Keith D. Calligaro

The Society for Vascular Surgery: Clinical practice guidelines for the surgical placement and maintenance of arteriovenous hemodialysis access

Recognizing the impact of the decision making by the dialysis access surgeon on the successful placement of autogenous arteriovenous hemodialysis access, the Society for Vascular Surgery assembled a multispecialty panel to develop practice guidelines in arteriovenous access placement and maintenance with the aim of maximizing the percentage and functionality of autogenous arteriovenous accesses that are placed. The Society commissioned the Knowledge and Encounter Research Unit of the Mayo Clinic College of Medicine, Rochester, Minnesota, to systematically review the available evidence in three main areas provided by the panel: timing of referral to access surgeons, type of access placed, and effectiveness of surveillance. The panel then formulated practice guidelines in seven areas: timing of referral to the access surgeon, operative strategies to maximize the placement of autogenous arteriovenous accesses, first choice for the autogenous access, choice of arteriovenous access when a patient is not a suitable candidate for a forearm autogenous access, the role of monitoring and surveillance in arteriovenous access management, conversion of a prosthetic arteriovenous access to a secondary autogenous arteriovenous access, and management of the nonfunctional or failed arteriovenous access. For each of the guidelines, the panel stated the recommendation or suggestion, discussed the evidence or opinion upon which the recommendation or suggestion was made, detailed the values and preferences that influenced the groups decision in formulating the relevant guideline, and discussed technical remarks related to the particular guideline. In addition, detailed information is provided on various configurations of autogenous and prosthetic accesses and technical tips related to their placement.

Venous aneurysms : surgical indications and review of the literature

BACKGROUND During the last 20 years we diagnosed five cases of venous aneurysm of the jugular (n = 4) and basilic (n = 1) veins. The purpose of this report was to determine the natural history and indications for surgery of venous aneurysms. METHODS Our five cases were included in an English-language literature review performed through August 1993. RESULTS In our series two aneurysms (one external jugular vein, one basilic vein) were excised for cosmetic reasons. Three internal jugular vein aneurysms were followed up for up to 4 years without complications with serial color duplex ultrasonography. Of 32 patients with abdominal venous aneurysms (18 portal, seven inferior vena cava, four superior mesenteric, two splenic, one internal iliac), 13 (41%) had major complications including five deaths. Of 31 patients with deep venous aneurysms of the extremity (29 popliteal, two common femoral), 22 (71%) had deep vein thrombosis or pulmonary embolism and in 17 recurrent deep vein thrombosis or pulmonary embolism developed when patients were treated with anticoagulation alone. CONCLUSIONS Prophylactic surgery is cautiously recommended for low-risk patients with venous aneurysms of the abdomen and strongly recommended for most patients with lower extremity deep venous aneurysms. Other venous aneurysms should be excised only if they are symptomatic, enlarging, or disfiguring.

Management of atherosclerotic carotid artery disease: Clinical practice guidelines of the Society for Vascular Surgery

The Society for Vascular Surgery (SVS) appointed a committee of experts to formulate evidence-based clinical guidelines for the management of carotid stenosis. In formulating clinical practice recommendations, the committee used systematic reviews to summarize the best available evidence and the GRADE scheme to grade the strength of recommendations (GRADE 1 for strong recommendations; GRADE 2 for weak recommendations) and rate the quality of evidence (high, moderate, low, and very low quality). In symptomatic and asymptomatic patients with low-grade carotid stenosis (<50% in symptomatic and <60% in asymptomatic patients), we recommend optimal medical therapy rather than revascularization (GRADE 1 recommendation, high quality evidence). In symptomatic patients with moderate to severe carotid stenosis (more than 50%), we recommend carotid endarterectomy plus optimal medical therapy (GRADE 1 recommendation, high quality evidence). In symptomatic patients with moderate to severe carotid stenosis (>/=50%) and high perioperative risk, we suggest carotid artery stenting as a potential alternative to carotid endarterectomy (GRADE 2 recommendation, low quality evidence). In asymptomatic patients with moderate to severe carotid stenosis (>/=60%), we recommend carotid endarterectomy plus medical management as long as the perioperative risk is low (GRADE 1 recommendation, high quality evidence). We recommend against carotid artery stenting for asymptomatic patients with moderate to severe (>/=60%) carotid artery stenosis (GRADE 1 recommendation, low quality evidence). A possible exception includes patients with >/=80% carotid artery stenosis and high anatomic risk for carotid endarterectomy.

