggest that the surgeon must carefully weigh the benefits and risks before combining vascular and nonvascular operations.

Renal microembolization syndrome: A cause for renal dysfunction after abdominal aortic reconstruction

Moderate renal dysfunction due to renal microembolization developed in eight patients who underwent abdominal aortic reconstruction for aneurysmal or occlusive disease. In each patient, the aorta around the renal arteries was thrombus-lined or severely ulcerated and was therefore the source of embolization, and aortic clamping near the renal arteries was required and provided the mechanism for embolization. Renal failure was moderate and did not require dialysis. Renal dysfunction appeared to be largely reversible, although some degree of permanent damage did occur. Similar changes in renal function were noted in a dog model of renal microembolization. Prevention of this complication depends on awareness of aortic lesions that increase the risk of renal embolization.

The risk of stroke with occlusion of the internal carotid artery

Reports of all cervicocephalic arteriograms (n = 1836) performed at one institution during a 10-year period were reviewed and the patients were classified into three groups according to the indication for arteriography. Group I included all patients with symptoms or findings compatible with occlusive disease of the carotid or vertebral artery (n = 806). Group II included patients with cerebrovascular symptoms unrelated to carotid or vertebral disease (e.g., patients with subarachnoid hemorrhage) (n = 367). Group III consisted of patients with no evidence of cerebrovascular disease (e.g., patients with primary and metastatic brain tumors) (n = 663). One hundred ten atherosclerotic occlusions of the internal carotid artery (ICA) were found in 106 patients in group I. Fifty-one percent of these patients had a history of stroke before arteriography, 24% had transient ischemic attacks (TIAs) or amaurosis fugax (AF), and 12% had nonhemispheric symptoms. Only 13% (1.7% of group I patients) were without symptoms. Ninety-one percent of the strokes and 75% of the TIAs or AF were ipsilateral to the ICA occlusion. Seventy-six percent of patients with stroke and 80% with ipsilateral TIAs or AF vs only 29% of patients without symptoms had contralateral stenosis of 60% diameter reduction or greater (p less than 0.003). No occlusions of the ICA occurred in groups II or III. Three hundred forty-six patients in groups II and III were more than 60 years of age. Assuming either Poisson or binomial distributions, the incidence of silent ICA occlusion in the population at large older than 60 years was estimated at less than 1% (p less than 0.03).

Effect of biliary decompression on morbidity and mortality of pancreatoduodenectomy

To evaluate the effect of levels of serum bilirubin on morbidity and mortality after pancreatoduodenectomy, a prospective study was designed to compare patients who underwent preoperative biliary decompression to those who did not. Preoperative biliary decompression decreased the mean serum bilirubin level from 15.8 to 5.8 mg/dl in one group of 10 patients (Group A). The only statistical differences between this group and the two other groups of patients (Groups B and C) who were not treated with preoperative biliary decompression was the level of serum bilirubin before pancreatoduodenectomy (5.8, 22, and 1.3 mg/dl in Groups A, B, and C, respectively). Only one death occurred in each group of patients. The numbers of nonfatal complications were comparable. These results suggest that there is no decrease in morbidity or mortality after pancreatoduodenectomy when the serum bilirubin level is decreased by preoperative biliary drainage.

Ultrasonographic and angiographic evaluation of polytetrafluoroethylene aortic bifurcation grafts

Arterial reconstruction in 50 consecutive male patients with aortoiliac aneurysmal or occlusive disease was performed with PTFE bifurcation grafts. Follow-up intervals ranged from 1 to 39 months. All patients were evaluated by physical examination at 19.5 +/- 1.3 months. In addition, 46 patients were evaluated by ultrasonography at 18.2 +/- 1.2 months, 19 by angiography at 19.8 +/- 2.2 months, and 4 by computerized axial tomography at 21.5 +/- 5.2 months. Intraluminal thrombus or pannus was found in one graft in a patient with compromised outflow, but all graft limbs were patent. There were no accumulations of perigraft fluid, graft dilatations, or anastomotic aneurysms. The results of this study provide support for the continued use of PTFE bifurcation grafts for aortic reconstruction.

Vascular Craft Selection

Twenty to thirty per cent of patients with arterial injuries and some patients with venous injuries require interpositional grafts. The first choice of grafting material for both arterial and venous injuries is autogenous vein. Injuries to large vessels such as the aorta and superior vena cava may necessitate synthetic prostheses.

Success of profundoplasty: The role of the extent of deep femoral artery disease☆

A review of 64 profundoplasties performed in conjunction with inflow procedures for multilevel vascular occlusive disease of the lower extremity revealed that the extent of deep femoral artery disease had a strong influence on results. Profundoplasty for proximal deep femoral artery disease resulted in an 80 percent success rate when carried out for claudication, and an approximately 65 percent success rate for limb salvage and in limbs with poor runoff. In contrast, profundoplasty for diffuse or distal deep femoral artery diseases resulted in a 62 percent success rate for claudication and decreased to approximately 20 percent for limb salvage or in extremities with poor runoff.