Acute arterial complications associated with total hip and knee arthroplasty

OBJECTIVE To our knowledge, ours is the largest single-center experience with diagnosis and management of acute arterial hemorrhagic and limb-threatening ischemic complications associated with total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS Between 1989 and 2002, 23,199 TKA procedures (13,618 total, 11,953 primary, 1665 revision) and THR procedures (9581 total, 7812 primary, 1769 revision) were performed at the orthopedic service of Pennsylvania Hospital, Philadelphia. Arterial injuries were grouped according to type (ischemia, bleeding, pseudoaneurysm, ischemia plus bleeding) and time of recognition of injury (0-5 days after orthoplasty). RESULTS Acute arterial complications developed in 32 patients (0.13%), associated with 24 TKA procedures (0.17%) and 8 THA procedures (0.08%; P =.0609). There were no deaths, and limb salvage was achieved in all patients. Arterial injury was detected by the orthopedic service on the same day (SD group) as performance of joint replacement in 18 patients (56%), but was not recognized until the first to fifth postoperative day (PO group) in 14 patients (44%). Arterial complications included acute lower-limb ischemia only in 18 patients SD group, 9; PO group, 9), bleeding only in 4 patients (SD group), arterial transection resulting in both ischemia and bleeding in 5 patients (SD group), and arterial pseudoaneurysm in 5 patients (PO group). Of the 18 patients with acute ischemia only, preoperative arteriography was performed in 12 patients (67%), and 6 patients (33%) were brought directly to the operating room because of advanced ischemia. Revascularization procedures in these 18 patients included bypass to the infrapopliteal artery (n = 7), popliteal artery (n = 5), or common femoral artery (n = 1); in only 5 patients (28%) was thrombectomy alone successful. These 18 patients tended to require fasciotomy (4 of 9 vs 2 of 9; P =.6199) and have foot drop (3 of 9 vs 1 of 9; P =.5765) more frequently when ischemia was recognized after the day of surgery. Bleeding was managed with arteriorrhaphy. Arterial transection was treated with end-to-end anastomosis (n = 3), interposition grafting (n = 1), and below-knee popliteal bypass (n = 1). Popliteal artery pseudoaneurysm was treated with percutaneous methods (n = 3) or surgery (n = 2). CONCLUSION In this series, risk for arterial injury associated with THA and TKA was remarkably low. Nonetheless, even at a high-volume orthopedic hospital, acute arterial injury was not recognized on the day of surgery in about half of patients. Judicious use of preoperative arteriography and aggressive revascularization are critical to achieving limb salvage. Simple arterial thrombectomy to treat ischemic complications of THA and TKA is rarely sufficient.

Complications of arteriovenous hemodialysis access: Recognition and management

English language citations reporting complications of arteriovenous access for hemodialysis are critically reviewed and discussed. Venous hypertension, arterial steal syndrome, and high-output cardiac failure occur as a result of hemodynamic alterations potentiated by access flow. Uremic and diabetic neuropathies are common but may obfuscate recognition of potentially correctable problems such as compression or ischemic neuropathy. Mechanical complications include pseudoaneurysm, which may develop from a puncture hematoma, degeneration of the wall, or infection. Dysfunctional hemostasis, hemorrhage, noninfectious fluid collections, and access-related infections are, in part, manifestations of the adverse effects of uremia on the function of circulating hematologic elements. Impaired erythropoiesis is successfully managed with hormonal stimulation; perhaps, similar therapies can be devised to reverse platelet and leukocyte dysfunction and reduce bleeding and infectious complications.

Impact of clinical pathways on hospital costs and early outcome after major vascular surgery

PURPOSE The purpose of this study was to determine whether major vascular surgery could be performed safely and with significant hospital cost savings by decreasing length of stay and implementation of vascular clinical pathways. METHODS Morbidity, mortality, readmission rates, same-day admissions, length of stay, and hospital costs were compared between patients who were electively admitted between September 1, 1992, and August 30, 1993 (group 1), and January 1 to December 31, 1994 (group 2), for extracranial, infrarenal abdominal aortic, and lower extremity arterial surgery. For group 2 patients, vascular critical pathways were instituted, a dedicated vascular ward was established, and outpatient preoperative arteriography and anesthesiology-cardiology evaluations were performed. Length-of-stay goals were 1 day for extracranial, 5 days for aortic, and 2 to 5 days for lower extremity surgery. Emergency admissions, inpatients referred for vascular surgery, patients transferred from other hospitals, and patients who required prolonged preoperative treatment were excluded. RESULTS With this strategy same-day admissions were significantly increased (80% [145/177] vs 6.2% [9/145]) (p < 0.0001), and average length of stay was significantly decreased (3.8 vs 8.8 days) (p < 0.0001) in group 2 versus group 1, respectively. There were no significant differences between group 1 and group 2 in terms of overall mortality rate (2.1% [3/145] vs 2.3% [4/177]), cardiac (3.4% [5/145] vs 4.0% [7/177]), pulmonary (4.1% [6/145] vs 1.7% [3/177]), or neurologic (1.4% [2/145] vs 0% [0/177]) complications, or readmission within 30 days (11.3% [16/142] vs 9.2% [16/173]) (p > 0.05). There were also no differences in morbidity or mortality rates when each type of surgery was compared. Annual hospital cost savings totalled

Management of infected aortic prosthetic grafts.

1,267,445. CONCLUSION Same-day admission and early hospital discharge for patients undergoing elective major vascular surgery can result in significant hospital cost savings without apparent increase in morbidity or mortality rates.

Congenitally absent inferior vena cava presenting in adulthood with venous stasis and ulceration: A surgically treated case

The management of infected prosthetic grafts is one of the most challenging problems facing vascular surgeons. High mortality and morbidity rates with traditional treatment have led many surgeons to consider different and novel strategies. Diagnosis is usually straightforward, but occasionally is unclear even after extensive clinical and radiologic investigations. Although routine total graft excision for all infected aortic grafts is still favored by some vascular surgeons, most favor only partial graft excision if only the distal limb of the graft is involved. Placement of in situ autologous vein or cryopreserved grafts have gained popularity, and investigations are continuing regarding the use of in situ antibiotic and silver-coated prosthetic grafts. In this article the authors review the incidence and etiology of aortic graft infections, methods to prevent these complications, the diagnosis of infected aortic grafts, and lastly the management of these complicated cases, including total graft excision and partial and complete graft preservation.

Duplex ultrasound imaging alone is sufficient for midterm endovascular aneurysm repair surveillance: A cost analysis study and prospective comparison with computed tomography scan

Absence of the inferior vena cava (IVC) is an uncommon congenital abnormality. Symptoms of lower extremity venous insufficiency resulting from this anatomic abnormality have been reported only once in the English literature, and no experience with surgical treatment of this condition has been published. We report the case of an otherwise healthy 41-year-old man with an 18-month history of severe venous insufficiency involving the right leg manifested by extensive ulceration that did not respond to aggressive conservative treatment. Duplex findings were not suggestive of venous obstruction or reflux, but venography documented no filling of the common iliac vein or inferior vena cava, and outflow was via collaterals to the azygous and hemiazygous systems. Computed tomography demonstrated complete absence of the inferior vena cava with azygous continuation. A prosthetic bypass from the external iliac to the intrathoracic azygous vein was performed with complete symptomatic relief after a 30-month follow-up period. Venous bypass surgery may play a role in treatment of this rare cause of venous insufficiency.

Endovascular versus surgical treatment for thrombosed hemodialysis grafts: A prospective, randomized study

OBJECTIVE Early in our experience with endovascular aortic aneurysm repair (EVAR) we performed both serial computed tomography scans and duplex ultrasound (DU) imaging in our post-EVAR surveillance regimen. Later we conducted a prospective study with DU imaging as the sole surveillance study and determined cost savings and outcome using this strategy. METHODS From September 21, 1998, to May 30, 2008, 250 patients underwent EVAR at our hospital. Before July 1, 2004, EVAR patients underwent CT and DU imaging performed every 6 months during the first year and then annually if no problems were identified (group 1). We compared aneurysm sac size, presence of endoleak, and graft patency between the two scanning modalities. After July 1, 2004, patients underwent surveillance using DU imaging as the sole surveillance study unless a problem was detected (group 2). CT and DU imaging charges for each regimen were compared using our 2008 health system pricing and Medicare reimbursements. All DU examinations were performed in our accredited noninvasive vascular laboratory by experienced technologists. Statistical analysis was performed using Pearson correlation coefficient. RESULTS DU and CT scans were equivalent in determining aneurysm sac diameter after EVAR (P < .001). DU and CT were each as likely to falsely suggest an endoleak when none existed and were as likely to miss an endoleak. Using DU imaging alone would have reduced cost of EVAR surveillance by 29% (